PATIENT SAFETY NOW

The conversation has shifted

The last six months have felt like a significant turning point for patient safety in England. Not because there has been any major new safety initiatives, but because the conversation has shifted.

For much of the last decade, the dominant narrative has been around building a patient safety movement: developing a patient safety strategy, implementing PSIRF, introducing Patient Safety Specialists, creating HSSIB, promoting safety I and safety II, just culture, learning systems and psychological safety (to name just a few).

However, over the past six months, the discussion has increasingly moved towards quality, accountability, simplification, financial issues and value. This is largely driven by Dr Penny Dash’s review and the Government’s response. The Dash Review argued that patient safety had become fragmented across multiple organisations, strategies and initiatives. It recommended embedding safety within a broader National Quality Strategy which has now been published. 

Just as an aside… it always fascinates me when safety is described as reducing the risk of unintended or unexpected harm when, we all know it is so much more than that. Anyhow. I know this is going to be an obvious statement – but this strategy is all about quality. I know it is in the title but if I wanted to understand what I needed to do in respect of safety, this isnt the strategy for me.

The framing and language is all about quality management and repeatedly uses words like:

• oversight
• accountability
• governance
• assurance
• metrics
• performance
• value
• productivity

The language of modern safety science is absent

It is reassuring that there will continue to be a patient safety strategy but I am less clear where patient safety sits both at a national level and local organisational level. Who is specifically championing safety?

My concern is that, in making quality the organising principle, patient safety risks becoming absorbed into a broader management agenda. Safety is treated as one of three domains of quality, rather than as a distinct scientific discipline with its own methods, concepts and expertise.

The danger is subtle. If safety becomes primarily about dashboards, governance, AI, oversight and performance management, we may become better at measuring risk without becoming equally better at understanding it. Patient safety is not only about detecting harm earlier—it is about understanding why care usually succeeds despite the complexity, and it is about creating the conditions in which people can work safely, speak up and be heard, and learning continuously from everyday work.

I think this strategy actually reinforces one of the points I have been making for some time, safety is a science, not simply a component of quality. If we lose that distinction, there is a risk that patient safety becomes something we manage rather than something we continually seek to understand.

We are good at:

• incident reporting (which to some extent we have overwhelmed the system)
• investigating (the people who designed PSIRF should really get an award)
• producing recommendations (tons of them)
• writing reports and running huge inquiries

We now need to get good at the other aspects of safety science, such as:

• Prevention
• Design for safety (yes the colour of the walls makes a difference)
• Looking at the architectural aspects of a building to incorporate safety systems
• Standardising environments and documentation
• Communication
• Human factors and systems thinking
• Resilience engineering
• Complex adaptive systems and systems thinking
• Safety culture
• Psychological safety
• Just and restorative culture
• Safety I and Safety II
• High Reliability Organising
• Normal Accident Theory
• Video Reflexive Ethnography
• Risk management and mitigation

This isn’t a collection of fashionable ideas. It is decades of research from psychology, engineering, sociology, organisational science, organisational change, social movement theory, behavioural science, architecture, innovative design thinking across healthcare that has fundamentally changed how we understand risk and safety.

What would I prioritise?

Having the privilege of working across the NHS in all kinds of care settings the aspects of safety that are also in urgent need of addressing all relate to culture:

• staff not feeling able to speak up
• leaders failing to hear concerns
• hierarchy
• incivility
• psychological safety
• relationships between boards and frontline staff

And the very most important thing we should be doing right now is trying to figure out how we capture early warning signals, or weak signals (as some call them).

These tell us what is actually going on in the system. Speak to most frontline staff and they know all of them but we don’t listen well, don’t hear their voices, rarely capture them or even rarer, learn from them. And I don’t mean that they need to be reported into an incident reporting system, lord knows they are already completely overwhelmed as it is.

There is a saying.. something like ‘If we can get people on the moon, we can surely sort out (insert your particular issue)’. So in that respect if we can get people on the moon, we can surely sort out how to capture early warning signs. Inspections, investigations, inquiries.. all too late.

As I say, for much of the last decade, the dominant narrative has been around building a patient safety movement. What is so very heartening is that because of the hard work that many people have done during this time at a national, regional and local level, we are starting to have a growing number of people who truly understand all aspects of safety.

I just hope that they will be able to continue to build that movement because we need it more than ever.