NHS Patient Safety 2024: Prioritising improvement efforts in a system under stress

For anyone working in the healthcare sector, Imperial’s National State of Patient Safety 2024: Prioritising improvement efforts in a system under stress (“Report”) [1], the second in its series makes for sombre reading.

The timing of the Report, shortly after the publication of Dr Penny Dash’s review [2] and just as government has started work on its 10 year plan, may impact on some of recommendations we expect to see in 2025. Whilst it is strongly recommended that the Report is considered in full, the purpose of this summary is to highlight the key theme; that change is needed to reverse the downward trajectory of patient safety incidents, as evidenced in the following key statistics:

• 13, 495 avoidable patient deaths, up from 12,675 [3]
• Maternal deaths increased to 13.4 per 100,000, a 52.3% rise from 2019
• 54% increase in C. difficile acquired in hospital
• 65% maternity units in England rated either “inadequate” or “requires improvement”
• 25 % of patients waiting more than 4 hours for a treatment decision in A&E
• 56% of patients reporting insufficient nurses on duty to provide care
• 7.6 million patients on waiting lists for elective care

In the two years since the first Report, there has been a decline in 12 out of the 22 metrics reassessed by the researchers. Professor Lord Dazi has called for urgent action so that an improved picture can be reported in 2026. This may well have been expressed in hope over expectation with such a short timeframe to effect change.

Read our full report attached detailing the report’s findings in relation to maternity, staff, costs, culture, regulation and the speed of change.

If you want to discuss the findings and its implications in more detail please contact us
 

Maternity

Performance in maternity care has worsened despite the strong recommendations from many sources that it must improve [4]. For the first time in a decade, rates of maternal and neonatal deaths have risen and, alarmingly, maternal death rates for women from Black ethnic backgrounds are almost three times higher than for White women and Asian ethnic backgrounds have twice the risk of adverse outcome. This risk is unacceptable on any metric, as is the Guardian’s finding that women from Black ethnic backgrounds are up to six times more likely to experience some of the most serious birth complications during hospital delivery. [5]

The Report concludes that the UK is now unlikely to achieve the Government targets for reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury by 2025 which most likely reflects the conclusions of Dr Dash and the Care Quality Commission (CQC) ratings 65% maternity units in England either “inadequate” or “requires improvement” with “poor transparency of reporting” and “weak or absent evaluation” preventing improvements in patient safety.  Significant changes are clearly needed, the question is how can this happen as we move into austerity measures?

Avoidable brain injuries arising from delivery and birth cause an emotional and financial toll.  NHS Resolution’s 2023/24 annual report [6] stated that 49% of £5.1 billion, so some £2.5 billion was paid out for maternity cases with improvement in maternity outcomes remaining a key target for them.

Staff

Not only has public confidence fallen, the result of a YouGov survey, highlights that staff working within the NHS are also losing confidence in the ability to provide safe care at times of urgent need with 2 in 3 members of staff  reporting that they were unable to carry out their jobs fully due to workforce shortages. 

Ambulance staff have the least confidence that their services will act on staff or patient concerns and there is a burn-out rate close to 40%.  Ambulance teams report the most-near misses or incidents that could have harmed patients with mental health emergencies amongst the most challenging for ambulance personnel  with a top concern rate of 23.91% of staff. Significant pressures were reported when dealing with mental health crises,  including safety concerns for the patient and staff during an acute mental health episode and an insufficient number of crisis units to support ongoing care and the liaison with other services.  

Ambulance staff ranked the wait for urgent care as their second priority, at 20.03% but the YouGov results for all NHS workers placed the wait for urgent care as their highest and number one safety priority.

Costs

The Organisation for Economic Co-operation and Development (OECD), has estimated that the direct costs of unsafe care in the UK [7] are sitting at £14.7 billion per year (8.7% of total health spending) and ranks the UK 21^st out of 38 for patient safety.

Whilst it may be reductive to equate patient safety with cost when every single statistic reflects harm caused to a patient, it cannot be ignored and was commented upon in the recent review by Professor Lord Darzi [8].

There are of course direct and indirect costs. The indirect costs are familiar to anyone working within healthcare:

• Public satisfaction with the NHS is the lowest since surveys began [9]
• Decease in staff morale, increase in sickness and burnout
• Working around unsafe systems and loss of productivity
• Loss of quality of life for patients/their families and the wider social burden
• Costs incurred in managing incidents

Culture changes

Whilst Professor Lord Darzi may have concluded that the NHS is in critical condition but with strong vital signs,  is the pace of change to improve patient safety meeting public expectations? A recent and very informal straw poll of patient/claimant representatives at a collaborative meeting would suggest that not many of them were even aware of the Patient Safety Incident Response Framework (PSIRF) [10] let alone what it was designed to achieve in replacing the Serious Incident Framework  with the shift from blame and performance management to learning and improvement. The Report recognises that support, expertise and resources are required to turn the learning into action.

There are inevitably common themes from PSIRF data and the safety plans analysed for the Report identified the top 6 as:

• Pressure ulcer prevention and tissue care management.
• Timely identification and management of patients at risk of deterioration.
• Falls prevention.
• Delayed, missed or incorrect diagnoses, including for cancer.
• Infection prevention and control.
• Medication safety.

Regulation and inaction

The Health Services Safety Investigations Body (HSSIB, formerly HSIB) 2024 report [11] distinguished between recommendations and regulatory action and highlighted that the lack of structure and monitoring was “not improving patient care while continuing to burden providers” and called for a reduction in the ‘noise’ with a proposal for a multiagency approach to provide oversight and a route for escalation if there was slow implementation.

The Report questions if there are too many patient safety priorities with multiple routes, could these be simplified to inform patient safety priorities at a national level by:

• Using claims and litigation data to set national strategic priorities

examples of this being the Early Notification Scheme and the Maternity Incentive Scheme

• Understanding the broader impact of unsafe care to design national safety improvement programmes

Researchers at Imperial measured  healthy life years (HLYs) lost due to six specific adverse events with preventable pressure ulcers had the greatest impact on people’s lives, resulting in 26 HLYs 

• Learning from coroners’ death investigations to make system-wide safety improvements

An analysis of over 4,000 Prevention of Future Death (PFD) reports published between 2013 and 2023 identified 29 maternal deaths reported by coroners in England and Wales. The PFDs frequently highlighted gaps in national guidance, inconsistent local guidelines, and poor communication – but only 38% of reports received a response. [12]

Speed of change

The Report concludes that the system as a whole “is failing to keep pace with the significant volume of recommendations it receives” and that the process for setting national patient safety priorities is “opaque”.

Unsurprisingly, there is a call for urgent change to reduce the overload of priorities and actions and loss of focus on the most pressing safety concerns. The Report calls for a sector-wide approach [13] so that the limited resources can be focussed on areas which will support the long-term improvement of patient safety in England:

Two solutions are proposed:

1. Local NHS organisations must be supported to adopt evidence-based interventions to tackle the most common safety problems causing significant harm to patients.
2. National organisations must agree on a focused set of patient safety improvement priorities for the system to rally around

The Report’s emphasis is on the National in the NHS title rather than local or even Regional plans. Many organisations are tackling the 6 top safety concerns collected via the PSIRF safety plans, but Report calls for national repository so that the evidence base and interventions are shared rather than each solution being developed from the ground up as an individual plan for that organisation. The Report states that this should bring consistency and speed from shared resource-pooling

The Report  infers that there may be too many patient safety bodies or, at the very least that there is a “crowded landscape” and repeats that processes are “opaque”.  It found that the system is flooded with such a volume of recommendations that it is drowning in its own good intentions and calls for rationalisation to support the NHS in delivering improvements against priorities.  

The authors of the Report also call on the government to embrace and endorse its recommendations and to co-produce clear patient safety priorities, jointly with patients and staff whilst increasing support for NHS organisations to implement and progress change.

Wider work will be conducted before the next Report in 2026 to look at an evidence basis for the impact of culture, workforce welfare and retention, effectiveness of regulation, leadership and reputation management on patient safety. 

There is no doubt that this is a complex problem to solve and it may require even more detailed analysis in the 10 year plan. Experiences and ideas can be shared via the portal [14] which will run until Spring 2025.