Mark Hughes

5 hours ago, naomi said:

I would like to know if the there has been a similar review in respect to access to beds across mental health services as there is known pressures across this system too and mental health has always been and continues to the the Cinderella service.

Where individuals require access to a mental health bed but are having to remain in a general hospital bed, this has impact on the ability of ED's to transfer into their own wards - these systems are connected and more evidence should be collated and shared alongside the above. 

I don't think there has been anything similiar to the Nuffield analysis quoted here specific to mental health beds but its definitely an area that needs greater investigation.

There was some analysis last year about the decrease in mental health beds more generally across the system (Guardian coverage here) and current occupancy levels remain above the recommended level (Royal College of Psychiatrists analysis here) but suspect that picture is more complicated regionally, you would imagine some areas are under much more strain than others. Also today's new National Audit Office report looking more broadly at mental health performance highlights bed occupancy issues.

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.

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/.