John Tingle
Three patient safety reports have been published in recent months which have given the NHS pivotal watershed moments to reflect on its efforts to develop an effective NHS patient safety culture. These reports are by the Professional Standards Authority (PSA),the Independent Investigation Into Maternity and Neonatal Services in East Kent and the CQC (Care Quality Commission).
Both collectively and individually they paint a worrying picture of how far the NHS is in England from developing a proper and effective patient safety culture.
PSA Report
The first report which has caused me to question the current NHS patient safety trajectory, pace of improvement is by the Professional Standards Authority (PSA) for Health and Social Care whose organisational origins were borne out of recommendations made in the seminal Learning from Bristol report into events at Bristol Royal Infirmary and children’s heart surgery. The inquiry chaired by Professor Sir Ian Kennedy made recommendations which included the need to improve professional regulation in health care.
Safer care for all
The PSA’s wide-ranging report contains several recommendations which address acute patient safety issues, challenges and concerns for patients and service users, currently and for the future. The current state of professional health and care regulation in the UK is discussed along with several other related issues. The report is structured around four main themes:
- Tackling inequalities
- Regulating for new risks
- Facing up to the workforce crisis
- Accountability, fear, and public safety
Structural flaws in the safety framework.
The PSA state in the report that a sector-wide problem of structural flaws in the safety framework was identified when these themes were examined.
The report states:
“…the patient and service user safety landscape is fragmented and complex. Concerns raised often fall between organisations or are left unaddressed due to jurisdiction issues or insufficient powers. Large-scale failures of care still occur frequently, and inquiries and reviews highlight similar themes and issues, with the system seemingly unable to prevent their recurrence.” (p10).
The report goes on to state under this heading that organisations maintain a singular lens within which they view safety problems. They principally use their own organisational remit as a focus from which to view things. As a result, we get a siloed approach to patient safety problem resolution. That the nature of the solutions is often being prejudged under our present system. A more expansive, multi sectorial overview approach across the health care and service user sector is needed.
The central recommendation
The central recommendation made in the report is for the appointment of an independent health and social care safety commissioner (or equivalent) for each UK country:
“An independent Health and Social Care Safety Commissioner (or equivalent) for each UK country to identify current, emerging, and potential risks across the whole health and social care system and bring about the necessary action across organisations. (p11).
This recommendation would envisage a much broader role from the current Patient Safety Commissioner for England ,(PSC) who has a more restricted remit. The report would give the PSC a coordination role for public inquiries and reviews into patient safety and to monitor the implementation of recommendations. “The report identifies:
“…a structural gap that appears to be hindering a more joined up, coherent approach to inquiries and reviews.” (p70).
A wide-ranging report
The report is a detailed and wide ranging one, traversing beyond the PSA’s own organisational remit to further encourage public discussion and debate of these pressing and critical issues. Reading the report, it is hard to disagree with the identified themes as critical issues that need to be urgently addressed.
Topics discussed in the report include work cultures, individual, professional accountability, just cultures, no-fault compensation systems, safe spaces and so on.
An NHS poor at lesson learning
A point that I have made on several occasions before is that the NHS is poor at learning the lessons from past adverse health care events and to changing practices. Patient safety reports published well over two decades ago show the same type of errors being repeated today. For example, we can see this happening with ‘Never Events’ in the NHS such as operating on the wrong limb, wrong patient, foreign bodies left in patients and so on. Never Events’ arguably can be seen to morph into ‘Common Never Events.’
These incidents are regularly reported and can be seen to be a stubbornly persistent feature in the NHS care environment. The PSC may be able to address this issue and others in a much more positive way than is currently being done so at present in the NHS.
Conducting policy checks
Another envisaged function of PSC in the report would be to:
“Carry out policy checks to ensure that any new national approaches linked to patient and service user safety are coherent with, and do not undermine, existing mechanisms to the ultimate detriment of patient safety” (p.85).
The PSA expresses concerns in the report about the Safe Spaces policy for national investigations and the HSIB (Healthcare Safety Investigation Branch).
Baby steps not enough
As a basic premise, you cannot dictate and develop a patient safety culture overnight. We do however have to make more positive, sustained progress towards implementing recommendations that are made in patient safety inquiry reports and in other reports about adverse health care events, health quality.
The same patient safety problems are reoccurring with alarming regularity which must imply that significant sections of the NHS are not learning from past adverse events and taking up recommendations made seriously enough. Further, that the information contained in the reports are not being widely disseminated across the NHS.
Not all recommendations, can and should be implemented.
The Government can and does in its responses to public inquiry reports disagree with some recommendations made. Similarly, they might not always be applicable to all health organisations or more research is needed to evaluate their efficacy. We could not have a one size fits all approach when it comes to recommendation follow up by the PSC.
An agenda for change
The PSA report creates an important agenda for discussion and change, usefully keeping alive the patient safety debate. The report reminds us clearly of the failings of our NHS patient safety system and how far away it is from developing an effective, joined up culture within a currently fragmented health regulatory system. All this being compounded by history not serving the NHS well when it comes to patient safety lesson learning from past adverse health care events.
Enormous and controversial tasks
These envisaged functions in the report of the PSC, on the face of it, look enormous and controversial. There are dangers that they could provoke conflict with established health and care regulators. Clashes of organisational autonomy, conflicts, agendas, remits and so on could result. That said, an attempt by the PSC at coordination, analysis and follow up of activities, recommendations would be a welcome matter hopefully having the benefits discussed in the report. The report contains laudable aims but whether they are all achievable in practice remains a matter of intense conjecture.
The report of the independent investigation into maternity and neonatal services in East Kent
This is a harrowing a difficult report to read because of the dire and terrible events reported. The readers confidence in the NHS can take a serious hit when reading it. The question of how such adverse events could be left to occur in a modern NHS trust in the NHS in England today in my view beggar’s belief. All calling into serious question the degree of progress that the NHS has made in developing a patient safety culture. The report found a discernible pattern, themes that led to terrible problems and failures occurring.
Consequences of failures:
The consequences of failures are starkly stated in the report:
“Had care been given to the nationally recognised standards, the outcome could have been different in 97, or 48%, of the 202 cases assessed by the Panel, and the outcome could have been different in 45 of the 65 baby deaths, or 69% of these cases.
The Panel has not been able to detect any discernible improvement in outcomes or suboptimal care, as evidenced by the cases assessed over the period from 2009 to 2020. (p1)”
Failure patterns
The report discusses the failure patterns found and goes into detail on the evidence given by staff, patients, and others. The comments they made are often disturbing to hear and show the full extent of events and problems that should never have happened.
“1.2 We have found a clear pattern. Over that period, those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.(p.1)
The report states that these poor behaviours by staff were visible to senior managers and the trust board through reports made to them. These failures: “… lay at the root of the pattern of recurring harm.” (p1).
The report identifies what it terms gross failures of teamworking. Problems between the midwives, obstetricians, paediatricians, and other professionals at East Kent which led to dysfunctional working practices. This all translated into suboptimal care.
“Some staff have acted as if they were responsible for separate fiefdoms, cultivating a culture of tribalism. There have also been problems within obstetrics and within midwifery, with factionalism, lack of mutual trust, and disregard for other points of view.
1.22. We found clear instances where poor teamwork hindered the ability to recognise developing problems, and escalation and intervention were delayed. “(p3).
Other issues identified in the report include:
-Failures of professionalism
-Failures of compassion
-Failures to listen
-Failures after safety incidents
-Failures in the Trust’s response and at Board level.
The inquiry report at East Kent was chaired by Dr Bill Kirkup who also was the chaired the investigation into maternity and neonatal care failings at Morecambe Bay. It is a good patient safety exercise to compare the East Kent report with Morecambe Bay which was published in 2015.To note the similarities of problems and solutions advanced.
Compounding the problem of poor NHS patient safety lesson learning
This all compounds my comment above about the NHS being poor, at least in some significant quarters, of learning the patient safety lessons of the past and to changing, improving practices.
On the outcome of failures at Morecambe Bay the report states:
“The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS.” (p5)
In terms of our maternity services, the report states that despite several improvement initiatives, service quality is getting worse:
“In fact, our ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (9 out of 139) now rated as inadequate and 32% (45 services) rated as requires improvement. This means that the care in almost 2 out of every 5 maternity units is not good enough,” (p62).
Across the whole health and social care spectrum, the report worryingly states that “In 2022, the health and care system is gridlocked, unable to operate effectively” (p4).
The report contains a detailed discussion of health and social care services and what has been happening with them, stresses, challenges and so on. A most concerning picture of the current state of health and social care in England is revealed.
Conclusion
In summarising these reports and reflecting on the old saying as to whether you view matters from the perspective of a glass being half full, or half empty? I would go for the glass half full viewing perspective on NHS patient safety matters.
Optimistically, I feel that patient safety in the NHS is improving, but I would argue at too slow a pace. There are lots of good patient safety practices, initiatives in the NHS and as the CQC state most people generally receive good care when they can access it. The problem is that reports such as the one in East Kent and Morecambe Bay seriously overshadow, undermine the good work that is being done.
The NHS needs to speed up its patient safety culture development work by learning more from past adverse health care events failures. To also identify and work on the structural and other challenges that the PSA identified in its report and to actively consider the recommendations made.
The problems identified in East Kent and Morecambe Bay strike at the very heart of NHS service delivery and unfortunately these events are not as uncommon as one might believe. As the CQC state, NHS maternity care needs to improve and is getting worse. The patient safety lessons coming from the East Kent and Morecambe Bay reports need to be cascaded more widely across the NHS and that more positive steps are taken to ensure compliance with the recommendations made. Such events as chronicled in the reports are unacceptable by any measure.
On the broader challenges facing the NHS and social care system in England. The CQC report discussions, research of issues ,clear statements of challenges and opportunities does provide valuable insights into patient safety and health quality issues. Insights that will hopefully inform government policy makers, health care leaders, clinicians, and others into making much needed system improvements.