While ministers play up the risks to health posed by nurses and ambulance workers striking over staffing levels and pay, the evidence over the past 12 months would suggest it’s the impact of government policies that represents the real threat to patient safety.
A detailed analysis of that evidence emerged earlier this month with the launch of the National State of Patient Safety 2022 report – ‘What we know about avoidable harm in England’. It identified issues linked to an under-resourced and consequently over-stretched workforce, and called for a robust workforce plan – long-promised but never delivered by the government – and improvements in the quality and breadth of patient safety data.
And a global study published in September in the British Medical Journal found that doctors suffering from burnout – a huge problem over the past 12 years among doctors working in the NHS, where sleep deprivation is widely accepted as contributing to mistakes – were more likely to compromise patient safety.
Earlier this year a General Medical Council survey revealed that the risk of burnout among trainee doctors was “at its worst since it was first tracked”, and a similar survey by the Medical Defence Union showed that 26 per cent of doctors said that tiredness had impaired their ability to provide safe care.
Under-resourcing and poor workforce planning are a key driver of problems with safety.
More than six months ago a report from the Royal College of Emergency Medicine made clear to the government that the loss of 25,000 NHS beds over the past 12 years had led to “real patient harm and a serious patient safety crisis”, and pleaded for at least 13,000 extra beds to tackle “unsafe” bed occupancy levels and “grim” waiting times for emergency care. The college noted that the UK has the second lowest number of beds per 1,000 people in Europe.
The NHS is almost 10 per cent down on its planned workforce – that’s more than 130,000 posts lying vacant across England. NHS Providers’ interim chief executive Saffron Cordery described this statistic, released three months ago, as “further proof that the NHS simply doesn’t have enough staff to deliver everything being asked of it. Royal College of Nursing general secretary Pat Cullen added, “Tens of 1000s of experienced nurses left last year at the very moment we cannot afford to lose a single professional, and patients pay a heavy price.”
Earlier in the year members of the Commons health and social care select committee warned that the NHS was facing “the greatest workforce crisis” in its history, which was putting patients at serious risk of harm. The committee’s report noted shortages of 12,000 hospital doctors and more than 50,000 nurses and midwives in England, and projected a shortfall of 475,000 jobs overall in the health sector by the early part of the next decade. The then committee chair (and now chancellor) Jeremy Hunt said, “Persistent understaffing in the NHS poses a serious risk to staff and patient safety, a situation compounded by the absence of a long-term plan by the government to tackle it.”
The BMJ recently published the results of an Imperial College Business School study, conducted at three hospitals within a single NHS Trust in England. This showed how patient safety benefited from rostering experienced, well-qualified, permanent nursing staff, and how additional healthcare support workers and agency nurses were not effective substitutes.
Commenting on the latest data on GP-patient ratios from the Office for National Statistics earlier this month, the Royal College of General Practitioners Kamila Hawthorne noted that, since 2019, GPs’ workload has increased by 18 per cent and each fully-qualified full-time-equivalent (FTE) GP now cares for an extra 120 patients, while the FTE workforce has fallen by nearly 700 – with no sign that the government is going to deliver on its manifesto promise of hiring 6,000 more GPs any time soon. In November the Observer reported that because of severe workplace shortages some GPs were treating up to three times more patients than permitted by the British Medical Association ‘safe care’ guideline of “not more than 25 contacts per day”.
Earlier this year Healthwatch England highlighted the growing practice of DIY dentistry, following a joint BBC/British Dental Association survey which had found that more than 90 per cent of NHS dental practices were no longer accepting new adult patients. The news came barely two weeks after access to NHS dentistry was further restricted, after the government announced it was scrapping the commitment to offer six-month checkups for most adults, replacing it with a an offer of check-ups only every two years.
And more recently, the health secretary’s ‘in denial’ default mode was clearly on display earlier this month when problems first arose over the supply of antibiotics to deal with the outbreak of strep A. On 7 December Steve Barclay suggested to the BBC that there were “good supplies” of this medication, and that any problems were down to distribution – in effect shifting responsibility from the Department of Health & Social Care onto the retail pharmacy sector. A week later pharmacists told the broadcaster that supplies of these key antibiotics had now “gone from bad to worse” over the intervening seven days, and that the government needed to act.
So how is the government proposing to address these threats to patient safety? Technology certainly doesn’t seem to be helping: last month the BMJ highlighted how failing IT infrastructure was undermining safe healthcare in the NHS – citing a ten-day IT system outage at one of the largest hospital trusts in the NHS – and noted the disconnect between this lived experience by clinicians and the government messaging promoting a bright and shiny digital, AI-infused future for healthcare.
Then there’s ‘self testing’. On the test launch of the Department of Health & Social Care’s ‘at home’ NHS Health Checks programme – presumably an initiative to reduce pressure on GP surgeries, and to build on already available sexual health and blood pressure at-home testing options – the Royal College of General Practitioners chair Kamila Hawthorne expressed concern over how digital health checks could reliably link up with GP patient records and how patients might interpret their findings. She was also worried about the associated staffing implications for surgeries, and about potentially adding to GPs’ already high workload.
How about advertising? More tinkering at the edges rather than addressing the main issues emerged late last month with (potentially) in excess of £28m of taxpayers’ hard-earned winging its way towards M&C Saatchi. Tasked with creating a three-year strategy to ease pressures on the NHS, the ad agency’s “Help Us Help You” campaign focuses on the idea of ‘more suitable alternatives’. That means persuading patients to see a pharmacist before bothering their GP, consulting GPs virtually rather than in person, and phoning 111 rather than going straight to A&E.
All ultimately benefiting patient safety, no doubt, but M&C’s windfall contrasts somewhat with the Department of Health & Social Care’s earlier decision to allegedly slash funding – by 63 per cent, from £11m down to just £4m – to promote the uptake of NHS England’s autumn covid and flu jabs.
Consistent underfunding has increased the take-up of independently provided healthcare. Record NHS waiting lists have encouraged those that can afford it to jump from public to private. But there’s growing evidence that patient safety isn’t all it’s cracked up to be in the lightly regulated independent sector, and 1000s of patients have been transferred to NHS wards after treatment as a result. Most private hospitals lack ICU facilities, and post-operative care in the sector is often handled by unsupervised, inexperienced and overworked agency-employed junior doctors. This business model has been cited as a contributing factor in several coroner’s inquests into the deaths of patients.
But the voluntary sector is being enthusiastically eyed up as a way to solve problems within the NHS, and potentially work around the threat of strike action. Last week the Guardian revealed that the Department of Health & Social Care is planning to recruit 1000s of unpaid volunteers to help ambulance crews and provide support in hospitals, building on the model offered by a £30m four-year contract the NHS signed with St John Ambulance back in August, under which the charity is to provide surge capacity to ten ambulance trusts.
The impact of this move on patient safety is unclear, but the roles being offered surely suggest some risk. The Guardian cited one ad, posted by an NHS Trust in northern England, seeking “urgent and emergency care volunteers”, as well as people to volunteer on a 33-bed ward for cardiology patients and older people. The latter roles were to include “ensuring patients stay hydrated [and] ensuring hygiene needs are met”.
When pressure on services is high and standards slip, management bullying has too often been the tried-and-tested way to deter whistleblowers from exposing threats to patient safety. A recent BBC investigation, for example, claimed that patients were being put at risk and doctors “punished” for raising safety concerns at the University Hospitals Birmingham NHS Foundation Trust, where some haematology patients had reportedly died without obtaining treatment. And going back three years, the Guardian revealed how the West Suffolk NHS Foundation Trust – former health secretary Matt Hancock’s local hospital – felt driven to hire fingerprint experts to unmask one particularly troublesome whistleblower.
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