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Patient Safety Watch: The evolving future of patient safety

Published on: 10 Mar 2023

HSJ is now hosting the Patient Safety Watch newsletter, written by Patient Safety Watch trustee James Titcombe.

Good afternoon and welcome to this fortnight’s Patient Safety Watch newsletter. As well as the usual patient safety news update, this edition also features a guest blog by national director for patient safety Aidan Fowler, reflecting on patient safety’s evolving future and progress made in the national patient safety strategy.

It’s been another busy fortnight for patient safety news, so let’s get stuck in.

NHS staff in tears as demand for care amid chronic staff shortages takes its toll

A report by the Healthcare Safety Investigation Branch said many NHS staff “cried or displayed other extreme emotions” when asked about their working environments in interviews. The watchdog also found the feeling they were unable to properly care for patients was driving increased levels of stress, worry and exhaustion.

One paramedic described to BBC News how over the last year she had “witnessed and helped with cardiac arrests in the corridors of hospitals and in the back of ambulances” and “spent four hours with an end-of-life patient”, while emergency call handlers described how “how many people are we going to kill today?” had become a common worry.

Shortly after the HSIB report was published, a survey by union GMB – which was among those involved in this winter’s ambulance staff strikes – found more than half of ambulance workers had witnessed a patient death following a delay in reaching them, while another third said they knew of a colleague who this had happened to.

The survey results were released as part of a Channel 4 Dispatches investigation. “We’ve seen patients this winter who have been harmed because of ambulance delays,” leading stroke doctor Sanjeev Nayak told the broadcaster. “If they’re late, we cannot treat them; there’s very little we as doctors can do. A couple of hours’ delay means the patient can die or suffer disability.”

The problem extends well beyond accident and emergency departments, too. A series of Freedom of Information requests by the Labour Party – as reported here by the Daily Mail – found 38 of 93 trusts with maternity units or birthing centres had been forced to turn away expectant mothers between November 2021 and October 2022 due to staff shortages, with some hospitals having to take such action on dozens of occasions.

NHS should listen to patients to improve

Speaking to The Times health commission, Healthwatch national director Louise Ansari said the NHS could make “efficiency and productivity gains” by listening to patients more. She also gave examples of how patients stories could highlight safety concerns, such as one from a nurse who, as a patient, had been left waiting in an emergency department corridor for 14 hours and a patient with suspected appendicitis who was told to wait in his car.

Health ombudsman on medical cover-ups

Health service ombudsman Rob Behrens was quoted in The Times this week with strong words about the cover-up culture prevalent in some part of the NHS. Speaking after issuing a stark warning about patient safety, leadership and cultural concerns at University Hospitals Birmingham Foundation Trust, Mr Behrens told The Times he had seen cases of medical records being changed after a death and had spoken to doctors who were “too scared to speak out about failings in their hospitals”, adding: “Too many leaders are interested in preserving the reputation of their organisation, rather than listening to citizens who have legitimate complaints to make.”

Mr Behrens’ words should be truly shocking, but sadly describe issues that, for many, are only too familiar. Despite the focus on culture change in the NHS in recent years, there is still a long way to go.

Maternity safety remains in the spotlight – for all the wrong reasons (again)

Last week, Office for National Statistics data revealed an overall increase in the rate of babies dying before, during or soon after birth in 2021. Commenting on the figures, Rob Wilson, head of Sands and Tommy’s joint policy unit, said: “Today’s ONS stats confirm that there is a concerning gap between government rhetoric on maternity safety and the reality of the numbers of babies dying… The target to halve the number of stillbirths and neonatal deaths in England by 2025 compared to 2010 levels is not on track.”

This week also saw the publication of the governments initial response to the East Kent investigation, which drew heavy criticism from  inquiry chair Bill Kirkup. He told the BBC and HSJ  he was “disappointed” with the initial response, while families affected by the care failings at the trust called it “weak”. 

Headlines about safety concerns at maternity services are now a regular occurrence. Addressing these concerns ought to be an urgent and pressing priority for the government. The message this week from experts and harmed families could not be clearer: what we are seeing so far simply isn’t good enough and more must be done.

But there are some reasons for optimism. Last week, England’s chief nursing officer Ruth May wrote to several bereaved families who raised concern about the “International Normal Labour and Normal Birth” conference due to take place on the doorstep of Morecambe Bay next month. I’m pleased to say Ms May backed the families concerns and distanced NHS England from the event. An overfocus on so-called “normal birth” has been linked as a major factor in the avoidable deaths of mothers and babies in a number of major inquiry reports, include at Morecambe Bay where this event is due to take place. It’s heartening to see our CNO taking a strong stand. Let’s hope this year’s conference (if the organisers go ahead) is the last of its kind.

Sharing some good stuff

What is sure to be a fantastic (and free!) symposium focusing on restorative health systems is taking place on 29 March (8pm UK time). The event is being hosted by the Te Ngāpara Centre for Restorative Practice in association with the Health Quality & Safety Commission in Aotearoa New Zealand and will reflect on the future of restorative initiatives in the health system context. More information and how to sign up here.

Evaluating PSIRF

As many readers will be aware, in August 2022, NHSE published the Patient Safety Incident Response Framework. This new framework aims to develop better ways to respond to and learn from patient safety incidents, so they don’t keep happening. The response study is a major, three-year research project, based at the University of Leeds to evaluate how PSIRF is rolled-out in the NHS in England. The study is looking to recruit members for its citizens’ panel, which will act as the public’s eyes, ears and voice; a group of “critical friends” to the response study research team. More information about the response study, the citizens panel and how to apply here.

Black Maternal Health Conference UK

The Motherhood Group is hosting this important conference in London on 20 March. The event will support rebuilding the trust between the community and service providers, exploring the role of systemic racism, human rights, and structural change, and how to effectively engage with Black mothers. The programme looks fantastic and will be of interest to everyone working in the maternity system, as well as families and maternity campaigners. More information here.

That’s all the news for this fortnight’s edition. I hope readers will enjoy Aidan’s thought provoking blog below.

Look out for our next newsletter in two weeks’ time. Until then, please stay safe.

The evolving future of patient safety by Aidan Fowler

Sutcliffe (of Weick and Sutcliffe – Highly Reliable Organisation fame) and Wears argue in their book – Still Not Safe: Patient Safety and the Middle-Managing of American Medicine – that we have not achieved what we should in healthcare safety because we don’t take advice from outside and have over-medicalised the effort.

It is a somewhat cynical take on the state of patient safety but a provocation that suggests “to err is human”, far from being the start of the patient safety movement, may have delayed it because it encouraged the medicalising and internalising of the effort. Quality improvement pioneer W Edwards Deming himself also talked about a system not being able to improve itself and needing outside help.

At the start of this year, a publication in the New England Journal of Medicine – an update to the 1991 Harvard Medical Practice Study but with different methodology – suggested hospital patients in Boston were harmed in one out of four cases. Far higher than the original HMPS study that suggested an adverse event rate of 3.7 events per 100 admissions. This makes me wonder what the state of the nation in patient safety really is.

The NHS Patient Safety Strategy is over three years old and about to have its second update published. The aim was to avoid 1,000 deaths a year and save the system £100m each year from 2023-24. We did not predict a pandemic, so some work has inevitably been delayed and is being done in an increasingly stressed system. It is still right for us to try and assess the impact of the work as we pass the three-year mark.

The strategy aimed to reform the whole system of safety with prevention ahead of better identification, investigation, action and improvement. At the front of that, the new Patient Safety Incident Response Framework has landed well and we have anecdotal indications of teams saying it has helped improve safety cultures, identify more effective risk reduction strategies, and enhance harm reduction; hard to quantify yet, but much hope for impact.

The Learn from Patient Safety Events service, the NHS’s new and improved national system for the recording and analysis of patient safety events, continues to develop. While changing digital systems always brings challenges, providers are embracing it in the main, and welcoming the great potential it brings. Evidencing outcome improvements as a result is tough but we do have evidence the novel analytics we are now able to apply are enhancing our ability to flag new and under-recognised risks.

Similarly, we know linking improved safety with the creation of the 800 patient safety specialists, a network of patient safety leaders across providers and integrated care boards, or the creation of the national patient safety syllabus, or training is very difficult. That said, evaluation of both shows they are welcome and positive developments.

In the improvement arena, however, we can demonstrate green shoots and arguably more. We have seen a reduction of lives lost in the world of neonatal health running into hundreds and the same for cerebral palsy cases in prems. We have seen the rapidly rising risk from opioid use turn down and a suggestion that more than 300 deaths have been prevented.

In addition, restrictive practice use has reduced in those mental health providers piloting our improvement approach and there are many more examples. I cannot say what the indirect effect of all the work being done across the system is, but I know there is impact from patient safety work – increasing interest and belief in what can be done, increasing engagement of our patients and their families, and recognition harm is not experienced equally.

I am optimistic about the future of patient safety. I don’t accept all that is said by Sutcliffe and Wears, but I do recognise the overfocus on error to the detriment of learning from good practice, that we have spent too much time focussing our efforts on harm that has already happened rather than identifying and addressing issues in real time. We also see more than ever that flow is critical for safety (and a good example of where input from the world outside healthcare could help us) and that we have much more to do.

When the patient safety strategy was first published in July 2019, we recognised it wouldn’t stand the test of time if it was static and not able to evolve with the changing challenges and priorities for the NHS. We committed to update the strategy periodically to ensure it remained relevant and can impact on the areas where need is greatest.

In 2021, through our first strategy update, we introduced fresh focuses on health inequalities in patient safety and supporting the NHS to keep patients safe in light of new risks brought about by the pandemic. In the soon to be published second update, we are adding elements around workforce, flow and capacity, focusing on real time safety issues, and an increased emphasis on learning from where things go well.

These new elements, and the continuation of key transformation programmes such as PSIRF and LFPSE, build upon the strategy’s original key pillars of culture, continuous improvement and effective patient safety systems. These remain fundamental in supporting the NHS to deliver safer care for all. We continue to grow our understanding of patient safety, supporting people to engage with patient safety, and focusing on making meaningful improvements in areas that will have the most impact.

We should be spurred on by our progress and re-energised by the opportunities. We can accept there is more to do but not be too quick to beat ourselves up for not having done it all so far.