By Dr Fiona Moss
All health systems worry about patient safety. Not only are lives lost or changed by failures in the health system, but avoidable harm is expensive and a drain on scarce resources. The NHS Patient Safety Strategy, published in July 2019 (1), addresses this harm and outlines how the NHS can develop a safety culture, support all its staff to act safely throughout the NHS, and focus on specific areas of improvement. To support this the Academy of Medical Royal Colleges (AoMRC) has just published the first national patient safety syllabus – for all 1.3m staff in the NHS (2).
The costs of failing to tackle patient safety have been enumerated in many ways, but the numbers are terrifying and reflect pain and harm to individuals. The NHS Patient Safety Strategy estimates the number of deaths from patient safety incidents as 11,000 each year. There are another 33,000 patient safety related disabilities and 110,000 patients requiring more treatment as a result of a patient safety incident. And that is just in hospitals.
The data available from primary care is more limited but the estimate is 22,000 incidents. These figures are not new. The estimates have come from published research and care has been taken to ensure that error-related deaths and harm are distinguished from the inevitable complications that attend medical interventions. What is new is that the figures are presented in support of a strategy that is written for the whole of the NHS and is designed to make a difference.
A seminal book from the US Institute for Medicine To err is human, published in 2000, focused on the faults that make all health systems unsafe and the designs needed to be built into health systems to reduce the possibility of unsafe actions happening.(3)
Problems with safety are pretty much the same in all health systems. All the research and comment and opinion on patient safety make it clear that “fixing patient safety” is a matter for the whole system of care. Solutions lie in somehow developing “safer systems” operated in the context of a “safety culture.” It is about understanding the human factors integral to the complexity of health care; how we work together; how we operate as teams; how we design safety into our care systems; and how we promote a safety culture that takes all this into account and essentially makes it difficult for errors to occur. But moving beyond understanding to knowing what needs to change has proved difficult. Perhaps the NHS Patient Safety Strategy offers a glimmer of a way forward: there are some signs that it might.
First, in the words of the forward, this strategy has been “curated” on behalf of the NHS. So, rather than being the product of a small group working on what they know, it is based on a six-month e-consultation process (4) supported by stakeholder meetings and focus groups. In addition, it is based where possible on evidence: it is a short paper but has over 100 references.
Second, there is a realistic and essential focus on the workforce. In the forward, Dr Aidan Fowler, National Director of Patient Safety, states that the strategy has “collective” intent to improve safety and recognises that to make progress, “we must significantly improve the way we learn, treat staff and involve patients”. Staff who are treated well, feel valued and who work in functional teams supported by good leaders, deliver better care (5) and safer care. The word kindness appears in the strategy, too. Focusing on supporting staff would seem to be an essential first step in developing a safety culture. But just as important as the focus on culture, the strategy recognises the impact of short staffing on safety. Work arounds become the order of the day when grappling with rota gaps and long hours. Successful implementation of this patient strategy will depend very much on effective recruitment and retention of staff as set out in the NHS Long Term Plan.
Thirdly, it is clear that this is a multi-pronged approach. The foundations are, as expected, the development of a safety culture and safer systems. The strategy is organised into three strands: insight, involvement and improvement. Briefly, insight is the real time awareness of the fragility of systems and the collection and collation of relevant data. Unsafe events are easier to predict and prevent if they are known about and understood, and easier to understand if they can be seen, that is, there is objective evidence.
So, a focus on measuring is crucial if an understanding about patient safety is to reach all parts of the NHS and have local impact. Involvement is the strand of work that aims to ensure that everyone who works in the NHS, and patients and carers too, have the skills and knowledge to be able to make care safer.
The final strand, improvement, includes, through commitment to deliver the National Patient Safety Improvement Programme, a continuation of the focus on preventing avoidable deterioration and also a focus on some specific areas: maternity and neonatal care; the Medicine Safety Improvement Programme; mental health safety; supporting safety improvement in priority areas including learning difficulties and older people; and antimicrobial resistance. There is also a commitment to support research and innovation in safety improvement.
Each organisation within the NHS is responsible for the safety of patients in its care. But this strategy looks beyond individual organisations, to the connections between parts of the NHS. It asks organisations to share local information and for CCGs and integrated care systems to oversee the provision of safe care across health economies. All of this will be supported by the national patient safety team.
Perhaps the most encouraging aspect of the NHS Safety Strategy is the commitment to ensure that all who work in the NHS know about safety. In other high-risk industries, the whole workforce learns about safety: the NHS should be no different. The new AoMRC patient safety syllabus suggests that this commitment is real.
By ensuring that all NHS staff learn about safety, the NHS Safety Strategy argues, concern about safety will change from being a reactive process that kicks in after harm has happened, to being proactive and part of the routine of a workforce who understand the antecedents of unsafe care; can speak up about the risks they see in their daily work; and are employed by organisations who can respond and make systems safer.
The aspiration is that from the syllabus, training programmes relevant to all 350 NHS career pathways will be developed and delivered to multidisciplinary teams. And for those a bit rusty on the difference between a syllabus and a curriculum, there is a helpful two-pager that outlines how to translate the syllabus into a curriculum (the syllabus is the high level outline of the broad content of a course and allows for future changes; the curriculum goes into more detail and is designed for particular groups and levels).
As a document designed using educational principles the syllabus has clearly articulated outcomes; is organised in five domains (systems approach to patient safety; learning from incidents; human factors and safety management; creating safe systems; and being sure about safety) and is expressed through four key themes (systems expertise; human factors; risk expertise; and safety culture).
The RSM, as a provider of CPD programmes across specialties is in a unique position to embrace this patient safety syllabus. The RSM Patient Safety Section will no doubt be discussing the implications and roll out of both the NHS safety strategy and the patient safety syllabus, but the patient safety syllabus has relevance for all RSM Sections.
So, the NHS has its first patient safety strategy and has clearly put education at the heart of its strategy for implementation. Much organisational effort will be needed at a time of significant stress and staff shortages to make sure that all this work is not simply put in the “too difficult to do now” pile. Getting to grips with the problems that make health care unsafe has be made a priority: there is no best time to start. Unsafe care causes too much harm and costs so much in so many ways.