Across the world avoidable medical errors, the result both of individual mistakes and system flaws, cost millions of lives. In the US, such iatrogenic morbidity has been calculated to cause up to 250,000 excess deaths a year, while safety failures may cost 11,000 lives in the NHS in England every year. Niall Dickson, chief executive of the NHS Confederation, looks at NHS Improvement’s recently published patient safety strategy and what it means to the NHS.
The publication this month of a patient safety strategy for the health service in England by NHS Improvement is therefore a welcome acknowledgment of how critical the journey to a safer system will be and the huge potential for preventing harm and saving lives.
In recent years there has been a welcome interest in this area and a recognition both of the scale of the problem and our ability to do something about it. Thankfully we have left behind a world in which professionals and the institutions in which they worked were to be flawless and unchallengeable or where all services were regarded as the same.
The journey started with the seminal considered report from the Institute of Medicine in Washington, To err is human, which for the first time signalled the extent to which healthcare is a safety critical industry, comparable in many (though not all) ways to aviation and nuclear power.
The most powerful testimony in this country came with Don Berwick’s 2013 report on safety, A promise to learn – a commitment to act, which called for the quality of patient care, especially patient safety, to be set above all other aims. His other principles are worth rehearsing:
- to engage, empower and hear patients and carers at all times
- to foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work
- to embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.
The new strategy seeks to build on this, although surprisingly it pays little explicit attention to what has worked and what has not worked since Berwick, nor is there any mention of the powerful work in Scotland on patient safety.
But it does set out a series of practical measures for the centre and for the service, as well as building on the new safety alert system. In keeping with the broader digital strategy for the NHS, the overhaul of the system used to process patient safety reports is welcome, as is the move to bring it in line with modern technology standards.
Realising just these technical ambitions will require major changes across the service which touch every area of clinical practice. It will mean bringing together advanced interoperable clinical information systems to provide a detailed record of every aspect of the patient journey through the NHS.
There is acknowledgment too that the NHS does not yet know enough about how the interplay between individuals and systems determines, but there is a welcome if familiar rejection of the blame culture which encourages cover up and the closing of ranks.
Fear is certainly the enemy of safety and, as Berwick stressed, above all we do need to continue to foster a learning culture within every healthcare institution, together with the systems and processes which help to ensure safe care.
Much of this is down to local leadership and values although this needs to be done in conjunction with clinical leadership, professional bodies and professional regulators. The centre can also support both through its own actions and behaviour and helping to spread good practice.
The strategy is therefore in part a call to arms, and it does set a target – it suggests we could save almost 1,000 lives and £100 million each year from 2023/24 if we share insights and empower staff. In some ways you might regard this as a modest ambition, but it is at least a good start.
The key lies in having the right systems in place but also professional behaviours – today nurses, doctors, allied health professionals and other members of the team are much more willing to challenge each other’s practice, thousands of multi-disciplinary teams reflect on safety issues every day and indeed patients are increasingly encouraged to be safety monitors (The strategy envisages a nationwide system of patient safety partners). The introduction of revalidation for both doctors and nurses is a critical measure to foster the reflective practice that is so important in creating a safe culture as is the growth of quality improvement in its various guises.
The ideals of this strategy – insight, involvement and improvement – are laudable. But they will not be nurtured by more top down regulation – for example by bestowing further new statutory powers on the Healthcare Safety Investigation Branch (HSIB) or worse by creating a regulator for senior managers in the NHS.
Likewise, while the creation of a medical examiner system is welcome to improve learning from deaths, the quality of death certification and the experience of those who have been bereaved, we must make sure any national oversight of this programme does not undermine the local autonomy in emerging NHS integrated care systems.
The strategy sets the right direction of travel for safety in the NHS – seeking to restore the faith of staff and patients in the health service’s ability to respond to mistakes and learn from harm so that it can be avoided in future. Its success though will be dependent on the extent to which this agenda becomes a social movement within the healthcare system and that, much more than performance management, is what we should be stimulating.
The key to realising this ambition then will be making NHS organisations have the commitment, the resources and the autonomy to put safety at the heart of everything they do.
Niall Dickson is chief executive of the NHS Confederation. You can follow him on Twitter @NHSC_Niall and the Confed @nhsconfed