• 62% of those who are currently providing or those who have previously provided unpaid care said that they had no choice in taking on the role because no other care options were available – this is around 10 million people.
• The impact of caring has been more negative than positive for all areas unpaid carers were asked about, particularly for employment, finances and savings, and physical and mental health.
• By far the biggest negative impact has been on mental health with 63% of current and former unpaid carers saying that caring had a negative impact on their mental health, with 24% saying it had a ‘very negative’ impact. An estimated 10.1m current and former unpaid carers in the UK experienced a negative impact on their mental health as a result of caring. An estimated 10.1 million current and former unpaid carers say caring had a negative impact on their mental health 48%
• Current and former unpaid carers also said that caring had a negative impact on their:

» Physical health (53%) – around 8.5m people in the UK

» Job and ability to work (48%) – around 7.7m people in the UK

» Finances and savings (47%) – around 7.6m people in the UK

• Of those who said they had no choice about taking on a caring role, a greater proportion of current unpaid carers and former unpaid carers experienced negative effects of caring.
• Women fared worse than men due to the impact of caring; they were far more likely to say that caring has had a negative effect on their physical and mental health, employment, pensions and relationships.
• Those aged 45 to 54 were most likely to have no choice when taking on a caring role and were most likely to say that caring has had a significant negative impact on their finances, career and pensions.

Carers Week also commissioned a second YouGov Political Omnibus poll of over 4,200 members of the general public, which found that:

• 73% of the UK adult population said that the next government should provide more support for unpaid carers
• When asked about what the next government should focus on to support unpaid carers, the most popular issues picked by the general public were financial support for unpaid carers (53%) and investment in social care to enable unpaid carers to take a break (53%).

• A rising number of NHS organisations are combining traditional approaches – responding to illness where it occurs – with population health approaches that seek to better understand, target and prevent illness. Our evidence suggests that when these changes are possible, they bring benefits for systems and citizens.
• Understanding how these have developed could help address some of the key challenges of increasing health inequalities and efficient use of resources and, at scale, help health and social care systems to create a better balance between treating existing conditions to preventing illness.
• This report explores four case studies where population health and population health management approaches have been developed in recent years and show demonstrable benefits.
• These case studies, combined with discussions with health leaders involved in their development, reveal some of the key components involved in shifting towards population health and population health management approaches.
• By taking account of the full range of factors contributing to wellbeing and gathering data to understand how they affect populations, it is possible to design far more targeted interventions. These interventions typically involve the NHS developing strong and broad partnerships, working with a range of partners, including the likes of housing associations and the voluntary sector.
• This requires good data and shared understanding, which can greatly support an understanding of specific populations and segments of populations. The more information that can be brought together from across relevant sectors, the greater the insight that is typically possible.
• The interventions which result from population health approaches often differ quite significantly from traditional understandings of how the healthcare system should operate. They involve the NHS taking on different responsibilities or addressing existing responsibilities in very different ways. This means there is a need for new approaches to funding and governance and changing perceptions if such transformation is to truly flourish.

To begin, you need to understand how regulatory change happens in aviation. The International Civil Aviation Organisation (ICAO) sets standards and recommended practices (SARPS), which are designed to ensure the highest practicable degree of uniformity across aviation in several areas, safety being one of them. All signatory UN states are required to incorporate the SARPS into their national regulations or declare a divergence. 

Typically, States do not like to diverge from ICAO SARPS. The International Air Transport Association (IATA) is the club most airlines belong to.  It has it’s own audit process that requires airlines to conduct a comprehensive review every 2 years. The audit is based on the ICAO SARPS. If you don’t do the audit you cannot be in the club, and if you are not in the club you cannot operate into some airports. Possession of a SMS, then, is an ICAO requirement, but is further backed up by the need to satisfy the IATA audit. This need for compliance is a key driver of the SMS concept.

The implementation of a SMS ran in parallel with the rollout of quality management in aviation, but also supported the move to ‘performance-based regulation’. Historically, aviation has been very prescriptive in term of oversight. The State Aviation Authorities laid down what was required of an airline and teams of inspectors would periodically visit and check that things were being done according to the rules. But Regulators were themselves becoming increasingly resource-constrained, so the philosophy changed. Airlines would be told the intent of the regulation and how to achieve it and the Regulator would now look at outputs from processes. SMS is an example of performance-based regulation. The transition to a SMS was not trouble-free. Quite often the argument for SMS was framed around cost savings on the part of Authorities. Canada is a case in point, where the savings were made ahead of implementation, and a report by the Auditor General of Canada found that safety was degraded during the transition as staff were cut and no one was tracking progress.

The SMS concept is now well-established in aviation, but what is it exactly? In simple terms, it is an organising framework. It is often described as having four pillars:

1. Safety policy.
2. Safety risk management.
3. Safety assurance.
4. Safety promotion.

These pillars pulled together existing concepts while adding some new requirements. The safety policy pillar lays out the management’s commitment to safety, sets objectives and defines the methods and processes that will be applied in the organisation. You might expect ‘just culture’ to be included in this pillar. The ‘just culture’ concept originated in the USA as a response to the prevailing punishment culture that characterised how aviation dealt with failure. It was product offered for sale. You could become qualified as a ‘just culture practitioner’ and the original just culture decision tree was trade-marked. However, the benefits of the approach were recognised and adopted by ICAO. The subsequent SARP required airlines to develop just culture policies and it is not uncommon to find that airlines have separate just culture and SMS manuals. Just culture illustrates how SMS has developed piece-meal over time.

The safety risk management pillar includes hazard identification and risk management. It could be considered the heart of SMS. It includes safety reporting systems as a means of identifying new hazards and evaluating risk. Again, safety reporting has developed over time. With the advent of complex jet aircraft after the 1939–1945 war, reporting systems were used to track the reliability of technology. Lists of types of failure were published and airlines were required to report any encounters. Over time, aircraft became more reliable and more sophisticated. The former prompted a recognition that the industry needed to track failures in other areas (humans) and, in the case of the latter, the list of technological failures to be reported just got longer and longer. Safety reporting (or, rather, why people do not report) is a complex topic, but what has happened over time is that ‘anonymous, confidential’ reporting has emerged as a possible solution.

The safety assurance pillar includes activities that provide analysis and oversight of safety, including periodic safety committee meetings, audits and data analysis.

The safety promotions pillar incudes the provision of findings and feedback to bolster safety, reinforce a positive safety culture and generally increase understanding of safety. Airlines struggle with this. Such is the fear of safety information leaking into the public domain, many airlines limit information sharing internally. But there are other problems. ICAO mandates that States must have an accident investigation capability. Equally, the range of events that falls under the remit of the State investigators is laid down. The complexity of a major investigation is such that the time taken for the report to be published is so long that the circumstances relating to that event have probably changed. And, in any case, few people in that airline would feel motivated enough to read the report. Events that fall outside of the scope of the ICAO mandate fall to the airline to investigate, but they often lack the resources or the skills to undertake meaningful investigations, let alone disseminate useful learning points.

To conclude, SMS is a concept with many component parts. It will stand or fall based on the quality of those parts. It is not a single solution: it is implemented differently in every airline. Would it add value to patient safety? Probably, in some areas. Is it a coherent solution to the problem of patient safety? Probably not.

Further reading on the hub:

• Why healthcare needs to operate as a safety management system: In conversation with Keith Conradi
• The involvement of patients and families in a healthcare safety management system: In conversation with Jono Broad
• Patient Safety Learning – The elephant in the room: Patient safety and Integrated Care Systems
• Error isn’t a problem – the problem is the word ‘error’: a blog by Norman MacLeod

While the EVO pilot framework ended after the fourth session, the trust was keen close the loop and measure the benefit of the changes made. Following pathway changes the service could see the  positive impact on patient experience but needed to work with the costing team to understand the  impact on activity and cost, and therefore demonstrate if there had been any realisable efficiency and  productivity gains.

• Because head CT scans are provided by a neighbouring acute trust, reducing the number of  patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT  scan referrals and a £7,800 direct cost saving.
•  The number of patients not attending appointments reduced from 572 in the baseline period  to 379 after implementing pathway changes. While not a cash releasing saving this improved  overall efficiency and productivity for the service and contributed to a reduction in overall unit  price per attendance.
• At the start of the project, the average unit price for patients attending the memory service  was £280.93. Through a combination of direct cost savings and efficiency and productivity  gains arising from the revised pathway, this figure had reduced to £205.12 in the review  period.

Read the full case study via the link below.