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Found 1,329 results
  1. News Article
    No senior NHS England director is prepared to take responsibility for ADHD services — which are facing waits of up to a decade and severe medication shortages — HSJ has discovered. Despite soaring demand for assessments and widespread drug shortages recently triggering a national patient safety alert, responsibility for attention-deficit/hyperactivity disorder services does not sit within any NHS England directorate. HSJ understands that none of NHSE’s mental health, learning disability, or autism programmes have been given any resources for ADHD. It is also claimed that the medical and long-term conditions teams “are not very interested” in taking responsibility, and “assumed someone else was doing it”. A senior source, very close to the issue, told HSJ that no NHS senior director had taken “ownership” of the issue, and there was a widespread misapprehension that responsibility for ADHD services was part of the autism remit given to the mental health directorate. “We haven’t got the attention we need around ADHD,” said the source, “we need a [dedicated] neurodiversity programme.” Read full story (paywalled) Source: HSJ, 26 October 2023
  2. News Article
    The Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
  3. News Article
    The Health Services Safety Investigation Branch has been accused of taking “divisive potshots” at NHS finance directors. Speaking at an event to mark the watchdog becoming an independent body, HSSIB chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa… Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress on safety would not be made unless it was tackled “in the same breath” as operational and financial matters. In response, the Healthcare Financial Management Association said Ms Bennyworth’s views had “incensed” its members. Commenting below the story, HFMA chief executive Mark Knight said: “I have been contacted by a number of finance directors who are incensed by the comments in this article. To gain a fuller picture of the views of the newly created HSSIB we will be asking for a meeting with Dr Benneyworth and [HSSIB chair Ted] Baker. The HFMA would like to understand the evidence on which the assertions in the article are based, which are completely at odds with how I know the vast majority of finance directors and their teams behave.” Read full story (paywalled) Source: HSJ, 23 October 2023
  4. Content Article
    Historically, patient safety efforts have focused mostly on measuring and responding to harm. However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present and future in all its complexity. Healthcare Excellence Canada and Patients for Patient Safety Canada held many conversations with users of the health system, people who work in healthcare and safety scientists. The ideas collected suggest a new way of approaching patient safety – where everyone can contribute to creating safe conditions and where harm is more than physical. This discussion guide summarises what has been learned so far and captured in this key statement: Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.
  5. Content Article
    The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This document sets out the terms of reference for this inquiry, following an engagement process led by the inquiry’s independent chair, Lady Justice Thirlwall, with the affected families and other stakeholders.
  6. News Article
    Financial directors need to take responsibility for safety, which should be at the core of how the NHS runs services, the leadership of the Health Services Safety Investigations Body (HSSIB) said at its launch Wednesday. The Healthcare Safety Investigation Branch is now an independent body – and has been renamed HSSIB – although maternity investigations are hosted by the Care Quality Commission. Questioning how many finance directors across the NHS take responsibility for safety, HSSIB’s interim chief investigator Rosie Benneyworth said: “We need a position where finance directors in every organisation are as responsible for safety as the person leading the safety agenda and vice versa, the safety person works with the finance agenda to support them. “Often you see the finance director and safety lead don’t work effectively together and we need to change that.” Dr Benneyworth said progress will not be made unless operational delivery, financial delivery and safety are tackled “in the same breath”. HSSIB’s new chair Ted Baker also called for safety to become a core part of running services “in the way running the accounts is”, as it is currently still seen “as an add-on”. He stressed that safety “drives efficiencies, enables innovation and saves costs”. Read full story (paywalled) Source: HSJ, 19 October 2023
  7. News Article
    Trusts haven been warned to be careful of “contentious” approaches to staff recognition, such as those that mimic the “clap for carers” initiative organised during the pandemic. NHS England has published a Staff Recognition Framework which stresses marking staff achievements is important. However, it also warns staff could also be demoralised by recognition they felt was derisory. The framework says: ”During the pandemic, studies suggested the weekly 8pm ‘clap for carers’ movement and use of the word ‘heroes’ were contentious approaches to staff recognition. The NHS is always in the media spotlight. Don’t let this put you off but do consider the broader political and economic context.” Recent strikes saw clinicians make the point that organised clapping was no substitute for increase-linked pay increases. The document for senior leaders recommends “developing a recognition strategy” which takes a triple track “formal, informal and everyday” approach to celebrating staff achievement. It said “evidence shows that pay alone will not influence staff wellbeing, engagement, and retention in the long-term – praise and social approval have also proved to be critical factors”. Read full story (paywalled) Source: HSJ, 12 October 2023
  8. Content Article
    Recognition is about thanking people for their contribution at work. It is embedded in the organisational values of the NHS. By improving recognition we can deliver the NHS Long Term Workforce Plan’s ambition to attract and retain the workforce we need to deliver improved patient care. One of the seven elements of the NHS People Promise is, ‘we are recognised and rewarded’. It defines recognition as: “A simple thank you for our day-to-day work, formal recognition for our dedication…” It is important that we recognise our staff because evidence shows that pay alone will not influence staff wellbeing, engagement, and retention in the long-term – praise and social approval have also proved to be critical factors. The NHS and wider health and care sector has faced unprecedented workforce shortages and pressures in recent years. Yet, the most recent NHS staff survey illustrates that approximately half of staff do not feel recognised at work. NHS England has drawn on research and evidence and has worked with NHS organisations to develop this framework. It provides simple, easy-to-follow guidance and ideas for organisations to inform their own strategies and approaches.
  9. Content Article
    The case of Lucy Letby has dominated recent headlines and caused widespread shock. Much of the early discussion in the media after the verdict has focused on whether NHS managers mishandled concerns and suspicions raised by doctors about the sudden deaths of babies and potential criminal actions—and has labelled the doctors raising those concerns as the problem. But a polarised narrative of doctors versus managers won’t help resolve many underlying systemic issues in the NHS, writes David Oliver in this BMJ opinion piece. Many managers are themselves current or former clinical practitioners, so the divide isn’t sharp. Many of the serious problems currently affecting culture and morale in the NHS workforce happen with doctors, nurses, and other clinical staff in influential leadership and management roles. Simplistic and politicised talk of “pen pushers,” “bureaucrats,” and “too many managers” ignores the fact that many of the people in charge have clinical qualifications.
  10. Content Article
    Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.
  11. News Article
    The NHS waiting list in England has hit a new record high, with almost 7.8 million people waiting for treatment, data shows. An estimated 7.75 million people were waiting to start treatment at the end of August, up from 7.68 million in July. It is the highest number since records began in August 2007. The waiting list for treatment has been growing for much of the last decade, passing three million in 2014, four million in 2017, five million in 2021 and seven million in 2022. As the NHS waiting list grows A&E pressures are “ running red hot”, a major think tank has warned, with new figures showing 123,000 patients waited more than 12 hours in emergency departments last month. Some 8,998 people in England are estimated to have been waiting more than 18 months to start routine hospital treatment at the end of August, up from 7,289 at the end of July, according to data. A total of 396,643 people in England had been waiting more than 52 weeks to start routine hospital treatment at the end of August, up from 389,952 at the end of July. The Government and NHS England have set the ambition of eliminating all waits of more than a year by March 2025. Read full story Source: The Independent, 12 October 2023
  12. Content Article
    In this interview, Derek Feeley, IHI President Emeritus and Senior Fellow shares the work of the Health Improvement Alliance Europe (HIAE) workgroup related to curiosity. He outlines five simple rules linked to complexity theory, which states that if you are trying to make sense of a complex situation, you should create simple, order-generating rules. The five simple rules are: Ask rather than tell. Listen to understand rather than to respond. Hear every voice rather than only those easiest to hear.  Prioritise problem framing rather than problem solving. Treat vulnerability as a strength rather than a weakness.
  13. Content Article
    Getting the president of the United States to consider enacting your policy proposals is a major achievement. Having him actually implement them is an accomplishment that can change lives. The patient safety movement reached that first milestone with a recent report by the President’s Council of Advisors on Science and Technology entitled, A Transformational Effort on Patient Safety. Whether advocates achieve the second, crucial goal remains very much an open question. The PCAST casts a wide net, examining everything from nanotechnology to the public health workforce. It appears until now to have addressed patient safety only tangentially, when in 2014 it was a small part of a larger report on accelerating health system improvement through systems engineering.  The good news for patient safety advocates is that President Joe Biden has shown a genuine understanding of the issue. Leah Binder, president of the Leapfrog Group, hailed the report in a statement that singled out two of the recommendations. The first one was to publicly report Never Events (medical errors that never should have happened) by individual facility. The second was a recommendation to establish a National Patient Safety Team. A major barrier standing between recommendation and implementation is the patient safety movement’s paltry political power. At present, patient safety has little public awareness and no grassroots constituency. Hospitals, on the other hand, are an integral part of almost every Congressional district, have a largely positive public image and are facing tough financial pressures. The White House will think long and hard about taking any actions hospitals see as unreasonable.
  14. News Article
    An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies. Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance. In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019. Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said. The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month. However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly. Read full story (paywalled) Source: The Times, 10 October 2023
  15. Content Article
    It is essential that the voices of people from diverse communities are heard and acted upon because we will only be effective in improving patient safety for everyone if we include these groups. This blog from the Patient Safety Commissioner Dr Henrietta Hughes outlines the importance of listening to patients and staff from diverse communities to identify and act on patient safety issues – and how to make this happen.
  16. Content Article
    The Association of Ambulance Chief Executives (AACE) and the Office of the Chief Allied Health Professions Officer (CAHPO) have launched three publications aimed at reducing misogyny and improving sexual safety in the ambulance service.
  17. News Article
    The NHS ombudsman has told a health trust chief to withdraw “not accurate” remarks about him amid an alleged attempt to play down up to 1,000 avoidable patient deaths. Rob Behrens wrote to Stuart Richardson, the head of the Norfolk and Suffolk mental health NHS trust, over remarks he made about him to Norfolk county council’s health scrutiny committee. The councillors on the committee were questioning Richardson over claims reported by the BBC’s Newsnight programme that his trust had “watered down” a report into what are thought to be the avoidable deaths of up to 1,000 patients. The changes between different versions of the document toned down criticism of the trust’s leadership, a move that drew criticism from Behrens and bereaved relatives. For example, the auditors, Grant Thornton, removed references included in the first version to the trust’s governance being “poor, … weak [and] inadequate”, after discussions with trust bosses. The trust and Grant Thornton said the changes were part of a normal factchecking process. Referring to the changes, Behrens had told Newsnight that “the differences in the texts at key points are so huge that this is not just a bureaucratic drafting issue”. Read full story Source: The Guardian, 5 October 2023
  18. Content Article
    The protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister. As the Patient Safety Commissioner for Scotland Bill makes its way into law, Alan Clamp, chief executive officer of the Professional Standards Authority for Health and Social Care, asks what this means for Scotland and the safety of its patients? See also: Working together to achieve safer care for all: a blog by Alan Clamp
  19. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: Task analysis Cognitive overload Reliability Non-technical skills Examples Register hub members receive 20% discount. Email info@pslhub.org for discount code.
  20. News Article
    Trust leaders have been asked to “self-assess” the quality of their “improvement culture” as part of an initiative launched by NHS England chief executive Amanda Pritchard in the spring to lead the service's new improvement drive. The call came from NHS Impact, led by former Modernisation Agency chief David Fillingham, who along with NHS Impact’s deputy chair – University Hospitals Coventry and Warwickshire Foundation Trust CEO Andy Hardy – has written to service leaders, setting out the first stage in the improvement drive. They have asked the boards and CEOs of trusts and integerated care boards to “engage directly” with a new self-assessment tool and maturity matrix created by NHS Impact. This is designed to gauge their progress on adopting the five practices that NHS IMPACT claim “form the DNA of an improvement culture”. Those five practices are: A shared purpose and vision which are widely spread and guide all improvement effort. Investment in people and in building an improvement focused culture. Leaders at every level who understand improvement and practise it in their daily work. The consistent use of an appropriate suite of improvement methods. The embedding of improvement into management processes so that it becomes the way in which we lead and run our organisations and systems. Read full story (paywalled) Source: HSJ, 29 September 2023 .
  21. News Article
    The U.S. Department of Health and Human Services (HHS), through the Agency for Healthcare Research and Quality (AHRQ), announced nine grant awards of $1 million each for up to 5 years to support existing multidisciplinary Long COVID clinics across the country to expand access to comprehensive, coordinated, and person-centered care for people with Long COVID, particularly underserved, rural, vulnerable, and minority populations that are disproportionately impacted by the effects of Long COVID. The grants are a first of their kind. They are designed to expand access and care, develop, and implement new or improved care delivery models, foster best practices for Long COVID management, and support the primary care community in Long COVID education. This initiative is part of the Biden-Harris Administration's whole-government effort to accelerate scientific progress and provide individuals with Long COVID the support and services they need. “The Biden-Harris Administration is supporting patients, doctors and caregivers by providing science-based best practices for treating long COVID, maintaining access to insurance coverage, and protecting the rights of workers as they return to jobs while coping with the uncertainties of their illness,” said Secretary Xavier Becerra. “Treatment of Long COVID is a major focus for HHS, and AHRQ is helping lead the way through grants to investigate best practices and get useful guidance to doctors, hospitals, and patients.” Read full story Source: AHRQ, 20 September 2023
  22. News Article
    A trust chief executive has warned of a ‘really significant increase’ in patient anxiety and frustration created by the ongoing doctors’ strikes. Lance McCarthy, the chief executive officer of Princess Alexandra Hospital Trust, made the comments during the most recent four-day junior doctors’ strike, which also coincided with two days of consultant strike action. The trust leader told Hertfordshire and West Essex integrated care board on Friday: “We shouldn’t underestimate the impact industrial action is having.” Mr McCarthy said this impact was not just confined to strike days but also affected the run-up and aftermath of each bout of industrial action. He said every series of strike days caused service disruption for at least another 72 hours. He said: “We are seeing increasing frustration [from] our colleagues around it, because we are constantly duplicating work, cancelling patients, rebooking the same patients, etc. “We are [also] quite understandably starting to see in the last two months a really significant increase in anxiety and concern and frustration from our patients, who took it quite well the first couple of rounds but are understandably really frustrated. It is having a really significant impact.” In a further statement to HSJ, Mr McCarthy reiterated comments that trust staff had noticed an increase in anxiety, concern and frustration among both patients and colleagues in recent months. Read full story (paywalled) Source: HSJ, 25 September 2023
  23. News Article
    The BMA’s GP Committee (GPC) has demanded an investigation into the Government and NHS England’s ‘mismanagement’ of this year’s vaccination programmes. A motion was passed at the GPC England meeting today which called for a review of the ‘circumstances which led to muddled and mismanaged communications’ and for reflection on how to ‘prevent a repeat occurrence’. Last month, there was confusion over the start date for the adult flu and Covid vaccination programmes, which usually start in September. NHS England said the programmes would start in October this year – a move which the BMA said would cause ‘serious disruption’. But the Government then announced that vaccination will begin on 11 September, in what the BMA has called a ‘u-turn’, following the identification of a new Covid variant. GPs were asked to vaccinate ‘as many people as possible’ by the end of October. The GPC has said today that these ‘conflicting instructions’ led to confusion among GPs while also impacting on patient safety. Read full story Source: Pulse, 21 September 2023
  24. Content Article
    Extensive cultural change is needed in the NHS to tackle sexual violence and prevent further institutional harm to patients and staff, writes Philippa Greenfield, co-presidential lead for women and mental health, consultant general adult psychiatrist, named doctor for adult safeguarding and trauma informed lead.
  25. Content Article
    The 15th annual HSJ Patient Safety Congress brings together more than 1000 attendees with the shared goal of advancing the national agenda for patient safety across health and social care. In this blog, Samantha Warne, the hub's Lead Editor, captures some of the key highlights and messages from day one of HSJ’s Patient Safety Congress.
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