Top ten patient safety priorities for the new Government

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: