Mark Hughes

This report highlights the burden of health care-associated infections (HAIs) and antimicrobial resistance (AMR) and the related harm to both patients and health workers in care settings. It also presents an updated global situation analysis of the implementation of infection prevention and control (IPC) programmes at the national and health care facility levels, including a focus on the WHO regions. Headline points from this report include: On average, out of every 100 patients in acute care hospitals, seven patients in high-income countries (HICs), and 15 patients in low and middle-income countries (LMICs), will acquire at least one HAI during their hospital stay. Almost up to one third (30%) of patients in intensive care can be affected by HAIs, with an incidence that is two to 20 times higher in LMICs than in HICs, in particular among neonates. One in four (23.6%) of all hospital-treated sepsis cases are health care-associated and this increases to almost one half (48.7%) of all cases of sepsis with organ dysfunction treated in adult intensive care units. In 2023–2024, according to the system established to monitor the status of country progress towards the implementation of the AMR global action plan (the Tracking AMR Country Self-assessment Survey), 9% of countries did not yet have an IPC programme or plan. Only 39% of countries had IPC programmes fully implemented nationwide, with some being monitored for their effectiveness.

This Safety for All webinar promises to deliver valuable insights into PPE standards and safety protocols that safeguard both healthcare professionals and patients in the operating theatre. This event is designed for perioperative practitioners, safety officers, and all healthcare workers committed to enhancing safety standards in high-risk surgical environments. Attendees will gain practical insights on PPE usage, standards, and quality control directly impacting healthcare safety. The webinar will feature two expert speakers who bring decades of hands-on experience and strategic expertise in PPE and healthcare safety. Dr. Ali Mehdi – Consultant Trauma and Orthopaedic Surgeon, Medical Director at Kent & Canterbury Hospital, and a prominent educator in global safety standards. Edward Curtin, BSc (Hons) – Clinical Theatre Manager, East Kent Hospitals’ Day Surgery Unit, with extensive practical experience in managing operating room safety. Topics to be covered will include: The essential role of PPE in safeguarding healthcare workers and patients Differentiating PPE standards for various perioperative roles Addressing variability in PPE standards and its impact on safety Best practices for PPE usage within surgical settings The session will conclude with a live Q&A, providing you with the opportunity to engage directly with the experts and address any specific questions or concerns you may have regarding PPE standards. Register here.

This is letter from #ThereForME calls for an inquiry into the persistent and historical gaps in care for those with ME and Long Covid. It is co-signed by 28 organisations and smaller initiatives and has been sent to the Chair of the Select Committee, Layla Moran MP. Patient Safety Learning are one of the signatories of this letter.  The letter recommends that an inquiry is undertaken by the Health and Social Care Committee with a remit to investigate: Current gaps in care for ME and Long Covid, and their connections to historic approaches to infection-associated chronic conditions (including NHS care and research funding). Economic impacts, including the relationship between growing economic inactivity in the UK’s working age population and the lack of meaningful service provision for people with ME and Long Covid. Recommendations to strengthen future care and research for people with ME, Long Covid and other infection-associated chronic conditions - and how this can inform wider pandemic preparedness (including public health prevention strategies to mitigate the future health burden of infection-associated chronic conditions). Attitudes towards and assistance for patients with ME and Long Covid in society, including benefits provision, disability assistance, social care and guidance for settings including workplaces and education.

In this podcast episode, hosts Liz Jones and Darren Kilroy from RLDatix speak to Helen Hughes from Patient Safety Learning about how people, technology, and healthcare come together to create great experiences and support patient safety. The Connection: Where Tech Meets Humanity in Healthcare, is a podcast series from RLDatix, which explores the intersection of technology and human-centred care with the health and care sector. Key talking points from the conversation include: the true scope of patient safety why healthcare leaders must prioritise patient safety how to make patient safety everyone's job essential principles for electronic patient record system implementation.

On Wednesday 15 October 2024, the Department of Health and Social Care announced an independent review of patient safety across the health and care landscape in England. This blog sets out Patient Safety Learning’s response to this announcement. Today the Government has published the terms of reference for a review of patient safety across the health and care landscape. This review will: “… assess whether the current range and combination of organisations delivers effective leadership, listening, learning (including investigations and their recommendations) and regulation to the health and care systems in relation to patient and user safety (and to what extent they focus on the other domains of quality).”[1] This follows on from the publication of Dr Penny Dash’s latest report highlighting significant failings at the Care Quality Commission (CQC), the independent regulator of care providers.[2] The main focus of the review will be on the following organisations: CQC – including the Maternity and Newborn Safety Investigations programme National Guardian’s Office Healthwatch England and the Local Healthwatch network Health Services Safety Investigation Body (HSSIB) Patient Safety Commissioner for England NHS Resolution (patient safety-related learning functions only, not clinical negligence functions). The review will focus on how these bodies work together, with the findings feeding into the government's 10-year plan for the NHS, expected to be published in the spring next year. Patient Safety Learning welcomes this announcement and sets out some initial reflections on this below. A fragmented landscape The landscape of organisations with patient safety roles and responsibilities is fragmented and lacks coordination. This makes it often ill-suited to tackling complex systemic challenges to patient safety. This is an issue we highlighted in our report last year, The elephant in the room: Patient safety and Integrated Care Systems.[3] Therefore, we welcome any steps to promote cross-organisational working and coordination between regulators, ultimately with the aim of reducing avoidable harm. Figure 1: Patient safety environment in England The need to review roles and remits of patient safety organisations in England is not a new issue. The CQC itself referred to this as early as 2018, in their report Opening the door to change: NHS safety culture and the need for transformation.[4] This was also highlighted in 2020 by the Independent Medicines and Medical Devices Safety (IMMDS) Review. Chaired by Baroness Julia Cumberlege, this looked at the harmful side effects of medicines and medical devices and how to respond to them more quickly and effectively in the future. It stated that: “We have found that the healthcare system – in which I include the NHS, private providers, the regulators and professional bodies, pharmaceutical and device manufacturers, and policymakers – is disjointed, siloed, unresponsive and defensive. It does not adequately recognise that patients are its raison d’etre. It has failed to listen to their concerns and when, belatedly, it has decided to act it has too often moved glacially.”[5] Again this was raised last year by the Parliamentary and Health Service Ombudsman. In their report, Broken trust: making patient safety more than just a promise, they stated that: “… political leaders have created a confusing landscape of organisations, often in knee-jerk rection to patient safety crisis points. HSIB, the Patient Safety Commissioner, PHSO, NHS England, NHS Resolution and more than a dozen different health and care regulators all play important roles in patient safety. But there are significant overlaps in functions, which create uncertainty about who is responsible for what. This means patient safety voice and leadership are fractured. This is not due to a lack of dedication and professionalism from those tasked with championing patient safety. The problem is structural.”[6] Patient perspective An overly complex system of regulation and oversight that cannot tackle underlying patient safety problems ultimately has a very real human cost. The persistence of avoidable harm, and every avoidable death and disability that accompanies this, is an unnecessary tragedy for patients, families and healthcare professionals. At Patient Safety Learning, we believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. We identify this as one of our six foundations of safer care in our report, A Blueprint for Action.[7] This is also one of the seven strategic objectives in the WHO Global Patient Safety Action Plan, which states that: “Patients, families and other informal caregivers bring insights from their experiences of care that cannot be substituted or replicated by clinicians, managers or researchers. This is especially so for those who have suffered harm.”[8] We would therefore stress the importance that this new review must feature a clear commitment to including and involving patients as part of the process. This should not be a top-down exercise without patient and public input. Safety culture We believe that we need a transformation in the health and care system’s approach to patient safety. Fundamental to this is patient safety not being seen as another priority, which in practice will be weighed (and inevitably traded-off) against other priorities, but as a core purpose of health and care. This will require a cultural shift in health and care in the UK. There remains a significant gap between what organisation leaders say about creating a patient safety culture in the NHS and what is done in practice. We see plentiful evidence of this in inquiries into unsafe care, whistleblower testimonies and staff survey results. This was an issue we examined in greater detail earlier this year in our report, We are not getting safer: Patient Safety and the NHS staff survey results.[9] In this context, we believe it would be beneficial if the review also considers the role of national leadership organisations in actively contributing and creating a just and fair culture in health and care. Safety Management System There is a growing debate in patient safety about the possible benefits that healthcare may gain from moving towards a Safety Management System (SMS) approach. SMSs are an organised approach to managing safety which are widely used in different industries. An SMS approach is used to: help enable proactive assessments of risks specify how risks should be managed set clear lines of accountability and responsibility in addressing risks. In considering the application of SMSs to UK healthcare, HSSIB in October 2023 published a report, Safety management system: an introduction for healthcare.[10] This identified the requirements for effective SMSs, how these are used in other safety critical industries and considers the potential of application of this approach in healthcare. A country-wide SMS would have the potential to provide a more structured and joined up approach to patient safety strategies, involving all the national bodies. Patient Safety Learning believes that integral to this is a standards-based framework to ensure safe, quality patient care is consistently delivered.[11] A patient safety standards framework helps organisations understand ‘what good looks like’ for patient safety, understand where more action is needed for improvement, with clearly defined safety aims and goals. Such a framework will enable organisations and regulators to demonstrate a risk-based approach to patient safety and evidence achievement, can provide assurance that patient safety sits at the organisation’s core, improves performance through increased effectiveness, and enables patients and families, staff, funders and communities to identify and differentiate good safety providers. This is an issue we believe requires serious consideration and we look forward to contributing as part of our submission to this review. References Department of Health and Social Car. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024. Department of Health and Social Care. Independent report: Review into the operational effectiveness of the Care Quality Commission, 15 October 2024. Patent Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023. CQC. Opening the door to change: NHS safety culture and the need for transformation, December 2018. The IMMDS Review. First Do No Harm: The report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020. PHSO. Broken trust: making patient safety more than just a promise, 29 June 2023. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. WHO. Global Patient Safety Action Plan 2021-2030, 3 August 2021. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024. Health Services Safety Investigations Body. Safety management systems: an introduction for healthcare, 18 October 2024. Patient Safety Learning. Standards: What Good Looks Like, Last accessed 15 October 2024.

In July 2024, the Secretary of State for Health and Social Care commissioned Lord Darzi to conduct an immediate and independent investigation of the NHS. Lord Darzi’s report provides an overview of the current performance of the NHS across England and the challenges facing the healthcare system. Lord Darzi has considered the available data and intelligence to assess: patient access to healthcare the quality of healthcare being provided the overall performance of the health system NHS Performance Concerning the performance of the NHS, the report states the following key areas of concern: How long people wait, and the quality of treatment, are at the heart of the social contract between the NHS and the people. The NHS has not been able to meet the most important promises made to the people since 2015. People are struggling to see their GP. Waiting lists for community services and mental health have surged. A&E is in an awful state. Waiting times for hospital procedures have ballooned. Cancer care still lags behind other countries. Care for cardiovascular conditions is going in the wrong direction. The picture on quality of care is mixed. The NHS budget is not being spent where it should be—too great a share is being spent in hospitals, too little in the community, and productivity is too low. The NHS is not contributing to national prosperity as it could. Considering the drivers of NHS performance, the report highlights four inter-related factors that have contributed to the current state of the NHS: Austerity in funding and capital starvation. The impact of the Covid-19 pandemic and its aftermath. Lack of patient voice and staff engagement. Management structures and systems. Patient safety It notes the following points specifically in regards to patient safety: There have been improvements in patient safety, with more error-free care in hospitals and a reduction in the number of suicides in inpatient mental health facilities, partly as a result of sustained political attention. The power of prevention is illustrated through the impressive achievements of the Diabetes Prevention Programme, which reduces the risk of type II diabetes by nearly 40 per cent. Pressure and stress are at high levels which contributes to poor morale. This leads to burnout, absenteeism, high turnover, and the loss of trained staff. This dynamic impairs patient safety. Training in silos impairs teamwork which compromises patient safety. This is partly a result of divergent curricula for different staff groups that damage attitudes and a lack of focus on learning the skills for teamwork. Unstable working patterns and the lack of rest space impair teamworking and morale. Having dedicated space and refreshments benefits staff and improves patient safety. Transgressive behaviour is more common than admitted, which is very difficult to deal with, and damaging to morale and patient safety. Response to safety incidents is dominated by personal reactions; fear of blame by colleagues and others is a significant disincentive to investigation and learning; a culture of openness is essential to patient safety, but often lacking. Good progress was made in reducing healthcare acquired infections from 2007-08 to 2011-12, though since then progress has plateaued. Deaths from venous thromboembolism (blood clots in the veins, which can result from hospital stays) spiked during the Covid-19 pandemic and have not yet returned to pre-pandemic levels. The report also states that: “There has been good progress in improving patient safety, partly as a result of sustained focus and political attention, notably from the Rt Hon. Jeremy Hunt MP who was the longest serving health secretary and a passionate advocate for improvement. The proportion of care that is error-free has increased, while avoidable harms like pressure ulcers have fallen.” To support the statement above, it references evidence in its Technical Annex relating to rates of harm-free care recorded under the NHS Safety Thermometer initiative which monitored four conditions (pressure ulcers, falls, UTIs in patients with a catheter, VTEs) between January 2013 and March 2017. Themes for the 10-year health plan It concludes by identifying the following major themes for the forthcoming 10-year health plan, which the Government is aiming to complete around spring 2025: Re-engage staff and re-empower patients. Despite all the challenges and low morale, NHS staff are profoundly passionate and motivated to raise the quality of care for patients. Their talents must be harnessed to make positive change. The best change empowers patients to take as much control of their care as possible. Lock in the shift of care closer to home by hardwiring financial flows. General practice, mental health and community services will need to expand and adapt to the needs of those with long-term conditions whose prevalence is growing rapidly as the population age. Financial flows must lock-in this change irreversibly or it will not happen. Simplify and innovate care delivery for a neighbourhood NHS. The best way to work as a team is to work in a team: we need to embrace new multidisciplinary models of care that bring together primary, community and mental health services. Drive productivity in hospitals. Acute care providers will need to bring down waiting lists by radically improving their productivity. That means fixing flow through better operational management, capital investment in modern buildings and equipment, and re-engaging and empowering staff. Tilt towards technology. There must be a major tilt towards technology to unlock productivity. In particular, the hundreds of thousands of NHS staff working outside hospitals urgently need the benefits of digital systems. There is enormous potential in AI to transform care and for life sciences breakthroughs to create new treatments. Contribute to the nation’s prosperity. With the NHS budget at £165 billion this year, the health service’s productivity is vital for national prosperity. Moreover, the NHS must rebuild its capacity to get more people off waiting lists and back into work. At the same time, it should better support British biopharmaceutical companies. Reform to make the structure deliver. While a top-down reorganisation of NHS England and Integrated Care Boards is neither necessary nor desirable, there is more work to be done to clarify roles and accountabilities, ensure the right balance of management resources in different parts of the structure, and strengthen key processes such as capital approvals. Change will only be successful if the NHS can recover its capacity to deliver plans and strategies as well as to make them.