New NHS patient safety strategy: The ‘golden thread’

The idea of the ‘golden thread’ isn’t new; Theseus followed a golden thread given to him by Ariadne to find his way out of the Minotaur’s cave in Greek mythology – and it has been used in many ways since then.

The Secretary of State asked NHS England and NHS Improvement to develop a new Strategy for Patient Safety as a ‘golden thread’ running through healthcare. A consultation was launched in December 2018 with a set of ideas – in excess of 500 responses were received from organisations and individuals (staff, patients and carers). The final strategy – the first of its kind was launched at the Patient Safety Congress earlier this month.

Described by Aidan Fowler, NHS National Director of Patient Safety in his foreword as a “collective intent” to improve safety recognising that improvements are required in the way we learn, treat staff and involve patients. The intent is that it will be adapted over time with an update published annually every summer.

This strategy will sit alongside the NHS Long Term Plan and the LTP implementation framework published in June. There is also a cross reference to the independent sector at pages 43 and 44 of the strategy document.

Getting patient safety right could save 1,000 extra lives and £100 million in care costs each year from 2023/24

Simply put the strategy is about: “maximising the things that go right and minimising the things that go wrong” for people that are experiencing healthcare. The strategy describes how the NHS will improve patient safety over the next five to ten years.

Getting the foundations for safer care right can be summed up using this simple formula: patient safety culture + patient safety system = safer care.

Three strategic aims will support the development of the patient safety culture and the patient safety system

So, the three “Is” are:

• Insight (pages 19 – 33): improving understanding of patient safety using multiple sources of patient safety intelligence

Within this strand of work, the new Patient Safety Incident Response Framework will replace the 2015 Serious Incident Framework – a framework that organisations have struggled to deliver according to national reviews, patients, families, carers and staff and an engagement programme in 2018.

The new PSIRF proposals include:

“A risk based approach:… organisations should develop a patient safety incident review and investigation strategy to allow them to use a range of proportionate and effective learning responses to incidents. The proposal is to explore basing the selection of incidents for investigation on the opportunity they give for learning...”.

“Governance and oversight: taking a different approach…emphasising the role of provider boards and leaders in overseeing individual investigations”.

New digital technologies are to be employed to support learning with National Reporting and Learning System / Strategic Executive Information System to be replaced with a new system.

This section also references the medical examiner system, the Healthcare Safety Investigation Branch and Getting It Right First Time.

• Involvement (pages 34 -44): up-skilling patients, staff and partners to improve patient safety

This is about creating new “patient safety partners” (PSPs), a recommendation made by Don Berwick’s when he said, “patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to trust boards”. The aim is to have two PSPs by April 2021 in all safety related clinical governance committees.

Other initiatives are the development of a network of patient safety specialists in local systems and plans for a universal patient safety syllabus and training programme for the whole of the NHS – and arguably “it will have more impact than any other action this strategy”.  

There is also a commitment to better align patient safety standards between the NHS and independent sector healthcare with the adaptation of a “whole systems approach” to safety.

• Improvement (pages 45 – 61): designing and supporting programmes that deliver effective change in the most important areas

The strategy looks at a number of areas including medicines safety, maternal and neonatal safety, preventing deterioration and sepsis and mental health safety.

The graphic below summarises the NHS Patient Safety Strategy

Delivering the strategy – how?

The strategy document includes a matrix identifying the objectives, who will deliver this and by when at pages 64 – 72. There are actions for local systems, the national patient safety team, Health Education England, NHS England and NHS Improvement. For example, local systems are to set out in their LTP implementation plans how they will work to embed the principles of a patient safety culture and how they will implement the new PSIRF.

Chief executives and boards must ensure that they establish nonpunitive environments and systems for reporting errors within their health and care organisation – of critical importance will be developing the “just culture” of safety. The health and care system has seen a shift in culture in recent years to one that is more just, open and transparent – this has been supported by improved practice around whistleblowing and speaking-up culture.

How can we assist

We deliver risk management programmes and training so please do not hesitate to contact us to discuss this new strategy.