NHS patient safety culture development efforts over the years can be likened to a revolving door. As one patient safety report or policy is published and fades into obscurity, another one is quickly ushered in and takes its place – and so the process continues. As I have said frequently in my BJN columns, the NHS has been no sloth when it has come to publishing excellent patient safety reports and policies.
The sloth analogy best describes the slow progress of NHS patient safety policy implementation and uptake in the NHS. It is taking far too long.
Several patient safety crisis investigation reports over the years have shown serious lapses of care taking place, which has resulted, in some cases, in avoidable deaths and serious injuries. Patient safety lessons from these events seem to have gone patently unlearnt in some quarters of the NHS.
Two recently published reports from the charity Patient Safety Learning (2024) and the House of Commons Health and Social Care Committee (HCHSCC) Expert Panel (2024) highlight once again the chasm that exists between NHS patient safety policies and practice.
Patient Safety Learning report
Patient Safety Learning (2024) is a charity for improving patient safety that provides excellent resources to share learning. It has recently produced a report analysing the results of questions relating to patient safety in the NHS Staff Survey 2023 (NHS England, 2024). The report includes discussions of:
- Survey results: reporting of errors, near misses, patient safety incidents, concerns about clinical safety and speaking up
- Scandals and whistleblowers: further areas of concern
- The NHS Patient Safety Strategy (NHS England/NHS Improvement, 2019): safety culture activities in the NHS
- Implementation, monitoring, and evaluation: the need to move from theory to practice.
In the section discussing the reporting of errors, near misses and patient safety incidents, concern is expressed over several survey responses, including the following:
- 59.45% of staff said that their organisation treats staff who are involved in an error, near miss or incident fairly (question 19a) (compared to 58.17% in 2022) (NHS England, 2024).
Looking at it from the other side, Patient Safety Learning (2024) states:
‘It is a deeply concerning finding that over 40% of staff cannot say with confidence that their organisation treats them fairly if they are involved in an error, near miss or incident.’
Patient Safety Learning, 2024: 5
A positive finding is noted by Patient Safety Learning (2024) that:
- 86.33% of staff said their organisation encourages staff to report errors, near misses or incidents (question 19b in the NHS Staff Survey) (86.07% in 2022) (NHS England, 2024).
Patient Safety Learning (2024) also comments on staff responses to concerns about clinical safety and speaking up:
- 56.81% were confident that their organisation would address their concern (question 20b) (2022: 56.73%, 2021: 59.52%, 2020: 60.51%, 2019: 59.90%) (NHS England, 2024).
The report (Patient Safety Learning, 2024) expresses concern that the NHS staff response to this question is currently lower than when the NHS Patient Safety Strategy was launched: it was 59.90% in 2019.
The report goes on to consider the wider NHS context of patient safety, including such matters as past patient safety scandals, whistle-blowers, progress with the NHS Patient Safety Strategy, and so on.
Recommendations
Two recommendations are made. One concerns the effective and consistent advancement of safety culture guidance and best practice and the other concerns actions to address the discrepancies identified in responses on patient safety and speaking up, with a focus on ambulance trusts and the ethnic background of respondents.
The report is hard hitting and clearly illustrates the slow; being made in the NHS to develop a proper patient safety culture with timelines, responses to the NHS survey and other matters discussed.
Report conclusions
The conclusions drawn are well reasoned and will find support with many concerned with patient safety and health quality in the NHS. The report ends with the posing of several questions around patient safety culture development, challenges, and progress:
‘We know the scale of the challenge, but we don't fully understand why so little progress has been made in this area. Is it the sheer difficulty of making this change? Is it lack of national or local organisational commitment? Are there too many poor role models, incompetent managers or bullies who enable blame cultures to persist?’
Patient Safety Learning, 2024: 17
A palpable sense of frustration comes through the report, with NHS progress towards developing a proper patient safety culture and the inordinate amount of time that it is taking.
House of Commons Expert Panel report
The House of Commons Health and Social Care Committee (HCHSCC) Expert Panel has reported on the Government's progress on meeting patient safety recommendations and has found that this requires improvement. Sections in the report include:
- Maternity safety and leadership
- Training of staff in health and social care
- A culture of safety and whistleblowing.
The report takes a deep dive into several recommendations made in past patient safety crisis investigation reports. It concludes:
‘Overall, despite good performance in some areas, the evidence we received has led us to rate the Government's overall progress in the area of patient safety as “requires improvement”. Our rating partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer.’
HCHSCC Expert Panel, 2024: 15-16
The report is well researched, detailed, insightful, and instructive on NHS patient safety culture development progress.
Evidence submitted to the expert panel
It is always useful to read the written evidence submitted by NHS patient safety stakeholders and others referenced in the reports. The evidence submitted is often detailed, providing rich insights and perspectives. Written evidence submissions were made to the HCHSCC (2024) by several key patient safety stakeholders, with two selected here for discussion.
Evidence from the Health Services Safety Investigations Body
In this submission, the role of the Health Services Safety Investigations Body (HSSIB), formerly known as the Healthcare Safety Investigation Branch (HSIB) is discussed. Valuable insights into the work of the organisation are given, alongside perceptions of the current state of NHS patient safety.
HSSIB (2024) notes that evidence from national inquiries, as well as from NHS incident reports, suggest that the same patient safety problems are often repeated. The concept of individual blame attribution is discussed, as are the problems caused by this. There is also a discussion of what HSIB and HSSIB investigations have found in terms of trends and the following comment is made:
‘On an individual level, staff have often appeared more willing to speak with HSIB and HSSIB investigations owing to the protection offered by “safe space.”’
HSSIB (2024) states that, too often in investigations, HSIB/HSSIB has found that they have been the first people to talk to staff, patients and families about incidents that have occurred and to ask them to share their experiences. HSSIB (2024) also discusses the ‘highly fragmented’, nature of patient safety policies, their implementation and regulation:
‘Safety recommendations from separate bodies often overlap and conflict, multiple guidelines exist for similar conditions, and local policies and guidelines often do not account for or acknowledge the complexity of healthcare work.’
Evidence from Graham Martin, The Healthcare Improvement Studies Institute, University of Cambridge
Martin (2024) describes the work of The Healthcare Improvement Studies Institute and makes key observations on NHS patient safety progress over the years. There is also a discussion of empirical research relating to speaking up and safety and learning. This is an excellent analysis of NHS patient safety issues:
‘While there is some evidence that cultures of safety and learning in the NHS have improved over the last 10 years, there is also evidence that this progress is stagnating or even reversing. Progress is also unevenly distributed, illustrated not only by egregious examples of organisations that have failed to protect the safety of their patients, but also in persistent patterns of variation between organisations and between sectors (notably mental health).’
This quote sums up well the current state of NHS patient safety and amounts to a clarion call to accelerate efforts to make an NHS patient safety culture a reality rather than a well-meaning aspiration.
Cultures do not change overnight
It can be seen from these reports that there are no quick fixes when it comes to NHS patient safety culture development. Cultures do not change overnight, and it is very much an incremental, iterative developmental process. NHS trusts are at different levels of maturity when it comes to the implementation of patient safety policies and practices. There cannot be a one-size-fits-all approach. To get a fair, balanced picture of progress we also need to factor in financial resource restraints and the vast scale of the NHS care enterprise. However, none of this excuses poor care resulting in patient injury and death.
Conclusion
The inescapable conclusion remains, highlighted by the two reports discussed above, that NHS patient safety culture development efforts need to be accelerated and that progress historically and currently has been too sloth like, and so is taking too long. An urgent step up of pace is needed.
It is possible to discern a palpable sense of frustration in the reports. Both show that there have been unacceptable delays in NHS patient safety culture development.
The reports usefully highlight key trends and provides an evidence base on which we can draw assumptions to build further patient safety policies and actions. They shine a light on what needs to happen next in NHS patient safety culture development.