Really depressed by this response from NHS England to the Berwick Review’s call for an open, transparent NHS Culture. The two documents ‘Lines to Take on the Berwick Review’ and ‘Q&A – NOT FOR PUBLICATION’ say it all in the title.

 As my source, a frightened and despondent senior NHS manager puts it: ‘Lots of us are really disappointed with this response. Here is this wonderful report saying all the things we all feel; a new culture, an investment in teaching improvement science, let’s do things differently, and the response feels like some ‘tell them we’re doing it already’. It feels like ‘meet the new boss, same as the old boss’. Please do something with it and please don’t identify me.’

So much for a culture of speaking up without fear. Full story in todays Private Eye

 

Lines to take – NHS England’s current actions in ensuring patient safety

Final

5 August 2013

Improving patient safety

1. National Reporting and Learning System:  NHS England already operates the world’s most comprehensive patient safety incident reporting and learning system, the National Reporting and Learning System (NRLS). This invaluable tool allows clinicians to report safety concerns to a central repository where they are used to ensure new tools and guidance can be provided back to the NHS to make care even safer.

 

• We are working to commission a new, improved, single national reporting and learning system for incident reporting and management. This will not only encourage increased reporting and provide a more responsive system for clinicians, it will increase our ability to use the data collected to improve patient care.

 

1. Patient Safety Alerting System:  related to this, and as recommended by Don Berwick, we are redesigning the Patient Safety Alerting System, to make it more responsive and flexible to the requirements of the NHS.

 

The new system will allow for more rapid identification of risks to the NHS, while still allowing the development of tools, advice and guidance that will help reduce those risks, and provide clarity around the expectations on organisations to implement solutions so that patients can be assured that action is taken rapidly and robustly.

 

1. NHS Safety Thermometers:  we are working with colleagues to develop and make available NHS Safety Thermometers in relation to mental health care, medicines safety and maternity and continue to support the use of the ‘classic’ NHS Safety Thermometer.

 

The ‘classic’ safety thermometer tool allows frontline staff to track the prevalence of pressure ulcers, falls, blood clots and urine infections, in order to understand where improvements are needed and to make progress on delivering those.

 

1. Patient safety collaboratives:  we are establishing a strategy and framework for the creation of patient safety collaboratives across England to deliver locally owned programmes of patient safety improvement that will deliver on our national objectives. This will lead directly on from the recommendations of the Berwick Group and is a key route for delivery of safety improvement at scale.

 

1. Patient Safety Expert Groups:  we have established a series of Patient Safety Expert Groups to act as formal vehicles for engaging professional associations and representative organisations in patient safety improvement.

 

Some of these have already met and they cover primary care, surgical safety,  children and maternity services, mental health services and medical services.

 

1. Key national patient safety issues:  we are focussing on key national patient safety issues as identified through the Mandate and the NHS Outcomes Framework, as well as those issues that represent the greatest burden of harm, have a high prevalence and a significant public profile.

 

• A key area for example will be improving the safety of the care of older people in the first 48 hours of acute illness, learning disability services, and medication, or where we know relatively little, like primary care.

 

1. Cross-cutting safety strategies:  we are working to develop strategies to tackle cross-cutting safety concerns like problems with handovers of care, falls, transitions of care and patient deterioration as well as working with partners in Government, Public Health England and across the NHS to support and deliver the ‘zero tolerance’ approach to MRSA as set out in the NHS England business plan.

 

1. New system-wide patient safety measurement:  we have been working with academic experts for over six months on developing a new way of measuring patient safety on a system-wide basis using clinical case note review to quantify the number of patient safety problems in care that lead to death.

 

For the first time in the NHS this will provide a direct measure of the overall safety of services. This new method will then become part of the NHS Outcomes Framework and the NHS will be held accountable for demonstrating continuous improvement in safety as measured by this new method. This work was endorsed by the recent Keogh Review and will be rolled out across the NHS shortly.

 

1. Core patient safety functions:  NHS England also continues to deliver ‘core’ patient safety functions including:

• clinical review of serious patient safety incidents;
• provide clinical expertise and support for existing advice and guidance in relation to patient safety: and
• provide wider clinical advice and support to the NHS on patient safety issues, for example on medication safety, nutrition and hydration, neuraxial devices, root cause analysis, serious incident policy and never events.

 

Compassion in practice

1. Training programmes for quality improvement including safety in nursing are being rolled out under the Compassion in Practice implementation plan. Health Education England is leading implementation of this by putting contracts in place with Local Education and Training Boards (LETBs) and Higher Education Institutions (universities and specialist training hospitals) to ensure comprehensive education in the science of patient safety.
2. NHS England, as part of “Compassion in Practice” has recommended that all providers use recognised tools to evaluate and decide staffing levels and skill mix for different ward types and occupancies, and to regularly publish their staffing levels, along with the evidence underpinning them, in their board papers.

Many hospitals are already doing this at individual ward level, in line with the best practice recommended in the Keogh Review, and we are working with CCGs to ensure commissioners use their power to demand clear, comprehensive evidence on staffing levels.

1. One of the key strands of the “Compassion in Practice” vision and strategy for nursing, midwifery and care, is “ensuring we have the right staff, with the right skills, in the right place”.

Ruth May, Director of Nursing for the Midlands and East region, is now leading implementation of this part of the strategy for NHS England, working in partnership with NICE to develop evidence-based staffing levels for mental health, community, learning disability services and care and support, as well as ensuring use and publication of hospital staffing levels as above.

Health Education England is working with providers, LETBs and NHS England to ensure that appropriate numbers of nurses are recruited and trained each year. In addition to this, also as part of Compassion in Practice, we are working with HEE to ensure the “6Cs” for compassionate care are fully embedded in nursing training

1. Our network of Care Makers is harnessing the knowledge, energy and commitment of student and newly-qualified nursing and midwifery staff in making them official, designated ambassadors of Compassion in Practice and the 6Cs. They are empowered to represent their professional peers, from the ward right up to the Chief Nursing Officer, in upholding professional standards, taking the lead in championing improvements and highlighting risks, and putting compassion at the heart of care.

• Around 250 student and newly qualified nurses and midwives applied to be care makers when the initiative was first launched last year. Recruitment is gathering pace and we are on track for our ambition for 1,000 care makers by April 2014.
• We are also working towards extending the Care Maker role into allied health professionals and carers.

Leadership

1. The NHS Leadership Academy is a part of the NHS, hosted by NHS England. Its stated key aim is to develop outstanding leadership in health for the continuing improvement of care and patient experience. Its programmes have support, listening and continual improvement at their heart.

• A key part of the Leadership Academy’s role is to commission and carry out continuing research into leadership and management for better patient care and safety, and ensure their courses develop in line with the latest understanding of the best techniques and behaviours.

1. One of the key ambitions set out in the Keogh Review was that junior doctors and student nurses, should receive much greater encouragement to become important members of clinical teams, feeling able to report patient safety concerns and be sure that they are addressed, and able to take forward their ideas for improvements.

Their unique perspective, based on latest training and regular movement between hospitals, is invaluable, as demonstrated by their excellent commitment to the Keogh Review. (NB – majority of student nurses on review panels were also Compassion in Practice Care Makers.)

1. Academic Health Science Networks are being put in place at the moment. Their specific function will be to support innovations that improve patient safety and care, and to ensure advances are quickly spread across the NHS. They will also help in “partnering” hospitals whose geographical or political isolation means they are not using the most up-to-date practice, with the best performers.

• All parts of the NHS are members of Strategic Clinical Networks and Clinical Senates, whose role it is to ensure constant safety and quality improvement across individual specialties and geographic areas.

 

Patient voice and experience

1. NHS England is leading the way in patient focus.  The Patients and Information Directorate, is committed to engaging with patients and developing the NHS system to ensure their views are constantly sought out and acted upon.  We are determined to make sure all patients are asked not “what’s the matter?” but “what matters to you?”

 

1. Patients were key members of inspection teams and played a huge role in the Keogh Review of hospitals with persistent outlying mortality rates. This model of inspection and regulation is to be taken on and developed by the CQC in its new hospital inspection regime, under the new Chief Inspector of Hospitals, Mike Richards.
2. A central part of the Keogh Review at each of the 14 hospitals was the active invitation of patients and their families to submit their views and experiences, good and bad. They were given a big variety of channels through which to do this, including public meetings, individual meetings with review team members, telephone lines, dedicated e-mail addresses and a smartphone app. We received 1,200 responses from patients, which were fed directly into the review process.
3. The explicit seeking of patient views is also a key theme of NHS England’s policy and strategy development, with engagement processes geared specifically towards patients in both the Call to Action development of NHS strategy, and in Sir Bruce Keogh’s review of urgent and emergency care.
   1. In April 2013, NHS England introduced PLACE (patient-led assessment of the care environment) – a new way of regularly assessing NHS wards and clinics with patients in charge. Local people form at least 50% of the teams which go into hospitals to assess how the environment supports patient’s privacy and dignity, food, cleanliness and general building maintenance. The assessments will take place every year, and results will be reported publicly.
   2. Full, all-round engagement and involvement of patients in the NHS is a key theme of the NHS Constitution. NHS England is contributing to Norman Lamb’s review of how the NHS Constitution can be fully embedded in the NHS. We are determined to ensure all parts of the NHS live and breathe the NHS constitution, as it is the contract we have with the people we serve.
   3. Named, recognised clinicians and personal care plans have been best-practice in the NHS for some time, though much more work needs to be done to ensure this actually happens throughout the system.  

NHS England will be publishing participation guidance shortly. The guidance explains collective and individual participation and what is expected. Further guidance and support will build on this over time.

The NHS Mandate sets an objective that everyone with long-term conditions, including people with mental health problems, will be offered a personalised care plan that reflects their preferences and agreed decisions’. Care plans should be digitally accessible as well as in printed for. There is no single standard care plan and care planning processes may also vary. However, there are some common themes:

• plans should be developed in partnership between patients and carers and their health professionals.  Plans should be holistic and consider health, wellbeing and life more widely;
• plans should be focused on agreed goals and outcomes, which are relevant to the person, with an agreed action plan for achieving these and contingency planning for crisis episodes, where relevant;
• people should have the right information and support to be able to manage their conditions in ways that works for them, this includes community and wider services;
• plans should be agreed by both parties and owned by the patient and be reviewed regularly at intervals which make sense to the individual.

1. NHS England has pledged to ensure every patient can access their own GP records online by 2018, and work is well under way to achieve this.

• Patient access to their own GP records will help enable them to work with their GPs to ensure they get the care and support that matters to them, both in their primary care and in any referrals to hospital services. NHS England, as commissioner of primary care, is working with GPs to encourage them to provide more flexible consultations, so that patients who need only a repeat prescription, for instance, can use e-mail or phone appointments, allowing more time for GPs to give longer consultations and spend more time in ensuring those patients who have more complex needs can fully explain their concerns, histories and hopes, building strong and lasting relationships with their doctors.
• Personalised care plans are being introduced across the NHS, developed in partnership with the patient and their carers. They are currently most often used in complex needs, but NHS is working towards full coverage (see Q9).

1.  NHS England is now working towards the ambitions stated in the Keogh Review report, which was clear in its calls for big improvements in the ways complaints are handled, with full transparency expected towards the patient and their family, and clear processes by which they are recorded, trends are actively sought, and actions are taken both across the individual issue and the identified trends.

• NHS England’s Customer Contact Centre has made a number of changes to their call handling processes and performance is now in a stable position.
• The majority of complaints and enquiries are dealt with on the first point of contact (69% of complaints and 76% of general enquiries).
• The actions taken by NHS England have now led to the number of cases being resolved each week increasing by 70%.
• NHS England would like to apologise for the early problems that were experienced during the first few months of service. Swift action has been taken to improve the situation and we are working hard to ensure that patients receive a high quality of service from NHS England.

 

1. The first results of the national Friends and Family Test – in which all A&E and overnight inpatients are asked whether they would recommend their unit/ward to friends and family, have now been published, giving hospitals a clear topline assessment of how good their patients’ experiences are. The test will soon be rolled out to maternity services, and NHS England is currently drawing up plans for its extension to GP services and all other NHS services.

• In line with our commitment to ensuring the NHS Friends and Family Test plays a key role in delivering transparency and improving patient experience, at the end of the second quarter we will carry out a review of the impact of the test, looking at what has worked well, all aspects of the methodology and the effectiveness of the presentation of the data, as well as working with trusts to ensure that they are able to explain the net promoter score to patients. The review will enable us to make any necessary adjustments to the FFT methodology that can be introduced in 2014/15.

1. Most hospitals, in line with the Keogh Review recommendations, hear patient stories in public at their board meetings.

• The Keogh Review has set an ambition for this to be the case for all hospitals, and for every NHS organisation to set clear programmes and policies to ensure full engagement with patients, with views actively sought through a variety of channels, and clear mechanisms to act on their feedback. The best Trusts already do this.

Transparency and data-sharing for improvement

1. Earlier this year, consultants from 10 specialties published detailed data about their performance for the first time – an important and pioneering first step to ensuring full transparency about individual performance, in the context of a supportive environment that encourages learning and improvement. The experience of publishing outcome data for cardiac consultants a decade ago has shown clearly that this type of publication drives up performance and patient confidence, encouraging clinicians who fall near the bottom of the performance list to update their knowledge and practice and reach for the level of the best.
2. NHS England’s care.data programme is developing apace. This will allow all NHS managers, clinicians and regulators to share, compare and analyse data from across the NHS, accurately benchmarking performance at individual organisations against their peers. It will help them to spot where things might be going wrong at their own organisations and encouraging lower performers to aim for, and learn from, the best.

 

1. Routine in-house collection and analysis of hard and soft data is a key ambition of the Keogh Review national report. The best organisations already do this, and we are working to make this the norm throughout the NHS, with routine publication of both the data and the actions taken as a result of it.

 

Berwick Review

NHS England Q&As (not for publication)

Final:  5 August 2013

1. 1.       Is the NHS safe?

There is no absolute definition of ‘safe’ – safety is a continually emerging property as the report makes clear. There is no evidence that the NHS is either more or less safe than other national care systems. As the report says ‘’It is a fine institution that can and should now become much better’’. The report also makes clear that every other system in the world experiences patient safety defects.

We will strive to deliver a continual reduction in harm as the report recommends.

1. 2.       Is “zero-harm” impossible? Was the PM wrong to ask for this?

What is absolutely right is that we constantly strive to make the NHS the best healthcare system in the world.  The report is clear that instead of  “zero harm” we must strive for continual reduction in harm

Harm to a patient should never be accepted if there was anything else at all which could have been done to prevent that harm.

1. 3.       Are staff working conditions so poor that patient safety is compromised?

The report found this may be the case in some places, as did Bruce Keogh’s recent review. We are clear that NHS organisations should use evidence-based tools to determine appropriate staffing levels for all clinical areas on a shift-by-shift basis. Boards should sign off and publish evidence-based staffing levels at least every six months, providing assurance about the impact on quality of care and patient experience

 

The National Quality Board will shortly publish a ‘How to’ guide on getting staffing right for nursing.

 

We know that in some cases, staff have felt unable to speak up when they have concerns about patient safety and care. We know that culture change is needed to ensure people feel able to speak up about their mistakes and are supported to prevent them in future, and the Compassion in Practice nursing strategy, in particular the 6Cs for compassionate care, are geared firmly towards this type of culture.

 

Our network of Care Makers is harnessing the knowledge, energy and commitment of student and newly-qualified nursing and midwifery staff in making them official, designated ambassadors of Compassion in Practice and the 6Cs. They are empowered to  represent their professional peers, from the ward right up to the Chief Nursing Officer, in upholding professional standards, taking the lead in championing improvements and highlighting risks, and putting compassion at the heart of care.

We also know that care can be compromised if the staffing levels and skills available on the ward is not properly aligned to the number of patients and the complexity of their needs.

NHS England, as part of “Compassion in Practice” has recommended that all hospital Boards to use recognised tools to evaluate and decide staffing levels and skill mix for different ward types and occupancies, and to regularly publish their staffing levels, along with the evidence underpinning them, in their Board papers.  Many hospitals are already doing this at individual ward level, in line with the best practice recommended in the Keogh Review, and we are working with CCGs to ensure commissioners use their power to demand clear, comprehensive evidence on staffing levels

1. 4.       How much can the NHS really know, at present, about the quality of care it gives?

 

There is a huge amount of information available about the quality of patient care in the NHS, but we must get better at using that data and understanding individual datasets in the context of others.

Training programmes for safety assessment and improvement in nursing are being rolled out under the Compassion in Practice implementation plan. Health Education England is leading implementation of this workstream, putting contracts in place with Local Education and Training Boards (LETBs) and Higher Education Institutions (universities and specialist training hospitals) to ensure comprehensive education in the science of patient safety.

We must also ensure all NHS organisations listen closely to their patients, actively seek their views, and act upon their concerns and comments.

A central part of the Keogh Review at each of the 14 hospitals was the active invitation of patients and their families to submit their views and experiences, good and bad. They were given a big variety of channels through which to do this, including public meetings, individual meetings with review team members, telephone lines, dedicated e-mail addresses and a smartphone app. We received 1,200 responses from patients, which were fed directly into the review process.

The explicit seeking of patient views is also a key theme of NHS England’s policy and strategy development, with engagement processes geared specifically towards patients in both the Call to Action development of NHS strategy, and in Sir Bruce Keogh’s review of urgent and emergency care.

In April 2013, NHS England introduced PLACE (patient-led assessment of the care environment) – a new way of regularly assessing NHS wards and clinics with patients in charge. Local people form at least 50% of the teams which go into hospitals to assess how the environment supports patient’s privacy and dignity, food, cleanliness and general building maintenance. The assessments will take place every year, and results will be reported publicly.

 

1. 5.       Why are so many leaders under-skilled in patient safety science? What is being done to rectify this?

 

There are many very good NHS employees who have skills in quality and safety improvement. We need to increase the breadth and depth of these skills. This is a challenge for every healthcare system

The NHS Leadership Academy is hosted by NHS England. Its stated key aim is to develop outstanding leadership in health for the continuing improvement of care and patient experience. Its programmes have support, listening and continual improvement at their heart.

A key part of the Leadership Academy’s role is to commission and carry out continuing research into leadership and management for better patient care and safety, and ensure their courses develop in line with the latest understanding of the best techniques and behaviours.

We will carefully consider the recommendations for leadership in the Berwick Report as we continue to develop excellent leadership for high-quality, safe care in the NHS.

1. 6.       What has NHS England done to ensure whistle-blowers are heeded in future? (G Walker etc…)

We understand that some NHS employees have felt unable to speak up, often due to misinterpretation of corporate agreements. NHS England is clear, and has repeatedly stated, that no-one should have anything to fear from raising concerns about patient safety and quality of care.

The report makes clear that everyone in the NHS has to seek out and welcome concerns about the quality of care, and act on those concerns. It also makes clear that staff should be free to state openly their concerns about patient safety without reprisal, and there is no place for compromise agreements (“gagging clauses”) that prevent staff discussing safety concerns. We agree.

 

1. 7.       Does the target culture still dominate the NHS? Will this increased focus on data just mean nurses spend more time ticking boxes and less time with patients?

Goals, incentives and targets are useful tools for improvement but the central focus must always be on the needs of patients and that is where our focus is.

1. 8.       Can the NHS afford to invest in new models of care for long-term quality improvement?

We know that investing in new, innovative models of care for quality improvement results in precious NHS resources being saved, because people are less likely to suffer complications that need further expensive treatment and after-care.

We have recently set out in our Call to Action some of the challenges that the NHS needs to face over the next decade, including how to change the way the NHS works in order to cope with increasing demand.

We will work with commissioners, providers and regulators of training and education in order to improve the skill set of NHS staff.

This report has some important actions for improving the spread of best practice and we will consider it carefully before setting our plans out.

Academic Health Science Networks are being put in place at the moment. Their specific function will be to support innovations that improve patient safety and care, and to ensure advances are quickly spread across the NHS. They will also help in “partnering” hospitals whose geographical or political isolation means they are not using the most up-to-date practice, with the best performers.

All parts of the NHS are members of Strategic Clinical Networks and Clinical Senates, whose role it is to ensure constant safety and quality improvement across individual specialties and geographic areas.

 

1. 9.       In the Health and Social Care Act, the Government clearly described “no decision about me, without me”. What progress has been made towards this in the NHS?

 

The needs of patients are central in the NHS. That is what no decision about me without me means. We are putting the patient voice at the forefront of what we do. This report provides a useful contribution to the work on ensuring everyone has a named clinician and we will continue to work  with our partners on this.

• Named, recognised clinicians and personal care plans have been best-practice in the NHS for some time, though much more work needs to be done to ensure this actually happens throughout the system.
• NHS England has pledged to ensure every patient can access their own GP records online by 2018, and work is well under way to achieve this
• Patient access to their own GP records will help enable them to work with their GPs to ensure they get the care and support that matters to them, both in their primary care and in any referrals to hospital services. NHS England, as commissioner of primary care, is working with GPs to encourage them to provide more flexible consultations, so that patients who need only a repeat prescription, for instance, can use e-mail or phone appointments, allowing more time for GPs to give longer consultations and spend more time in ensuring those patients who have more complex needs can fully explain their concerns, histories and hopes, building strong and lasting relationships with their doctors.

Also: We are awaiting Ann Clwyd’s report on the NHS complaints system and will respond to her recommendations.

• Most hospitals, in line with the Keogh Review recommendations, hear patient stories in public at their Board meetings. The Keogh Review has set an ambition for this to be the case for all hospitals, and for every NHS organisation to set clear programmes and policies to ensure full engagement with patients, with views actively sought through a variety of channels, and clear mechanisms to act on their feedback. The best Trusts already do this.

 

1. 10.   Are commissioners unable to pay for and assure high-quality care because of real-terms funding cuts?

The financial backdrop is of course difficult for the NHS, and Prof Berwick’s report recognises that resources are not infinite and there is a need to achieve proper balance between resources and risks.

We also know that investing in new, innovative models of care for quality improvement results in precious NHS resources being saved, because people are less likely to suffer complications that need further expensive treatment and after-care.

• Academic Health Science Networks are being put in place at the moment. Their specific function will be to support innovations that improve patient safety and care, and to ensure advances are quickly spread across the NHS. They will also help in “partnering” hospitals whose geographical or political isolation means they are not using the most up-to-date practice, with the best performers.
• All parts of the NHS are members of Strategic Clinical Networks and Clinical Senates, whose role it is to ensure constant safety and quality improvement across individual specialties and geographic areas.

 

1. 11.   What progress has been made towards a re-designed safety alert system?

NHS England has been working on this over the spring and summer and we will put the new system in place shortly.

1. 12.   What is NHS England going to do on the back of this report?  What will be your priority / first steps taken?

 

We will consider the report carefully in conjunction with our partners from across the healthcare system and set out our response in due course. The report contains a number of actions that everyone in the NHS can implement immediately – improve how we listen to patients and seeking out and addressing risks to patient safety, raising concerns where necessary. We are already making good progress in these areas and will continue to develop this work in line with Prof Berwick’s recommendations.

 

1. 13.   How does the NHS currently analyse, monitor and learn from safety and quality information (the report recommends that this gap is costly and should be closed)?

We already run the world’s most comprehensive incident reporting and learning system and are already re-designing it to make it more responsive, relevant and easier to use. We must get better at using quality and safety information that is available and off the back of this report and the Keogh review we will step up our efforts to do so. A lot of this activity will be done at local level – that is where this information is most useful to drive improvement and we will work with the whole NHS to improve our capability.

Routine in-house collection and analysis of hard and soft data is a key ambition of the Keogh Review national report. The best organisations already do this, and we are working to make this the norm throughout the NHS, with routine publication of both the data and the actions taken as a result of it.

NHS England’s care.data programme is developing apace. This will allow all NHS managers, clinicians and regulators to share, compare and analyse data from across the NHS, accurately benchmarking performance at individual organisations against their peers. It will help them to spot where things might be going wrong at their own organisations and encouraging lower performers to aim for, and learn from, the best.

Earlier this year, consultants from 10 specialties published detailed data about their performance for the first time – an important and pioneering first step to ensuring full transparency about individual performance, in the context of a supportive environment that encourages learning and improvement. The experience of publishing outcome data for cardiac consultants a decade ago has shown clearly that this type of publication drives up performance and patient confidence, encouraging clinicians who fall near the bottom of the performance list to update their knowledge and practice and reach for the level of the best.

1. 14.   Isn’t this report a sad indictment of poor leadership of the NHS and an over reliance on targets?

No, while it/we recognise that there are problems and sometimes the NHS gets it wrong, this report is a very timely and useful summation of the cutting edge science and knowledge around patient safety improvement which will help us become the safest healthcare system in the world.

(see also answer to Q1)

1. 15.   Is this report further evidence that the ‘ship is sinking’ and that the NHS is failing in is most basis role – the care and safety of patients?

No, the report clearly states, ‘’we do not…suggest that the NHS has fundamentally lost its way.  It is a fine institution that can and should now become much better…We do not believe that the NHS is unsound in its core. On the contrary, its achievements are enormous and its performance in many dimensions has improved steadily over the past two decades’’.

(See also answer to Q1)

1. 16.   NHS England has repeatedly stated that ‘patients are at the centre of everything’ it does and this report fully recognises the importance/need to ensure the patient voice is heard at every level.  What has NHS England done/is doing to make this aspiration a reality as clearly it is failing in this respect so far?

 

NHS England is leading the way in patient focus. We have developed a new Patients and Information Directorate, whose sole focus is on engaging with patients and developing the NHS system to ensure their views are constantly sought out and acted upon.  We are determined to make sure all patients are asked not “what’s the matter?” but “what matters to you?”

Patients were key members of inspection teams and played a huge role in the Keogh Review of hospitals with persistent outlying mortality rates. This model of inspection and regulation is to be taken on and developed by the CQC in its new hospital inspection regime, under the new Chief Inspector of Hospitals, Mike Richards.

A central part of the Keogh Review at each of the 14 hospitals was the active invitation of patients and their families to submit their views and experiences, good and bad. They were given a big variety of channels through which to do this, including public meetings, individual meetings with review team members, telephone lines, dedicated e-mail addresses and a smartphone app. We received 1,200 responses from patients, which were fed directly into the review process.

The explicit seeking of patient views is also a key theme of NHS England’s policy and strategy development, with engagement processes geared specifically towards patients in both the Call to Action development of NHS strategy, and in Sir Bruce Keogh’s review of urgent and emergency care.

In April 2013, NHS England introduced PLACE (patient-led assessment of the care environment) – a new way of regularly assessing NHS wards and clinics with patients in charge. Local people form at least 50% of the teams which go into hospitals to assess how the environment supports patient’s privacy and dignity, food, cleanliness and general building maintenance. The assessments will take place every year, and results will be reported publicly.

NHS England has pledged to ensure every patient can access their own GP records online by 2018, and work is well under way to achieve this. Patient access to their own GP records will help enable them to work with their GPs to ensure they get the care and support that matters to them, both in their primary care and in any referrals to hospital services. NHS England, as commissioner of primary care, is working with GPs to encourage them to provide more flexible consultations, so that patients who need only a repeat prescription, for instance, can use e-mail or phone appointments, allowing more time for GPs to give longer consultations and spend more time in ensuring those patients who have more complex needs can fully explain their concerns, histories and hopes, building strong and lasting relationships with their doctors.

1. 17.   What’s NHS England’s role/responsibility in respect to patient care and safety?

 

NHS England has a legal duty to secure continuous improvement in quality, including in patient safety, and more widely has specific legal duties to collect, analyse and use information about patient safety incidents to provide tools and guidance for the NHS to reduce the risks to patients. The Outcomes Framework makes us accountable for ensuring patients are cared for in a safe environment and are protected from avoidable harm and we will continue to do so.

 

 

 

1. 18.   Has political interference muddied the waters around patient safety?

The NHS has a duty to gather and present clear evidence about how the NHS is working, how successful it is at providing safe, high-quality care, and how good an impact our improvement work is producing. MPs are important stakeholders and champions for their constituents, and all parts of the NHS aim to work closely with them, to give them a clear picture of how their organisations are working, and to listen to their views on how it can be improved.

1. 19.   Between Berwick, Keogh, Francis, Neuberger and Cavendish, the NHS has dozens of high-level recommendations, with more to come from Ann Clwyd and Norman Lamb. How can all these be realistically implemented?

All of these reports make incredibly valuable contributions to the NHS system. We need to look at them in the context of one another, and identify the consistent themes, taking in and considering each report’s recommendations across each theme, working with our partners across the health and social care system.

 

Dial M for Mistake

The ‘call 111 cock-up’  has shown why competitive tendering, outsourcing and the fragmentation it brings are hopeless for safe, coordinated emergency care. Many NHS staff, academics and government advisers predicted the risks, but the government ploughed on regardless.  It  has ‘delayed’ minimum pricing for alcohol and plain cigarette packaging to await ‘more robust evidence’, and yet rushed through massive, unmandated market reforms of the NHS that have no evidence base at all. And as MD pointed out (Eye 1340), out of hours care is high risk and dangerous, triaging calls is extremely complex and the system has to have experienced clinical staff on hand, have a clear safety net, agreed and enforced quality standards and be joined up with the rest of the NHS. Since when was rushed outsourcing on the cheap going to be the solution?

Health Minister Earl Howe told the Lords that contractors were offered ‘an extra six months to bed in NHS 111’ but only two took up the offer’. NHS England should have insisted on the 6 month delay to make the service safer. Howe now claims ‘the NHS 111 service is not unsafe ? it is a safe service. In the vast majority of the country it has been provided very well for patients’ – a statement that may well come back to haunt him. Where 111 is being run by ambulance and GP out of hours services, it seems working well. But evidence of safety is distinctly lacking.

Like the Liverpool Care pathway, the principle of 111 is sound – it’s the variable implementation by staff, some of whom have inadequate expertise and all under extreme time pressure, that’s the problem. The simplification of out of hours calls to two numbers – 999 and 111 – sounds reasonable but it’s never that simple. Patients are expected to be able to differentiate between life-threatening 999 emergencies, and urgent but not life-threatening 111 problems. Even experienced GPs who know a patient well have trouble separating the two over the phone, so what chance a call centre employee with no medical training, an algorithm and possibly the odd nurse to ask for help if he can attract her attention? Risk-averse call handlers are likely to refer to 999 to cover their backs, others may completely miss the cues of subtle, but life-threatening illness. Safer advice would be to try your GP first. You might get lucky – or you might get referred onto 111.

Labour came up with the idea  a national, three-digit number for out-of-hours healthcare services in 2007, but for once Hunt has decided not to blame them. Labour did not intend to replace NHS Direct, which was not perfect but was at least staffed by experienced nurses and had developed into a good service. Instead of building on that, Lansley decided to rip it all up and replace NHS Direct with 111

 

NHS Direct could still bid for the tenders and, in a panic, put in  ridiculously low bids despite knowing the complexity of the work it would be doing. Even worse, the Department of Health accepted the bids and awarded them 11 of the contracts. NHS Direct has now realised – as many callers have – that it can’t provide a safe, reliable service at such a low price and is pulling out of all 11 contracts, leaving NHS England scrabbling around for a ‘failure regime’ which will doubtless mean paying other companies over the odds to take on work they don’t have the capacity for. And patients with urgent health problems will just have to shop around in the out of hours market.

NHS Direct is at least tax-payer owned, so the government and NHS England can blame it without tarnishing private sector providers. But as Channel 4’s Dispatches showed, Harmoni is also struggling to deliver a safe, low cost service too. As one (secretly filmed) manager put it: ‘We had a very bad service. Still realistically on the weekends we still are unsafe. We don’t have the staff to deal with the calls that are coming in.’

NHS England now claims that 90% of 111 calls are answered within a minute, a simplistic target that says nothing about whether the advice is competent. Harmoni has a third of contracts, and will probably now mop up some more. It beat Care UK to the contracts, but Care UK retaliated by buying Harmoni and then recruiting, as its managing director, Jim Easton, who was lured from the Department of Health and then NHS England having … er … ‘overseen  the NHS 111 procurement process’.

 

Hunt Balls

Mr Justice Silber’s ruling that Jeremy Hunt’s decision to cut services at Lewisham hospital in south London was unlawful was spot on. Lewisham was being used as collateral damage in a battle  it had nothing to do with, namely to bail out nearby South London Healthcare NHS trust (SLHT) , which is losing £1m a week and will be £356m in debt by the end of the year. And a significant chunk of that debt is to service two ludicrously expensive PFI debts for Queen Elizabeth hospital in Woolwich and the Princess Royal hospital in Bromley.

The Lewisham campaign was evidence-based,  united clinicians and patients, and was funded by donations via 38 Degrees. There was no rational case for downsizing such a high performing and popular hospital, and neighbouring trusts would not be able to take on the extra work without patients suffering. The decision does not, alas, solve the looming disaster of PFI debt (Eyes passim ad nauseum). As MD observed back in 1997, PFI is ‘political diktat triumphing over common sense, open debate and the will of the people.’ (Eye June 20) 21 PFI NHS trusts now have debts of  £130 million between them, and the total bill for repayments has risen by £200 million (18%) in 2 years. The government seems desperate to keep PFI shareholders sweet, but the contracts either have to be renegotiated or the debt spread right across the NHS rather than punishing nearby hospitals.

Spare a thought also for Mid Staffordshire NHS Trust, which has greatly improved its care, come in the top 10 for the Friends and Family test in its A&E department and achieved a glowing CQC report. The Trust Special Administrator has recommended that it doesn’t open its A&E overnight again, and that it loses its maternity and paediatrics services, which have never been criticised. Local campaigners may well appeal this, just as Jeremy Hunt may appeal the Lewisham decision. The issue for the government is that is simply isn’t trusted. It promised to protect hospitals or departments from closure in opposition, and an end to top down reorganisation. It then foists a massive market-driven  structural reorganisation on the NHS, and further service reorganisations – even if clinically rational – are seen as another ‘top down’ betrayal. The biggest winners, as ever, are likely to be lawyers.