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Event
HFMA members' summer series
Patient Safety Learning posted an event in Community Calendar
untilThis unique series of online events will provide Healthcare Financial Management Association (HFMA) members with a variety of engaging sessions over three days. The programme will be centred around several key themes: Career development – including resilience training, progression within the NHS, qualifications mapping and developing your personal brand. The bigger picture – technologies of the future, system working, diversity and inclusion. Thought leadership – case studies from across the four nations of the NHS, with real-life examples. At the halfway point of the year, the event will reflect on what’s gone on in the past six months and considering the learnings to take forward and how to make improvements. By the end of the three days, you’ll be well equipped to take on the second half of the year both on a personal, and professional level. Best of all, this event is free to HFMA members. All registered delegates will have access to all the session on demand for 3 month after the event. Speakers will include: Jo Howarth, CEO of The Happiness Club Max Siegel, LGBTQ+ content creator, activist, educator and speaker. Jennifer Holloway, personal brand specialist and author Helen Hughes, CEO Patient Safety Learning. Download programme Register -
Content ArticleThis report set out an infectious disease strategy for England, including new arrangements to counter old and new threats, such as radiological and chemical hazards through bioterrorism, by describing the scope of the threat posed as well as establishing the priorities for action to combat this threat. It aimed to overhaul previously fragmented systems and to place a new emphasis on communicable diseases through direct action plans, programmes to inform understanding and legislative reform.
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Content Article
Patient Safety Commissioner for England website
Patient Safety Learning posted an article in England
The role of the Patient Safety Commissioner for England is to promote patient safety in relation to medicines and medical devices and to promote patients’ voices. This site provides information and resources related to this role and is for everyone interested in promoting patient safety and making sure that patients’ voices are heard. -
Content Article
Partha Kar, National Specialty Advisor for NHS England, has led work that has had an enormous impact for patients and for patient safety. In this video podcast, Steph O'Donohue from Patient Safety Learning talks to Partha about his leadership style and how it has helped him drive forward significant change in an often challenging context. Partha talks about the power of the patient community, workforce morale, sharing failures and leading with honesty. -
Content Article
An understanding of the social sciences within infection prevention and control (IPC) is important for those working in health and social care. This new book positions the specialty of IPC as more than a technical discipline concerned with microbes. It is about people and their behaviour in context and the book therefore explores a number of relevant social sciences and their relationship to IPC across different contexts and cultures. IPC is relevant to every person who works in, and accesses health care and it remains a global challenge. Exploring novel approaches and perspectives that expand our collective horizons in an ever changing and evolving IPC landscape therefore makes sense. -
Content Article
The National Institute for Health and Care Research (NIHR) Evidence Collections draw together evidence from important NIHR-funded and wider research. They aim to help people in policy and practice understand recent important research in a topic area. The most recent Collection is Maternity services: evidence for improvement. In this blog, one of the Collection's authors, Candace Imison, describes how it was framed by the findings from a recent investigation into failings in East Kent Hospitals’ maternity services. She focuses on some key messages from evidence on how to identify poor performance and provide effective board governance and oversight. -
News Article
‘Devastated’ director quits after ‘bullying’ row with consultants
Patient Safety Learning posted a news article in News
A trust director has stepped down after a row with consultants about the leadership culture within her department, HSJ has learned. Pratima Gupta quit as director of women’s services at University Hospitals Birmingham Foundation Trust last week after a group of consultants expressed “no confidence” in her leadership. They claimed there was “intimidating and bullying behaviour” by individual managers. However, Ms Gupta said the allegations are untrue, and said she has faced “obstruction at almost every step” from some consultants when trying to improve training and culture within the department. Trainee doctors in obstetrics and gynaecology have previously expressed concerns around a lack of support from consultants, with the trust recently receiving a further warning around this from the General Medical Council and Health Education England. Read full story (paywalled) Source: HSJ, 1 June 2023 -
Content ArticleBurnout is a workplace syndrome characterised by three core attributes: 1) energy depletion or exhaustion, 2) a cynical or negative attitude toward one’s job, and 3) reduced professional efficacy. That second attribute, workplace cynicism, may be the least-understood aspect of burnout in part because of its complexity. In contrast to exhaustion and diminished efficacy, whose causes and effects are relatively straightforward, cynicism can be caused by a number of workplace factors, and it can be expressed in a broad range of emotional states and behaviours. Cynicism is dangerous to both individual and organisational health and can also spread rapidly throughout teams through a phenomenon known as “emotional contagion.” It’s possible to improve even deep-seated cynicism — and better yet, to prevent it from infecting your organization in the first place. The author of this Harvard Business Review article offers strategies to help reverse existing cynicism and to create an anti-cynical culture at work.
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News Article
East Kent: A decade of failure in maternity care
Patient Safety Learning posted a news article in News
After health inspectors considered closing a maternity unit over safety fears, the BBC's Michael Buchanan looks at a near-decade of poor care at East Kent Hospitals NHS Trust. "I've been telling you for months. The place is getting worse." The message in February, which Michael received from a member of the maternity team, was stark but unsurprising. In a series of texts over the previous few months, the person had been getting increasingly concerned about what was happening at the East Kent trust. The leadership is "totally ineffective" read one message. "How long do we have to keep hearing this narrative - we accept bad things happened, we have learned and are putting it right. Nothing changes." Friday's report from the Care Quality Commission (CQC) is unfortunately just the latest marker in a near-decade of failure to improve maternity care at the trust. The revelation that inspectors considered closing the unit at the William Harvey Hospital in Ashford comes nine years after the trust's head of midwifery made a similar recommendation for the same reasons - that it was a danger to women and babies. The failure to act decisively then allowed many poor practices to continue. Read full story Source: BBC News, 28 May 2023 -
News Article
NHS England workforce plan delayed amid rumours of cost issues
Patient Safety Learning posted a news article in News
NHS leaders have raised concerns about the delay to the long-awaited workforce plan, after the health secretary, Steve Barclay, refused to give a deadline for its publication and with rumours suggesting it is considered too costly. The plan, which was expected to be published on Tuesday, appears to have been delayed, according to the deputy chief executive of NHS Providers, Saffron Cordery. Barclay blamed the pandemic and “various things that have been happening in recent years” for the delay during broadcast interviews over the weekend. He had previously promised that the plan to increase the number of doctors and nurses would be published before the next general election. Cordery said the plan, which aims to fix the UK’s crumbling healthcare system by plugging chronic staff shortages but which has already been postponed from last year, was needed “as quickly as possible”. Until this weekend NHS Providers – which represents all England’s hospital, ambulance, community and mental health trusts – had believed publication of the plan was “imminent”. Cordery suggested that the failure to release it could be linked to the need for funding. Read full story Source: The Guardian, 29 May 2023 -
Content ArticleWhen people don't feel their actions will make a difference because of the vast scale of a problem, they are less likely to act, and this has implications for attempts to improve patient safety and reduce avoidable harm. In this article, Brian Resnick, science and health editor at Vox, interviews psychologist Paul Slovic, who has been researching human responses to risk and compassion since the 1970s. They discuss the psychological impact of large numbers of people on our ability and willingness to respond compassionately and to act on that compassion. They look at Slovic's research into the concepts of psychic numbing and the prominence effect, focusing on the global refugee crisis and why individuals and governments fail to act in the face of immense suffering.
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Content ArticleIn England, the NHS National Breast Screening Programme (NHSBSP) offers routine breast screening to all women, some trans men and non-binary people, between the ages of 50 years and up to their 71st birthday, every 3 years. The unfolding Covid-19 pandemic in early 2020 was understandably a time of great anxiety and concern. Culturally we were seeing strong behavioural shifts such as social distancing and a general change in all our daily life patterns. Conceptually, and as leaders, we understood the vulnerability we observed, but felt that we did not have the 'right language' and in fact lacked the relevant experience of how to address and communicate with staff and clients during this crisis. A semiotic, observational research project was utilised that aimed at providing insight how cultural behaviour was being shaped and expressed during the early onset of the Covid-19 pandemic in England. The recommendations of the project were then integrated and implemented into an action plan and subsequent practice. Semiotic analysis revealed that several factors (positive and negative) impacted on peoples' confidence and had practical and emotional implications. Eleven main codes which are belief systems about oneself and others were identified and expressed in a multitude of different ways revealing three main themes or needs i.e. Reassurance, Trust and Clarity. An action plan was developed in response to the project findings and recommendation were implemented. Effective leadership relies on situational awareness. This semiotic project enabled the authors to find the 'right' language and communication style so that they could connect with staff at the time of crisis.
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Content ArticleThe NHS in England has largely relied on a human resources trilogy of policies, procedures and training to improve organisational culture. Evidence from four interventions using this paradigm—disciplinary action, bullying, whistleblowing and recruitment and career progression—confirms research findings that this approach, in isolation, was never likely to be effective. Roger Kline proposes an alternative methodology, elements of which are beginning to be adopted, which is more likely to be effective and to positively contribute to organisational cultures supporting inclusion, psychological safety, staff well-being, organisational effectiveness and patient care.
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News Article
Trust top team was ‘least cohesive I’ve ever joined’, says new CEO
Patient Safety Learning posted a news article in News
A review into how a reporting error came about has uncovered tension among an ambulance trust’s previous senior leaders, including that its new CEO felt it was ‘the least cohesive team I have ever joined’. Management consultancy Verita was commissioned by London Ambulance Service Trust to carry out a review of how it came to be misreporting category 1 (the most serious) response times. The report, published in board papers on Thursday, said it was caused by a contractor’s programming error going unnoticed and concluded it was “impossible to typify the events of August 2020 as other than an avoidable failure of governance and process”. Daniel Elkeles, who joined the trust as CEO in August 2021, told the review that when he joined the senior team it was “the least cohesive team I have ever joined” and said the organisation was not “psychologically safe” for those who wanted to speak up. Read full story (paywalled) Source: HSJ, 26 May 2023 -
News ArticleThe health secretary is set to signal a major delay to one of the headline promises in the last Conservative manifesto by suggesting the delivery of 40 new hospitals in England is likely to be pushed back until after 2030. In a move that will spark anger among MPs who wanted “spades in the ground” before the next election, government sources said Steve Barclay would make the announcement today. The pledge to build and fund “40 new hospitals over the next 10 years” was one of the major headlines of Boris Johnson’s pitch to the electorate in 2019. Sources indicated the government had been ready to make the announcement about the probable delay for some time, but it was repeatedly pushed back because of fears about a backlash from Tory MPs. Rundown NHS hospitals have become a danger to patients, warn health chiefs Read full story Source: The Guardian, 25 May 2023
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Content ArticleStandardised data and integration of systems are vital for full traceability, improving patient safety, and enabling swift action in healthcare incidents. The PIP breast implant scandal was not the first and transvaginal mesh will not be the last. In fact, the next national patient safety scandal is likely manifesting today. “There needs to be better processes to ‘track and trace’ patients who have received a device when a problem arises,” says Professor Sir Terence Stephenson, Nuffield professor of child health at UCL Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England, in the Scan4Safety 2020 report. “Clear strategies and channels are needed to inform patients, the public and clinical professionals to help improve safety.” One common denominator among such incidents is the lack of traceability – limited visibility of the devices used, when and where they are used and, most importantly, in or on which patients. This is where standardised data comes into play. There is no shortage of data in the NHS. However, the ability to standardise and share that data between systems and organisations is something the health service as a whole still lacks. Today, achieving full traceability remains a key challenge for the NHS, with repercussions that continue to have a detrimental effect on patient care.
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News Article
World must prepare for disease more deadlier than Covid, WHO chief warns
Patient Safety Learning posted a news article in News
The head of the World Health Organisation warned on Tuesday that governments need to prepare for a disease even deadlier than Covid-19. Dr Tedros Adhanom Ghebreyesus, director general of WHO, told its annual health assembly in Geneva that it was time to advance negotiations on preventing the next pandemic. He warned that nation states cannot “kick this can down the road” and that the next global disease was bound to “come knocking”. Dr Tedros said: “If we do not make the changes that must be made, then who will? And if we do not make them now, then when?” He added: “The threat of another variant emerging that causes new surges of disease and death remains. And the threat of another pathogen emerging with even deadlier potential remains.” Read full story Source: The Independent, 24 May 2023 -
Content Article
NHS Impact resources
Patient Safety Learning posted an article in NHS England
NHS Impact ‘improving patient care together’ is the term NHS England is using for the new single, shared NHS improvement approach. This includes the five components which form the ‘DNA’ of all evidence-based improvement methods, which underpin a systematic approach to continuous improvement: Building a shared purpose and vision. Investing in people and culture. Developing leadership behaviours. Building improvement capability and capacity. Embedding improvement into management systems and processes. When these 5 components are consistently used, systems and organisations create the right conditions for continuous improvement and high performance, responding to today’s challenges, and delivering better care for patients and better outcomes for communities. -
News Article
Trust execs accused of creating a ‘cult of the individual’
Patient Safety Learning posted a news article in News
Regulators are probing a series of whistleblowing claims about the leadership culture of a trust which is rated ‘outstanding’ for its management, HSJ has learned. It is understood multiple current and former staff members at Bolton Foundation Trust, including people in senior positions, have been in contact with NHS England and the Care Quality Commission in recent months. The claims include a dramatic worsening in leadership culture at the trust, particularly around the FTSU process and people who speak up being bullied, side-lined and silenced. And investigations and meetings are stage-managed and tightly controlled by executives, with constant “sugar-coating” and positive spin on board reports, and intolerance of people who disagree. Read full story (paywalled) Source: HSJ, 22 May 2023 -
News Article
Labour vows to reverse rise in suicides in England and Wales within five years
Patient Safety Learning posted a news article in News
A Labour government would reverse the rise in the number of deaths from suicide as part of a health plan to replace pain and anxiety with a “hope of a renewed NHS”, Keir Starmer will pledge. In a speech today, the Labour leader will say his plan for reforming the NHS will focus on the biggest causes of death in the UK including suicide. He will point to coroners’ statistics showing that deaths from suicides have been rising since 2008, and reached a record high last year in England and Wales. If the party takes power Labour will reverse this rise within five years, Starmer will say. A segment of his speech previewed by the party says: “Suicide is the biggest killer of young lives in this country. The biggest killer. That statistic should haunt us. And the rate is going up. Our mission must be and will be to get it down.” Labour has not provided details on how it proposes to meet this pledge other than an aspiration to shift from “sickness to prevention”. Starmer will also propose introducing new NHS targets on cutting deaths in England from heart disease and strokes by a quarter over 10 years. Read full story Source: The Guardian, 21 May 2023 -
News Article
‘Pathetic and dishonest’: trust’s deputy CEO blasts NHSE approach to cancer
Patient Safety Learning posted a news article in News
NHS England’s approach to recovering cancer services has been described as ‘pathetic and dishonest’ by the deputy chief executive of a major trust. Andy Welch, deputy chief executive and medical director of Newcastle Hospitals Foundation Trust, has publicly criticised comments made in November by NHSE’s national cancer director Dame Cally Palmer, who said “we have our foot on the gas” towards reaching cancer waiting time targets. Mr Welch is an outspoken figure who has also slammed NHSE for “destroying” the morale of midwives through its “failed ‘continuity of care’ concept”, and described the potential “toppling” of the government as “brilliant” within the last three weeks alone. The Newcastle medic is the chair of the Northern Cancer Alliance. His criticism of Dame Cally comes as performance against the flagship cancer target remains largely unchanged since last year. Read full story (paywalled) Source: HSJ, 18 May 2023 -
Content ArticleIn a blog for the Healthcare Financial Management Association (HFMA), Patient Safety Learning’s Chief Executive Helen Hughes highlights both the human and financial costs associated with the persistence of avoidable harm in healthcare. She outlines how Finance directors should play a key role in improving patient safety and argues that they have an essential corporate leadership role to ensure healthcare is both effective and safe.
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News Article
Intervention at major trust as junior doctors flag patient safety risks
Patient Safety Learning posted a news article in News
Trainee medics in a troubled maternity department have flagged concerns with national regulators over the safety of patients, it has emerged. Last year the General Medical Council said it had concerns about the treatment of obstetric and gynaecology trainees at University Hospitals Birmingham and placed medics at Good Hope Hospital and Heartlands Hospital under intensive support known as “enhanced monitoring”. The GMC’s review flagged serious concerns about emergency gynaecology cover arrangements and said there was a real risk trainees would become hesitant and reluctant to call on consultant support. In September it placed additional restrictions on training, due to “ongoing significant concerns about the learning environment and patient safety”. Now it has emerged in board papers for Birmingham and Solihull integrated care board that Health Education England, now part of NHS England, and the GMC carried out a follow-up visit to UHB in late March to review progress. Board documents state that “several patient safety concerns [were] reported by postgraduate doctors in training to the visiting team”, with a subsequent feedback letter from HEE urging immediate changes to dedicated consultant time and job plans. Read full story (paywalled) Source: HSJ, 17 May 2023 -
Content Article
Martin Hogan, Lead Professional Nurse Advocate (PNA) at Central London Community Healthcare NHS Trust, tells us about the PNA training programme and the impact and improvements it can have on both staff and patient safety. He shares his own personal development from taking the programme, how he has used the skills learnt to educate and support his colleagues, and explains why he is championing the PNA to others and has set up a network of PNAs. -
News ArticleAn ‘outstanding’ trust’s Care Quality Commission rating has been dropped to ‘requires improvement’, after inspectors found potential safety risks and a disconnect between board and ward. A highly critical report on University Hospitals Sussex Foundation Trust also downgraded its well-led rating to “inadequate” and recommended the trust be placed in segment four – the bottom tier – of NHS England’s system oversight framework. Its main tertiary centre – the Royal Sussex County Hospital – was also rated “inadequate”, including for safety. Deanna Westwood, Care Quality Commission’s director of operations in the South, said “staff and patients were being let down by senior leaders, especially the board, who often appeared out of touch with what was happening on the wards and clinical areas and it was affecting people’s care and treatment”. Read full story (paywalled) Source: HSJ,12 May 2023
