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News Article
Trust’s treatment of Muslims heavily criticised by board director
Patient Safety Learning posted a news article in News
A board director has publicly criticised his trust for its treatment of Muslim staff and patients. Mohammed Hussain posted on social media that some board members at Bradford Teaching Hospitals “are not heard and listened to”, and that there is a “dissonance” between its espoused values and the “lived experiences” of minority ethnic staff. Mr Hussain, a non-executive director since 2019, was responding to a post by CEO Mel Pickup, who had said the trust had a “variety of support offers for colleagues observing Ramadan”. He said there are “many examples” of Muslim families experiencing poor responses to complaints to the trust, while claiming that “outstanding” Muslim staff are having to “move out of the area to progress because they are not promoted internally”. The trust said its launching an investigation into the concerns raised by Mr Hussain. Read full story (paywalled) Source: HSJ, 12 March 2024 -
Content ArticleA common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction—this is known as The Triple Aim. However, this framework does not allow the experience and human factors of providing care to be integrated into high-level decision making. This report describes the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center, which resulted in an integrative model of patient safety and clinician wellbeing. Developing the fourth aim of improving the experience of providing care was widely accepted and aligned with other health system goals of optimisation of safety, quality and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations.
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Content Article
In this blog, I discuss the limitations associated with FFP3 (Filtering Face Piece) tight-fitting masks as respiratory protective equipment (RPE) for the healthcare sector during the ongoing Covid pandemic. I highlight inequalities in the distribution of effective RPE among healthcare workers (HCWs) and also draw attention to the underlying reasons for the shortage of RPE that has beset our healthcare services since the start of the pandemic. -
News Article
£35 million investment to boost maternity safety
Patient Safety Learning posted a news article in News
Almost £35 million will be invested to improve maternity safety across England with the recruitment of additional midwives and the expansion of specialist training to thousands of extra healthcare workers. The investment, which was announced as part of the Spring Budget 2024, will be provided over the next 3 years to ensure maternity services listen to and act on women’s experiences to improve care. The funding includes: £9 million for the rollout of the reducing brain injury programme across maternity units in England, to provide healthcare workers with the tools and training to reduce avoidable brain injuries in childbirth investment in training to ensure the NHS workforce has the skills needed to provide ever safer maternity care. An additional 6,000 clinical staff will be trained in neonatal resuscitation and we will almost double the number of clinical staff receiving specialist training in obstetric medicine in England increasing the number of midwives by funding 160 new posts over 3 years to support the growth of the maternity and neonatal workforce funding to support the rollout of maternity and neonatal voice partnerships to improve how women’s experiences and views are listened to and acted on to improve care. Health and Social Care Secretary Victoria Atkins said: "I want every mother to feel safe when giving birth to their baby. Improving maternity care is a key cornerstone of our Women’s Health Strategy and with this investment we are delivering on that priority - more midwives, specialist training in obstetric medicine and pushing to improve how women are listened to in our healthcare system. £35 million is going directly to improving the safety and care in our maternity wards and will move us closer to our goal of making healthcare faster, simpler and fairer for all." Read full story Source: Gov.UK, 10 March 2024 -
Content Article
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Over the years, we have worked with many amazing women who share our aim of reducing avoidable harm in health and social care. In this blog, to mark International Women’s Day 2024, we are celebrating women who campaign for patient safety. -
News Article
NHS England leaders welcome £6bn budget boost but say much more is needed
Patient Safety Learning posted a news article in News
NHS leaders have welcomed the £6bn budget boost Jeremy Hunt handed the beleaguered service to help it meet rising demand, tackle the care backlog and overhaul its antiquated IT system. The chancellor gave the NHS in England an extra £2.5bn to cover its day-to-day running costs in 2024/25, after the Institute for Fiscal Studies had warned that it was set to receive less funding next year than this. Julian Hartley, the chief executive of hospital body NHS Providers, said the money would offer “much needed – but temporary – respite” and “some breathing space” from the service’s acute financial difficulties, which have been exacerbated by inflation and the costs incurred by long-running strikes by NHS staff. However, there was little to stabilise England’s creaking adult social care system, and Hunt’s budget delivered an ongoing squeeze on resources, said the Association of Directors of Adult Social Services (ADASS). “Millions of adults and carers will be disappointed,” said Anna Hemmings, joint chief executive of ADASS. “Directors can’t invest enough in early support for people close to home, which prevents them needing hospital or residential care at a greater cost.” Read full story Source: The Guardian, 6 March 2024 -
News Article
Neil Gray’s backroom deal with NHS unions ‘risks patient safety’
Patient Safety Learning posted a news article in News
Patient safety has been put at risk by ministers striking a backroom deal with unions to cut the equivalent of 10,000 health service jobs by reducing the working week, NHS bosses have warned. Briefings prepared by the chief executives of Scotland’s NHS boards reveal top management thrown into chaos after appearing to be blindsided by the new health secretary, Neil Gray. Two weeks into the role, Gray, who replaced the scandal-hit Michael Matheson on 8 February met with unions without NHS staff present and signed off sweeping changes to working conditions, setting a deadline to implement them within five weeks. The Scottish Conservatives have called the deal “deeply alarming”, while Labour accused the new health secretary of “standing idly by while chaos looms”. Read full story (paywalled) Source: The Times, 4 March 2024 -
News Article
Medical leaders back rise in number of physician associates
Patient Safety Learning posted a news article in News
Medical leaders support a planned increase in the number of physician associates (PA) in the NHS. But the British Medical Association (BMA) is concerned about a new law allowing the General Medical Council (GMC) to regulate PAs, who must be supervised by a fully qualified doctor. The doctors' union says it blurs the lines between doctors and PAs and could risk patient safety. Two families whose relatives were seen by PAs want the roles defined. The NHS has 3,286 PAs, who assist healthcare teams and are not authorised to prescribe or request scans. PAs and anaesthetic associates (AA) qualify after a funded two-year master's degree. They often have a science undergraduate degree, but that is not a prerequisite. Their role includes taking medical histories, conducting physical examinations and developing treatment plans. Like PAs, AAs are healthcare professionals who work as part of a multidisciplinary team with supervision from a named senior doctor. The Academy of Medical Royal Colleges said on Tuesday that it welcomes a push to increase the number of PAs in the NHS, but that it is "vital" that there are clear guidelines on how they are deployed. Read full story Source: BBC News, 5 March 2024 -
News Article
CEO admits ‘risk aversion’ clogging up hospitals
Patient Safety Learning posted a news article in News
Medics and managers must overcome a system-wide “aversion” to risk after their integrated care system was identified as a national outlier for low numbers of patients discharged home, according to the ICS’s chief executive. Kate Shields, CEO of Cornwall and Isles of Scilly ICS, has highlighted a discrepancy between the ICS and the rest of England, with a lower proportion of patients discharged with no new social care requirements, or discharged directly to their own home, with only intermediate additional care (known as ”pathways” 0 and 1 in national discharge guidance). Problems with delayed patient discharges – known as “no criteria to reside” patients – are a major contributor to overcrowding and long waits in the emergency department at Royal Cornwall Hospitals Trust, as well as severe delays for ambulances to handover patients. Discharge on pathways 2 and 3 – to a care home or intermediate care bed, with substantial additional care requirements – typically take a lot longer, and require more resources. Ms Shields’ comments come 18 months after an external report warned of an “over-reliance on bedded care” in Cornwall. Speaking at a meeting of Cornwall and Isles of Scilly Integrated Care Board last month, Ms Shields said the health economy needed to “look at how we get people out of hospital faster”. Read full story (paywalled) Source: HSJ, 4 March 2024 -
News ArticleScrapping the new Therapeutic Products Act (TPA) will leave thousands of New Zealanders exposed to ongoing harm from dodgy medical devices, warn patient safety advocates and legal experts. The act, which was due to come into force in 2026, would have modernised the regulation of medicines and natural health products, and made medical devices, as well as cell, gene and tissue therapies, subject to a similar regulatory regime as drugs. The industry has backed the move, saying the new law was heavy-handed and would stop people getting access to the latest lifesaving technological advances. However, Auckland woman Carmel Berry — who was left in constant knife-like pain from plastic mesh implanted during surgery — said she was “living proof” of the old system’s failures. It took more than 10 years of lobbying by her and the other founders of Mesh Down Under to get authorities to take action — a decade in which hundreds of other people were injured. She is horrified that the TPA, signed into law in only July, is on the chopping block. Beginning work to repeal it was No 47 out of 49 points on the Government’s to-do list for its first 100 days. “I’m horrified. After so many years of developing and rewriting the act and getting it through ... shame on them.” Read full story Source: New Zealand Herald, 18 February 2024
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News Article
New director ‘competency’ requirements unveiled by NHSE
Patient Safety Learning posted a news article in News
NHS board members must speak up against discrimination, challenge others constructively and help foster a safe culture, under a new NHS England assessment framework. The new leadership competency framework, published today, sets out six domains which board members are required to assess themselves against as part of an annual “fitness” appraisal. Each domain (see below) contains competencies directors must exhibit, such as: Speak up against any form of racism, discrimination, bullying, aggression, sexual misconduct or violence, even when [they] might be the only voice; Challenge constructively, speaking up when [they] see actions and behaviours which are inappropriate and lead to staff or people using services feeling unsafe, or staff or people being excluded in any way or treated unfairly; and Ensure there is a safe culture of speaking up for [their] workforce. Each competency statement gives board members a multiple choice to assess themselves against, ranging from “almost always” to “no chance to demonstrate”. Organisations have been told to incorporate the six competency domains into role descriptions from 1 April, and use them as part of board member appraisals. Read full story (paywalled) Source: HSJ, 28 February 2024 -
Content ArticleThis framework is for chairs, chief executives and all board members in NHS systems and providers, as well as serving as a guide for aspiring leaders of the future. It is designed to: support the appointment of diverse, skilled and proficient leaders support the delivery of high-quality, equitable care and the best outcomes for patients, service users, communities and our workforce help organisations to develop and appraise all board members support individual board members to self-assess against the six competency domains and identify development needs.
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Content ArticleA framework for boards and an example of what has worked in practice.
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Content Article
Audit committee handbook (29 May 2013)
Patient Safety Learning posted an article in National/Governmental
The audit committee handbook reflects developing best practice in governance. -
Content Article
That’s the way to do it! (19 February 2024)
Patient Safety Learning posted an article in Regulatory issues
On 8 February 2024, Ombudsman, Rob Behrens and Patient Safety Commissioner, Henrietta Hughes, wrote a joint letter to government. Both have regulatory roles to play in improving patient safety and both are struggling to gain headway with the recalcitrant NHS. Supposedly independent of government, this correspondence shows they are in fact totally dependent on government, due to their limited powers writes Della Reynolds in this blog. -
Content ArticleLeadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aimed to identify a framework, metrics and tools to improve surgical leadership and safety outcomes. It identified three areas of leadership needed to build a culture of safety in surgery: Control risk (risk management) Drive progress (opportunity management) Rally support for the mission (people management) A leadership assessment tool (SLAM) was developed to provide objective metrics of surgical leadership behaviours based on nine key performance indicators.
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Content Article
To coach or not to coach? Part 3 – by Dawn Stott
Dawn Stott posted an article in Good practice
In a new series of blogs, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), discusses how coaching and developing teams can support patient safety and its outcomes. In part one and part two, Dawn looked at the strategies and coaching methodologies that can be used to develop individuals and to support patient safety, and discusses the indicators of improvement, prosocial behaviours and the importance of good communication to improve culture and, ultimately, patient safety. In the final blog of the series, Dawn discusses the importance of reflective practice and how it encourages learning and growth, and helps us to identify and address challenges. -
Content ArticleOmbudsman, Rob Behrens and Patient Safety Commissioner, Henrietta Hughes, have written a letter to the Government sharing their joint concerns regarding what they see as the confrontational culture created by the complaints process in some areas of the NHS that undermines patient safety.
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News ArticleAn NHS trust has concluded that its former chief executive is not a “fit and proper person” to be on an NHS board, after investigating allegations of sexual harassment and inappropriate behaviour, HSJ has learned. HSJ understands The Robert Jones and Agnes Hunt (RJAH) Orthopaedic Hospital Foundation Trust commissioned a specialist external workplace investigation into Mark Brandreth, which considered serious allegations made about his behaviour during his time as trust chief executive between April 2016 and August 2021. Mr Brandreth is understood to dispute the allegations as well as the investigation’s findings, and is seeking to challenge RJAH’s handling of the complaints and its process for deciding he did not meet the Fit and Proper Person Test. Sources with knowledge of the situation said almost 30 female RJAH staff members came forward to give information to the investigation, but it focused on 12 employees who were willing to give evidence. HSJ has been told that as a result of the investigation, which concluded at the end of last year, the trust’s chair has informed NHSE in writing that it believes Mr Brandreth does not meet the “Fit and Proper Person Test”, implying he should be ruled out of board roles – or roles with equivalent responsibility – at English NHS organisations and adult social care providers. However, the trust, in Shropshire, is not planning to publish its ruling and – with no professional regulation in place for health and care managers and/or board members – it is unclear how effective the conclusion will be if it is not made public. A female staff member told HSJ of her concerns that “nothing is being done”. Read full story (paywalled) Source: HSJ, 21 February 2024
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Content ArticleExtracts of a letter from David Osborn to the UK Covid-19 Public Inquiry Legal Team regarding misleading evidence by Professor Yvonne Doyle, which: Highlights errors in Prof Yvonne Doyle’s evidence to the Inquiry relating to the declassification of Covid‑19 as a high consequence infectious disease. Calls into question Professor Sir Jonathan Van Tam’s evidence to the Inquiry in which he sought to attribute responsibility for the downgrade from FFP3 to FRSM to Public Health England. The letter sets out his involvement in the issue of the 4-Nations IPC guidance version 1.0 which implemented that downgrade. Further reading on the hub: Healthcare workers with Long Covid: Group litigation – a blog from David Osborn
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Content Article
In December 2022, a newly formed group called 'Long Covid Doctors for Action' (LCD4A) conducted a survey to establish the impact of Long Covid on doctors. When the British Medical Association published the results of the survey, the findings were both astonishing and saddening in equal measure.[1] The LCD4A have now decided that enough is enough and that it is now time to stand up and take positive action. They have initiated a group litigation against those who failed to exercise the ‘duty of care’ that they owed to healthcare workers across the UK during the pandemic. In this blog, I summarise how and why I feel our healthcare workers have been let down by our government and why, if you are one of these healthcare workers whose life has been effected by Long Covid, I urge you to join the group litigation initiative. -
Content Article
To coach or not to coach? Part 2 – by Dawn Stott
Patient Safety Learning posted an article in Good practice
In a new series of blogs, Dawn Stott, Business Consultant and former CEO of the Association for Perioperative Practice (AfPP), discusses how coaching and developing teams can support patient safety and its outcomes. In part one, Dawn looked at the strategies and coaching methodologies that can be used to develop individuals and to support patient safety. In part two, Dawn looks at how coaching can improve individuals, and discusses the indicators of improvement, prosocial behaviours and the importance of good communication to improve culture and, ultimately, patient safety. -
Content ArticleDr Phil Hammond dissects the medical lives of professionals at all levels of the health service in his podcast, Doctor, Doctor. In this episode, he speaks to Dr Rosie Benneyworth, interim Chief Executive Officer of the Health Services Safety Investigations Body (HSSIB).
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Content ArticleThere are many unheard and under-acknowledged voices and perspectives in the health and social care workforce, and they usually belong to those in the most junior, poorest-paid and precarious roles. All these voices deserve more attention than they get, but those of newly qualified and registered nurses and midwives are especially important given the current retention crisis in both professions. Since spring 2023, the King's Fund have been working with 22 newly qualified - newly registered if they trained internationally – nurses and midwives on a project called Follow Your Compassion. A documentary record of the everyday working lives of these nurses and midwives across a variety of settings across the UK health and care system, the project is a companion piece to The Courage of Compassion (2020), a report by The King’s Fund and RCN Foundation which described the core workplace needs of nurses and midwives, and what must be done to meet them.
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Content Article
Patient Advocacy Leadership Collective
Patient Safety Learning posted an article in International patient safety
The Patient Advocacy Leadership Collective (PALC) is an innovative hub that provides connectivity, community resources, and tools focused on sustainable capacity building for patient advocates globally. The PALC is an excellent platform with a focus on supporting the growth, development, and leadership of patient advocacy organizations and offers a NextGen Leadership, Mentorship, and Global Health Fellows programme.
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