World Patient Safety Day 2023
17 September 2023
For this year’s Patient Safety Day, Jono Broad explores the importance of elevating patients’ voices and the WHO’s patient safety aims.
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The World Health Organisation (WHO) launched a World Patient Safety Day in 2019. It called for global action for patient safety and, as part of that call, the NHS responded with the National Patient Safety Strategy.
In 2023, 4 years on, the theme is ‘Engaging patients for patient safety’. As the WHO puts it – “in recognition of the crucial role patients, families and caregivers play in the safety of healthcare.” The NHS Patient Safety Strategy delineated this into two clear areas: ensuring patients were involved in their own personal safety when in the care of the NHS, and ensuring there is a voice for patients at the strategic decision-making level.
Patients’ involvement in their own personal safety is done better in some organisations that others. If you have seen the video put out by NHSE’s national team to support this, I hope you realise we have failed completely get to the depths of this.
The simple fact is that when it comes to safety, we need to think not only of the easy quick fixes, but also of directly engaging with patients to help them understand care, engage with the delivery of care and allow them to take responsibility for their care. After all, care is not just given but must be received in the right way to be effective.
Much has been noted recently of the campaign to ensure that patients have access to a second opinion, known as Martha’s Rule following the tragic case of Martha Mills who died following poor care that led to sepsis. I support this when needed, however if clinicians and care staff were open to challenge and people were fully involved in the discussions and decisions around their care, then the need for a second opinion would be dramatically reduced. After all, I still don’t understand why at an MDT (Multi-Disciplinary Team) the only person not present is the patient or their representative.
The second area that our National Patient Strategy is clear about is ensuring there is a patient voice in strategic decision-making processes. The inclusion of patient safety partners for every trust was not supposed to be an ‘if you do this you’ve got it covered’ but was intended to be a starting point. The involvement of those with lived experience brings an additional viewpoint and focus to strategic policy planning, and the development of safe care practices.
Last week in the run up to Patient Safety Day, I had the privilege of speaking at a conference at the Royal Society of Medicine. The audience included many professionals in the patient safety world. I asked one simple question: Could anyone in the room name the two patient safety partners that their organisation had recruited? Sadly, as I expected, only 2 out of 200 people could answer.
Now before you celebrate and think that at least it wasn’t none, I should tell you that the two people that could name their patient safety partners simply named each other as they were the patient safety partners within the organisation, and it was brilliant to see them in the audience.
In the improvement world, as well as in the safety world, we are taught to hold ourselves to account by having clear aims and ensuring we look back to assess if we have been successful.
Let’s look at the aims of the WHO from their own patient safety website:
1. Raise global awareness of the need for active engagement of patients and their families and caregivers in all settings and at all levels of healthcare to improve patient safety.
I do believe that there has been a raising of the profile of patient safety within the UK. However, sadly most of the awareness around patient safety has come from significant issues within the NHS and national press investigations, along with high profile safety reviews such as the Ockenden Review. We have to ask ourselves honestly if we have significantly moved the dial on safety since 2013.
2. Engage policymakers, healthcare leaders, health and care workers, patients’ organizations, civil society, and other stakeholders in efforts to engage patients and families in the policies and practices for safe healthcare.
In terms of engagement, there is partial success, but there is also ‘Policy Blindness’. We have some very good policies in place and then for various reasons we make these policies advisory rather than mandatory. There is excellent training for patient safety for all staff, but this is not mandatory. The inclusion of lived experience people at board level has shown excellent outcomes and yet this is still only advisory in the NICE guidelines. We have engaged but that engagement is not effective without both the guidance and policy decision being applied and having the funding to back it up.
3. Empower patients and families to be actively involved in their own healthcare and in the improvement of safety of healthcare.
Let’s be honest, in campaigns such as ‘Ask me if I have washed my hands’, we have missed the mark because we are aiming it at the wrong people. If we want to ensure patient safety, then the people we need to educate are in fact staff. The most important thing in patient safety is listening to the patient, listening to their relatives and taking positive affirmative action to respond to their concerns. Not responding with a professional arrogance or personal upset but responding with what we, as the NHS, are renowned for: care, compassion and kindness.
4. Advocate urgent action on patient and family engagement, aligned with the Global Patient Safety Action Plan 2021–2030, to be taken by all partners.
If we do respond in the right way then actually, we will together achieve this final aim this Patient Safety Day. We will together advocate for our patients, work together with patients and their carers to ensure that the NHS and social care do in fact deliver high quality effective healthcare that is, at its heart, safe for all patients.
There is though one other very important message I wish to give you this Patient Safety Day and I hope you will hear it. I have been involved as a long-term conditions patient in every aspect of the NHS, literally from Bed-to-Board.
There is one thing that is missing most of all and it affects everyone. The NHS does not do enough to care for you, the wonderful and caring staff who every day give so much of yourselves to those you are caring for.
Whilst it may not be much, I want to say something directly to you. Thank You.
Two simple words that are not said enough and are not heard enough in our world. But from me – thank you – you have literally saved my life and given me the best care possible. You’ve given me the opportunity to work with you to make things better for everyone: patients, families, carers and, also, importantly you – our staff.
We are only safe when we are safe together.