Health Secretary Jeremy Hunt has unveiled a range of new measures to boost safety and transparency in the NHS, including an independent Healthcare Safety Investigation Branch and legal protection for anyone giving information following a hospital mistake.
Announcing the plans at the first ministerial-level Global Patient Safety Summit this week, Hunt stressed that those co-operating with investigations will be supported and protected to speak up to help bring new openness to the NHS’s response to tragic mistakes.
From April 2018, expert medical examiners will independently review and confirm the cause of all deaths, as originally recommend by the Shipman Inquiry and subsequently by Robert Francis following the safety scandal at Mid Staffs, in the first real shake-up of the system for more than 50 years.
“To deliver a safer NHS for patients, seven days a week, we need to unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people,” said Hunt. “Every week there are potentially 150 avoidable deaths in our hospitals and it is up to us all to make the need for whistleblowing and secrecy a thing of the past as we reform the NHS and its values and move from blaming to learning”.
Also under the new plans, NHS Improvement will publish the first annual ‘Learning from mistakes league’ under which NHS provider organisations will be ranked on their level of openness and transparency for the first time. According to this year’s league This year’s league shows that 120 organisations were rated as outstanding or good, 78 had significant concerns and 32 had a poor reporting culture.
Elsewhere, guidance for the General Medical Council and Nursing and Midwifery Council will be updated so that a professional tribunal will give healthcare professionals credit for honesty about mistakes, just as it will hand out sanctions for covering up any errors.
NHS England will work with the Royal College of Physicians to develop a standardised method for reviewing the records of patients who have died in hospital, and England will become the first country in the world to publish estimates by every hospital trust of their own – non-comparable – avoidable mortality rates, the Department of Health noted.
Avoidable harm too high
The announcement came as two reports published by researchers at Imperial College London show that avoidable harm to patients in the UK is still too high, and urge healthcare providers to foster a more open and transparent culture to boost the safety of care.
The first, which investigated the current system used by NHS staff to report patient safety incidents, the National Reporting and Learning System (NRLS), highlights issues around under-reporting of safety incidents and concerns within the system’s structure, which it argued have restricted its efficacy in driving safety improvement.
“The UK has one of the biggest incident reporting systems in the world. But despite this, evidence suggests that as little as 5 per cent of patient safety incidents are reported,” said Erik Mayer, lead author of the report, from the Department of Surgery and Cancer at Imperial. “This is often related to the culture of institutions and the culture of medicine. For instance, staff may witness an incident that should be reported, but are hesitant to do so for fear of repercussions.”
The second report, Patient Safety 2030, advocates use of a ‘toolbox’ to improve patient safety, which should include greater use of digital technology providing, ramping up training and education, and strengthening leadership at all levels. But the authors also stress that interventions must be engineered with the whole system in mind.
“Although we currently face many changes – such as increasingly complex patient cases and limited resources – we must focus on creating safer environments for patients,” said Ara Darzi, director of the NIHR Imperial PSTRC and senior author of the reports. “This should involve a systems-based approach, and coordinating action across all levels of the political and health systems. We also must ensure patients and staff are integral to any solution, and not just seen as victims or culprits.”
