It is important to take time out to reflect on some of the fundamentals of NHS patient safety. This helps to scope out what needs to be done to develop a proper NHS patient safety culture.
We can consider some basic foundational issues of patient safety, the frequency and volume of publications and the problems this can cause. There needs to be a reflection on personal and professional duties of healthcare staff to keep informed of developments in their professional practice areas and where end responsibility lies.
There should also be some reflection on the organisations that generate patient safety information in the NHS and whether there are mixed messages being sent out. Is the messaging system too complex? Can matters be simplified? Do we need to alter the NHS patient safety landscape? Reflections on all these issues can help clarify issues in the NHS patient safety debate and inform agendas for change and assist towards culture development.
Patient safety as a discipline of study attracts a lot of discussion and attention, which results in the publication of a wealth of materials. This is inevitable given its topicality. We all need to access health services at some point in our lives and it is important that these are safe. At the same time, we must also accept that health care can never be totally error free. As human beings we all make mistakes. Nursing and medicine depend on complex human interactions and there can also be complex equipment and processes involved. The best that we can try to do is to properly manage risk. Patient safety reports and publications help us to manage the risk of error through professional updating. Reflecting on end responsibility, there is a professional and a legal duty to to keep up to date and there have been court cases on what this means. This, I feel, could be stressed more in patient safety reports and publications and in policies more generally.
A professional and legal duty to stay up to date
There is a need for nurses, doctors and others, I would argue, not to rely too much on the centre, NHS organisations and their employers to funnel patient safety information and developments to them. There needs to be much more professional ownership of patient safety updating.
All professionals have a duty to keep up to date and informed. It is a pre-requisite to being called a professional – someone with unique knowledge that others need. I would like to see a greater move towards each individual health professional taking personal ownership of the need to update, recognising their own personal role in and duty towards the development of a proper NHS patient safety culture.
A chronic patient safety problem continues to be the failure of some clinical staff in some quarters of the NHS to learn the lessons from past adverse healthcare events and to change practice. This can be seen in several national patient safety investigation reports.
It is also important to look at the individual health professional's legal responsibilities. I feel that this should also be stressed much more in patient safety policy-making reports and more generally.
There is a legal duty on nurses, doctors and others to keep up to date with significant changes in their clinical practice areas. There is a need to demonstrate a reasonable professional updating regimen. The adequacy of professional updating could well be an issue in a clinical negligence action. An allegation could be made in a clinical negligence case that the injury to a patient was caused, or materially contributed to, by the nurse or doctor not being aware of a significant development in their clinical practice area. This has been an issue in some clinical negligence cases. It is a complex issue to determine, with a lot of factors to be considered, and much will depend on the facts of each case.
‘Further, a doctor will not be expected to have read and digested research that has only just become available … It is arguable that the existence of the Internet, making research more readily available, will mean that doctors will be expected to be more up to date than they were in the past.’
It is a question of acting reasonably and achieving a reasonable balance. We need to try to balance our competing time commitments with staying current.
‘The reasonably skilful doctor has a duty to keep themselves informed of major developments in practice, but this duty obviously cannot extend to the requirement that they should know all there is to be known in a particular area of medicine.’
‘The practice of medicine has, however, become increasingly based on principles of scientific elucidation and report, which has been referred to as “evidence-based medicine”. As a result of such developments, the pressure on doctors to keep abreast of current developments is now considerable, rather than just relying on long clinical experience.’
Farrell and Dove, 2023:364-365
Information overload: too much noise?
I feel that we should address much more in patient safety policy development and reports the risk of information overload – the danger of overwhelming nursing, medical and other staff with a tidal wave of patient safety information. There is a considerable body of patient safety literature produced on a regular basis, and this itself can cause problems, particularly for those whose job it is to disseminate materials and to advise which can be accommodated in policies.
Too many guidelines and protocols issued by the many NHS bodies and professional regulators can work to confuse and inhibit the development of a patient safety culture:
‘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, 2018:6
I would argue that this should be generally recognised far more than it currently is. There is a need for much more joint action between health regulatory, governance and patient safety organisation; more joined-up thinking and collaboration on research and education/training provision. There is some positive evidence of this happening already, but more co-working is needed.
A valuable concept to incorporate into reflections on issues of NHS patient safety, particularly professional updating, is the concept of ‘noise’:
‘The “noise” created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement recommendations, concentrating on those which are addressed directly to the provider, or where there are immediate patient safety risks.’
Health Service Safety Investigations Body, 2024: 4
This is fair comment and captures key concerns about professional patient safety updating and says something about the complex nature of our health regulatory and governance system within which patient safety sits.
Reflecting on an overengineered system
Hopefully, this year there will be some attempt to rationalise the patient safety information flow, at least from the main NHS organisations that have patient safety and health quality remits. The Dash Review is due to be published soon, and it is helpful to consider its terms of reference:
‘The primary task of this review is to assess whether the current range and combination of organisations delivers effective leadership, listening, learning (including investigations and their recommendations) and regulation to the health and care systems in relation to patient and user safety (and to what extent they focus on the other domains of quality).’
Department of Health and Social Care, 2024
Any reflection must also involve consideration of the broad nature of the NHS patient safety landscape as a whole. We have what I would regard as an ‘over-engineered’ NHS patient safety system, as I have said in previous columns. It is too complex for both patients and staff. It is too fragmented, with overlapping functions such as organisational education and training remits. There is an urgent need for the rationalisation of NHS bodies with patient safety remits. This over-engineering has contributed, in my view, to the current problems that we have with the information ‘tidal wave’.
The Professional Standards Authority (2022) has considered some of the structural flaws in the safety framework. It highlights how the patient and service user safety landscape is fragmented and complex, with each body looking at the problems ‘principally through the lens of its own remit, often prejudging the nature of the solutions as a result’ (Professional Standards Authority, 2022:10)
I would agree, there is a danger of looking at patient safety issues just from the viewpoint of one NHS body or organisational remit and this can cause acute patient safety problems.
Organisational and policy drift
It is also important to reflect on what can be termed NHS patient safety organisational and policy drift. Our NHS health regulation and governance bodies and other patient safety policy developments have grown and developed largely by accretion over the years in response to the patient safety and care quality crises of the day. The events of the time have driven change. We have seen this to be the case with the significant – and valuable – patient safety policy output and drive for change that came after the Mid Staffordshire crisis. However, developments after various crisis events all add up over time. They are also reactive in nature. This all needs sorting and rationalising at some point, as there is a risk that changes, however necessary at the time, may become irrelevant and incompatible with present and future needs.
Conclusion
To know where you are going in patient safety policy making and practice it is equally important to know where you have been. From time to time there does need to be some reflection on some of the fundamental issues of NHS patient safety, and in this column I have addressed some of these issues.