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Found 177 results
  1. Content Article
    This article by the consultancy firm Carnall Farrar looks at the opportunity the newly established Integrated Care Systems (ICSs) have to improve health outcomes, tackle inequalities, enhance productivity and support broader social and economic development. The relationship between deprivation and health outcomes is well known and evidenced, and by working collaboratively, the NHS, local authorities and Voluntary, Community and Social Enterprise (VCSE) organisations can address the wider determinants of health outcomes, starting with the impact of deprivation.
  2. Content Article
    This report by the National Medical Examiner, Dr Alan Fletcher, summarises the progress made by medical examiner offices in 2021 and outlines areas of focus going forward. It highlights that medical examiners continued to receive positive feedback from bereaved people—many said they appreciated being given the opportunity to have a voice in the processes after a death and knowing any concerns were listened to. It includes information on: The national medical examiner system Implementation Guidance and publications Training Stakeholders Increasing the number of non-coronial deaths scrutinised Feedback received by medical examiners in England and Wales
  3. Content Article
    This document outlines the standard operating procedure (SOP) adopted by University Hospitals Bristol NHS Foundation Trust, relating to parental involvement in escalation of clinical care for acutely ill children. It aims to clarify the process of empowering parents to escalate concerns if they are worried about the clinical condition and care being delivered to their child, or themselves if they are a patient. It also aims to ensure accurate and appropriate information is provided to parents on admission (elective and acute) regarding how they should escalate concerns about the care their child is receiving.
  4. Content Article
    When a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme.
  5. Content Article
    Co-production is a way of working that involves people who use health and care services, carers and communities in equal partnership; and which engages groups of people at the earliest stages of service design, development and evaluation. This poster by NHS England and the Coalition for Personalised Care outlines five values and seven practical steps to help create a culture where co-production becomes an integral part of health systems and organisations.
  6. Content Article
    This document outlines the Escalation Policy for Leicester Children’s Emergency Department. It identifies five particular factors that lead to difficulty within the department. Acknowledging that these issues can be closely interlinked and may not occur in isolation, it provides practical way to deal with these factors to try and prevent secondary events.  Staffing Overcrowding Inflow Outflow Acuity
  7. Content Article
    In 2021. the National Quality Board (NQB) refreshed its Shared commitment to quality, which describes what quality is and how it can be delivered in integrated care systems (ICSs). It reflects the ambition set out by the NQB in 2015: "We want improving people’s experiences to be as important as improving clinical outcomes and safety." This document provides an overarching context for work on improving experience of care as a principal and integral part of delivering safe and effective care. It sets out a shared understanding of experience and what the best possible experience of care looks like, and outlines key components for delivering the best possible experience of care: Co-production as default for improvement Using insight and feedback Improving experience of care at the core priority work programmes The NQB was set up in 2009 to promote the importance of quality across health and care on behalf of NHS England and Improvement, NHS Digital, the Care Quality Commission, the Office of Health Promotion and Disparities, the National Institute for Health and Care Excellence, Health Education England, the Department of Health and Social Care and Healthwatch England.
  8. Content Article
    In this opinion piece for The BMJ, David Oliver, consultant in geriatrics and acute general medicine, highlights the findings of three recent reports into the growing crisis in social care: Falling short: How far have we come in improving support for unpaid carers in England? (The Nuffield Trust) The state of the adult social care workforce in England 2022 (Skills for Care) The Cost of Caring: Deprivation and Poverty among Residential Care Workers in the UK (The Health Foundation) The reports evidence a lack of support for unpaid carers, growing vacancies in the sector and a high proportion of the residential care workforce living in poverty and food insecurity. David Oliver highlights that in spite of Government promises, there is still no feasible, future-proof plan to protect social care and its staff.
  9. Content Article
    In this BMJ feature, journalist Emma Wilkinson looks at how a shortage of health visitors in England is leaving babies and children exposed to safeguarding risks, late diagnosis and other problems. An estimated third of the health visitor workforce has been lost since 2015, and research by the Parent-Infant Foundation suggests that 5000 new health visitors are needed. Families are not getting the minimum recommended number of contacts with health visitors during the first three years of life, and research into the impact of this on children's outcomes is ongoing. Emma speaks to different mothers, including Phillippa Guillou, who had a baby in 2020 and struggled to breastfeed. Philippa felt unsupported and ignored by her local health visiting service, who only saw her once by videocall when her baby was one year old.
  10. Content Article
    This three-hour online course introduces the concept and approach to thematic analysis in safety investigations. It builds on the concepts discussed in HSIB's Level 2 course A systems approach to learning from patient safety incidents, so attendees must have completed the Level 2 course prior to enrolling on this course.  The course will run on the following dates: 11 June 2024 24 June 2024 10 July 2024 15 July 2024 HSIB courses are aimed at NHS staff in health and social care settings in England, who are involved in safety investigations for learning. Courses run online and are free of charge to attend for NHS staff.
  11. Content Article
    This joint report by the APPG on Baby Loss and the APPG on Maternity is a culmination of over 100 submissions to an open call for evidence from staff, service users and organisations, on the maternity staffing crisis. It paints a picture of a service that is at breaking point and staff that are over-worked, burnt out and stressed.
  12. Content Article
    The Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England. The pilot published three investigations focused on cross boundary and multi-agency safety events: Investigation 1: incorrect patient identification Investigation 2: incorrect patient details on handover Investigation 3: transfer of a patient with a stroke to emergency care The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.
  13. Content Article
    Patients with head and neck cancer may be required to travel significant distances for treatment, follow up and rehabilitation. This article in thr journal Cancer Nursing Practice presents findings from an evaluation of a pilot head and neck cancer service redesign in Thames Valley Cancer Alliance to enable patients from Swindon and Wiltshire to receive follow up and rehabilitation closer to home. The evaluation identified a decrease in overall outpatient visit time for these patients, resulting in reduced travel costs and improved quality of life.
  14. Content Article
    In this blog, Saffron Cordery, Interim Chief Executive at NHS Providers, examines progress on the Government's manifesto pledge to build 40 new hospitals in England by 2030. Known as the New Hospital Programme (NHP), many of these projects are facing serious delays, with seven of the 40 not yet having a completion date. In a recent survey by NHS Providers, nearly two in three leaders said delays to the programme affected their ability to deliver safe and effective patient care, with all those facing delays reporting cost implications. Saffron highlights the opportunity the NHP presents to boost healthcare and renew services, and argues that the impact on communities will be huge if the new hospital plans are scrapped.
  15. Content Article
    In England, around 10 million adults and 12,000 children have a musculoskeletal (MSK) condition. Ethnic minority groups, people from lower income households and those living in areas of high deprivation are most affected. In this guest blog for the Arthritis and Musculoskeletal Alliance (ARMA), Bola Owolabi, Director of the National Healthcare Inequalities Improvement Programme at NHS England, highlights the role that MSK health inequalities play in people's lives. She looks at the link between socio-economic disadvantage and poor health outcomes, and discusses the wider implications of disability due to MSK conditions. She describes work being done by the NHS, and highlights ARMA's work to narrow MSK health inequalities through listening to the experiences of underserved communities and working in partnership to improve care.
  16. Content Article
    This article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
  17. Content Article
    This longitudinal study in BMJ Quality & Safety aimed to examine the impact of nursing team size and composition on inpatient hospital mortality. The authors found that registered nurse staffing and seniority levels were associated with patient mortality. The lack of association for healthcare support workers and agency nurses indicates they are not effective substitutes for registered nurses who regularly work on the ward.
  18. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Sarah and Jaydee are working on an innovative project at NHS Dorset Integrated Care Board (ICB) to ensure general practice is a central part of improving patient safety across services. They talk about the value and challenges of collaborative working, how they are tailoring their offer to fit the needs of local GP practices, and making patient safety a core part of training for all healthcare professionals.
  19. Content Article
    This guidance from NHS England aims to support Integrated Care System (ICS) leaders as they develop their approach to quality management, providing clarity on how quality concerns and risks should be managed through systems. It provides an overarching approach to quality risk response and escalation, including guidance on routine, enhanced and intensive quality assurance and improvement activity.
  20. Content Article
    This mixed method case study in The BMJ aimed to evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. The authors found that creating individual summary care records (SCRs) was a complex, technically challenging and labour intensive process that occurred more slowly than planned. They concluded that complex interdependencies, tensions and high implementation workload should be expected when rolling out SCRs.
  21. Content Article
    The Francis Inquiries in 2010 and 2013 highlighted nurse staffing as a patient safety factor contributing to the care failings identified at Mid Staffordshire NHS Trust. The reports and government response led to the development of national ‘safe staffing’ policy. This two-year study by the University of Southampton and Bangor University examined the impact of safe staffing policies nationally and explored variation in local responses. The authors concluded that: Policies provided leverage and raised the profile of nursing workforce issues at board level, contributing to a willingness to invest in increasing nursing numbers. However, a lack of assessment of the likely scale of investment (and human resources) required nationally to achieve ‘safe staffing’ led to financial considerations becoming a barrier to achieving the policy vision. External pressures, such as lack of workforce supply and reduced access to temporary staffing, have constrained Trusts’ abilities to fully implement policies aimed at ensuring safe staffing on acute wards.
  22. Content Article
    In this opinion piece, Kath Sansom, Founder of the Sling the Mesh Campaign, argues that when health services fail to engage meaningfully with patients it causes patient safety issues. Drawing on her own experience as a patient and the founder of a large patient support group, she talks about the invaluable perspective that patients who have experienced healthcare harm can offer policymakers. She also explains why it is important to hear from a wide group of patients who have experienced a variety of issues.
  23. Content Article
    Polypharmacy refers to the prescription of many medicines to one patient. As more people live longer with multiple long-term conditions, the number of medicines they take often increases. This can have a significant burden on the person managing and trying to adhere to multiple medicines regimes, and can also be harmful. The Academic Health Science Networks (AHSN) Network's Polypharmacy Programme aims to support healthcare professionals to identify patients at potential risk from polypharmacy, and to support better conversations about medicines. Based on the recommendations of the National Overprescribing Review (NOR) published in September 2021, the programme aims to achieve the following outcomes: A national network of Polypharmacy Communities of Practice, all working to address the system-wide challenges of problematic polypharmacy in their geographies. Routine use of the NHSBSA Polypharmacy Prescribing Comparators to identify and prioritise patients for a shared decision-making Structured Medication Review. Increased confidence amongst the primary care prescribing workforce to safely stop medicines identified to be inappropriate or unnecessary. A change in patient expectations – to anticipate having a shared decision-making conversation about their medicines regularly, especially as they get older. A contribution to the evidence base around how to help patients to feel more empowered to open up about their medicines issues. A contribution to the evidence base around how to tackle problematic polypharmacy.
  24. Content Article
    This document outlines the terms of reference for the independent review into maternity services at Nottingham University Hospitals NHS Trust (NUH), commissioned by NHS England and led by Donna Ockenden. The review has been established in light of significant concerns raised about the quality and safety of maternity services at NUH, and concerns voiced by local families. It replaces a previous regionally-led review after some families expressed concerns and made representations to the Secretary of State for Health and Social Care. The review began on 1 September 2022 following early engagement with families and NUH from June 2022. It is expected to last 18 months, although this timeframe is subject to review. Learning and recommendations will be shared with NUH as they become apparent, to allow rapid action to improve the safety of maternity care. The only and final report is expected to be published and presented to NUH and NHS England around March 2024.
  25. Content Article
    The Patient Experience Library aims to gather research and evidence about patient experience in one place, so that it can be accessed and used to improve patients' experiences of healthcare. In this annual report, The Patient Experience Library presents its top picks of evidence gathering about patient experience in England from the last twelve months. The research featured in the report includes studies by patient voice organisations, health charities, academic institutions and policy think tanks. The research takes variety of formats, from peer-reviewed formal research to less formal approaches built on community relationships, that lead to trusted dialogue and deep insight.
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