In any professional endeavour there is a need for optimism, to believe a promising future lies ahead and that what we are doing means something and makes sense. We don't want to be seen to be running to stand still and that all our efforts are directed to crisis handling and firefighting. We don't want to be caught in a loop where there is no thinking about the future because we are all too busy for reflection.
Looking at the history of patient safety policy making and practice in the NHS it is possible to detect elements of the crisis handling approach. The NHS has been rocked over time by patient safety crises, discussed in my previous columns, and they continue.
When we look back to An Organisation with a Memory (Department of Health (DH), 2000), we can see that many of the patient safety problems highlighted then are still largely with us today. It is a salutary exercise to reflect on this quote from the report and ask whether it still applicable today:
‘It would be quite wrong to conclude that the NHS as an organisation is incapable of learning and improving, but the evidence suggests that learning generally takes a long time and that implementation of lessons can be very patchy.’
A look at Sirrs' (2023)NHS Patient Safety Timeline reveals the litany of NHS patient safety crises over the years and compounds the above point. The same or similar errors are being made. Failings include poor leadership, poor patient–health worker communication, a failure to demonstrate empathy, a lack of clinical competence, a failure to learn lessons and so on. NHS staff also have to navigate a complex, fragmented system of NHS health governance and regulation. I would also add staff patient safety information overload is a problem, along with the NHS's focus on system approaches to developing its patient safety infrastructure and culture development.
More emphasis should be given to the professional accountability and responsibility of the individual nurse or doctor. As professionals they have a duty to the patient to practise properly. A focus on system approaches can obscure the exercise of individual professional duties and responsibilities. There is a tendency to blame the system rather than the individual. Sometimes the individual can be at fault and, in the interests of transparency, this needs to be recognised. I would argue that attributing blame still has an important role to play in NHS patient safety policy development and practice.
Taking patient safety more seriously
Recent reports call for NHS patient safety to be taken more seriously. In her annual report the Patient Safety Commissioner (2023) stated:
‘It is clear that the culture is getting worse and unless leaders set a strategic intention to listen and act, we are heading straight back to the days of Mid Staffs and other health scandals, severe harm, and avoidable deaths.’
Patient Safety Commissioner, 2023: 6
She also noted that some positive patient safety steps have taken place and called for a much more patient-centred approach:
‘As well as asking “What's the matter with you?” we should be asking “What matters to you?” so that healthcare is personal, meaningful, and safer.’
Patient Safety Commissioner, 2023: 6
The Parliamentary and Health Service Ombudsman (PHSO) (2023: 7) stated that patient safety must be put ‘at the very top of the agenda’ and we need to get past the politics. The title of his report is hard hitting: Broken Trust: Making patient safety more than just a promise.
Both reports can be seen to raise issues about the pace and trajectory of NHS patient safety culture development and change. They stress the need to accelerate efforts to make patient safety a top political agenda item and more patient centred. The views of the Patient Safety Commissioner and the PHSO are greatly valued, they have a wealth of experience in dealing with these issues.
The case for optimism
I would suggest that we move towards seeing NHS patient safety policy and practice development more from a ‘glass half full’ perspective rather than a ‘glass half empty’ one.
It is important to be optimistic about NHS patient safety culture development. This aids staff morale and helps to properly convey important patient messages – that the NHS is constructively moving forward in patient safety culture development, that the future looks more promising and that we have evidence to support this view.
On reading the Patient Safety Commissioner's report (2023), I personally do not see the possibility of an NHS patient safety drift back to the problems highlighted in the Mid Staffordshire report (Francis, 2013). The stark messages coming from that report seem to me to have secured a firm place in the NHS patient safety psyche from my reading of key literature.
Government response to the East Kent report
In terms of optimism building, the Government response (Department of Health and Social Care (DHSC), 2023) to the harrowing East Kent maternity crises report (Kirkup, 2022) shows some good actions being taken in response to the incidents. Several recommendations are made, including:
‘Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning.’
DHSC, 2023: recommendation 2
The DHSC will co-ordinate activity to understand how compassionate care is currently being taught, share good practice, identify gaps, and support sustainable change in the area. The DHSC document is a wide-ranging response that will have an impact beyond maternity care (DHSC, 2023). This response provides room for optimism in that acute patient safety problems are being addressed. However, the stark and unforgivable nature of the events that took place in East Kent and at Shrewsbury and Telford (Ockenden, 2022) must never be forgotten. We must learn the lessons.
NHS England response framework
Another cause for optimism is the Patient Safety Incident Response Framework (PSIRF) (NHS England, 2022). There are several documents connected with the PSIRF found at https://www.england.nhs.uk/publication/patient-safety-incident-response-framework-and-supporting-guidance/
The framework has key steps to address key patient safety issues. NHS England (2022) stated that the PSIRF approach:
- Advocates a co-ordinated and data-driven approach to patient safety incident response that prioritises compassionate engagement with those affected
- Embeds the patient safety incident response within a wider system of improvement
- Prompts a significant cultural shift towards systematic patient safety management.
National Patient Safety Strategy progress
Another cause for patient safety optimism is the progress being made with delivering the NHS Patient Safety Strategy (NHS England/NHS Improvement, 2019; NHS England, 2023). NHS England stated:
‘Emerging evidence shows that the NHS patient safety strategy is making progress towards the impact we anticipated in 2019: saving an additional 1000 lives and £100 million per year. Latest figures from June 2023 indicate we are halfway to achieving that aim. Much progress is being made across the strategy's main programmes of work.’
NHS England, 2023
Is only measured optimism possible?
In discussing the need to show some optimism when discussing NHS patient safety policy and practice development, we also need to locate the discussion within the existing NHS patient safety environment. We need to be realistic and to also acknowledge that there are major endemic patient safety issues that need to be addressed in the NHS. These have been discussed in several reports.
History shows that, while the NHS is no sloth when it comes to developing well-crafted patient safety policies and initiatives, terrible patient safety crises continue to occur with alarming regularity.
We cannot ignore the fact that the NHS does seem bad at properly learning the lessons from past patient safety adverse healthcare events and avoidable patient injuries and even deaths continue to occur.
This means that we need to qualify our optimism with some degree of caution, demonstrating what can be termed ‘measured optimism’. We need to be aware of adverse patient safety trends so that staff can be prepared for them and are not too disappointed if things do not work out as planned. This will be a delicate and difficult balance to draw and is probably much easier said than done in practice.
Developing an NHS patient safety culture is never going to be an easy task, given the large size of the NHS, resource constraints, workforce issues, and the volume of work it undertakes. The NHS faces an infinite demand for finite healthcare resources and budgets need to be maintained. There are many NHS structural and complex issues that feed into the patient safety debate. However, that said, patients' rights and safe healthcare delivery should never be compromised.
Conclusion
There is, in my view, a perceived need to be more upbeat and optimistic about NHS patient safety policies and progress. It is good to see some green shoots of recovery. There are grounds for saying that there are good, promising patient safety policies and practices already in place or about to be put in place.
Optimism enables staff to look more positively towards the future and this should be encouraged. It enables staff to become more open to learning and to see the benefit of the patient safety steps that they are taking. They can recognise that it is all making a difference and is not a waste of time and resources. It is important that complacency and tolerance of poor practices does not set in. However, at the same time, it must be recognised that there are major obstacles to NHS patient safety policy development and practice and that any optimism must be measured to some degree.