Importance of non-patient facing NHS services

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Russell Evans, Senior Safety Investigator.

When many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families.

However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated.

Craig Hadley, Senior Safety Investigator.

Non-patient facing services provide essential support functions to clinicians delivering visible care, in the same way that a Formula One driver is reliant upon an extensive team in support of delivering the quickest car possible. Both the Formula One driver, and the wider support team, can have considerable impact to the performance of the car and the result of a race.

Examples of non-patient facing NHS services

Examples of some non-patient facing services in the NHS include:

Administrative and support services, including receptionists, secretaries and medical records clerks.
Estates and facilities management who are responsible for NHS buildings and grounds. This also includes infrastructure essential in providing care, such as oxygen systems and ventilation.
Sterile service departments who provide decontamination, sterilisation, and storage of reusable medical devices and equipment. They ensure that equipment is cleaned and disinfected to minimise the risk of infections to patients.
Medical laboratory services, such as pathology that have been undertaking quality checks on blood samples for more than 60 years.
Medical equipment services who inspect, test and repair medical devices.

Non-patient facing services in HSIB investigations

HSIB has carried out investigations in these areas that help stress the important role they play in keeping patients and staff safe.

Decontamination of surgical instruments

Our decontamination of surgical instruments investigation explored a situation where a contaminated medical device was used on a patient during a procedure. The investigation looked at the governance arrangements surrounding sterile service departments (SSD) - those departments responsible for cleaning and sterilising medical devices. This included regulation and risk and quality management.

The SSDs are essential for the safe running of operating theatres and many other areas of hospitals. Staff described that they were the engine room for operating theatres, and if these services failed, there would be delays and cancellations to planned procedures and surgery.

One SSD manager said to the investigation “you wouldn’t get into a plane without its engines working” and that the staff working in the SSD are an “important cog in a complex healthcare system” but often feel “forgotten” and “undervalued”. Many SSDs are often separated from the main parts of hospitals- some in remote parts of a hospital and some off site.

Without the essential service that SSD provide, many procedures including elective care and routine running of hospitals would not be possible.

Detection of jaundice in newborn babies

Our detection of jaundice investigation explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, we explored delayed diagnosis due to no obvious visual signs of jaundice apparent to clinical staff. In some cases, there was a reliance on a blood test to indicate whether a baby was at risk of brain damage.

The investigation found that some results of routine blood samples, which could have indicated that jaundice was present, were not always being reported to clinical staff. This indicated variability across the national laboratory network and posed a risk to patient safety.

The investigation highlighted the importance of the role of the laboratory network in maintaining patient safety and identified the need for the pathology network to further understand laboratory practice. HSIB made two recommendations to help further improve the networks’ approach to the safe care of patients.

Suitability of equipment and technology used for continuous fetal heart rate monitoring

Our fetal heart rate monitoring investigation reviewed the procedures that NHS trusts undertook when looking to purchase new equipment, which included the staff that were involved and the disciplines they came from. It was clear that trusts took different approaches, with some not involving the equipment users in the process. This resulted in frustration and a lack of buy-in to the new equipment in some cases.

By not including change management processes staff did not feel involved in the purchase process and were often confronted with equipment that they were not familiar with. The training regime for staff varied nationally, with some receiving short training sessions, and the majority of learning being completed on the job.

The investigation found that centralised monitoring was often installed with no clear direction for staff as to the purpose of the equipment and who was responsible for monitoring it. This led to variation in monitoring standards and potential issues with patient care, such as staff carrying out assessments from outside of a patient’s room.

These findings highlighted the important role that thorough procurement processes, combined with change management processes, have in supplying new equipment. Efficient procurement of equipment, which staff are consulted on and are given the correct level of training and competency to be able to use, ensures a smooth transition from the old to the new while maintaining patient safety.

Oxygen issues during the COVID-19 pandemic

Our oxygen issues investigation explored challenges hospitals faced in providing piped oxygen during the COVID-19 pandemic. Some hospitals were struggling to provide oxygen to patients due to the demands on their medical gas pipeline systems (MGPS).

The investigation found that key staff from estates and facilities teams who understood MGPS were not always included in meetings to help plan the COVID-19 response. This meant that clinical decisions on how to treat patients did not always consider what was possible from the perspective of the MGPS infrastructure.

The investigation highlighted the lack of shared ownership and knowledge of MGPS and made a safety recommendation to help ensure that estates and facilities knowledge was included in decision making at medical gas committees.

Importance of behind-the-scenes NHS services

Non-patient facing services rarely get the same recognition or scrutiny as some other NHS staff groups. We have been attempting to do this by shining a light on those areas to help stress the critical importance of these services for patient safety.

We encourage organisations at the local, regional and national level to ensure that non-patient facing services are considered fully when thinking about the delivery of patient care. This can help to ensure that healthcare systems at every level fully integrate these services into governance and risk management systems and make sure that the importance of these ‘behind-the-scenes’ services are not forgotten.

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