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Found 176 results
  1. Content Article
    NHS trusts have often reported emergency department doctors having low levels of satisfaction and high rates of burnout, leading to a high turnover. In 2017, Brighton and Sussex University Hospitals (BSUH) and Western Sussex Hospitals merged to form University Hospitals Sussex NHS Foundation Trust. The Trust found that the organisation of shifts at Royal Sussex County Hospital (RSCH) and Princess Royal Hospital (PRH) and lack of flexibility were adding to the strain already felt by doctors working in the high pressure emergency department. To combat the pressure consultants and other doctors were under, the Trust implemented a system to help improve rota design and flexible working. The hope was that the system would help the trust retain and recruit staff, whilst saving locum costs and improving patient care.
  2. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists.
  3. Content Article
    This document outlines NHS England's approach to learning from safety culture best practice. It covers: Safety culture context within the NHS patient safety strategy Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities Case studies
  4. Content Article
    Cardiovascular disease (CVD) causes 1 in 4 deaths in England, and is a leading cause of morbidity, disability and health inequalities. The Covid-19 pandemic has added to the urgency of tackling CVD because CVD significantly increases the risk of severe disease and death from Covid-19. This report by The King's Fund looks at published data, literature, policy and evidence on CVD. The writers also carried out interviews and a workshop with key stakeholders working in health and care to inform their research.
  5. Content Article
    In 2022, the Co-Production Collective worked with several partners and hundreds of co-producers to try to answer the question, "What is the value of co-production?" The aim of this project was to make the case for the value of co-production for individuals, organisations and society. This webpage contains information about the project and resources about co-production that it has generated, including videos, reports and stories relating to these stages: Survey Rapid critical review Community reporting Pilot projects
  6. Content Article
    This poster produced by researchers at Warwick Medical School summarises a qualitative research project that examined attitudes and behaviours related to patient safety culture at a single West Midlands Trust. The study's objective was to gain an understanding of staff’s views regarding the culture within the Trust and of their attitudes and behaviours when reviewing clinical incidents and mortality and morbidity. The poster was a winner at the HSJ Patient Safety Congress 2022 in the category 'A just culture for learning and change'. Read the full research paper.
  7. Content Article
    This article in BMJ Open Quality aimed to improve patient safety by examining the organisational and individual factors that contribute to adverse events, enabling corrective action so that errors are not repeated. Using interviews and observations of Trust meetings at a single Hospital Trust in the Midlands, England, this qualitative study: analysed whether the attitudes and behaviours of clinicians and managers are aligned with a Just Culture. identified barriers and enablers to an organisation adopting a Just Culture. The study found evidence of a fair incident management process within the Trust; however, there was no agreed vision of a Just Culture and the majority of the staff were unfamiliar with the term. Negative perspectives relating to clinical incidents and their management persist among staff with many having concerns about being the subject of an investigation and doubts about whether they drive improvement.
  8. Content Article
    Healthcare professionals are encouraged to use feedback from their patients to inform service and quality improvement. This study in the journal Sociology of Health and Illness aimed to understand how three NHS Trusts in England were interacting with patient feedback through online channels. The authors found that organisations demonstrated varying levels of ‘preparedness to perform’ online, from invisibility through to engaging in public conversation with patients within a wider mission for transparency. Engagement varied between the Trusts; one organisation employed restrictive ‘cast lists’ of staff able to respond to patients, while another devolved responding responsibility amongst a wide array of multidisciplinary staff.
  9. Content Article
    This report from the National Oesophago-Gastric Cancer Audit (NOGCA) focuses on the care received by patients diagnosed with invasive epithelial cancer of the oesophagus, gastro-oesophageal junction (GOJ) or stomach, or high-grade dysplasia (HGD) of the oesophagus between April 2019 and March 2021. For outcomes of curative surgery among people with OG cancer, data are reported for a three year period (April 2018 to March 2021).
  10. Content Article
    This report from the National Asthma and COPD Audit Programme (NACAP) offers a view of the care of people with asthma and COPD in England and Wales, and is informed by 103,194 case records submitted to the audit programme. It is the first report to combine data on asthma, COPD and pulmonary rehabilitation across primary and secondary care services to underpin key messages, optimising respiratory care across the pathway.
  11. Content Article
    The Fracture Liaison Service Database (FLS-DB) collects, measures and reports on the care provided by Fracture Liaison Services (FLSs). This annual report presents the results of secondary fracture prevention care received by patients aged 50 and older following a fragility fracture between January and December 2021. Based on 70,384 patient records in 2021 (compared with 70,614 in 2019), it found that there has been a reduction in both case identification and assessment performance, but an improvement in treatment recommendation, monitoring and follow up, when comparing national data from 2021 with 2019.
  12. Content Article
    In this article, Richard Murray, Chief Executive of The King's Fund, reflects on what 2023 has in store for the health and care system in England. Acknowledging the intense pressure all services are currently under, he highlights that patients aren't currently receiving the care they need meaning that coping with operational challenges is going to dominate the early part of the year for the health and care sector. He warns of the futility of the Government adding new performance management measures to the sector, and expresses hope that Integrated Care Boards (ICBs) could make a difference by bringing together stakeholders to tackle longer-term problems such as integration, population health and inequalities.
  13. Content Article
    In this article for NHS Confederation, Sir Chris Ham reflects on progress made against his recommendations on the conditions ICSs need to succeed and on next steps for the Hewitt review. He argues that progress has been made in acting on some of the recommendations in the report Governing the Health and Care System in England. This can be seen in plans to create a new NHS England (NHSE), reduce staffing at the centre and regions and co-produce the operating framework. However, he highlights that more work is needed to reduce the number of national NHSE programmes, ensure greater consistency in how these programmes work and bring an end to constant bidding for funds tied to specific priorities. He recommends that high priority be given to an organisational development (OD) programme to support the development of collaboration, mutual respect and trust and determine how peer support, shared learning and improvement collaboratives can play a bigger part in improving performance in future. Sir Chris highlights that the Hewitt review offers an opportunity for these and other issues to be addressed with priority being given to ensuring that planning guidance for 2023/24 is short and focused on a small number of national priorities, leaving scope for ICSs to add local priorities. Leaders in the DHSC and NHSE must recognise the exceptional pressures facing the health and care system and set out what a realistic set of medium-term objectives for ICSs looks like under current circumstances.
  14. Content Article
    Even before the Covid-19 pandemic, rural and remote health services in England faced long-standing workforce, financial and capacity issues. This report by the Nuffield Trust explores the impact the pandemic has had on the delivery of rural and remote health services, highlighting the underlying challenges faced by these services. It outlines how the challenges faced are different for rural areas when compared to more urban areas. The authors also discuss how performance could be monitored to signal the risk of any significant service pressures over the coming months.
  15. Content Article
    In this episode of the What the HealthTech? podcast, Radar Healthcare's Chief Product Officer Mark Fewster speaks to Helen Hughes, Chief Executive of Patient Safety Learning. to get the lowdown on NHS England's new Patient Safety Incident Response Framework (PSIRF). Helen talks about how PSIRF is going to drive an open and just culture, what can be expected after the transition and why the implementation process is key to PSIRF's success. Listen on Spotify Listen on YouTube
  16. Content Article
    This study in the journal Health and Social Care Delivery Research aimed to assess the scale, scope and impact of changing the type and number of different healthcare practitioners in general practice in England. The authors undertook an analysis of employment trends, looked at motivations behind employment decisions, examined staff and patient experiences, and assessed how skill mix changes are associated with outcome measures and costs. They found that: employing clinicians who are not GPs did not reduce GPs’ workload or improve their job satisfaction. patients appreciated the longer appointments they had with other clinicians. patients wanted better information about what other practitioners can do, and how to use new booking systems.
  17. Content Article
    The Secretary of State for Health and Social Care, Rt Hon Steve Barclay MP has announced that Dr Ted Baker has been formally appointed as the new chair of the Health Services Safety Investigations Body (HSSIB). This blog describes Dr Baker's experience and outlines what his new role will involve, including setting up the new board for HSSIB. He said, “My focus will be to build on the strong legacy of the HSIB and make sure, as the HSSIB, that we take even greater strides along our journey to improving patient safety.”
  18. Content Article
    In this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
  19. Content Article
    The King’s Fund and Engage Britain commissioned Bill Morgan, a former Conservative special adviser, to explore what can get in the way of ministers taking meaningful, long-term action to address NHS workforce shortages. In this report, he focuses on the role of politicians in workforce planning and delivery.  The report sets out the scale of the workforce crisis and the impact that it has. It also considers the political reasons around why it has been so hard to fix and considers three factors that could contribute to tackling the current shortages: Transparency in workforce forecasts The establishment of an independent workforce-planning organisation Accepting the NHS’s historical reliance on recruitment from outside the UK as explicit future policy and planning accordingly
  20. Content Article
    The workforce crisis engulfing the health and care system is well documented. In the NHS, increases in staff numbers are not keeping pace with demand for staff and services; in 2021/22, for the first time, the number of people working in adult social care in England fell, and there are now 165,000 vacancies.  In this long read, Sally Warren, Director of Policy at The King's Fund, looks at a report by Bill Morgan, commissioned by The King's Fund and Engage Britain, to consider why politicians have failed to act, where only they can, to deliver the workforce that the health and care system needs. The article covers the following areas: Transparency in workforce planning assumptions   Training and international recruitment Retention: it’s not just about pay More than a numbers game, getting the culture and leadership right Productivity and skill mix Action at all levels Service improvement ambitions matched to the available workforce
  21. Content Article
    This report by the Harmed Patients Alliance (HPA) explores the needs of injured patients and their loved ones for independent advocacy, advice and information when they have been involved in patient safety incidents that are believed to have led to harm. It examines the extent to which this is available or resourced, and aims to stimulate and inform a national discussion about this issue in England among key stakeholders. It looks at the historical context and the moral and economic arguments and implications of resourcing these kinds of services.
  22. Content Article
    Deaths from Covid-19 are rare in children and young people, and the high rates of asymptomatic and mild infections complicate assessment of cause of death in this group. This study assessed the cause of death in all children and young people with a positive Covid-19 test since the start of the pandemic in England. The authors concluded that:Covid-19 deaths remain extremely rare in CYP, with most fatalities occurring within 30 days of infection and in children with specific underlying conditions.Covid-19 was responsible for 1.2% of all deaths in <20 year-olds in this period.
  23. Content Article
    In July 2022, HSIB launched a national investigation into the safety risk of clinical investigation booking systems failures. Specifically, the investigation explores the use of paper or hybrid booking systems and the production of appointment letters. This interim bulletin highlights a safety risk identified by the investigation and presents a safety observation for the attention of NHS care providers. Some vital NHS services still use paper-based or hybrid systems, which may have been developed over time and could leave unintended gaps where patients can be lost in the system. The reference case for this investigation is the experience of a patient whose magnetic resonance imaging (MRI) scan was not rescheduled following a cancellation, leading to a delay in the diagnosis of cancer. Hybrid systems were in use, which did not assist staff to keep track of patients. Additionally, the hybrid systems in use did not allow appointment letters in non-English languages to be produced.
  24. Content Article
    This article for Vogue explores the experience of a midwife working in an overstretched maternity unit in England. Melissa Newman, who has been a midwife for nearly six years, highlights the impact of staff shortages on midwives—she describes how she does not have time to eat, avoids drinking because she will not have time to go to the toilet, and sometimes works fifteen hours without any break. She calls on the Government for more funding to fix the crisis facing NHS maternity services, and the NHS more widely.
  25. Content Article
    Core20PLUS5 is NHS England's approach to reducing health inequalities at both national and system level. The approach defines a target population cohort and identifies five focus clinical areas that require accelerated improvement. This infographic outlines the specific Core20PLUS5 approach to reducing health inequalities for children and young people.
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