Patient safety has become an important global and national service industry with many stakeholders all keen to advance sometimes competing agendas. This is to be encouraged as it keeps the subject alive and vibrant. The downside of all this patient safety activity is that healthcare staff and leadership are faced with tsunami levels of policies and reports to digest, and must work out which are the most appropriate to apply. This creates particular problems in a resource-constrained environment such as the NHS, where busy staff are inundated with such reports and policies on a frequent basis – as highlighted by the Care Quality Commission (CQC) in 2018, when it was already an established problem. In an NHS context, we also need to add to the problem mix the complex, fragmentary nature of the healthcare regulatory and governance framework environment that hosts patient safety work.
Patient safety stakeholders can be of an infinite variety, ranging from regulatory government departments, their arm's length agencies that carry on aspects of their work, professional bodies, international non-governmental organisations (NGOs) university research groups and so on.
Many of the NHS heath regulatory and governance organisations have overlapping and competing functions when it comes to patient safety and health quality. It can then sometimes become difficult for patients, NHS staff and leadership to work out which stakeholder has final responsibility and the priority afforded to the report or policy (CQC, 2018).
Frequency of patient safety publications, overlapping health regulatory and governance functions, similar remits, competing agendas – all must impede the development of a proper NHS patient safety culture.
Expert panel evaluation of progress
An independent expert panel commissioned by the House of Commons Health and Social Care Committee (HSCC) has issued the report of its findings on the Government's progress on meeting patient safety recommendations and found that this requires improvement (HSCC, 2024). An analysis of some of the written evidence submitted to the panel provides valuable insights on the issues discussed above. The submissions make important contributions to the patient safety research literature and deserve wide dissemination. Several have been selected here for discussion. Some were briefly highlighted in my previous column (Tingle, 2024)
Patient Safety Commissioner's evidence
Henrietta Hughes, the Patient Safety Commissioner (PSC) (2024), provides a thought-provoking, reflective account of her role, activities, priorities and of what needs to happen in order to improve patient safety matters in the NHS. She makes the point early on in her evidence that organisations and officeholders with the power to make recommendations must do better to make them effective and impactful. She discusses the efforts of Rosie Benneyworth, Interim CEO of the Health Services Safety Investigations Body (HSSIB) to rationalise the making and follow up of recommendations made by such bodies as the regulators, ombudsman, and others. The PSC states that this work will start by agreeing key principles and will report into NHS England's National Quality Board.
In terms of her strategy priorities, the PSC includes an overhaul of the complaints and clinical negligence compensation processes with a focus on the promotion of restorative practices. There is also a discussion of the NHS culture, which she states inhibits the patient voice and makes positive change harder to implement:
‘This often means that energy is focussed on the consequences of harm, with the defensive, dismissive approach that has featured in so many recent reviews.’
PSC, 2024: paragraph 34
The PSC states that, in many places in the NHS, patient harm is seen as inevitable. The healthcare system can and should do more to instil a culture of safety, she argues. The PSC also discusses, along with other matters, the importance of good leadership for patient safety processes.
Professional Standards Authority view: a complex landscape
The Professional Standards Authority (PSA) (2024) addresses the issues raised by the expert panel in its evidence and also provides some valuable insights more generally on NHS patient safety culture development and what needs to happen to improve matters. A detailed discussion of this can be found in an earlier report (PSA, 2022), which the PSA refers back to in its evidence.
The PSA (2024) notes once again the complex nature of the NHS health regulatory and governance framework. It talks about the health and social care safety system being made up of ‘a complex jigsaw’ of institutions:
‘Each has a specific remit, and no single body is tasked with ensuring that together they create an effective safety system that protects patients and service users.’
There is a reference to an earlier proposal of creating a Health and Social Care Commissioner or equivalent for each UK country (PSA, 2022). This would be to identify, monitor, report and advise on ways of addressing patient and service user risks. The PSA (2024) argues that the current PSC role could be broadened to take on a wider oversight and co-ordinating role than at present – the current role has certain statutory restrictions – and that there is a need to rationalise the complex NHS regulatory and governance structure:
‘An expansion of the Patient Safety Commissioner role should be considered in parallel with expanding or rationalising the roles and remits of different bodies to close the gaps and ensure a safety system that works as a coherent whole.’
Expansion and rationalisation
The proposal to expand the remit of the PSC is an interesting one but I wonder whether it would cause more problems than it would solve. It could add more overlap and complexity to an already fragmented, disjointed health regulatory and governance system. We already have several NHS and other bodies with patient safety remits – the Health Services Safety Investigations Body (HSSIB), NHS Resolution, NHS England, the Parliamentary Health Service Ombudsman, CQC and so on.
We do, however, need to take steps to simplify matters and advance the development of a proper NHS patient safety culture, but this is much easier said than done. All NHS patient safety stakeholders will have agendas and well-established functions. Rationalisation would mean that some organisations would lose current patient safety functions – remits that they most probably would not be happy to lose. There would be no doubt concerted efforts made to resist any rationalisation efforts. Organisations will have invested significant resources and staff time in their patient safety functions, such as education and training, and also will have significant expertise in this area. Rationalisation of the NHS patient safety system will not be an easy task.
HSSIB evidence
The submission from the HSSIB (2023) is a detailed one at 12 pages in length. It provides an excellent discussion of the questions raised specifically by the expert panel and also about patient safety more generally. This information deserves a wide dissemination as it contains a lot of valuable information that I have not seen published elsewhere. I did cover some of the HSSIB response in my previous column. Investigations by HSSIB and its predecessor, the Healthcare Safety Investigation Branch (HSIB) have identified that patient safety policies, their implementation and regulation are highly fragmented. There is often overlap, and conflict with multiple guidelines existing for similar conditions. HSSIB (2023) also notes the piecemeal nature of the current NHS patient safety system:
‘The current patient safety system has developed over time, often piecemeal, in response to individual safety incidents. As a result, it is overcomplicated, and this potentially leads to fragmentation of the management of safety across the health and care system and reducing impact of any learning and the potential for improvement. This is felt particularly where recommendations are made to improve safety across the system.’
HSSIB, 2023: paragraph 39
When responsibility for risk is unclear
This echoes comments made by other stakeholders who have submitted evidence over the years. It is also stated in HSSIB (2023) that both the HSIB and HSSIB have encountered numerous occasions where it has been challenging for them to identify which organisation is responsible for taking specific action within the healthcare system to improve safety. They have encountered gaps in the system where safety risks appear to fall between organisations, and it is not clear where ownership and final responsibility lies.
HSSIB (2023) points out that professional and academic work has shown that there are more than 120 organisations with either regulatory or quasi-regulatory responsibilities. The submission contains a great deal of valuable commentary about key NHS patient safety issues and the movement towards developing a proper culture.
Conclusion
Valuable expert commentary on several key NHS patient safety matters is given in the evidence submitted to the expert panel with common themes emerging. The complexity and fragmentation of the NHS health regulatory and governance framework is a central theme. There are organisations with key NHS patient safety responsibilities that overlap with others, creating a confusing landscape. Patient safety risks can fall between the cracks with no organisation being immediately apparent in terms of the ownership and responsibility for dealing with the risk.
We have also seen that the NHS patient safety environment is a highly active one in terms of frequency of publication of policies and that these can conflict. NHS staff and others face an ever-increasing tide of these. It can be confusing for them to know which to give priority to. There are persuasive clarion calls made for rationalisation and simplification, and changes in the evidence submitted to the expert panel. To achieve this will be no easy task. Complexity of task, however, should not be a disincentive to take action. There is an urgent need to do this in order to achieve a proper NHS patient safety culture.