There are many buzzwords and acronyms in the debates and literature dealing with NHS patient safety and healthcare quality. The NHS is seemingly wedded to acronyms and buzzwords and they abound in the patient safety domain. A ‘buzzword’ can be defined as a flavour-of-the-month, transient type word describing a concept that can be seen to direct current policy until eventually it becomes less topical and fades away from general use. We have such terms as ‘clinical governance’ (Department of Health, 2000) or ‘patient empowerment’ (Local Government Association, 2021). We have had ‘controls assurance’ (Personnel Today, 2000) and ‘patient advocacy’ (Society and College of Radiographers, 2008). Some of these words do stick around longer than others. The public rarely seem to see discussion of these in the media that they will reasonably encounter, yet public understanding of them is fundamental as a basic principle of equality, transparency and justice.
Addressing emerging concepts
A key issue is how best to deal with this kind of concept. One buzzword that has been doing the rounds for some time now is ‘decolonisation’, which seems to pervade vast areas of academic and professional discourse. In terms of our research interests the decolonisation of patient safety seems to raise interesting questions and perspectives. However, we are also mindful of the extent to which we can relate the concept of ‘decolonisation’ to global and NHS patient safety developments, policies and practices without stretching established meanings of that term too far.
Problems of definition abound, and it may be that we can take the essentials of the concept and use other words that have generally accepted more open meanings, such as the need for areas of academic discourse and professional practice such as patient safety to regularly, reflect, declutter, reappraise and reset key areas of thinking and practice. These may be better words to use than decolonise when talking about certain aspects of NHS patient safety policy development and practice as they have less established meanings, but they also share conceptual similarities.
There is a moral and just need for patient safety policy makers nationally and globally to make deep dives into reflecting on what they do and how well they perform their functions in order to satisfy issues such as exclusivity, fairness, equality, diversity, transparency and accountability in patient safety policy development and application. If, for example, the patient safety policy making is found to be in the hands of a select few with exclusive and personal agendas, then that surely raises acute concerns, as outlined above.
In addressing these issues, we also need to fully reflect on the public's and patients' understanding of NHS patient safety and health quality publications and debate. We need to question whether all this is clouded in some form of NHS mystique. The fact that the NHS is a national public resource raises fundamental questions of openness, transparency, equality and exclusivity when access to NHS patient publications, research and literature is concerned.
Decolonisation
We can talk about the decolonisation of global health (Khan et al, 2021), or legal education (Socio-Legal Studies Association, 2021). We can talk about the decolonisation of almost any subject that we care to name. There are many competing definitions of the term with wide and narrow meanings. The University of Warwick has this helpful definition:
‘Decolonisation itself refers to the undoing of colonial rule over subordinate countries but has taken on a wider meaning as the “freeing of minds from colonial ideology” in particular by addressing the ingrained idea that to be colonised was to be inferior. Decolonisation then offers a powerful metaphor for those wanting to critique positions of power and dominant culture.’
Department of Education Studies, University of Warwick (DES), 2021
We would subscribe to the much wider definition where we are, among other matters, critiquing power and dominant culture.
What is important in discussing or trying to dissect any term is that the labels are not so important, it's the ideas behind them that matter. The label is a call to arms and is useful in instigating debate. This is the exercise of value—the discussion.
We can try to relate these concepts and ideas to patient safety and begin to unpack their impact. We can use the concepts as disrupters of established thinking and seek to establish new foundations of knowledge. We can use them to address the transparency, legitimacy and balance of research in the area. We can challenge established assumptions, the distribution of power, the accepted ideologies, look at the agendas of stakeholders, how representative they are and whom they serve.
By way of example, ‘systems theory’ appears as a dominant ideology in the patient safety field. It would be good to see other concepts considered equally robustly in patient safety policy-making discussions and practice. This may be more a question of ‘refresh, reappraise and reset’ rather than decolonisation.
We are not forcing a change in mindset, but just saying it is important to consider alternatives as well. Have patients a true voice in patient safety policy development, are all groups equally represented? Are some stakeholders too dominant (Mulumba et al, 2021)?
Power structures
Some initial thoughts on how we can use terms such as reflect, declutter, reappraise, reset and decolonise in relation to patient safety would include matters such as hierarchical NHS structures, control and command. Are some professional, ethnic or gender groups more powerful in terms of influence than others in hospitals and in policy making? We can see hierarchical management and staff culture issues as possibly contributing to Never Events:
‘The culture of professional groups was explored by some investigation reports, commenting on how different healthcare professions had their own beliefs and practices, some of which might have undermined safety…’
‘… Interview evidence suggested that it was accepted practice among teams for a surgeon to leave theatre before the end of a procedure.’
Healthcare Safety Investigation Branch, 2021:38–39
Bullying (uneven power relationships and abuse) features consistently in patient crises and Care Quality Commission (CQC) inspection reports. The need for a just culture also raises key issues. The NHS Just Culture Guide states:
‘This guide supports a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely. Action singling out an individual is rarely appropriate—most patient safety issues have deeper causes and require wider action.’
NHS England/NHS Improvement, 2021
Patient participation
How far do we cast our net in terms of patient participation and involvement in patient safety policy development and in investigations? Is this the preserve of a select few?
‘In general, we found that national bodies, for example CQC, the National Institute for Clinical Excellence (NICE) and NHS Improvement, were good at involving patients in developing guidance to make sure that it is robust and takes account of all relevant views. However, at a local level we did not see similar examples where patients were involved in improving patient safety processes in hospitals.’
Always the same people?
We also need to question who sits on government or arm's-length patient safety and health quality boards and advisory panels. Do the same people sit on these? This raises several issues including diversity, equality of opportunity, transparency and power relationships.
Where are patient safety regulators, arm's-length bodies and other government and global organisations getting their patient safety research and advice from? Is it the same or similar organisations? There are competitive tenders for advice and research but if the same organisations are winning bids all the time, then that raises issues of decolonisation. Yes, there must be competent advice and research, but if it is the same people advising all the time then where are the fresh perspectives coming from? Views become stale, organisations hear what they want to hear, and feathers are not ruffled.
‘When it comes to academic research decolonisation takes a number of forms, some mainstream, some more contentious. Decolonisers ask questions such as: How do assumptions about power affect what we select as problems for research; who pays for this research; and what purposes does the research serve? A critique of research practice might take on the neo liberal globalisation agenda in higher education, institutional reliance on private money and an over eagerness to put knowledge at the service of the highest bidder.’
A view could be taken that our underpinning patient safety systems framework is crafted too much on Eurocentric viewpoints. We can have much to learn from other systems of thought, knowledge and ethics.
These are just some possible patient safety issues that can be seen to engage some of the current buzzwords we have mentioned. When speaking about the term decolonisation we also need to reflect on whether the decolonisation movement needs decolonisation itself:
‘The attempt to incorporate the disruptive violent process of undoing colonization within colonial frameworks and matrices is itself an act of colonization as it ignores the inherent intent of decolonization and presents as an unwillingness or an inability to change. It is also emblematic of the ego-centrism and lack of self-introspection that often peppers well-intended decolonization actors and their actions.’
If all or a significant number of actions to decolonise take place within the structures that colonise then we are not moving that much more forward. A fresh, open, decluttered perspective is needed.