Select Committee on Health Written Evidence

Memorandum by the NHS Confederation (PS 67)


  The NHS Confederation is the only independent membership body for the full range of organisations that make up today's NHS. We represent over 95% of NHS organisations. We have a number of Networks which represent sector-specific services including Foundation Trust Network, Primary Care Network, Mental Health Network, Ambulance Services Network and the NHS Partners Network, which represents independent (commercial and not-for-profit) healthcare providers of NHS care.

  We also have dedicated teams and steering groups working on behalf of our acute trusts and independent sector providers.

  The NHS Confederation welcomes the opportunity to give evidence to the Health Select Committee on patient safety. This evidence sets out our views, based on feedback from our members and our ongoing work programme.

  The NHS Confederation accords high priority to patient safety and is actively involved in a range of initiatives to promote improvements in patient safety across the NHS. The Confederation is a signatory to the Patient Safety Charter and participates in the National Patient Safety Forum and the Strategy Advisory Group for the National Patient Safety Campaign. We hold regular stakeholder meetings with key agencies, and are exploring with the Healthcare Commission opportunities to support our members to learn from investigations.

  Earlier this year the NHS Confederation produced a briefing with the NPSA to promote learning from high reporting trusts and to support development of the national reporting and learning system. Quality and safety featured in our 2008 annual conference programme and will be featured in the NHS Employers conference in November this year.


    —  More than a million people are treated safely and successfully in the NHS every day.

    —  Error cannot be eliminated and therefore the emphasis should be on minimising the incidence and impact of harm.

    —  A systemic approach to preventing, analysing and learning from errors is essential to embed changes for patient safety.

    —  Identifying risks, learning and feedback need to be underpinned by a "fair" blame culture

    —  Leadership from the top is essential for promoting safety cultures.

    —  There is more to be done to encourage reporting from GPs.

    —  The wider system, including regulators, has a role to promote high reporting of patient safety incidents as good news.

    —  The Care Quality Commission must take ownership of the quality and safety agenda, and lead a co-ordinated approach to ensuring patient safety.

    —  The role of commissioners in improving safety needs to be clarified.

    —  There is more to done to engage patients in improving safety.


  1.1  Every day more than a million people are treated safely and successfully in the NHS. But in complex healthcare systems the evidence tells us that errors will and do occur, despite the commitment and professionalism of staff. And when things go wrong, patients are at risk of harm (NPSA, 2004). Harm can occur when there is a failure to avoid, prevent and ameliorate adverse outcomes or injuries stemming from the process of health care.

  1.2  When a patient is harmed the effects can be devastating for patients and their families. Patient safety incidents can also be distressing for the staff involved and members of their clinical teams can become demoralised.

Risks to patients

  1.3  Data from the NPSA for England for the period April 2007 to March 2008 indicates the most commonly reported type of incident is patient accidents, accounting for more than a third of all incidents (34 per cent). Other common types of reported incident include:

    —  treatment/procedure incidents (10 per cent)

    —  medication incidents (9 per cent)

    —  access/ admission/transfer/discharge (including missing patient) incidents (7 per cent)

    —  infrastructure (including staffing, facilities and environment) (7 per cent).

  1.4  However, a significant proportion of these incidents (65 per cent) were reported as resulting in no harm to patients. So alongside prevalence, it is important to consider the degree of harm caused by different types of incidents. Some incidents may occur less frequently, but are associated with severe harm so it is appropriate to prioritise work in these areas.

  1.5  It is impossible to eradicate all risk and it is therefore important that when incidents do occur, efforts are made to minimise the impact. The major focus should therefore remain on avoiding incidents occurring in the first place through effective risk management and learning from system failures.

Systems failures

  1.6  Safety first (Department of Health, 2006) indicated that one in ten patients admitted to hospitals in developed countries will be unintentionally the victim of an error and that around half of these events could have been avoided if lessons from previous incidents had been learned. In essence the same errors and system failures are often repeated.

  1.7  This is emphasised in Healthcare Commission reports on investigations and research on learning from inquiries where common themes recur of organisations having long standing problems which are well-known but not tackled and a lack of management systems (for quality review, reporting and performance management). Issues are also raised about openness to discussing errors for fear or blame and the "club culture" of clinicians (Healthcare Commission, 2008).

  1.8  An Organisation With a Memory (Department of Health, 2000) identified organisational culture as a key barrier to reducing the number of patient safety incidents and promoted the value of a system approach to preventing, analysing and learning from errors. A cornerstone of the systemic approach is root cause analysis (RCA) of incidents. The NHS Confederation supports this methodology which involves studying the underlying causes of error and near misses and sees it as imperative for promoting, learning and embedding change.

  1.9  Identifying risks, learning and feedback needs to be underpinned by a "fair" blame culture. This requires a non-punitive environment where staff can report incidents but individuals are held to account if appropriate. Blame cultures may obscure finding the real causes of failures and problems with underlying systems by focusing on individual actions.

  1.10  Although many organisations are now adopting the reassurance of fair blame reporting systems, the wider national system also needs to support trusts in developing open and fair cultures where reporting is valued. Regulators and others can contribute by educating the media about the importance of reporting in improving patient safety and emphasising that high reporting levels can be indicative of a positive safety culture.

The role of public perceptions in determining risk in determining NHS Policy

  1.11  Patients and the public can offer an important perspective on patient safety issues, and it is therefore important that they are involved. Data through reporting systems can never tell an organisation everything it needs to know about risks to patient safety and bringing together incident data with other sources, including investigations, patients' experience and complaints can help to identify key risks for local action.

  1.12  Issues that may be of particular concern to patients and the public are not always consistent with actual risk of harm. So while we know that healthcare associated infections are a concern to patients, data suggests that patient accidents such as slips, trips and falls are a greater risk to patients receiving healthcare. We need to make patients aware of the different levels of risks to patient safety and help them to understand their role to reduce risks.

  1.13  It is important that communication with the public is transparent, genuine and open and it is right that patients have access to information on patient safety, but this information does need to be presented in a way that is meaningful. A central premise to High Quality Care for All (Department of Health 2008) is to improve data quality and provide better information for patients. Again, there is also a role for a responsible media who can help patients understand and interpret data appropriately.

  1.14  Local organisations should determine how best to involve patients and the public in their efforts to improve patient safety. National organisations have a role to play to ensure national learning and to shape policy through trends in data.


  2.1  Although there have been some major failures reported by the Healthcare Commission, there has been significant progress to address patient safety in recent years.

|.In acute care

  2.2  Acute trusts are increasingly reporting incidents and increasing the propensity for local and national learning. An overwhelming majority of reported safety incidents take place in acute/general hospitals (73%) according to NPSA data (2008). Earlier this year the NHS Confederation worked with the NPSA to learn from consistently high reporting acute trusts. Strong messages emerged about what good reporting looks like and how it can be achieved by all organisations through five key changes:

    —  giving feedback to staff,

    —  focusing on learning,

    —  engaging frontline staff,

    —  making it easy to report

    —  making reporting matter.


  York Hospitals NHS Foundation Trust demonstrated improved reporting by getting the right team in place, and a balance between a central team and staff on the wards. Creative use of two vacancies in the central team enabled the hospital to use ten staff from clinical directorates for one day a week. This meant that ten full-time people took their awareness back to the frontline to do their jobs. (Please see appendix one for the full briefing and further case studies)

|.In primary care

  2.3  There is a perception that the prevalence of risk in general practice is not as high compared with hospital care. It is believed GPs largely deal with less acute illnesses and undertake fewer complex procedures. However general practice has a key role in the prevention and early identification of disease and illness as well as supporting many patients with complex long term conditions. Complaints received about GPs tell us that late referral or delay in diagnosis is a key issue (Healthcare Commission, 2004-2006, 2006-2007) and many patients feel that they should have been referred sooner for specialist treatment or further investigation of their symptoms.There is however a lack of good understanding of the nature and extent of patient safety incidents in primary care.

  2.4  Although primary care trusts encourage reporting as much as possible from general practice, it remains low. This could be attributed to the perceived lack of risk or complexity of care compared with the acute sector, but clearly patient safety incidents occur in primary care and can cause significant, long term harm. Other explanations suggest patients may be reluctant to bring errors to light and complain for fear of damaging their relationship with their GP or even fear of being removed from their GP's list. Additionally, despite PCTs and the NPSA wanting GPs to report all problems in an open way, GPs may have concerns about their contract being renewed by the PCT if there are too many complaints or safety audit event returns.

  2.5  A key factor in the low reporting response to the NPSA by GPs may be the voluntary nature of the scheme and because the initial drive to encourage reporting has focused on the acute sector. It has taken a long time to embed patient safety in acute care and general practice is no different, but the fact that significant event audit has been popular for some time shows willingness to report. (Significant event audit refers to the systemic analysis of a safety incident as a means to identify change that might lead to future improvements).

  2.6  In our report with the NPSA, we proposed that high reporting rates could be indicative of an organisation that is open and transparent and learns from errors and has a good patient safety culture. The wider system needs to support and encourage this across all sectors. PCTs have a continued role to encourage reporting and to look to local initiatives to engage GPs.

|.In mental health

  2.7  Mental health service users, especially the acutely ill, are vulnerable to a number of potential risks related to their own behaviour or that of other patients, as well as safety risks associated with the ward environment. These include self harm, aggression and violence.

  2.8  Over recent years many mental health trusts have made significant improvements to provide an appropriate environment in which people are cared for and to minimize risks to patient safety. Many hospitals have built completely new units or refurbished existing units to optimize the healing environment and to promote safety and dignity. Careful consideration has been made to eradicate ligature points to deter self harm, to provide single rooms and to develop protocols for observations of vulnerable patients.

  2.9  The NPSA's first report on mental health and patient safety (2006) recommended the need for greater awareness of sexual vulnerability and that the risks of inappropriate sexual behaviour, or vulnerability to sexual harassment should be considered in each patient's initial assessment. By definition people admitted to inpatient services may be emotionally vulnerable and this may influence the personal choices they make in relation to developing a friendship or sexual relationship. As such staff are responsible to ensure, as far as possible, that service users are protected from abuse, harassment, violation and to shield them from situations and activities they may regret and to prevent and stop such activities.


  Cornwall Partnership Trust has introduced a "vulnerable adult unit" which consists of a six- bedded unit. When a person is admitted to the ward, as part of the assessment process, a "vulnerability assessment" is undertaken to ascertain whether it is appropriate to provide care in the main ward or within the vulnerable adult area. The vulnerable adult area can only be accessed via a swipe card system by staff and people who have been assessed as requiring this high level of care. It has individual en-suite bedrooms, a small dining area/activity room, and a conservatory which looks out onto a small courtyard. The quiet, calm environment provides a low stimulus environment to aid the recovery process.

  2.10  While patient accidents still accounted for the largest proportion of patient safety incidents reported by mental health trusts (34%) to the NPSA between April 2007 and March 2008, the second most commonly reported incident was disruptive/aggressive behaviour (19%) followed by self harm (15%). Healthcare Commission reports (2003-2005) indicate that high levels of boredom are one of the main factors contributing to the levels of violence experienced on inpatient wards. Many trusts are now seeking to address this through the provision of more meaningful activities on wards by using the "Star Wards" initiative.

  2.11  Star Wards works with mental health trusts to enhance acute inpatients' daily experiences and treatment outcomes. The independent initiative advocates that services work towards providing a full programme of daily activities to encourage service users to build and retain community ties (Bright 2006). Longer term projects consist of links with community arts organisations to enhance ward staff skills to work creatively with service users and with the local authority for gym and lifestyle sessions.

The role of boards

  2.12  Increasing attention has fallen on promoting cultural changeto promote patient safety (Department of Health, 2000) and approaches to safety are now targeting improvements across whole organisations with leadership as a fundamental. NHS leaders are being encouraged to take ownership of patient safety in their organisation and to require that all their staff do the same. This means that while it is a board's priority to provide strategic direction, they must also ensure they have an operational focus in order to govern for safety. This is a complicated challenge, as boards are not expected to get into the detail but they do need to know that their decisions have been successfully operationalised. (Appointments Commission, 2003)

  2.13  Boards of trusts recently investigated by the Healthcare Commission were found to be consumed by the business of healthcare, mergers and reconfiguration, deficits and targets, which, in conjunction with other factors, compromised infection control and resulted in major outbreaks of C. difficile. However boards know that they must maintain a sharp focus on clinical quality and ensure they have relevant information to act on. The following case studies demonstrate how some NHS trusts are working to close the gaps between the board and the ward to ensure that a safety culture is embedded throughout their organisation.


  Guys and St Thomas's Foundation Trust made patient safety a core board objective. However, to ensure this a reality the organisation, invested £6 million into patient safety. The focus of the investment was in infection control, nurse leadership and cleaning. In addition to supporting the management of infection control, increasing numbers of matrons and backfilling ward sister posts a key aim was to reduce the gap between the most senior and the most junior members of the organisation. This was facilitated by the return of all senior nurses, in uniform, to clinical practice every Friday, matrons visible in their clinical areas 75% of the time and management teams undertaking weekly patient safety walkabouts.

  Every Friday, senior nurses work on the wards, which means they have a clear understanding of the clinical context and the experiences of both patients and staff. Where issues or problems arise solutions may be readily found and implemented or brought to the attention of the board.

  Equally the leadership walkabouts into clinical areas, involving the members of the executive team enable understanding of the patient's perspective and experience and makes for meaningful conversation at board level about safety issues. More widely these initiatives have led to increased awareness of safety cultures, the importance of reporting safety incidents and an increasingly open culture to raise safety concerns. Staff are seeing physical changes due to issues raised and this is providing confidence in the reporting system. Furthermore directors are empowered to take any safety concerns they might have to the board.


  Developing a safer culture from the top has enabled Calderdale and Huddersfield NHS Foundation Trust to change behaviours within the organisation.

  For example historical hierarchies in healthcare can make it very difficult for staff to challenge consultants, which in surgery could lead to wrong site surgery. Calderdale and Huddersfield Foundation NHS Trust has been working to empower staff and to build teams to make patients safer in surgery by developing a culture of "challenge." A brief now takes place before surgery where the team debate and work together so all levels can contribute. Attention is raised to high risk patients for example those on warfarin or who have been identified as having MRSA or HIV. There is also a "pit stop" during the list to allow for additional checks.

Targets, objectives and regulation

  2.14  There is a lack of clear ownership of quality in the system. The number of organisations involved in this agenda can obscure the focus. There needs to be better working between the NPSA, Healthcare Commission/Care Quality Commission, Monitor and the NHS Litigation Authority. The onus must be on the Care Quality Commission to take a lead on this issue and ensure concerted and co-ordinated action by all parties.

  2.15  There would also be benefit in clarifying what the role of the commissioner should be in improving patient safety. The Primary Care Trust Network is working with the NPSA, Healthcare Commission and some pilot PCTS to see how this could work in practice.

  2.16  Patient safety needs to be an integral part of the focus on quality. It needs to link with key drivers in High Quality Care for All (Department of Health, 2008) including the CQUIN (Commissioning for quality, innovation and outcomes) initiative, the establishment of NHS Evidence, a single portal for clinical and non clinical evidence and best practice and be an ongoing agenda item for the National Quality Board.


  3.1  The NHS has made good progress to improve safety but more needs to be done. There continue to be innate barriers and hurdles in the system that need to be overcome to ensure that it receives the same priority as finance and that it is on everyone's agenda. When competing for resources with other national priorities safety can lose out.

  3.2  There needs to be a constant awareness and surveillance of safety issues, with protocols implemented, audited, revised and updated. The NPSA have developed work on root cause analysis and seven steps to implement change and organisations can helpfully use these and other tools. Lessons need not only to be learned but change embedded. Analysis of events should also occur across a pathway of care for full understanding.

  3.3  Organisations can also work with patients to educate them about what they can do, including informing them of questions to ask for example around medication, the steps they can take to prevent slips, trips and falls and the importance of hand washing in relation to healthcare associated infections. This requires real engagement and support for patient empowerment.


    APPOINTMENTS COMMISSION (2003) Governing the NHS: A Guide For NHS Boards. London: NHS Appointments Commission.,_A_Guide_for_NHS_Boards.pdf

    DEPARTMENT OF HEALTH (2008) High Quality Of Care For All: NHS Next Stage Review final report London, The Stationery Office

    DEPARTMENT OF HEALTH (2006) Safety First: A Report for Patients, Clinicians and Healthcare Managers. London.

    DEPARTMENT OF HEALTH (2000) An Organisation with a Memory. London, The Stationery Office

    HEALTHCARE COMMISSION (2008) Learning from Investigations London, Healthcare Commission.

    HEALTHCARE COMMISSION (2006-2007) Spotlight on complaints London, Healthcare Commission.

    HEALTHCARE COMMISSION (2004-2006) Spotlight on complaints. London, Healthcare Commission.

    HEALTHCARE COMMISSION (2003-2005) The National Audit of Violence Final report

    NATIONAL PATIENT SAFETY AGENCY (2008) Patient Safety Incident Reports in the NHS: National Learning and Reporting System Data Summary. Issue 9: August 2008 -England.

    NATIONAL PATIENT SAFETY AGENCY (2004) Seven Steps to Patient Safety An Overview Guide for NHS Staff

    BRIGHT (2006) Star Wards London

September 2008

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2008
Prepared 30 October 2008