It has been a month since the publication of the Cumberlege Report, which detailed the harm that has happened to tens of thousands of patients over many years. Following a 2-year period of gathering evidence, listening to views and deliberation, the report made several important recommendations. Since then, it has generated only modest headlines and within healthcare circles little debate. Has there ever been such an important report that has generated such little discussion and debate following publication?
It would be easy and obvious to cite Covid as the reason for this, but surely the current pandemic is all the more reason for the importance of patient safety to be integral to our planning and priorities as we restart and reset services and look to the future.
The report made several key recommendations across a number of devices, procedures and drugs. The main themes were to:
involve patients more in their care and to listen and take their views seriously
move away from a culture of blame so that staff could speak up and voice concerns
improve data collection and incident reporting to aid learning
provide more support to patients after things have gone wrong
better address health inequalities
improve leadership and regulation.
It is one of several reports in the last 20 years that has considered patient safety scandals and sought to address this persistent and fundamental problem within healthcare. It is not just a UK problem, the OECD estimates 15% of healthcare budgets are spent on harm, much of it entirely preventable, and the remainder on rectifying or compensating for the problems created.
Within the Cumberlege report was this quote:
"I have to say 20 years later it is very frustrating how little progress we have made. It’s clear to me that we still have not got the leadership and culture around patient safety right. As long as you have that culture of people trying to hide things - then we are not going to win this."
Professor Ted Baker, Chief Inspector of Hospitals, CQC
At this time of unprecedented change, with an acceleration of acceptance and adoption of innovation and technologies like never before, surely now is the time to bring patient safety to the fore of the debate about how our healthcare services should be run and managed. If it is not deemed important now will it ever truly be important? Or will it remain forever in the camp of “too difficult” to solve?
To ensure the safety of patients we should also recognise the need for people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. Patient Safety Learning’s the hub plays an important part in this, providing a platform to share resources, stories and good practice for anyone who wants to make care safer for patients.
At PEP Health (Patient Experience Platform), we have one of the largest databases of patient comments tracking back to Jan 2018. It covers every hospital in the UK and includes every comment made by patients across social media platforms and online review sites. Our analysis of these comments demonstrates that what patients say matters and that patients provide remarkable insight and perspective. It also highlights that patient experience and patient safety are not two discrete components of “quality” but are closely interwoven and linked. For example, we hear patients commenting on issues such as repeated medicine errors, an inability to access essential services and being provided with either poor or confusing information
So, in the spirit of starting some discussion following the Cumberlege report, here are my recommendations and thoughts:
Without better, faster data to support change nothing will happen. This data needs to be a balance of quantitative and qualitative data that brings together patient safety, patient experience and the patient voice.
A patient safety commissioner can provide leadership but they cannot change the culture alone. After so long trying internally without success, we should now publicise results and be more transparent than ever before. Organisations should be benchmarked and compared against their peers.
Greater celebration and promotion should be made of successes. Best practice and learning is too slow to take hold. Teams should not only be encouraged to adopt change but be empowered to make change locally.
The patient voice must be taken much more seriously by organisations and clinicians so that in 20 years’ time we are still not publishing reports following scandals with little change to celebrate and few lessons learnt.