Author Bio ▼

Dominic Cooper PhD is a chartered fellow of IOSH and a professional member of the American Society of Safety Engineers. He is co-founder and CEO of BSMS Inc., a global safety consulting firm based in Franklin, IN, USA. A chartered psychologist, Dominic consults with senior executives on safety leadership, culture and behaviour change. He has authored many books, articles and scientific research papers on safety culture, behavioural-safety and leadership.

January 30, 2015

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The UK safety profession and patient safety in the NHS

879205_33166407The problem

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 prioritisation of budgets before safety: NHS pay-for-performance schemes have not been universally successful. [3]
  • The culture of fear that causes problems to remain hidden: NHS staff who raise concerns at work are bullied and badly managed. [4]
  • 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. [5]
  • Managements and staff’s noncompliance 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. [6]
  • Miscommunication regarding key safety risks among all stakeholders: Only half of patient handovers were understood by the doctors expected to treat them. [7]
  • 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. [8]
  • Ignoring ‘lessons learned’ from previous incidents: The NHS currently has no consistent approach to investigating and learning from safety issues. [9]

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

  1. 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
  2. Cooper, MD & Finley, LJ (2013) Strategic Safety Culture Roadmap. BSMS Franklin IN
  3. Marshall, L., Charlesworth, A., & Hurst, J. (2014). The NHS payment system: evolving policy and emerging evidence.Nuffield Trust.
  4. Kmietowicz, Z. (2014). Problems for NHS whistleblowers persist.BMJ,349, g5809.
  5. 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 Leadership6, 75-83.
  6. 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
  7. Till, A., Sall, H., & Wilkinson, J. (2014). Safe Handover: Safe Patients-The Electronic Handover System. BMJ Quality Improvement Reports2(2), u202926-w1359.
  8. 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.
  9. 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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Jenna

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.

Dominic Cooper

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!

Heather Beach

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

Dominic Cooper
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… Read more »
Patrick Keady
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… Read more »
Dominic Cooper

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.

Caroline
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… Read more »
Dom Cooper
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… Read more »
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