Select Committee on Public Accounts Fifty-First Report

3  What more needs to be done?

18. The Committee considered it unsatisfactory that one in ten patients admitted to hospital is unintentionally harmed. The Department agreed that based on experiences in other high risk industries such as aviation, year on year improvements (to 1 in 15 or 1 in 20) could in time be achieved. However, like these other industries it could take the NHS a decade or more systematically to improve safety to such a standard. More immediate improvements should be achievable through the advent of the electronic patient record which is expected to reduce the number of incidents due to lost, poor or fragmented clinical information and improve drug dispensing, by eliminating the risk of misinterpretation of clinicians' handwriting.[18]

19. England is one of the few countries to have a nationwide approach to patient safety. It has national structures in place such as: a comprehensive quality framework; national inspectorates; bodies to help embed an open and fair culture; systems for reporting and learning; and national training curricula. This approach should help to identify risks that might otherwise have been missed and enable solutions to be developed in a systematic, cost-effective way that avoids duplication. However, the National Patient Safety Agency has been slow to develop and disseminate solutions to NHS trusts. Given that enhancements to patient safety can only happen at trust level, at the interface between healthcare workers and patients, any national solutions need to be seen by trusts to be effective.[19]

20. Some trusts still have some way to go to establish an open and fair culture, including developing more effective team working and better communication with patients. Trusts also need to improve routine feedback of data and findings on incidents to staff, with time for reflection and learning. In those trusts where these principles are well-established, there are good examples of local learning to improve patient safety, some of which have been demonstrated to be cost-effective. The National Patient Safety Agency has not sought to capture these local examples and doubts amongst healthcare workers remain as to whether the Agency can make a difference.[20]

21. The National Reporting and Learning System now receives 60,000 reports a month, proportionately greater than any other system in the world, significantly increasing the level of information the NHS has on the number and extent of patient safety incidents. The National Patient Safety Agency has yet to demonstrate that it is using this information and knowledge effectively to change healthcare practices rather than simply collecting statistics.[21]

22. The Department concurred that, although the National Patient Safety Agency had produced a number of specific solutions, the learning system was not yet working as well as it could. Trusts generally perceive that the Agency has failed to maximise learning because it has not provided feedback quickly and regularly. The agreement of the Department to publish quarterly reports from the Patient Safety Observatory (an arm of the Agency which quantifies, characterises and prioritises patient safety issues) will go some way to address this, particularly once information from the reporting system is brought together with information from other systems recording complaints and litigation.[22]

23. The Agency will have to analyse nearly one million incident reports a year, two-thirds of which may not have caused any actual harm to the patient. The collection of risk based, aggregate data, would allow the Agency to prioritise more effectively, for example by gathering details on the number of deaths and serious injury resulting from patient safety incidents. This would also enable the Agency to focus on high impact solutions, such as new methods for dispensing medication to reduce medication errors (25% of all reported incidents). [23]

24. The National Reporting and Learning System has increased rather than reduced the complexity of NHS reporting, and trusts still have to report the same incidents to more than one organisation (for example, medical devices errors are also reported to the Medicines and Healthcare Products Regulatory Agency). There is a need for greater co-ordination between NHS organisations. The Department's National Programme for Information Technology in the NHS is intended to create a single portal for reporting with data then passed onto the relevant stakeholder.[24]

25. Learning lessons is most likely to come from the information on contributory factors and currently only a small percentage of reports to the National Patient Safety Agency contain this information in either the data or free text fields. The National Patient Safety Agency would like to see more trusts providing this information. It was working with NHS Connecting for Health to explore making contributory factors a mandatory field in the national specification for risk management systems.[25]

26. Independent providers of NHS funded care are covered by the Healthcare Commission's inspection process, which requires them to comply with National Minimum Standards, including having an incident reporting system. Currently, however, independent providers are not obliged to share that data with any NHS body. Service Level Agreements should ensure that such data on patient safety incidents is made public. Indeed, if GPs and their patients are to be able to make informed choices between providers, as part of the new patient choice agenda, there will be a need for robust comparable data on all providers.[26]

27. For this reporting and learning to have a demonstrable impact on the experience of patients, the level of data submission and implementation of safety alerts and guidance at trust level needs to be monitored. Trusts self-certify that they have implemented safety solutions from the Safety Alert Broadcast System (a Departmental system for notifying trusts of matters that require attention) and strategic health authorities monitor this data. However, actual compliance with this guidance is not audited.[27]

28. Worldwide there are few examples of where reductions in risk can be quantified and attributed to particular interventions. Few trusts have quantified the cost of specific patient safety incidents and the National Patient Safety Agency has only produced one template business case for trusts to customise to argue for investment in safety solutions. More information on the cost-effectiveness of solutions would enable trusts to prioritise scarce resources more effectively.[28]

29. The NHS needs to be open in its dealings with patients involved in safety incidents. Patients expect an apology, a full explanation, to be involved in an investigation, and to help determine what actions might prevent future harm. Australia and the Veterans' Health Service of the United States of America have had policies advocating these principles for a number of years, and the National Patient Safety Agency's guidance Being Open, issued in September 2005, has drawn on their experiences. The Agency has also launched teaching materials to allow trusts to develop appropriate local policies and give clinicians practice in informing patients about incidents. The Chief Medical Officer has produced a report on reforms to the medical litigation system, Making Amends, and there is a proposed new Bill on this.[29]

30. The Department, through its former agency, the National Clinical Assessment Authority, has made some progress in providing support to poorly performing doctors and in resolving long running suspensions, whilst ensuring patients are protected. The expanded role of the National Patient Safety Agency now covers these responsibilities, but is still only providing support to doctors and dentists. A similar service should be available to nursing and other clinical staff. Whilst the Chief Nursing Officer and the National Patient Safety Agency have sought to strengthen local systems which deal with poor performance of this much larger group of staff, all staff need equal access to some degree of independent support.

18   Qq 22, 24-27, 95-97 Back

19   Qq 3, 77, 90-91, 116 Back

20   C&AG's Report, Executive Summary para 6, paras 3.10-3.11 and Case Examples 6-7; Q 119 Back

21   Qq 2-3, 7 Back

22   Qq 26, 86 Back

23   Qq 117, 133 Back

24   Qq 19, 112-114 Back

25   Qq 32-33, 66-69, 87 Back

26   Qq 35, 38-41, 43-46, 50-53 Back

27   C&AG's Report, paras 3.25-3.28; Q 98 Back

28   Qq 89, 94 Back

29   Qq 29-30, 61, 139 Back

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Prepared 5 July 2006