In analysing complex problems and situations, often a simple solution can turn out to be the best one. It is possible to overcomplicate our approach and to neglect the obvious. It is increasingly difficult for NHS staff to keep up to date with the amount of patient safety information produced and to distil, analyse and if appropriate incorporate into policies and practice at the workface.
All this adds up to what can be regarded as a perfect storm of patient safety information overload for NHS staff and others, presenting the question: how can we effectively navigate through all this information and select what is relevant to us? Not surprisingly, there are no easy answers, which has been flagged before:
‘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 that send these messages.’
Care Quality Commission (CQC), 2018: 6
Add to this the compounding problem of a complex, fragmented, overlapping NHS health regulatory structure within which we need to fit in patient safety policies and practices (Cumberlege, 2020). It would seem easy to overlook the patient safety basics as we explore the more nuanced and complex patient safety policy reports and papers. They all make important contributions to the patient safety culture development debate – there are various levels of debate and analysis from which to view any subject. However, we have seen in several reports of patient safety crises investigations over the years the repeated problems of basic failures such as poor leadership, poor teamworking, poor communication, poor documentation, lack of empathy towards patients and so on.
These basic aspects of patient safety need to be regularly re-stated and researched because of their frequency of recurrence.
Poor communication in the NHS
We know what the prime patient safety problems are, but the NHS seems in some quarters to be patently incapable of learning the lessons from past crises and of adapting practices. Poor communication is one of those common, basic patient safety problems that continue to plague the NHS.
Brunton-Douglas et al (2023) have recently published an excellent report on communication in the NHS. They discuss issues across several broad and narrow spectrums in the NHS and argue for improvements with some suggested reforms. The report is based on a project by Engage Britain (now part of Demos) involving engagement with just under 2000 members of the public, patients and staff asking about their NHS experiences. The report states that this work exposed poor NHS communication as one of the public's greatest concerns and the cause of growing dissatisfaction with the NHS. Poor NHS communication, say the authors, appears in three main ways. First, navigating and accessing the health system itself can be difficult. It can be unclear at various points in the system who best to contact and what contact or communication to expect. Second, administrative errors can create inaccurate, erroneous communications. This leads to problems with patient care, treatment, and experience. Third, communication issues can impact on patients when their medical history cannot be accessed properly. Healthcare staff don't know or understand enough about the patient's medical history.
‘Over and over again we heard stories from patients and staff of critical appointments missed, diagnoses not shared or shared too late, and referrals for treatment that simply went missing. This can lead to harmful delays in care or treatment, it can detrimentally affect patients' mental health, and can cause unnecessary disruption to the health system.’
Brunton-Douglas et al, 2023: 8
Considering the political agenda
Brunton-Douglas et al argue that improving communication between the NHS and its patients and also between NHS staff is, ‘nowhere on the political agenda’ and is not an NHS priority because of this. It is not given sufficient weight by politicians or NHS leaders:
‘There is currently very little electoral gain in addressing poor communication as an issue because it lacks the resonance, visibility and headline grabbing quality of issues like ambulance response times or A&E waiting times. That is despite the fact that poor communication links to – and in some case underwrites – all of these in ways that are increasingly well understood.’
Brunton-Douglas et al, 2023: 31
This issue of NHS communication, the political agenda and NHS leadership is a complex one. There is clearly a distinction to be made between implied and expressed awareness of the seriousness of the NHS communication issue.
Government and NHS leadership support for improvement in NHS communication can be viewed from the perspective of the NHS patient safety culture development debate. This is more of an implied perspective on the issue. From here, political and NHS leadership support for NHS communication practice improvement is visible and, in my view, sustained. Although the focus is on patient safety, NHS communication can be seen as an integral part of the discussion.
Past patient safety crises – including the most recent in Shrewsbury and Telford, East Kent, and Nottingham – have all hit the national headlines. When looking at media coverage of these and other crises and the responses to them, they appear to have concentrated some political and NHS leadership minds in terms of patient safety improvement strategies and next steps. Improvement in NHS communication can be seen as a key component of change in this area. We can add to this the NHS Patient Safety Strategy (NHS England/NHS Improvement, 2019) and the projects underpinning this such as the national patient safety syllabus and associated training programmes (https://www.e-lfh.org.uk/programmes/patient-safety-syllabus-training/). Taken together this shows, in my view, firm Government and NHS leadership commitment to patient safety improvement. An intrinsic part of which is the importance of good NHS communication strategies.
The work of regulators and stakeholders such as NHS Resolution, the CQC, the Health Services Safety Investigations Body (HSSIB), Patient Safety Commissioner, and the Parliamentary and Health Service Ombudsman, to name but a few, compounds this point, showing through their engagement and published reports support for improvement in NHS communication processes. This adds up to a clear, positive trajectory for NHS communication practice improvement and change with evident political and NHS leadership support.
Limits to what a Government and NHS leaders can do
It must also be recognised that there are, inevitably, limits as to what Government and NHS leaders can do to improve NHS communication processes. NHS culture change cannot be mandated overnight, change is gradual and necessarily incremental.
NHS trusts are also at differing levels of maturity when it comes to the exercise of good patient safety policies and practice, which will include communication practices. There cannot be a ‘one size fits all’ approach to communication improvement strategies.
Brunton-Douglas et al (2023) make excellent points on the need to increase the sense of priority afforded to NHS communication by politicians and healthcare leaders and they support this with evidence. We do need to explicitly raise this issue more and it cannot be always viewed through the broader lens of being a component part of the patient safety debate.
The more we focus on improving NHS communication, the safer NHS care will be. Poor communication underpins many complaints and cases of clinical negligence – when they are analysed there is often a direct correlation. Three possible ways to alleviate the worst impacts of poor communication are given by Brunton-Douglas et al (2023):
- Expanding the system of care co-ordinators
- Expanding the system of care navigators
- Improving uptake and use of the NHS App.
This report is a detailed one and raises key findings from the underpinning research. There are useful facts and figures from the results of public polling of issues and the discussions held for the report also reveal key insights.
Good communication with patients waiting for care
NHS England (2023a) has recently published a guide to good patient communication with patients who are waiting for planned care or treatment. There are eight core principles, set out in an at-a-glance sheet (NHS England, 2023b) and discussed further in the full guide.
- Personalised
- Reasonable adjustments
- Clear language
- Shared decision-making
- Contact point for patients
- Managing appointments, delays, and cancellations
- Interim information and services
- Communication methods.
A key action for the principle of ‘personalised’ is given as:
‘All communications should give clear steps for the patient's care, including likely and honest timescales, and what they can expect to happen and when. This will enable the patient to have an informed discussion about their treatment.’
This is all well-structured, clear advice on NHS communication, which will work towards developing good communication practices with patients and enhancing patient safety.
Conclusion
To improve patient safety in the NHS and to move more positively towards the development of a proper culture, we should not neglect the basics when we discuss and research issues. It is always good to devote time to research basic issues such as communication practices, leadership, teamworking, documentation, demonstrating empathy towards patients and so on.
We also have to accept that in an area as critical as patient health and safety there will always be an increasing flow of key information contained in research, reports and publications. This is an inevitable fact of daily life in any health service. Health care is complicated and there are a myriad of issues surrounding the subject.
Brunton-Douglas et al (2023) have shown the value of a deep dive into a basic patient safety problem in the NHS, that of poor communication and the impact it can have, and the steps to remedy it. NHS England (2023a; 2023b) has provided valuable principles and steps to deliver good communication with patients who are waiting for care.