Patient safety is at a pivotal point

Dr Howard Freeman

Quality and safety issues have been dominating the Independent Healthcare Providers Network (IHPN) agenda. Its clinical director Dr Howard Freeman reports – and asks for consultants’ help.

The IHPN is looking to welcome volunteer consultants to join our recently formed ‘share and learn’ sessions.

This is a small community of senior clinical leads from independent providers who meet in person – safely and maintaining strict confidences – to discuss real-life case studies and the associated patient safety issues. 

Meetings are usually held in London and again, at our most recent session, we found it a very powerful process which throws up real challenges, opportunities to learn and to reflect and change clinical practice. 

One of the things our year-old group would greatly value is for greater insight and perspective from senior consultants – surgeons or anaesthetists particularly. I suspect the value would be very much reciprocal.

Spare an hour

So I would like to welcome and strongly encourage any consultants of any specialty reading this in Independent Practitioner Today to consider if you might be interested and able to spare an hour.

You could either bring forward a case of your own or just be willing to bring your own expertise and perspective to this group. Do please contact if you are interested. 

Civica Medical Billing

I was very pleased to chair the IHPN’s annual quality and safety conference recently at the Law Society, in central London. 

Now in its fifth year, the meeting had a particular focus around the theme of patient involvement in safety and quality. 

Run by the IHPN in partnership with the Care Quality Commis­sion (CQC), it is one of the highlights of our calendar. It brings together colleagues from member organisations, many of whom are clinicians, from across the network.

Participants learn from each other about what makes ‘great’ in quality and safety and they get tips from expert speakers to help deliver the safest possible services in the sector.

Changes afoot

The backdrop for this year’s event is that, over the course of the next 12 months, we are seeing significant changes in the patient safety world. These are both an opportunity to do things better but also may represent challenges we must rise to meet. 

This conference provided a fantastic and timely moment to hear from key leaders at the heart of the patient safety world, to understand the impact of upcoming developments on the independent healthcare sector and to share experiences and ideas. 

The quality and calibre of speakers this year was the highest I have ever seen. 

Opening the conference, the CQC’s chief inspector of healthcare, Dr Sean O’Kelly, spoke about the importance of patient safety and how the watchdog is working to improve it across the healthcare system.

Other high-profile speakers included Dr Henrietta Hughes, patient safety commissioner for England; Nick Day, policy and programme lead at the National Medical Examiner System, and Dr Rosie Benneyworth, chief investigator at the Healthcare Safety Investigation Branch (HSIB). 

They and others from the CQC shed light on the ways the patient safety system is changing and what the impacts might be – whether it be the CQC’s changing regulatory approach or the merger and restructure as HSIB becomes the Health Services Safety Investi­gation Body (HSSIB).

All these seismic moves, along with the introduction of new policies, frameworks and ways of working, such as the Patient Safety Incident Response Framework (PSIRF), could have a significant impact. 

Opportunity to grasp

I believe this is an opportunity we must collectively grasp to make sure the safety issue is raised to the level of prominence, focus and attention it should always be. And that it remains there. 

James Titcombe, of the Harmed Patient Alliance, was perhaps the most powerful speaker of all. He is an engineer by profession, but is also now an expert in patient safety, having sadly suffered the loss of his son Joshua after negligent care in the days immediately after his birth. 

It was and is a difficult story to hear – I urge any reader unfamiliar to read James’ book, Joshua’s Story.   

Despite the terrible circumstances he and his family have endured, James spoke on the day – and again in a short video featuring the main speakers, which gives a flavour of their sessions and the day overall, available to watch on our website – of cause for optimism and positivity. 

He spoke of the vital importance of creating a ‘just culture’ for both patients and staff, and what that entails: a recognition that errors in healthcare do happen, but most of the time when things go wrong, it is not the the fault of any individual but the wider system and the processes. 

James was clear that we can only make progress if staff feel supported, confident and safe in engaging in those processes, so that we can be open and honest. 

A positive reaction

Many people gave much positive feedback and found the networking opportunities invaluable. It is worth remembering in these days where Zoom and virtual events have become so widely used, that there is nothing which quite beats being there in person. 

I believe this was particularly the case given the content and the stories several presenters told, with examples of patients, which were both emotive and powerful. 

The patient stories which were told by Sean O’Kelly, by Henrietta Hughes and by James Titcombe especially did a quite remarkable job of making the need for patient safety ‘real’.  

We all learn by taking the opportunity every now and again to reflect, to think about where things have gone right or wrong. 

Let me return to some words of James Titcombe to sum up the very essence of what all this is all about and why it matters.

He said: ‘It’s been a huge journey. It’s coming up to 15 years since Joshua died and there have been changes. I think that they’ve been much slower than I would have liked to see, but right at the moment is a really interesting time for patient safety. 

‘We’re at a really pivotal point, and what keeps me going really is, if I can use Joshua’s story to kind of reinforce – actually – what could the future look like if we got this right? What would that look like?

‘And I think “Keep that vision in our minds”. There is a better place and we can get there if we all carry on working together. So, yeah, that’s very much the message that I’d like to give people.’