House of Commons - Public Accounts

Select Committee on Public Accounts Fifty-First Report

2 Action to improve patient safety

9. In its 2001 policy document, Building a Safer NHS for Patients, the Department advocated that patient safety and risk reduction should be at the heart of its framework for improving quality of clinical care. A key action was the establishment of the National Patient Safety Agency in July 2001, to collect and analyse information, assimilate other safety-related information from a variety of existing reporting systems, learn lessons and produce solutions. The Department also advocated that lessons could be learned from others, in particular from the airline industry.[10]

10. The Department allocated an annual budget of around £15 million to the Agency, which by 2004-05 had increased to £17 million and in 2005-06, following an increase in its remit as a result of reconfiguring the Department of Health's Arm's Length Bodies, was £35 million (Figure 3).[11]

Figure 3: A breakdown of the National Patient Safety Agency's 2005-06 budget

Total National Patient Safety Agency budget 2005-06	£35.154 million
Original National Patient Safety Agency budget plus corporate services for all functions mentioned below (IT, Human Resources, facilities, communications, finance and Board)	£19.218 million
National Clinical Assessment Services budget	£7.36 million
Central Office for Research Ethics Committees budget	£5.175 million
Confidential Enquiries	£3.034 million

Source: National Patient Safety Agency

Note: In 2005-06, the pay budget was £17.587 million, or 50% of the overall spend (excludes cost of staff engaged by the confidential enquiries.)

11. The National Patient Safety Agency was charged with supporting an open and fair culture in the NHS, where staff feel they can report concerns without fear but on the understanding that they are accountable for unsafe acts. It has made some progress, for example its Seven steps for patient safety document and guidance on good practice in dealing with staff involved in incidents. It has also trained 8,000 staff in contributory factors analysis, provided leadership training to 154 non-executives from 113 trust boards and issued guidance for chief executives on their role in promoting safety. The Department believes that there has been a change in attitudes towards safety and, paradoxically, sees the increase in reported incidents as an indication of an improved safety culture in the NHS.[12]

12. A key target for the National Patient Safety Agency was to develop a national reporting system by December 2001, with all trusts to provide information to it by the end of 2002. The early years of developing its "National Reporting and Learning System" have been beset by problems. The system was three years late in being linked to trusts' own reporting systems and was over-spent by approximately £1 million. In addition, the parallel, anonymous, electronic reporting system (e-Form) was only available from September 2004.[13]

13. The main reason given for the delay is that, following an evaluation, the pilot system proved to be unsatisfactory due to technical difficulties. The National Patient Safety Agency therefore considered it should not be rolled out to the whole of the UK. The scale of the proposed replacement system meant that the Agency had to obtain Treasury approval for its full Business Case (February 2003) before re-tendering. This further contributed to the delays. The Department did not accept that it had set unrealistic target dates for the implementation, but believed that it was better to make sure that it was getting quality and value for money for a system that would work for all 607 NHS trusts.[14]

14. The motivation for developing the eForm was the need to have a system that enabled those who might not report through their local systems still to report to the Agency. By January 2006, it had received 2,914 e-Form reports, 9% of which were from doctors, a higher percentage than from the trust reporting systems. Whilst encouraging better compliance by this hard to reach group, the lessons learned are constrained by being unable to trace these reports to the original event.[15]

15. The National Patient Safety Agency developed a bespoke taxonomy for reporting incidents in England and Wales rather than adopting existing taxonomies in use in other parts of the world. It judged that the NHS required a description and classification that covered all health care sectors, including mental health and primary care, and this comprehensive taxonomy did not exist anywhere else. Two-thirds of trusts reported that the taxonomy for their sector was not specific enough for their purposes and were continuing to use their own for local reporting. Meanwhile, the World Health Organisation is developing an international taxonomy to which the NHS is expected to sign up.[16]

16. Each trust had to map their taxonomy on to that provided by the Agency, which created problems for 82% of trusts and led to some of the delays. By January 2006 all trusts had started to report regularly to the National Reporting and Learning System. Some trusts are however questioning the value of submitting data to the National Reporting and Learning System given the lack of feedback on solutions to specific patient safety incidents. The Department nevertheless believes that the National Reporting and Learning System is one of the main achievements of the National Patient Safety Agency.[17]

17. In relation to its primary role of providing feedback and maximising learning in the NHS, the National Patient Safety Agency has issued 15 solutions since 2002, which it expects trusts across England to implement. These include the national 'cleanyourhands' campaign and the standardisation of crash call numbers. It has issued an alert on infusion devices, which it estimates has reduced the risk of incorrect use by half; and recommended that undiluted potassium chloride should not be kept on wards.



© Parliamentary copyright 2006	Prepared 5 July 2006