As the adage goes, to know where you are going, you need to know where you have been. This is true of any professional endeavour. A period of appraisal and reflection is periodically needed on past efforts and events to assess progress. A reset, or recalibration, may be called for, either because there has been failure or, conversely, because everything is tracking towards expectations.
The key point in developing any policy is to be forward thinking and not to be rooted in the past. I have said this in previous columns, and it is worth repeating again, because it is particularly relevant to the efforts of the NHS in developing a patient safety culture: too much of a backward-looking perspective can hamper the development of a safety culture, and there are concerns that such a focus is hampering the NHS to deal with patient safety issues. Such sentiments were recently expressed by the patient safety commissioner, Dr Henrietta Hughes. In her First 100 Days Report, she stated:
‘In health we focus too much on the consequences, looking backwards at what has gone wrong. We need leaders to stop harm in advance, identifying and managing the causes and the controls.’
Danger of information overload
It is hard to be proactive and forward looking while we are still trying to fan out the flames on the latest patient safety crises. There is also the danger that patient safety policy and practice development fatigue and overload will set in. Messages can get lost and staff can switch off, becoming desensitised, due to information overload and message repetition.
A lot of patient safety and health quality material has been produced over the years, with the volume showing no sign of abating. A significant amount of this material is repetitive because the same patient safety problems often arise, with lessons seemingly going unlearnt.
The Care Quality Commission (CQC) has highlighted previously that NHS staff work in a confusing health governance regulatory landscape:
‘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.’
Proliferation of reports
Whenever new reports on patient safety and health quality are published it is important to bear in mind that the NHS is awash with these, and that they have been a continuous feature of NHS care for several years, going back to at least 2000 (Department of Health (DH), 2000; Sirrs, 2023). The danger of staff enduring information overload, fatigue and switching off due to the frequency and repetition of reports should not be overlooked.
Pause, reflect, rewind and reset?
Bearing in mind the above caveats, two recent analyses of NHS patient safety offer valuable, so-called ‘helicopter overviews’ (Patient Safety Learning, 2022; Martin et al, 2023).
The authors look back at what has happened in NHS patient safety since the Francis report (2013) – gaps, problems, successes – and what must happen in future to put things right. These retrospective reports are particularly valuable, providing excellent and thoughtful staging posts from which to view NHS patient safety matters.
After Francis
Martin et al (2023) note that it is 10 years since the publication of the Francis report (2013) into care failings at Mid Staffordshire NHS Foundation Trust, which gave harrowing accounts of care standards and made major recommendations for patient safety system improvements at several levels.
The authors ask whether, a decade on, the NHS is safer and more open. Have lessons been learnt and sustainable changes made? I would ask, more broadly: have we made significant progress towards developing an NHS patient safety culture after Francis? The answer to that questions is that it is hard to tell. The authors state that evaluation of the policy changes resulting from Francis (2013) are rare and it is difficult to assess progress. Policy responses to Francis included, the statutory duty of candour, ‘freedom to speak up’, guardians and a revamped CQC inspection regime, which continues today. There is also the Healthcare Safety Investigation Branch formed in 2017 to support patient safety improvements through independent scrutiny.
Martin et al (2023) point to some evidence of aggregate improvement across the healthcare system as a whole, but this cannot be specifically linked to policy responses to Francis. One positive observation is that NHS staff seem more confident in raising concerns. But not all the signs are good. The report states that changes to the CQC approach do not seem to have affected organisational improvement. Negatives include NHS staff indicating that there are problems surrounding openness when reporting safety concerns and being treated fairly. Many staff also raise concerns about their organisation's responses to safety issues.
Some of these concerns are repeated in the latest NHS Staff Survey (2023:58), with regard to reporting errors, near misses and incidents:
- 58.1% of staff said their organisation treats staff involved in an error, near miss or other incident fairly
- 86.1% said their organisation encourages staff to report errors, near misses or incidents. More than eight out of 10 staff in all types of trust agreed that reporting is encouraged
- 67.3% said that when errors, near misses or incidents are reported their organisation takes action to ensure they do not happen again.
These figures need to improve and, 10 years after Francis, it is disappointing that only 58.1% of staff say their organisation treats those who have been involved in errors etc fairly.
Major patient safety crises still occur
I share Martin et al's (2023) view that:
‘Among the most disheartening features of the post-Francis NHS are recurrent organisational catastrophes.’
These crises can include, but are not limited to, those reported in the review of maternity services at Shrewsbury and Telford Hospital NHS Trust (Ockenden (2022) and in East Kent (Kirkup, 2022). CQC inspection reports continue to show significant patient safety failings in maternity care:
‘… ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (9 out of 139) now rated as inadequate and 32% (45 services) rated as requires improvement … the care in almost 2 out of every 5 maternity units is not good enough.’
Martin et al (2023) also discuss the disproportionate representation of vulnerable groups in patient safety disasters, which include maternity service users, infants and people with learning disabilities. The report discusses three overarching priorities for improvement: the need for organisations to start listening, to learn, and provide strong leadership.
Mind the implementation gap
The excellent, detailed report from Patient Safety Learning (2022) covers a variety of patient safety policy and practice issues. It focuses on ‘a patient safety implementation gap’ in the UK that results in the perpetuation of avoidable harm. There is, the report states, a gap between theory – what we know improves patient safety – and what is done in practice. The report highlights six policy areas where there is a shortfall:
- Public inquiries and reviews
- Healthcare Safety Investigation Branch reports
- Prevention of future deaths reports
- When patients and families take legal action
- Patient complaints
- Incident reports.
The report goes into detail on how changes could be made to improve matters, identifying four common underlying themes:
- Absence of a systemic and joined-up approach to safety
- Poor systems for sharing learning and follow-up action
- Lack of system oversight, monitoring and evaluation
- Unclear patient safety leadership.
The report makes six recommendations, including one on clinical negligence issues:
‘NHS England and NHS Improvement and NHS Resolution need to work together to improve the process for identifying the causal factors of unsafe care identified through litigation, ensuring this can be disseminated widely and acted on to improve patient safety.’
Patient Safety Learning 2022:4
Role of court cases in patient safety
The above is an interesting recommendation, which I have considered in past BJN columns, in terms of whether we can learn lessons from past litigation cases and make legitimate changes to how health care is delivered. It is also worth considering discussions that took place as part of the NHS Litigation Inquiry (House of Commons Health and Social Care Committee, 2022), as well as evidence submitted to the inquiry by the Bar Council (2021) and Hempsons Solicitors (2021).
A view could well be taken, considering all these sources, that past clinical negligence litigation cases should only be used to show broad, patterns and themes. Systemic, clinical changes should only take place after proper clinical research takes place. You should not change clinical practice without research just on the basis of one or more past clinical negligence cases (Hempsons Solicitors, 2021).
Clinical negligence litigation is not designed to bring about systemic NHS patient safety care improvement. There is no such thing as the clinical negligence system; we have the law of tort, applied to medical cases (Bar Council, 2021).
We can conclude from the above that we should not be asking lawyers and judges – through clinical negligence cases – to help improve our healthcare system. Litigation is not designed for that. The system is adversarial in nature, designed to find fault, attribute blame and award monetary compensation in the form of damages, if the case is proved.
The report by Patient Safety Learning (2022) illustrates that there are significant patient safety implementation gaps that urgently need to be addressed.
Conclusion
The two reports discussed here (Patient Safety Learning, 2022; Martin et al, 2023) show that 10 years after Francis (2013) there has been some improvement in NHS patient safety. This can be termed ‘measured improvement’, but this has been no big-bang trajectory. The arguments advanced in both reports need to be discussed more widely, and they provide an excellent basis for patient safety reform.