The UK safety profession and patient safety in the NHS
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). 
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 :
- The prioritisation of budgets before safety: NHS pay-for-performance schemes have not been universally successful. 
- The culture of fear that causes problems to remain hidden: NHS staff who raise concerns at work are bullied and badly managed. 
- Ineffective leadership: Large scale public inquiries have shown that considerable patient harm results from the absence of effective leadership, and there continues to be a major disconnect between clinicians and managers, and clinical and bureaucratic imperatives. 
- Managements and staff’s non‐compliance to rules and procedures: The chaotic, turbulent, and complex environment characterising the NHS’ workplace prevents staff from fully complying with the declared safety goals practices and procedures. 
- Miscommunication regarding key safety risks among all stakeholders: Only half of patient handovers were understood by the doctors expected to treat them. 
- Competency failures where people do not possess the necessary knowledge, skills, tools or ability to do their jobs properly: Directors with clinical backgrounds remain a minority (<30 per cent) on most NHS boards despite policies to increase their representation. 
- Ignoring ‘lessons learned’ from previous incidents: The NHS currently has no consistent approach to investigating and learning from safety issues. 
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?
- Donaldson LJ, Panesar SS, Darzi A (2014) Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012. PLOS Med 11(6): e1001667. doi:10.1371/journal.pmed.1001667
- Cooper, MD & Finley, LJ (2013) Strategic Safety Culture Roadmap. BSMS Franklin IN
- Marshall, L., Charlesworth, A., & Hurst, J. (2014). The NHS payment system: evolving policy and emerging evidence.Nuffield Trust.
- Kmietowicz, Z. (2014). Problems for NHS whistleblowers persist.BMJ,349, g5809.
- Daly, J., Jackson, D., Mannix, J., Davidson, P. M., Hutchinson, M., Daly, J., … & Hutchinson, M. (2014). The importance of clinical leadership in the hospital setting. Journal of Healthcare Leadership, 6, 75-83.
- Drach-Zahavy, A., & Somech, A. (2014). Occupational Medicine & Health Affairs. http://esciencecentral.org/journals/from-standardization-to-resilience-how-daytoday-life-in-healthcare-organizations-shapes-safety-2329-6879.1000179.pdf
- Till, A., Sall, H., & Wilkinson, J. (2014). Safe Handover: Safe Patients-The Electronic Handover System. BMJ Quality Improvement Reports, 2(2), u202926-w1359.
- Mannion, R, et al. (2015): “Overseeing oversight: governance of quality and safety by hospital boards in the English NHS.”Journal of health services research & policy20.1 suppl(2015) 9-16.
- Macrae, C., & Vincent, C. (2014). Learning from failure: the need for independent safety investigation in healthcare.Journal of the Royal Society of Medicine, 107(11), 439-443.
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