Making patients our purpose: a recent discussion at the Patient Safety Management Network

Summary

This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 9 June 2023. At this meeting, members of the Network were joined by Dr Henrietta Hughes, Patient Safety Commissioner for England.

The PSMN is an informal voluntary network for patient safety professionals in England. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out about the network.

Content

The office of Patient Safety Commissioner for England was created by the UK Government following a recommendation from the Independent Medicines and Medical Devices Safety (IMMDS) Review, chaired by Baroness Julia Cumberlege. The Review examined the response of the healthcare system in England to the harmful side effects of three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants.

Role and work of the Patient Safety Commissioner

Opening the meeting, the Patient Safety Commissioner, Dr Henrietta Hughes, outlined the background to her post, explaining that her role is:

• to seek improvements to patient safety around the use of medicines and medical devices
• to amplify patients’ voices and champion the value of listening to patients.

Henrietta noted that much of her initial activities have involved collaborating closely with patients and families impacted by the medical interventions covered by the IMMDS Review.

She spoke about working with Emma Murphy and Janet Williams from the Independent Fetal Anti Convulsant Trust (In-FACT), who have both had children affected by exposure to sodium valproate during pregnancy. She emphasised the importance of their campaigning efforts in helping to support a strengthening of regulations so that valproate medicines cannot be used in women of childbearing potential unless a Pregnancy Prevention Programme is in place. She also spoke about their work with the World Health Organization and other health systems internationally to reduce the risk of children being born exposed to sodium valproate.

She moved on to highlight working with Kath Sansom from Sling the Mesh, who was seriously harmed following a pelvic mesh implant. Henrietta spoke about how the Patient Safety Commissioner’s office had developed, in partnership with the patient campaign groups Sling the Mesh and the Rectopexy Mesh Victims and Support, a letter for patients to help GPs identify the complications of pelvic mesh. It explains signs and symptoms of women presenting with pelvic mesh-related conditions and, if required, where to signpost them for further help.

Talking about her first few months in office, Henrietta said that she had already been contacted about a wide range of safety issues relating to medicines and medical devices, varying from painful gynaecological procedures such as hysteroscopy to the after effects of medications such as isotretinoin.

She also outlined culture change as another key area of initial focus in her work, noting that she was:

• Working with healthcare leaders to ensure the patient voice is heard and making it easier to speak up, tackling the issue of epistemic injustice in cases of healthcare harm where professionals fail to treat patient reports seriously.
• Supporting professions to improve consent and shared decision-making processes, in particular working with all regulators to attempt to align approaches to consent across different healthcare professions.

She spoke about promoting the benefits of patient participation, for patient experiences, outcomes and the wider efficiency of the healthcare system, and the need to strengthen and improve responses to patient feedback. Henrietta also emphasised the importance of patient safety being on healthcare leaders’ agendas, with a greater focus on stopping harm in advance by identifying and managing the causes and controls.

Network discussion

Subsequently the session opened out into a broader discussion of patient safety and patient involvement, in which the following issues were raised:

•  What we can do to move away from an adversarial approach to staff who raise patient safety issues; noting that where this exists for staff it may often be an even greater issue for patients and families.
• Acknowledgement that much more work needs to be done to create a culture where it is safe to speak up. This was highlighted by the latest National Guardian report, which raises concerns from the most recent NHS Staff Survey that we are actually going backward in this area, which Henrietta noted was ‘extremely disturbing’.
• Considering how the healthcare system and organisations can better engage with patients raising safety concerns and valuable insights through groups on social media. Henrietta spoke about the challenge of the hierarchy of evidence when it comes to avoidable harm, where too often anecdotal patient experiences are dismissed when these can provide important patient safety insights.
• The importance of co-production and how you embed this, with an emphasis on the need for true leadership support for this to be successful.
• The value of exploring the role of restorative practice after avoidable harm, with Henrietta noting that she would soon be meeting with a team from New Zealand who have been working on this.
• The need for NHS patient involvement processes to not just focus on the role that staff can play in improving this, but also looking at creating opportunities for patients to raise concerns that do not simply end up in complaints processes.
• The value of patient safety insight and experiences that can be gained from sources external to the NHS, such as Care Opinion.
• The importance of linking up the work of the new Patient Safety Partners in organisations with Freedom to Speak Up Guardians.
• How implementing the new Patient Safety Incident Response Framework (PSIRF) is presenting opportunities to increase and improve patient involvement in incident investigations and gain important insights and learning as part of this.

How to get involved in the Patient Safety Management Network

 Are you a patient safety manager interested in joining the Patient Safety Management Network? You can join by signing up to the hub today. When putting in your details, please tick ‘Patient Safety Management Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email claire@patientsafetylearning.org.