On a flight, there is generally no doubt in passengers' minds that they will arrive safely at their destination—air accidents are extremely rare. However, when it comes to healthcare treatment it is difficult to have the same level of confidence in outcome. The World Health Organization (WHO) has published a ‘fact file’ on patient safety, which begins with the following statement:
‘Patient safety is a serious global public health concern. It is estimated that there is a 1 in 3 million risk of dying while travelling by aeroplane. In comparison, the risk of patient death occurring due to a preventable medical accident, while receiving health care, is estimated to be 1 in 300.’
It makes the point that industries with a perceived higher risk, aviation and nuclear industries, have a much better safety record than health care. From a global perspective, WHO (2019) says adverse events as a result of unsafe care are likely to be in the top 10 causes of death and disability.
On the domestic patient safety front the Care Quality Commission (CQC) regularly publishes inspection reports of the health and care facilities it regulates. These reports present a window to the world on what is happening in terms of safety and quality in NHS health and care organisations in England.
What becomes apparent when reading these inspection reports is that quality of care and patient safety are not consistent across England. There are wide variations between core services in the same hospital or in the same locality as well as regionally.
Reflecting on risk
Reflecting on the WHO (2019) fact file and the differences between the aviation and health industries, troubling issues arise when the two are compared. Airlines that become outliers and have a poor safety record are banned from flying in certain regions of the world. You also don't generally hear mainstream news reports about an airline having a poor safety record, but the same cannot be said about a hospital and poorly rated core services. CQC reports regularly identify major service failures and the hospitals are still open. Clearly you cannot close a hospital that is providing essential care to a community in the same way you can an airline. The CQC will act in a proportionate way, taking all the circumstances into account.
In terms of NHS care generally, the general public does seem to have become largely de-sensitised to the issue of patient safety, despite the well-publicised patient safety scandals of recent times. Several CQC patient surveys show high levels of trust and confidence in NHS services and staff.
Variation in CQC reports
Two recently published CQC inspection reports of hospital A&E services in different parts of England will be discussed. Both reports provide good examples of major variance in patient safety and health quality, which is shocking given the importance of the A&E core services to the local community. The problems identified are compounded by the fact that patients do generally have faith and confidence in NHS services and are clearly being let down in certain circumstances. Patients, in terms of power and their situation, are always the weaker party in the health care equation. They are in unfamiliar environments often fearing the worst about their condition, dependent on others for essential, professional knowledge.
Several CQC state of health care and adult social care in England reports have discussed variation in care quality and safety. Indeed, the issue of significant variation appears to be a constant theme.
‘As we explored in last year's report, there are parts of the country where relative concentrations of poor-quality care, as shown by ratings, mean that people living there may find it more difficult to access good care. Despite being able to detect some narrowing of differences in quality at regional level, there are still considerable differences that will affect people's experiences.’
Pilgrim Hospital
Between December 2012 and July 2019 the CQC inspected urgent and emergency care services at Pilgrim Hospital, Boston, 10 times. The CQC has previously taken urgent enforcement action. The latest report, published in February 2020 (CQC, 2020a), makes for uncomfortable reading as it shows a litany of care failings.
The department was too small for the number of patients arriving. This had an impact on patient flow with some being treated in corridors or the central space of the department, compromising the dignity of those patients. Patients who self-presented were triaged in line with national guidance although some continued to wait a considerable time before being clinically assessed and treated. The longest wait in the department was 20 hours and 20 minutes.
The resuscitation area operated at full capacity for the duration of the inspection:
‘Department staff worked tirelessly to try and stabilise patients as quickly as possible in order [that] further resuscitation space could be created to meet demand.’
The inspectors noted one case in which a patient was held on an ambulance for over an hour despite the paramedic twice raising concerns about the patient's deteriorating condition. Staff caring for the patient were clearly distressed because of the delay.
The report highlights concern over the management of patients with diabetes, which led to a conclusion that:
‘There remains a lack of embedded learning following serious incidents.’
Management of neutropenic septic patients remains an area that requires significant improvement. Staff also were not following revised guidance on completing an ECG within 10 minutes for all patients presenting with chest pain. The inspectors noted a patient presenting with chest pain where an ECG was not carried out for approximately 30 minutes.
Staffing and compassionate care
The inspectors found the service did not have enough permanent nursing or medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. There was reliance on a substantial number of bank and agency staff.
Some staff, the CQC said, did not treat patients with compassion and kindness and did not respect their privacy and dignity. The individual needs of the patients were not always considered or acted upon and staff did not always provide appropriate emotional support to patients.
Leadership and organisational culture
The inspectors had previously reported concerns over how well the nursing leadership of the department managed other health professionals during times of increased departmental activity.
‘Despite the paramedic having given the patient morphine to manage their pain, the nurse-in-charge was dismissive of the paramedic's concerns and did not afford sufficient priority to meet the needs of the patient who had underlying neurological deficit and so was at increased risk of distress.’
The CQC found that leaders lacked the skills and abilities to run the service. Poor clinical leadership resulted in poor situational awareness when risks within the service increased. Local leaders did not fully understand or manage the necessary priorities and issues that were being faced by the service. They were unable to find sustainable long-term solutions:
‘The service did not have a specific vision at service level for what it wanted to achieve or a clear strategy to turn it into action, developed with all relevant stakeholders.’
The ratings for this report were all marked inadequate. Overall, it makes for grim reading. Many issues such as staff recruitment, shortages, and working at full capacity are ones that appear in other CQC reports for other providers. This report, however, gives a deep dive into specific patient safety lesson-learning issues. It provides a clear case study of patient safety and health quality issues.
North Middlesex University Hospital
It is a useful exercise to contrast the report for Pilgrim Hospital with one for North Middlesex University Hospital in Haringey published on the same day (CQC, 2020b), which also involved an A&E inspection.
The CQC inspectors found that the design, maintenance and use of facilities premises and equipment kept people safe. Staff were trained to use them. In terms of assessing and responding to risk, this was found to be positive. The department had a safe and working triage system:
‘Patients arriving by ambulance were received quickly and both nursing and medical staff undertook rapid assessments of patients. Where necessary, interventions such as analgesia, administration of urgent antibiotics, electrocardiograms (ECG) or blood tests were carried out. Once stable, patients were then relocated to the most appropriate clinical area such as a cubicle in major's …’
Safety huddles every 2 hours involving the consultant in charge, nurse in charge and operations staff were observed by the inspectors. High-level findings included that despite there being a relatively high vacancy rate within specific bands, there were enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care. The service had managers at most levels with the right skills and abilities to run a service which provided high-quality, sustainable care. Leaders operated effective governance processes.
Conclusion
It is clear, reading CQC inspection reports, that safety and quality in health care is extremely variable, a fact that will come as no surprise to those who work in the NHS. Some trusts are simply better than others at delivering safe and quality care. The reasons why are myriad and can be seen detailed in the inspection reports. However, the key issue remains of the permissible extent to which the NHS and the general public will allow or at least tolerate significant variation of quality and safety of trust services. The general public may not view CQC inspection reports as essential bedtime reading but these two reports paint very different pictures of NHS emergency care. The reports contain some common issues and it is important to compare them as they both well illustrate the challenges and opportunities facing the NHS in developing safe, good-quality care.