Search the hub

In this blog, Dr Amy Proffitt, Royal College of Physicians (RCP) patient involvement officer, explores how the patient voice is represented in patient safety. She highlights the importance of engaging patients from a diverse range of backgrounds and responding to research that highlights particular populations who are experiencing worse outcomes. Eddie Kinsella, chair of the RCP’s Patient and Carer Network, then goes on to share his thoughts on patient safety, highlighting the role of patient partners in bringing about culture change in the NHS, and as advocates for the wider community, especially those who are most disadvantaged.

Patients are increasingly feeding back about their healthcare experiences online and NHS Trusts are adopting different approaches to responding. This study in the journal Digital health aimed to explore the sociocultural contexts underpinning three organisations who adopted different approaches to responding to online patient feedback. The authors identified a range of barriers facing organisations who ignore or provide generic responses to patient feedback online and demonstrated the sociocultural context in which online interactions between staff and patients can be used to inform improvement. However, they highlight that this represented a slow and difficult organisational journey.

In January 2023, The Patients Association celebrates its 60th anniversary. In this interview, CEO Rachel Power talks about why The Patients Association was set up and how the organisation still aims to  ensure that everyone can access and benefit from the health and care they need to live well. She describes the benefits of shifting to free membership, how patient partnership is vital to improving health and care services and The Patients Association's role in highlighting the key issues facing patients to the Government. She also highlights the key role that pharmacies play in promoting health information and delivering services to the communities they serve.

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.

This blog by Victoria Vallance, Director of Secondary and Specialist Care at the Care Quality Commission (CQC) discusses how engagement with frontline NHS maternity staff has informed the CQC's inspection approach, and is being used to support improvements in care. She highlights that recent reviews and reports highlight recurring concerns that affect maternity safety: the quality of staff training, poor working relationships between obstetric and midwifery teams, and a lack of robust risk assessment. She then goes on to talk about an event held by the CQC that brought together staff from NHS maternity services across England to discuss the challenges that they face and seek their views on what needs to change to overcome them.

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.

This cross-sectional study in BMJ Quality & Safety aimed to assess patient comfort in speaking up about problems during hospitalisation, and to identify patients at increased risk of having a problem and not feeling comfortable speaking up. The authors assessed the responses of 10,212 patients at eight hospitals in Maryland and Washington to the question, "How often did you feel comfortable speaking up if you had any problems in your care?" The study found that 48.6% of respondents indicated that they had experienced a problem during hospitalisation. Of these, 1,514 (30.5%) did not always feel comfortable speaking up. The authors concluded that creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience.

In order to become competent clinicians, doctors need to appropriately calibrate their clinical reasoning, but lack of follow-up after transitions of care can present a barrier to this. This study in the Journal of Hospital Medicine aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners' self-efficacy. The authors concluded that structured feedback for overnight admissions is a promising approach to improve residents' diagnostic calibration, particularly given how often diagnostic changes occur.

To improve their diagnosis and management skills, doctors need consistent, timely and accurate feedback, as it helps them become better calibrated, leading to more appropriate clinical decisions. Despite its benefits, clinicians do not consistently receive information on the subsequent clinical outcomes of patients they have diagnosed and treated, known as patient outcome feedback. This paper discusses challenges faced in developing systems for effective patient outcome feedback. The authors propose applying a sociotechnical approach using health IT to support these systems. The concepts they discuss are applicable not only to fragmented systems of care, but also to integrated health systems that plan to harness the benefits of integration for providing effective clinician feedback.

This decriptive study in BMC Health Services Research aimed to increase understanding of how patient and family education affects the prevention of medical errors, and provide basic data for developing educational content. The authors surveyed patients, families and Patient Safety Officers to investigate the relationship between educational approaches and medical error prevention. Participants thought that educational contents developed through this study could prevent medical errors. The results of this study are expected to provide basic data for national patient safety campaigns and standardised educational content development to prevent medical errors.

This document has been produced as part of a project to develop EU guidance for the safe management of hazardous medicinal products (HMPs) at work, including cytotoxins. The project involves the collection of information from key stakeholders across 27 European countries through direct requests, workshops and pilots. The document provides practical guidance on preventing and reducing occupational exposure to HMPs for employers, workers, occupational health and safety (OSH) services and experts, personal training managers and others concerned with advice on the safe management of HMPs at work. The project team is inviting feedback on the draft guidance by 19 September 2022. The guide primarily addresses the following problems: Lack of awareness of HMPs Lack of support tools Unclear definition of HMPs Deficiencies in the flow and/or transfer of information.

Jeremy Hunt, former Secretary of State turned patient safety campaigner, will be joined by the newly appointed Patient Safety Commissioner, Dr Henrietta Hughes OBE as part of a panel of keynote speakers at an annual congress [15-16 September] which pledges to 'drive forward' the current national commitment of putting patient safety and quality at the heart of patient care

Safety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.

Video and telephone consultations have, through the course of the pandemic, become a central of daily operations across the NHS. In this blog, Ben Gadd and Amanda Nash of University Hospitals Plymouth NHS Trust share their experiences about how they are being received and the potential lessons we can learn.

The Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.

Presentation from Julia Wood given to the Patient Safety Manager Network (PSMN) on the importance of finding joy and happiness in work and how you can support your staff.

Rather than measuring how safe care is, the focus is often on measuring levels of harm in healthcare systems. This report by Healthcare Excellence Canada outlines findings from a research study which aimed to answer, “How safe is care from the perspective of patients, families, care partners, and care providers?” Through a literature review, interviews, focus groups and a World Café wthe study aimed to increase understanding of how patients and their care partners view safety. The Measuring and Monitoring of Safety Framework (MMSF) (Vincent et al., 2013b) was used to guide the study. The MMSF offers a broader, more comprehensive and real-time view of patient safety and helps shift away from a focus on past cases of harm towards current performance, future risks and organisational resilience. The report concludes that the MMSF represents a critical shift in how patients can enable safer care. Inviting patients and care partners to contribute meaningfully to safety will enhance healthcare providers’ view of harm and understanding of what it means to feel safe.

The National Audit of Care at the End of Life (NACEL) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). It was carried out by the NHS Benchmarking Network in collaboration with The Patients Association and aims to assess the quality of care that patients receiving end of life care and their families experience, as well as staff perceptions of their confidence and ability to deliver end of life care. The audit included: an Organisational Level Audit covering Trust/Health Board and hospital/submission level questions for 2020/21. a Case Note Review which reviewed 20 consecutive deaths between 12th April 2021 and 25th April 2021 and 20 consecutive deaths between 1st May 2021 and 14th May 2021 for acute providers and up to 40 consecutive deaths in April and May 2021 for community providers. a Quality Survey completed online, or by telephone, by the bereaved person. a Staff Reported Measure, completed online. Key findings Recognising the possibility of imminent death The possibility that the patient may die within the next few hours/days was recognised in 87% of cases audited, compared to 88% in 2019. The median time from recognition of dying to death was recorded as 44 hours (41 hours in 2019). Communication with the dying person Results on all key metrics regarding the recording of conversations with the dying person remain similar to 2019, pre-pandemic levels However, from the Quality Survey, the proportion strongly disagreeing or disagreeing with the statement ‘staff communicated sensitively with the dying person’ increased from 7% (2019) to 11% (2021). Communication with families and others There was little change in 2021 when compared to 2019, with continued high compliance on recording of conversations about the possibility that the person might die and on the individualised plan of care. As in 2019, discussions on hydration and nutrition with families and others were documented, or a reason why not recorded, in only around half of cases. Involvement in decision making Findings from the Case Note Review in 2021 suggest continued strong compliance on involvement in decision making, with similar results to those reported when this theme was last tested in 2018. However, from the Quality Survey, in 2021, 23% of people felt they would like to be more involved in the person’s care compared to 19% in 2019. Individualised plan of care Third round findings from the Case Note Review showed similar results for the existence of an individualised plan of care, 73% of cases compared to 71% in 2019, suggesting this is an ongoing area for improvement. Documented evidence of an assessment of wider needs such as emotional/psychological, spiritual/religious/cultural and social/practical shows a reduction since 2019, which may be a result of continuing pressures of the Covid-19 pandemic on services during 2021. Needs of families and others The needs of the family were identified as an improvement area in both round one and round two of the audit. Comparison with 2019 findings suggests performance has deteriorated, which may reflect the impact of the pandemic on the ability of visitors to access wards and the capacity of staff to assess and address the needs of families and others. Families’ and others’ experience of care The overall rating of care and support to the person who died, and the overall rating of care and support provided to families and others, are lower than in 2019. Governance Governance was last measured in 2018 and Trusts/Health Boards (HB) continue to show high compliance with the existence of key policies related to care at the end of life in 2021. Workforce/specialist palliative care The results show an improvement in access to specialist palliative care, in particular, face-to-face access 8 hours a day, 7 days a week was available in 60% of hospitals/sites compared to 36% in 2019. The increased provision may reflect a response to the pandemic and it is not yet clear whether the change will be permanent. Staff confidence Staff completing the survey expressed confidence in recognition of dying, communication, responding to the needs of the dying person and those important to them, involving people in decision making, accessing specialist palliative care and managing pain and physical symptoms, with less than 6% stating they strongly disagreed or disagreed with positive statements of confidence in these areas. Staff support Training was identified as a potential area for improvement with only 49% of respondents stating they had completed training specific to end of life care within the last three years. Although staff felt support was available from the specialist palliative care team, only 66% felt managerial support was available to help provide care at the end of life. Care and culture Although 83% felt able to raise a concern about end of life care, this should be closer to 100%. Only 80% answered positively that they felt they work in a culture the prioritises care, compassion, respect and dignity, which is also a concern.

This online community has been set up by the Care Quality Commission (CQC) to engage with members of the public on a range of topics related to the CQC's work as regulator of health and social care services in the UK. The site invites people to get involved in different ways, for example: by sharing expertise, experience and thoughts through discussions. by reviewing documents. by taking part in polls and surveys. by contributing to idea boards. When signing up, you can either use your own name or your organisation’s name, and you'll be asked to choose what groups you represent and what sectors you work in or use.

This survey conducted by the Care Quality Commission (CQC) explored the experiences of people who used community mental health services between September and November 2020. The results show that people are consistently reporting poor experiences of NHS community mental health services, with few positive results. Many people reported that their mental health had deteriorated as a result of changes made to their care and treatment due to the pandemic. Analysis also showed disparities in the experiences of people with different mental health diagnoses, and in the experience of people using different methods to access care, such as telephone consultations. On this webpage you can also access a benchmark report for each NHS trust, which provides detail of the survey methodology, headline results, the trust score for each evaluative question and banding for how a trust score compares with all other trusts.

Following the Shrewsbury maternity scandal where "at least 201 babies would have survived with better care", outgoing CQC chief inspector of hospitals Ted Baker said the NHS should listen to criticism to be able to change. Ted Baker said the NHS faced a resistance to being challenged and "for anyone to refuse to listen to criticisms of what the NHS does I think is a big mistake." Listen to Ted Baker's, CQC's outgoing chief inspector, full interview on Times Radio.