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Report: ‘Improve NHS safety’

Published on 07/08/13 at 09:50am
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Patient safety is the key to future NHS success, according to a new review commissioned after the final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.

Professor Don Berwick’s new report - the latest of several major investigations into patient care this year already - recommends putting patient safety above all else and says the NHS must “engage, empower, and hear patients and carers at all times”.

Staff must also be nurtured and developed ‘wholeheartedly’, with transparency to the fore everywhere “in the service of accountability, trust, and the growth of knowledge”.

Quantitative targets - such as waiting times, for example - should be used ‘with caution’ and “should never displace the primary goal of better care”.

Perhaps conscious of the fact that Mid Staffs and other scandals have seen staff heavily - and, some believe, unfairly - criticised, it puts much of the blame for failures in care at the door of systems which operate in hospitals rather than doctors and nurses.

“NHS staff are not to blame,” Berwick insists. “In the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.”

To counter this, the report says supervisory and regulatory systems should be “simple and clear, avoiding diffusion of responsibility and being respectful of the goodwill and sound intention of the vast majority of staff”.

The NHS must ‘abandon blame as a tool’, he says.

Berwick also believes that criminal sanctions “should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment”.

This appears to be at odds with the comments of health minister Norman Lamb, who last month said that directors responsible for failures in care such as those at Mid Staffs should face prosecution.

The Department of Health has already pledged a ‘renewed focus on putting patients at the centre of everything we do’ following the Mid Staffs Francis report’s 290 recommendations on issues such as improving basic standards, creating more transparency, increasing compassion in care and strengthening leadership.

And last month health secretary Jeremy Hunt announced that 11 hospitals in England were to be put into ‘special measures’ following NHS medical director Professor Sir Bruce Keogh’s report on hospitality mortality rates.

Berwick, a health safety expert, was asked by prime minister David Cameron to conduct the review, and looked at what happened at Mid Staffs, taking into account Francis’ findings.

Berwick’s ten recommendations are:

1. The NHS should reduce patient harm by embracing learning

2. All leaders concerned with NHS healthcare should put patient safety at the top of their priorities for investment, inquiry, improvement, regular reporting and support

3. Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future

5. Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health professionals, including managers and executives

6. The NHS should become a learning organisation, with its leaders creating and supporting the capability for doing this

7. Transparency is crucial: all data on quality and safety should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public

8. All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care

9. Supervisory and regulatory systems should be simple and clear, avoiding diffusion of responsibility and being respectful of the goodwill and sound intention of the vast majority of staff

10. There should be responsive regulation of organisations, with a hierarchy of responses - but recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment.

Adam Hill

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