The Scottish Patient Safety Programme - more than mortality rates

The Scottish Patient Safety Programme (SPSP) is often hailed as a success story of Scotland’s NHS, and this year marks its tenth anniversary.

The programme, which uses the practical application of improvement methodology to drive changes in working practice, was originally set up as a five-year programme to reduce the Hospital Standardised Mortality Ratio (HSMR) by 20 per cent by 2015.

Although it fell narrowly short of that aim, it was hailed internationally. Former adviser to the Obama administration, Don Berwick, suggested England should follow Scotland’s lead.

A new HSMR target was set in 2016 to achieve a further 10 per cent reduction by December 2018, and the headlines and plaudits continued.

Last year a report by the health think tank the Nuffield Trust praised Scotland’s approach, albeit with a caveat that funding should be maintained.

The report’s author, Mark Dayan, said: “Scotland’s well thought-through system of improving patient safety and quality of care works by engaging frontline staff in the process, and importantly, the country has stuck with that approach rather than chopping and changing every couple of years.  

“Scotland has also worked on getting its healthcare services to co-operate for longer than the other nations of the UK. So we’re urging healthcare leaders from England, Wales and Northern Ireland to think about what elements they might want to import from Scotland.”

And in February, Health Secretary Shona Robison hailed the news that the target on HSMR had been hit 15 months early, a drop of 10.6 per cent since 2014.

“Most importantly, it means more lives have been saved that may otherwise have been lost,” she said.

“This comes at a time when our NHS is treating more people, with more complex needs. While we want to go further, it shows that we continue to lead the way on patient safety, with other countries looking to learn from our approach.”

Given its initial remit, it is perhaps understandable that the headlines have focused on HSMR, but in reality, the Scottish Patient Safety Programme is about much more than hospital mortality.

In fact, the aim of the programme has always been to improve the safety and reliability of health and social care across the NHS and care system, and to “reduce harm, whenever care is delivered”.

Using the same methodology, safety programmes have been introduced into mental health, maternity, neonatal and paediatrics (MCQIC) and primary care settings, as well as introducing specific tools to reduce medicines harm and other aspects.

Different disciplines, local teams and health boards learn from each other in a collaborative approach using what is called the ‘Breakthrough Series Collaborative Model’, developed by the Institute for Healthcare Improvement in Boston, Massachusetts.

It is a whole system approach.

“Perhaps the most important ingredient in the success of the SPSP has been the involvement of frontline staff,” says chief executive of Healthcare Improvement Scotland, Robbie Pearson.

“The collaboration, the commitment and the energy has been central to that success.”

Joanne Matthews, the head of improvement and safety at Healthcare Improvement Scotland, describes the SPSP as a “nationwide safety movement” which has proved that “change can happen at scale”.

“This hasn’t been one ward, one hospital or one GP practice, this is change across Scotland,” she tells Holyrood.

“It is also sustained change, now. It has involved every aspect of care as a national effort.”

The tenth anniversary year of the SPSP is being celebrated on social media using a hashtag #spsp10 and a dedicated space on the Healthcare Improvement Scotland’s Improvement Hub (ihub) website. Events are being held throughout the year to hear from those who “have been part of the journey”. 

by Tom Freeman

Special report: leading on safety

ihub director Ruth Glassborow says there is frequent contact from individuals from overseas keen to find out more about the SPSP.

“In particular, they are interested to know how we’ve managed to deliver improvements across such a diverse range of settings,” she says.

These improvements include some impressive statistics, including a 21 per cent reduction in mortality from sepsis since 2012.

There has been an eight per cent reduction in the cardiac arrest rate in hospital in the same period.

And it is thought the SPSP has played a role alongside other initiatives in a 19.5 per cent reduction in the rate of stillbirths. 

Matthews says the improvements also go beyond the stark numbers, pointing to a 31 per cent reduction in the more severe pressure ulcers since 2015. 

The 31 per cent drop is equivalent to 46 fewer pressure ulcers a month, says Matthews, which has a knock-on positive impact on hospitals. A pressure ulcer can increase the length of stay in hospital by five to eight days, representing a cost saved of between £184,000 and £460,000 per month on this measure alone.

“Now that’s not funds that can be taken out of the system, but it is a cost avoided,” says Matthews. “Improving quality of care costs less money to deliver, and in our fiscally challenged system that is important.”

The statistics are important for many reasons, according to Matthews. “Alongside the impact that we see for patients and families – there are people alive today and walking about due to the fantastic work that teams have delivered, improving the care for those individuals – there’s real improvement there for the system.”

Arguably, the most impressive achievements of the SPSP have been in mental health settings, where a ‘bottom-up’ approach has been taken in acute admission wards and intensive psychiatric care units.

Since 2014, the work by staff in this area has led to up to a 64 per cent reduction in patients self-harming, up to an 80 per cent reduction rate in the need to restrain patients and up to an 80 per cent reduction in rates of violence. 

“It has absolutely involved the staff understanding where their priorities are for improvement. But one of the key differences in the mental health programme has been the role of the service user in driving and informing how the improvements were developed and how they are delivered,” says Matthews. 

This is echoed by Dr Dame Denise Coia, the chair of Healthcare Improvement Scotland, who is a clinical psychiatrist.

“For me, and I would say this as a psychiatrist, the biggest achievement in the Scottish Patient Safety Programme has been that we’ve reached out to the most vulnerable in our society,” she said.

Gordon Johnston, who has lived experience of a mental health condition, sits on the delivery group that oversees the SPSP mental health work.

He tells Holyrood the group is particularly proud of the Patient Safety Climate Tool, which enables staff to have constructive engagement with patients.

“In mental health, we have greatly reduced the use of restraint and seclusion,” he says. 

“The successes of SPSP have been achieved by a great deal of hard work, and by ensuring that the excellent central team managing the programme, staff in NHS boards across the country, third sector organisations and patients all work together towards a common goal of improving patient safety.”

It is an approach which Matthews describes as a “gold standard” which can be applied to other aspects of the work. 

“When you’re thinking about prevention, that gets right down to how the teams function on a daily basis, about their safety briefings in the morning to understand where they have concerns, where they maybe need to provide additional support to individuals, and that goes right through to how they communicate that, how that support is through a therapeutic intervention which involves the person they are caring for within that.”

This and the work on reducing medicines harm fits right into Chief Medical Officer Catherine Calderwood’s ‘Realistic Medicine’ agenda which seeks to move away from over-medicalising patients and giving them more control over their lives.

“It is about understanding that the patient is part of that team,” says Matthews. “The person has a role in their care just as equally or probably more importantly than those who are delivering it. How can we support people to make informed choices about their care?”

But it is the staff who have worked hard to make the Scottish Patient Safety Programme a success who Matthews hails to mark its tenth anniversary. This has relied on engagement from boards and hard work on the ground.

The changes that have been needed, she says, are conceived and made by teams locally and are increasingly becoming embedded in their work.

“We see this work now becoming part of day-to-day life for people,” she says.

“Next month the new community pharmacy contract will have within it a piece that relates to non-steroidal anti-inflammatories, which will be about how community pharmacies can support people taking non-steroidals to ensure they’re getting the safest care possible. 

“That’s been work through SPSP that now becomes the standard way of working.”

As SPSP improvements become embedded in standard practice, what happens next, and what can policymakers do to support further improvements and sustain progress? 

Pearson says the focus will be on perseverance and extending the work into new areas. It’s a sentiment shared by Matthews.

“I continue to go back to the quality strategy that was published back in 2010. That’s an excellent read, and remains as relevant today as the day it was published,” she says.

“For me, it’s about how can we continue to create the conditions to support improvement? How do we enable teams to have the time, the capacity and the belief and commitment? Taking a quality approach, an improvement approach will get you to where you need to be.”