The new NHS patient safety strategy, launched on 2 July, promises many things and lays out the future trajectory of NHS patient safety policy-making in England. It is important to consider whether this can be regarded as bringing fresh ideas or whether it is simply a rehash of old ones that failed. Will it lead to an ingrained NHS patient safety culture? To answer these questions it is important to look back at how patient safety policy has developed.
Safety policies come and go
NHS patient safety policies come and go, accompanied by the creation of new NHS organisations, policy refinement and repeated calls to arms for NHS staff to embrace the concept of a patient-centric service.
Patient safety policy development goes back to at least 2000 and the seminal NHS patient safety publication, An Organisation with a Memory (Department of Health, 2000). Despite a lot of government effort over the years, endemic patient safety problems persist. Major patient safety crises are all too common, showing that past lessons have largely gone unlearnt.
‘There seems to be a prevailing attitude of defensiveness in the NHS when things go wrong, and a reluctance to admit mistakes, which is likely to be leading to more clinical negligence claims.’
Patients injured by adverse health events and errors may feel forced to complain formally or litigate to receive a satisfactory explanation of what went wrong. Research for NHS Resolution on why patients make a claim for clinical negligence found that:
‘Themes emerging from the interviews identified that staff reactions fell below the standards expected:
History and patient safety policy
History does not serve the NHS well in terms of NHS patient safety policy development and attempts to develop a patient-centred safety culture. There have been many problems and patient safety policy has, in my view, been too centre led from the Department of Health in London and has not embraced other parts of the Government or professions such as law. A more inclusive and holistic approach to developing patient safety policy is needed:
‘The Government lacks a coherent cross-government strategy, underpinned by policy … to tackle the rising cost of clinical negligence.’
There has also been too much overlap and duplication in the roles of organisations regulating the quality of care. There has been a marked degree of over-regulation, with trusts reporting to and being inspected by too many organisations when an adverse health incident occurs. In addition, there has been a lack of conceptual underpinning of patient safety policy ideas and organisational remits, and this has only improved recently.
The Francis report (2013) portrayed well the patient safety organisational problems that occurred and that recur today. The failings discussed in the report included:
‘The culture at the Trust was not conducive to providing good care for patients or providing a supportive working environment for staff; there was an atmosphere of fear of adverse repercussions; a high priority was placed on the achievement of targets; the consultant body largely dissociated itself from management; there was low morale amongst staff; there was a lack of openness and an acceptance of poor standards.’
This quote clearly identifies patient safety problems, which remain with us today, despite patient safety policy changes introduced since Francis. NHS trust boards do need to take patient safety more seriously when it comes to resource allocation priorities.
Even after Francis, the Care Quality Commission (CQC) has viewed patient safety problems as its main concern when inspecting trusts and has said so in several recent reports:
‘Fundamentally, the safety culture of the NHS has to radically transform if we are to reduce the toll of Never Events and the much greater number of other safety events. Cultural change is not easy … A new era of leadership, focused on safety culture, engaging staff and involving patients is essential.’
Some improvements, but more can be done
The NHS has been on a long road since at least the year 2000, trying to develop an effective patient safety policy that changes and improves NHS culture. There have been positive changes, but we are still a long way from reaching the end of the journey as several recent patient safety crises reports show (Kirkup, 2015; 2018):
‘A large new NHS Trust was established from scratch with an inexperienced Board and senior staff and received inadequate scrutiny because it was regarded as low risk … The end result was unnecessary harm to patients over a period of several years, and unnecessary stress for staff who were, in some cases, bullied and harassed when they tried to raise concerns about deterioration in patient services.’
Will the new NHS patient safety strategy make a difference?
Aidan Fowler, NHS National Director of Patient Safety, highlights the scale of the patient safety problem in the foreword to the strategy:
‘Too often in healthcare we have sought to blame individuals, and individuals have not felt safe to admit errors and learn from them or act to prevent recurrence … The opportunity is huge. Hogan et al's research from 2015 suggests we may fail to save around 11 000 lives a year due to safety concerns … The extra treatment needed following incidents may cost at least £1 billion.’
The strategy builds on a public consultation paper (NHS Improvement, 2018) and it is based on two foundations—a patient safety culture and a patient safety system—supported by three strategic aims:
There is a discussion in the strategy on how these three strategic aims will be actioned.
Insight actions
Involvement actions
The establishment of principles and expectations to involve patients, family carers and other lay people in providing safer care:
Improvement actions
The strategy pledges to deliver several programmes including:
A vision for patient safety
Safety is not seen in the strategy as an absolute, immovable concept with a single objective or defined point. The vision sees NHS patient safety as being flexible and responsive to patient and NHS system priorities.
The ‘Just Culture’ concept is discussed in the strategy and how this can be thwarted by fear and blame. It is acknowledged from responses to NHS Improvement (2018) that NHS staff feel that fear is too prevalent among them, particularly in relation to involvement in patient safety incidents. Culture change, the document states, cannot be mandated by strategy, but you cannot ignore its role in determining safety.
The strategy is to be welcomed
The strategy is detailed and there is a helpful resource section on the accompanying website. There is evidence of deep thinking and reference to much academic writing and research. This is not a case of old wine in new bottles, and there is evidence of fresh thinking. There is also a conceptual underpinning as to what is proposed and a clear route forward. We now have a strategy in place, but can it be effectively delivered, or will it be consigned to the history books and eclipsed by further NHS patient safety crisis reports?
Will the strategy be delivered?
The British Medical Association's (BMA) (2019) response to the consultation paper (NHS Improvement, 2018) captures concerns about implementation of the strategy. The BMA supports the aims and principles that informed development of the strategy, but states that it needs to acknowledge the scale of current pressures in the system and the persistence of a culture of fear and blame. Bullying and harassment in the NHS must be dealt with and steps taken to create a more supportive and inclusive culture:
‘There needs to be a clear shift in priorities so that quality and safety of care takes precedence over operational and financial targets.’
Conclusion
History has not served the NHS well in terms of patient safety policy development. Endemic problems remain after many years by Government and others trying to make changes and improve matters. The new patient safety strategy has excellent potential to bring about a good and sustainable patient safety culture and system. However, the task is Herculean and everything depends on a changed NHS mindset that adequately resources the strategy and deals with the problems and challenges identified by the BMA and by the Government itself.