By John Tingle
The English National Health Service (NHS) was 75 years of age on 5th July 2023 and there was a lot to celebrate. We are proud of our universal health care system which provides free care at the point of delivery. The NHS is an intrinsic part of our national heritage and culture.
The King’s Fund provide some facts and figures on the NHS. It has one of the world’s largest workforces with around 1.26 million full-time equivalent staff in England, as of November 2022. In terms of patient care and treatment, the King’s Fund states that on an average day in the NHS, more than 1.2 million people attend a general practitioner (GP) appointment, and around 260,000 an outpatient appointment. The NHS faces high demand for finite health care resources. We have a growing elderly population in England presenting often with comorbidities. Staffing levels are also a problem, which is being addressed in the NHS long term workforce plan.
The NHS model of care delivery
The NHS is a particular model of health care delivery, and, when discussing patient safety, policy, and practice, the context of care delivery must always be taken into account. The facts that the NHS provides free health care, is very busy, and is an organization of immense size with a large compliment of staff do not provide an excuse for compromised health care standards. (Though there is no evidence of this excuse being used.) In actuality, there is a lot of good patient safety development work going on, including the NHS’ National Patient Safety Strategy and Syllabus, and the new Patient Safety Incident Response Framework (PSIRF) holds out a great promise in helping the NHS further develop an effective patient safety culture.
Patient safety crises
All that said, the NHS is still rocked by major patient safety crises, despite having a sophisticated, highly engineered patient safety health regulatory and governance framework. Key patient safety messages do not always seem to permeate down to key sections of the NHS workforce to effect positive practice change.
This problem was noted as far back as the year 2000 in the seminal report “Organisation with a Memory” and still holds true today. Issues include staff failing to learn the lessons from past adverse health care treatment events and not sufficiently changing practice. Past and contemporary national reports of investigations into major patient safety crises reports confirm this; these include Mid Staffordshire, Morecambe Bay, Shropshire and Telford, East Kent. Dr. Christopher Sirrs provides an NHS Patient Safety Timeline that catalogues these crises.
We know what the patient safety problems are
The NHS’s patient safety problems have been well documented and today there is a veritable tidal flow of international and national patient safety policy and practice information coming from a myriad number of stakeholders.
Within the NHS, after each patient safety crisis, a detailed investigation report is produced saying the same or similar thing to all the other past reports. There is often a commonality of themes and problems identified.
Given the vast size of the NHS workforce and high level of activity, permeating down patient safety messages and policies was always going to be a problem.
However, given the frequency of national investigation reports into patient safety crises in the NHS, all containing the same or similar messages, this could well lead to staff tuning out the messages because of repetition, becoming desensitized by them. The Care Quality Commission (CQC) noted in their report the problems caused by multiple patient safety messages emanating from national organizations:
“This adds pressure on trusts who often feel overwhelmed with the volume of guidance, and makes it difficult for them to prioritise what needs to be done.”
An implementation gap
The Parliamentary and Health Service Ombudsman (PHSO) recently published a report pointing out the gap between what we know in terms of patient safety policies and good practice, research into causes of patient safety errors, and what actually happens in practice. That there is a mismatch or gap between what we know and what we do. The fact that we also still have major patient safety crises in the NHS shows that we have what can be termed an “implementation gap.” The PHSO states:
“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.”
The charity Patient Safety Learning has produced a report on the “implementation gap,” and state:
“We consider that a key reason for the persistence of avoidable harm is an ‘implementation gap’ in patient safety in the UK, the difference between what we know improves patient safety and what is done in practice.”
The Patient Safety Learning report and PHSO report both provide an excellent contemporary analysis on the current state of patient safety in the NHS.
Conclusion
In discussing patient safety issues, we must always take into account the model of health care delivery being used. There is a lot of good patient safety development going on in the NHS in England, and it has been going on for some time. We have excellent patient safety, health regulatory and governance infrastructures, and policies, but there are problems of delivering key messages to staff at the workface. Patient safety lesson learning in the NHS has been poor, as we can see from past and current national investigations into major patient safety crises.
The danger now is that as we have such a wealth of intelligence on patient safety matters through reports and information coming from a myriad of national and international stakeholders that some NHS staff could possibly suffer from patient safety information overload. Repetition of messages could result in their loss of impact and meaning to staff.
A possible solution to help matters could be for patient safety policy makers and leaders in health quality, regulation, and governance to focus far more on emphasizing to health care providers their individual professional responsibilities to update practice reflectively, rather than looking at centralized command and control systems to drive change.
