We have significantly high levels of harm resulting from adverse patient safety incidents in the NHS and have had so for several years. The NHS should apply the same good resolve, commitment and resources that it has shown in dealing with COVID 19 to the NHS patient safety problem.
By John Tingle.
After the COVID-19 pandemic ends everybody will go back to a, ‘new normal’ life including the NHS. Areas of clinical practice in the NHS will no doubt change. A key issue to consider in life after the pandemic is whether the NHS will improve significantly on its patient safety record? Will there be less avoidable patient harm, less ‘never events’ occurring, less headline grabbing patient safety crises? It is fair to say that patient safety crises regularly appear in our national media and they have done so for many years. Will these crises continue to appear at the same rate after COVID-19?
Unfortunately, history has not served the NHS well when it comes to patient safety and learning the lessons from past adverse health care events. In the year 2000 the seminal NHS patient safety document, ‘An Organisation with a memory’, was published .This document stands today as a salutary reminder that we have a long way to go before we can say today, 20 years on, that we have managed to create an ingrained patient safety culture in the NHS:
“The NHS does not, in our experience, learn effectively and actively from failures. Too often, valid lessons are drawn from adverse events but their implementation throughout the NHS is very patchy. Active learning is mostly confined to the individual organisation in which an adverse event occurs. The NHS is par excellence a passive learning organisation. “(p77-78)
To what extent does this year 2000 statement hold true today? I would argue that it does hold true today. Whilst some improvements have been made to how the NHS learns from avoidable adverse health care events to patients much more needs to be done. The NHS can significantly improve on its record.
In 2018 the CQC (Care Quality Commission) looked at NHS safety culture and the need for transformation. The CQC pointed to endemic problems in NHS patient safety:
“The current patient safety landscape is confused and complex, with no clear understanding of how it is organised and who is responsible for what tasks. This makes it difficult for trusts to prioritise what needs to be done and when. Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and greater clarity around the roles of the various organisations that send these messages.” (p23).
In 2019 the NHS national patient safety strategy was published which maintains a promising potential to make our NHS safer.
The NHS has been no sloth over the years in developing and publishing well-crafted, researched patient safety policy papers and reports. Unfortunately, endemic patient safety problems stubbornly persist and continue to blot the NHS care landscape. NHS England and NHS Improvement give an analysis of the patient safety incidents reported in England to the National Reporting and Learning System (NRLS) up to September 2019.
The report states:
“Nationally, most incidents are reported as causing no or low harm. Almost three quarters were reported as causing no harm (72.6%; 1,564,635) and 24.4% (525,885) as causing low harm (Table 5). Only 2.5% (53,839) were reported as causing moderate harm, 0.3% (5,647) as causing severe harm and 0.2% (4,283) as causing death. This pattern is consistent with data for October 2017 to September 2018.” (p13)
Peter Walsh the chief executive of the charity for patient safety and justice patient, AvMA (Action against Medical Accidents) discusses the death rate caused by COVID 19 and the significant harm, death rate in the NHS caused through lapses in patient safety. He states:
“Many people have said things will never be the same after COVID19. When it comes to patient safety, I hope they are right. If the country can rise to the challenge of COVID 19 and can come up with the billions of pounds being spent to do so, and achieve brilliant things like setting up emergency hospitals in a matter of weeks , it should be obvious that investing in our NHS to prevent the horrendous amount of avoidable every year makes sense. Yes, it will cost money, but it will save lives-just like we are doing with the pandemic” (p2)
The figures above from NHS England and NHS Improvement show that there are over 60,000 incidents causing moderate harm to death. Compare this figure to the current UK COVID 19 death rates, currently standing at just under 30,000 at the time of writing. Failures in NHS patient safety can also be seen to cause significant harm.
The NHS has done remarkable things during the COVID-19 pandemic and has spent a considerable amount of money fighting the pandemic. This level of enthusiasm, resolve, commitment and resources should also be waged against avoidable patient error as that equally causes significant harm and sometimes death.
John is a lecturer at Birmingham Law School, University of Birmingham, where he specialises in health law. He has a particular interest in issues relating to clinical negligence litigation and patient safety. He has a fortnightly column in the British Journal of Nursing. He is a frequent contributor to the Bill of Health published by the Petrie-Flom Center at Harvard Law School where he was a Visiting Scholar in November 2018. John is also a Visiting Professor of Law at Loyola University Chicago, School of Law.