There is an urgent need for a movement away from the cluttered patient safety organisational landscape that we have. The NHS must put its patient safety house in order and review, rationalise and consolidate its organisations with responsibilities in this area. The review of patient safety organisations recently announced by the government (Department of Health and Social Care (DHSC), 2024a) as part of Penelope Dash's final Care Quality Commission (CQC) review (DHSC, 2024b), provides the opportunity to do so.
Dash review
No doubt the final Dash report on the CQC will also find that the NHS health regulatory, governance framework, patient safety system is too complex, overlapping, fragmented and ripe for reform. This is a well-known fact and has been chronicled in several reports over the years and continues to be reiterated. According to the CQC (2018:6):
‘Arm's-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what. This makes it difficult for trusts to prioritise what needs to be done and when.’
The Dash review need look no further than the CQC (2018) report on the NHS safety culture to advocate for the review, rationalisation, consolidation and reform of NHS patient safety organisations.
It is difficult for NHS trusts, other healthcare organisations, stakeholders and patients to see where responsibilities for patient safety lie, which advice is authoritative and who leads on initiatives. There are gaps. Referring to ‘safety clutter’, the Health Services Safety Investigations Body (HSSIB) (2023) stated:
‘HSIB and HSSIB investigations have identified that patient safety policies, their implementation and regulation are highly fragmented. Safety recommendations from separate bodies often overlap and conflict, multiple guidelines exist for similar conditions …’
As the seminal Cumberlege (2020) report found, patients find it difficult to work out how to complain, which organisation is accountable and which is responsible for specific issues. The Dash review will find Cumberlege (2020) enlightening because it was excellent in capturing NHS patient safety culture development problems. Cumberlege cited, among other things: the system does not work in a joined-up fashion; there is a defensive, blame-focused culture; it lacks leadership; and it has no coherent and fully integrated patient safety policy, directives and standards.
The case for reform
The case for some reform of NHS patient safety organisations has been clearly made in several reports, including CQC (2018), Cumberlege (2020) and HSSIB (2023). The next stage is to identify the NHS organisations and arm's length bodies that require reform, review, rationalisation and consolidation. We need to urgently simplify the patient safety structure and avoid expensive duplication of functions that are clearly causing confusion to patients and healthcare providers.
A review of annual reports
The annual report and accounts of an organisation offer a window into its world. It shows what how the organisation has been performing: its successes, failures, challenges, trends and opportunities; direction in strategy; how it spends its money and more. These documents are an important mechanism for transparency and accountability. Shareholders and stakeholders can hold the organisation to account for its activities and challenge it.
NHS patient safety organisations also provide annual reports, which provide valuable insight on the state of patient safety. The reports show there are areas of overlap, leaving open possibilities for consolidation.
This article discusses two NHS patient safety organisation annual reports.
NHS Resolution
The first is this year's report from NHS Resolution, which is an NHS patient safety stalwart. It has been in operation since 1995 as a special health authority and is a not-for-profit, arm's length body of the DHSC. Its various functions span different areas, which include NHS litigation claims management on behalf of NHS trusts and other healthcare organisations. NHS Resolution runs claims indemnity schemes.
Annual report
The 2024 NHS Resolution annual report contains, as always, key and valuable information on clinical negligence trends and costs, as well as information on other activities. Headlines from the 2024 report include the number of clinical negligence claims, settlements and costs.
The report states that, in terms of clinical negligence claims and incidents reported, it saw a 3% increase compared with the previous year. These rose from 10 567 in 2022-2023 to 10 834 in 2023-2024.
Clinical negligence claims
Under the Clinical Negligence Scheme for Trusts (CNST) – one of NHS Resolution's indemnity schemes – the annual report identifies by specialty four main clinical claims categories for 2023-2024: emergency medicine, obstetrics, orthopaedic surgery, and general surgery
‘… obstetric claims accounted for 13% of clinical claims reported by volume (excluding GPI [General Practice Indemnity] but accounted for 57% of all clinical claims by value received in 2023/24 (compared with 64% in 2022/23) …’
The estimated annual cost of harm under the various NHS Resolution schemes was £5.1 billion. It has also factored in £58.5 billion for future claims. The annual report notes the production of five insight papers and the hosting of a range of webinars and events.
Multifaceted
In terms of activity, NHS Resolution has several important remits. An outsider looking in would have difficulty scoping all of its activities and seeing how they fit together. As stated, NHS Resolution manages litigation on behalf of NHS trusts and others, but is simultaneously a public NHS special health authority with obligations to patients (the public) who sue the NHS.
How well NHS Resolution balances these interests, which on the face of it appear to conflict, is a matter of conjecture and, in my view depends, on who you ask. While some patient claimant lawyers may hold a negative view on the success of balancing of interests, citing lengthy delays with regard to some matters, defendant trust lawyers may have a different view.
There are mixed views on how well NHS Resolution performs this delicate balancing act. In my view, it has worked well over the years, and has been a stable and unifying influence in NHS litigation and patient safety management. We do, however, ask a lot from this organisation.
Commonality of education and training
Annual reports from NHS Resolution and other NHS patient safety organisations have common themes, such as stakeholder engagement, education and training. There may therefore be a potential for review and perhaps consolidation of NHS Resolution's patient safety education and training function with those of some other NHS patient safety organisations. Among those with this remit are HSSIB, the Parliamentary and Health Service Ombudsman (PHSO), the Professional Standards Authority (PSA) and the Patient Safety Commissioner.
Should NHS Resolution become the core provider for NHS patient safety education and training? Or should this be the HSSIB or another organisation? How can a more joined-up patient safety education and training programme across the NHS be achieved? Clarity is needed, as NHS staff can be overwhelmed by the multitude of courses on offer and which should have priority – and poor messaging from provider organisation means they could miss out on a course.
The government's latest review could suggest a consolidation of education and training, which could lead to costs savings due economies of scale and better use of resources across the NHS; such a move would also lead to better market penetration, improve stakeholder engagement, as well as better patient knowledge and awareness. NHS patient safety organisations need to move away from seemingly operating in silos.
NHS is poor at patient safety lesson learning
Some areas of the NHS are patently bad at learning lessons following adverse events and in changing practices, as investigation reports have shown. Similar patient safety errors continue to appear to be made in some quarters. Maternity and Never Events are cases in point. Improving and simplifying access to patient safety education and training therefore could help improve NHS staff learning from past adverse health care events.
HSSIB
There is some useful intelligence in the HSSIB (2024) annual report on the organisation's operation and functions, along with important patient safety themes. It is a fully independent arm's length body of the DHSC and its core role is to carry out independent safety investigations and to report on these.
As stated in the report, the investigations do not find blame or liability with individuals or organisations. The HSSIB make safety recommendations and observations.
It also provides education and training programmes that, the report states, are targeted especially at those who undertake patient safety investigations or who have oversight of them (https://hssib-education.turtl.co/story/nhseducation-prospectus). Since 1 October 2023, the HSSIB has had over 9000 new enrolments across its suite of eight programmes. It is also working with others to begin delivering Level 3 content of the National Patient Safety Syllabus.
Overall, the HSSIB has a significant patient safety education and training function. The annual report highlights its achievements and presents its financial reports. Between 1 October 2023 and 1 March 2024 eight investigation reports were published and 12 investigations launched. Its other achievements include 89 000 visits to its website:
‘… with most interest being in our education course pages, our individual investigation pages and our us pages.’
Conclusion
Taking a sample of just two NHS patient safety organisations, NHS Resolution and the HSSIB, we can see that they have distinct roles but that there are also areas of commonality of function and overlap in terms of patient safety education, training and other areas.
The final Dash review, as discussed, should take the opportunity to review, rationalise and consolidate NHS organisations that have a significant patient safety remit. The result will be more financial efficiency and effective function, not to mention less complexity, fragmentation and overlap of function. Wider messaging about good patient safety practices must be shared across the NHS, so it can better learn from the patient safety errors of the past.