Professor Ted Baker, The Chief Inspector of Hospitals at the Care Quality Commission (CQC) has said that there has been “little progress” in improving NHS patient safety over the past 20 years. Baker made the comments whilst speaking at the Patient Safety Learning Conference in London last week.
The comments come after new data was published revealing that up to 11,000 patients a year may be dying as a result of NHS mistakes.
At the conference, Baker revealed that he receives reports of between 500 and 600 reports of “never events” every year. “Never events” are incidents classed as wholly preventable. Earlier this year it was revealed that 621 “never events” occurred in NHS hospitals between April 2018 and July 2019 – the equivalent of 9 patients every week.
Some of the mistakes include surgical tools being left inside the patient, doctors operating on the wrong body part, and multiple instances of ovaries being removed in error during hysterectomies. There were also incidents in which patients had procedures that were intended for someone else, as well as patients that were given overdoses of drugs, the wrong type of oxygen or transfused with the wrong type of blood. Baker recounted one case of a patient who underwent an operation on the wrong eye and, despite being awake for the procedure, felt he could not speak out.
Professor Derek Alderson, president of the Royal College of Surgeons, said such mistakes are “exceptionally traumatic for patients”.
Baker told the conference “These are things that if there was a good safety culture, a reliable safety culture, they just would not happen.”
“I have to say, 20 years later it is very frustrating how little progress we have made,” Baker said, adding;
“It’s clear to me that we still have not got the leadership and culture around patient safety right.”
Baker suggested that an “insidious” culture of defensiveness and blame has prevented NHS leaders from regarding patient safety as a core purpose. Barrister Tom Kark QC, also speaking on the panel, added that there is no requirement for anyone on a trust board to have any knowledge of patient safety. He told the audience that plans for new competencies for board directors are currently being drawn up.
Another speaker, Neal Jones, Assistant Director of Patient Safety at the Royal Liverpool and Broadgreen Hospitals NHS Trust, echoed Baker’s concerns. He told the conference that it is “not good enough” to train people to spot patient safety traps; “we need to fix the environment in which they work.”
Lubna Haq, head of healthcare consulting for Hay Group, speaking on the same panel, added “culture and behaviour are as important as having processes, leadership.”
Baker told the conference that hospital managers routinely hide evidence from the CQC, because they regard the organisation as out to blame them. Calling for a fundamental change in culture whereby NHS staff drive safety improvements for their own sake, rather than passing an inspection, Baker said;
“As long as you’ve got that culture of people trying to hide things…then we’re not going to win this”
“If you haven’t changed the underlying culture that allowed the problems to develop in the first place, all we’re doing is managing the symptoms of the problem, not the underlying cause.”
Peter Walsh from charity Action against Medical Accidents said:
“Ted Baker is right, not enough progress has been made on patient safety. But that is a euphemism – lives are being needlessly ruined or lost in a way that would not be tolerated in any industry.”
Critics have also voiced concerns about serious issues within the NHS affecting patient safety. One campaigner pointed out that a hospital with concerns regarding its patient safety can still be graded as ‘Good’ by the CQC.
On the other hand, healthcare unions have pointed to the increasing staff vacancy rates as a threat to patients. This week, NHS chiefs raised concerns that mental health patients were at risk of suicide because so many of the units they are treated in are dangerously decrepit. Newly released figures show that patient safety incidents in mental health units caused by problems with staffing, facilities or the environment in which people are treated have risen by 8%. In all, 19,088 such incidents occurred in 2018-19 compared with 17,693 the year before.
In October, it was also revealed that the number of safety incidents which led to patients being harmed at the Morecambe Bay Hospital Trust had risen by almost 100 per cent in the last year.
A recent survey of members of the Royal College of Emergency Medicine found that 98% of respondents believed that new staff pension tax arrangement rules would have a detrimental effect on patient safety due to reductions in consultant presence. Nine out of 10 of those surveyed believed that the rules would result in rota gaps at senior decision maker level (89%) and over three quarters were considering reducing their clinical care commitments (77%).
However, NHS leaders have said that there are significant plans to focus on patient safety in the coming years. In December 2018, Dr Aidan Fowler, NHS National Director of Patient Safety, called for “Directors of Patient Safety” to be appointed in every NHS organisation. He also called for plans to introduce a curriculum for patient safety across the NHS to standardise how incidents should be reported and acted on.
In September 2019, Patient Safety Learning announced a campaign to end thousands of avoidable deaths from unsafe patient care. As part of the campaign the charity has designed an online ‘hub’ platform where anyone committed to improving safety will be able to share experiences, case studies, investigation reports, research papers, policy guidelines and other resources. Users will be able to ask questions, seek advice and share ideas for free.
Speaking at the University College London Hospitals last month, Fowler also shared plans to develop the world’s first and largest reporting system. He announced that the National Reporting and Learning System (NRLS), a central NHS database of patient safety and incident reports, will be replaced by the ‘Patient Safety Incident Management System’, which will explore using Artificial Intelligence (AI) to better analyse data and faster identify potential patient safety risks and improvements. The new Patient Safety Strategy will also allow patients to anonymously submit information if they are unhappy with their treatment or care.
Fowler said: “The NHS Long Term Plan sets out a package of care which will save thousands of lives, and our new strategy to enhance patient safety will mean people get care in the safest possible setting.
“The NHS has tough protections to deal with deliberate wrongdoing by staff, but in the vast majority of cases, it is either honest mistakes or problems with systems that are at fault. We need to help NHS staff to speak up when they see things going wrong, this is crucial to improving patient safety over the next decade and will ensure that the right lessons are learned, and errors minimised.”
The document revealing the new plans stated;
“‘Just cultures’ in the NHS are too often thwarted by fear and blame. A consistent message in the consultation responses was that fear is too prevalent across NHS staff, particularly in relation to involvement in patient safety incidents,”
“Too often in healthcare we have sought to blame individuals, and individuals have not felt safe to admit errors and learn from them or act to prevent recurrence,”
“Blame relies on two myths. First, the perfection myth: that if we try hard, we will not make any errors. Second, the punishment myth: if we punish people when they make errors, they will not make them again.”
Fowler added “The NHS is already a trailblazer on safety with the world’s first and largest reporting system, and to future-proof the NHS for the 21st century, this new system is part of a decade-long vision for improving patient safety in the NHS, using the latest technology to make it easier for patients, their families and staff to report incidents, learn lessons and keep the NHS in England safe and effective for our patients.”
