At the end of June, Sajid Javid MP was appointed as the new as Secretary of State for Health and Social Care in the UK Government. In this blog, Patient Safety Learning Chief Executive, Helen Hughes, outlines why patient safety should be at top of his agenda, setting out six patient safety priorities for the new Minister.
Sajid Javid MP enters his new role as Secretary of State for Health and Social Care in an extremely challenging set of circumstances. The Covid-19 pandemic continues to have a major impact on the delivery of health and social care services across the country, while also creating a range of longer-term challenges as we transition back to ‘normal’, such as the growing backlog of patients waiting for non-Covid care and treatment.[1]
Like his predecessors, he will also face the huge task of tackling the persistent problem of avoidable harm in health and social care. This blog will outline the scale of avoidable harm in healthcare, the persistence of its underlying causes, action is needed to address this and six patient safety priorities for the new Minister.
The overlooked pandemic
Patient safety is defined by the NHS as ‘the avoidance of unintended or unexpected harm to people during the provision of healthcare’.[2]
The problem of avoidable harm is faced by all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[3] It has been described by the G20 Health and Development Partnership as ‘The Overlooked Pandemic’, not only having an untold physical and emotional impact on those effected, but also forecast to cost the global economy approximately $383.7 billion by 2022.[4]
In the UK, avoidable unsafe care kills and harms thousands of people each year, with the NHS stating that there are around 11,000 avoidable deaths annually due to safety concerns.[5] This is estimated at costing the health service a staggering £5 billion annually, money that could be spent instead on improving patient safety and delivering care.[6]
Persistence of the underlying causes of unsafe care
Despite the efforts and good work of many people to address patient safety issues, unsafe care continues to persist. In 2020 we saw this underlined by the publication of several reports highlighting serious patient safety concerns in the UK:
- Report of the Independent Inquiry into the Issues raised by Paterson: prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated.[7]
- The Independent Medicines and Medical Devices Safety (IMMDS) Review: examining how the healthcare system in England responded to reports about the harmful side effects of hormone pregnancy tests, sodium valproate and pelvic mesh implants.[8]
- Ockenden Report: Emerging findings and recommendations: assessing the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust.[9]
Amidst the shocking scale and severity of avoidable harm detailed in each of these reports there lay many themes consistent with other patient safety scandals over the past twenty years.[10] [11] [12] [13] Underlying causes of unsafe care continue to stubbornly persist in several areas, including:
- A failure to recognise and act to ensure safety is a core purpose of health, ensuring we design and deliver our systems, organisations, and services accordingly.
- Gaps in leadership, governance, and action.
- Blame culture discouraging staff from speaking up, highlighting risks, and identifying where improvements are needed.
- A failure to involve patients in their care.
- A failure to learn from unsafe care, act on that learning and consistently apply good practice across all health care organisations.
In addition to these underlying causes, reports such as the IMMDS Review and Ockenden Maternity Review emphasise a continued lack of support for patients after having experienced unsafe care.
Patient safety as a core purpose of health and social care
At Patient Safety Learning we recognise that the main causes of unsafe care are systemic. Avoidable harm in healthcare has complex roots and to make real progress we need to address these underlying system issues.
We believe that key to this is patient safety being treated as core to the purpose of health and social care, not as one of several competing priorities to be traded off against each other. In our report, A Blueprint for Action, we set out an evidence-based analysis of why harm is so persistent and what is needed to deliver a patient-safe future, identifying six foundations of safe care.[14]
For the new Health Secretary to tackle the patient safety challenge we face head on, it is vital that he recognises that the concerns and recommendations from recent patient safety reports fit within in this wider context.
What we need is a transformation in our approach to patient safety, one that responds to actions and recommendations from reports and inquiries form the last 20 years. This will be a particularly important issue to consider as the new Health Secretary embarks on one of his first major tasks, recruiting a new Chief Executive for the NHS. We need to ensure that the new Chief Executive puts patient safety as a top priority for them and the NHS leadership team.
Six patient safety priorities
While taking a systems approach to patient safety will be key for the new Secretary of State Secretary, there are also six specific patient safety issues that I would put at the top of his in-tray:
1. Implement existing inquiry recommendations
The Department of Health and Social Care has currently provided partial responses to the recommendations of the Paterson Review, published on 4 February 2020, and the IMMDS Review, published 8 July 2020. We believe that new Minister needs to:
- Ensure these responses are prioritised, along with expected recommendations from the next phase of the Ockenden Maternity Safety Review and the inquiry into safety concerns at East Kent Hospitals University Trust.
- Ensure that the new Patient Safety Commissioner for England, which is being created as a result of one of the recommendations from the IMMDS Review, has the resources and powers they need to influence change.[15]
2. Tackling staff safety concerns relating to Covid-19
The Covid-19 pandemic has highlighted how staff safety is intrinsically linked with patient safety.[16] We believe that urgent action needs to be taken particularly in regards to:
- Ensuring PPE access and guidance protects both staff and patients.[17] [18]
- Providing appropriate support to NHS staff with Long Covid.[19]
3. Placing safety at the heart of addressing the care and treatment backlog
As mentioned in the introduction, the NHS faces a huge challenge addressing the backlog of cases created by the pandemic while also meeting the regular demand for services.
We believe a clear strategy is needed to tackle the demand on NHS services, ensuring decisions to prioritise delayed treatments are made transparently and with patient safety at the forefront.[20] We are hearing alarming concerns of inadequate service provision (due to huge demand and trained workforce scarcity) and patients on waiting lists not being properly prioritised. We believe this will lead to increasing errors and avoidable serious harm if action is not taken to address this.
4. Getting to grips with the Long Covid crisis
Official statistics indicate that there are currently hundreds of thousands of people living with Long Covid in the UK. Earlier this year with the patient group Long Covid Support we called for an urgent and significant increase in the scale and pace of the response to this crisis.[21]
While the NHS has recently taken the promising step of publishing its Long Covid Plan 2021/22, we believe that much more activity is needed to engage with and support people living with Long Covid; providing information to help with diagnosis, assessment and treatment and for services to be tailored to their needs.[22] People living with Long Covid are frustrated by the lack of information, support and the inconsistency of service provision across the UK.
5. Patient safety and health inequalities
In a recent evidence-based blog we published for international Women’s Day, and in our submission to the call for evidence on the Women’s Health Strategy, we highlighted the risk to patient safety resulting from sex and gender bias.[23] [24] We believe that this, alongside the how other protected characteristics, such as race and disability, impact on patient safety, requires a greater degree of focus. Equality, human rights, and patient safety are intrinsically bound together. We need to do more to understand the reasons why avoidable harm is higher in certain groups and take action to address this.
6. Maternity safety
There is a recurring theme of patient safety failings in maternity care in the UK, highlighted again this week by a new report from the Health and Social Care Select Committee.[25]
This has been an area of focus in recent months for the Department of Health and Social Care and the NHS, with an announcement in March of an additional £96 million to improve safety at maternity units and a further £2.45 million pledged this week.[26] [27]
While it is positive to see such funding commitments, there remains serious underlying concerns regarding midwifery workforce levels, the implementation of existing safety recommendations, persistence of blame culture and significant disparities in outcomes for women from Black, Asian and minority ethnic groups. There are several patient safety concerns in this area that will require close and continued focus from the new Secretary of State.
References
[1] Results from a statistical analysis revealed more than 1.5 million operations were cancelled due to the pandemic and it is believe the number of cancelled operations may continue to increase by 2.4 million. Thomas Dobbs et al, Surgical activity in England and Wales during the Covid-19 pandemic: a nationwide observation cohort survey, British Journal of Anaesthesia, 18 June 2021. https://bjanaesthesia.org/article/S0007-0912(21)00273-7/fulltext
[2] NHS England and NHS Improvement, Patient Safety, Last Accessed 30 June 2021. https://www.england.nhs.uk/patient-safety/
[3] World Health Organization, Patient Safety Fact File, September 2019. https://www.who.int/features/factfiles/patient_safety/patient-safety-fact-file.pdf?ua=1
[4] The G20 Health and Development Partnership and RLDatix, The Overlooked Pandemic: How to transform patient safety and save healthcare systems, 25 March 2021. https://www.ssdhub.org/the-overlooked-pandemic/
[5] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. https://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf
[6] Estimated at a £2.2bn annual cost of litigation and approximately £2.5bn cost of unsafe care. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409.
[7] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, February 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/863211/issues-raised-by-paterson-independent-inquiry-report-web-accessible.pdf
[8] The IMMDS Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf
[9] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf
[10] Liam Donaldson, An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS, 2000. https://qi.elft.nhs.uk/wp-content/uploads/2014/08/r_02-an-organisation-with-a-memory-l-donaldson.pdf
[11] Ian Kennedy, Learning from Bristol: The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984- 1995, 2002. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/273320/5363.pdf
[12] Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf
[13] Dr Bill Kirkup, The Report of the Morecambe Bay Investigation, 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf
[14] Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409
[15] Helen Hughes, Early thoughts on a Patient Safety Commissioner for England, 23 December 2020. https://www.patientsafetylearning.org/blog/early-thoughts-on-a-patient-safety-commissioner-for-england
[16] Patient Safety Learning, Why is staff safety a patient safety issue, 3 September 2020. https://www.patientsafetylearning.org/blog/why-is-staff-safety-a-patient-safety-issue
[17] Dr David Tomlinson, PPE guidance continues to put staff and patients at risk, Patient Safety Learning’s the hub, 10 June 2021. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/ppe-guidance-continues-to-put-staff-and-patients-at-risk-by-dr-david-tomlinson-r4707/
[18] Fresh Air NHS, Patient Safety Learning and the Safer Healthcare Biosafety Network, Government guidance continues to put staff and patients at risk from the airborne nature of Covid-19, 6 July 2021. https://shbn.org.uk/wp-content/uploads/2021/07/Government-guidance-continues-to-put-staff-and-patients-at-risk-from-the-airborne-nature-05.07.21.pdf
[19] Dr Asad Khan, How will NHS staff with Long Covid be supported, 27 May 2021. https://www.pslhub.org/learn/coronavirus-covid19/273_blogs/how-will-nhs-staff-with-long-covid-be-supported-r4672/
[20] Patient Safety Learning, The return of elective surgery and implications for patient safety, 15 June 2020. https://www.patientsafetylearning.org/blog/the-return-of-elective-surgery-and-implications-for-patient-safety
[21] Patient Safety Learning and Long Covid Support, Long Covid Minister needed to respond to the growing crisis, 3 February 2021. https://www.patientsafetylearning.org/blog/long-covid-minister-needed-to-respond-to-growing-crisis
[22] NHS England and NHS Improvement, Long COVID: the NHS plan for 2021/22, June 2021. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/06/C1312-long-covid-plan-june-2021.pdf
[23] Patient Safety Learning, Dangerous exclusions: The risk to patient safety of sex and gender bias, 8 March 2021. https://www.patientsafetylearning.org/blog/dangerous-exclusions-the-risk-to-patient-safety-of-sex-and-gender-bias
[24] Patient Safety Learning, Patient Safety Learning responds to Women’s Health Strategy Call for Evidence, 10 June 2021. https://www.patientsafetylearning.org/press-releases/patient-safety-learning-responds-to-womens-health-strategy-call-for-evidence
[25] Health and Social Care Select Committee, The safety of maternity services in England: Fourth Report of Session 2021-22, 6 July 2021. https://committees.parliament.uk/publications/6578/documents/71201/default/
[26] The Independent, NHS to spend almost £100 million improving maternity safety after Shrewsbury care disaster, 25 March 2021. https://www.independent.co.uk/news/health/shewsbury-care-maternity-nhs-b1822260.html
[27] Department of Health and Social Care, Government pledges £2.45 million to improve childbirth care, 4 July 2021. https://www.gov.uk/government/news/government-pledges-245-million-to-improve-childbirth-care