The gold standard aims of all those concerned with patient safety policy and practice is to see the development of a proper NHS patient safety culture. There have been myriad calls for this over the years that continue to be made strongly today in policy documents, reports into care quality and in many other places. Calls are also frequently made in the media when patient safety crises are reported.
In this column I will be discussing a recent report and consultation call that address key NHS patient safety culture development issues. First, the expert report submitted by Professor Mary Dixon-Woods to the Thirlwall Inquiry, which has been set up to look at events at the Countess of Chester Hospital and implications following the trial and subsequent convictions of Lucy Letby (Dixon-Woods, 2024). Second, a joint consultation from Action against Medical Accidents (AvMA) and the Harmed Patients Alliance (HPA) on a ‘Harmed Patient Pathway’ (AvMA and HPA, 2024). These both cast an important light on the development of an NHS patient safety culture, raising critical issues and concerns.
What do we mean by ‘an NHS patient safety culture’?
We are knocking on an open door when it comes to the need to develop an NHS patient safety culture. Everybody who works in or is connected with the NHS, including patients, would agree that this must happen. Most patients probably already assume that we have a well-established, robust NHS patient safety culture. The million-dollar questions are what this culture should look like and whether what we have already is working properly.
Another key question that can be fairly raised is whether it is feasible to even talk about the development of a singular NHS patient safety culture. The NHS is one of the biggest organisations in the world with a vast workforce and range of activity. It is made up of many different professions along with non-clinical staff such as NHS managers. Is it more correct to say that any NHS patient safety culture must be by definition a composite one, consisting of other different cultures, which should all conform to certain norms of behaviour?
We need to take into account that health professions have different ways of doing things – their own traditions. We can see that in reports dealing with maternity care failings, such as the Morecambe Bay tragedy:
‘Many of the reactions of maternity unit staff at this stage were shaped by denial that there was a problem, their rejection of criticism of them that they felt was unjustified (and which, on occasion, turned to hostility) and a strong group mentality amongst midwives characterised as “the musketeers”.’
The Healthcare Safety Investigation Branch (HSIB) – now replaced by the Health Services Safety Investigations Body (HSSIB) – published a report on Never Events noting that professional groups had their own beliefs and practices (culture). This culture point was explored in some investigation reports, and it can have an adverse impact on patient safety:
‘4.5.5 Culture: Interview evidence suggested that it was accepted practice among teams for a surgeon to leave theatre before the end of a procedure. A scrub nurse said that in general there were occasions when those who were present for the procedure were not all present for the WHO sign out.’
References to professional hierarchies, cultures, silo thinking, and practices can be seen in many past patient safety investigation reports and in other reports, along with the adverse implications and consequences.
There can be risky and wrong professional cultures as highlighted above. It is, however, difficult to mandate one cultural approach. NHS trusts and other types of healthcare organisations will be at various stages of development, and forming an NHS patient safety culture is always going to be a fraught, fragile exercise. Dealing with differing professional cultures is just one problem that must be successfully negotiated.
Report to the Thirlwall Inquiry
Dixon-Woods (2024) presents an excellent and detailed discussion of several issues relating to NHS patient safety culture development, including the point above about diverse professional cultures existing. In section 2, selected key concepts are discussed such as voice, system, conduct issues, forgivability and normalisation. Section 3 is a deep dive into culture and the difficulties of defining such are discussed:
‘Despite its prominence, and its significance across so many sectors and industries, no single standard definition of “culture” exists, nor is there a single consensually agreed way of measuring or assessing it.’
The term ‘institutional secrecy’ is used to show how information and intelligence relevant to quality and safety can become obscured in the NHS. In section 3.3 there is a discussion of the influence of human sensemaking processes on detection of problems and warning signs:
‘The psychology behind cognitive biases and heuristics (rules of thumb) is increasingly well understood, though the science is also diverse, with many different definitions and approaches and much debate and dispute.’
Several other critical issues are discussed, such as the challenges of addressing quality and safety concerns – what ‘good’ looks like for culture in healthcare organisations. In section 4 there is a discussion of concepts of culture over time.
The report runs to 119 pages and difficult concepts are explained in a clear manner. The discussion is linked to academic commentary. The report is both practical and academic with lots of references to supporting literature. It is comprehensive and, in my view, a unique and most valuable account of patient safety in the NHS and should be read by all those concerned with health quality, regulation and governance. It should form essential reading for the NHS patient safety syllabus and on patient safety study days.
The report concludes by suggesting six recommendations for the inquiry to make in the light of its terms of reference (Dixon-Woods 2024: 101–102):
Harmed Patient Pathway
AvMA and HPA (2024) have published a joint consultation on a proposed pathway for patients who have come to harm. The closing date for responses is Monday 2 December 2024. The Harmed Patient Pathway (HPP) is a key document with the potential to better safeguard the interests of patients, their families and healthcare staff when avoidable patient harm has occurred. It will help them in the aftermath of the event and will avoid more harm being done (compounded harm) as matters proceed. The HPP is centred on securing compassionate engagement. The adversarial legal system and other related redress mechanisms in the NHS do take their toll; resolution systems are complex, and patients, their families and staff can get lost in and feel overwhelmed by them.
Knowledge gaps
AvMA and HPA (2024) state that we have a lot of detailed knowledge about the science of patient safety but know markedly less about looking after the patient and their family. This is where the HPP comes into focus. Compounded harm can be avoided, or at least minimised, if certain steps are taken. There is a need, for example, to avoid over-legalistic letters, poor, empty apologies and explanations, and poor communication practices. These will all make matters much worse for all concerned. The HPP is an excellent way forward to improve matters.
‘Suboptimal healing and recovery and/or avoidable compounded harm have become an almost inevitable consequence of the way the current system operates. Harmed patients and families routinely do not have their needs understood and met when truthful answers and explanations emerge only after prolonged adversarial processes involving constantly reliving what happened.’
As set out, the HPP is built around six key commitments and firm NHS trust commitment and engagement is needed to support them. They have been based on what harmed patients and their families have stated is needed (AvMA and HPA, 2024):
These commitments are discussed in moredetail in the consultation document. The HPP will prove an invaluable aid in strengthening the patient and family's position and interests when they have suffered from harm that should never have happened. The consultation also states that the commitments will also help staff better communicate with harmed people, more compassionately and openly.
Conclusion
Developing an NHS patient safety culture is never going to be an easy task given the size and complexity of the NHS. Culture change cannot be mandated overnight, and NHS trusts are at various stages of patient safety maturity. A one-size-fits-all approach will not work, the approach has to be much more nuanced. Dixon-Woods (2024) report clearly highlights the problems of NHS patient safety culture development and how it is a multifarious concept. It cannot be approached in the singular because of its multi-layered nature.
Dixon-Woods (2024), Kirkup (2015), and the HSIB (2021) are just some of those who have made the point that there are subcultures in the NHS to negotiate and the challenges that this brings. The report by Dixon-Woods (2024) discusses several other key patient safety-related issues, providing an excellent practical and academic backdrop to key issues.
The pathway from AvMA and HPA (2024) is to be welcomed as it has real potential to strengthen the harmed patient's position. The six key commitments are open for discussion and NHS staff and others are strongly encouraged to comment on these.