Hardly a day goes by without the newspaper headlines highlighting NHS failures, with reports of patient deaths being the inevitable result of being denied access to A&E departments, or waiting for hours on hospital trolleys without receiving the necessary care. The underlying problems are related to staffing and bed shortages, and the sheer volume of people seeking medical help: some with, and some without potential life threatening illnesses or injuries.
Despite the medical profession’s best efforts to cope, the adverse pressures are compounded by the UK’s ageing population, the lack of availability of GPs at nights and weekends, and the UK’s decreased medical capacity resulting from cost-cutting closures.
The NHS is a nationwide service provider subject to health and safety legislation. Section 3(1) of the Health and Safety at Work etc. Act 1974 (HSWA) states that, “It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety”. In other words, the NHS as a whole has a statutory duty of care to ensure patients are not exposed to practices that put their health and safety at risk. Clearly, there is compelling evidence that this statutory requirement is breached daily in many of the UK’s 151 Primary Care Trusts (PCTs). [1]
Potential solutions
So what is HSE doing about it, and what can they do? HSE stated in 2014 that it has a, “policy to investigate deaths that occur in the health sector where there is evidence that clear standards have not been met because of a systematic failure in management systems”. Clearly, insufficient EMT resources, being short-staffed and insufficient bed capacity are the result of systemic failures in management systems. Perhaps it is time they started enforcing this policy with a vengeance, as currently they are very reluctant to do so, judging by the very small number of prosecutions of NHS care trusts.
Prosecuting those responsible for these daily breaches as a matter of course could help to force the brightest intellects in the NHS to confront their problems and resolve them. HSE could also be much more proactive and help to stop the escalation of patient safety incidents simply by exercising their right to enter a workplace unannounced at any reasonable time for the purpose of inspection. Of course, this takes a willingness to tackle the issues and their root causes, which HSE just may not have, as it would be a case of one government agency inspecting and prosecuting another!
Similarly, what are safety professionals employed by the NHS actually doing about these problems? The PCT’s safety professionals have a huge role to play in shaping the patient safety culture of their PCT. It would be helpful if they could focus on the following common safety culture elements [2]:
The above are the ‘meat and drink’ issues that we in the safety profession are employed to tackle, but seemingly we do not appear to be very successful (given the above evidence are all 2014 examples). Is it that NHS safety professionals don’t have sufficient power in the NHS to actually influence people and events? If not how can things be changed? Could it be their recommendations are ignored? If so, why and by who? Could it be they are focused on other things? Would data-mining their records to focus on salient issues be more productive? I do not know the answers, but I am naïve enough to think that we could do better. What do you think?
References
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What year was this article written in? “151 Primary Care Trusts (PCTs)” – primary care trusts were replaced with Clinical Commissioning Groups almost 5 years ago.
Hi Jenna
Thank you for pointing out my error. Appreciate it. I wrote the article yesterday morning on my return form Asia. The reference I used was a House of Commons Library Note: “NHS funding and expenditure Standard Note: SN/SG/724 Last updated: 03 April 2012 Author: Rachael Harker, Social and General Statistics. http://www.nhshistory.net/parlymoney.pdf
I now see that indeed there has been a renaming / shakeup: Primary care trusts were abolished on 31 March 2013 . ,However, I am sure you would agree the change does not seem to have been for the better given the scale of the current crisis!
This is a particular area of work for RoSPA Dr Dom, Tom Mullarkey talks about it a great deal. He also raises though that most accidents happen in the home or travelling to work rather than at work itself. Also you talk a lot about safety here, surely health is a bigger issue in terms of impact on the NHS Dr Dom? And we know how neglected an area that has been….. HB
Hi Heather
Glad to hear RoSPA also believes that Patient Safety is an important issue. Yes, those seeking medical attention for workplace injuries is a “relatively” small part of the pressure on the NHS, in comparison to those from the general population seeking assistance for their health issues. However, the point of my blog was not to distinguish between workplace safety injuries and/or adverse health outcomes.
To be clear, I was trying to say that the HSE and the safety profession have a huge role to play in helping the NHS get over its current problems: Both have the necessary weapons at their disposal, but neither appear to use them (I may be wrong). The HSE in particular could do much more from a “strategic” perspective to force the “powers that be” to address the underlying systemic issues (staff and bed shortages, etc). The in-situ safety professionals could also do a lot more to improve their patient safety cultures (which is why I pointed out particular areas of opportunity and gave the references).
It would be nice to hear comments from both the HSE and those ‘at the frontline” on their thoughts about using safety risk controls as a means of forcing the NHS to get things under control for the betterment of the entire UK population who wish to avail themselves of a quality NHS service.
Dom,
It is true that the UK’s four NHS’s are not perfect. However, there is plenty of evidence to support the view that they are better than most health care purchasers and providers around the World. This is despite the four NHSs caring for just under one million patients every working day – and less at weekends and bank holidays.
In terms of cost versus health outcomes, the four NHSs have a strong record of saving the largest number of patient lives relative to money spent – second only to Ireland. This conclusion comes from a review of 19 western health systems where the ratio was 1:557 for the four NHSs – well ahead of the USA [1:205] and Switzerland [1:140].
Source: Pritchard (2011) J R Soc Med Sh Rep 2011;2:60. DOI 10.1258/shorts.2011.011076
Healthcare is considered the riskiest of all industries in most Countries around the World. The US-based Commonwealth Fund noted last month that in the NHS, 8% of patients experienced medical, medication, or lab test errors in past two years. While this is not ideal, it is better than in the USA (22%), Netherlands (20%), Germany (16%) and more.
Source: The Commonwealth Fund (2015) International Profiles of Healthcare Systems
Relative to the majority of health systems in the western world, the NHS is considered good value for money. It costs 7.8% of the 9.3% GDP that the UK spends on healthcare. OECD reports that the UK spends less on publicly funded healthcare than the US (7.9% of 16.9% GDP), France (9.1 of 11.6%), Germany (8.8 of 11.3%) and others.
Source: http://www.oecd.org
When it comes to regulation of the NHS in England, HSE is the national regulator for the OSH of workers and the public mainly, while the Care Quality Commission is the independent regulator responsible for the patient safety only. Unlike HSE, the CQC lacks the power to secure justice. HSE’s role seems more restricted today compared to when they started to regulate the NHS after the removal of Crown Immunity in 1991. The respective roles of HSE and CQC are detailed in the updated liaison agreement between HSE, CQC and Local Authorities – this takes effect from 1st April 2015.
Source: http://www.hse.gov.uk
I have worked with 49 NHS organisations and I fully support the ‘meat and drink’ issues identified in the article. However I have seen for myself, plenty of examples of where things are at the other end of the spectrum in comparison to the NHS organisations cited the article.
Unfortunately, I also know of NHS provider organisations where people with no formal training in OSH or patient safety, are in OSH and/or patient safety roles. With consistent pressures to reduce management costs since the early 2000s, some NHS organisations’ do not replace SHPs who move on to other roles.
All employees in NHS purchasing organisations in England are put at risk of redundancy every five years, as a consequence of structural changes introduced following General Elections – since 2000, we have seen PCGs, PCTs, super-PCTs, CCGs – this adds uncertainty and at times instability. It can have the unintended consequence of shifting too much of the focus away from influencing and managing healthcare towards just managing the management structures.
As for the future, clarity about the NHS’s purpose and how it engages with it’s ‘shareholders’ is urgently needed – including people who are and have paid 12% of their salaries in National Insurance. The NHS vision of healthcare being free at the point continues to be a given for the time being. However, the NHS vision seems to be somewhat silent with respect to what health care outputs and outcomes should look like.
Health care around the world has just a 10% impact on people’s health – this is why more needs to be done to nudge you me and everyone else to play our part in preventing ill health – through reasonable levels of exercise, in addition to minimising our consumption of processed foods and alcohol.
At the same time, patients and the public need to have a much louder voice and in their terms – so that they have a greater say in identifying what is going well in the NHS, what needs to be improved and the changes that patients want to see implemented – as well not being one of the 8.6% of patients not turning up for appointments and the higher percentages of patients who only follow treatment plans for awhile or not at all.
The four NHSs are not perfect and I fully agree that all NHS organisations need to live the ‘meat and drink’ issues listed in the article. I hope that my contribution helps balance some of the concerns raised and please do let me know if you would like to discuss.
@QualityRiskMgt http://www.about.me/patrickkeady
Hi Patrick
Very thorough defence of the NHS I have to say. Well done and thank you for supplying an alternative view. Nonetheless, I still feel that the HSE could play a much bigger role than it does. It is also sad to hear that non-qualified people are being used as ‘safety professionals”. Still, all we can do is raise the issues. The actions are in the hands of others, should they take note.
As a NEBOSH qualified professional working in healthcare, I feel there are gaps between OSH and patient safety that do not seem to be recognised – take slips, trips, falls – if Clinical Governance Committees only look at patient safety stats and staff safety issues are considered elsewhere, we may have the same root cause but not recognise the extent of the risk.
In the same way that Safeguarding is ‘everybody’s business’ so should health and safety.Some Clinical Governance Committees have no OSH representatives. The CQC in ‘Essentials of Quality and Safety’ (now replaced) identified safety of premises / equipment as a Clinical Governance reponsibility but I’ve not seen this in practice. Food safety is another area – there is a focus on hydration and nutrition but not so much on other key areas which sit under Facilities.
I’d be interested to hear from anyone who has overcome this successfully..
Great comments Caroline.
Fragmentation of approaches / systems, etc, always leads to duplication of effort and issues falling through the gaps (excuse the pun).
The issue you have highlighted is that fragmentation of HSE is widespread. Take for example the UK’s national injury statistics. These are reported separately through many different bodies e.g. Healthcare, the Military, the HSE, etc. The only way Britain will get a true picture of the level of fatalities, serious injuries and lesser injuries is if they are collated in some way, with all reporting bodies adopting the same reporting criteria, and presented as one data set. In this way we may actually be able to focus on the root causes and recognise the true extent of the HSE risks involved in the workplace.
However, I don’t think will ever happen, as the collated annual statistics would reveal the true magnitude of Britain’s current failures to address Health and Safety in the workplace. This would take away the UK’s bragging rights, leaving some unable to “sell” their services to other countries, on the back of these, even though the cost to UK Plc of the true injury rate far outweighs the revenue raised selling such services overseas.