In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on the charity’s work and some of the key patient safety developments in the past 12 months and looks ahead to 2024.

The persistence of avoidable harm in healthcare remains a major global challenge. At the same time, health systems in countries across the world continue to face enormous pressures in the wake of the Covid-19 pandemic.

In the UK, this pressure can be seen reflected in figures published in just the last few weeks indicating that at least 8,000 patients were harmed in 2022 as a direct result of enduring long waits for an ambulance or surgery.[1] In this context, the estimate of around 11,000 avoidable deaths annually due to safety concerns in the NHS Patient Safety Strategy looks to be increasingly dated and in need of re-examination.[2]

Despite the hard work of many people seeking to reduce avoidable harm, we remain a long way off patient safety being treated as a core purpose of health and social care. At Patient Safety Learning we believe it is now more important than ever that we listen, learn and promote the voice of the ‘patient safety frontline’, both healthcare professionals and patients, and act on that insight.

the hub and its networks

During 2023 the hub, our award-winning platform to share learning for patient safety, has continued to go from strength to strength. the hub offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients.

Since its launch in October 2019, the hub has received 928,000 site visits and had over 1.6 million page views. It now has more than 5,000 members from 90 different countries, representing over 1,500 different organisations. We have also recently hit another major milestone, with the hub now featuring more than 10,000 different knowledge resources.

The numbers speak for themselves as to the value that the hub brings to healthcare professionals, patients, policy makers and patient safety experts. But the greatest value is hearing how the knowledge and connections people are making are inspiring and inform improvements in patient safety in the UK and beyond; over 40% of those accessing the hub are from outside the UK.

This year we have also seen the hub become home to a growing number of communities of interest and peer support networks for people involved in patient safety, which now include:

• Patient Safety Management Network – an innovative network for patient safety managers and everyone working in patient safety.
• Patient Safety Education Network – a peer network for those in patient safety education and training roles.
• Patient Safety Partners Network – a group for Patient Safety Partners, paid and voluntary roles within NHS organisations aimed at improving patient safety.
• National NatSSIPs Network – a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures.

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].

NHS Patient Safety Strategy

This year there has been continued progress on a number of activities relating to the delivery of the NHS Patient Safety Strategy.

Patient Safety Incident Response Framework (PSIRF)

A core component of this has been the implementation of PSIRF. This is a significant and complex change in approach to incident investigation, the success of which we believe will largely depend on having the right organisational leadership and resources to support this transition. We have recently published a simple guide to PSIRF and have also been collating a range of different resources relating to this on the hub:

• Top picks: PSIRF tools, templates and examples
• Top picks: PSIRF insights and opinions
• PSIRF Risk Register and Risk Management Plan: Free tool to help you transition

Learn From Patient Safety Events (LFPSE) service

In 2023 NHS trusts have also been introducing the LFPSE service, a new system for recording and analysing patient safety incidents. There have been significant challenges faced by many trusts in seeking to move towards this, and we welcomed a decision earlier in the year to increase flexibility around the deadline for introducing this in September, following serious concerns raised by staff at a number of different trusts across the country.

Patient safety culture

One area of the Patient Safety Strategy where we do not feel there has been enough progress to date, however, is building a patient safety culture in the NHS. The results of the NHS Staff Survey this year underlined the scale of this challenge, with over 170,000 staff (28.1% of respondents) unable to say that they would feel secure raising concerns about unsafe clinical practice.[3] [4]

NHS England has established a Safety Culture Implementation Group to drive forward work in this area; however, there is little detail in the public domain about its membership or activities. There remains no clear picture of how the rollout of patient safety culture good practice guidance is being implemented, monitored or evaluated. There also appear to be no mechanisms in place to identify poor performance and, if necessary, intervene.

All organisations involved in health and social care, ranging from individual healthcare providers to regulatory bodies, need to do more to assess their culture, determine what changes they need to make and take strong and committed leadership to address the often-toxic blame culture that undermines staff wellbeing and patient safety.

Building a patient safety culture is identified as one of the two key foundations of the NHS Patient Safety Strategy. If this is to be more than rhetoric, the NHS needs to significantly step up its activity in the next year.

Patient engagement

At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, in advocating for changes and in holding the system to account. We identify patient engagement as one of our six foundations of safer care in our report A Blueprint for Action.[5]

Engaging patients for patient safety was the theme of this year’s World Patient Safety Day, which took place on Sunday 17 September. In the run up to this event, we shared a range of different blogs, resources and interviews on this theme, including:

• An interview with Derek Richford about how East Kent Trust and other agencies engaged with his family following is grandson Harry’s death in November 2017.
• A video where we spoke to three people about the experience of campaigning for safety as a patient, family member or advocate.
• An interview with James Munro from Care Opinion about how patient feedback can enable organisations to make patient safety improvements.
• A blog by our Chief Digital Officer Clive Flashman about the benefits and barriers to engaging with patients in developing digital healthcare solutions.

We also co-hosted a joint webinar with the Patient Safety Commissioner for England, Dr Henrietta Hughes, which featured a panel discussion about the opportunities and barriers to increasing patient engagement.

Anyone with a patient perspective or experience can write a blog or share an experience with us on the hub. You can find out more by taking a look at our blog writing guide or contacting us at [email protected].

Public inquiries

Following on from the publication of reviews of maternity services at Shrewsbury and Telford Hospital NHS Trust and East Kent Hospitals NHS Trust last year, there were no reports from major patient safety inquiries published in 2023 although there are several that are currently ongoing and have been recently commissioned:[6] [7]

The review into maternity services in Nottingham, which could prove to be the largest maternity scandal to date, having been expanded again this year to now cover 1,700 families’ cases.[8]

The inquiry into the deaths of at least 2,000 mental health inpatients in Essex, originally established in 2021. This was relaunched as a statutory inquiry with new powers this year following extremely low engagement by staff at the Trust.[9]

The Thirlwall Inquiry began its work examining events at the Countess of Chester Hospital following the trial and subsequent conviction of former neonatal nurse Lucy Letby for the murder and attempted murder of babies at the hospital.[10]

Public inquiries and reviews can function as a vital source of insight and learning that can be applied to improve patient safety, highlighting serious and systemic failures in unsafe care. However, there remain serious question marks about how effectively we are able to translate findings and recommendations from such inquiries into meaningful patient safety improvements, as highlighted last year in our report Mind the implementation gap.[11] Therefore, we welcomed the Health and Social Care Select Committee’s announcement in October that its Expert Panel will undertake a review of the Government’s progress against recommendations from public inquiries and reviews on patient safety.[12]

Too often we see inconsistent approaches to such inquiries and reviews, coupled with the absence of frameworks for subsequently monitoring and evaluating the effectiveness of their

recommendations. Next year we will be making the case for the Panel to pick up on these issues and the need to put in place transparent performance monitoring of the implementation of their recommendations.

Patient Safety Standards

One of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards of good practice for patient safety in the way that it does for other issues. Standards that do exist are insufficient and inconsistent. At Patient Safety Learning, we believe that health and social care organisations need to have standards for patient safety. These can inform 'what good looks like' and enable organisations to self-assess against them.

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:[13]

• Leadership and Governance
• Culture
• Shared Learning
• Professionalisation of Patient Safety
• Patient Engagement
• Data and Insight
• Delivery of Patient Safety Services

The Standards that we have developed in response are based on 20 years of research, as well as learning from inquiries, policy and good practice from healthcare, both in the UK and internationally. This year and moving into 2024, we will continue to work with Great Ormond Street Hospital and other NHS trusts to use the ‘What Good Looks Like’ standards framework to assess their performance and develop organisation patient safety improvement strategies.

You can read more about our patient safety standards on our website.

Integrated Care Systems

In July, a year on from Integrated Care Systems (ICSs) being placed on a statutory footing, we published a new report arguing that there needs to be a greater focus on the role that these bodies play in patient safety.[14]

ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, we think patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. There is no clear guidance or support to ensure that ICSs treat patient safety as a core purpose of healthcare. We believe they need to have specific aims for reducing avoidable harm and improving patient safety.

In the report, we also set out that there needs to be greater clarity on where the patient safety role of ICSs fits into the wider healthcare system. The landscape of organisations with patient safety roles and responsibilities in England is fragmented and lacks coordination, which makes it often ill-suited to tackling complex systemic challenges to patient safety. We believe that the Department of Health and Social Care and NHS England need to consider how to better join up this system, to promote cross-organisational working, coordination and, ultimately, reduce avoidable harm.

Looking ahead to 2024

July next year will mark five years since the NHS first published its Patient Safety Strategy. Much has changed since its initial publication, ranging from the impact of the Covid-19 pandemic to the introduction of ICSs. While there have been incremental updates on the progress to date in the last year, we believe next year is the time for a comprehensive assessment and evaluation from NHS England on the delivery of the strategy, with room to consider adjustments that may be required.

In their inaugural report this year, the Health Services Safety Investigations Body (HSSIB) recommended that NHS England should explore the development and implementation of a safety management systems approach to managing safety in healthcare.[15] The principles of this approach are not sufficiently covered by the current Patient Safety Strategy, and we believe that a thorough review of this would be particularly timely in light of the recommendation.

The implementation of a safety management systems approach, alongside the work that needs to be done to create a safety culture in healthcare, are just two of the areas that we will be exploring at Patient Safety Learning in the new year. We will continue to be an independent voice speaking up for patient safety, work in partnership with others to share learning and seek to amplify the voice of the ‘patient safety frontline’ to create safer healthcare.

References

[1] The Guardian, NHS care delays in England harmed 8,000 people and caused 112 deaths last year, 27 November 2023. https://www.theguardian.com/society/2023/nov/26/nhs-england-care-delays-harmed-8000-people-and-caused-112-deaths-last-year?CMP=Share_iOSApp_Other

[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] NHS Staff Survey, NHS Staff Survey National Results, March 2022. https://www.pslhub.org/learn/culture/nhs-staff-survey-results-2022-9-march-2023-r8969/

[4] Patient Safety Learning, Still not safe to speak up: NHS Staff Survey Results 2022, 23 March 2023. https://www.patientsafetylearning.org/blog/still-not-safe-to-speak-up-nhs-staff-survey-results-2022

[5] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://www.patientsafetylearning.org/resources/blueprint

[6] 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

[7] 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

[8] BBC News, Nottingham maternity review to become UK’s largest, 10 July 2023. https://www.bbc.co.uk/news/uk-england-nottinghamshire-66151746

[9] Hansard, Commons Chamber Debate - Mental Health In-patient Services: Improving Safety, 28 June 2023. https://hansard.parliament.uk/Commons/2023-06-28/debates/D469A916-2E9C-4E9C-82CA-7C8C91315952/MentalHealthIn-PatientServicesImprovingSafety

[10] Thirlwall Inquiry, Transcript of the Chair’s opening statement, 22 November 2023. https://thirlwall.public-inquiry.uk/2023/11/22/transcript-of-the-chairs-opening-statement/

[11] Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm the NHS, April 2022. https://www.patientsafetylearning.org/blog/mind-the-implementation-gap-the-persistence-of-avoidable-harm-in-the-nhs

[12] Health and Social Care Select Committee, Government progress against recommendations on patient safety in the NHS to be evaluated, 24 October 2023. https://committees.parliament.uk/committee/81/health-and-social-care-committee/news/198070/government-progress-against-recommendations-on-patient-safety-in-the-nhs-to-be-evaluated/

[13] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://www.patientsafetylearning.org/resources/blueprint

[14] Patient Safety Learning, The elephant in the room: Patient safety and Integrated Care Systems, 11 July 2023. https://www.patientsafetylearning.org/blog/the-elephant-in-the-room-patient-safety-and-integrated-care-systems

[15] HSSIB, Safety management systems: an introduction for healthcare, 18 October 2023. https://www.hssib.org.uk/patient-safety-investigations/safety-management-systems/investigation-report/

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