By Dr Mike Durkin, NHS England director of patient safety:
Patient safety has been a key priority in NHS England’s first year. There can be no question that it should always be of paramount importance to everyone working in the NHS, but safety quite rightly came under particular scrutiny following the inquiry into Mid Staffs by Robert Francis QC and the subsequent report into safety across the NHS in England by Professor Don Berwick and the National Advisory Group on the Safety of Patients in England.
Therefore, the formation of NHS England, in many ways, came at the right time for patient safety. It allowed us to refresh, refocus and double our efforts as we began work to implement the recommendations of the reports mentioned above, through a number of new initiatives we have either already put in place or are working to introduce in the near future. It should also be recognised that the work of our predecessor organisations didn’t just cease to exist. It continues to thrive under the NHS England Patient Safety Domain, as we progress in continuing to tackle the leading causes of preventable harm to keep our patients safe.
One of the most important elements of patient safety is somewhat understated and often misunderstood. It is a little known fact that in England we have the most comprehensive system in the world for reporting and learning from patient safety incidents. Now in its 10th year, the number of incidents reported to the National Reporting and Learning System (NRLS) continues to grow year on year. This shows a maturing culture of safety incident reporting across the NHS as it is increasingly recognised that only by learning from incidents can we take action to prevent them from continuing to happen elsewhere by developing and sharing solutions and best practice.
The structure of the NHS in this country is like no other healthcare system in the world. It provides opportunities for collective change on a national scale and to be responsive as new issues and risks emerge. Professor Berwick’s landmark report last summer made clear that the NHS has the potential to become the safest healthcare system in the world. We are determined to achieve that and with the determination, dedication and compassion of all those working in the NHS it is an achievable aim.
Our landmarks towards achieving that goal in the last 12 months include:
- The continually-developing and improving reporting culture was celebrated and reaffirmed at Patient Safety Congress in May, where it was announced that reports of incidents and near-misses – the majority of which caused no harm to patients at all – were topping 100,000 per month.
- In July, setting up Patient Safety Expert Groups covering each of the main areas of healthcare to bring a range of experts together to collaboratively improve the culture and safety of patients in NHS funded care and lead on the development and dissemination of advice and guidance for both commissioners and providers.
- In November, work published by the Quality & Outcomes Research Unit at the University Hospitals of Birmingham NHS Foundation Trust demonstrated the impact of the national VTE prevention programme in that reaching a sustained level of risk assessment saves lives. Risk assessment for VTE now happens for over 95% of patients.
- In December, the first detailed, hospital-level data on never events was published. From April, that information will be updated every month.
- In January a new patient safety alerting system, that ensures warnings are distributed much more quickly and does more to monitor compliance with safety advice, was launched.
- Also in January NHS England’s Board approved the development of a network of Patient Safety Collaborative groups to ensure that safety is at the heart of all healthcare provision in every region of England, and established an NHS Patient Safety Improvement Fellowship programme that will see 5000 fellows appointed within five years.
- In February the Surgical Never Events Taskforce, commissioned by NHS England, published its report into all incidences of wrong-site surgery, wrong implant or prosthesis, and retained foreign object. How to implement these recommendations for improved systems throughout the NHS is now being considered by NHS England and other national partners.
Looking ahead to the next 12 months we will introduce a range of other initiatives, including:
- Launch and roll-out of patient safety collaboratives.
- Recruitment of patient safety improvement fellows.
- Launch of patient safety data website.
- Implementation of surgical never events taskforce recommendations including development of national standards.
- National Reporting and Learning System (NRLS) redevelopment.
- Launch of medication, mental health, maternity and paediatrics safety thermometers.
Patient safety is now more than ever at the forefront of the minds of those providing NHS care, and thanks to the efforts of frontline staff we are continuing to take great strides in making healthcare settings safer and preventing harm to patients. We have come a long way in shifting the culture of the NHS since the establishment of the National Patient Safety Agency (NPSA) in 2001, when patient safety was a new discipline and seen as an add-on to the core business of treating patients.
Under the reforms of the health service, the NPSA’s functions were taken on by NHS England, firmly embedding patient safety where it should be, at the heart of our health service.
The improvements we have made since then are just the beginning – patient safety takes constant monitoring, discussion and improvement, and I look forward to working with every part of the NHS to make all our patients as safe as possible across all healthcare settings.