There is a lot in the government's patient safety in-tray for 2025. The year 2024 was significant in terms of the number of consultations launched on key patient safety issues, including reviews of the NHS Constitution (Department for Health and Social Care (DHSC), 2024a) and Never Events (NHS England, 2024a). The Duty of Candour review was launched the year before (DHSC, 2023) and it is among the government responses beginning to come through (DHSC, 2024b).
The terms of reference for the Dash review, published in October (DHSC, 2024c), will look at NHS patient safety organisations and could fundamentally alter the NHS patient safety landscape, hopefully making it simpler and more efficient.
The fact that these consultations have been launched demonstrates a government willingness to engage, be open and reflective on some key NHS patient safety issues and concerns. Whether these are then dealt with by root and branch reform, fine-tuning or moderate recasting remains to be seen. Taken together, these consultations represent an important roadmap for future NHS patient safety change that we should hopefully see in the coming year.
A joined-up thinking approach to policymaking
All the consultations touch on care quality and NHS patient safety. One will have a knock-on effect on another, so they should not be considered in isolation from each other. There all form part of a complex NHS patient safety jigsaw. We are looking for well thought out, conceptual and joined-up thinking, not policymaking in silos.
Never Events
Never Events continue to plague the NHS and vividly show indefensible lapses of care, causing serious harm and, in some, cases death. The argument that we are fallible and sometimes make mistakes, becomes weak when the same sort of Never Events recur regularly, merging into what can be termed ‘Common Never Events’. The consultation on Never Events (NHS England, 2024a) closed in May 2024, with the response hopefully coming in 2025.
Reform options
NHS England (2024a) set out a number of possible options to address Never Events:
My preference is for Option 1: no change, continue with the current framework. The present system is well understood and clearly covers matters that are Never Events. The language used is clear. These are all catastrophic adverse healthcare events that should never happen. There are arguments to be made for adopting the other options (NHS England, 2024a), but in my view the present process is a commonsense system that clearly describes the grave nature of the errors made.
Never Event data
The Never Event data produced monthly by NHS England (2024b) serves as a powerful, poignant reminder of the tragic and devastating impact that such unforgivable failures of care can have. Between April 2024 and October 2024 there were 225 patient safety incidents that appeared to meet the definition of a Never Event (NHS England, 2024b). Figures were correct at the time of going to press. Never Events reported included those listed below.
Wrong-site surgery
There were 101 such Never Events reported, including (NHS England, 2024b):
Retained foreign body
There were 67 Never Events listed under the heading ‘retained foreign object post procedure’, including:
NHS England (2024b) also lists Never Events by the healthcare provider: three hospitals had 5 Never Events listed against them and three had 6.
These Never Events continue to be reported, raising questions as to whether health carers are properly learning lessons from the errors of the past and are sufficiently changing practices.
The stories from the patients' perspective, as told to Wooller and Elliott (2024) by some of the patients who suffered Never Events, provide us with a new and interesting dimension. Wooller and Elliott (2024) also highlighted some statistics on Never Events:
‘The number of patients left needing further treatment because of botched NHS operations has soared more than 70 per cent in five years. Blunders include using dirty tools, cutting the wrong body part, and leaving equipment in patients' bodies at the end of a procedure.’
NHS managers' accountability
In the case of nurses and doctors, there are several mechanisms of accountability and regulation, such as professional regulators and codes of ethical conduct. Not so when it comes to NHS managers: there is no regulatory body and no ethical professional codes.
This all raises important questions of how to ensure NHS managers safeguard patient interests and properly contribute to the development of a proper NHS patient safety culture. If the preoccupation of some managers, when an error is made, is primarily towards institutional damage limitation and management, then we have severe problems of accountability, fairness and justice. Rob Behrens, the former Parliamentary and Health Service Ombudsman, spoke in a Guardian interview (Campbell, 2024) about an NHS ‘cover-up culture’ in England:
‘Hospitals are cynically burying evidence about poor care in a “cover-up culture” that leads to avoidable deaths, and families being denied the truth about their loved ones, the NHS ombudsman has warned. Ministers, NHS leaders and hospital boards are doing too little to end the health services deeply ingrained “cover-up culture” and victimisation of staff who turn whistleblower, he added.’
Wider concerns
More recently, there were accusations against managers made in the Lucy Letby case, that they placed an undue focus on maintaining institutional reputation (Fletcher, 2023). Further on this issue, the Infected Blood Inquiry's final report (Langstaff, 2024:286), recommended:
‘Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done so. Any person in authority to whom such a report is made should be personally accountable for a failure to consider it adequately.’
Strong words that call for a legal duty that, if fully followed through by the government, would be a forceful drive towards developing a proper NHS patient safety culture. The DHSC (2024d) consultation discussed below addresses several matters, including the duties that NHS leaders should have in relation to recording, considering and responding to safety incidents.
New government consultation on NHS managers' regulation
The DHSC (2024d) consultation is a detailed document spanning 39 pages, with sections on its objectives, policy proposal, consultation questions, how to respond and so on. Among the matters discussed are the types of regulation possible, a statutory barring system, a professional register, full statutory regulation and an accredited voluntary register. The benefits of regulating a profession are stated as including public protection, professional accountability, protected titles and so on.
Overall, the document (DHSC, 2024d) captures well the issues that need to be discussed in regulating managers and hopefully it will receive a wide response. The consultation closes on 18 February 2025.
Thirlwall Inquiry
The Dixon-Woods (2024) report presents a detailed discussion of issues relating to NHS culture, along with the role of NHS managers and regulation. It provides an excellent context against which to read and respond to the consultation on managers (DHSC, 2024d). Key sections in the report include:
Section 9 includes a discussion of the qualities of an effective senior manager, effective direction on acceptable standards of conduct and practice, proposals to regulate managers and so on.
Dixon-Woods (2024:95) includes a personal summary of the qualities of an effective senior manager relevant to the interests of the inquiry, based on her own research and experience. It outlines excellent attributes, for example:
‘Clear about the values that drive them, and demonstrate value congruence – what they say is aligned with what they do
- Articulates and reinforces the expected behaviours and standards of conduct on a daily basis through role modelling and through leading by example
- Works effectively as part of a senior team, with clear goals that are shared with others and aligned with the mission and vision of the organisation.’
Conclusion
The year ahead is set to be a busy one in terms of patient safety policy development, new changes and so on. Last year saw a raft of new government consultations on several important patient safety matters and we await the government responses. In giving these policy responses, it is important that the government does not adopt a siloed approach but takes a holistic view of the changes and what these mean collectively for NHS patient safety. One consultation will have a knock-on effect on another. We have a complex, interwoven NHS patient safety system that is integrated across many seams of clinical practice.
What is clear is that we cannot stand still with our efforts to develop a proper NHS patient safety culture and that this has been recognised by government.