Photograph of a report on a table, the report is labeled, "NHS"

The Care Quality Commission (CQC) in England: Annual Review of Progress

By John Tingle

The Care Quality Commission (CQC) occupies a pivotal role in the National Health Service (NHS) and social care sector in securing health quality and patient safety. Its inspection activities through its reports and publications form the backbone of quality and safety in these sectors. As the independent regulator of health and social care in England it faces a mammoth task. The CQC has recently published its annual report and accounts, which provide useful insights into its work. The report provides a window on how England regulates health, social care quality, and patient safety. There is detailed reflection in the report about how the organisation can better perform its functions and the challenges and opportunities currently facing it.

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Nurse holding a patient's hand

Toward a Just and Learning Culture in the NHS

By John Tingle

NHS Resolution has several functions in the NHS (National Health Service) in England which include managing legal claims brought against NHS hospitals and other health organisations, as well as important patient safety responsibilities. They have recently published guidance on supporting a just and learning culture for staff, patients, and caregivers following incidents in the NHS.

The guidance is wide ranging and includes examples of just and learning culture development practices. Example one is a just and learning charter that NHS hospitals and other health organisations can adapt or adopt. The NHS charter provides in the first paragraph a sample introductory pledge:

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The NHS in England Launches a New Patient Safety Strategy

On July 2, 2019 a new National Health Service (NHS) patient safety strategy was launched in England. The strategy promises many things and lays out the future trajectory of NHS patient safety policy making.

Aidan Fowler, the NHS National Director of Patient Safety highlights the scale of the NHS patient safety problem in the foreword to the strategy:

 Too often in healthcare we have sought to blame individuals, and individuals have not felt safe to admit errors and learn from them or act to prevent recurrence…The opportunity is huge. Hogan et al’s research from 2015 suggests we may fail to save around 11,000 lives a year due to safety concerns, with older patients the most affected. The extra treatment needed following incidents may cost at least £1 billion (p3).

 

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A group of surgeons perform an operation in a hospital operating theatre.

Keeping up to Date with Global Patient Safety

One of the great difficulties in patient safety and health quality is keeping up to date with all the material that is produced. A myriad number of patient safety and health resources exist globally. By sharing good quality resources, we can help advance the global patient safety agenda.

NHS Resolution (the operating name of the National Health Service Litigation Authority) has excellent patient safety and clinical negligence resources, learning materials and should be viewed as a priority global information source.

NHS Resolution is a Special Health Authority and is a not-for-profit arm’s length body of the Department of Health and Social Care.It is a part of the NHS and has several functions including handling negligence claims on behalf of NHS organizations and independent sector providers of NHS care in England who are members of the NHS Resolution indemnity schemes. Read More

NHS logo on the side of a building

Update on the Future Direction of Patient Safety in the National Health Service

Matt Hancock, the Secretary of State for Health and Social Care on February 6 gave a wide-ranging speech on the future direction of patient safety in the NHS. The speech is important as it gives key insights into government priorities for patient safety policy development in the NHS.He stated that we all trust nurses and doctors more than any other profession. He spoke about the importance of a “just culture” in the NHS and openness, honesty, and trustworthiness. Read More

Patient Safety and Emergency Room Care in the NHS

By John Tingle

UCL A&E entrance
Pedestrian entrance to the Accident and Emergency Unit at University College Hospital as viewed from the pavement on the Euston Road. (Amanda Lewis/Thinkstock)

In the UK, emergency and urgent care patients visit the A & E (Accident and Emergency) units of local hospitals (known as ERs in the U.S.) A & E service provision is the public face of the NHS. It is seen by many as the bellwether of the national health care system and the basis on which its performance is judged.

The Health and Social Care Regulator of England, the Care Quality Commission (CQC), which maintains important patient safety and health quality reviews, has recently published a report on A & E urgent care that found that the 2017-2018 winter season saw an unprecedented demand for emergency services, continuing a year-over-year increase. The number of emergency admissions has grown by 42 percent over the last 12 years, adding pressure to the NHS.

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The Health Service Ombudsman: NHS Failing Patients with Mental Health Problems

By John Tingle

Failings in National Health Service (NHS) care for patients with mental health problems is a worryingly persistent story in the English media. Many reports show harrowing and dramatic failings in NHS care provision for the mentally ill some of which result in avoidable deaths.The Health Service Ombudsman  (HSO) represents the final stage in the NHS complaints procedure and is an independent  office reporting  directly  to Parliament.The HSO carry’s out investigations into complaints  and makes the final decisions on those that have not been resolved by the NHS in England.In a recently published report the HSO reveals reveals unjust, shocking and tragic failings  in NHS care provision for patients with mental health problems.Some mental health care complaints figures are given in the report.In 2016-2017 there were 14,106 complaints made to NHS mental health trusts (hospitals) with ,65% being upheld or partly upheld by the local organisation.Case work data between 2014-15 and 2017-18 was analysed and five key themes showing persistent failings that the HSO see in complaints being made emerged from this exercise:

  • Diagnosis and failure to treat.
  • Risk assessment and safety
  • Dignity and human rights.
  • Communication.
  •  Inappropriate discharge and provision of aftercare.

The HSO also points out in the report that the other common factor in the cases examined is too frequent substandard complaint handling by the NHS organisation. This adds insult to injury, compounding the impact of failings. Read More

The New NHS Never Events Policy and Framework

By John Tingle

In tort law we have a very well-known Latin phrase, ‘Res Ipsa Loquitur’ (the thing speaks for itself). An inference of negligence can be raised by the events that occurred. In the National Health Service (NHS) in England there is a similar concept,‘the Never Event’. The Never Event concept is a USA import into the NHS and was introduced  from April 2009. The list of what is to be regarded as a Never Event has been revised over the years in the NHS and is currently set out by NHS Improvement.

Never events include, wrong site surgery, wrong implant/prosthesis, retained foreign object post procedure, mis-selection of a strong potassium solution, administration of medication by the wrong route and so on. Never Events are defined in NHS policy documentation as:

“…patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.  Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event.” (p.6) Read More