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In February 2022, we launched our Patient Safety Spotlight interview series to share stories and insight from people working on the frontline of patient safety—from patient campaigners and healthcare professionals to researchers and health and care leaders.
For our final Patient Safety Spotlight of 2022, members of the Patient Safety Learning team share a personal patient safety reflection from 2022 and talk about their hopes for next year.
I have spoken a number of times in the last 12 months on the need to embed patient safety into the design of new digital health and care innovation. I mentor on a number of digital health accelerator programmes and try to convince all of my mentees that this should be a priority for them, normally with a large degree of success. I do worry however, that with less funding around for this type of innovation in the current economic climate, patient safety will be pushed down the list of priorities that innovators consider when designing and producing their new solutions. I also worry that innovators can’t easily access the patients they need, to test out their products/ services so that they have the evidence to know that they are safe and reliable for everyone who needs to use them. We need better ways to bring these two groups together, as it is in everyone’s interests that innovative new health and care solutions are properly tested by the patients who are likely to use them.
Over the next 12 months, I foresee an increasing use of AI-based technologies, which have the potential to interact with patients and potentially deliver prescriptive analytical solutions, and basic elements of clinical judgements – or at least clinical recommendations. I’m also interested to see how digital twins might improve patient safety so that digital health technologies, surgical procedures and other patient facing interventions can be tested on the patient’s digital twin before being implemented with/ on the patient themselves.
I returned from maternity leave six weeks ago and I was reminded immediately of the power and importance of collaboration in the realms of patient safety. But what do we actually mean by genuine collaboration?
In my experience, the collaborations that have the greatest impact are inclusive, respectful and action-focused. Where people come together with shared goals and an understanding that different perspectives are essential. When I'm part of a diverse group of people, I feel grateful for their unique skills and experience, and energised to contribute my own.
Bring people together. Really listen to their perspectives. Talk about your motivations so you can refine what you want to achieve. Set the scene for a respectful, safe space. And, importantly, work out what actions you are each going to take as part of your collaboration to get you closer to those goals. Because talking is great, but when it comes to patient safety, impact is even better.
My hope for next year is to see more diverse collaborations on key patient safety issues. I'd particularly like to see patient and family insights proactively welcomed and given equal weighting. We've seen some incredibly successful patient-led campaigns, but too often their contributions are sidelined to the detriment of safety improvements.
Healthcare is pressurised more than ever in a (nearly) post pandemic world. Across the globe, clinicians, leaders and politicians are grappling with demand for services in health systems with staff who are often exhausted and covering workforce capacity and skills gaps. This does not bode well for the delivery of safe care and planned reductions in avoidable harm.
But despite this rather grim reflection, for me, this has been another year of hope. I’ve had the privilege of working with and supporting amazing clinicians, patient safety experts, patients and campaigners who are passionate in their commitment to safe and effective care. There are networks of people sharing good practice, leading the implementation of system improvements and challenging the healthcare system to be more accountable to patients and families.
I feel privileged to contribute to this, through our work at Patient Safety Learning and in collaboration with our partners, and know that 2023 will be another year closer to our goal of reducing avoidable harm.
This year has seen the publication of two more major reports into serious patient safety failings in NHS maternity services. Both reports have highlighted the all too familiar themes of patients’ safety concerns being dismissed, poor quality investigations and the persistence of a culture in parts of the healthcare system that deters speaking up. The latter is particularly concerning to me; I felt a sense of déjà vu reading this year’s NHS Staff Survey results which illustrated the wider prevalence of this, with over 160,000 staff who responded not able to say that they would feel secure raising concerns about unsafe clinical practice.
If we’re to break these patterns in inquiry after inquiry, we need our healthcare leaders to get to grips with the systemic issues and put patient safety at the core of their thinking. As noted in our report earlier in the year, 'Mind the implementation gap', a helpful starting point would be to introduce effective and transparent performance monitoring to ensure inquiry recommendations are translated into action and improvement.
In 2023 we need to make real progress in implementing outstanding safety recommendations, which will not be easy in the context of the wider challenges we face, particularly staff shortages in both health and social care. My hope for the new year is that with a bit more political continuity in the Department of Health and Social Care, our healthcare leadership can begin to move towards to more system-focused approach to these challenges. This would help to ensure that we can maximise the benefits of new institutional developments, such as the establishment of Patient Safety Commissioners in England and Scotland and the transition to the new Health Services Safety Investigations Body and Maternity and Newborn Safety Investigations Special Health Authority, to improve patient safety.
As Editor for the hub, I am privileged to work closely with patients, helping them share their stories and supporting them to get their voices heard. Often there is frustration felt that no one is listening and that their concerns are being dismissed. This is particularly true in women’s health. Sadly, many women are still facing barriers in getting the treatment they need and we are seeing doctors failing to take women’s concerns seriously.
This year, we heard from hub member Sophie about the pain and gaslighting she experienced when having an IUD fitted, shared appalling accounts of how women who have been harmed by pelvic mesh surgery have been treated by their doctors and have seen women continuing to share with us their awful experiences of painful hysteroscopy. The damaging narratives around female pain cause harm to patients far beyond their initial experience.
But we are seeing changes. In July, the Government published the first ever Women’s Health Strategy for England to tackle the gender health gap. In October the All Party Parliamentary Group on Menopause published their final report with their recommendations following a year-long inquiry to assess the impacts of menopause. As hub topic lead Saira Sundar wrote earlier this year, “there is a real change being forced by women themselves, with the public increasingly questioning and insisting on improvement and the right to be heard.”
My hope for 2023 is that we will see continued positive action being taken in women’s health and that the hub can help bring to the forefront the patient safety issues women experience.
The issue that has most troubled me this year is health inequality; we are still such a long way from closing the access gap. There are so many people who are unable to access the care and treatment they need, for complex and varied reasons, and evidence suggests that the Covid-19 pandemic and the resulting pressure on health services has widened the gap. It’s more important than ever that the Government and NHS invest in new approaches.
In April 2022, I read the Diabetes UK report Recovering diabetes care: preventing the mounting crisis, which highlighted the stark inequalities in access to diabetes care between the most and least deprived areas of the country. What really saddened me was reading that this disparity is happening among children as well as adults, for example, in access to life-changing diabetes technology such as insulin pumps. However, there are many charities and organisations doing great work and research in this area, and it will be interesting to see the impact of NHS England Core20PLUS5 approach to tackling specific areas of the health system where inequalities have the biggest impact.
My hope for next year is that we will see increasingly effective application of research insights so that services can reach those individuals who are missing out on care. How can organisations tailor their approach and make clinics and information more accessible and culturally competent? How can fellow patients help reach those with poor health literacy or limited access to online technology? There are some innovative ideas out there that can be amplified, and I hope we can use the hub to help share them.
Do you have a story, reflection or resource to share? the hub is designed for frontline staff, patients, managers, and anyone else with an interest in patient safety, to come together and share their insights.