Safety of patients is being compromised


In late 2016, The NHS Support Federation and the TUC published “Patient Safety - A Warning From All Sides” an overview of reports and articles published by the Royal Colleges, such as the RCN and RCM, unions, charities and think-tanks spanning all areas of the NHS - nurses, midwives, hospital doctors, GPs, and mental health professionals.

Since 2016, more and more evidence has been presented by those same organisations and others that little has changed. Patient safety is still being compromised and the NHS continues to be stretched almost to breaking point by lack of funds and lack of staff. 

Consensus on what leads to safety issues

A 2019 report, “Patient Safety Learning: A Blueprint for Action”, opens the summary by stating that despite 20 years of effort, avoidable unsafe care still leads to tens of thousands of patients suffering every year.

The July 2022 Parliamentary Committee report - Workforce: recruitment, training and retention in health and social care - included evidence from over 150 organisations, including all medical Royal Colleges, charities, healthcare analysts, such as The King’s Fund, The Health Foundation, and The Nuffield Trust, independent researchers at universities, councils, and unions representing staff in the NHS. The overall conclusion - staff and patient safety was at risk due to the ongoing workforce crisis.

In November 2022 a report in the Sunday Times covered a number of stories of people dying due to long waits for ambulances. The coroner for Cornwall Andrew Cox wrote to the Health secretary Steve Barclay, to tell him he must act to prevent more deaths. Mr Cox, who investigated deaths in his area discovered what was driving long waits for ambulances in his area - the lack of care home beds and investment in social care.

The deaths he investigated included, 90-year-old Winnie Barnes-Weeks who had to lie on the floor for 19 hours with a broken hip waiting for an NHS ambulance that never came.

An 87-year-old RAF veteran David Morganti who fell at home and had to wait nine hours for paramedics. Experts told the coroner he might have survived if he'd arrived at hospital sooner.

Then there was Bob Conybeare who was ready to leave hospital after a fall but was stuck for four weeks as no care home bed was free. He became confused and fell, dying from his injuries. The coroner learned that five wards were full of patients ready to be discharged at the Royal Cornwall Hospital Trust, but no care packages could be arranged.

Tony Reedman, 54, was on holiday in Cornwall when he suffered a stroke. The 2.5 hour delay in an ambulance reaching him meant treatment was too late to save him.

A Guardian investigation published in November 2023 managed to get NHS England to release data on the harm a long wait for an ambulance or surgery can have.

Analysis of the data concluded that almost 8,000 people were harmed and 112 died in 2022 as a direct result of enduring long waits for an ambulance or surgery.

They show that patient deaths arising directly from care delays have risen more than fivefold over the last three years, from 21 in 2019 to 112 in 2022, as the NHS has come under huge strain. The number of people who came to “severe harm” has also jumped from 96 to 152 during that period.

Nurses stretched to the limit

RCN survey highlights safety issues

The key issues for nurses in the NHS continue to be recruitment and retention. Latest statistics from the Royal College of Nursing reveal there are 40,000 nursing vacancies across health and social care settings in England. More on staffing shortages can be found here.

The RCN’s June 2022 survey on workplace staffing levels in the NHS offers sobering evidence of how one of the Tories’ 2019 manifesto commitments – to employ 50,000 more nurses by 2024 – has done little, if anything, to lessen the impact of nursing shortages on patient safety, or to address the reasons behind those shortages.

Among the findings of the RCN survey of its 20,000 members were the following:

  • 84% said staffing levels on their last shift were not sufficient to meet all the needs of patients safely and effectively;
  • only 25% of shifts had the full number of planned registered nurses;
  • just one in five respondents agreed they had enough time to provide the level of care they would like, with four in five judging that patient care was compromised due to not having enough registered nurses on the shift;
  • more than 40% of respondents said that due to lack of time they had to leave necessary care undone.

The RCN have previously called for urgent action on the crisis in nurse recruitment in September 2017.  The RCN’s report “Safe and Effective Staffing: Nursing Against the Odds”, based on the experiences of more than 30,000 nurses, had found “a perturbing picture of staff stretched to the limit and compromised patient care.” Once again, in their 2019 report the RCN noted that if there is understaffing care is more likely to be compromised, of poor quality, or left undone.

Staffing ratio guidance abandoned

Despite recommendations from the Francis report in 2013, that the ratio between staff and patient was of fundamental importance to safety and quality of care, the government has consistently drawn back from producing adequate guidance in this area.

Some guidance was published in 2014/15, on staffing in acute wards, but soon after this NICE was told to halt the work on safe staffing levels in A&E and urgent care. NHS Improvement took over and in November 2017,  its guidance for A&E and urgent care set no staffing ratios and states there is “no evidence base to support a specific ratio”. This is in contrast to the guidance produced by NICE by experts working in A&E leaked to the press in January 2016, which did set minimum nurse to patient ratios and staffing levels for areas of A&E departments. More on safe staffing levels and plans can be found here.

Midwives - safety of mothers and babies compromised

There is a serious issue in the NHS with the shortage of midwives that is affecting the safety of mothers and babies. The predominant issue influencing safety is a lack of staff, with staff feeling under severe pressure with excessive workloads. Lack of staff also leads to the closure of maternity units.

Parliamentary reports says thousands of staff needed

In July 2021, the House of Commons Health and Social Care Committee report - The Safety of Maternity Services in England - made a number of recommendations to improve safety in maternity services. It recommended that NHSE needed an additional 2,000 midwives and 500 obstetricians to operate at a level that the staffing tool Birthrate Plus considered safe. Plus the budget for maternity services should be increased by £200–350m per year.

Staffing situation continues to deteriorate

Despite the committee recommendations, little has happened, instead the situation is deteriorating with midwife numbers falling month on month, worsened further by pandemic related staff sickness and absences.  Data for April 2022 show the number of midwives has dropped by 600 compared to April 2021 and the fall is accelerating particularly in the north of England. The RCM says these figures are “alarming”.

An RCM State of Maternity Services report released in July 2023 noted that the impact of staffing shortages on women is ‘stark and sobering’ and highlights historical failures to invest appropriately in maternity services. 

According to the report’s findings, if the number of NHS midwives in England had risen at the same pace as the overall health service workforce since the last general election, there would be no midwife shortage. Indeed, there would be 3,100 more midwives in the NHS, rather than having a shortfall of 2,500 full-time midwives.

According to the latest survey by the Royal College of Midwives (RCM), 57% are considering leaving their role as a midwife or MSW. Concerns over staffing levels and the ability to deliver safe care are the top reasons midwives are leaving or have considered leaving the profession, with 84% were not happy with staffing levels and 67% not satisfied with the quality of care able to deliver.

Safety scandals hit the media

One of the most notable safety scandals was that of Shrewsbury and Telford hospitals. A review, led by Donna Ockenden, found patterns of failures led to deaths and harm to mothers and babies between 2000 and 2019. The Ockenden review, which was published in 2020, found 1,862 serious incidents including hundreds of baby deaths and a high number of maternal deaths. A number of recommendations emerged from the report including greater oversight on maternity care by senior doctors, ring-fenced funding for maternity training and development of regional specialists in maternal medicine.

In May 2022, Donna Ockenden was appointed to begin a review of the quality and safety of maternity services at Nottingham University Hospitals NHS Trust (NUH) and concerns of local families.

RCM survey shows serious concerns

An RCM survey released in June 2023 found that midwives give 100,000 hours of free labour to the NHS per week to ensure safe care for women. As a result, the mental and physical health of midwifery staff is being compromised by excessive workloads, with staff feeling burnt out and exhausted at the end of shifts. 

The survey "paints a deeply worrying picture of workplace conditions and the impact on safety in England’s maternity services" said the RCM.

Dr Suzanne Tyler, Executive Director, Trade Union, at the RCM, said: “Report after report have made a direct connection between staffing levels and safety, yet the midwife shortage is worsening."

The survey also showed that maternity services are consistently understaffed which is hitting safe staffing levels. Almost nine out of 10 (87%) respondents said their maternity units were not staffed safely in the week of the survey.

Hospital doctors - too few leads to safety concerns

Job vacancies go unfilled and unsafe rotas

Recent research by the Nuffield Trust submitted to the Health and Social Care Parliamentary committee in 2022 suggests that the NHS in England could be short of 12,000 hospital doctors.

Previous research by the Nuffield Trust found that two in five consultants and nearly two-thirds of senior trainee doctors said there were daily or weekly gaps in hospital cover in 2019. Gaps in rotas can mean there are not sufficient senior medical staff to ensure quality and safety of training. This can result in junior doctors withdrawing from hospitals, exacerbating staffing issues.

The latest Royal College of Physicians (RCP) census found a record number of physician jobs unfilled; more than half (52%) of advertised consultant physician posts in England and Wales went unfilled in 2021. This was up from 43% before the pandemic and 48% in 2020 and the highest rate since records began in 2008. Of the 52%, nearly three quarters (74%) were unfilled due to a lack of any applicants at all.

Waiting times in A&E lead to unsafe care

In A&E waiting a long time to be seen is costing lives. A paper published in the BMJ in April 2021 found that the risk of death in the month following A&E attendance was 16% higher for those who waited over 12 hours than those seen within four. Based on this paper and additional data, John Burn-Murdoch's analysis in the FT in August 2022 concluded that the collapse of emergency healthcare in England may be costing 500 lives every week due to excess waiting times. For June 2022, Burn-Murdoch's analysis found 2000 excess deaths associated with waiting so long for urgent care or admission.

The official figures for July 2022 show almost 30,000 patients were kept waiting over 12 hours in A&E following a decision to admit. The delay was largely due to lack of staff, which means beds can not be made available. This has been worsened by delays in discharging people who no longer need hospital care due to the lack of social care and community health services.

Time-critical cancer care not possible

In cancer treatment, time is critical if a patient is going to survive - time to get a definite diagnosis and time to treatment - so targets were set to make sure patients got the best chance possible of surviving the disease.

In August 2022, Figures leaked to the HSJ and shared with BBC’s Newsnight team showed almost a third of a million people (327,000) are on cancer waiting lists in England, almost 40,000 of them waiting for treatment to begin more than 62 days after a GP referral.

Worse still numbers waiting over 104 days have more than doubled in a year, to more than 10,000: in 2018, NHSE said there should be “zero tolerance [of] non-clinically justifiable 104-day delays”.

The most recent official cancer waiting time figures show how far performance has fallen back in the past year, even as the peak of the pandemic has passed.

In the year since April-June 2021 numbers of cancer patients have increased by less than 5% to 676,000: but the number missing the standard for a 2-week maximum wait for a first consultant appointment after an urgent GP referral has rocketed by almost 48%, from 91,000 to 135,000.

Compared to pre-pandemic (April-June 2019) numbers of patients have increased by 15%, but longer than target waits have more than doubled (up 160% from 58,000 to 135,000).

It has been eight years since services for patients with suspected breast cancer met the target of ensuring 93% receive appointments within two weeks. The one month wait for treatment target has not been met since the summer of 2018, and the proportion within target has continued falling despite reduced numbers of patients.

It’s even worse with the 62-day (two month) target, which has not been met since early 2014:  in the past year while numbers of patients have increased by 2% to 43,000, numbers waiting longer than 62 days have increased by 71% to 16,000, and performance is falling back, with just 62% treated within the standard time.

The figures leaked to the HSJ show 10,189 of the 327,395 people on the national cancer waiting list, about 3%, had waited 104 days or more, around double the figure from a year ago, with a further 28,406 having waited between 62 and 103 days as of the end of July.

Mental health - many issues mean vulnerable patients are not safe

Lack of staff = safety issues

The workforce crisis within the whole NHS is particularly acute within the mental health services sector. More details can be found in Staff Shortages. The safety of patients with mental health conditions is being compromised both by a lack of staff and a lack of bed capacity.

A lack of staff, which translates into a lack of beds in inpatient units, compromises patient safety because:

  • Long waiting times for appointments means that a patient’s health deteriorates before they can be treated, leading to longer recovery times or worse outcomes for the patient, with suicide whilst waiting for care a major issue;
  • Inpatient units with too few staff struggle to monitor patients adequately, which can lead to patients coming to harm;
  • Patients have to be sent to inpatient units far away from home, which can negatively impact on recovery.

Waiting lists rocketing

In late 2021, the official waiting list for mental health services stood at 1.6 million people and NHS Providers estimated that there are around eight million people in England that are denied access to mental health services because they do not have severe enough symptoms to get put onto a waiting list.

The eight million figure is based on the known prevalence of mental health conditions and the thresholds dictating who gets access to treatment; NHS England considers it an accurate figure for the number of people who are missing out on care because services are not adequate. So the true figure of people waiting for mental health services is around 10 million.

This is 10 million people whose conditions are potentially getting worse as they wait and as a result may harm themselves.

Vulnerable patients not monitored

In August 2022 NHS data was released that showed that vulnerable patients released from inpatient care were not being properly monitored. The risk of suicide is highest on the second and third days after leaving a mental health unit, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. A target of at least 80% of people being followed up within this timeframe was introduced in the year 2019-20, but this has never been achieved. The problem is lack of staff, including trained specialists, and funding, according to The Royal College of Psychiatrists, which called for more of both.

Long waiting lists increases suicide risk

In July 2022 the charity YoungMinds reported that thousands of young people are being left waiting so long for mental health support or treatment that they have attempted to take their own lives. Almost 14,000 young people aged under 25 completed a survey for the charity.

More than one in four young people (26%) said they had tried to take their own life as a result of having to wait for mental health support. More than four in ten (44%) waited more than a month for mental health support after seeking it and almost one in 10 (9%) of young people were turned away. More than half of young people (58%) said their mental health got worse while they were waiting for support.

The figures come as latest NHS data shows 66,389 young people aged 19 and under were referred to Child and Adolescent Mental Health Services (CAMHS) in April 2022, a 109% rise compared to the same month pre-pandemic.

In February 2020 A survey published by the Parliamentary and Health Service Ombudsman found that one in five people did not feel safe while in the care of the NHS mental health service that treated them. Over half of people with mental health problems in England also said they experienced delays to their treatment, while four in ten (42%) said that they waited too long to be diagnosed.

Deaths of patients due to lack of services

In March 2018, the Guardian reported that coroners had identified 45 cases in the last six years where a lack of beds, staff and specialist services affected the care of dozens of mental health patients who later died. The Guardian's own investigation found that at least 271 highly vulnerable mental health patients have died over the last six years after failings in NHS care.

Despite evidence that the safety and recovery of mental health patients is compromised by sending patients miles away from home for treatment, reports in August and September 2018, looking at child/adolescent and adult mental health patients, found that patients with serious mental health conditions are still being sent hundreds of miles from home for treatment due to the lack of beds. By 2022, things had not improved.

The NHS does not have the capacity to treat all the mental health patients, particularly those needing inpatient care, and is heavily reliant on the private sector. The leading companies, including The Priory, Cygnet Healthcare and Elysium Healthcare, provide hundreds of beds across the country. However, the past few years has seen many private hospital units closed down or rated 'requires improvement' by the CQC due to safety concerns. Details of many of these issues can be found on our website.

GPs - surgery closures and unmanageable workload

There are widespread problems with both the training and recruitment of new GPs and the retention of current GPs. The lack of GPs leads to patients not seeing patients as soon as they would like, as well as large and often unmanageable workloads for the GPs.

In 2015 the Government promised 5,000 extra GPs by 2020, then extended to 2021. In 2016 and 2017, the pledge was repeated. In the 2019 general election campaign, Boris Johnson announced a new commitment to increase the number of GPs in England by 6,000 by 2024. However, Sajid Javid, the then health secretary, admitted in November 2021 that this pledge was unlikely to be met because so many family doctors were retiring early.

In reality, the number of GPs in England has fallen every year since 2015. There were 29,364 full-time-equivalent GPs in post in September 2015, but by September 2020 the number of family doctors had dropped to 27,939, a fall of 1,425. NHS workforce data for June 2022 show the number has fallen still further to 26,859.

Patient safety is at risk if GPs are overworked or if patients can not get to see a GP in a timely manner.

An investigation by Pulse reported in May 2018 found that since 2013 over a million patients have had to move surgeries due to practice closures. In this time, nearly 450 GP surgeries have closed. Closures have been due to problems with recruitment and funding, as some practices had huge cuts due to Government reforms. Patients often have to travel further to a new surgery and lose continuity of care.

In October 2018, the interim findings from a review of the partnership model of GP practice found that the workload for a GP is rising to the point where it ‘verging on unmanageable’ and in some regions of the country may be putting patients at risk.

In 2019, nearly 100 GP practices closed in the UK and GPs warn Covid-19 could prompt more closures in the year to come. The figures collected by Pulse show branch practice closures and mergers meant nearly 350,000 patients were forced to change surgery.

Just one of several examples of the state of the crisis in GP recruitment and funding, is evident in the Kent town of Folkestone. Back in 2017, a surgery with 4,500 registered patients was forced to close following recruitment struggles. Since, numerous other GP surgeries in the area have applied to their CCG to close their patients list stating they were ‘unable to take on more patients safely’. The CCG refused which has forced the closure of Park Farm Surgery in March 2020, with its 3,000 patients having to find new surgeries.