Roundabouts, groundhog days and patient safety in the NHS

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In this post John Tingle discusses the circular nature of NHS patient safety policy making, practice and warns about the risk of health care staff becoming desensitised by the frequency of patient safety reports into crises and repetition of messages.

John Tingle

The Parliamentary and Health Service Ombudsman (PHSO) has recently published a report describing recent casework, unpacking themes, and making several recommendations. In the report there is a discussion of what can be termed an ‘implementation gap,’ also seen in the report by the Charity, Patient Safety Learning. That there is a gap between sophisticated, centralised DHSC (Department of Health and Social Care) patient safety policies, the health care regulatory, governance framework and as to what happens in the NHS workplace. That key patient safety messages seem to get lost and don’t permeate down to the NHS workforce which inhibits proper culture development. Patient safety lessons go unlearnt, and errors continue to happen, evidenced by the frequency of crisis reports that are published. We have had in recent times, Shrewsbury, and Telford, East Kent and others.

The PHSO Report

The PHSO stated:

“And yet, it is clear from the analysis of our most serious patient safety cases through this report that there is a gaping hole between best practice policy and consistent real-life practice” (p7)

In the report the PHSO points to a fragmented and confusing patient safety regulatory, governance landscape with organisations have overlapping functions. A call is made for the DHSC to commission an independent review to determine what an effective patient safety organisational oversight landscape should look like.

The PHSO shares other insights in the report such as reviewing the operation of the duty of candour and themes from complaints investigations.

In terms of the direct causes of harm which led to avoidable patient death in the complaint investigations analysed in the report, the following themes are identified:

“-failure to make the right diagnosis.

-delays in providing treatment

-poor handovers between clinicians

-failure to listen to the concerns of patients or their families” (p8).

This is a hard-hitting report with the PHSO expressing well founded concerns over the present patient safety systems that operate in the NHS in England and the worrying repetition of errors which can result in avoidable patient deaths.

The patient safety roundabout

The PHSO report is one of several recent ones that have advocated what can be regarded as root and branch patient safety reform. The PSA (Professional Standards Authority) in 2022 expressed similar views in their report. They too pointed to structural failings in the NHS patient safety framework and that each organisation can view incidents through their own organisational remit lens, prejudging solutions:

“Structural flaws in the safety framework: 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 PHSO and PSA tread on a well-worn path of patient safety reform insights and proposals which. have appeared before in other reports over several years.

In reading these reports the reader does get a sense of déjà vu, of being on a patient safety roundabout or stuck in a Groundhog Day event cycle. That the same type of messages can be seen to be repeated time after time. There is a danger that NHS staff could well become desensitised by the recurrent patient safety messages. These could well morph into just being seen as well-meaning mantras.

Given the size of the NHS workforce and the high level of clinical activity there is a need to focus more on the professional accountability and responsibility of doctors, nurses, and other health carers. On professional duties to keep up to date with changes, developments in clinical practice. All professionals maintain a duty to practice reflectively, to communicate properly between each other and with their patients, clients. This is all an essential prerequisite of being called a professional. This approach should be explored more in NHS patient safety policy making and practice. It is preferable to what I see happening now which is a too stringent focus of bundling everything, patient safety wise around system approaches, focussing on no-blame cultures, deemphasising individual fault to mitigate against a generally perceived defensive NHS culture when things go wrong.

This blog is based on my British Journal of Nursing (BJN ) fortnightly column: Issue No15 2023.


John Tingle, Assistant Professor, Birmingham Law School, University of Birmingham


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