Select Committee on Health Written Evidence

Memorandum by The Health Foundation (PS 21)



  1.1  NHS care and treatment is replete with avoidable error. The bulk of this is caused by system failure resulting in chronically unreliable care delivery.

  1.2  The managerial and clinical leaders of all acute hospitals in England should make patient safety their top priority, implementing proven changes in clinical practice to reduce harm; banishing the blame culture; and changing the way they identify risks and measure performance.

  1.3  Ministers and NHS top management can aid this by ensuring a coordinated use of managerial, commissioning and regulatory levers. They should lead by example, putting patient safety, visibly and practically, at the very top of their agendas. Responsibility for patient safety at the Department of Health should be clarified and backed with sufficiently senior and experienced technical expertise. In the context of High Quality Care for All: NHS Next Stage Review Final Report, they should act to build a cadre of expert clinical leaders in patient safety[153].

  1.4  Other industries have seriously addressed safety and the same can be done in the NHS. Healthcare is highly complex and there are no quick fixes. A holistic approach is necessary. Senior leadership, clinical engagement and a committed workforce are all vital. Time must be invested in embedding a long-term safety culture.

  1.5  The Health Foundation's work over four years with 24 hospitals across the UK has many lessons for the rest of the NHS.

  1.6  The Safer Patient's Initiative (SPI) is a cost effective intervention and is just one important element of The Health Foundation's development of a suite of approaches to transform patient safety. The four home nations are now introducing core elements of it into all acute hospitals.

  1.7  SPI has shown that care processes can be improved to deliver reliable, high quality care. It has built on positive will to change, leadership attention on safety and implementation of evidence-based measures designed to make routine care processes as reliable as possible.


  2.1  The Health Foundation works to improve the quality of UK healthcare. Uniquely, we identify international learning and practice, demonstrating the benefits by working with healthcare organisations across all four home nations.

  2.2  The Foundation is independent of interest groups, forming constructive partnerships in healthcare policy, research and practice. We spend £25 million annually to close the gap between the best care and what patients routinely receive.

  2.3  The Health Foundation's patient safety work interlocks with our approach to developing leadership, improving quality by engaging clinicians and patients and building knowledge of what works. These are all facets of quality. Creating and sustaining safe and reliable healthcare requires a holistic approach with the following important elements: developing clinical teams to become learning communities providing constructive feedback; providing structure and discipline around testing and measuring outcomes; stimulating local adaptation anchored in evidence and encouraging multidisciplinary learning drawing on patient perspectives. Safety culture must be embedded over time in daily practice to be truly effective.

  2.4  Safety needs long-term commitment, senior leadership and engagement, passionate clinicians and experienced managers. The Health Foundation has supported a range of initiatives: the independently evaluated SPI, Professor Charles Vincent's Journey to Safety[154] and Quality Improvement Fellowships which enable clinical staff to become quality and safety experts. We are continuing our catalytic investment through Safer Clinical Systems a programme to design systems that can support defect free care.


  3.1  The National Patient Safety Agency (NPSA) estimates that 850,000 incidents and errors occur every year in the NHS. Other estimates suggest that one in ten patients in hospital experiences an incident that puts their safety at risk, roughly half of which could have been prevented[155].

  3.2  In 2000 the Department of Health's An Organisation with a Memory[156] painted a stark picture of an NHS without systematic ways of identifying error, learning from its causation and reducing risk for future patients.

  3.3  The vast bulk of human error in healthcare is attributable to system failures rather than poor clinical judgement. We must abandon the belief that healthcare is inherently unreliable and tackle system failures by investigating, understanding and acting upon avoidable harm as a departure from the norm.

  3.4  SPI built a system-wide approach by recognising the size of the challenge; shifting from a culture of individual blame; focusing leadership attention on safety as a first priority; using evidence to make routine care processes as reliable as possible and building the will and skills of staff to support these strategies.

  3.5  With this approach, the NHS could strive to match the safety culture and performance of industries such as commercial aviation. Only one in every 10,000 plane landings is unsafe. In healthcare, anaesthesia has reached this level of reliability. This is not matched by other healthcare areas where one patient is harmed for every 100 medication doses given in hospital.

3.6  The role of public perceptions of risk in determining NHS policy

  NHS policy is too easily led by media and public focus on single issues such as healthcare acquired infections (HAI). Though valuable, this focus cannot ensure that hospitals address safety issues throughout the patient journey. HAIs are symptoms of leadership, systemic and cultural failures. Isolated initiatives such as deep cleaning may satisfy public anxiety but there is little evidence they can address root causes unless they are undertaken within a long-term safety strategy.


  4.1  The 24 hospitals participating in SPI demonstrate the NHS's potential to ensure patient safety. SPI's success lies in the recognition that care processes must be improved to give all patients the care and treatment they need all of the time. As the case studies below illustrate, SPI hospitals have found that improving the reliability of care leads to reduced harm.

4.2  Case Study 1: Reliable monitoring of patients

  The National Confidential Enquiry into Patient Outcomes and Death found that patients who died in hospital often showed signs of deterioration long before death. The Luton and Dunstable Hospital NHS Foundation Trust estimates that there are 1.5 fewer cardiac arrests per week following the introduction of an early warning score system on the wards. The system allows staff to monitor the condition of patients and take rapid action if they go into decline. It has led to a fall in the crash call rate as the rapid response team can now take action sooner to avoid patients developing serious life-threatening conditions.

4.3  Case Study 2: Critical care

  It has been known for some time that systematically implementing four actions reduces the risk of ventilator acquired pneumonia (VAP). Yet, SPI hospitals measuring whether these steps were being taken in their units found poor compliance with all actions. Conwy and Denbighshire hospital increased compliance from 87% to 100%, virtually eliminating VAPs from a starting point of 30 infections per 1000 bed days. As infection free patients need less time in critical care, bed availability increased. Conwy and Denbighshire treated 350 more patients over the last two years within the same capacity as well as reducing medication and saving £78,000 over a 12 month time period in the medications budget.

4.4  How far Boards of NHS bodies have established a safety culture

  Demonstrating that it is possible to avoid infections, medication errors and other routine defects in care taps into staff's intrinsic motivation to help patients. SPI hospitals work to build on staff's will to change, not their fear of punishment. Overcoming the traditional view that mistakes leading to harm are regrettable but an unavoidable aspect of routine care.

  4.5  Boards can provide the key leadership and vision to help staff improve. They can drive change by simple methods of staff engagement ensuring that on the ground solutions and challenges are brought home to the executive and non-executive levels.

  4.6  SPI senior leaders receive monthly reports against a basket of key outcome and process measures from which it is possible to drill down to specific areas of concern. Executives and non-executives are involved in weekly leadership "walk rounds", taking them into clinical areas to discuss areas of risk and potential harm. Senior leaders identify actions needed to create a safer clinical care context, signalling to frontline staff the priority of patient safety.


  5.1  In much of the NHS there is limited available, real-time, clinical performance data. In SPI hospitals, teams track safety improvements against a range of process and outcome measures. The collection of meaningful data enables each team to see in real-time the impact of the changes they are making and equips them to identify areas for practical improvement.

  5.2  The quality agenda has largely focused on the dissemination of guidelines and standards. Little attention has been paid to how to introduce change reliably. All SPI hospitals had extensive quality assurance and risk management systems in place at the start of their work with the initiative. However, all found highly variable compliance with agreed standards when monitoring actual practice.

  5.3  SPI teaches "the model for improvement"[157], enabling staff to make planned, small-scale changes to care delivery and assess their impact before attempting to make wholesale changes to clinical practice. This approach focuses not on what should be done but how it can be done reliably. Clinical teams build confidence and take ownership of changes in care, resulting in greater compliance and sustainability.


  6.1  The Health Foundation welcomed, and participated in, the formulation of the recommendations made by Safety First. However, progress towards the review's objectives has been regrettably slow. The failure of the National Patient Safety Forum to make significant progress in driving forward the patient safety agenda has been disappointing.

  6.2  The Foundation welcomes High Quality Care for All's strong focus on quality, the emphasis on outcome metrics and clinical leadership. It recognises that real sustained change can only happen if driven by clinical leaders on the ground.

  6.3  National targets are necessary and helpful but are not sufficient in themselves.


7.1  Are measures taken to improve safety supported by adequate evidence regarding their clinical effectiveness and cost effectiveness?

  We know what works in healthcare, the challenge is how it is reliably implemented to benefit every patient. SPI was the first national or international programme to bring together evidence-based interventions to improve the safety of clinical care and the leadership responsibility to create a safe environment of care. It was based on the knowledge that there was:

    —  growing evidence of widespread harm to patients that needed to be addressed

    —  an evidence base for what works to ensure patients' safety, but a substantial gap in the implementation of best practice

    —  an internationally recognised and respected technical partner organisation (the Institute of Healthcare Improvement, Boston, USA) to implement the teaching and support programme.

  7.2  There are numerous examples of how participation in SPI has improved the reliability of evidence-based care processes, including:

    —  by November 2006, NHS Tayside increased its hand hygiene compliance to 96% on general wards, helping to reduce HAIs

    —  Down Lisburn Health and Social Services Trust reduced the percentage of times to below 10% that the medication given to a patient in hospital does not match those they are already taking when admitted. This followed the development of a system for tracking and managing the drugs their patients take. The system also links to GP patient records and helps to reduce mistakes in primary care

    —  compliance with pre-operative briefings in Luton and Dunstable increased from 8% in June 2005 to 100% by April 2007 and has been sustained

    —  NHS Tayside has experienced a reduction in surgical site infections in orthopaedics from 6.1% to 1.3% per 100 surgeries between November 2006 and June 2007.

  7.3  Health Foundation SPI funding, acts as a catalyst for the improvement of patient care. These hospitals have shown that for the relatively small investment of £90,000 per trust per year, and another £55,000 per year in skills development, they have been able to utilise existing resources in a new way to deliver lasting benefits. Encouragingly, hospitals who failed to win an award have decided to implement a safety agenda without Health Foundation funding.

7.4  Spread of best practice

  The Health Foundation is driven by a belief that it is possible to speed on-the-ground uptake of interventions that could address a known and serious problem. The impact of SPI has been far-reaching. It has led to demonstrable improvements in patient safety in the 24 participating organisations. It has also shaped the landscape of patient safety across the UK as each of the four home health departments has developed their approach to safety.

  7.5  The four home nations are now introducing core elements of SPI into all acute hospitals. The health departments of Wales, Scotland and Northern Ireland have all responded positively to this work, each now actively leading safety initiatives across their territories to which we are contributing advice and support.

  7.6  More work is needed in England to deliver a national spread strategy backed by sustained and coordinated activity at every level. In partnership with the National Patient Safety Agency and the NHS Institute for Innovation and Improvement we are supporting and developing the English safety campaign which spreads SPI approaches across English acute hospitals.

7.7  Implementing learning

  Building and sustaining capacity and capability in improvement methodologies is a significant challenge. While the NHS Institute and some SHAs are starting to offer training in these areas, current provision falls short of demand. The demand for open days run by SPI sites is increasing. At Luton and Dunstable NHS Foundation Trust each session has upwards of 70 participants.

  7.8  A high proportion of the individuals working on safety at regional and national level have come from SPI sites. Yet previous modernisation efforts could not be sustained when key individuals moved on. This is a matter of concern.

7.9  Incentives

  The publication of performance data by individual hospital, such as mortality statistics where HAIs were the main or a contributory cause, has the potential to incentivise clinicians and managers to improve the quality of care[158]. Under the new Commissioning for Quality and Innovation scheme proposed in High Quality Care for All, by 2010 the payment providers receive for the care they deliver will be dependent on outcomes[159]. If applied appropriately such financial incentives could be beneficial.

  7.10  The Foundation opposes the imposition of financial sanctions on hospitals which have unintentionally harmed a patient. Fining publicly-funded institutions penalises the population and can lead to the manipulation of performance data and the demoralisation of staff.


  8.1  The Health Foundation will continue to invest in patient safety by building a new network of safety-minded organisations across the UK able to test, develop and export approaches to improve safety and build capability in the wider system. This will generate new knowledge and practice that can be used across healthcare. By supporting some sites to become expert in the training and mentoring of these approaches they will be able to export expertise to the wider system.

  8.2  Safety is a complex challenge with no easy answers but the managerial and clinical leaders of all acute hospitals in England could make patient safety their top priority. They could act now to:

    —  implement tried and tested changes in clinical practice to ensure safe care is delivered every time to every patient

    —  banish the blame culture and harness the energy and enthusiasm of their staff to improve patient safety

    —  change the way they identify risks and measure performance to better support clinical teams to take responsibility for their own performance.

  8.3  The Department of Health should ensure a coordinated use of its managerial, commissioning and regulatory functions to ensure this is achieved. Additionally, they could influence immediate improvement if they ensured that:

    —  ministers and NHS top management recognise there are no quick fixes in patient safety. It depends on developing leaders and providing them with the skills to lead improvement, at every level of the system. It cannot be driven from Whitehall. Ministers and NHS top management must lead by example, putting patient safety—visibly and practically—at the very top of their agendas

    —  responsibility for patient safety is clarified at the Department of Health and is backed with sufficiently senior and experienced technical expertise

    —  a strong emphasis is placed on building a cadre of expert clinical leaders in patient safety in the light of the potentially more conducive policy environment created by High Quality Care for All: NHS Next Stage Review final report, with its strong focus on developing clinical leadership.

September 2008

153   Darzi A, High Quality Care for All: NHS Next Stage Review Final Report. Department of Health, 30 June 2008. Back

154   Journey to Safety is a five year programme aiming to address questions about what steps need to be taken to create safe healthcare organisations. Back

155   Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001;322:517-9. Back

156   An Organisation with a Memory: Report of an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer. Department of Health,13 June 2000. Back

157   "The Improvement Guide: A Practical Approach to Enhancing Organisational Performance". Langley et al; San Francisco, California, USA: Jossy-Bass Publishers; 1996. Back

158   Shekelle P G, Lim Y, Mattke S, Damberg C (2008) Does public release of performance results improve quality of care? A systematic review. Quest for Quality and Improved Performance, The Health Foundation. Back

159   Darzi A, High quality care for all: NHS Next Stage Review final report. Department of Health, 30 June 2008, p42. Back

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Prepared 30 October 2008