In July, the review of patient safety by Dr Penny Dash was published. This was followed by an acceptance of all the recommendations made in the review by the government. Up until then I had not been party to what the findings had been or the recommendations so was somewhat surprised when I read it. I wrote a blog about the review, in the anticipation that it would be one of many commentaries on the subject, especially from the patient safety community. I wrote it in my usual ‘chatty style’ opinion piece thinking others will add to the debate with more comprehensive and, dare I say it, professional critiques.
Since then there have been responses by organisations which are limited in detail and largely uncritical, leaving in my view important questions unexplored. There are many that have welcomed the review and are positive about the recommendations. Notably there have been some who have questioned the review in more detail, such as the Health Foundation and Carl Macrae. I have given a flavour of the mix of comments below*.
During this time I have been searching the internet, forums such as LinkedIn, social media platforms and specialist patient safety sites. There is some but really not what I would expect in terms of commentary about the review by those who work in patient safety. Most of the critiques are in relation to the patient experience findings or the aim to simplify the landscape and amount of recommendations aimed at frontline services. Given this lack of critical scrutiny by the patient safety community there is a risk it appears that general approval is given to the findings and recommendations. Surely, a review of this significance should be debated.
As my wonderful colleague David Naylor* would say, silence always tells us something. So what is the silence in relation to, in particular, the patient safety aspects of the review telling us?
The factors that prevent people from speaking up or feeling silenced are not new to the world of patient safety, I just didn’t expect it in relation to any debate about what actually is happening to the patient safety landscape and focus in the NHS. What are the possible factors that may cause this lack of debate? David describes the different silences which I think are useful to think about here.
Acquiescent silence – there is nothing I can do here. Is there a kind of inertia? Does it all feel an inevitability? The Government after all has accepted the nine recommendations in full.
Anxious silence – I am too frightened to speak. Are people really fearful of challenging and what does this say about our healthcare culture if this is the case? What does this say about psychological safety in healthcare?
Pro-social silence – I am protecting others. Are people worried about their colleagues in patient safety organisations or roles so don’t want to rock the boat for them or make it hard for them, noting they are already in a difficult situation.
Power silence – I am not senior enough to speak. This is obviously common in patient safety as we see it all the time in hierarchical teams, meetings, huddles and so on. It is because people feel they lack the seniority to question the review?
Exhausted silence – I have nothing left to give. Is it because people are simply too tired, too low, too much ‘done to’, that they wonder what is the point of commenting? Is it because people are too busy and not aware that there has been a review at all?
Imposter silence – I am not good enough to speak. Is it because people feel they lack the knowledge to question the review? Also the review does not actually talk about patient safety – it talks predominantly about quality and patient experience, so those who work in patient safety may not feel able to comment about these aspects. I certainly am not an expert in either of these areas.
I have therefore decided to provide a more considered response to the review.
1. Scope of the review
First, the review, as I said in my previous blog, confuses things by talking mostly about quality and patient experience, without a doubt important for patient safety, but detracts from a robust conversation about patient safety itself. In reality, the three are often bundled together as if they are the same thing. The areas are not in isolation, as there are overlaps between the three, but just as quality and patient experience have their own experts, methods, theories and so on, safety is a particular science of its own.
It is often hard to argue about the differences because of the overlaps; the fact that if you have poor quality of care it can impact on safety, if you have a bad experience it too can impact on a feeling of safety. If we simplify these complex areas for the sake of explanation it can feel clumsy so I can only describe what safety means to me. I set it out here because the review failed to acknowledge the complexity of safety.
Safety
Prevention: Risk assessment and risk management. Studying ‘work as done’ to find out what people actually do and how healthcare staff work safely every day. What adaptions they are having to do, what adjustments to policies or their work they need to do in order to keep people safer. Proactive design of environments, equipment, working practices, tasks, policies and so on in order to help. Asking how can we make this as safe as feasibly possible, knowing that there is the potential for things to not go to plan. It is about understanding the complex adaptive system and working out how we can support the people who work in this kind of system. Studying the cross cutting factors such as communication and information methods and systems, team behaviours, connections and relationships. Cultural tools to help people speak up and share such as creating a psychologically safe environment.
Detection: Identifying the signals within the organisation both strong and weak. Asking ourselves what these are telling us about the safety of the system. Looking at the seemingly random or disconnected pieces of information that at first appears to be background noise but can be recognised as part of a significant pattern when you connect the pieces of information. The type of information and performance patterns that are experienced by those using the system or performing the task. Small events that are not usually reported. They can be habits, routines, and common workarounds that most of the time lead to the expected outcomes. Incident reporting is only one mechanism to detect these and usually only detects the strong signals.
Response: When something does go wrong, when there is an incident or complaint or strong signal that something has not gone to plan, we ask why and collect the information for learning, investigate where necessary and use all of the data, looking at what the system should do or what the actions should be, what was expected to happen compared with what actually happened. Asking why did it fail this time when most of the time it goes ok. Then deciding what changes are needed (or not) to the system, the tasks performed, the environment, the tools and resources.
Safety has unique methods and there are unique cultures that are linked to safety. For safety it is essential that we have both psychological safety (the ability to speak up and be heard) and a restorative just culture (the ability to be understood and supported when things don’t go to plan balanced with learning and accountability). There is so much to do in relation to the culture of safety. It is here that I disagree with some of my colleagues in that I think you can work on culture and it is important as a particular area of focus. However, along with all aspects of safety it requires a certain level of knowledge and understanding in order to do this.
There was discussion in the review about standardisation and lean methodology. I wrote at length about this in the first blog so I wont repeat that here.
Over the last decade there have been changes in our thinking with people describing the ‘new view of safety’ or ‘safety differently’ or ‘safety I and safety II’. The most recent discourse has been even about the term safety. [See Erik Hollnagel] . To paraphrase Professor Hollnagel, the term safety is used on its own and so frequently that no one ever asks what it actually means even though it is rarely defined. Managing safely means we have to understand how work goes well and then to understand why occasionally but rarely it fails. The change of wording from safety to safely means it is no longer safety that is managed but rather the essential functions of a system are managed safely to ensure that as much as possible goes well.
When you read any review, report or article about any subject matter you want to feel that the writer(s) have researched the subject matter in great detail. In this case it didn’t feel like the safety science was truly represented. In fact it feels like the review oversimplifies the complex issues that we are studying everyday. What worried me was the implication that too much effort and resources have been given to safety rather than other dimensions of quality. As I said in my blog why is the answer to this potential finding that we should do less on safety and more on the other dimensions. Safety is not optional. It is fundamental.
2. The recommendations
a) Revamped and revitalised National Quality Board with a refreshed strategy for improving quality of care.
There is a need for national leadership for patient safety. Is this the NQB or the DHSC? A refreshed strategy is expected to balance all dimensions of quality. This has the potential to diminish the focus and efforts to date on patient safety via the current patient safety strategy. We need to continue to build on this strategy and continue its aims and expectations.
The NQB remit appears to be huge. For example it appears to be expected to be similar to NICE in deciding which interventions have the most effectiveness, it is expected to look at the operating function of the NHS and to create something like a recommendation hub or repository. The review describes it as ‘an organisation’ rather than a ‘Board’ or committee which it currently is. In terms of resources, the expectations will require a considerable amount of money and people in order to carry out these new functions. It would be helpful to see the terms of reference and membership of the ‘new’ NQB in order to have any understanding of how this will impact on patient safety across the system. What powers will the NQB have? The NQB is a committee how can it ensure it has knowledge of the latest safety thinking, influence and monitor improvement in patient safety?
b) The Care Quality Commission is recommended to rebuild with a clear remit and responsibility and overhaul its registration and inspection processes to ensure they are “sector specific.” The detail described in the review’s recommendations are what I would have expected CQC to already be doing, so I am not sure what is new here. I have always had the view that people who work at CQC need to either have or access to expert safety knowledge. Without this expert understanding of patient safety the inspection process for safety is flawed.
c) Health Services Safety Investigation Body and investigations in general
Most investigations into safety incidents are already managed within provider organisations and supported by commissioners (ICBs). The new Patient Safety Incident Response Framework is already helping to ensure that investigations are done quickly and with the right level of expertise. This takes time to build and embed. I presume this is what is meant when it states that NHS England, transferring to the new proposed structure within DHSC, should ‘support excellence in investigation and learning throughout the health and care system’.
It says that HSSIB should continue to operate as it is and to collaborate with DHSC (through NQB) to agree the scope of any investigations it carries out and have a role advising and supporting best practice in local investigations. It should share learnings and retain its role in upskilling health organisations through its education function. I thought it already did all of this.
Recommendations arising from all HSSIB investigations should be considered as part of the clearing-house function of NQB. This seems sensible to me but I am not sure why there is a need to ensure a ‘clear distinction’ between HSSIB’s patient safety investigations, and the wider leadership of patient safety investigations and policy by DHSC?
The role of HSSIB seems to be being diluted away from patient safety to support the improvement of other investigations (e.g. royal colleges or the Parliamentary and Health Service Ombudsman) and to ensure that learning from recommendations of such investigations is co-ordinated – is that not the role of the new NQB?
The review states that the maternity investigations are more complex than other investigations – which is odd. There is the same complexity not matter where and what the investigation is doing. It also appears that maternity and neonatal investigations are being returned to the function of HSSIB. Somewhat disrupting.
The final aspect is the bit that I find difficult to understand given that the review actually says that many other industries separate out an investigation function from regulation. It suggests by consolidating with CQC it would help clarify roles. How will it do that? It also states that it would also ‘enable a clear link between identifying poor performance and investigating its cause‘. This is a deeply troubling statement. In the absence of what the review means by this it could be interpreted that the identification of poor performance by CQC will be somehow connected or correlated with the causal findings of investigations.
In fact what you need is the opposite of this. We know from decades of research and experience that if you link patient safety investigations with looking for individual poor performance it leads to apportioning blame, causes fear and silences people. There are other established HR and workforce functions for this. In respect of organisational poor performance the moment people feel that any investigation of their organisation by HSSIB will be in some way shared with CQC (even if this is not the intention) will not create the safe space that is so important for the role of HSSIB. I recall when the National Patient Safety Agency set up the national reporting system people would be worried about who would have access to then data. In the beginning the assurance was that the data was to be collected for learning only. Over time this changed and the data was used to place organisations in league tables and in the end was indeed shared with the regulator.
The recommendation to transfer the functions of HSSIB to CQC (even as discrete branch within CQC and retained independence for providers) goes against all other high risk industries, and has no rationale other than cost.
d) The Patient Safety Commissioner
The recommendation is that the Commissioner should transfer to the Medicines and Healthcare products Regulatory Agency (MHRA) to ‘strengthen links between the patient voice in medicines safety and the MHRA’s work’ to capture adverse events more effectively. As I said before I have always been surprised by the limited remit of the Patient Safety Commissioner’s work and have never really been given a convincing rationale for this. I would expect the individual who advises on patient safety across the system should cover the whole remit of patient safety. However this wider ‘function’, it says, is to be transferred into a new directorate of patient experience (not patient safety) in DHSC.
e) Local Healthwatch and the engagement functions of integrated care boards (for healthcare) and local authorities (for social care) are to be brought together to ‘ensure patient and community input into the planning and design of services’, and the strategic functions of Healthwatch England are to also be transferred into the new patient experience directorate in DHSC. This needs to be matched with resources, people and expertise within this new directorate.
f) Staff voice functions should be strengthened, with the responsibilities of the National Guardian for Freedom to Speak Up incorporated into the new DHSC structure and providers. Again what is the rationale for this. It feels like a function to listen to staff voices at a national level is being diminished rather than strengthened.
g) The responsibility for and accountability of commissioners and providers to deliver and assure high quality care should be reinforced. Reinforced by whom and how? We already have a regulatory to inspect on safety (and all the other domains), we already have other oversight bodies which do the same. What does it mean by reinforced?
h) Technology, data and analytics should play a much more significant role in supporting the quality of health and social care. Agreed.
i) There should be an evidence-based national strategy for quality in social care. Agreed but it should also have a dedicated safety strategy too, which should include safety in the home.
*Here is a sample of quotes from other responses.
The Patients Association
“While we understand and agree with the need to reduce the ‘overwhelming number of recommendations’ identified in the Dash review, streamlining shouldn’t come at the cost of independent oversight that patients desperately need.”
NHS Confederation
“NHS leaders will welcome Dr Penny Dash’s review, which supports the direction of the Ten-Year Health Plan in streamlining the role of the centre and devolving accountability to local leaders, while giving the public the tools to make informed choices about their care.”
“However, NHS leaders would encourage the government to not forget the failings in care that led to these bodies being set up in the first place and tread carefully so as to ensure their vital missions continue in future. Staff and patients will still need safe spaces where they can speak up”.
The RCN
The Royal College of Nursing has warned that government reforms to improve patient safety will “fall short” unless the nursing workforce crisis on wards is urgently address.
The Health Foundation
“Dash points to a drift towards prioritising resources for safety over other areas of quality. This is an important challenge for the system overall but leaders must avoid a clumsy trade-off. Harm caused by health care remains shockingly high in the NHS – as across the globe. Every instance is a deep and egregious affront to patients and families, and causes moral injury to staff. If staff see their organisations de-prioritising safety, it will damage engagement and may prompt many to consider leaving.“
Dash highlights the disparity in spending on safety compared with other areas of quality, such as experience and effectiveness. But arguably more significant is the discrepancy between organisational spending on business as usual versus on efforts to improve quality overall. The £160m spent directly on safety that Dash highlights (£60m a year on safety related bodies and £100m on safety reviews and inquiries) is half of what an average-sized acute trust spends in a year. The true challenge to leaders is how to align the full resources of organisations to achieve a consistent and holistic approach to driving up quality.
“Modern approaches to safety, combined with well-developed improvement tools, offer systemic, proactive approaches. Safety and improvement specialists bring critical expertise as we move beyond the historical focus on the most visible sources of harm in hospitals, to support continuous improvement that spans sectors”
and (yes I could have just reprinted all of their commentary!)
“It would be understandable if leaders under huge pressure implement Dash in a way that takes advantage of top-line signals to redirect resources, with limited consideration of the deeper cultural and operational design challenges and opportunities. Given how central safety and quality are to motivating staff – the most important resource in the NHS – this would be a costly mistake and mean that challenges to delivering reform could repeat themselves”.
National Guardian
Dr Jayne Chidgey-Clark, the National Guardian, said: “Improving the safety and quality of care that patients receive is at the heart of Freedom to Speak Up. This review is an important opportunity to examine the impact of the patient safety organisations and how we work together. It will also enable us to see how the work we do to improve the speaking up culture in healthcare can have more impact. We look forward to working closely with Dr Dash and other patient safety leaders over the coming weeks.”
NHS Providers
Daniel Elkeles, chief executive, NHS Providers, said:
“Dr Dash is spot on. Regulation is important but must focus on issues that really matter and continued improvement. ….The system has been too complex for too long. This review is an important step in simplifying and streamlining how patient care is regulated without ever compromising safety.”
“Trusts welcome this review. A revamped National Quality Board will set clear, robust, consistent priorities and ensure that NHS services are held accountable for providing high-quality care, and we welcome proposals for trusts to appoint a senior executive responsible for ‘patient experience’.
“We welcome too proposals to streamline the complaints process. If something goes wrong NHS trusts are determined to put in place measures quickly to improve the quality and safety of patient care.”
Carl Macrae
All of which is worth reading here… https://journals.sagepub.com/doi/10.1177/01410768251366879
“While change to the landscape is clearly needed, the Dash review is an earthquake. One change in particular risks setting back progress in the systematic improvement of quality and safety by a decade, and would be unthinkable in any other sector that manages serious risks to the public. The national independent body charged with conducting system-wide and learning-focused investigations into the most serious risks to patient safety is to be merged with England’s struggling regulator of health and care providers, the Care Quality Commission (CQC). This institutional change will abruptly remove the health system’s nascent capacity for independent system-wide safety investigation, and will bring to an end England’s globally leading role in pioneering a model that is emulated internationally.“
and
“The proposal to subsume HSSIB as an arm of the regulator undoes years of steady progress at a stroke, and would be unconscionable in any other safety-critical sector. It will bring to an end England’s pioneering efforts to build a permanent capacity for independent, rigorous, system-wide and learning-focused analysis of the most pernicious threats to care quality. And, as part of the regulator, HSSIB will inevitably risk being viewed as doing the footwork of punitive regulatory enforcement, destroying the hard-won safe space that HSSIB – and its underpinning legislation – was beginning to create for open and honest learning.”
Reference:
*See his wonderful book here. Speaking Up in a Culture of Silence: Changing the Organization Activity from Bullying and incivility to One of Listening and Productivity
PATIENT SAFETY NOW 