The Care Quality Commission (CQC) examines Never Events in a report on NHS safety culture and the need for transformation published today.
The report - Opening the Door to Change - was generated by the CQC working with NHS Improvement at the request of the Secretary of State for Health and Social Care. It looked at issues in NHS Trusts that contribute to Never Events taking place and sought to understand what makes it easier - or harder - for the people and organisations within the NHS to prevent them. It also considered what could be learned from other industries and countries.
The review sought to answer four questions:
* How do Trusts regard existing guidance to prevent Never Events?
* How effectively do Trusts use safety guidance?
* How do other system partners support the implementation of safety guidance?
* What can we learn from other industries?
The CQC visited 18 NHS Trusts from the acute and mental health sectors between April and June 2018. It carried out one-to-one interviews, visited different services and reviewed policies and procedures.
Forums and workshops were held with patient representatives, people from the NHS as well as other healthcare organisations, focus groups were held for frontline staff and arm’s length bodies were asked about their role in patient safety.
The CQC also consulted experts from other sectors, including aviation, nuclear and fire and rescue, with a view to understanding the approach to safety of other safety-critical industries.
The report reveals a confusing and complex system. Whilst patient safety alerts are viewed as an effective way to share safety guidance, the lack of a process or system to co-ordinate implementation or drive and monitor progress is a problem for many Trusts. The CQC found that implementing patient safety alerts can be approached in a mechanistic and siloed way by under-pressure staff with high workloads. This can result in multiple individuals taking responsibility leading to many adaptations of the same piece of guidance. Greater standardisation could help and make it easier for people to speak up if a process is not being followed as it should be. Leadership styles and hierarchies can also have a detrimental effect on Trust safety culture.
Arm’s-length bodies, including the CQC, royal colleges and professional regulators, also have a substantial role to play within patient safety, but there is no clear understanding of how the current system is organised and who is responsible for what. This makes it difficult for them to prioritise what needs to be done and when.
The same problem applies to education. With multiple organisations involved with professional education in the NHS in England it is not easy to establish who is responsible for which elements or who has the authority to deem any element of training mandatory, for example around patient safety, and place it consistently within training programmes.
With so many different bodies having a role in education, the importance of patient safety training is slipping through the cracks both at undergraduate level and throughout careers.
The CQC concludes that Never Events continue to happen despite the hard work and efforts of frontline staff. Everyone who has a role in health care or who receives health care in England should recognise the importance of making patient safety a top priority and the extent of the cultural change needed to make this a reality.
NHS Improvement has also this week announced a commitment to halve avoidable patient harm, with reducing Never Events one of the key priorities. Read this story here.
Click here to download the full CQC report.
