Mark Hughes

In February 2022, NHS England published a plan to recover elective and cancer care over three years from April 2022 to March 2022. Analysing the implementation of this plan to date, the Public Accounts Committee’s has come to the following conclusions and recommendations: Cancer waiting times are at their worst recorded level and NHS England (NHSE) will not meet its first cancer recovery target. Recommendation: NHS England should be able to treat 85% of people with cancer within 62 days of an urgent GP referral and no one should ever have to wait more than 104 days for cancer treatment. It is unacceptable that 8,100 people waited over 104 days in the first five months of 2022–23. As a matter of urgency, the Department of Health and Social Care and NHS England should do whatever is required to bring cancer treatment back to an acceptable standard. NHS England was over-optimistic about the circumstances in which the NHS would be trying to recover elective and cancer care. Recommendation: NHS England and the Department of Health and Social Care should revisit their planning assumptions for the recovery and publicly report any updates to targets so that patients and NHS staff can see a clear and realistic trajectory to achieve the 62-day cancer backlog target, the 52-week wait target for elective care, and, ultimately, the 18-week legal standard for elective care. NHS funding has increased, but to deliver key priorities such as elective and cancer recovery it will need to be spent in the most cost-effective way. Recommendation: NHSE should transparently describe how the additional funds for elective recovery have been allocated. Alongside the Treasury Minute response, it should also write to us providing details of the programmes on which it expects the £14 billion to be spent, the independent evaluations it has put in place to monitor the effectiveness of additional spending, and how it expects additional spending to improve NHS productivity. NHS England’s elective recovery programme partly relies on initiatives which have potential but for which there is so far limited evidence of effectiveness. Recommendation: NHS England should know more about the conditions necessary for individual programmes to make the greatest contribution possible to recovery. Alongside its Treasury Minute response to this report, it should write to us more fully describing the real-world impact of community diagnostic centres, surgical hubs, increased use of the independent sector, and the advice and guidance programme. It should set out its understanding of the extent to which these initiatives have so far generated genuinely additional activity, rather than simply displacing activity elsewhere in the NHS. NHSE started 2022–23 with a strategy but spent most of the year dealing with tactical issues and its strategic and programme management of the recovery must improve. Recommendation: NHS England must lift its sights and refocus on its strategic duty to offer direction to the whole NHS. This should involve making difficult trade-offs to address historical inequalities between areas, and by having a clear set of actions to improve leadership. To demonstrate progress, NHS England should write to us by the Summer recess setting out the action is has taken to address variation in elective and cancer performance and provide evidence of the impact this has had on patient waiting lists. The NHS’s recovery cannot succeed without comprehensive, realistic and sustainable plans for the future of the workforce and the capacity of adult social care. Recommendations: The Department of Health and Social Care should work with NHS England to reassess the achievability of elective and cancer recovery targets following the publication of its workforce plan in 2023, and planned improvements to the discharge of patients into adult social care. It should write to us as soon as possible describing the conclusions of this achievability assessment. The Department should publish the underlying assumptions of its workforce projections alongside the forecasts in the workforce plan. This should include quantification of key assumptions, particularly on productivity, domestic training and overseas recruitment and, in full, the independent reviewer’s assessment.

The report includes summaries of Conference's keynote speeches by: John Dean, Clinical Vice President at the Royal College of Physicians Dr Henrietta Hughes, Patient Safety Commissioner for England Patricia Marquis, Director for the Royal College of Nursing Dr Lesley Kay, Deputy Medical Director at the Healthcare Safety Investigation Branch It also provides overview of the following panel sessions and presentations featured across the day: Hearing the patient voice – a panel session focused on the importance of engaging with patients and families at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. Extravasation – a presentation from Andrew Barton, Chair of the National Infusion and Vascular Access Society, on the risks posed by extravasation injuries . Improving staff safety – a panel session focused on the importance of ensuring the health, safety and wellbeing of staff across the healthcare system and the benefits that this has for patient outcomes and developing a safety culture. Creating a safe environment in hospital theatres – a presentation from Lisa Nealen, Peri-operative Practitioner at Gateshead Health NHS Foundation Trust, setting out the hazards posed by surgical smoke. Persistence of avoidable harm – a panel session focused on the persistence of avoidable harm in healthcare and the action needed to tackle the implementation gap that exists between what we know improves patient safety and what is done in practice. Preventing workplace stress – a panel session considering workplace stress, how to prevent and link between this and patient safety. Read the full report online or download it as a PDF at the bottom of this page. Other Safety for All campaign resources Mind the implementation gap: The persistence of avoidable harm in the NHS (7 April 2022) Safety for All: Patient and healthcare worker safety – two sides of the same coin (20 October 2021) Staff Support Guide: a good practice resource following serious patient harm (29 June 2022)

What is a Westminster Hall debate? Westminster Hall debates give Members of Parliament (MPs) an opportunity to raise local or national issues and receive a response from a government minister. Any MP can take part in a Westminster Hall debate. Essex Mental Health Independent Inquiry Vicky Ford MP opened this debate by raising concerns about the Essex Mental Health Independent Inquiry. This centred on a recent open letter from the inquiry's Chair, Dr Geraldine Strathdee, who stated that as a non-statutory inquiry she felt they would be unable to fulfil their terms of reference, due to extremely low engagement from staff at Essex Partnership University NHS Foundation Trust. She had highlighted that, of the 14,000 members of staff whom the inquiry had written to, only 11 had agreed to give evidence. In the debate it was noted that Vicky Ford MP, Sir James Duddridge MP, Priti Patel MP and Sir John Whittingdale MP were now all calling for the Essex Mental Health Independent Inquiry to be converted into a full statutory inquiry, which will compel witnesses to give evidence, to ensure full transparency and greater public scrutiny of its progress. This debate was responded to on behalf of the Government by Neil O’Brien MP, Minister for Primary Care and Public Health. He noted that the Secretary of State for Health and Social Care had recently met with Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust, to ask about the actions the Trust is taking to encourage staff engagement with the inquiry and to seek assurance that the Trust will provide all the evidence and information requested by the inquiry. Regarding the potential of converting this into a statutory inquiry, he stated that: “Our view is that a non-statutory inquiry, if it is possible, remains the most effective way to get to the truth of what happens. It is quicker, and potentially involves not having to drag clinicians through the public processes of a statutory inquiry. When my right hon. Friend the Member for Witham was Home Secretary, she used the non-statutory process to protect those who did not want to be named and dragged through a statutory process. It is faster and more flexible, which is why it was chosen in the first place. Although statutory inquiries can compel witnesses to give evidence under oath, that does not necessarily mean that it will be easier to obtain the evidence we want. However, all that turns on people co-operating with a non-statutory inquiry, and we now need to see a quantum leap in the level of co-operation. We will not hesitate to move to a statutory inquiry if we do not see a dramatic increase in the level of co-operation. Given how long this has gone on, we cannot wait for a long period for a transformation in the level of engagement. While the approach remains non-statutory for now, we will not hesitate to change that approach if we do not see the change we need rapidly.”

In this statement the Minister sets out that the rapid review will: Focus on data and evidence currently available to healthcare services, including information provided by patients and families. Consider how this data and evidence can be used more effectively to identify patient safety risks and failures in care. Be chaired by Dr Geraldine Strathdee, who is also the Chair of the Essex Mental Health Independent Inquiry. The review will be separate from, but complementary to, the Essex Inquiry.

In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, 4 January 2023) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)

This study looked at the frequency and types of harm in 11 hospitals in Massachusetts, considering a sample of 2809 randomly selected admissions. It identified at least one adverse event in 23.6% of these admissions. Among the adverse events, around 22.7% of these were judged to be preventable. Discussing the findings, the authors note that preventable adverse events were identified in approximately 7% of all admissions in this sample, with those categorised as serious, life-threatening or fatal identified in approximately 1%. The most common type of event was adverse drug events (39%), followed by adverse events related to a surgical or other procedure (30.4%).

What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. Foetal valproate spectrum disorder: Fatalities Caroline Nokes, MP for Romsey and Southampton North, opened this debate by talking about the case of Jake Alcroft, a 21-year-old who died in April this year after an infection triggered by problems with his kidneys. The coroner listed foetal valproate syndrome as a contributing factor to his death because of the physical damage done to Jake as an exposed baby, which meant that his bowel and bladder did not work properly and he relied on urostomy and colostomy bags. Some key points highlighted in this debate included: Warnings about sodium valproate and the risks during pregnancy are still not being consistently displayed on pharmacy prescriptions. Some of the recommendations made in relation to this by the Independent Medicines and Medical Devices Safety (IMMDS) Review have still not been implemented effectively. There are concerns that the illness can continue down the generations, and that is not yet well understood but it is causing real fear for the families who have been affected so far. Towards the end of this debate, Caroline Nokes made three requests for the Minister: To acknowledge that sodium valproate has contributed to a death. Asking if she was satisfied that the pregnancy prevention programme is adequately effective and that the information is properly communicated to women of child-bearing age. Calling for redress for patients and families affected by this, as recommended by the IMMDS Review. Maria Caulfield MP, Minister for Mental Health and the Women's Health Strategy, provided the Government response at the end of this debate.

What is an Adjournment Debate? There is a 30 minute Adjournment Debate at the end of each day's sitting of the House of Commons. They provide an opportunity for an individual backbench MP to raise an issue and receive a response from the relevant Minister. Unlike many other debates, these take place without a question which the House of Commons must then make a decision on. Diagnosis of pulmonary embolisms In this debate Helen Hayes, MP for Dulwich and West Norwood, outlined significant patient safety issues relating to misdiagnosis of pulmonary embolisms. She highlighted concerns raised by her constituent, Tim Edwards, relating to the premature death of his mother Jenny. His research has estimated that there was a minimum of 400 excess pulmonary embolism deaths across England from April 2021 to March 2022, and that that excess figure is attributable to cases that were missed. She asked the Minister to agree to work with NHS England to commission a review of the data set out in a forthcoming report from Tim Edwards and the related concerns raised by the Royal College of Radiologists, with a view to ensuring that the rate of misdiagnosis of pulmonary embolism is greatly reduced.

The report highlights six key themes, identified from discussions and good practice ideas, to help develop a safety culture: Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities It also provides a brief overview of three case studies, with links to full versions of these on the FutureNHS Collaboration Platform.

Bell Ribeiro-Addy, Member of Parliament (MP) for Streatham, who secured this debate, highlighted some of the key statistics around black maternal health and mortality in the UK: Black babies have a 121% increased risk of stillbirth and a 50% increased risk of neonatal death. Asian babies have a 55% increased risk of stillbirth and a 66% increased risk of neonatal mortality. Black women have a 43% higher risk of miscarriage, and black ethnicity is now regarded as a risk factor for miscarriage. She also referred to the findings of black maternal experiences survey carried out by grassroots organisation Five X More published earlier this year. She noted that this report highlights all the negative interactions that women experienced with healthcare professionals, from feeling discriminated against in their care to receiving a poor standard of care, which put their safety at risk, and being denied pain relief because of the trope that black women are less likely to feel pain. The Government response in this debate was provided by Maria Caulfield MP, Minister for Mental Health and Women’s Health Strategy.