Select Committee on Health Written Evidence

Memorandum by Stuart Emslie and John Step (PS 71)



  1.  This submission addresses two areas listed in the Committee's press notice dated 17 July 2008: the cost effectiveness of past spending and the National Patient Safety Agency (NPSA).

  2.  At the time the NPSA opted to develop its National Reporting and Learning System (NRLS), there were existing systems that, on the face of it, might have been adapted and implemented less expensively, and more quickly, to enable the NHS to learn from experience and improve patient safety.

  3.  The NPSA delivered the National Reporting and Learning System substantially later than originally planned, at a cost to patients. There are also indications that they may have missed out an important and well understood element of system development. We provide an example of a similar system that was delivered in less time and at less cost.


  4.  The Department of Health identified the Australian Patient Safety Foundation "AIMS" system as a practical answer to the need originally identified in An Organisation with a Memory and elaborated in Building a Safer NHS for Patients. This system had already demonstrably delivered an effective working national learning system in Australia and was the subject of a Department of Health procurement exercise. After responsibility for implementing An Organisation with a Memory passed from the Department of Health to the NPSA, that Agency decided not to use AIMS.

  5.  There was another relatively inexpensive option available at the time. Safecode, a quality, safety and risk management system, included an advanced incident recording and information system (IRIS) developed to meet the needs of the NHS. At the time of the NPSA's procurement exercise, Safecode was, according to the National Audit Office[374], the most commonly used such system in the NHS (in the mid-nineties, it had been provided by the health departments and the NHS to all UK NHS hospitals free of charge). Further, it was a Crown product, having been conceived and funded by the four UK health departments and the NHS at a cost of under £1 million. According to Mr John Denham MP, then Minister of State for Health, the system could have been taken back in-house at a cost of £1 (one pound) and further developed by the NHS[375].

  6.  The NPSA, however, decided to pursue their own solution, the National Reporting and Learning System. While there is no doubt that they had good reasons for doing so, this course of action involved substantial development costs and delays in implementation with implications for taxpayers and for patients.

  7.  The Committee may wish to consider whether the NPSA's opting to develop their own system, rather than adapt one of the existing tried and tested systems, represented good value for money..


  8.   Building a Safer NHS for Patients, which the Department of Health published in 2001, set out, inter alia, the implementation deadline for a national reporting system. It expected 60 per cent of trusts to be in a position to provide information for learning to the national reporting system by the end of that year, and the remaining 40 per cent by the end of 2002. The NPSA's National Reporting and Learning System was not operational in terms of collecting information from all trusts until early 2005 (NPSA NRLS quarterly data summary Issue 9 August 2008, Figure 1) and it has taken until early 2008 for the system to reach what some might consider an "acceptable" incident reporting rate. This is a substantial over-run when measured against the original timetable. This observation is not an arcane point about project management. The principal purpose of the NPSA was to save lives and prevent injuries to patients through learning from experience. Any delay in implementation thus denies patients the benefit of that learning and, by extension, means that patients may have died or suffered harm as a result of incidents that could have been averted with the knowledge coming from an effective national reporting and learning system.

  9.  With reference to the latest NPSA NRLS quarterly data summary (Issue 9, August 2008), the information coming from the NRLS does not contain root cause data, which are critical to learning and improving patient safety. In introducing the NPSA at a conference in London on 10 October 2001, Lord Hunt, Parliamentary Under Secretary of State for Health (Lords), stressed that root cause analysis was "the key to learning" from patient safety incidents and the NPSA would be collecting this information, together with information from other sources, to provide "relevant and timely feedback to organisations and clinicians to help them improve patient safety." Given the sums of money that have been spent on the NPSA over the past seven years, there appears to be surprisingly little evidence of any significant learning coming from the NRLS. Indeed, based on a presentation made by the CEO of the NPSA at the Patient Safety Congress on 23 May 2008 in London, our understanding is that the NPSA appears to have yet to determine exactly how it will analyse the incident data collected since 2004.

  10.  The Patient Safety Authority in the Commonwealth of Pennsylvania, USA, has implemented a web-based patient safety reporting system covering around 550 healthcare facilities, including 260 hospitals. The system was designed and is run by ECRI Institute[376], a major independent non-profit patient safety organisation. The Pennsylvania patient safety reporting system was fully up and running within a year and its development cost was significantly less than the NPSA's NRLS. The system has been feeding back important information to hospitals and clinicians almost since becoming operational in 2004. Further information on this system is appended.

  11.  In designing the NRLS, the Chief Medical Officer made clear in An Organisation with a Memory that "The reporting format and precise information to be collected [from NHS Trusts, etc.] should be determined only after thorough consideration of the analytical purposes to which it is to be put." This is a fundamentally crucial step in the development of any system for learning from incidents. If a minimum data set is defined without first considering the exact purpose to which the data will be put, then it is unlikely that any system utilising the data set will be able to produce much useful substance. If the NPSA's NRLS is not producing learning information based on root cause analysis, this, together with the Agency's apparent challenges with analysing the information that it has, suggests that the NPSA may have overlooked that crucial aspect of reporting system design.

  12.  The Committee may wish to consider why the delay in implementing the NRLS, compared with the original timetable, was so great when its development was the single most important task facing the NPSA; whether the system is now generating information that is useful to those who are providing NHS healthcare to patients; and whether the NPSA did, in fact, build the information reporting requirements from the NHS to the NRLS based on a thorough consideration of analytical requirements of the national system.


  13.  Following the Public Accounts Committee findings in relation to the NPSA in 2006, Stuart Emslie has written a number of articles on improving patient safety in the NHS and, in particular, the role of the NPSA. The following articles are pertinent to this submission:

    Emslie, S V (2006). 2001-2006: a patient safety odyssey where the vision remains unfulfilled. Health Care Risk Report. September 2006.

    Emslie, S V (2007). Towards an international classification for learning from patient safety events. Health Care Risk Report. April 2007.

    Emslie, S V (2007). Size doesn't matter: extracting the learning from the data. Health Care Risk Report. May 2008.

September 2008

374   A Safer Place to Work: Protecting NHS Hospital and Ambulance Staff from Violence and Aggression (HC 527, March 2003. Back

375   Speaking in an adjournment debate in the House of Commons on 23 November 2000. See Hansard. Back

376   Stuart Emslie provides occasional consulting services to ECRI Institute's European Office. Back

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