Not harming patients has been a key principle of professional medical practice for at least 2,500 years but nevertheless patient safety remains a concern not just in the NHS but in all healthcare systems. It is estimated that annually up to 30,000 patients die in the NHS as a result of avoidable medical errors. In this article, we ask what more can be done to make NHS care safer.
The Quality Agenda
Patient safety is not a new concept, the Labour government having started the quest to improve the quality of NHS care by introducing the “quality agenda” in 1997 as a 10 year plan to modernise the NHS. The key to the framework for quality improvement was:-
- To produce clear quality standards through the introduction of the National Institute for Clinical Excellence (NICE) which would provide guidance on clinical and cost effectiveness and National Service Frameworks to help raise standards of care and reduce unacceptable variations.
- Effective local delivery of standards through a new system of clinical governance to be underpinned by lifelong learning for health care professionals and modern systems of regulation.
- Strong monitoring mechanisms
Is patient care any safer?
Ten years on many would ask whether, overall, the NHS has been made safer as a result of the policy innovations introduced over the past decade. Broadly the answer to this question is yes. It is reported that every 36 hours a million people use NHS services and the vast majority are treated safely and effectively. However, there remains a significant percentage of patients who suffer some form of harm during their care, too much of which is avoidable.
- At least 100 patients are dying or suffering serious harm each year after they are given the wrong medication.
- A recent report indicated that 33 deaths of children and 39 deaths of new born babies had “indicators of avoidable factors”.
- Up to one in ten hospital patients are harmed by their treatment, while errors occur in primary care anywhere from 5 to 80 times per 100,000 consultations (between 40 and 600 errors a day).
- 12% of deaths or serious injuries were attributed to cases of mistaken identity due to inconsistency of colour-coded patient wristbands in the NHS.
The above statistics are, however, likely to be an under estimate due to under reporting.
What more can be done: The Health Select Committee Report
This detailed review of patient safety in the NHS concluded that there are significant deficiencies in current government policy on patient safety. Set out below are the main criticisms raised by the Committee and the corresponding progress made by the NHS and others to meet these criticisms.
Measurement and evaluation
Whilst the Committee accepted that reporting incidents is a useful tool from which to learn, their view was that it is not a reliable way of measuring the extent of the harm caused. The Committee recommended that in order to monitor whether patient services are getting safer, data on incidence of harm must be systematically collected by Hospitals and gathered at a national level by the NPSA.
The NPSA has, since 2001, had a system in place to do just
that. The National Reporting and Learning Service provides an
online service to NHS Trusts to report incidents, whether they
result in harm to patients or not. The reports are then analysed to
identify common risks and opportunities to improve patient safety.
Feedback and guidance is given to the NHS Trust to improve patient
safety. However, the success of this system relies upon Trusts to
report incidents. It is recognised that there is a problem with
under-reporting in the NHS but this is something the NPSA is
working with NHS Trusts to improve.
In addition, whilst improvements in data collection may help to make patient care safer, in the Government’s response to the Committee’s report, it indicated that large scale reviews of patient records all over the world are remarkably consistent in showing that 10% of all patients admitted to hospital will experience some form of harm associated with their admission. Not all of this harm is preventable or serious. The government indicated a careful cost analysis would need to be undertaken to establish whether more frequent reviews would actually improve patient safety.
Harmed patients, their families and carers
The Committee indicated that patients who have suffered harm are entitled to receive information, an explanation, an apology and an understanding that the harm will not be repeated. Specific criticism was made by the Committee of the Department of Health’s failure to implement the NHS Redress Scheme resulting in most harmed patients instead enduring lengthy and distressing litigation to obtain justice and compensation.
To improve the culture of openness in the NHS, the NPSA has reviewed the existing ‘Being open’ policy. This encourages the NHS to apologise and explain what has happened to patients who have been harmed as a result of a patient safety incident. This has also been endorsed by the NHSLA who encourage timely and meaningful apologies and stress that no point will be taken against any NHS body or clinician seeking NHS indemnity on the grounds of an apology or explanation provided to patients in good faith. Apologies do not constitute admissions of liability. The MDU, MPS, MDDUS, RCN, NPSA, BMA and GMC have all signed up to this advice in a joint letter dated 1 May 2009.
Patient safety at the front line/ an open, reporting and learning NHS
The Committee was concerned that known patient-safety solutions can sometimes fail to be adopted at the front line in the NHS and at times a culture persists in the NHS which accepts that easily avoidable harm is an inevitable risk of treatment. The Committee’s view was that the NHS lags behind other safety-critical industries in recognising the importance of effective team working and other non-technical skills to address these issues.
This issue has most recently been highlighted by the Patient Safety First campaign which has raised awareness of the importance of “human factors” in delivering improvements in patient safety. For example, it is reported in the airline industry that human factors are present in 75% of aviation accidents. The airline industry, therefore, seeks to train its staff to better understand human factors and designs equipment and manages procedures with human factors in mind. It is part of the airline industry’s everyday language. The Patient Safety First campaign is seeking to bring human factors into the everyday language of NHS care too.
Commissioning, performance management and regulation
The Committee highlighted the key role for Primary Care Trusts in commissioning services with an eye to the quality and safety of those services but found that regulation has been costly and burdensome and has failed to pick up major failings in some cases. The Committee criticised the performance management role of Strategic Health Authorities (SHAs) which it considered to be ill-defined. It also concluded there is a lack of clarity about the role of Monitor.
It is hoped that with the increase of information about the safety for a particular Trust’s services, PCTs will be better able to choose providers on the basis of the quality of their services and improve in their role as quality controllers for patients. In addition, Monitor and the CQC have accepted that they need to share information more effectively to ensure failings in patient care are picked up and acted upon. CQC is also working with partner regulators to align their processes and data collections to identify and remove duplication and overlap.
In light of the criticism that Monitor’s role is ill-defined, Monitor has stressed that whilst SHAs manage the performance of PCT commissioners and NHS Trusts, its role is to regulate NHS Foundation Trusts to ensure they maintain the standards required in their terms of authorisation. This includes ensuring that the Foundation Trusts are well led and financially robust, delivering to the contractual obligations with their commissioners. Whilst Monitor does not directly assess standards of care, one of the terms of authorisation to be a Foundation Trust is to maintain registration with the Care Quality Commission (CQC).
Registration (which needs to take place by January 2010) with the CQC requires all providers of health and social care to meet essential standards of care. Providers will also be subject to the full range of safety and quality standards. If your organization has not already registered, please follow this link to our e-bulletin dated 11 November 2009 for your ease of reference.
The role of managers and boards
It was the Committee’s view that patient safety must be a top priority of Boards and, to show this, it should, without exception, be the first item on every agenda of every Board. The Committee also encouraged Trusts to undertake all Board meetings in public for increased accountability. In response, whilst the government does not accept that Boards’ have neglected their duty to promote improvements to services, it accepts that a minority of Boards may have overlooked some aspects of quality by focusing on national priorities. From 2010, all NHS Trusts and Foundation Trusts will have to publish Quality Accounts to ensure Boards focus directly on the quality of care provided by their Trust.
As legislation will be required to force all Board meetings to be held in public the government has indicated it is considering what legislative changes are needed, in light of the failings of the Board at Mid-Staffordshire NHS Trust, but it is difficult to see that this will be a legislative priority.
Summary: What more can the NHS do to make patient care safer?
The key learning points for Trusts from the most recent review of patient safety in the NHS can be summarised as:-
- Encourage frontline staff to report all incidents (including incidents that do not cause harm) and ensure staff are aware of how to report incidents to the NPSA.
- Have systems in place to learn from incidents and try and identify the root cause of the problem to prevent it happening again.
- Encourage a culture of openness; for example ensuring training for staff so they are supported when the need arises to apologise and explain when something goes wrong.
- Ensure staff understand human factors and how they can affect clinical care.
Despite the Government’s attempt to modernise the NHS and reduce risks to patients over the last ten years, there is still a long way to go. The recent Dr Foster report, which scored NHS Trusts on their patient safety measures, found that 12 Trusts were significantly underperforming, 7 Trusts were not compliant with National Patient Safety Agency alerts and that 5024 people admitted with low risk conditions died in hospital last year. However the validity of the report is not universally accepted and legal action has been threatened over the data house’s publication of unexpected patient death rates in UK hospitals which use a methodology that has been described as “fundamentally flawed and misleading to the public”. The increasing use of comparative performance data encouraged in “Putting the Frontline First: Smarter Government” is not without risk. Whilst this may have a role to play in driving up the safety and quality of public services whilst increasing the accountability for the standards and results achieved, will it leave the patient population bewildered?
Policy initiatives alone will not have a dramatic impact on improving patient safety. Front line NHS staff are likely to hold the key in tandem with NHS Boards ensuring that local non-punitive policy exists to provide support.
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