Responsibility for the safety of patients is a cornerstone of healthcare. Alison Moore looks at how changes to the NHS will affect its approach to this fundamental commitment.
In the next two years many organisations tasked with ensuring and improving patient safety will be swept away – in their place will be a new structure of commissioning groups and a powerful NHS Commissioning Board with myriad responsibilities. Management costs will have been slashed, budgets tightened and services will be provided by more private firms and social enterprises in different settings. Will safety suffer?
That question is hard to answer but there are growing fears that the abolition of the National Patient Safety Agency, in particular, will leave a void that will be hard to fill. Action against Medical Accidents (AvMA) chief executive Peter Walsh says: “Patient safety overall will be a loser as a result of the reforms.”
The NPSA will be abolished in March 2012 but has already lost many staff, he says, and the funding available to the commissioning board for safety is likely to be a fraction of the NPSA’s budget. Mr Walsh fears there are no definitive plans for the transition period as the NPSA bows out. Some of its safety functions will pass to the commissioning board, which will also be picking up other roles from different organisations.
“Although some people have been critical of the NPSA, one of the things that was a real strength was that there was a national body focused entirely on patient safety,” he says. “There is a danger that it will become diluted and lost.”
Against that, he says, the commissioning board will be a very powerful body, perhaps with greater clout than the NPSA – AvMA’s research suggests patient safety alerts from the NPSA are not universally adopted.
Mr Walsh has pressed the Department of Health for information on how the patient safety landscape will look in the future but has received no answer. One complication is that, although the commissioning board is an England-only body, some of the NPSA’s functions also cover the devolved nations; they are likely to have to make their own arrangements in future.
Royal College of Nursing policy director Howard Catton says there has been a surprising amount of concern over the NPSA from nurses, who would not normally be worried about the demise of an arm’s length body. Its role in collating untoward incidents was seen as particularly important.
“I think there is a real concern around the data collection, research and good practice. It is more important than it ever has been because of the financial challenge the NHS is facing. Nursing staff are acutely aware that what is being sold to them as efficiency savings feels like a cut in services, which has the potential to have a detrimental impact on patient care,” he says.
“It does feel as if a very important safety net is being removed at a time when it is most needed,” says Mr Catton.
He is also concerned the abolition of the NPSA may cause a shift away from the “no blame” culture the NHS has tried to develop. The Department of Health does not see it like that.
A spokesperson says: “Moving these patient safety functions to the NHS Commissioning Board means we can embed patient safety into the health service through GP commissioning and the contracts they agree with providers.
“This will ensure that across the NHS there is a culture of patient safety above all else. We have already set out how we intend to free NHS staff from central control and targets that are not clinically justified to allow them to focus on what really matters – reliable, effective and, above all, safe care for each patient.”
Plans for the transition are being worked on.
The Health Protection Agency is also being abolished but its functions are being transferred to a successor body – Public Health England – and there seems to be less concern. The Care Quality Commission’s role as regulator will remain largely the same, while the development of HealthWatch, the new consumer champion, may mean it gets a consistent flow of “on the ground” information about problems at trusts.
At the moment, local involvement networks work with the CQC and information from them helps it to form an overall picture of a trust; with HealthWatch this will become more structured and there is the potential for more of an “early warning system” for care or safety failures. The national side of HealthWatch will be able to propose investigations into areas of concern.
Will this prevent another Mid-Staffordshire or Maidstone and Tunbridge Wells? That is hard to say but HealthWatch’s powers don’t seem significantly stronger than those of the existing LINks; the DH says they will “evolve” from LINks, take on complaints advocacy and be dependent on local authorities for funding.
The Patients Association, which was initially fairly positive about HealthWatch, is now very concerned it will grow out of the existing LINks system without any analysis of the networks’ success. LINks have been ineffective and unpopular in some areas, the campaign group says.
But how will individual NHS organisations approach safety when cash is increasingly tight? The answer is complex; while there may be pressure to cut corners, they will be acutely aware of the risks – financial and reputational – of not operating safely. Doing it right first time is cheaper than doing it wrong and having to put it right; for example, “never events” – the list of which was recently expanded from eight to 25 – can lead to payment being withheld by commissioners.
NHS Confederation deputy policy director Jo Webber thinks this will keep patient safety uppermost in people’s minds, promoting both quality care and financial efficiency. However, for most trusts, the effect of this will be minute – and there are fears it could discourage reporting.
Reporting serious untoward incidents is already a mixed blessing for trusts. Although many in the NHS appreciate it may indicate an open culture around safety, when there are a lot of reports this is sometimes treated in the media as evidence that something is wrong in an organisation.
Another matter has also been highlighted by the British Medical Association. It has expressed concern that trusts struggling to meet the deadline for foundation trust status could prioritise this above everything else, including patient safety.
Can clinical commissioning groups add muscle to the patient safety system? Mr Walsh points out that reporting of incidents in primary care is “appallingly low.
“There are certainly worries that clinical commissioning groups won’t have the same ability or strategic overview to work on patient safety,” he says.
Loss of knowledge
The loss of people with knowledge of patient safety issues as a consequence of the abolition of primary care trusts and strategic health authorities – is another concern. Will this affect “organisational memory”?
Health Foundation director of improvement programmes Jo Bibby feels this is increasingly seen as a holistic issue in the NHS, with more interest in the organisational and systemic approach than looking at just one issue, such as hand hygiene.
“People are looking for a wider set of approaches and solutions,” she says.
But Ms Bibby does see risks ahead.
“There is a risk that people may have less time and space. We know that doing improvement needs downtime for thinking and planning.”
Another risk is the perception that only frontline staff have a role in patient safety and losing other staff won’t impact on it.
Jo Webber thinks one big driver for patient safety will be the increased amount of data available to patients through the outcomes framework. It is uncertain how many people will use it, but this will enable patients to see a hospital’s safety record in great detail.
Many private hospitals already emphasise their safety records in certain areas – such as healthcare-acquired infections – when trying to attract patients; NHS hospitals too are likely to seize on safety “selling points”.
“If you are going to improve your competitive position you have to focus on patient safety all the way through everything you do,” says Ms Webber.
And patient safety is linked to quality of care issues – which have been widely explored in the media recently. However, too much information may confuse patients and they may need someone to guide them through it. It is hard to see who will fulfil that role – GPs may be too busy, providers will have a vested interest in emphasising what makes them look good and the media rarely goes into the depth patients need. And, Ms Webber points out, there is plenty of evidence that patient choice is influenced by numerous other factors.