NHS Safety: Warnings from all sides
A report by Sylvia Davidson and Paul Evans
After the Francis report (Feb 2013) the government made clear its intention to change the culture of the NHS towards patient safety. Three years on and the NHS is in the midst of a financial crisis. Many organisations that represent NHS staff are coming forward to highlight fundamental problems with its capacity to meet demand.
They are revealing a decline in the standards of care but also worrying concerns about the safety of patients. Many of these concerns have been communicated by staff to managers throughout NHS organisations and also up the line to central government. However, what is different about 2016 is an unprecedented number of professional bodies, trade unions, think tanks and NHS organisations that have stepped into the public arena to present evidence about the impact of the financial pressure on the NHS.
While it is clear that a huge amount of successful treatment is being delivered, these reports contain repeated warnings about threats to patient safety. The reports through the year were finally echoed by the findings of inspections by the health watchdog, the
Care Quality Commission, whose report in October stated:
“The safety of care is our biggest concern (10 per cent of NHS acute trusts were rated as inadequate for safety). Ensuring consistently safe care remains the single biggest challenge for hospital providers.”
This report seeks to summarise the warnings about safety and declining performance and explore the link with the financial crisis. It is crucial that the government listens and responds to the powerful evidence and testimony from the frontline of our healthcare system.
1. Since the beginning of 2016 there has been an unprecedented series of warnings raising the alarm about the pressures on the NHS.
Among these are 12 reports from professional bodies, trade unions, think tanks and NHS organisations based on the recent experiences of NHS staff and patients. Each report offers evidence about how the huge pressures on services are affecting the standard of care, increasing delays and raising the risks to patients. Reading them leaves little room for doubt about the scale
and urgency of the problem and makes this period distinct from any previous crisis in the NHS. And survey findings presented for the first time in this report suggest that the vast majority of NHS staff feel that the squeeze on staffing and resources is putting patient safety at risk, that the situation has worsened over the last five years and that the current crisis is the worst most of them have experienced in their careers in the health service.
2 The warnings in these reports about declining quality of care and threats to the safety of patients are explicit and numerous.
The Royal College of Physicians identified that 20 per cent of consultants felt that understaffing was frequently affecting patient safety. The Royal College of Midwives’ research revealed that 40 per cent of maternity units are having to close temporarily because they cannot cope with demand.
A BMA survey found that many junior doctors with little specialist experience are having to take responsibility for entire wards of patients, such as intensive care, stroke and surgical units. In October 2016, the Royal College of Nursing survey of mental health nurses concluded that the rationing of care and the shortage of beds was so bad that young people risk harming or killing themselves.
Since the beginning of 2016 the following organisations have all issued warnings, supported
by evidence from NHS staff, about threats to patient care:
- The Royal College of Physicians
- Royal College of Radiologists
- Royal College of Anaesthetists
- British Medical Association
- Royal College of Midwives
- NHS Providers
- Royal College of Paediatrics and Child Health
- Royal College of Nursing
- Royal College of GPs
- The King’s Fund
- Community Practitioners and Health Visitors Association
- the government’s own taskforce on mental health
- the Children’s Commissioner for England
- Health Select Committee.
3. The situation is complex but it is clear that a chronic lack of staffing is affecting hospital, GP and community healthcare settings. It is now common for health organisations to report that staffing is below the recommended safe levels.
In just the last few months The Royal College of Physicians, Royal College of Anaesthetists, Royal College of Paediatrics and Child Health and the British Medical Association all reported widespread problems with rota gaps–where shifts start with too few staff.
UNISON, The Royal College of Midwives and the Royal College of Nursing have all reported staff fears about understaffing and how they view these as “unsafe”.
In community healthcare the number of district nurses and health visitors has been falling, while GP staffing levels are virtually static.
Lack of staff is also causing temporary closures of maternity and A&E units. The declining performance figures for the NHS through 2016 reflect the problem of lack of staff. More than 10,000 patients waited at least two hours before handover from an ambulance to a casualty unit in 2015/16 – a five-fold rise in just two years. The Royal College of Emergency Medicine warned “the risks to patients aren’t acceptable.”
4. There are worrying indications that the financial crisis is preventing NHS organisations from reaching safe levels of staffing and addressing safety concerns.
The paybill (cost of employees) of each trust has come under close scrutiny in 2016 and NHS
Improvement has targeted this for control or reduction. Jim MacKey, CEO of NHS Improvement, noted in an interview in July 2016 with the Health Service Journal that “trusts exceeding the ratio of one nurse to every eight patients could be told ‘we can’t afford that.’” here was a strong hint that finances should take precedence over safety.
The launch of the sustainability and transformation process seeks to deal with the financial crisis by reorganising care and finding new ways of working. One of the key goals of Sustainability and Transformation Plans is to return all of the newly formed 44 footprints to financial surplus.
This has led to widespread speculation about the necessity for further cuts to services. “Some areas are focusing on plans to reorganise acute hospital services, despite evidence that major
reconfigurations of hospital services rarely save money and do not necessarily improve care,”
says Chris Ham, chief executive of the King’s Fund think tank. STPs released in October 2016 by four councils show that hospital organisation is definitely part of the process, as are A&E closures.
5. Low funding increases from the government leads to short-term fixes that ultimately will increase the cost of healthcare.
In 2015, almost all radiology departments were unable to meet scan and X-ray reporting demands and were relying on expensive short-term fixes. As a result, in 2015 the NHS spent £88.2m on outsourcing radiology reporting, up 51 per cent on 2014. The Royal College of Radiologists noted that this amount of money could have paid for over 1,000 fulltime consultant radiologists.
The CPVA and 10 other organisations wrote to The Times to highlight the false economy of cuts to health visiting posts. In health care terms “any money saved by reducing health visitors would simply be eclipsed by the resulting added pressure on the NHS.”
Health economist Anita Charlesworth has pointed out that the government has not increased all parts of the health budget. Her analysis was confirmed by a report by the Health Select Committee. Some areas will experience large cuts. Junior doctor training, health visiting, sexual health and vaccinations face real terms reductions of 20 per cent by 2020/21. The MPs report
concluded that “cuts to public health were a false economy”.
6. Too many staff feel that they are not listened to when they raise concerns. UNISON found that over half of respondents to its survey of nursing staff didn’t feel confident about raising a concern at work.
One midwife, cited in a report by their Royal College, said, “It was not safe to look after 15
mums and babies on a postnatal ward by one midwife. We were not listened to when we raised
issues over staffing and safety.”
In its report on the Royal Sussex County Hospital the CQC stated: “Inspectors found that staff remained afraid to speak up or share concerns in case of repercussions.”