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News Article
UK nursing regulator’s new chief resigns after four days following racism row
Patient Safety Learning posted a news article in News
The UK nursing regulator’s new interim chief executive has stepped down just four days into the job after facing widespread staff backlash over her links to a high-profile race discrimination case. Multiple staff working at the Nursing and Midwifery Council (NMC) raised concerns to its directors over the appointment of interim CEO Dawn Broderick, who was head of HR at another trust when it was found to have discriminated against a Black employee. The Independent can now reveal Ms Broderick resigned from the NMC on Monday evening. It is the latest in a succession of controversies to hit the nursing regulator, following reports uncovered by The Independent last year. These include allegations from whistleblowers that racism within the NMC was allowing complaints against nurses to go unchecked. Staff have come forward to The Independent, warning they do not have confidence the NMC’s board will take the issue of racism seriously. Read full story Source: The Independent, 2 July 2024 -
Content Article
The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. In 2023 the standards were revised (NatSSIPs 2) with the Centre for Perioperative Care (CPOC), with a focus on bolstering of the organisational standards (people, processes and performance) in addition to the sequential steps that teams follow. The standards are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. Patient Safety Learning spoke to Annie Hunningher and Claire Morgan about the changes to the revised NatSSIPs 2, how NatSSIPs 2 is being implemented and what more needs to be done to promote and engage leadership for action. -
News Article
Trust ‘exited’ 170 staff in three years due to poor behaviour
Patient Safety Learning posted a news article in News
An ambulance chief has said his trust “exited” more than 170 staff due to culture and behavioural problems in the last three years. East of England Ambulance Trust chief executive officer Tom Abell gave the figure while speaking publicly about his team’s efforts to get a grip on the organisation’s long-standing cultural problems. Mr Abell, who is leaving the trust next month to lead Mid and South Essex Integrated Care Board, told a session at the NHS Confed Expo conference that the trust’s leadership knew suspending a large number of staff would create challenges in providing services. But he said it was the only way to ensure the right cultural standards were met and he did not want to “bottle” the decision to tackle this issue. Mr Abell, who became CEO in 2021, said: “The decision we had to make was do we suspend [the staff] and recognise the fact that’s potentially going to have a significant impact in terms of our ability to deliver services, or do we bottle it? “And [so] we suspended and dismissed [the staff in question]. Staff told me after that, ‘we never thought the organisation would ever do that’. “We’ve tried to be consistent. We’ve exited, probably over 170 people from the trust, since I started, for issues around culture and behaviour. It’s not just about being fluffy and engaging, it’s around actually taking practical symbolic action.” Read full story (paywalled) Source: HSJ, 17 June 2024 -
News Article
‘Burdensome’ patient safety inquiries taking up too much time, says NHSE chief
Patient Safety Learning posted a news article in News
NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content ArticleCancer Research UK has published a manifesto that sets out the measures and commitments the next government can make to help prevent 20,000 cancer deaths every year by 2040.
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Content ArticleThis publication describes East London NHS Foundation Trust’s 10 years of experience with learning how to apply quality improvement throughout the organisation and embed a culture of improvement, in partnership with the Institute for Healthcare Improvement (IHI).
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Content ArticleThis guide is for trusts who have an electronic patient record system (EPR) already in place and want to realise the transformational opportunities it presents. It focuses on the role of the board in leading these changes. In December 2022, NHS England estimated that over 85% of trusts in England had some form of EPR and set a target for EPRs to be implemented in at least 90% of trusts by December 2023. A well implemented and optimised EPR improves patient safety, staff satisfaction, patient flow and data quality. But this can only be achieved with continuous optimisation and investment. A poor EPR implementation, followed by a lack of investment in its ongoing development, can frustrate staff and create disillusionment. This in turn leads to poor usage and unsafe workarounds. In time this will negatively impact productivity and result in substandard data informing clinical decision making. If you are part of an integrated care system (ICS) looking to share or align EPRs across a number of organisations, this guide will also help you consider issues of convergence, scale and shared governance. It does not address procurement and implementation.
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EventThere is currently remarkable consensus across think tanks, institutions, and political parties that a move towards a preventive state is key to creating a healthier nation. A preventive approach can help people live healthily for longer while also addressing many of the problems within the health and care system, allowing for proactive population health management and tackling of health inequalities. Creating a healthier nation needs a collaboration between people, places, the NHS, and businesses, as well as government. If the new government wants to improve the health of the nation, it should create an approach to health that spans all government departments, includes actions to reduce health inequalities, and implements measures that help people to make healthier choices. At this in-person event, the case is presented for how prevention can create a healthier nation, why it is particularly important now, and propose tangible actions for making this shift at the national, system and local levels. Join the King's Fund to understand why prevention is key to supporting healthier lives and how it can be made a reality. Join leaders and experts from across health and care, thinks tanks and politicians to explore: why moving towards a preventive state is particularly important now given the context of widening health inequalities and stalling of life expectancy how to make the shift to prevention a reality at national, system, and local levels the importance of measuring preventive expenditure the role of prevention when taking a population health approach the link between health and housing and how healthier communities can support a wider approach to prevention. how place-based approaches to prevention are key. Register
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News ArticleThe negotiation of a pandemic accord intended to prevent the global disaster seen during Covid-19 should be completed in the next year, WHO have announced. “The amendments to the international health regulations will bolster countries’ ability to detect and respond to future outbreaks and pandemics by strengthening their own national capacities and coordination between fellow states, on disease surveillance, information sharing, and response,” said WHO’s director general, Tedros Adhanom Ghebreyesus. “This is built on commitment to equity, an understanding that health threats do not recognise national borders, and that preparedness is a collective endeavour.” The revised international health regulations includes a commitment to strengthening access to medical products and financing, and stronger, more precise language that should accelerate the detection of health threats and the necessary global action to manage them. “Full implementation of the international health regulations brings the world closer to being safer from pandemic threats. A new pandemic agreement with equity at its heart would further strengthen the rules around and guide international collaboration,” said Helen Clark, former New Zealand prime minister and co-chair of the Independent Panel for Pandemic Preparedness and Response. Read full story Source: BMJ, 4 June 2024
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News ArticleThe NHS and government have failed to implement a single recommendation from a key Jimmy Savile inquiry – almost 10 years after plans to prevent future sex abuse of patients in hospitals were put forward, The Independent can reveal. The shocking discovery was uncovered by the panel tasked to chair the public inquiry into Lucy Letby, the nurse who killed several newborn babies in her care. Analysing the progress made by the NHS and government after some of the most high-profile health scandals in the UK, it found across 30 inquiries, dating back to 1967, just 302 out of more than 1,400 key recommendations had been adopted. Alan Collins, a lawyer who represented dozens of victims in claims against Savile’s estate, slammed politicians and public bodies over the failure. He says: “The thread that runs through the numerous reports, the investigations behind them, and the ongoing failures with lack of implementation is the lack of accountability. “We have seen time after time the lack of professional curiosity in the face of glaring wrongdoing yet this cultural vacuum rarely sees those charged with responsibility for safeguarding subject to any consequences.” Read full story Source: The Independent, 3 June 2024
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EventDelivering high-quality care and ensuring the best patient outcomes and safety levels should be the goal of all health care providers; however, these can only be achieved if staff are able and encouraged to work to the best of their abilities. Leaders play a crucial role in creating a culture that drives good staff and patient experience and, in turn, quality across the system. In this context, this session from the King's Fund will: help to provide understanding about the relationship between working culture and high-quality patient care explore how leaders can create a safe and supportive work culture that drives quality discuss how a culture of quality can improve staff wellbeing and resilience provide insight into how successful quality-improvement strategies place a strong focus on staff engagement and staff experience. Register
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Content ArticleIn this blog, pushed by BMJ Opinion, David Gilbert, patient director, Sussex MSK Partnership (Central) looks at patient leadership.
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Content ArticleThis handbook produced by the Healthcare Financial Management Association (HFMA) is designed to help NHS governing bodies and audit committees in reviewing and reassessing their system of governance, risk management and control. This is to make sure the governance remains effective and fit for purpose, whilst also ensuring that there is a robust system of assurance to evidence it.
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News Article
Patient safety commissioner warns calls for changes are 'falling on deaf ears'
Patient-Safety-Learning posted a news article in News
England's patient safety commissioner says her calls for changes following failings highlighted in three health scandals are "falling on deaf ears". Dr Henrietta Hughes made the comments at a meeting in Westminster on Tuesday of MPs and campaigners of medical scandals. It comes after Sir Brian Langstaff's highlighted a decades-long "subtle, pervasive, chilling" cover-up by successive governments and the NHS in the conclusion of his report on the infected blood scandal. Like the victims of that scandal, those affected by epilepsy drug Valproate, as well as vaginal mesh implants, and the hormone pregnancy test Primodos, are also waiting on the government to implement a redress scheme. The three campaign groups have already had a combined review. In July 2020, the Cumberlege review found similar failings to the blood scandal: damaging products, poor regulatory decisions, and one government after another refusing to accept wrong had been done. In February this year, the patient safety commissioner set out her "blueprint" of a redress scheme for victims. However, Ms Hughes, who attended the First Do No Harm All Parliamentary group meeting, said on Tuesday: "I'm itching to get the changes that are needed, but I feel my words are falling on deaf ears." Read full story Source: Sky News, 21 May 2024 -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Mark talks to us about his role as a National Patient Safety Partner (PSP). He explains the important role that PSPs play at national, regional and local levels of the healthcare system and identifies key opportunities and challenges they face in bringing the voice of patients and families at a strategic level. He also highlights the challenge of implementing the Patient Safety Incident Response Framework (PSIRF) across a diverse range of providers and the complexities arising where PSIRF interfaces with systems and processes outside of the NHS. -
Content ArticleThe use of restrictive interventions, such as mechanical restraints, has been a common practice in behavioural health settings since the field’s early infancy. The use of restraints has a harmful impact on both patients and providers alike, working against the therapeutic treatment environment aimed to support the healing journey. In this quality improvement project, the use of mechanical restraints was fully eliminated from a 252-bed inpatient setting in the US. This was achieved using a strategy of leadership, workplace development and data, and performance was sustained over the following year.
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Content ArticleThe Thirlwall Inquiry is examining events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. As part of this Inquiry, its Terms of Reference asks: “Whether recommendations to address culture and governance issues made by previous inquiries into the NHS have been implemented into wider NHS practice? To what effect?”. To help inform its work in this area, the Inquiry Legal Team has produced this Table of Inquiries and reviews which have been conducted in England and Wales over the last thirty years. Recommendations from each Inquiry have been set out in a comprehensive table, alongside details of whether or not those recommendations have been implemented.
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Content Article
This fellowship program from the Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Building on the World Health Organization (WHO) Global Patient Safety Action Plan, the fellowship aims to develop future leaders particularly from lower middle- and middle-income countries. We aim to have learners from all WHO regions as learners on the program and from any profession within or allied to healthcare. The program combines a year-long curriculum developed by patient safety experts in a variety of areas, taught via monthly live virtual classroom sessions. Fellows complete monthly readings on specific topics, actively participate in discussions on the interpretation of theory and methods, and its implication to practice. Fellows submit monthly reflections on their learning as well as a longer reflection at the end of the fellowship. Applied learning is achieved by completing a hands-on improvement project that explores and advances issues of patient safety in each fellow’s respective professional environment. Fellows are encouraged to publish the outcome of their project and present at conferences. Our fellows are driven by a deep passion for patient safety, often sparked by first-hand encounters with patient harm events, and a desire to improve care outcomes in their home communities and workplace settings. They become part of a global social movement for patient and healthcare worker safety. The program consists of 12 sessions that run from will run from January to December 2025. Fellowship applications are accepted from 1 May to 1 August 2024. -
News Article
Staff ‘belittled’ for contacting senior doctors, NHSE finds
Patient-Safety-Learning posted a news article in News
The safety of a teaching hospital’s out-of-hours supervision has been questioned, including reports trainees were told not to ask for help “unless your patient is dying”. The General Medical Council put University Hospital Southampton Foundation Trust’s general surgery training under enhanced monitoring at the end of 2023 following a referral and quality management visit by NHS England South East, Workforce Training and Education – Wessex. The NHSE team’s visit and subsequent report said doctors in training had claimed senior staff were “not contactable” out of hours and there was “difficulty” in securing senior clinical advice, particularly on Sundays. The report added foundation year doctors were “discouraged” from contacting senior staff out of hours by “inappropriate” and “belittling” comments and behaviours, such as being told not to ask for help “unless your patient is dying”. Foundation doctors also reported starting rotation on call and conducting ward rounds without appropriate supervision. While the GMC open case is centred on patient safety concerns relating to supervising trainee doctors, the workforce and training directorate report also raised concerns about bullying, inappropriate sexual comments made by consultants, and a feeling that foundation doctors were unable to speak up. Read full story (paywalled) Source: HSJ, 1 May 2024 -
Content ArticleIn this HSJ blog, Ken Jarrold highlights three key things he learned during his ten years as chair of NHS trusts: Focus on the people that matter—service users and frontline staff Keep an appropriate level of contact and relationship with the chief executive Live the values of the trust. He emphasises chairs keeping their focus on the people they serve and ensuring they feel at home interacting with staff and service users, as well as other leaders. He also states his hope that the Leadership Competency Framework for conducting annual appraisals of NHS chairs published by NHS England in February 2024, if applied appropriately, will result in improvements in how chairs serve their organisations.
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Content ArticleThis White Paper sets out the Labour Government's proposals to reform and expand community health and social care services in order to meet local needs, especially in poorer deprived communities. Four key objectives are highlighted in the White Paper: better health prevention services with earlier intervention; increased patient choice; tackling inequalities and improving access to community services; and increased support for people with long-term needs to live independently. Specific measures include: expansion of local care settings outside hospitals; increased joint commissioning between PCTs and local authorities to improve service integration; the introduction of practice based commissioning, where GPs are given more responsibility for local health budgets; increased provision for new primary care providers to compete for PCT contracts; and the introduction of a new NHS ‘Life Check’ to promote healthier lifestyles with a pilot scheme in spearhead PCTs by 2007-08.
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Content ArticleThis report from the BME Leadership Network comprises examples of anti-racist initiatives from BME Leadership Network members, to help advance equality within the workforce and for service users.
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News Article
Trusts and NHSE ‘neglecting whistleblower training’
Patient Safety Learning posted a news article in News
Trusts and NHS England are failing to prioritise training for senior leaders on listening to whistleblowers — despite repeated findings of serious concerns going unheard — the National Guardian’s Office has said. The Guardian’s Office — set up by the government to ensure whistleblowers and other staff raising concerns are properly listened to — made the claim in its written evidence to an inquiry into NHS leadership, performance, and patient safety. The Commons health and social care committee is considering regulation of NHS leaders and managers, among other issues, including progress made on the 2022 report for ministers by General Sir Gordon Messenger. The NGO’s evidence, published on Wednesday, said: “In our opinion, there has been little progress on recommendations from the Messenger Review to date… “The NGO has developed, in collaboration with [NHSE], three e-learning modules (Speak Up, Listen Up, Follow Up) which are freely available for anyone who works in healthcare. We have recommended to the sector that these modules should be a minimum standard for all staff and be made mandatory. “Although accessible to all, many organisations have not adopted them, and NHS England has not prioritised these across the system.” Read full story Source: HSJ, 18 April 2024 -
Content ArticleAs the NHS’s digital transformation journey enters a new phase, there are opportunities to improve the quality and productivity of the healthcare system. This phase is not just about advancing the maturity of electronic health records (EHRs) but also about embracing the vast potential of generative artificial intelligence tools. In this HSJ article, Robert Wachter and Harpreet Sood explore the reasons why EHRs have not yet delivered promised productivity improvements and look at how GenAI offers opportunities for the NHS to realise productivity benefits faster, cheaper and at a greater scale.
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News Article
UK swapped to fatal US blood products to save money, minutes suggest
Patient Safety Learning posted a news article in News
The British government was willing to risk infecting NHS patients to get “lower-priced” blood products, according to a document that campaigners claim proves state and corporate guilt in one of the country’s worst ever scandals. A public inquiry into the deaths of an estimated 2,900 people infected with conditions such as HIV and hepatitis will publish its final report in May, four decades after the NHS started prescribing blood and blood products – including from drug users, prisoners and sex workers – sourced from the USA. Within the thousands of documents disclosed to the inquiry, internal company minutes have emerged that campaigners say provide the final compelling piece of evidence of the commercial greed and state negligence that destroyed thousands of lives. In November 1976, Immuno AG, an Austrian company that was a major supplier to the Department of Health, was seeking a licence change to allow it to supply a blood product from those paid to donate in the US rather than donors without a financial incentive in Europe. According to the minutes of a meeting of medics in the company, it had been “proven” that there was a “significantly higher hepatitis risk” from a concentrate known as Kryobulin 2 made from US plasma compared with that from Austria and Germany. The company had concluded there was a “preference” in the UK for the cheaper US option. The memo of the meeting said: “Kryobulin 2 will be significantly cheaper than Kryobulin 1 because the British market will accept a higher risk of hepatitis for a lower-priced product. In the long-term, Kryobulin 1 will disappear from the British market.” Read full story Source: The Guardian, 14 April 2024
