Top ten patient safety priorities for the new Government

  • 19th December 2019

Every year, avoidable harm leads to the deaths of thousands of patients. While patient safety is typically treated as one of several strategic priorities in the NHS, in practice this means that it is inevitably traded off against other priorities, such as finance and efficiency targets.

The newly elected Government has an opportunity to tackle this issue head on, focusing on patient safety as a core purpose of health and social care. To do this they will need to put in place clear standards for patient safety, training for all staff and place patient engagement at the heart of these new ways of working. This requires strong and compassionate leadership to help move from a culture of blame and fear towards one of transparency and learning.

We outline below the scale of the problem, why unsafe care is so persistent, what action is needed to create a patient-safe future and our suggested top ten patient safety priorities for the new Government.

Scale of the problem

1 in 10 patients globally are harmed when receiving hospital care, with the occurrence of adverse events due to unsafe care likely to be one of the 10 leading causes of death and disability across the world.[1]

In the UK avoidable unsafe care kills and harms thousands of people each year, with the number of deaths resulting from patient safety incidents annually estimated at 11,000.[2] This causes not only untold physical and emotional damage, but is estimated as costing the NHS £5bn a year.[3]

The persistence of unsafe care

Despite the efforts and good work of many people to address patient safety issues, unsafe care continues to persist. We have seen more evidence of this in recent months in two particularly high-profile cases.

One is the ongoing independent review, being led by midwife Donna Ockendon, into maternity services at Shrewsbury and Telford Hospitals NHS Trust, following several serious clinical incidents. She is leading a team of experts who are currently investigating ‘more than 800 allegations of poor care at the trust in over 40 years’.[4]

Another case recently in the news has been that of Cwm Taf Morgannwg University Health Board. The Health Inspectorate Wales and Wales Audit Office released a joint review in November which investigated concerns about maternity services at the Health Board. The conclusions of this review followed a all too familiar pattern when it comes to cases of unsafe care, highlighting a reluctance to report issues due to the feeling of a blame culture and missed opportunities for learning.[5]

These are recent examples of multiple failures in patient safety, harrowingly outlined in Inquiry reports into Morecambe Bay[6], Mid Staffordshire NHS Foundation Trust[7] and others, and in the impact on families and friends of the tens of thousands of lives lost and people seriously harmed by unsafe care.

In the run up to the General Election last week there was a renewed focus on the number of deaths of patients in the care of the NHS that were linked to safety incidents, and questions about resourcing and staffing levels.[8]

Creating a patient-safe future

At Patient Safety Learning we believe patient safety is not just another priority; it’s part of the purpose of health care. Patient safety should not be negotiable. We think that there needs to be a transformational approach to sharing knowledge and information about patient safety initiatives; learning from good practice as well as learning from errors and harm.

In June this year we published A Blueprint For Action in which 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 with practical actions to achieve these:

  • Shared Learning
  • Leadership
  • Professionalising Patient Safety
  • Patient Engagement
  • Data and Insight
  • Just Culture

To work towards the first of these foundations we launched in October the hub, an online platform for patient safety learning. This is a platform and community for people to share learning about patient safety problems, experiences and solutions. We believe this is a crucial missing piece to developing a system-wide approach for safer care with common standards, shared learning and much greater transparency.

What action is needed?

The NHS Long Term Plan disappointingly made scant reference to patient safety.[9] Although its programmes are planned to significantly improve services, there is a real opportunity to design patient safety into transforming care as well as reducing the risk of avoidable harm. NHSX have set themselves five missions focused on how they can make things better for staff and patients and rightly identify patient safety as one of these as an outcome to be achieved through digital technology.[10]

The NHS Patient Safety Strategy, published by NHS England & NHS Improvement earlier this year, although to be welcomed, does not offer a specific approach to the sharing of learning.[11] We believe that we must move beyond the current initiatives and take a more transformation approach to improving patient safety.

So, what can Prime Minister Boris Johnson’s new Government do to help create a patient-safe future? We have composed a list of ten key areas of focus that we think they should prioritise:

Top ten patient safety priorities for the new Government:

  1. Patient Safety should be treated as a core purpose of health and social care, not simply one priority to be juggled alongside many others.
  2. There should be explicit standards for patient safety in every organisation in the health and social care system
  3. There should be commitments to share knowledge for patient safety. This will help to improve learning and actions from when things go wrong as well as sharing of good practice.
  4. Boards should prioritise safety and coordinate at local and national level to design and deliver safer care.
  5. There should be specialist patient safety experts with resources to improve safety in every health and social care system organisation.
  6. All staff should be trained in patient safety and have the knowledge, skills and behaviours to deliver safer care.
  7. Patients should be at the heart of patient safety - when they receive care, if things go wrong, advocating and redesigning systems for safer care.
  8. All organisations should collect, report and act on patient safety performance data.
  9. The fear and blame culture must be eradicated. This prevents good staff from highlighting concerns and suggesting improvements. A toxic culture is unsafe for staff and patients.
  10. Government and Parliament should take a leadership role in patient safety. Some simple steps to start this process could be to establish a Minister for Patient Safety and re-establish the All-Party Parliamentary Group for Patient Safety.

We need a resurgent commitment to patient safety and for health and social care leaders, politicians and other influencers to come together, supporting an approach where patient safety is embedded as a core purpose health and social care. We want sharing, learning and action for improvement to come from patients’ positive experiences and good practice, not just as a response to when things go wrong and patients are harmed.

Let us hope for the sake of the thousands of people who lose their lives each year due to unsafe care, that through collective will, we can deliver on this once and for all.

[1] World Health Organization, Patient Safety Fact File, September 2019. https://www.who.int/features/factfiles/patient_safety/patient-safety-fact-file.pdf?ua=1.

[2] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safe systems, safer patients, July 2019. https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf.

[3] 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.

[4] The Independent, Shrewsbury maternity scandal: Senior doctors censured for ‘poor judgement’ over Facebook posts, 10 December 2019. https://www.independent.co.uk/news/health/shrewsbury-maternity-scandal/shrewsbury-maternity-babies-facebook-ockenden-a9239626.html.

[5] Wales Audit Office & Health Inspectorate Wales, A review of quality governance arrangements at Cwm Taf Morgannwg University Health Board, November 2019. http://www.audit.wales/system/files/publications/Cwm-Taf-Morgannwg-UHB-Joint-review-Eng.pdf.

[6] Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/408480/47487_MBI_Accessible_v0.1.pdf.

[7] Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013. https://www.gov.uk/government/publications/report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry.

[8] The Guardian, Deaths of 4,600 NHS patients linked to safety incidents, 8 December 2019. https://www.theguardian.com/society/2019/dec/08/deaths-of-4600-nhs-patients-linked-to-safety-incidents-says-labour.

[9] NHS, The NHS Long Term Plan, January 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf.

[10] NHSX, What we do, Last accessed 19 December 2019. https://www.nhsx.nhs.uk/what-we-do

[11] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safe systems, safer patients, July 2019. https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf.

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