Patient Safety Commissioner consults on draft ‘Principles of Better Patient Safety’ to help guide and deliver change

This article was co-authored by Claudia Macey, Solicitor Apprentice.

On 24 July 2024, the Patient Safety Commissioner (PSC) launched a public consultation on a set of draft ‘Principles of Better Patient Safety’ (the Principles), aimed at placing patient safety, and patients, “at the heart of everything”.

The Principles (once finalised), are intended to be a guide for those in leadership positions within healthcare to proactively apply to minimise risk and reduce avoidable harm. 

Kennedys submitted a response to the consultation, which closed on 6 September 2024.  Here we consider the consultation and three key themes, which stand out to us.

The PSC

Dr Henrietta Hughes, the first PSC for England, was appointed in July 2022.  

Prior to this role, Dr Hughes was the NHS National Guardian, a Medical Director at NHS England, and in 2019 she was made a fellow of the Royal College of General Practitioners.  Additionally, in 2020, Dr Hughes was honoured with an OBE.  She remains a practising GP.

Consultation

Via the public consultation, the PSC sought views on seven draft principles, from all with an interest in patient safety across the healthcare system, including patients, families, carers, professional groups, regulators, and advocacy groups.  

The PSC wants the NHS to have a greater understanding of the importance of the views of patients and what needs to be done to put patients first.

Key themes to patient safety

  1. Culture of safety 
  • A patient safety culture is vital to high quality care. By creating a culture of safety both within an organisation and between patients and healthcare staff of all levels, it allows and encourages openness with patients and families when things go wrong.
  • The above correlates with the 2013 Francis Inquiry, which brought about the duty of candour.
  • This also links with the ‘Freedom to Speak Up Guardians’ initiative, which encourages healthcare professionals to raise concerns with confidence, so that that feedback can be given to the organisation, with action to be taken.
  • Not only does candour evidence integrity, it is also a professional requirement, whilst aiding improvement of patient safety.
  • Good governance is part of this from those in leadership positions. However, there needs to be accountability, and ownership of patient safety issues, at all levels for a sustainable culture of safety. 
  1. Patient centred care 
  • Ensuring patients are heard; they have a voice, is fundamental. Allowing patients to collaborate with healthcare professionals reduces the risk of missed diagnoses  and/or misdiagnosis. It is the patient that knows how they are feeling.
  • This is important for patient autonomy. Patients have a right to make an informed decisions about their own medical care.  They should be able to give their informed agreement before any investigation or treatment takes place, assuming they have capacity and the circumstances allow. 
  • Having the patient at the heart of the care aids policy, strategy and governance issues, all of which are aimed at delivering better and safer care.  
  1. Equitable approach to providing care
  • This is at the core of the NHS Constitution. Patients should have equal rights and opportunities within healthcare, including protection from discrimination against protected characteristics, such as ethnicity, gender, culture, sexual orientation, religion and disability.
  • To secure equity for patients, people need to be treated according to their respective, and different, needs. It is vital that these behaviours are modelled by leaders who are visible, so that staff, patients and families are treated in this way as equals.
  • This, we believe, links with staff experience, as covered by NHS Resolution in ‘Being fair’ and ’Being fair 2’, which highlights the significant variation between NHS Trusts as to the likelihood of staff being disciplined or suspended.

Next steps

Feedback received from the consultation will be used to shape the final Principles, with publication to follow on 23 October 2024.

Related item: Kennedys Patient Safety Forum: a focus on Martha’s Rule

 

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