Patient safety is at the heart of everything we do – how often have we heard this being stated by leaders of healthcare organisations? And yet, report after report on scandals which have happened in the health sector speak of patients being ignored, dismissed, or treated with callous disregard. Sir Brian Langstaff in the report of the Infected Blood Inquiry recommended that patient safety must be paramount. So why is it neglected?
Patient safety is seen as implicit and complex, difficult to measure, difficult to engage with and the area of experts. This is very different from high safety industries that put safety at the centre of their activities, with a leadership intent to develop a just and learning culture. I welcome the appointment of Baroness Merron as Minister for Patient Safety and Life Sciences, but does it send the right signals that safety has been downgraded from Minister of State to Parliamentary Under Secretary of State?
The National Patient Safety Strategy sets out three pillars to improve the safety culture – insight, involvement, and improvement. The national safety syllabus which accompanies the strategy has been enthusiastically welcomed by the workforce, with over a million frontline staff having completed level one of the training. Patient Safety Specialists have gone further, with hundreds of patient safety experts completing the higher levels of training, supported by HSSIB which offers training for those with decision making and patient safety and investigation roles.
But what about leaders? Not only of provider organisations but all the bodies that surround the NHS – the politicians, officials, inspectors, regulators, commissioners, representative bodies and patient groups? Having completed the patient safety syllabus myself, I found it a very valuable exercise. It helps us to have a shared understanding of safety, fluency in the language of safety, a chance to assess the organisational culture in which we are working, and a common purpose to keep people safe. How can leaders of organisations state that patient safety is the heart of everything they do, if they have not engaged with the patient safety strategy and completed the training themselves?
For frontline staff and patients alike, it is vital that leaders speak the same safety language, understand the impact that they have on the safety culture and embrace patient partnership.
But it is hardly surprising that senior leaders don’t talk about safety because it is not on their radar. The absence of patient safety training offered to senior leaders was evident to me when I was a non-executive director of an NHS trust. Patient safety was not included in our induction training, which focussed on finance and data. The Board of NHS England have not yet undertaken the training created by their own national patient safety team. To achieve the strategic aims of safer culture, safer systems and safer patients, it is vital that leaders prioritise safety and demonstrate leadership at all levels of the health system. And this starts with the Office of the Patient Safety Commissioner.
Naming this gap has had some positive responses: the NHS England Board is going to have a special session on patient safety in September. NHS Providers has developed a module for patient safety training for trust non-executive directors which will soon be launched. And the board of NHS Resolution has also pledged to undergo the training.
Let us all become fluent in the language of safety. I am asking national bodies to align with this direction of travel for the good of patients and those who care for them. If you are a chair, invite your highly trained patient safety specialist to lead a Board session. Ask your board whether you are a bureaucratic or generative organisation. Your patients and service users need you to join the million NHS staff who have already started this journey so we can truly achieve the goals of safer culture, safer systems, and safer patients.
Everyone can sign up for the training NHS Patient Safety Syllabus training – elearning for healthcare (e-lfh.org.uk)