As we begin 2021 it is important to look back and consider whether there have been any landmark changes in clinical negligence and patient safety in the NHS, whether it is possible to discern any positive or negative progress towards the development of ingrained patient safety culture. My columns throughout 2020 discussed several clinical negligence and patient safety issues. Although the COVID-19 pandemic has forced major changes and challenges for the NHS, we have seen staff and systems rise to meet these. New ways of working, for example with online GP consulting, better cooperation, collaboration and communication between local and national health agencies are just some positive outcomes.
State of health and social care
The Care Quality Commission (CQC) (2020)State of Care annual assessment of health and social care in England noted some improvement in NHS acute care, where 75% of core services were rated as good or outstanding compared with 72% the previous year. However, major patient safety problems persist:
‘For example, the quality of urgent and emergency care in NHS acute hospitals had barely changed compared with the previous year, and there was still too much that needed to improve. Seven per cent of these services were rated as inadequate at 31 March 2020, and 44% were rated as requires improvement. The quality of maternity services has barely changed, with at least one in four “maternity” core services rated as requires improvement overall at 31 March 2020.’
Maternity care
Looking back on 2020 a notable theme of maternity patient safety failings and litigation emerges. There have been several high-profile failings identified, with investigations continuing. This issue is not new and it is a salutary reminder of the perpetuating problems in some NHS maternity units to reflect on the words of the chairman of the Morecambe Bay investigation, Dr Bill Kirkup, who set the scene in his introduction to the 2015 report. A lethal mix of issues led to the unnecessary deaths of mothers and babies:
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth ‘at any cost’; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.’
Over five years later we can see many of the same problems emerging again with the lessons of the past seemingly going unlearnt:
‘A hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff.’
Parliamentary inquiry
There is currently a Parliamentary Health and Social Care Committee inquiry in progress into the safety of maternity services in England. The committee's remit is to:
‘“[The] Morecambe Bay [report] did talk about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.”’
Dysfunctional teams and midwives and obstetricians not working effectively together resulting in serious patient safety errors beggars belief. Surely it cannot be that complicated for different health professions to really work together when the alternative is possibly the death or serious injury of mothers and babies?
It is worth re-reading the report of the Morecambe Bay investigation. Some of the findings still make for very uncomfortable reading in an NHS that for well over two decades has been trying to develop a patient safety culture that puts the patient first.
NHS resolution: maternity claims
NHS Resolution's Annual Report and Accounts for 2019-2020 (NHS Resolution, 2020a) gives the financial cost to the NHS of maternity claims. The emotional cost to the injured and the health professionals involved will always remain incalculable. Money can never compensate fully for a baby's or mother's ruined or lost life caused by clinical negligence.
‘Maternity claims represent around 9% of the total number of clinical negligence claims received by NHS Resolution each year but are 50% of the total value of new claims. They also relate to 69% of the annual £8.3 billion cost of harm in relation to the CNST [Clinical Negligence Scheme for Trusts] (covering England and secondary care).’
NHS Resolution (2020a) also states that the total value of maternity claims continued to increase, despite a downward trend in claims received since 2016/17. The volume of claims has varied historically between 180 and 230 and has been on a downward trajectory in recent years. However, the cost of those claims has steadily risen.
Claims across care specialties
The NHS Resolution annual report is also a good barometer on the levels of NHS litigation across all NHS care specialties. When it comes to the indemnity schemes that it manages:
Looking forward in patient safety
In 2021 several investigations into poor maternity care are due to report and it will remain to be seen whether patient safety lessons identified will be taken on board across NHS maternity units. Unforgivable patient safety failings over an extended period have been shown in past reports.
In 2021 the reports of organisations such as the CQC and NHS Resolution will continue to reveal what is happening in the areas of patient and clinical negligence litigation. These reports and others from a variety of national and international organisations will present key real-time information on trends, which can be distilled and applied to a variety of healthcare settings and organisations. Such reports contain valuable lessons and insights on what has gone wrong and what should have gone right in patient safety. The key issue, however, still remains: how best to capture, distil and cascade down this information to busy NHS staff.
Another useful source of real-time information on patient safety and clinical negligence are the reports and blogs of solicitor law firms involved in litigation concerning the NHS. These reported cases provide a valuable snapshot of current patient safety and clinical negligence issues and are written in a clear and accessible way.
Global Patient Safety Action Plan
In 2020 the World Health Organization (WHO) published its Global Patient Safety Action Plan 2021–2030, with the subtitle ‘Towards zero patient harm in health care’. It has a framework with seven strategic objectives, which can be achieved through 35 specific strategies. The first objective stated is:
‘Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’
This has the potential to improve the standard of care across health systems nationally in the NHS and worldwide. Making zero avoidable harm the default mindset is essential for achieving improvements in patient safety.
Conclusion
I have no doubt that the NHS will continue to see patient safety crisis reports published in 2021. The CQC now more frequently prosecutes Trusts for breaches of regulations and these give publicity to poor care quality. Law firms will also continue to take on and to publicise cases. It is an unrealistic proposition to say that there should never be any negligence or patient safety issues in the NHS and thankfully nobody, to my knowledge, is saying that. Error will always be with us, it is an inevitable feature and consequence of care in any setting and in any part of the world. Health care is delivered by human beings who are fallible. Often, they are dealing with highly complex treatment regimens, with complex equipment, in challenging care environments. The best we can all hope for is that risk is managed competently and appropriately.
WHO's (2020) objective of a zero avoidable harm mindset is an essential one to achieve long-term sustainable improvements in patient safety everywhere. We all need to aim high in our various endeavours in this field. Hopefully in 2021 we will see some positive evidence of the development of an ingrained patient safety culture in the NHS. There are positive steps showing progress towards this goal from several reports that I have discussed in my columns during 2020. However, as we have seen here, there are also systemic problems to resolve.