HelenH

Hi @Claire Kilpatrick Great comment and it would definitely be great to hear more about the barriers to implementation gaps and how they’re being addressed. That would be a fabulous resource for others, given your expertise and experience on this area. Many thanks

Thx Liz, I know! Where has the time gone? Fabulous that you’re a regular PSMN network meeting attendee and active contributor too. What will the next 5 years bring? Looking forward to you and colleagues shaping that journey. Would love to build some communities of practice too

Thanks @Jules I've used AI to summarise this. Will watch the full presnetation too! “Can improvement and innovation save the NHS?” by Professor Mary Dixon-Woods Below is an AI generated concise summary report of the video “Can improvement and innovation save the NHS?”, a keynote by Professor Mary Dixon-Woods published by THIS Institute in May 2026. The lecture argues that improvement and innovation can help the NHS, but only when they are evidence-based, realistically implemented, attentive to inequality, and supported by well-functioning organisations rather than treated as universal solutions in themselves.[1][2] Executive summary The lecture presents a sober assessment of current NHS performance across access, timeliness, quality, effectiveness, and equity, using examples such as elective delays, cancer treatment delays, unwarranted variation in diabetes and breast cancer care, and persistent inequities in maternity outcomes. Professor Dixon-Woods argues that these problems are not simply deficits of effort or goodwill, but symptoms of deeper organisational, policy, and system design failures that limit the impact of improvement work.[2] Her central message is that innovation and improvement are necessary but insufficient unless they are grounded in evidence, matched to context, and protected from hype, overclaiming, and poorly designed large-scale programmes. She cautions that the NHS has often adopted interventions with excessive optimism, weak evaluation, and inadequate attention to implementation, creating cycles of enthusiasm followed by disappointment.[2] Main arguments The lecture identifies several core challenges facing the NHS: care is not consistently accessible, timely, high quality, effective, or equitable, and these deficits vary substantially by geography, deprivation, ethnicity, and sex. Examples cited include falling public satisfaction, persistent elective backlogs, non-compliance with guidance in some diagnostic testing, and marked disparities in maternal mortality and severe morbidity.[2] A major theme is that variation should not be dismissed as inevitable background noise, because it often indicates remediable organisational weakness, uneven capability, or failure to apply existing knowledge reliably. The lecture also highlights the continued use of some low-value activity alongside failures to deliver proven beneficial care, showing that both underuse and overuse coexist in the NHS.[2] Improvement lessons Professor Dixon-Woods argues that improvement succeeds least when it is treated as a slogan, a centrally imposed programme, or an assumption that any change is inherently beneficial. She emphasizes that large-scale initiatives often fail when they are oversold, under-specified, weakly evaluated, and inattentive to frontline realities, staffing pressures, and competing operational demands.[2] The lecture supports a more disciplined model of improvement: test interventions properly, understand mechanisms, use robust evidence, and distinguish genuinely effective innovation from attractive but weakly evidenced ideas. In practice, this means improvement should be designed as serious applied inquiry rather than as advocacy, branding, or policy theatre.[2] Governance implications For board and governance audiences, the lecture implies that oversight should focus not only on performance outcomes but on the organisational conditions that make safe and effective improvement possible. These conditions include the ability to identify risk early, hear uncomfortable information, respond to variation, evaluate change honestly, and sustain attention on inequity as well as aggregate performance.[2] The talk is particularly relevant to patient safety governance because it links poor outcomes to structural and cultural issues rather than isolated individual failings. It therefore supports governance approaches that emphasise system surveillance, speaking up, learning capability, and critical scrutiny of improvement claims before scale-up.[2] Actions for leaders A practical reading of the lecture suggests five priorities for NHS leaders and boards: · Treat major improvement claims as propositions requiring evidence, not as self-validating solutions.[2] · Target unwarranted variation as a governance signal of uneven quality and possible safety risk.[2] · Examine inequity explicitly, especially where deprivation, ethnicity, sex, or geography are linked to worse outcomes.[2] · Avoid adopting innovations at scale without credible implementation planning and evaluation.[2] · Strengthen organisational conditions for learning, challenge, and candour so that weak signals are detected earlier.[2] An example of the lecture’s practical relevance is its treatment of maternity inequity: disparities in mortality and morbidity are presented not as unfortunate externalities but as evidence that service design and care delivery are failing some groups more than others. That framing is directly applicable to board assurance, quality committees, and patient safety improvement programmes.[2] Would you like this converted into a more formal board paper style with headings such as background, key issues, implications, and recommendations? 1. https://www.youtube.com/watch?v=E_iCWIazGtU 2. https://support.google.com/youtube/answer/15930243?hl=en-GB

How awful, I'm so sorry it wsa so ghastly for you. I agree, it is inequitable, why some procudures routinely offer sedation and others don't. Convention and geneder bias I guess. It's not good enough.

Absolutely, as you say, this must be system-wide

Thanks @JULES STORR And I strongly agree with their vision: 'In response, this paper proposes a transformational vision for quality of care that moves beyond traditional models. This vision is rooted in two interconnected pillars. First, a focus on outcomes that truly matter to people and populations, prioritizing health and well-being over service volume. The second pillar is a whole-systems perspective that embeds quality across all levels of governance, policy, and financing.' The narrative of reducing waiting lists and addressing financial defeicits, the predominant focus of current leadership, is an eaxmple of why there needs to be a great focus on outcomes, including safer care.

I’m sorry, what’s wrong with my acting as Doreen 😂 It’s a useful resource to help teams better understand risk and patient safety and take action to mitigate and manage. We’re very keen on developing more. As you say, Elaine, the need is great

It’s a challenge, isn’t it, evaluate and evidence that impact? Research needed!

Fascinating, thanks for sharing. I've started reading. Loved this advice: 'The Chief Nursing Officer at my hospital gave me great advice when I started, stating “You are no longer being paid for your subject matter expertise. You are now being paid for your leadership and ability to drive change, get people on board and be an inspirational leader…So, you must stop worrying about knowing everything - you have people for that, and they will help you.'

Thanks @harrisestate1 for sharing your experience. Very reassuring to know that you had excellent support after this rare event. Must have been a real shock and very alarming.

@lzipperer You and your collegues have been beacons of professionalism, collaboration and knowledge sharing for decades. You'll be sorely missed and we'll try to honour the impact you've had through our work and this hub. It is shocking not only the demise of PS Net but the speed of the removal of valuable content to not only the PS community in the US but also the global patient safety community. With much sadness but also gratitude for everything you've done personally and professionally x

Hello all, avoidable harm causes immeasurable harm to patients, families and carers. So sorry Carrie for the pain you and your family has suffered; that doesn't ever really go away especially where there is inexcusable denial and cover up. Second victim was an expression of the distress that staff feel when they are unintentionally involved in avoidable harm. My good friend and collegue, Professor Albert Wu, coined the phrase many years ago and has since said that he wished he hadn't - of course the second victims are family and friends of harmed patients. But the name seems to have stuck and as Leah mentions, there's even an organisation that supports staff affected by patient safety of the same name. If staff work in conditions where safety isn't a priority, then they will unitentionally contribute to avoidable harm. And the distress will also be felt by staff undertaking investigations, especially where they might see the same serious harm over and over again if the organisation they work for doesn't take the action needed to improve patient safety. So we all need to design and deliver for patient safety - for patients and families (who experience the worst impact) and also for clinicial staff, investigators, everyone. Best wishes, Helen

Hi @Miss Elaine Freeman Thank you for the comment. All voices are valuable, I agree. I'm assuming that you're a member of the Patient Safety Partners network and the collaboration we support there to give voice to PSPs, share resources and promote the valuable role that PSPs do? We'd love to share perspectives from PSPs and if you'd like to write for us, attributably or otherwise, we'd be very happy to support you and publish your insights. The netwrok are thinking of developing a newsletter for PSPS so that's another way, of course. Do please get in touch if you'd like to follow up. Helen [email protected] See PSP resources here

apologies @Tom Rose I've only just seen this comment. A bit late I know. I think they were shared on the National Natssips Network community site. Hi @Sam - please can you advise/share.

Thanks so much for undertaking this hugely insightful and alarming work. Just thinking of community and social care. Much research needed. If we can help support you on this quest, please let us know. Helen

Well said. There’s a huge assumption that computer records are always right and inadequate mechanisms to correct them.

Really valuable insight into how to get the most impact from an After Action Review. A deceptively simple tool but lots of TLC and support is needed in its application. Fabulous driving analogues! Thinking there maybe more…. - Making sure you’ve got all the passengers in the car before you start. And they’re safely strapped in! Make it easy for everyone to be involved in an AAR and they feel and are psychologically safe - When you get to your destination, do a quick check to make sure everything is in place for the next journey. Review the AAR process and outcome, any changes needed next time? - The whole vehicle needs MOT and insurance, to make sure it’s safe to drive in. Trying to do AARs when there’s a toxic organisation culture will be very hard. But might help change the culture too. - Etc Do you agree? Any others?

Work as imagined vs work as prescribed vs work as done. There needs to much more insight into the reality of decision making, resources and how and why decisions are made. Yes, we 'should' have effective, safe and well resourced mental health services. Investigations need to explore and expose the 'why' in order to inform the action needed for improvement.

It's shocking isn't it, awful for the staff and terrifying as a prospective patient

Thank you @Suze for sharing your experiences. My family have similar experiences with ADHD medication, it’s so frustrating and debilitating. And clearly a risk to you too, without your medication.

Hi @mo_hafeez Thank you for sharing your information. It sounds that the supply challenges are long standaing, not just in relation to more recent concerns. Would you be able to share more information, either attributly or anoynmously? If so, a collegue of mine would be happy to contact you and help write up your experience in more detail for publication on the hub. It would be very helpful to share the personal impact of these challenges, it sounds very hard for you and your family. Best wishes and thanks again Helen @Stephanie O'Donohue

Care Opinion are great, and it’s information that’s in the public domain so most Trusts do respond. Worth it if you feel it’s right for you.

Someone close to me is prescribed ADHD medication. They were given a repeat prescription but told by the pharmacist that it wasn’t available in the dose prescribed. The patient and the pharmacy rang round other pharmacies to be told that this wasn't an isolated incident, none available. There was a slightly lower dose available but no pharmacy would dispense without a new prescription. The GP wouldn’t prescribe without going back to the Consultant who originally diagnosed ADHD and made the first prescription. Then a run around trying to get a prescription that managed to match the dose available; the later changing daily as the demand was so great that the drug flew off the shelves as if it was a prize Christmas present that all kids wanted. Farcical and hugely stressful. The outcome was the patient went without ANY medication for over a month. Now resolved but really worrying. No long term effect but it was having a negative impact on mood, motivation, employment etc. And the worry that will this happen again. Is anyone reporting this and if so where? Don’t think MHRA’s Yellow Card scheme would pick this up nor the NHS patient safety incident reporting system. So it’s a big unknown the impact on patient wellbeing and patient safety?

Hi Tom, thank you, it’s been a great collaboration and we built on a well received presentation at the Health Plus Care show earlier this year. Not sure I’ve seen your roadmap and framework for change. Something we can add to the hub? Do let me know [email protected]

Hi @Gethin and @Callum Brown A few collegues are actively discussing creating a PS Ed & Training network. There seems to be a lot of interest in this, focusing particularily on PSIRF but more broadly too. Would that be something you'd like to engage with? Copying to @Claire Cox @Chris Elston @Elizabeth Akers Helen