Patient safety problems risk waning public confidence in the NHS
20 May 2021
Many have voiced their shock, dismay and disappointment at the revelations by BBC Panorama that patient safety issues are being buried in confidential hospital reports. The programme shared the heart-breaking stories of real people whose lives had been turned upside down through care failures which had been made worse by revelations of secrecy and a lack of transparency. BBC Freedom of Information Act requests revealed that only 26 out of 111 reports from medical royal colleges had been shared in full with the regulating Care Quality Commission, despite a duty to share. Only 16 reports released to the BBC had been put into the public domain.
The programme added to the body of evidence that urgent action is required to prioritise patient safety and ensure that an effective system of reporting, learning and meaningful change is put in place.
Views that the hospital trusts involved put reputation ahead of patient safety improvements appear reasonable given the secrecy and lack of transparency that is apparent. How can patient safety improve unless reports are shared? The reporting and analysis of errors is central to building improvements and it is clear that there is systemic failure and a culture which is not focused entirely on learning from mistakes to ensure improvements in patient safety. There can be no doubt that this needs to change.
Last year the IPPR in its ‘Better than Cure’ report highlighted the estimations from the NHS Patient Safety Strategy that 11,000 deaths per year result from patient safety incidents. The report claimed that the increased pressures on the NHS to deal with backlogs as we emerge from the pandemic will bring increased pressures on services.
A joined-up strategic approach to patient safety is urgently required. The current disjointed approach is demonstrated by the Government’s response to the First Do No Harm report following the review led by Baroness Cumberlege and the legislation to appoint a Patient Safety Commissioner for England and Wales, with a similar role being considered in Scotland. While this is a very welcome step forward, the role, as it was in response to the Cumberlege review, is limited in scope to medicines and medical devices and is therefore restricted. The Government’s own factsheet claims that the PSC will be a ‘champion for patients’. But only in relation to medicines and medical devices. The Cumberlege Report highlighted the need to strengthen advocacy for patients but the PSC role needs to go further to help people who have experienced failings across health care to understand what went wrong, why and ensure it doesn’t happen again.
APIL is committed to the prevention of needless injury and we believe that Government should treat injury prevention as a public health priority, including the implementation of a new Injury Prevention Commissioner. Our members are there to pick up the pieces after a tragedy, but we would all prefer that tragedy not to happen in the first place. Without transparency in patient safety problems being reported and concerns being dealt with, the public will lose confidence in the healthcare system. The risk of waning public confidence makes this an urgent priority and the Government needs to take a lead in bringing together the various well-meaning stakeholder organisations involved in improving patient safety in partnership to formulate a collaborative strategy.
While progress in patient safety learning has been made, for example, through the introduction of the duty of candour, it is not being consistently applied and needs to go further.
If we are to maintain the highest levels of public faith and confidence in the health care system, patient safety, as part of a wider strategy for injury prevention, must be prioritised. To ensure progress against clear milestones for improvement, this requires a culture of learning, openness and transparency to be developed alongside a consistent approach to learning from mistakes at individual NHS Trusts across the country. As a first step it should at least be made mandatory for NHS trusts to disclose patient safety reports to the healthcare regulators to ensure that the public are being protected from avoidable harm and adverse events.