Memorandum by the NHS Confederation (PS
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
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
medication incidents (9 per cent)
(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.
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
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
2. CURRENT EFFECTIVENESS
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,
engaging frontline staff,
making it easy to report
making reporting matter.
NHS FOUNDATION TRUST:
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
|.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
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.
HUDDERSFIELD NHS FOUNDATION
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. WHAT SHOULD
THE NHS DO
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.
DEPARTMENT OF HEALTH (2008) High Quality Of Care
For All: NHS Next Stage Review final report London, The Stationery
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