Senior female woman patient in wheelchair sitting in hospital corridor with nurses and doctor

Care Quality Commission Annual Assessment of Health and Social Care

By John Tingle

The independent regulator for health and social care in England, the Quality Care Commission (CQC) has recently published its annual report on the real-time state of health and social care in England. It analyses trends, shares examples of outstanding, good, and poor health care care practices. It provides a true, unabashed account of issues facing the National Health Service (NHS) and health care delivery.

A Health System Stretched

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Hand placing wood toy block on top of a tower. The blocks all have images of medical-related items on them, like pills, stethoscope, syringe

Lost in the Jungle of Patient Safety Reports, Publications and Initiatives?

By John Tingle

In terms of the progress of developing a patient safety culture in the National Health Service (NHS) in England, the Daily Telegraph reports comments made by Professor Ted Baker, the Chief Inspector of Hospitals at the Care Quality Commission (CQC) at a recent conference in London. He held the view that “little progress” has been made improving patient safety in the NHS in 20 years, and that never events such as wrong site surgery were still happening because the overall culture is one of defensiveness. The Telegraph reported, “He told The Patient Safety Learning conference that hospital managers routinely hide evidence from the CQC, because they regard the organisation as out to blame them.”

The Telegraph also mentions an NHS estimate in July that 11,000 patients a year may be dying as a result of blunders, partly as a result of a “blame game” culture between staff.

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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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Photograph of a gavel in front of a British flag

Trends in NHS Clinical Negligence Litigation Revealed in Latest NHS Resolution Annual Report and Accounts

By John Tingle

NHS Resolution is a major National Health Service (NHS) organisation concerned with patient safety, health quality, and litigation management in the NHS and provides essential infrastructure services. NHS Resolution has recently published its 2018/19 annual report and accounts, which contains valuable insights into the current state of clinical negligence litigation in the NHS in England. Several key themes and trends are identified in the report.

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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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NHS logo on the side of a building

Testing the Temperature of Patient Safety in the NHS

In terms of transparency and accountability the National Health Service ( NHS) in England is excellent at producing insightful, well-produced reports on health quality and patient safety. It does this on a regular basis and one of the great difficulties faced by NHS nurses and doctors today is the sheer volume of reports published. It’s an impossible task for nurses and doctors to keep up to date with all the reports published and to maintain heavy workloads in resource constrained environments. It’s also hard for health care staff to know which reports to prioritize and which are authoritative.

There is an urgent need for the NHS to create a one stop, patient safety information hub which collects reports from all NHS sites and other important global sites, putting everything into one accessible place. Some recent reports on written patient complaints have been published which are helpful in assessing, testing patient safety and health quality in the NHS. Read More

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

hand of a doctor holding a stethoscope

Patient Safety: The Urgent Need for Global Information Sharing and Learning

Patient harm is the 14th leading contributor to the global disease burden, according to a new report by WHO, OECD, and the World Bank.

In resource-constrained health care environments, it is important not to reinvent the wheel and waste money when existing, proven patient safety solutions already exist in other countries. Global patient safety knowledge sharing, and learning helps all countries, regardless of income level and this needs to be encouraged. Read More