In the run-up to the general election there is no shortage of health and patient safety stakeholders stating what they would like a newly elected government to do. Each stakeholder is advancing their own agendas.
When reading these ‘manifestos’, it is an interesting exercise to ask whether what they are asking for would make a difference to NHS patient safety culture development. Would their policies, if adopted by a government, advance NHS safety culture development progress?
Government control over NHS patient safety
A fundamental question I also ask when considering election manifestos is how much control governments have over NHS patient safety culture development. Governments come and go, as do patient safety policies and practices. The nature of NHS patient safety problems are perhaps too big, complex and ingrained to be effectively solved by any one government at any one time.
The seminal patient safety document, An Organisation with a Memory, published in 2000, nearly a quarter of a century ago, highlighted significant patient safety problems, many of which are still with us today. Has much changed, patient safety-wise, since then?
The document stated, under the heading ‘The way forward’:
‘The time is right for a fundamental re-thinking of the way that the NHS approaches the challenge of learning from adverse health care events. The NHS often fails to learn the lessons when things go wrong and has an old-fashioned approach in this area compared to some other sectors.
The implementation gap
We can see the same sentiments being expressed today in many patient safety crises investigation reports. Sadly, history has not served the NHS well when it has come to lesson learning from past crises and effecting meaningful practice change. We can see this happening with the ongoing patient safety crises that we have in NHS maternity care, in Never Events and many other clinical areas.
We have today a much better understanding, nearly 25 years on from DH (2000), of the science of patient safety, why errors happen and strategies for cure. However, theory does not always translate into practice and the same or similar patient safety errors are often repeated. There is an implementation gap as Patient Safety Learning (2022) highlighted in its report. Other patient safety stakeholders have also discussed this, including the Parliamentary and Health Service Ombudsman (PHSO) (2023):
‘And yet, it is clear from the analysis of our most serious patient safety cases through this report that there is a gaping hole between best practice policy and consistent real-life practice. We may have a very sophisticated understanding of how to prevent patient safety incidents and avoid compounding harm for patients, families, and staff when things do go wrong. But our evidence suggests that, on the ground, this is regrettably not always implemented.’
The litmus test for the health and patient safety stakeholders' manifestos for a newly elected government will be how well what they are suggesting deals with the patient safety implementation gap discussed above. Although it is clear that there have been patient safety successes over the years, acute patient safety problems remain.
Stakeholders' manifestos
Medical Protection Society
The Medical Protection Society (MPS) (2024) has listed priorities for the next government under the headings accountability, wellbeing, and workforce. In terms of accountability, the MPS wishes to see a new government bring in reforms to the General Medical Council (GMC), improve the conduct of NHS disciplinary investigations, tackle the rising cost of clinical negligence, and stop the criminalisation of medical errors. This would be by reviewing how the law on gross negligence and manslaughter in England and Wales can be reformed.
In terms of wellbeing, the MPS wants local access to mental health support for NHS staff. On workforce, it calls for maintaining and growing the numbers of doctors trained in the UK and retaining NHS staff.
All the calls made by the MPS on the new government will impact on the development of an NHS patient safety culture in diverse ways. Training and retaining more doctors and nurses will have clear benefits as many patient safety investigations show a lack of staff and of suitably trained staff as factors of concern.
The rising cost of clinical negligence is a perennial concern and has been for many years. I acknowledge that the compensation paid could well be used to provide front-line NHS care, but the patient who has been negligently harmed by those who were meant to care for them also needs to be able to properly access legal help and just compensation.
We have an adversarial tort civil justice compensation system that determines fault and is applied to all professionals in any discipline. Tort damages are designed to put the claimant in the position that they would have been in had the negligence not occurred. Money can, however, be seen as poor compensation for the loss of a faculty or amenity or even death. We need to guarantee a patient's right to legal help and just compensation.
Why a joint strategy?
On the subject of clinical negligence, the MPS (2024) manifesto calls for the health and justice departments to publish a joint strategy. I am not clear what this would achieve in practice. We can see from the many past reports of patient safety crisis investigations the root problems of patient safety errors. The East Kent maternity investigation report (Kirkup, 2022) catalogued many of these:
‘This Report identifies four areas for action. The NHS could be much better at identifying poorly performing units, at giving care with compassion and kindness, at teamworking with a common purpose, and at responding to challenge with honesty. None of these are easy or necessarily straightforward, because longstanding issues become deeply embedded and difficult to change.’
The Patients Association
The Patients Association manifesto (2024) states:
‘The next Government must ensure more people can get the care they need and make patient partnership a reality across health and care services. Reversing the normalisation of the crisis in health and care and rebuilding the relationship patients have with the services they need to live well must be addressed urgently. Political parties can take the followings steps to make that happen.
One of the steps stated is ‘taking patient partnership from theory to practice’. Under this heading there would be a government commitment to urgently review and update the NHS Constitution – including the status of patient choice – in partnership with patients. The manifesto also states that shared decision-making is the default operating model, expanding formal routes for patient involvement in NHS structures and decision-making bodies.
Other areas discussed include that increasing the availability of quality care should be a national priority, placing health at the heart of government. Another is that there should be genuine two-way communication between patients and health professionals and that there is a need to improve how patient complaints are handled.
Action against Medical Accidents
Paul Whiteing, Chief Executive of Action against Medical Accidents (AvMA) wrote in a blog post about what he would include in what he describes as his ‘dream manifesto’ (Whiteing, 2024), under the following headings:
Healthcare
Advocacy and accountability
In terms of eliminating compounded harm, Whiteing (2024) discusses the problem, the need to improve and benefits to be gained:
‘Too often, when medical harm occurs, the healthcare staff involved in trying to deal with the after effects can make matters worse. This is seldom deliberate but points to a poor culture of safety combined with a lack of understanding and training for staff in how to resolve such matters using best restorative justice practices.’
Benefits would also include savings in downstream litigation costs as the AvMA sees compounded harm driving some patient court actions.
It should be noted that, under the previous government, there were several consultations proceeding on important patient safety matters before the dissolution of Parliament, including on the NHS Constitution, Never Events and duty of candour.
A mammoth task
Patient safety, health regulation and governance reform can be seen to have been taken seriously by successive governments over the years. DH (2000) began the current NHS patient safety reform trajectory and it still largely continues on the themes outlined in that report.
The issues of patient safety are enormous and are too big to be solved in one swoop by any government, whatever its political persuasion. There are no silver bullets out there to solve the endemic, deep-set patient safety problems that beset the NHS. Successive governments have over the years attempted to deal with the problems and well-crafted health regulatory, governance policies and practices have emerged.
History, however, has not been kind to NHS patient reform efforts and acute problems remain and have remained for some time. Past patient safety crises investigation reports have chronicled the issues and the nature of the implementation gap we have between theory and practice.
Although health and patient safety stakeholders and the political parties may create and advance their manifestos, we have to ask whether they will they make any significant difference to NHS patient safety culture development and properly deal with the problems identified. It is hoped that some will, and they do encourage informed debate and discussion, but a mammoth task lies ahead for all.