Every healthcare system should be able to demonstrate progress towards developing an ingrained patient safety culture. There are many research reports discussing the intrinsic link between universal health coverage, health quality and patient safety—you really can't have one without the other. The World Health Organization (WHO) et al (2018) put the issue neatly in perspective:
‘But universal health coverage should not be discussed and planned, let alone implemented, without a focus on quality … If countries can afford to provide any health care—and even the poorest can and should do so— they must provide care of good quality. The alternative—poor-quality care—is not only harmful but also wastes precious resources that can be invested in other important drivers of social and economic development …’
Towards an Ingrained Patient Safety Culture
Whether it is the NHS in England or in a developing or transitioning country, a patient safety culture and a focus on health quality are intrinsic, inseparable features. Common sense dictates that a patient safety culture is an essential prerequisite to the delivery of quality health services. Poor quality, unsafe healthcare services are a waste of any country's scarce resources. They also become a financial and emotional drain on the poorly treated individual patient and their family.
My columns have regularly tracked progress towards developing an NHS ingrained patient safety culture. Progress has been slow and patchy over the years, but I would argue that some good efforts have been and continue to be made towards achieving the aim. There is a national political and NHS policy imperative to develop a patient safety culture, which has been apparent for at least the past 20 years from successive governments. Patient safety messages, however, have yet to fully permeate down into the NHS. This is evident through investigation reports from the Care Quality Commission (CQC) and the all too frequent media reports that regularly appear on poor healthcare practices. The NHS is still subject to too many patient safety crises and the lessons of past adverse events still, alarmingly, go unlearnt in many places.
The NHS Patient Safety Strategy
The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019) laid down a road map for continuing to improve patient safety. This will be built on the foundations of a patient safety culture and system. The report gave three strategic aims, tied to three key watchwords:
The development of a national patient safety syllabus for the whole NHS and creating a network of patient safety specialists are two key measures. There are several others such as ensuring that an understanding of patient safety is embedded across regulatory bodies and that learning from litigation is enhanced.
Update on Strategy Progress
The merged organisations recently published an annual progress report for year one of the NHS patient safety strategy. Despite COVID-19 affecting the pace of strategy implementation there has been progress:
‘Increased flexibility; problem-solving at pace; and more collaborative team working in support of colleagues redeployed to the COVID-19 response and clinical services.’
Overall, a promising start has been made in implementing the strategy. The new patient safety measurement unit has been established, and links have been made with the wider NHS culture work in the NHS People Plan. Patient safety advice has been provided for development of the first local long-term plans and a safety culture 'toolkit’ is in development.
It also evaluates progress made against safety system objectives, such as publishing a definitive guide as to who does what in relation to patient safety. National arm's length bodies have been doing this work and a series of public and patient focus groups have been held to help define information needs and target audience. There has also been the development of the new patient safety curriculum and training, preparation for the introduction of patient safety specialists and commitment to patient safety partners.
The report is a detailed one and lays out the progress made against the objectives in a clear and transparent way. It can be seen from the report that there are pockets of good patient safety culture and system activity taking place within the context of the COVID-19 pandemic. The pandemic itself can also be seen to have had a positive effect on practices in some areas. The downside is that there is always a risk that the NHS could edge forward to becoming too risk tolerant as it tries to cope and adapt to challenging new circumstances brought on by the pandemic.
The Negative Eclipsing the Positive: Maternity Units
Unfortunately, when patient safety reports are published any positive messages can often be obscured by subsequent crises reported in the media. Lovett (2020), writing in the Independent, reported that MPs were told that some NHS maternity units are continuing to ‘conceal’ patient safety failings endangering the lives of women and their babies. Dr Bill Kirkup, who was the chair of the Morecambe Bay Inquiry (Kirkup, 2015) and Professor Ted Baker, chief inspector of hospitals at the CQC, were giving evidence to the Parliamentary Health and Social Care Committee. Kirkup was quoted as saying:
‘“There are some units that actively conceal what they're doing. When they get in sufficient trouble, their response is to stop communicating with the outside world and disguise the failings they've got” … “I think they do that with the intention that they can sort it out themselves before they have to tell anybody, but it's quite difficult to get past that barrier I think when units get into that slippery slope”.’
Baker was also quoted, saying that under the CQC's current ratings, 38% of maternity units in England require improvement for safety, which reflected the ‘cultural issues’ found in many services. The comments provide a very worrying real-time window on NHS patient safety. They point to a concerning prevalent negative culture that is incompatible with the ambitions, aims and objectives set out by NHS England and NHS Improvement (2019; 2020).
Duty of Candour
The CQC reported (CQC, 2020) its first prosecution of an NHS trust for failing to comply with Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, Duty of Candour.
‘The intention of this regulation is to ensure that providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment…’
University Hospitals Plymouth NHS Trust was fined £1600, a £120 victim surcharge and ordered to pay £10 845.43 court costs at Plymouth Magistrates Court on 23 September 2020. This was the first prosecution of its kind. The patient in the case suffered a perforated oesophagus following an unsuccessful endoscopy procedure. She was transferred to a ward for observation where she later collapsed and died. There was no prompt apology given, nor a full explanation given.
‘Following the operation, it was found that the trust had not communicated what had happened with the pensioner's family in an open and transparent way, nor had it apologised for what had happened to her in a timely way.’
The surgery took place in December 2017, so we are dealing with a relatively recent event and the duty of candour is not a new concept for trusts.
This case demonstrates once again that there are pockets of the NHS where urgent culture change is needed. The CQC prosecution can be regarded as a warning shot across the bows of trusts that they do need to take the duty of candour seriously. The charity for patient safety and justice, Action against Medical Accidents (AvMA), published a critique of CQC inspection reports and regulation of the duty of candour (Negri, 2018). This found that the CQC required improvements in the way it regulated the statutory duty of candour. Several recommendations for improvement were made including that the CQC should develop a more robust framework for inspections to assist with assessing compliance with the duty of candour. The report did note some positives:
‘Since 2015, there has been significant improvement not only in the inspection of the duty of candour but also, it would seem, in its application by NHS trusts. However, there are still problems with compliance.’
In order to have an ingrained patient safety culture in the NHS, the duty of candour under regulation 20 must be properly exercised and enforced.
Conclusion
The efforts to develop an NHS patient safety culture and patient safety system outlined in the NHS Patient Safety Strategy is promising as is the implementation progress being made. However, it should be remembered that the NHS and successive governments have a history of developing well-crafted, well-researched patient safety policies. We have all been down this road many times before. The NHS has been trying for a long time to develop a patient safety culture, with efforts going back at least 20 years. History has not served the NHS well when it comes to the practical application of policies and developing a patient safety culture. Major problems still stubbornly persist, as we can see.