New role is needed to oversee patient safety report concludes

In its new 104 page report, Safer care for all – solutions from professional regulation and beyond, the Professional Standards Authority (PSA) highlight some of the key challenges facing the quality of health and social care today. It examines the current state of health and care regulation in the UK and proposes solutions to some of the wide ranging challenges it identifies.

The report’s Foreword from the Chair and Chief Executive of the PSA says that while professional regulation has improved over the last two decades successive high-profile failings such as the recent Ockenden report into maternity failings at Shrewsbury and Telford Hospital NHS Trust revealed “harm on a shocking scale” with warnings that the contributory factors are unlikely to be limited only to this Trust.

They ask: “Are patients safer now than they were at the turn of the millennium?” “Are we learning from public inquiries?”

The PSA’s report explores how professional regulation needs to adapt to the unresolved challenges for patient safety which it covers under four key themes – all individually wide and complex topics:

1. Tackling inequalities – affecting registrants and patients / service users
2. Keeping pace with changes to technology and the delivery of care – in respect of funding, commercial providers, online services, conflicts and “high street” providers
3. Facing up to the workforce crisis
4. Addressing issues of accountability, fear and public safety – specifically with regard to just culture and safe space with a tension noted between learning from mistakes and taking responsibility

Examination of these themes also identified a sector wide issue – structural flaws in the safety framework – where concerns raised “often fall between organisations or are left unaddressed” with large scale failures of care still occurring and inquiries and reviews revealing similar issues.

Several possible solutions are discussed as well as one overarching recommendation: that each UK nation should have a Health and Care Safety Commissioner spanning public and independent sector provision. Each commissioner would have broad responsibility for identifying, monitoring, and advising on ways of addressing patient and service user risks.

Four solutions are proposed:

1. Sector wide initiative to improve collection, analysis and sharing of demographic data to help understand and address health inequalities in care.
2. Government reforms to the professional regulators to equip them to respond to risks arising from developments in how care is funded and delivered.
3. A new strategy for the regulation of health and care professionals to be developed by the four UK Governments to support delivery of their national health and social care workforce strategies.
4. Build on the ‘safe spaces’ approach of HSIB (noting this only applies in England and not in Scotland, Wales and NI) to ensure improvements in safety culture and support candour and accountability. It asks the UK Government to build in a review of the policy and assess how compatible it is with the professional duty of candour because it is concerned there is an undermining of existing mechanisms.

Interestingly, as the UK Covid19 Public Inquiry gathers momentum the report also recommends that there should be an independent mechanism for centralised coordination and oversight of public inquiries, particularly reporting on progress against recommendations so lessons are learnt and mistakes not repeated.

This is a brief canter through the report and its recommendations: the appendix (pages 90-91) sets out all the PSA’s recommendations and commitments signposting readers to the “what?”, “who?” and the relevant chapter.