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One year ago today, Professor Don Berwick published A promise to learn – a commitment to act, his report on the safety of patients in England.
We have since made a lot of progress in responding to his findings and this anniversary is a good time to consider both what we have achieved and what is still to come.
NHS England is putting in place systems that will amplify local and national patient safety improvements, to reduce the risk of avoidable harm for every patient, whenever they come into contact with the NHS.
The Berwick report followed tragic events at Mid Staffordshire NHS Foundation Trust, which triggered a need to re-examine what the NHS does and determine how it can improve further. Don Berwick’s report did just that, and found that “The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care”.
The service is learning and improving. For example:
- the NHS is becoming much better at recognising and reporting patient safety incidents, with general incident reporting up 6 per cent during the past year and reporting of death and severe incidents up 7 per cent
- the number of cases of health care associated infection is falling, with 10 per cent fewer MRSA cases than this time last year, and 12 per cent fewer cases of C. difficile
- NHS Safety Thermometer suggests a 15 per cent reduction in the number of patients with pressure ulcers on the day of survey, compared with last year
- the number of patients recorded as ‘harm free’ by the NHS Safety Thermometer is now at 93.6 per cent, up from 92.7 per cent this time last year
Looking at our achievements since August 2013, you can see that Don Berwick’s recommendations are at the heart of many new safety initiatives, including the redesigned National Patient Safety Alerting System, the monthly publication of ‘never events’ data and the launch of the three-year Sign up for Safety campaign.
These achievements are just the beginning. The major initiatives we will launch this autumn are what will really invigorate Don Berwick’s vision by changing the culture of patient safety across the NHS.
This autumn we will formally launch the Patient Safety Collaboratives programme, perhaps the most important recommendation of the Berwick Report. The 15 collaboratives will be the largest patient safety initiative in the history of the NHS and will bring continual learning and safety improvement to every part of our health care system.
The collaboratives will be managed and delivered by the Academic Health Science Networks, and owned by local patients and NHS staff. They will provide local learning and improvement hubs, and bring together clinicians, managers, academics and patients to develop and test solutions to local priority safety issues.
The collaboratives will also provide a basis for the most successful innovations to be shared on an unprecedented national scale, so that proven best practice can be adopted rapidly across the country.
A key aim of the collaboratives will be to ensure continual patient safety learning sits at the heart of healthcare in England. To support this learning we will create 5,000 Patient Safety Fellows who will serve as safety experts in their own healthcare organisations.
Patient safety is now a mainstream concern, at the heart of the work of every single member of staff in the NHS; on the hospital ward, in the GP’s surgery and in community services. It will take hard work, dedication and commitment from many individuals to ensure we have a whole system of continuous learning and safety improvement, but we owe this to each and every patient that comes into our care.
By working together in this way, we can showcase the shared compassion and care that I know is at the heart of our NHS. As Professor Avedis Donabedian, pioneer in the study of health care quality, once wrote: “Systems awareness and systems design are important for health professionals, but they are not enough… It is the ethical dimensions of individuals that are essential to a system’s success.”
Patient safety is not by its nature absolute. We can always be safer, we can always improve and we will always have to strive to reduce further the risks for our patients. But patient safety is also about being bold and taking great leaps forward. A journey of continuous improvement coupled with ambitious goals will transform the NHS into the safest health care system in the world.