Supplementary memorandum submitted by
the Department of Health
Question 2 (Mr Edward Leigh): Updating information
relating to patient deaths
There remains considerable discussion, both
nationally and internationally, over the variation in estimates
of death due to patient safety incidents. This was reflected within
the National Audit Office Report A Safer Place for Patients: Learning
to improve patient safety. The NAO noted 2,181 deaths in response
to their survey—we do not know whether this figure was adjusted
for the over-reporting of deaths which would not be strictly classified
as patient safety incidents. Staff may report deaths of people
who died as a result of their illness rather than an error, although
an error may have occurred in the course of their care.
In July 2005, the NPSA published its first Patient
Safety Observatory (PSO) report where we gave an estimate of 840
deaths that would be reported to us from acute trusts only. The
estimate was based on data from consistently reporting trusts
and was also adjusted for over-reporting of deaths which were
not patient safety incidents.
Further caveats apply to an estimate of deaths
reported to the NRLS, in addition to those for the number of incidents:
1. attributing a patients' death to an incident
is not straightforward;
2. trusts may record deaths as incidents,
even when no patient safety incident has occurred, in order to
support other risk management or local requirements (for example
deaths of mental health service users outside of hospital are
often reported within mental health trust risk management systems).
In order to try and reconcile the difference
between NAO and NPSA figures, we have tried to estimate deaths
in mental health trusts (it was felt that reported deaths in ambulance
trusts were likely to not make a large enough difference to the
numbers, the exercise was more about reconciling figures than
about arriving at a very precise figure).
Work done has given a very approximate estimate
of deaths from mental health trusts of 1,350 deaths/year. This
estimate has been made on the basis of:
— reporting rates from consistently
reporting trusts (1.55/100 bed days);
— numbers of bed days in England in
2003-04 (6.7 million, from Hospital Episode Statistics);
— proportion of reports from mental
health trusts which are deaths (1.3%);
— this estimate does NOT adjust for
over-reporting of deaths which are not PSIS This proportion is
likely to be higher than for acute trusts, on the basis of analysis
for the forthcoming PSO report.
It is not feasible to estimate deaths from other
settings, given the relatively low reporting rates from ambulance
trusts at the moment.
Despite the limitations of this analysis, we
conclude that much of the difference between the NPSA and NAO
estimates is likely to be because the NAO estimate includes mental
health trusts, but the estimate in the PSO report was for acute
trusts only.
840 (July PSO report)+1,350 (estimate from mental
health trusts)=2,190 deaths (compared to NAO figure of 2,181).
Question 6 (Mr Edward Leigh): Update of international
comparisons made in the NAO Report
In the increasing number of countries where
research has been carried out, studies consistently show similar
levels of health care errors, broadly in the order of 10% of hospitalisations.
The NAO Report [Appendix 4, third paragraph
and figure 23] makes the point that a comparison of international
studies found an average incidence of 8.9%, and also that "the
variation in data can in part be explained by differences in the
underlying methodologies for screening records to determine patient
safety incidents".
Health care systems the world over are turning
their attention to the importance of focusing on organisational
culture and underlying systems for improving patient safety. International
research suggests that healthcare is no more unsafe in the UK
than in the USA, Australia, New Zealand or Denmark. No country
can yet claim to have completely solved this problem.
More generally, through our drive for safer
patient care, this country is acknowledged as one of the world
leaders in patient safety: in recognising the problem and systematically
trying to address it.
The World Health Organisation has recognised
the innovative work being done in this country, in developing
the World Alliance for Patient Safety—launched 27 October
2004 in Washington. The World Alliance for Patient Safety has
identified a number of key actions required to enhance patient
safety in any country:
— increased ability to learn from mistakes
through better reporting systems
— greater capacity to anticipate mistakes
and probe systemic weaknesses
— identification of existing knowledge
resources
— improvements in the health-care delivery
system itself, so that structures are reconfigured, incentives
are realigned and quality placed at the core of the system.
Against these requirements, as the NAO Report
acknowledges [Appendix 4 figure 24], we compare very favourably
with other countries. As examples, we have established:
— a truly national approach to patient
safety with one of the few national reporting systems [note: American
and Australian systems cover only parts of each country]
— a national body to focus our efforts
to improve the safety of patients
— "safety" as the first domain
of the new NHS Standards—against which the Healthcare Commission
assess NHS Trusts
— numbers of incident reports to our
national system that are unlikely to have been surpassed anywhere
in the world, either numerically or proportionately.
As noted in the NAO Report [eg paragraph 2.5],
higher levels of reported incidents suggest a safer culture within
health care organisations.
Reporting levels to the NPSA's national system
continue to increase significantly, suggesting improvements in
safety culture across the NHS. Staff from all NHS Trusts are now
reporting patient safety incidents to the National Reporting and
Learning System (NRLS)—with the NPSA currently [at January
2006] receiving around 60,000 reports every month.
Reporting levels to the NRLS in England and
Wales are already broadly level with those to the Veteran's Administration
(VA) system in the USA, established in 1999, and significantly
higher than those to the Danish national system, established in
2003.
In terms of whether reporting to a national
system should be anonymous or confidential:
The NAO review itself makes the case for anonymous
reporting in paragraph 2.16, which suggests an anonymous reporting
system to tackle the acknowledged problem of under-reporting in
medication errors and drug-related incidents.
There are advantages in having anonymous or
confidential reporting. In this country, our aim has been to raise
the level of reporting rates. A system where reporting is anonymous
at the national level was felt to be the best means to achieve
this in the short term.
Our approach is similar to that taken in the
Danish system, where reporting is also confidential at the local
level—allowing local action and follow-up—but anonymous
on the national reporting system.
In terms of whether reporting to a national
system should be "mandatory":
In this country, reporting errors forms part
of the assessment criteria for the NHS Standards, independently
assessed by the Healthcare Commission, reporting is now, in effect,
"mandatory".
At the same time, the NPSA's position has been
to encourage (rather than enforce) a culture of reporting—with
the emphasis on ensuring that the reporting system is seen to
be non-punitive.
For international comparison, the Danish system
places an obligation on frontline personnel and Hospital Owners
to report incidents, whereas the Veteran's Administration (VA)
system in the USA has, as guiding principles, voluntary participation,
confidentiality protection, and non punitive reporting.
Question 102 (Mr Greg Clark) & Question 152
(Mr Richard Bacon): Detailed breakdown of NPSA budget
The NPSA budget for 2005-06 is £35.154
million.
Following the publication of Reconfiguring
the Department of Health's Arm's Length Bodies in July 2004,
from 1 April 2005 the NPSA assumed responsibility for:
— the National Clinical Assessment
Service (NCAS, formerly the National Clinical Assessment Authority);
— the Central Office for Research Ethics
Committees (COREC);
— the Better Hospital Food Programme,
some aspects of cleanliness in the NHS, the safety of hospital
design (transferred from NHS Estates);
— and the contracts with the confidential
enquiries into maternal and child health (CEMACH), patient outcome
and death (NCEPOD) and suicide and homicide by people with mental
illness (NCISH)—which moved from the National Institute
for Clinical Excellence and Health.
This merger released £1,360,000 Gershon-related
savings in its first year as detailed below:
— Discontinuation of NCAA Board = £150,000
— Savings from merging Finance Departments
= £280,000
— Savings from merging Human Resource
Departments = £280,000
— Savings from merging Communications
Departments = £300,000
— Savings from merging Information
and IT functions = £70,000
— Vacating the 7th floor of Market
Towers = £290,000
The NPSA's overall budget increased to reflect
the responsibilities stated above
A breakdown of the budget for the most recent
financial year is given below:
| Total NPSA budget 2005-06
| £35.154 million |
| Original NPSA budget plus corporate services for all functions mentioned below (IT, HR, facilities,communications, finance and Board)
| £19.218 million |
| NCAS budget | £7.36 million
|
| COREC budget | £5.175 million
|
| Confidential enquiries | £3.034 million
|
| NHS Estates | £0.357 million
|
| |
By way of comparison, NPSA budget in the years preceding
the ALB review was:
| Year | Budget
|
| 2001-02 | £1.763 million
|
| 2002-03 | £12.12 million
|
| 2003-04 | £17.552 million
|
| 2004-05 | £17.108 million
|
Pay budget
| |
— The annual projected pay budget (at month 9),
including NPSA, NCAS, COREC and NHS Estates is £17.587 million
and includes the new salaries under Agenda for Change
— Budgeted pay as a proportion of income is 50%
— WTE cost per budgeted staff is £55,655 (£17,587,000/316)
— This excludes Confidential Enquiries (NPSA simply
manages contracts for the enquiries—details of staff pay
and staff numbers, if required, must be sourced from the enquiries
themselves as these organisations are independent of the NPSA).
Staff numbers
The ALB review increased staffing also. The breakdown is
as detailed below:
| Organisation | Staff numbers
|
| Total (post-ALB review) WTE staff budgeted for 2005-06, excluding Confidential Enquiries
| 316.27 |
Breakdown of staff salary
|
|
| NPSA pre-ALB | 2004-05
|
| Under £30,000 | 40.00 |
| £30,000-£40,000 | 20.80
|
| £40,000-£50,000 | 40.97
|
| £50,000-£60,000 | 25.00
|
| £60,000-£70,000 | 3.00
|
| £70,000-£80,000 | 3.20
|
| £80,000-£90,000 | 3.00
|
| £90,000-£100,000 | 2.00
|
| |
| 137.97 |
| |
NPSA post-ALB
(all functions excluding Confidential Enquiries)
| 2005-06
WTE |
| Under £30,000 | 77.00 |
| £30,000-£40,000 | 68.43
|
| £40,000-£50,000 | 52.73
|
| £50,000-£60,000 | 23.94
|
| £60,000-£70,000 | 8.60
|
| £70,000-£80,000 | 3.00
|
| £80,000-£90,000 | 3.80
|
| £90,000-£100,000 | 8.20
|
| £100,000-£110,000 | 1.00
|
| £170,000-£180,000 | 1.00
|
| |
| 247.70 |
| |
— In 2005-06, there are a total of 316,27 WTE in
our planned establishment
— As at 31 December 2005, the number of WTE on the
NPSA payroll is 247.7
|
