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  • Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’

    Summary

    Last week the Professional Standards Authority for Health and Social Care (PSA) published a new report, Safer care for all – solutions from professional regulation and beyond, which examines the current state of professional health and care regulation in the UK. In this blog, Patient Safety Learning considers this report from a patient safety perspective. 

    PSA's chief executive, Alan Clamp, has also written a blog for the hub on the report, which can be read here.

    Content

    The Professional Standards Authority for Health and Social Care (PSA) is an independent body which oversees the ten statutory bodies that regulate healthcare professionals in the United Kingdom and social care in England. Its aim is to protect the public by improving the regulation and registration of people who work in health and social care.[1]

    In its new report, Safer care for all – solutions from professional regulation and beyond, the PSA set out their view of the main unresolved challenges which impact the quality and safety of health and social care.[2] This is structured around four main themes:

    1. Tackling inequalities – considering the persistence of unequal and unfair outcomes for protected groups in aspects of professional regulation.
    2. Regulation for new risks – noting the need to adapt to both the risks and opportunities posed by rapidly developing and increasingly accessible new technologies and approaches in health and care.
    3. Facing up to the workforce crisis – considering the impact of workforce shortages on patient safety and the capacity of healthcare professionals.
    4. Accountability, fear and public safety – looking at the balance that needs to be struck between making individual accountability work in a system that is safe for patients and fair to healthcare professionals.

    The report also highlights a sector-wide issue which it describes as “structural flaws in the safety framework”.[2] This concerns the fragmentation and complexity of our current system-wide approach to safety in health and social care. The report highlights that no one organisation currently takes an overarching view of this, noting that instead this is only looked at through individual organisational remits.

    In this blog, we will consider the four main themes highlighted in this report from a patient safety perspective and reflect on the sector-wide issue of structural flaws in the safety framework. 

    Tackling inequalities

    Health inequalities pose a serious threat to patient safety, with poorer outcomes for specific patient groups presenting themselves in a variety of different ways.[3] This report highlights some specific examples of this, such as abuse and neglect of people with learning disabilities, highlighted by reviews such as the Muckamore Abbey Hospital Public Inquiry, and people from specific ethnic and racial backgrounds being disproportionately affected by certain types of patient safety incidents.[4] [5]

    The PSA make a number of recommendations in this area, emphasising the importance of collecting appropriate health and social care data relating to people with protected characteristics, reducing barriers to raising complaints and identifying issues that disproportionately impact particular groups.

    We welcome the proposals set out in the report and also what appears to be a growing acknowledgement more broadly of the patient safety concerns raised by health inequalities, as evidenced by the recently announced Government call for evidence on the potential racial and gender bias of medical devices.[6]

    However, much more work is needed to ensure this becomes a key focus for all health and care organisations. To date, the most thorough work in this area has often been carried out either by tenacious patient campaigning groups, such as FIVEXMORE on disparities in maternal outcomes for Black women, or very specifically tasked bodies, such as the NHS Race and Health Observatory.

    Regulation for new risks

    The second key theme this report focuses on changes to how health and care is funded and delivered, including the use of new technologies. The PSA stresses the importance of the Government and regulators being ahead of the curve on such changes, ensuring they identify emerging risks and protect the public.

    We agree with this view and believe it is vital that we ensure that patient safety considerations are at the heart of new healthcare innovations and technologies, from the point of development through to their deployment. We also need to ensure there is a direct role for patients in the development and implementation of new innovations, and consistent use of Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS) to monitor their safety in use.

    Facing up to the workforce crisis

    There is a wide body of research highlighting the negative impacts on patient outcomes as a result of insufficient staffing levels.[7] [8] In addition, reports into major patient safety scandals, such as the Francis report on the Mid-Staffordshire NHS Foundation Trust, have made clear the link between patient safety incidents and safe staffing levels.[9] It is about having the right numbers of staff, with the right skills, in the right place at the right time.[10]

    PSA rightly identifies the serious workforce shortages we currently face in both health and social care in the UK as a key challenge to the quality and safety of care. We welcome their recommendation that the four UK governments should work together to develop a coherent strategy for the regulation of professionals, to support delivery of the national workforce strategies.

    Accountability, fear and public safety

    The fourth theme of this report is focused on striking the balance between making individual accountability work in a system that is safe for patients and fair to healthcare professionals. The PSA emphasise the importance of ensuring that workplace cultures do not unfairly punish healthcare professionals for mistakes when things go wrong whilst also retaining the importance of individual accountability.

    At Patient Safety Learning we believe it is vital that we create an environment in health and social care organisations with an open and fair culture that enables patient safety issues to be raised, discussed and resolved, ensuring incidents of avoidable harm are responded to with empathy, respect, rigour and action for improvement. To achieve this, patient safety incidents must be reported consistently, and staff and patients feel safe and supported in doing so.

    Related to this, we would agree with the PSA’s recommendation that professional regulators are seen to be fair and transparent, with clear explanations of how and why decisions are taken. 

    This section of the report also considers the issue of ‘safe space’ principles in patient safety investigations by the Healthcare Safety Investigation Branch. This is where, as part of safety investigations, material such as transcripts, witness statements from staff and patients involved in the incident, notes written by investigators, electronic recordings of interviews and other information generated by the investigation are non-disclosable and inadmissible, except on the order of the High Court.

    The report raises concerns that this approach may run counter to the professional duty of candour that requires professionals to be open and honest when things have gone wrong. They suggest that:

    The UK Government should ensure that the ‘safe spaces’ investigation approach being implemented in England does not cut across the duty of candour or otherwise negatively impact on transparency or accountability.[2]

    Structural flaws in the safety framework

    Considering the health and social care landscape more broadly, the PSA highlights that the current approach to safety across health and social care is too complex and fragmented. It points out that while many individual organisations take a view on safety, they all do so only through the lens of their own remit, with no one taking an overarching overview. They also note this occurs in the case of public inquiries too, which can often vary considerably and are not necessarily looked at in a joined-up way.

    In response to this, the report makes a core recommendation that:

    Each UK country has a Health and Social Care Safety Commissioner, or equivalent function, with broad responsibility for identifying, monitoring, reporting, and advising on ways of addressing patient and service user risks. The commissioners should sit above all other health and care organisations, spanning public as well as private provision. They would also be independent of Governments, and transparent in both their approach and outputs.[2]

    We agree with the PSA’s diagnosis of this issue. In our recent report, Mind the implementation gap, we highlighted that part of the difficulty in implementing improvements in patient safety in the UK lies in absence of a systematic and joined-up approach to these issues and unclear leadership at a system level.[11]

    This is not a new problem, previously identified in a 2018 report by the Care Quality Commission, Opening the door to change, which stated:

    Arm’s-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what.[12]

    The PSA’s proposals for independent commissioners have significant merit and are worth further exploration as part of an effective Safety Management System.

    However, the introduction of a Health and Social Care Safety Commissioner, while potentially bringing significant benefits of coordination and oversight at a system level for patient safety, will not alone bring about a significant improvement in patient safety. In our view, any such change must be part of a wider transformation in our approach to patient safety, placing this at the heart of our healthcare system. This cannot just be limited to the most senior levels of health and social care, we need everyone – politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders – involved in this effort. 

    References

    1.  PSA., Who we are. Last Accessed, 6 September 2022.
    2. PSA. Safer care for all – solutions from professional regulation and beyond. 6 September 2022.
    3. Patient Safety Learning., Health inequalities and patient safety. 15 December 2021.
    4. Muckamore Abbey Inquiry. About the inquiry. Last Accessed 7 September 2022.
    5. Chauhan A, et al. The safety of health care for ethnic minority patients: a systematic review. Int J Equity Health 2020: 8;19(1):118.
    6. Department of Health and Social Care. Equity in medical devices: independent review call for evidence. 11 August 2022.
    7. Rafferty AM. Research proves we need safe staffing. RCN Bulletin, 23 July 2019
    8. National Institute for Health and Care Excellence. Safe staffing for nursing in inpatient mental health settings. Last Accessed 22 August 2020
    9. Robert Francis QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. February 2013.
    10. Royal College of Nursing. Safe and Effective Staffing: Nursing Against the Odds. 2017.
    11. Patient Safety Learning. Mind of the implementation gap: The persistence of avoidable harm in the NHS. 7 April 2022.
    12. CQC. Opening the door to change: NHS safety culture and the need for transformation. 2018.
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