Mark Hughes

On the hub now is a link to the transcript of Tuesday's debate in the Scottish Parliament on the Scottish Government's response to the First Do No Harm report. While no formal details were given about the nature of this role, other than it will be open to consultation, some notable comments in the debate included: Alex Neil MSP suggested the role should be 'a parliamentary appointment, not a Scottish Government or NHS appointment', calling for the role to have real powers and should be (unlike the Scottish Human Rights Commissioner) able to investigate specific cases. Kenneth Gibson MSP also concurred with the suggestion this should be a parliamentary appointment. Pauline McNeill MSP stressed that 'the independence of a patient safety commissioner is paramount'. Neil Findlay MSP said 'that person must carry the confidence of survivors of mesh, Primodos and sodium valproate, and I suggest that survivors should be heavily involved in the recruitment of that person'.

Earlier this summer the Independent Medicines and Medical Devices Safety Review, led by Baroness Cumberlege, published its report First Do No Harm, which looked at how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. One of the central recommendations of this report was the proposed appointment of a Patient Safety Commissioner who would “would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices”. The UK Government has yet to respond to the recommendations of the report and on the specific suggestion of Patient Safety Commissioner the Care Quality Commission’s chief executive Ian Trenholm recently suggested he was not sure such a role was needed. However today in their new Programme for Government the Scottish Government have confirmed that they will seek to “establish the role of a Patient Safety Commissioner”, following the Health Secretary Jeane Freeman suggesting they were looking into this in August. While its still early days – we’re yet to hear details on the proposed Commissioner's responsibilities, resources and reporting lines – would be keen to hear other people’s thoughts on this. Do you think a proposed Patient Safety Commissioner in Scotland or any of the other three countries in the UK would be a positive development? If so, what would this type of role need in order to be successful and really make a difference?

Patient Safety Learning have now submitted our formal consultation response on Patient Safety Specialists which you can find on the hub below. In this we've identified some key areas of the draft requirements for the role which we believe should be made more explicit (such as understanding human factors/ergonomics) and some key elements of this notable by their lack of detail (experience of engaging patients, families and carers in patient safety) or complete absence (how these role holders will engage with staff on the frontline). We'd be keen to hear thoughts on this and share any other feedback that people have submitted as part of this consultation process.

While the survey shows some improvements in percentage terms in responses specific questions around safety issues, this progress needs to be situated in the context of the overall size of the NHS and persistence of the systemic patient safety challenge we face. So for instance, 59.7% of staff said that their organisation treats staff who are involved in an error, near miss or incident fairly, which is up on 52.2% in 2015. However due to the number of survey respondents (569,440) this still means in practice that more than 200,000 of those surveyed feel their organisation does not treat fairly staff involved in a error, near miss or incident. Even taking account of the improvement, this clearly cannot be seen as an endorsement of a NHS culture where staff can feel safe and secure in reporting concerns. You can find the full Patient Safety Learning blog looking at the responses that relate to the ‘Safety culture’ theme in the survey here.

On the issue of training for the police in regards to mental health, there’s been an interesting recent review on the broader issue from a police perspective by Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (the body responsible for reporting on the efficiency and effectiveness of police forces in England and Wales). Policing and Mental Health (November 2018) reflects on the increasing degree to which the police are responding to people living with mental health problems in variety of situations. It noted that while forces are investing in training, the quality of this remains inconsistent across England and Wales, stating: Only around a third of forces have invested heavily in mental health training (in terms of time allocated in the training calendar and the breadth of different areas of mental health the training covers). Many forces are too reliant on e-learning with less opportunities for face-to-face, instructor-led discussions to cover more complex topics. The report also found ‘a general lack of understanding by forces of the extent and nature of their mental health demand’ and emphasised the need for more collaborative work with partner organisations to gain a clear picture and help plan out their approach. Some of these findings do seem to ring true with the specific example cited here. Whether the officers should have been put in a position of needing to care for the people involved for several hours is obviously a question, but it appears as though there certainly isn't the capacity to do this, nor the appropriate training. In terms of security staff, again there is a question of whether we should be reaching a situation where they are responsible for caring for people living with mental health problems for extended periods of time in these circumstances, but either way it would seem sensible that those working in health care settings do undertake appropriate training in this respect. The National Association for Healthcare Security act as a professional body for security staff in the NHS, though I don't believe membership is mandatory for those carrying out these roles in the NHS, maybe this is an issue they are aware of and could help to take this forward.

This report raises some really important questions about who has responsibility for monitoring this, noting that the ‘role and responsibility of national organisations to oversee the implementation of these alerts was unclear and ineffective in some cases’. Who should be responsible for this? NHS England and NHS Improvement, the CQC or perhaps the National Patient Safety Alerting Committee? You can find the full Patient Safety Learning response here: https://www.patientsafetylearning.org/blog/response-to-avma-report-patient-safety-alerts

Unfortunately this is not a new problem, with a report published by the National Patient Safety Agency in 2009 drawing on data from 135 cases from the National Reporting and Learning System where patients had ‘lost their sight or suffered deterioration in their vision because appointments are postponed, cancelled or patients are not put into the follow up system at all’ to highlight this issue. You can find the full Patient Safety Learning response to this report, considering how the implementation of these recommendations will be key to their success, here: https://www.patientsafetylearning.org/blog/response-to-hsib-investigation-lack-of-timely-monitoring-of-patients-with-glaucoma

On Twitter we've had a user follow up and suggest that it could be appropriate to report this type of issue with the Medicines and Healthcare Regulatory Authority's (MHRA) Yellow Card scheme. They've suggested that implementing NEWS into a electronic system formally comes under the category of 'Creating a Medical Device' so therefore could fall under this: https://yellowcard.mhra.gov.uk/.

It would be interesting to look in more detail at how politicians have engaged with patient safety in recent years, my suspicion would be that outside of the specific reports from regulators and major incidents such as the Mid-Staffs Inquiry it has been on quite an ad-hoc basis. From a parliamentary perspective, a quick review of Hansard seems at first to suggest a low level of engagement, revealing that there have been only 4 debates on patient safety (3 in 2014, 1 in 2018) and 47 written ministerial statements in the last ten years. However there have been numerous debates on issues such as dispensing errors, safety of medical devices and major incidents, so the main challenge may be harnessing these to help draw attention towards the bigger picture and need for changes at a system level. Aside from the top down down role politicians have in setting priorities for the health care system they can also provide a conduit for increased patient engagement and input. If politicians can make the case for patient safety, providing a spotlight for their constituents in cases where mistakes are made and/or learning subsequently implemented, this could be really beneficial. An active All Party Parliamentary Group would certainly be one way of doing this, providing a platform for sharing stories and highlighting good and bad practice.