The first hospital I visited as a health journalist was billed as an exemplar of patient safety. Standing in the melee outside the operating theatres I learned that one of their procedures was ensuring everyone on the operating team knew everyone else's name before opening up the patient. Nothing about their strengths and weaknesses as a clinician; nothing about their experience; no understanding of how they would react in an emergency. Just their name. That was "safe surgery".
Since the review of the NHS led by eminent surgeon Lord Darzi in 2008 the NHS has made strong progress on improving safety. But too many trusts still mouth the words "patient safety is our top priority" without demonstrating it in their care.
Yesterday's revelation by the campaign group Action Against Medical Accidents that scores of trusts are routinely failing to comply with safety alerts issued by the National Patient Safety Agency exposes significant system failures. It indicates poor collaboration between managers and clinicians to ensure alerts are propagated and systems overhauled. It shows a corporate inability to distinguish between yet another bureaucratic instruction from the Department of Health and a clinical imperative that will save lives. It uncovers complacent clinicians who are not keeping pace with the latest procedures. Above all it exposes a failure to put the patient at the centre of everything the NHS does.
It is important to recognise that the improvements being made in safety are deep and widespread. Walk into hospitals such as Salford Royal and you will see organisations imbued with a safety culture. But elsewhere there is still arrogance and complacency. Some surgeons have objected to complying with standardised operating procedures on the grounds it compromises their freedom, as if the prostrate body before them is simply a canvas waiting for the artist's scalpel.
Safety alerts are not a blizzard of paper; there were just 53 in the six years covered by the study, affecting both hospitals and primary care. They highlight risks across the spectrum of treatments, from drug doses to feeding tube insertions.
Safety standards will be raised by transparency, enforcement and patient-centred care. Action Against Medical Accidents should not have needed to exploit the Freedom of Information Act to get this data into public view; NHS organisations should be compelled to publish their failure or success in compliance. Exposure to the ire of the local press gets results.
The regulator – the Care Quality Commission – should monitor compliance and have the power to force action. But the key is centring care on the patient. The greatest weakness in the health service is that, nearly 62 years after its creation, patient-centred care is still an aspiration. To give this failure a sense of scale, the Department of Health believes up to 25,000 hospital patients' lives could be saved each year if they were risk-assessed and treated for venous thromboembolism. Clinicians and managers still have a long way to go to deliver a world-class healthcare system.