'Safety cases' in the NHS – the example of hospital capacity: A blog by Norman MacLeod

Summary

Ambulances lined up outside hospital Emergency Departments (EDs) are a vivid, and politically embarrassing, indication of inadequate capacity in the NHS. Media reports of diktats demanding that hospital CEOs meet performance targets suggest a desire for action, but are the local solutions being implemented to ease the pressure in the best interest of patient safety?

The use of ‘safety cases’ in healthcare has received some interest in recent years but the conclusion drawn by, for example, Leberati and her colleagues,[1] was that while they have some potential value they are "fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors".

A survey of the literature suggests that there is a danger of conflating ‘safety cases’ with ‘safety management’ or ‘quality’ systems. Part of the problem might be that safety cases are more a concept rather than a methodology: there is no script to follow. In this blog, Norman MacLeod discusses whether the the current crisis in hospital capacity can be explored through the safety case lens.

Content

What is a safety case?

Safety cases are used to manage complex socio-technical systems. The goal is to provide evidence that the system described by the 'case' is safe. A safety case has three elements.

1. First, we have some top-level, over-arching statements about the system. For example, you might say that a hospital is ‘fit for purpose.’ Another top-level statement might be that the hospital ‘meets the needs of its hinterland.’ While these examples may seem very broad, they aim to capture the essence of why the hospital exists and what its function is.
2. Next, we need corroborating data. The top-level statement is, in effect, a logical proposition and the safety case owner must provide data to prove the proposition to be true. If a statement cannot be proven to be true then the safety case fails and the system must be considered to be unsafe.
3. Finally, we need to declare any inference rules used to provide the data necessary to support the top-level statement. For example, direct performance measures might not be available and we might choose to use surrogates or data derived from extrapolations instead. Both direct evidence and that derived from inference rules must be valid and reliable – that is, they must be shown to measure what they claim to measure and must function consistently across time.

A hospital safety case would require, as a minimum, evidence to show that the estate (design and maintenance), resources (equipment and consumables) and staff (numbers, grades, skills mix, recruitment, retention, training, etc.) were appropriate to satisfy the requirements of the top-level statement; in this case that the hospital was fit for purpose. However, the safety case is not static. It must be applicable to the lifecycle of the entity it covers. Which means that it must cope with change. And now we come to the ways hospitals are currently trying to cope with excessive demand.

Hospital responses to increased demand

The solutions being implemented by hospitals to cope with demand seem to fall into two groups: buffers and lubricants.

Buffers are ad hoc capacity where patients can be held prior to moving to the next stage in their care. For example, EDs are creating additional spaces where patients can be held between arriving in an ambulance and entering the ED, or after treatment and being accepted on a ward. Some Trusts have made provision for discharge-ready patients to be moved to local hotels pending community care becoming available. Corridor nursing is an example of buffering.

Lubricants include those measures aimed at expediting flow. The Positive Flow philosophy, where patents are force-fed from ED onto wards at fixed intervals, is one example. Discharging surgical patients from recovery rather than a discharge suite is another.

A safety case would require changes to the existing system to be tested against the top-level arguments. So, we would need to understand the steady-state condition and then be able to compare the impact of any changes made. We need to assure that the new provisions are equally fit for purpose. Unfortunately, the experience to date suggests not.

The creation of buffers is adding to the burden of supervision and increasing the requirement to move patients between stages of treatment. In some cases, inadequate logistical provision means that patients are in spaces with no oxygen supply or call bells. Care is being delivered in spaces where the minimum levels of dignity and privacy cannot be met. Rooms are being used that are difficult to observe and, in one case, had access to an exit allowing a patient to abscond undetected.

Meeting the demands of positive flow can require additional beds in rooms or corridors. In one case, a Trust is replicating measures it had already removed because they were deemed unsafe in a previous Care Quality Commission report. Patients are being discharged without appropriate follow-up because the staff involved are untrained in the necessary procedures.

It seems, then, that measures taken to solve one problem – capacity – have introduced new risks.

Conclusion

Applying the safety case concept requires an organisation to answer a simple question: are you configured to function in a safe way? The answer to that question must apply equally to the steady state and to any changes, no matter whether permanent or temporary. In the example of coping with excessive demand, local fixes are being implemented but it is not at all clear that solutions are safe.

Perhaps it is time to look again at the safety case concept?

Reference

1. Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case study. BMJ Quality & Safety 2024 Feb 19;33(3):156-165. doi: 10.1136/bmjqs-2023-016042.

Further reading on the hub:

• A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift
• What is a ‘safety management system’? A blog by Norman MacLeod
• Can you measure safety? Part 1 - Improving patient safety
• Errors as clues in the search for safety measures: Measuring safety part 2

About the Author

Norman MacLeod served for 20 years in the RAF involved in the design and delivery of training in a variety of situations. He stumbled across 'CRM' in 1988 while investigating leadership in military transport aircraft crews. From 1994, he worked around the world as a consultant in the field of CRM in commercial aviation, latterly employed as the Human Factors Manager for a blue chip airline in Hong Kong. Now semi-retired, he is one of the Patient Safety Partners at James Cook Hospital in Middlesbrough.