Dr Blogs

Patient Safety in the NHS remains a problem despite all the initiatives

“To know where you are going, you have to know where you have been”, as the old adage goes. As we move into 2017 and with recent patient safety crises in hospitals in mind it’s useful to reflect on what has been achieved over the years since 2000 when the Department of Health published its seminal report, An Organisation with a Memory.

This report set out clearly the patient safety challenges that faced the NHS. Alan Milburn, the then Secretary of State for Health said in the Foreword:

“Too often in the past we have witnessed tragedies which could have been avoided had the lessons of past experience been properly learned.”

Since then we have developed a good top-down, centralised patient safety infrastructure – but all this failed to pick up the tragic events at Mid Staffordshire.

According to The Guardian“A disputed estimate … suggested that between 400 and 1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire”.

Have things significantly improved? The Morecambe Bay investigation in 2015, reports of London’s St George’s Hospital Trust in special measures in November and “wrong baby” security fears at Royal London Hospital reported in December might suggest not.

Governments have tried hard with NHS patient safety initiatives over the years and the policy focus traditionally has been on developing agencies and centralised systems to deal with patient safety error. There are also a number of locally-focused patient safety initiatives.

The Care Quality Commission (CQC) has greatly improved its inspection processes but worryingly its annual report on the state of health care and adult social care in England 2015/16 says that the safety of care is its biggest concern with 10% of NHS acute trusts being rated as inadequate for safety.

The work of the National Health Service Litigation Authority (NHSLA) and the former National Patient Safety Agency (NPSA) have pushed the patient safety agenda forward and hopefully the new Healthcare Safety Investigation Branch (HSIB) will do the same.

In the light of recent news reports, however, it is questionable whether we have our patient safety policy development right. Over the years we have seen duplication of health quality regulatory functions and over-regulation with little conceptual underpinning of what our patient safety system should look like. We have had 17 years of trying to develop an ingrained patient safety culture and as recent events show we still have a long way to go to achieve this.

In the NHS patient safety problems have been around for a long time with the same errors and problems often being repeated. Perhaps energies should now be more focussed on helping ensure that we fully address patient safety at the local level? Ensuring that health carers have a true sense of, ‘patient-centred professionalism’ and ‘advocacy’.

History does not serve the NHS well in regard to its patient safety track record, and we need a new, less centralised approach.

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