Inside Patient Safety Commissioner’s first 100 days

Dr Henrietta Hughes, England’s Patient Safety Commissioner, has released a report of her first 100 days in the role where she says that she has heard ‘a yearning desire for patient safety to be at the top of the agenda’. Instead, she finds the focus of the health service is on productivity, operational performance, and financial control.

The 100 Days report arrives a decade after Robert Francis’s report into the failings at Mid Staffordshire was published in February 2013. Since then, issues of patient safety, quality of care and leadership have been in the public eye more than ever, with Dr Hughes commenting that “culture is getting worse and unless leaders set a strategic intention to listen and act, we are heading straight back to the days of Mid Staffs and other health scandals, severe harm, and death”.

The report outlines how Dr Hughes has heard from patients, families, healthcare professionals and senior leaders on what needs to change to improve the safety of medicines and medical devices following the Cumberlege report, First Do No Harm.  In it, she calls for a cultural change throughout the health system and sets out her priorities and plans for the future. Her term is three years – a short time to transform attitudes, behaviours, and culture of a system under pressure.

In her report, she comments that everyone has a part to play in delivering safe care by putting safety at the top of agenda. She says health systems should introduce patient voices into Board meetings (she singles out NHS England and the Department of Health and Social Care in particular for not doing so), commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition.

She talks powerfully in her report of “needing a seismic shift in the way that patients’ and families’ voices are heard” and of how “medicine is industrialised when it needs to be humanised”.  She is concerned about a lack of progress with digital systems observing that drivers for digital transformation are productivity and cost when the overwhelming driver should be the benefits to patient safety.

Top priorities are

• Culture change

• Pelvic mesh complications

• Sodium valproate

For each priority a set of plans are outlined. Of note on culture, we can expect a public consultation on the principles of better patient safety for the patient safety commissioner, support for the professions to improve consent and supported decision-making and challenging organisations to identify a named patient voice on all Boards.

Coinciding with the Patient Safety Commissioner’s report is the announcement that a new study will examine safety and quality across the independent and NHS hospitals. According to LaingBuisson Healthcare Markets, researchers from York and Manchester University will be leading this first major study into how the sectors have changed since the pandemic. The research is supported by broad set of stakeholders from the CQC and the Independent Healthcare Providers Network, NHS England, and the General Medical Council.