Being sensitive to poor care

The headlines last week about the Care Quality Commission’s (CQC) handling of concerns at University Hospitals of Morecambe Bay NHS Foundation Trust have reignited the debate about how to ensure healthcare is safe. Here at the Health Foundation our focus is on developing a robust and comprehensive way to answer the apparently simple question: how safe is care today?

We can point to an array of initiatives that demonstrate real improvements in safety – for instance the falls in rates of MRSA and Clostridium difficile. At the same time, the contention over the use of hospital standardised mortality rates, and the question over the safety of children’s heart surgery services in Leeds, tell us that data can be anything but conclusive.

Much of the available data can be described as lagging rather than leading – in other words, it may tell you to what degree patients were harmed in the past, but it does not tell you how safe a patient would be today or tomorrow.

On 17 June, before the news broke about allegations of a cover up, the CQC published its consultation, A New Start, proposing changes to the way it regulates, inspects and monitors care. The emphasis is on risk-based, in-depth inspections led by specialists making evidence-based judgements. A surveillance system will be at the heart of this approach, using information from a wide range of sources, not to draw definitive conclusions on, but to be used as ‘smoke detectors’ for signs that a hospital is performing below the expected standard.

But probably the most revealing aspect of the consultation is the recognition that the CQC will ‘approach this work with humility’. At a seminar held last week, I heard David Prior, Chairman at the CQC, talk about the importance of listening to the concerns of patients and the public. He spoke of the personal cost to Julie Bailey in her efforts to raise the serious safety concerns at Mid Staffordshire with the trust and the wider establishment.

We have recently published a report of a roundtable discussion held at the Health Foundation on involving people in safety. We heard that patients can feel subordinate in their interactions with the NHS, where their feedback is not seen as credible or legitimate. But to ignore the patient is to ignore the most important safety barometer, where the issues people raise can be an early warning to a risk upstream.

Information from patients – or rather citizens who have a stake in their local services – is vital in diagnosing problems. So while you may have two trusts with apparently high mortality rates, it will likely be for very different reasons. The data may tell you that there’s a problem, but it will only be people’s stories, as well as other sources of qualitative information, that will tell you why the problem exists and what can be done about it.

This brings us back to our question: how safe is care today? We commissioned Charles Vincent and colleagues from Imperial College London to develop a framework for the measurement and monitoring of safety. It proposes that looking at past harms is only one part of a broader framework for understanding how safe care is. It should also incorporate a ‘sensitivity’ to what is going on – in other words, getting real time feedback on how a service is performing, and being alert to any safety concerns This is what we at the Health Foundation would understand to be CQC’s ‘smoke detector’.

This ought to include the kind of information Julie Bailey talked about in an audio interview with us, with organisations actively seeking out the views of patients. We heard at our roundtable that staff do not necessarily see the risks to safety in some aspects of care. For instance, a patient may complain that a glass of water is out of reach, but staff ought to be aware of the risk of dehydration and subsequent problems that can arise from that. And it goes without saying that helping a frail older person have a drink of water is being ‘sensitive’ in the truest sense of the word.

We have a consultation running until 1 July to hear people’s views on the framework. We want to know whether it reflects your experience of healthcare and how it can be applied in practice.

From the responses received so far, we know that people are thinking about how it could apply to their roles as clinicians and service managers in particular. For instance, we heard how the framework could be used in a visual way, drawing together a range of different information sources to give a more comprehensive picture of the safety of joint replacement surgery. We would particularly encourage responses from members of the public about how they would like to see it applied.

John is a Policy Manager at the Health Foundation.