In July 2019, the NHS announced a new strategy for improving patient safety. ‘The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients’ claims to have the potential to save nearly 1,000 lives and up to £100m in care costs each year from 2023/24. So, how will this be achieved, and what does it mean for patients?
Why is a new patient safety strategy needed?
Up until now, the NHS’s approach to patient safety has focussed on individual effort, on the assumption that NHS staff who try hard will avoid making errors. The result of placing all responsibility and accountability on individual healthcare practitioners, instead of accepting that NHS organisations and the NHS as a whole share responsibility with individuals for patient safety, has resulted in a culture of blame. Evidence shows that punishing individual “wrongdoers” does not prevent mistakes being made again. Instead, a new approach to patient safety is needed.
What is the new approach?
The focus now is on developing a culture of learning within the NHS, so that when things go wrong the question becomes ‘what can we learn?’, rather than ‘who can we blame?’.
There is a new recognition that errors are usually made honestly (i.e. they were not intended), or involve wider problems, such as the systems and structures in place, including issues caused by staff shortages.
There are 3 pillars to this strategy which are:
- Insight – increasing understanding, by making better use of patient safety data;
- Involvement – providing patients and staff with the skills and opportunities they need in order to improve patient safety;
- Improvement – designing and supporting programmes and initiatives in specific areas, such as maternity care.
Some of the specific recommendations include creating a patient safety syllabus and education framework for members of NHS staff at all levels from ‘ward to board’, developing existing staff and appointing them as patient safety specialists, along with introducing a new national incident management system and a new medical examiner system so that patient deaths receive greater scrutiny.
What difference will this make to patients?
Many of our clients who have suffered avoidable harm from medical negligence tell us that they would like to ensure that no one else suffers in the same way. Sadly, we cannot reassure them that their claim will change others’ experience because we tend to see the same mistakes being made time and time again.
The NHS needs to be willing to learn from its mistakes and accept responsibility for the true causes of its failings. Part of that process includes listening and communicating openly with patients who have been harmed. The new strategy accepts that patients who have been harmed by the NHS have a role in contributing to staff training and becoming patient safety partners. In an organisation which historically has been defensive towards injured patients, this must be regarded as a step in the right direction and a good thing for both the staff, and the patient.
So, the key to this new strategy is inclusivity. Everybody throughout the organisation is to be encouraged and empowered to take patient safety seriously. If the information generated can be harnessed effectively to bring about changes in patient care, then the opportunities for learning and reduction in patient harm could be enormous.
Learning needs to be applied if it is to make a difference, and the strategy identifies certain key priorities, such as using technology to halve the number of drug errors, and to prevent falls in hospitals by identifying and supporting frail patients.
Another key area is maternal and neonatal safety, an area in which mistakes cause devastating harm to babies and lifelong hardship to their families, and which accounts for a large proportion of the NHS’s spending on negligence claims. The strategy reflects the Department of Health and Social Care’s ambitious target of halving the rate of stillbirths, neonatal deaths and asphyxial (oxygen deprivation) brain injuries by 2025.
Only time will tell whether these commendable goals will be achieved, however, if workable, the strategy has the potential to vastly improve the experience of all those working in, and being treated by, the NHS.