Patient safety 5 – The impact of healthcare inequality on patient safety

Health inequalities are widening in paediatrics. Those that are more disadvantaged experience more safety issues whilst in health care.  If we can make our healthcare systems more equitable for the children and young people we can for, they will be safer in our care.

In episode 5 of our series on paediatric patient safety, we speak with Dr Helen Stewart, Dr Cian Wade and Dr Mimi Malhotra to explore how patient safety and health inequalities are inextricably linked. Tackling healthcare inequalities can improve safety and vice versa. 

Dr Stewart shares her knowledge and experience as the RCPCH Officer for Health Improvement as to how our children are impacted by health inequalities. Dr Wade and Dr Malhotra discuss their BMJ paper, Action on patient safety can reduce health inequalities, and explore some of the improvement avenues that are available to clinicians and service providers.

Thank you for listening.

Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber, RCPCH Head of Quality Improvement | Produced by 18Sixty

Please be advised that this podcast series contains stories relating to child death and harm. All views, thoughts and opinions expressed belong to the guests and not necessarily to their employer, linked organisations or RCPCH.

Download transcript (PDF)

About the Patient Safety series

As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings.

We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.

The RCPCH Patient Safety Portal has lots of resources, including a wealth of learning about paediatric patient safety. The RCPCH health inequalities programme of work can be found on our key topics pages.

It is imperative to turn this knowledge into action through improvement activities. 

About the speakers

• Dr Helen Stewart is a Consultant in Paediatric Emergency Medicine at Sheffield Children’s Hospital. She also has an interest in public health and health inequalities, which has led to her becoming the Officer for Health Improvement at RCPCH.
• Dr Cian Wade completed a National Medical Director Clinical Fellowship with NHS England. He is a Fulbright Scholar who recently completed a Master of Public Health at Harvard University and now consults for health systems and healthcare providers.
• Dr Mimi Malhotra completed a National Medical Director Clinical Fellowship with the Health Foundation. Dr Malhotra continues to work as a respiratory trainee in London with ab honorary clinical lectureship at UCL.

Topics/organisations/papers referenced in this episode

• Wade, C, Malhotra, A.M., et al (2022). Action of patient safety can reduce health inequalities. BMJ
• North West & North Wales critical care transport service
• Michael Marmot
• Royal College of Emergency Medicine (RCEM)
• RCPCH Health Improvement Committee
• National Medical Directors Fellowship
• The Health Foundation 
• RCPCH Child health inequalities driven by child poverty in the UK - position statement
• Increased risk of perioperative pulmonary embolism and sepsis in black patients (Urban Institute)
• Increase risk of adverse drug events in black people (Medical Care)
• MBRRACE study: A comparison of the care of Asian, Black and White women who have experienced a stillbirth or neonatal death
• Racial and ethnic differences in bystander CPR for witnessed cardiac arrest (The New England Journal of Medicine)
• Skin Deep
• WHAM (Wellbeing and Health Action Movement) health inequalities map
• Race-based vs race-conscious model of medicine (The Lancet)
• Decentralisation of public services in Greater Manchester (PDF)
• Sugar tax explained
• Vaping in children (RCPCH response to Government plan to ban disposable vapes)
• Health and Social Care Committee - a Commons Select Committee
• Core20PLUS5 – An approach to reducing health inequalities for children and young people
• Nationwide Children's Hospital (US)
• Shared decision making framework (NICE)
• Closed feedback loop communication
• Ian Sinha: The cost of the clinic visit (European Respiratory Journal)
• RCPCH Engaging children and young people resources
• RCPCH Six step toolkit for child health inequalities and poverty
• WHAM (Wellbeing and Health Action Movement) portal
• Institute for Healthcare Improvement
• Natural language processing (Wikipedia)

It is imperative that children and young people are central to the co-design and co-production of our patient safety improvement interventions.

In this episode, we speak with Dr Jane Runnacles, consultant paediatrician at St. George's Hospital, and Dr Victoria Dublon, paediatric diabetes consultant at the Royal Free Hospital. Both are champions of improvement work that puts the young person and their needs first.

As Jane and Victoria describe, involving children, young people and their families in improvement work improves the experience and outcome for all involved. There are fantastic examples of co-creating and co-producing safety improvements in healthcare.

We discuss the practicalities of how to do this and who to involve in your healthcare setting, and we hear about some of Jane and Victoria’s successes.

Thank you for listening.

Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement 
Produced by 18Sixty

Please be advised that this podcast series contains stories relating to child death and harm. All views, thoughts and opinions expressed belong to the guests and not necessarily to their employer, linked organisations or RCPCH.

Download transcript (PDF) 

About the patient safety series

As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings.

We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.

The RCPCH Patient Safety Portal has lots of resources. And our engaging children and young people web pages can help you get started on your engagement journey to effectively work with children and young people to improve their healthcare. 

Dr Victoria Dublon is based at the Royal Free Hospital and part of the Trust-wide diabetes team. She has been a paediatric diabetes consultant for eight years, working primarily at the Royal Free Hospital as well as running clinics at Barnet Hospital and Chase Farm Hospital. As a registrar, she trained in adolescent health as well as endocrinology and diabetes and this continues to be a big part of her work. Victoria is involved in improvement work within the department as well as being a champion of ‘Me First’, striving to put the young person and their needs first.

Dr Jane Runnacles is a consultant in ambulatory paediatrics at St George's hospital NHS Foundation Trust, London and clinical governance lead for her department. She has an interest in acute paediatrics, simulation and quality improvement. During her postgraduate training in London, she was awarded distinction in her MA in clinical education and spent a year as a Darzi clinical leadership fellow at Great Ormond Street Hospital. Jane is a Training Programme Director for the London School of Paediatrics and leads their leadership and QI education programmes.

Topics/organisations/papers referenced in this episode

• Great Ormond Street Hospital
• Royal Free Hospital
• Darzi Fellowship
• Peter Lachman
• RCPCH SAFE Collaborative
• RCPCH QI Central
• Don Berwick
• Whiteboard communication project (on QI Central)
• Yincent Tse
• NHS blog - Asking "What Matters To You?"
• NHS - Co-production
• Paediatric Early Warning System (PEWS)
• St George's Hospital
• St George’s Hospital - Children and Young People’s Council
• Wac Arts
• WHO World Patient Safety Day (17 September)
• ‘Listening to you’ project at Birmingham Children's Hospital
• NHS Patient Safety Incident Response Framework
• Safety huddles (part of Situation Awareness for Everyone)

It is not enough just to collect data on harm occurring to children in healthcare settings. We need the data to be robust, comparable across the NHS and for it to be transformed into effective, meaningful changes in outcome.

In episode 3 of our series on paediatric patient safety, we speak with Dr Damian Roland, a paediatric emergency medicine clinician scientist and head of service for the Children's Emergency Department at Leicester Royal Infirmary.

As Damian discusses on the podcast, in order to learn from harm and prevent it occurring again we need to collect data and investigate what is occurring across the healthcare system rather than looking to individuals. Removing the individual, more punitive approach to harm investigations could improve the quality of how we record and report harm.

There is already a wealth of learning available from a range of sources including national reports, coroner’s findings described in regulation 28 reports to prevent future death and large-scale reviews like those of the Health Services Safety Investigations Body. We can investigate whether the causes of harm identified in these reports are occurring where we work and make proactive steps to avert it.

Damian also shares the progress of the SPOT programme (System-wide Paediatric Observation Tracking). This looks to reduce harm and improve how we learn from harm by creating a standardised common language to identify and discuss children whose health is deteriorating.

Thank you for listening.  

Hosted by Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement | Produced by 18Sixty

Download transcript (PDF)

Please be advised that this series contains stories relating to child death and harm. All views, thoughts and opinions expressed in this podcast series belong to the guests and not necessarily to their employer, linked organisations or RCPCH. 

About the Patient Safety series

As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings. We hope you will be entertained, educated and energised to make strides in improving the safety of the children that you care for.

The RCPCH Patient Safety Portal at https://safety.rcpch.ac.uk has lots of resources. It includes a wealth of information summarising reports and investigations that identify what puts children at risk of harm. It is imperative to turn this knowledge into action through improvement activities.

More about Dr Damian Roland

Damian is a paediatric emergency medicine clinician scientist and is head of service for the Children's Emergency Department at Leicester Royal Infirmary. Among his many achievements, Damian has been focused on addressing the challenges of identifying deterioration in health in children. He created the Paediatric Observation Priority Score for Children's Emergency Care and currently he is instrumental in the NHS England SPOT programme.

Topics/organisations/papers referenced in this episode

• John Madar (PDF)
• Datix
• Health Services Safety Investigations Body
• Royal College of Emergency Medicine
• Royal College of Paediatrics and Child Health
• René Amalberti
• Adrian Plunkett
• Learning from Excellence
• David Sinton (on X)
• POPS (Paediatric Observation Priority Score for Children’s Emergency Care) - (PDF)
• Swiss Cheese Model (on National Library for Medicine)
• NHSE SPOT: System-wide Paediatric Observation Tracking programme - guidance
• Emma Lim
• Critically Careful forums (University Hospitals of Leicester NHS Trust)
• Peter Lachman
• Ronny Cheung
• Eric Hollnagel: From Safety-1 to Safety II (PDF)
• Charles Vincent
• Mary Dixon Woods: How to improve healthcare improvement - BMJ
• The Health Foundation
• Creating Communities of Practice
• Rhizomology - Rhizomatic Knowledge Communities, Edtechtalk, Webcast Academy

Psychological safety in healthcare settings is the condition in which you feel included, safe to learn, safe to contribute and safe to challenge the status quo - without fear of being embarrassed, marginalised or punished. And it's an essential foundation in building a safety culture.

Individually, feeling psychologically safe improves performance and innovation, while feeling unsafe reduces productivity and harms retention. In a highly productive team, it is about feeling safe to take risks, to learn from each other and to feel resilient and able to tackle the difficult and varying challenges of healthcare with a healthy mindset.

This is the second episode in our patient safety series and features Dr Dal Hothi and Dr Jess Morgan. Learn how you can reflect on your own behaviour, champion effective communication and create a psychologically safe space within your team.

Hosts: Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber, RCPCH Head of Quality Improvement

Produced by 18Sixty

Please be advised that this podcast series contains stories relating to child death and harm. All views, thoughts and opinions expressed belong to the guests and not necessarily to their employer, linked organisations or RCPCH.

If you are a healthcare professional and you are worried that you are suffering with burnout please speak to your team, your GP or Practitioner Health.

Download transcript (PDF)

About the speakers

Dr Dal Hothi is a paediatric nephrologist at Great Ormond Street Hospital. She's also a Director of Leadership Development at the Faculty of Medical Leadership and Management, as well as being an Officer for Lifelong Careers at the RCPCH.

Dr Jess Morgan is a paediatric doctor and Dinwoodie RCPCH Fellow who leads on the RCPCH Thrive Paediatrics Project along with Dal.

About the patient safety podcast series

As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings.

We hope you will be entertained, educated, and energised to make strides in improving the safety of the children that you care for.

To learn more, visit the RCPCH Patient Safety Portal and begin your journey in improving your own psychological safety and that of those you work with.

Links for topics/organisations/papers referenced in this episode

• Dinwoodie
• Thrive Paediatrics at RCPCH
• Amy Edmondson and psychological safety
• Tim Clark’s four stage model of psychological safety
• Freedom to Speak Up (The National Guardian)
• Charles Vincent ("Safety is not defined by the absence of negative outcomes") - The Health Foundation: The measurement and monitoring of safety

Healthcare is inherently risky and so as child health professionals we need to make patient safety a priority in all our actions. We need to think about safety all the time. 

In episode 1 of our series on paediatric patient safety, we speak with Dr Peter Lachman, who develops and delivers programmes for clinical leaders in quality improvement at the Royal College of Physicians in Dublin.

As Peter explains on the podcast, we healthcare professionals need to know patient safety theory - but, more importantly, we need to know how to apply it, drive improvement and create a workplace culture that fosters safe working practices.

Everyone - from the most junior member of the team to the most senior paediatric clinical leader - needs to think about patient safety all day every day. A safe culture takes time to build. Shared activities such as handover, huddles and debrief can model good behaviour and benefit performance. Repeating behaviours that represent a safe culture can create a virtuous cycle which can change deeply held attitudes and beliefs, then ultimately the safe culture overall.

Thank you for listening.

Dr Natalie Wyatt, RCPCH Clinical Fellow and Jonathan Bamber RCPCH Head of Quality Improvement

Produced by 18Sixty

Please be advised that this series contains stories relating to child death and harm. All views, thoughts and opinions expressed in this podcast series belong to the guests and not necessarily to their employer, linked organisations or RCPCH.

Download transcript (PDF)

About the Patient safety podcast series

As doctors we ‘first, do no harm’. However, the systems in which we work are rife with safety issues and resultant harm. In thinking about how to improve this, we have brought together leaders in the field to discuss challenging and thought-provoking issues around keeping our children safe in healthcare settings. We hope you will be entertained, educated, and energised to make strides in improving the safety of the children that you care for.

There are lots of resources that expand on this on the RCPCH Patient Safety Portal, including the theory of patient safety culture and examples of how people across the UK are doing this well. Visit at https://safety.rcpch.ac.uk.

More about Dr Peter Lachman

Dr Peter Lachman develops and delivers programmes to develop clinical leaders in quality improvement at the Royal College of Physicians in Dublin. He works with HSE Global in Africa, and he was Chief Executive Officer of the International Society for Quality in Healthcare (ISQua) from 1 May 2016 to 30 April 2021. Peter was a Health Foundation Quality Improvement Fellow at IHI in 2005-2006 and then went on to be the Deputy Medical Director with the lead for Patient Safety at Great Ormond Street Hospital 2006-2016. Peter was also a Consultant Paediatrician at the Royal Free Hospital in London specialising in the challenge of long-term conditions for children.

Peter is the lead editor of the OUP Handbook on Patient Safety published in April 2022; Co-Editor of the OUP Handbook on Medical Leadership and Management published in December 2022; and Editor of the OUP Handbook on Quality Improvement to be published in 2024.

Topics/organisations/papers referenced in this podcast

• ISQUA (International Society for Quality in Healthcare)
• Oxford Professional Practice: Handbook Of Patient Safety
• IHI (Institute for Health Improvement)
• Human factors - on RCPCH Patient Safety Portal
• S.A.F.E. Collaborative - on RCPCH Patient Safety Portal
• Cincinnati Childrens Hospital patient safety
• Paediatric Early Warning System (NHS England)
• BMJ Quality & Safety journal
• Lachman, P., Linkson, L., Evans, T., Clausen, H., & Hothi, D. (2015). Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report. BMJ quality & safety, 24(5), 337–344
• Health Foundation
• A framework for measuring quality, with Professor Charles Vincent et al
• WellChild: the national charity for sick children
• Applied human factors - on RCPCH Patient Safety Portal
• 5 whys
• SEIPS (Systems Engineering Initiative for Patient Safety)
• Psychological safety- on RCPCH Patient Safety Portal
• Situational awareness - on RCPCH Patient Safety Portal
• MaPSaF (Manchester Patient Safety Awareness Framework)
• Top Gun
• Irish Certificate in Essential Leadership for New Consultants
• Rolfe et al's reflective model (PDF) (what now what so what)
• NHS England: Improving patient safety - a practical guide

Richard Burley, Executive Director of Digital talks with Professor Shah about how digital technology can support child health, and how paediatricians can embrace it - with a dose of healthy scepticism.

Professor Sam Shah is Chief Medical Strategy Officer at men's health company, Numan, and Honorary Lecturer at University College London's Global Business School for Health. He spoke at RCPCH Conference 2023 with a session titled, 'Could healthcare technology address the challenges in child health? Richard Burley here at the College was fortunate to be in the audience and invited Sam to discuss further.

As Sam notes on the podcast, there is no shortage of technology from mobile apps to wearables. But, he says there's a challenge, especially as we look to reduce anxieties:

"...how we try and make the environment of child health - really, the treatment end - more accessible to children, young people and their families. And also less imposing, less scary. Especially that moment when families will be scared about accessing treatment, when children will be in unfamiliar environments."

Sam and Richard talk about examples where digital technologies, particularly augmented and virtual reality, are making a real difference. They consider the unique experiences of children and young people as patients, and the differing needs of communities around language, culture and digital maturity. They step into the thorny issues on privacy, security and safety - and how digital tech intersects with real-life clinical care.

Sam finishes with practical advice on how paediatricians can identify, evaluate and use digital technology in their practice.

Download transcript

Climate change poses an existential risk to child health and is exacerbating health inequalities. But, paediatricians can play an important role in sharing information and advocating for action.

Dr Helen Stewart and Dr Alex Lemaigre introduce the College’s new toolkit for paediatricians. Our first tool helps you understand how climate change impacts on children and young people’s health and exacerbates health inequalities. And our second equips you to influence climate change policy locally, regionally and nationally.

Alex and Helen talk about why paediatricians have a role in addressing health inequalities impacted by climate change. And they provide advice on how to start conversations with key decision makers to address this. 

"With climate change affecting food production globally plus the energy crisis and everything else, those households who have more limited income are going to really struggle to maintain the same level of food quality and/or quantity. And that brings all of its own health problems – be that malnutrition, obesity... Familiarise yourself with things locally - you know, if there are food banks or third sector kind of organisations that might be able to help support a household with getting food on the table." - Dr Alex Lemaigre

In this episode, Alex and Helen refer to a condition called eco-anxiety. We now use a preferred term, eco distress.

Download full transcript (PDF)

See our toolkit and take action at www.rcpch.ac.uk/ShiftTheDialOnClimateChange

You can listen to other RCPCPH Podcasts episodes on this topic:

• Child health inequalities part 1 - Talking with families
• Child health inequalities part 2 - interviews with two quality improvement projects
• Our voices: young people and climate change

Talking about the intentionality behind what the College does to train and support paediatricians: RCPCH Vice President for Training and Assessment, Dr Cathryn Chadwick interviews Trainees Committee Chair, Dr Emma Dyer.

Our College Strategy 2021-24 outlines four strategic aims to support our mission of improving health outcomes for children and young people. In this series we look at our College Strategy in action. Hearing stories from clinicians, children and young people and staff about the impact our work has made on the community and within paediatric clinical practice.

In this episode we learn about what it takes to build a paediatrician. The intentional decisions that have been made to train members and set them up for a long and rewarding career. The new Progress+ curriculum and our Thrive Paediatrics initiative and learning hubs are some of the examples of the work being done to support trainees at each level of their career.

Download transcript (PDF)

Two paediatricians share thoughts around vulnerability, compassion and belonging at work. Jess and Anna talk about brave spaces, the importance (and limits) of self-care and those "small moments of human connection".

Dr Jess Morgan is a paediatrician and working as a Dinwoodie RCPCH Fellow on an exciting new project, Thrive Paediatrics, which aims to create meaningful change in the working lives of paediatricians. She speaks with Dr Anna Baverstock, a consultant paediatrician at Somerset NHS Foundation Trust.

Find out more about Thrive Paediatrics on the RCPCH website at https://www.rcpch.ac.uk/thrive. We're creating Wellbeing and Innovation Networks (WINs), communities where paediatricians come together and, using our newly published roadmap, draw from each other’s experiences to activate change.

We’re organising some Thrive 'listening events', so look out for those soon. And if you're a College member and interested in this project, email us at thrive@rcpch.ac.uk.

Download the transcript (PDF)

Links to people mentioned in the podcast:

• Amy Edmondson
• Mary Freer (Welcome to Freer Thinking)
• Brené Brown 

In a first for our podcasts, we delve into the world of government and parliament. RCPCH President Camilla Kingdon speaks with Dame Andrea Leadsom MP, Conservative Member of Parliament for South Northamptonshire about her experiences of advocating for infant and child health.

Dame Andrea wants every baby to have the best start in life - a message shared by the College. She chaired the Government's Early Years Healthy Development Review and its March 2021 report, The best start for life, a vision for the 1001 critical days, outlines areas for action to improve the health outcomes of all babies in England, including new Family Hubs.

She now chairs the Start for Life Unit, a team of civil servants tasked with implementing the review's recommendations.

Dame Andrea talks with Camilla about her experiences of championing infant and child health in Parliament, and why she's so passionate and focused on this early period of life. Camilla asks how paediatricians can use their voice to support policy change, particularly where there are competing priorities, and how to consider poverty's impact on child health outcomes.

Ensuring decision-makers introduce the best public policy for children and young people is an important part of our work at RCPCH. We engage regularly with Ministers, senior civil servants, MPs, Lords and advisers on a wide range of matters. On some occasions, like this one, that will mean engaging with individuals from specific political parties. However, we never endorse political parties or movements, and work with representatives of all parties equally and that remains the case with this podcast.

We are grateful to Dame Andrea for sharing her views as someone with a central role in government policymaking on early years. Do keep an eye out on our podcasts for future conversations with policymakers from across the political spectrum.

Links from the podcast

Family Hubs and Start for Life programme (GOV.UK)

The best start for life: a vision for the 1,001 critical days (GOV.UK)

Rt Hon. Dame Andrea Leadsom website

RCPCH work in public affairs

RCPCH toolkit on child health inequalities

RCPCH position statement on breastfeeding