The new minister for patient safety has a substantial task ahead of her – but digital systems will play a big part in addressing historic problems
"Digital technologies can be deployed to collate, analyse and use data so that common failings can be identified and best practice shared. The fragmented nature of the NHS means that opportunities to learn from mistakes have historically been missed." Greg Allen, FCC CEO
The Prime Minister’s recent reshuffle sees a new minister responsible for patient safety: Maria Caulfield. Caulfield, whose full title is minister for patient safety and primary care, is going to be faced with a number of difficult and pressing issues – her brief takes in community health, maternity care, patient experience, rare diseases and long Covid, among other things.
Patient safety is, however, going to be a major topic that she needs to address. In the past week alone, there have been three significant reports relating to patient safety:
The Health Safety Investigation Board’s review into intrapartum stillbirths during the first wave of Covid-19. This identified certain key problems, including poor management of risk, inconsistent application of guidance and poor communication. Its recommendations included that NHS England and NHS Improvement lead work to develop a process to ensure consistency and clarity across national maternity clinical guidance and that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information.
Also, the CQC’s report into the safety of maternity services, which noted problems such as: a lack of consistent and clear leadership and governance; poor team working; and poor incident reporting.
And there was the launch of a digital clinical safety strategy from NHSX, NHS Digital and NHS England and NHS Improvement. This made five important commitments: collect information about digital clinical safety; develop new clinical safety training materials; create a centralised source of digital clinical safety information; accelerate the adoption of digital technologies to record and track medical devices; generate evidence for how digital technologies can best be applied to patient safety challenges.
The implementation of digital technologies has an important role to play in improving patient safety, yet, according to a speech by Sajid Javid this week, one in 10 NHS trusts are still operating on paper-based systems and 71% of the social care sector has no digital access to information on patients’ medication.
Digital technologies can be deployed to collate, analyse and use data so that common failings can be identified and best practice shared. The fragmented nature of the NHS means that opportunities to learn from mistakes have historically been missed.
This is particularly true in maternity care. Litigation as a result of poor maternity care has cost the NHS £4bn over a period of 10 years, yet practice varies widely from trust to trust. The Ockenden Review demonstrated that failings in Shrewsbury and Telford went ignored for a period of nearly 40 years. Intelligent implementation of digital technologies makes it possible to introduce greater consistency across patient care.
The wider implementation of electronic health records (EHRs) is also crucial to improving safety, both in terms of accurate record keeping and sharing information, but there are risks in transitioning to EHRs that need to be minimised.
This is, however, an exciting time for the NHS, and there is a real opportunity for the new patient safety minister to make her mark by presiding over systems that reduce patient safety errors and improve care across the board.