There is a famous quote attributed a former Prime Minister, Harold Wilson, that ‘a week is a long time in politics'. A lot can happen in a week politically and the same can be said about patient safety in the NHS. Recently the media spotlight has turned yet again on some poor NHS care practices in maternity care, following the publication of the Care Quality Commission's (CQC) survey findings. Another development has been publication of the national NHS patient safety syllabus. Before discussing these, it is important to provide some context.
The cyclical nature of NHS patient safety publications and events
I have said before in my BJN column that the NHS is no sloth when it comes to developing patient safety initiatives, policies and reports. The problem is that these so often seem to falter at the implementation stage, largely at trust level, and some get parked or even forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some progress has been made, but not enough when the history of NHS policymaking in the area is analysed.
There also appears to be a cyclical patient safety publication report trend. When one report is published another frequently seems to follow addressing the same or similar issues, reaching the same or similar conclusions.
The cycle continues with unlearnt lessons from previous patient safety event crises, which seem to repeat themselves with the same attendant issues. The NHS does so often seem to be running to stand still with its efforts to develop an ingrained NHS patient safety culture that puts the patient first.
Patient safety: a global industry
To add to this eclectic mix of issues, there is a myriad of organisations nationally and globally, each with their own patient safety policies, reports and agendas. Patient safety is now a big national and global service industry. This is all to be welcomed because it enriches the patient safety research culture and provides useful tools. This continuous tide and flow of information, however, makes it difficult for NHS staff to keep up-to-date and to prioritise information. A point well made by the CQC (2018:6) in Opening the door to change:
‘Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and greater clarity around the roles of the various organisations ….’
The CQC also drew attention to the complex and confusing nature of the NHS patient safety regulatory landscape with arm's-length bodies, the CQC, royal colleges and professional regulators all playing important roles:
‘… the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what. This makes it difficult for trusts to prioritise.’
Recent crises events
Maternity care patient safety failings
Lintern (2020) in the Independent newspaper reports that the paper has learnt of dozens of deaths at East Kent Hospitals, with more than 130 babies over a 4-year period suffering brain damage as a result of being starved of oxygen during birth.
This maternity crisis follows another investigated in Shrewsbury and Telford, with BBC (2019) headlining it: ‘Shrewsbury and Telford Hospital: Babies and mums died ‘amid toxic culture’.
The events chronicled by Kirkup (2015) in the Morecambe Bay maternity care inquiry report are still with us in some form. The extent to which patient safety lessons have been learnt from past patient safety maternity care reports and investigations is questionable. Also raised by all these recent events is the extent to which there may be more crises in maternity care waiting to be discovered. Hopefully, East Kent Hospitals and Shrewsbury and Telford are not the tip of a developing NHS maternity crises iceberg.
Recent reports
Women's experiences of maternity care
In a largely positive report, the CQC (2020) presents the findings of a national survey of women's experiences of maternity care. Overall, women reported many positive experiences of care in 2019. The survey received responses from 17 151 women who gave birth in January–February 2019, a response rate of 37%. Positive results were found in relation to interaction with staff. In their antenatal check-ups, most women (83%) said midwives ‘always’ listened to them. A positive result was also found in postnatal care:
‘Women's experience … continues to be positive, particularly during labour and birth. In 2019, 88% felt that they were given appropriate advice at the start of labour, compared to 86% last year. Most women (84%) also … felt their concerns were taken seriously when raised during labour and birth.’
The report notes a trend of improvement in the proportion of women saying they ‘definitely’ had confidence and trust in the staff caring for them. There was also an upward trend of women saying that, while in hospital after the birth, they were ‘always’ treated with kindness and understanding. The report identifies several areas for improvement: seeing the same midwife, continuity of care, perinatal mental health, availability of staff and antenatal classes. In terms of staff availability:
‘Less than two thirds (62%) of women said they were always able to get a member of staff to help them when they needed attention in hospital after the birth. Eighty-one percent reported that they were always able to get help from a member of staff when they needed it during labour, or that a member of staff was with them all the time.’
Overall, the CQC (2020) presents positive results of women's experiences of maternity care with several care challenges identified.
Worryingly, we continue to see concerning maternity patient safety issues being revealed in some trusts that require urgent investigation.
‘Some women claim that they are being denied epidurals because of what the Sunday Telegraph says is “a cult of natural childbirth” … Several claimed they were told they were either insufficiently dilated or too far dilated to have an epidural.’
National patient safety syllabus
A fundamental prerequisite to developing an ingrained patient safety culture in the NHS is to provide education and training to all staff. A national patient safety syllabus was heralded in the NHS Patient Safety Strategy (NHS England, NHS Improvement, 2019) and the first iteration of this has recently been published (Academy of Medical Royal Colleges (AOMRC), 2020). Described as the first NHS-wide patient safety syllabus that it is applicable to all staff, it provides a common language and patient safety framework: incident reporting and investigation is included, along with content such as creating a safety culture, human factors and proactive risk management: The syllabus contains a number of domains, the outcomes for these and underpinning knowledge, expertise required for each stage. The domains are:
Dangers
There are, however, always dangers with a systems approach to patient safety because it can work to deflect or obscure the personal, professional accountability of NHS staff for error. Yes, we want to guard against developing a blame culture that promotes fear and leads to a lack of reporting incidents and defensive practices. At the same time, we need to promote the fact that nurses and doctors also owe patients individual, professional and legal duties they cannot detract from. If they do, they risk legal action and formal complaints. I fear a lot of patient safety policy development in recent years has been focused more on systems theories and less on the professional and legal accountability of NHS staff.
The use of case studies
In implementing the new national patient safety syllabus, educators and trainers will hopefully not forget about the professional legal and professional accountabilities of healthcare staff. Some learning outcomes address the importance of case studies.
Domain 1, Systems approach to patient safety, ‘Applies lessons from key case studies in patient safety’ (AOMRC, 2020:13). Domain 5, Being sure about safety, ‘Uses case studies from health care and other industries to ensure a continuing focus on safety management (AOMRC, 2020:25).
A wealth of case studies from the Parliamentary Health Service Ombudsman and the CQC and NHS Resolution can be used in teaching the syllabus. They can also be used to highlight the legal and ethical patient safety interface. Materials from the charity for patient safety and justice, Action against Medical Accidents (2020) should also be used.
Two sides to every story
It should not be forgotten that there are two sides to every story, and it is important to access a broad range of case studies. Law firms that act for patients suing for clinical negligence and those defending NHS trusts are also useful sources of patient safety educational, training material. These firms often have blogs addressing current medicolegal issues, and many have case studies on their websites.
The safety syllabus (AOMRC, 2020) is to be welcomed: it has a lot of potential to galvanise NHS staff action and learning. It is clear that a lot of effort has gone into creating the syllabus—a good first step has been taken with this draft publication. A key issue will be how well various sections of the NHS respond to, resource and teach the syllabus. In a cash-strapped NHS the syllabus will hopefully be seen by trusts as a priority spend and not be forgotten about or parked.
Conclusion
Patient safety crises events continue to rock the NHS on a regular basis and, because of this, we need to guard against public and health carer complacency. The public and the NHS should not accept that these types of events are normal and become desensitised. The spate of recent maternity care crises is worrying.
On the positive side, it is good to see the CQC report findings on maternity care and it is to be welcomed along with the new NHS national patient safety syllabus, which has excellent potential to help develop a proper patient safety culture in the NHS.