The House of Commons Health Committee has published it final report on patient safety, extending to 120 pages.
Not surprisingly, they criticise the the NPSA’s National Reporting and Learning System as being “limited in its effectiveness” and note that the system does not collect root cause information – a key feature of the design of the System as set down in 2001 in the Department of Health’s Building a safer NHS for patientspublication. The NPSA was established in June 2001, which means that 8 years later the NPSA still has not delivered an effective national reporting and learning system.
NPSA Chief Executive, Martin Fletcher, is quoted in the Health Committee report as saying that “an undertaking of this scale was a lot more complex than anybody had perhaps at first realised. You have to remember that when this system was set up five years ago it was the first of its type in the world.” Healthcare Governance Reviewfundamentally disagrees. We had the skills, we had the people and we had the technology. Much of what needed to be done had been demonstrably done prior to establishing the NPSA Sadly, the wrong people were put in charge and the rest is history. It is, perhaps, a sobering thought to consider that in the 8 years that the NPSA has failed to get its act together on national reporting and learning, many, many patients will have suffered needless harm or death.
The report appears to be critical of clinical governance. It states at para. 289 that “Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services. The concept of clinical governance may be to blame for spawning a structural approach, focused on processes rather than on the actual state of frontline services.” The fact that the report seems also to be criticising boards for addressing governance issues (i.e. the board performing its proper role!) might indicate that the Health Committee fundamentally failed to understand the concept of governance!
RECOMMENDATIONS FOR NHS MANAGERS AND BOARDS
Readers might be particularly interested in the recommendation made in the report for managers and boards. They are:
– “There is disturbing evidence of catastrophic failure on the part of some Boards in cases such as Maidstone and Tunbridge Wells Trust and Mid-Staffordshire Trust. While other Boards are not failing as comprehensively, there is substantial room for improvement.
– Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services. The concept of clinical governance may be to blame for spawning a structural approach, focused on processes rather than on the actual state of frontline services.
– Many managers and non-executive members of Boards with responsibility for patient safety seem to have little or no grounding in the subject. There is a case for providing specialist training in patient safety issues, particularly to non-executives, to help them scrutinise and hold to account their executive colleagues. We agree with [the] suggestion about giving one non-executive member of each Board specialist training, to allow them to take particular responsibility for it. The example of Luton and Dunstable Hospital in having committees of the Board of Directors to Patient Safety look specifically at patient safety and patient experience should be recommended to all Trust boards.
– Patient safety must be the top priority of Boards. In order to fulfil their duty to ensure “that the quality and safety of patient care is not pushed from the agenda by immediate operational issues”, patient safety should without exception be the first item on every agenda of every Board.
– We commend to NHS organisations the measures piloted as part of the Safer Patients Initiative to ensure that Boards maintain safety as their foremost priority, namely
• implementing tried and tested changes in clinical practice to ensure safe care;
• banishing the blame culture;
• Providing the leadership to harness the enthusiasm of staff to improve safety;
• changing the way they identify risks and measure performance, by using information about actual harm done to patients, such as data from sample case note reviews.
We strongly urge the adoption of these throughout the NHS.
– In addressing the blame culture, we recommend that Trusts use means such as the Texas Safety Climate Survey to measure and monitor how far staff feel confident about being open and reporting incidents.
– We strongly endorse the DH’s view that no Board in the NHS should always be meeting behind closed doors. We urge the Government to legislate as necessary to ensure Foundation Trust Boards meet regularly in public; the public should only exceptionally be excluded.
– Many healthcare workers remain fearful that if they are open about harm to patients they will be unfairly blamed for causing it; and that if they whistleblow they will be victimised. Where information is available about incidents, it is too often not used to make lasting improvements to services. We have insufficient evidence to comment on the adequacy of statutory protection for whistleblowers. However, the information we have received indicates that the NHS remains largely unsupportive of whistleblowing. We recommend that the DH bring forward proposals on how to improve this situation and that it give consideration to the model operated in New Zealand, where whistleblowers can complain to an independent statutory body. We recommend that Annex 1 of the Health Service Circular, HSC 1999/198, “The Public Interest Disclosure Act 1998—Whistleblowing in the NHS” be re-circulated to all Trusts for dissemination to all their staff as a matter of urgency.
– Regarding Mid-Staffordshire Trust, we are unconvinced of the case for a full public inquiry into the Trust, given the work that has already been done by the Healthcare Commission, Professor Sir George Alberti and Dr David Colin-Thomé, and the likely further Patient Safety disruption to the Trust. However, we do see merit in the idea, recommended to us by the Royal College of Nursing, of holding hearings in private to allow members of staff to give evidence confidentially to discover how the state of affairs progressed so far without detection by the Trust Board. As this would look at the past and involve those in post in previous years, it would not impede the process of improvement and the rebuilding of confidence in the hospital. Although held in private its findings should be made public with protection of individual witnesses as appropriate.”
The full report Patient Safety Sixth Report of Session 2008-09, Volume I- Report, together with formal minutes can be downloaded here.