Economic case for reducing inequities in patient safety

Introduction

Patient safety is a fundamental aspect of healthcare quality, yet significant inequities persist that adversely affect patient outcomes. Recent commentaries have highlighted these inequities in high-income countries, particularly the USA and the UK.^{1 2} The WHO defines health equity as:

[…] the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (eg, sex, gender, ethnicity, disability, or sexual orientation). Health is a fundamental human right. Health equity is achieved when everyone can attain their full potential for health and well-being.³

In recent years, several systematic reviews of the international literature have highlighted important inequities in patient safety, manifested in numerous dimensions, including socioeconomic status, ethnicity, gender, language proficiency and geographic location.4,6

Addressing these inequities is not only a moral and ethical imperative; there is an emerging economic case to do so, too. Inequities in health and healthcare hinder economic prosperity in many countries. For instance, a report by the Northern Health Science Alliance showed that the inequities in health and healthcare between the North and South of England led to reduced economic productivity of approximately £13.2 billion per year in the North.⁷ In 2022–2023, payments for clinical negligence in the National Health Service (NHS) in England rose to almost £2.7 billion.⁸ However, this aggregate figure is likely to mask inequities that are disproportionately higher in certain population subgroups.

Worldwide, health and care services are facing unprecedented ‘squeezes’ and are being asked to make considerable cost savings while continuing to provide high-quality care. In theory, improving patient safety can lead to substantial cost savings for healthcare systems, enhance workforce productivity and reduce the societal economic burden. In this viewpoint, we explore the economic case for narrowing inequities in patient safety, drawing on international evidence to underscore the potential benefits.

Cost of inequities in patient safety

Many inequities exist in health and care, particularly relating to availability, access, service quality and outcomes. The focus of this article is on patient safety and adverse outcomes, but it is important to note that these other inequities, particularly in regards to availability and access, are of equal significance. In particular, availability and access need not be distinct from our focus on patient safety. Problems with availability and access to services can often lead to harm, for example, incorrect or delayed diagnoses of cancer. We highlight issues around the importance of access and availability later on in some of the examples that we provide.

Direct healthcare costs

Inequities in patient safety elevate the risk of adverse events occurring, which in turn increase healthcare costs. These costs include extended hospital stays, additional unnecessary treatments and the use of more intensive and expensive healthcare services. For instance, a study by the Health Foundation found that adverse events in the NHS account for approximately £1 billion annually in direct healthcare costs.⁹ However, there is no estimate of these costs for population subgroups who are most likely to experience adverse outcomes due to inequities in patient safety.

In further work, Elliott et al estimated that adverse drug events that were classified as ‘definitely avoidable’ cost the NHS £98 462 582 per year and consumed 181 626 bed-days, resulting in an estimated 1708 excess deaths.¹⁰ Camacho et al estimated that around 1.8 million medication errors occurred at hospital transitions in England.¹¹ The authors focused on four types of transitions: (1) primary care to secondary care (planned hospital admission); (2) secondary care to primary care (hospital discharge); (3) intrahospital transitions (transfer of information from one electronic prescribing system to another, within the same hospital); and (4) interhospital transfer. These medication errors adversely affected around 31 500 patients, with 36 500 additional bed days of inpatient care, estimated to cost around £17.8 million and more than 40 excess deaths per year.¹¹

While the estimated financial costs of patient safety events in healthcare are concerning, disadvantaged groups are much more likely to experience adverse events.4,6 This means that the aggregate financial costs worldwide are likely to mask a marked heterogeneity by subgroups based on ethnicity, socioeconomic status and gender. Sociodemographic subgroups are known to be at greater risk of adverse health outcomes and often receive lower quality care. A priori, it is therefore reasonable to assume that the costs for these subgroups of the population will be considerably higher (per person) when considering the additional burden caused by inequities. Further work is required to analyse the distribution of the costs of adverse patient safety outcomes by individual- and area-level characteristics to reveal the full extent of the costs of these inequities.

Indirect costs

Beyond direct healthcare costs, there are significant indirect costs associated with inequities in patient safety. These include lost productivity due to prolonged illness or disability, the economic impact on families and caregivers, and the broader societal costs related to decreased workforce participation. For example, the loss of productivity due to adverse events has been estimated to cost the UK economy over £13 billion annually.¹² Addressing patient safety inequities can help mitigate these indirect costs by learning from and preventing these adverse events.

Economic benefits of narrowing patient safety inequities

Improved health outcomes

Enhancing patient safety for disadvantaged groups can lead to better health outcomes, which in turn can narrow inequities, reduce healthcare costs and raise economic productivity. For instance, interventions aimed at reducing medication errors in ethnic minority populations have been shown to decrease hospital readmissions and associated costs significantly,¹³ thereby reducing health inequities. Internationally, targeting interventions to address inequities in safety for socioeconomically disadvantaged groups could lead to similar improvements, thereby reducing the financial burden on health and social care services and improving overall population health with a strong focus on reducing health inequities.

The USA attempted to address patient safety inequities through the implementation of the Affordable Care Act (ACA). The ACA included provisions aimed at reducing health disparities, such as increasing access to preventive services and promoting quality improvement initiatives in underserved areas. Studies have shown that these efforts have led to reductions in adverse events among minority populations and decreased healthcare costs.¹⁴ It is possible to learn from the initiatives of other counties when implementing and evaluating the clinical and cost-effectiveness of policies that focus on reducing inequities in patient safety.

Likewise, Australia’s approach to addressing patient safety inequities has focused on improving healthcare access and quality for Indigenous populations. The National Safety and Quality Health Service Standards include specific criteria aimed at reducing disparities and improving safety for Aboriginal and Torres Strait Islander patients. These criteria included¹⁵:

• Working in partnership with Aboriginal and Torres Strait Islander patients.

• Addressing the health needs of Aboriginal and Torres Strait Islander patients.

• Implementing and monitoring target strategies.

• Improving cultural competency.

• Creating a welcoming environment.

• Identifying people of Aboriginal and Torres Strait Islander origin.

These measures have led to improvements in patient outcomes, narrowed inequities and reduced healthcare costs.¹⁵

Enhanced workforce productivity

A healthier population is inherently more productive. By narrowing patient safety inequities, a more resilient and efficient workforce can be fostered. Research has shown that individuals from disadvantaged backgrounds often face greater barriers to accessing high-quality healthcare, leading to poorer health outcomes and reduced economic productivity.¹⁶ By ensuring that all patients receive safe and effective care, regardless of their social background, countries can unlock the full potential of their workforces, driving economic growth and reducing the need for social support services.

Intergenerational effects

Maternal and child health provides a clear example of the economic impact of healthcare inequities. The MBRRACE-UK report highlights significant disparities in maternal mortality rates, with black women being five times more likely to die during pregnancy or childbirth compared with white women.¹⁷ These disparities result in not only extreme levels of distress but also high economic costs due to increased medical interventions and prolonged hospital stays.

Improving maternal care for marginalised groups can lead to healthier pregnancies and births, reducing the need for costly medical treatments and interventions. This, in turn, can lead to significant economic savings for the healthcare system. Heckman highlights the point that investing in disadvantaged children can lead to large potential future returns in terms of increased education and higher economic productivity, coupled with reduced costs to the health and care systems.¹⁸

Broader societal benefits

Beyond the immediate economic benefits, reducing patient safety inequities contributes to broader societal gains. These include improved public trust in the healthcare system, enhanced social cohesion and greater overall health equity. A healthier, more equitable society is inherently more productive and resilient, further justifying investments in reducing patient safety disparities.

Policy recommendations

Strengthening data collection and analysis

To address patient safety inequities effectively, it is essential to have robust data on the incidence and impact of adverse events across different population groups. Internationally, we should invest in improving data collection and analysis to identify and monitor disparities in patient safety. This includes expanding the scope of existing data collection efforts to capture information on socioeconomic status, ethnicity, gender and other relevant factors as deemed by researchers and the health and care system. Further, measures of individual-level socioeconomic status should be included in data collection. Typically, there is a reliance on neighbourhood-level or practice-level indices of deprivation (eg, the Index of Multiple Deprivation in the UK). While useful for exploring place-based inequities, it does not capture the socioeconomic status of individuals. This is a significant information gap because many people who are socially and/or economically disadvantaged live in neighbourhoods and in towns and cities that are not among the most deprived places nationally, and vice versa. Better quality socioeconomic information at the individual level in electronic health records and other routinely collected datasets would allow a better understanding of socioeconomic status. Similarly, there is an important case for better reporting of ethnicity data within healthcare records.¹⁹

Implementing targeted interventions

Internationally, we should develop and implement targeted interventions aimed at reducing patient safety inequities. These interventions could include training healthcare providers on cultural competency, increasing access to preventive services for disadvantaged groups and implementing quality improvement initiatives in areas with high rates of adverse events. Tailoring interventions to meet the specific needs of different populations can help ensure their effectiveness and maximise their impact. NHS England has developed a review tool to support NHS organisations in reducing inequities in patient safety: https://www.pslhub.org/learn/improving-patient-safety/health-inequalities/nhs-england-patient-safety-health-inequalities-review-pshir-tool-14-july-2022-r8578/. However, to date, there is little evidence on whether this tool has achieved its aim. Formal evaluation of such tools is required to understand if and how they work. The latter is important because without a proper understanding of the mechanisms of action, it is impossible to make the enhancements that could improve patient safety, reduce inequities and lead to considerable cost savings.

Promoting policy and system-level changes

Governments should prioritise policies that promote health equity throughout their various departments. Health is not just the responsibility of departments of health; health public policy is required throughout government. However, departments of health do have greater responsibility for addressing patient safety inequities, and this requires systemic change. National-level policy initiatives could include increasing funding for safety-net healthcare providers, expanding access to high-quality care for underserved populations and ensuring that all healthcare settings adhere to rigorous safety standards. Additionally, integrating health equity considerations into broader health policy and planning efforts can help create a more inclusive and effective healthcare system.

In the UK, the recently created Integrated Care Boards can also play an important role by maximising patient safety within their local areas. Although their impacts on reducing inequities have not yet been evaluated, more localised decision-making should inform more tailored policy responses, so long as such bodies are adequately financed from central governments. Wade et al² offer important suggestions that should be taken on board to address patient safety inequities (box 1).

Box 1. Selected solutions to reduce inequalities in patient safety through action by individual healthcare professionals, healthcare leaders and system-level action.

Individuals

More routine involvement of advocates from patients’ communities in healthcare interactions to reinforce communication and ongoing support in care.

Purposeful consideration of how the social background of a patient may dictate risk of harm from healthcare, and adjust management and follow-up plans accordingly.

Use of culturally and linguistically appropriate shared decision-making tools to empower the involvement of marginalised patient groups in their care and safety.

Healthcare leaders

Support a diverse healthcare leadership that pushes these issues into the consciousness of the workforce and mobilises the system towards meaningful action.

Race-conscious approaches to healthcare education with greater emphasis on racism and discrimination (rather than race) as determinants of disease.

Systematised codesign of clinical services and clinical information with members of marginalised patient communities.

System level action

Avoid using systematically biased clinical prediction tools and algorithms unless clear empirical justification for race adjustment has been established.

Strengthen capabilities for stratified analysis of patient safety event reports according to important patient characteristics and the translation of these data into tangible action.

Clinical trials must recruit an appropriately diverse cohort, report relevant social determinant characteristics and conduct relevant stratified analyses that determine the effectiveness and safety of drugs and devices.

Sourced from box 2 of Wade et al.²

Conclusion

The economic case for improving inequities in patient safety is compelling. Reducing disparities in patient safety can lead to substantial cost savings for the healthcare system, enhance workforce productivity and reduce the overall societal economic burden. Due to the intergenerational nature of health, these cost savings are likely to continue well into the future and have the potential to lead to considerable longer-term savings as well as in the short- and medium-term. By learning from international examples and implementing targeted interventions and policy changes, healthcare providers can address these inequities and improve health outcomes for all its citizens. Better data infrastructure is essential to enable us to track changes in inequities over time. Investing in patient safety is not only a matter of justice and fairness but also a prudent economic strategy that can yield significant long-term benefits.