How patient opinions are shaping services

When nurses at Royal Devon and Exeter Foundation Trust starting asking patients for feedback about their experiences on the orthopaedic ward, they got some surprising results.

“Someone pointed out to us that when they were washing there weren’t any shelves close by for their toiletries and clothes,” says matron Debra Larsen. “This meant that patients were reaching to the floor and risking falls or dislocation of their new joints.” Perhaps it should have been obvious, but it took a patient to point out the safety risk and prompt the ward staff to put it right.

This was just one piece of invaluable information from a pilot scheme run by the trust in April 2009 that sought patients’ feedback – not after they had left the hospital, but while they were on the ward – and used their comments daily during ward safety briefings.

Real-time element

As Ms Larsen points out: “The real-time element was a departure from the historical patient survey approach. Patients told us what they felt or thought about their hospital stay – anonymously if need be – and this prompted action to address any shortfalls and safety issues.

“The loop was completed by patients receiving updates on what happened as a consequence of them sharing their views on their experience.”

The approach is now used routinely in surgery, day surgery and critical care at the trust, helping to embed patient safety in the ward culture.

The idea of using patients to inform on safety in the NHS is not new. It came to the forefront in 2006 with the chief medical officer’s report Safety First, which led to the appointment of regional patient safety champions. It has been the subject of extensive research and there is now a £2m grant from the National Institute for Health Research to find out what works best (see box, bottom).

There has been a lot of work in this area in the last five years, but the imminent demise of the National Patient Safety Agency and the lack of a clear future for the regional champions is raising concerns that all their hard work may be diluted into a broader “patient centric” focus, of which safety is just one aspect among many.

Dundee University professor of values in healthcare Vikki Entwistle has reviewed the evidence around patient involvement in patient safety. She identifies three ways in which clinicians have sought to involve patients in improving safety: consulting them about treatment plans; involving them in making sure their treatment is given as planned; and asking them to identify safety risks. Her review of 745 papers found little evidence about the impact of such initiatives on safety outcomes.

She did, however, find one problematic area: asking patients to speak up if they see practices that could compromise safety, for example nurses and doctors not washing their hands.

“There is a difference between promoting safe self care and asking patients to challenge healthcare professionals,” she says. “It’s hard for patients to speak up, especially if the staff are brusque or appear overly busy.”

In her qualitative study of patients who had spoken up about safety deficiencies, some reported that staff responded well and either made changes or reassured them; others did not. “Patients’ ability to get things done is not just the product of their knowledge or assertiveness but also the healthcare environment in which they find themselves,” says Professor Entwistle. If healthcare professionals are not ready to listen, patients will not speak to them.

Peter Walsh, chief executive of the charity Action for Victims of Medical Accidents, has also met resistance from the NHS to hearing what patients have to say. He deals daily with people who have been harmed by the NHS – and says many are keen to make sure their experiences are not repeated and want to make a positive contribution. His organisation has done a lot of work with the NPSA and others to get their voices heard.

It is an uphill battle.

“There is a bit of a blind spot in the NHS about involving people who have actually suffered harm,” says Mr Walsh. “It is a difficult place to go and health professionals can feel threatened by it. But actually, people who have suffered harm, or their loved ones, have a unique insight and should be among the first people the NHS should call on.”

Patients Association chief executive Katherine Murphy  agrees. Her organisation publishes regular reports telling patients’ stories of poor care. “Listening to these stories is very powerful,” she says. “We get calls from many, many NHS senior nurses telling us they use them as part of their teaching.”

Board level action

At Bedford Hospital Trust every board meeting opens with a patient’s story. This ranges from healthcare professionals talking about how they handled a complaint to videos of patients talking about instances that have led them to complain.

“It leads the board to ask some very tough questions,” says medical director Ed Neal.

“If patients have had a bad outcome then we do ask them to help us sort out our policies. We ask them to be a sense checker for what we are going to do to prevent it happening again. They are very, very powerful. Staff do find it difficult but little by little we are chipping away.”

The trust – which has won awards for its safety work – tries to involve patients in every aspect of safety. There is a patient representative on the patient safety committee, for example, and in 2010 the trust held a Patient Safety Matters open day presenting 12 patient safety initiatives.

East of England regional patient safety champion Peter Metherall has worked closely with Bedford Hospital and found it both rewarding and enjoyable. He is most proud of work on venous thrombo-embolism that has resulted in 95 per cent of surgical patients receiving a risk assessment.

But with the NPSA due to be abolished and the demise of the strategic health authorities, he says: “The government says they want to involve patients but they do not mean it. I cannot see what my role will be in future.”

Professor John Wright, director of the Bradford Institute for Health Research and now researching patient involvement in patient safety, says safety needs a clear and distinct focus: “Error costs the NHS £3bn-£4bn a year and for me it is a fundamental issue: errors are not going away,” he says. “To date, most of the safety initiatives have been around staff and equipment but it is clear that patients have a very important role. The trick is how we embed safety and quality improvement in the NHS; making it more patient focused may be the next step we need to keep it up the agenda.