In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
At Patient Safety Learning we seek to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm.
The scale of this challenge remains immense. Each year, millions of patients suffer injuries or die because of avoidable harm in healthcare. The World Health Organization (WHO) states that in high-income countries 1 in every 10 patients is harmed when receiving hospital care.[1] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[2]
In 2022 we have seen positive new patient safety initiatives, such as the launch of the NHS Patient Safety Incident Response Framework (PSIRF), the creation of a Patient Safety Commissioner for England and efforts to increase awareness of medication safety issues as part of this year’s World Patient Safety Day. However, much more work is needed to tackle the complex systemic causes that result in the persistence of avoidable harm in health and social care.
More inquiries, but are lessons being learnt?
This year we have seen two new major reports that detail more shocking cases of avoidable harm in maternal and neonatal care in the NHS. In March the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its final report, which made a range of recommendations for improving care and safety in maternity services across England.[3] Subsequently, in October the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Trust was published, revealing a series of serious patient safety failings at the Trust between 2009-2020.[4] Added to this, there is now an ongoing review into maternity services in Nottingham, which could prove to be the largest maternity scandal to date, exceeding 1,500 cases.[5]
The findings of these inquiries echo concerns highlighted in many reports in the last decade. Time and time again we see the same themes emerging – the failure to listen to patients; a corrosive blame culture and the lack of an effective regulation and organisational leadership and governance.[6] At Patient Safety Learning, we believe that the Department of Health and Social Care and NHS England need to recognise these system-wide issues and consider them in their wider context – not simply issue individual responses to each new report with a commitment to ‘learn lessons’.
There also needs to be a more rigorous approach to ensuring that the recommendations of these inquiries and reviews are implemented. In our report ‘Mind the implementation gap’, published earlier this year, we make the case that there needs to be transparent performance monitoring of the implementation of recommendations to ensure that these actions are translated into evidenced patient safety improvement.[7]
Implementing the NHS Patient Safety Strategy
NHS England has initiated a number of new activities in 2022 as it continues to implement the NHS Patient Safety Strategy. The most noteworthy has been the publication of detailed guidance for the new Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s new approach to developing and maintaining effective systems and processes for the purpose of learning from patient safety incidents. All organisations are expected to transition to this by Autumn 2023. This is a potentially very significant change in approach and culture and over the past 12 months we have shared a range of resources in relation to this, including:
- Patient Safety Management Network discussions about the new systems-based approaches to learning.
- Examples of the application PSIRF, such as in relation to pressure ulcers.
- An interview with Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England.
There has also been ongoing work to develop and rollout the Learn From Patient Safety Events (LFPSE) service, a new national incident reporting system for the NHS. In the latter half of this year, specialist staff working in patient safety and local risk management system leads have raised with us concerns about the development and implementation of LFPSE. Many have said that they did not feel they were being listened to and we have supported them in highlighting their concerns with NHS England. Subsequently, in recognition of these concerns, there has been changes made to the taxonomy requirements for the new system and an extension of the implementation deadline from March to September 2023.
July 2023 marks four years since the publication of the NHS Patient Safety Strategy. Over the next year we will be looking more closely at the implementation of this to date, considering where progress has been made and where improvement is required.
Highlighting topical patient safety issues
Over the course of the past year, we have continued to use the hub to share learning and campaign for improvements in patient safety. Throughout the year we have continued to highlight topical patient safety issues, both directly and through shining a light on the work of others, including:
- Kath Sansom highlighting 10 problems with NHS England’s specialist mesh centres.
- The risks posed to patient safety by rejected GP referrals for investigations and outpatient treatment.
- The Surviving in Scrubs campaign to call out the sexist and misogynist culture within healthcare.
- Concerns about the ability of staff to speak up on patient safety concerns, reflected in the results of this year's NHS Staff Survey.
- Hope Virgo pointing to the need to confront barriers to accessing support in the healthcare system for people with eating disorders.
- A doctor examining the link between Covid-19 and cardiovascular disease.
- Keith Conradi setting out why healthcare needs to operate as a safety management system.
We also launched our Patient Safety Spotlight interview series this year, interviewing staff and patients working to improve patient safety, about their role and what motivates them. You can read all the interviews so far on the hub.
Safety for All campaign
Patient Safety Learning has been working in partnership with the Safer Healthcare and Biosafety Network on several different activities in 2022 as part of the Safety for All campaign. This campaign highlights how poor staff safety standards and practice impact adversely on patient safety and vice versa. It promotes the need for a systematic and integrated approach to improve safety practice for staff and patients across the health and social care so that the sum is greater than the parts. As part of this we have:
- Published the report ‘Mind the implementation gap: The persistence of avoidable harm in the NHS’, which calls for system-wide action in healthcare to transform our approach to learning and improvement.
- Held a Parliamentary reception on the 29 June, hosted by Dean Russell MP, where we launched a new good practice support guide for staff involved in serious safety incidents.
- Held a Conference on 7 December at the Royal College of Physicians with a range of panel sessions and speakers, including the new Patient Safety Commissioner for England, Dr Henrietta Hughes.
We will be sharing resources from our recent Conference and undertaking more work as part of this campaign in the new year.
Patient safety standards
We consider that one of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards for patient safety in the way that it does for other safety issues. The standards it does have are insufficient and inconsistent.
We believe that by adopting and implementing comprehensive patient safety standards, organisations will be able to deliver safer care and embed a commitment to patient safety throughout their work. This would also enable patients, leaders, clinicians, the wider public and regulators to assess their progress and performance in improving patient safety.
Based on our original research and policy document ‘A Blueprint for Action’, Patient Safety Learning has developed a set of unique patient safety standards centred around seven key foundations for patient safety:[8]
- Leadership and governance
- Culture
- Shared learning
- Professionalisation of patient safety
- Patient engagement
- Data and insight
- Delivery of patient safety services
The seven foundations are supported by 26 specific patient safety aims. In total, there are 144 identified standards, based on 20 years of research, as well as learning from inquiries, policy, and good practice from healthcare. This year we have begun working with several organisations to implement these standards as part of their organisational safety improvement strategies and will be taking this work forward in the new year. You can read more about our patient safety standards on our website.
Continued growth of the hub
This October the hub, our free award-winning platform for patient safety, officially turned three years old. To date, the hub has received over 565,000 visits and had over 1.1 million page views. It now has over 3,300 members from 80 countries working in over 1,000 different organisations, and offers 7,500 knowledge resources, viewed by people from 221 countries.
In addition to the rich content of patient safety topics, some of which we mentioned earlier in the blog, this year we have also seen significant growth in our community networks. The Patient Safety Management Network – an informal voluntary network created by and for patient safety managers – continues to go from strength to strength, providing a weekly drop-in session with guests to talk through issues of importance, offering peer support and creating a safe space for discussion. This now has over 800 members. the hub also now hosts the National NatSSIPs Network, a group of over 400 UK healthcare professionals involved in the implementation of NatSSIPs/LocSSIPs in their organisation.
If you are interested in joining one of the networks or would like to set up your own network on the hub, please do get in touch at [email protected].
Looking forward to 2023
This has been another seriously challenging year in health and social care. While many of the restrictions associated with the Covid-19 pandemic have been scaled back, infections from the disease remain a serious issue and healthcare systems across the world are continuing to deal with the strains and pressures both created and exacerbated by the pandemic. Going into the new year we will continue to be an independent voice speaking up for patient safety and seek to work in partnership with others to share learning and create safer healthcare.
References
[1] WHO, 10 facts on patient safety, 26 August 2019. https://www.who.int/news-room/photo-story/photo-story-detail/10-facts-on-patient-safety
[2] NHS England, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/
[3] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf
[4] Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. https://www.gov.uk/government/publications/maternity-and-neonatal-services-in-east-kent-reading-the-signals-report
[5] The Independent, NHS could face biggest maternity scandal ever as Nottingham probe expected to exceed 1,500 cases, 30 November 2022. https://www.independent.co.uk/news/health/nottingham-maternity-scandal-review-b2235149.html
[6] Patient Safety Learning, Will lessons be learned? An analysis of systemic failures in the East Kent maternity report, 17 November 2022. https://www.patientsafetylearning.org/blog/will-lessons-be-learned-an-analysis-of-the-systemic-failures-in-the-east-kent-maternity-report
[7] Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, April 2022. https://www.patientsafetylearning.org/blog/mind-the-implementation-gap-the-persistence-of-avoidable-harm-in-the-nhs
[8] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://www.patientsafetylearning.org/resources/blueprint
