NHS staff should be supported to learn from mistakes, and patients and carers must be put above all to make the NHS a world leader in patient safety, says a former adviser to US President Barack Obama.
In a new report, international patient safety expert Professor Don Berwick emphasises that the quality of NHS patient care - and especially safety - should be paramount. He calls for patients and carers to be empowered, engaged and heard, Service staff supported to develop themselves and improve what they do, and for complete transparency of data to improve care.
Dr Berwick’s review, conducted at the request of Prime Minister David Cameron following the Francis Report into the breakdown of care at Mid-Staffordshire Hospitals, also recommends that:
- the NHS must adopt a culture of learning. This cannot come from regulation but from "countless, consistent and repeated" messages to staff so that goals and incentives are clear and in patients' best interests;
- staffing levels must be adequate, based on evidence. He echoes NHS England medical director Sir Bruce Keogh's recent findings that staffing levels cannot be dictated from the centre - boards and local leaders should take responsibility for ensuring that clinical areas are adequately staffed;
- complaints systems need to be continuously reviewed and improved;
- transparency must be complete, timely and unequivocal;
- there is no single measure for safety. The NHS should continue using mortality rate indicators to detect potentially severe problems, but these remain a "smoke alarm" and should not be used to generate league tables;
- supervisory and regulatory systems should be clear. An in-depth, independent review of the structures and the regulatory system should be completed by end-2017, once recent changes have been operational for three years; and
- new criminal offences should be created around recklessness, wilful neglect or mistreatment by organisations or individuals and for healthcare organisations which withhold or obstruct relevant information. But the use of criminal sanctions should be extremely rare and unintended errors must not be criminalised.
He also finds that the duty of candour is already adequately addressed in professional codes of conduct and guidance.
Above all, cultural change is the most important factor in continuously reducing harm, he says, and particularly distinguishes clearly between mistakes and negligence and for the need for a transparent culture where mistakes are reported and learnt from.