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Found 110 results
  1. Content Article
    ICS Futures is a roundtable series held by the Public Policy Projects ICS Network and chaired by Matthew Swindells, Chair of the North West London Acute Collaborative and former Deputy CEO of NHS England. The Network is made up of senior leaders from across the health and care sectors. The Network convened for three Chatham House roundtables between 16 May and 17 June 2022. The objective of discussions was to highlight challenges and opportunities in integrated care based on real-world examples, to scale best practice and provide ongoing practical advice for system leaders and care providers. Thoughts were also given on key legislative developments, with some national policy recommendations highlighted. This document summarises the key findings and recommendations from each meeting. It is not an exhaustive description of health and care system leaders’ views but rather provides a snapshot into the thoughts and concerns of a specific cohort of senior stakeholders
  2. News Article
    Systems and processes in place around patient safety failed in terms of the work of a Belfast-based neurologist, an inquiry has found. Dr Michael Watt was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. Almost a fifth of patients who attended recall appointments were found to have received an “insecure diagnosis”. The final report following the Independent Neurology Inquiry found that problems with Dr Watt’s practice were missed for years and opportunities to intervene were lost. It makes 76 recommendations to the Department of Health, healthcare organisations, General Medical Council and the independent sector. “While one process or system failure may not be critical, the synergistic effect of numerous failures ensured that a problem with an individual doctor’s practice was missed for many years and, as this inquiry finds, opportunities to intervene, particularly in 2006/2007, 2012/2013, and earlier in 2016 were lost,” the inquiry found. Read full story Source: The Independent, 21 June 2022
  3. Content Article
    The Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
  4. Content Article
    This article in The BMJ examines the risks and benefits of current prostate cancer screening methods in the UK. It highlights issues that prevent early diagnosis including great variation in how prostate cancers behave and the poor performance of prostate specific antigen (PSA) testing in identifying disease that requires treatment. As a result of the limited benefits of screening for prostate cancer, routine screening is not recommended by the UK’s National Screening Committee or the US Preventive Service Task Force. The authors highlight that a bid by NHS England to find an estimated 14,000 men who have not yet started treatment for prostate cancer due to the pandemic, seems to contradict this recommendation. The NHS campaign warns that people shouldn’t wait for symptoms and encourages men to use a risk checker which informs patients of risk factors including family history, age and ethnicity. The authors express concern that the campaign implies there is great benefit in detecting asymptomatic disease, which could lead people to believe that the NHS is promoting screening. They argue that the NHS needs to be clearer and more consistent in its messaging, making sure that information aimed at the public emphasises that although PSA testing is available on request for men older than 50, it is not currently recommended, and why.
  5. Content Article
    Clinicians play an essential role in implementing infection prevention policy, but little is known about how infection control policy is implemented at an organisational level or what factors influence this process. This study explores the policy implementation process used in the introduction of a national large-scale, government-directed infection prevention policy in Australia.
  6. Content Article
    This document is a short introduction to systems thinking for civil servants. It is one component of a suite of documents that aims to act as a springboard into systems thinking for civil servants unfamiliar with this approach.
  7. News Article
    Contractors could be required to provide trusts with the findings of criminal records checks on their employees, an update from Michael inquiry into mortuary security has suggested. The independent inquiry, chaired by Sir Jonathan Michael, was set up to examine the implications of the sexual assaults on the bodies of women and children in hospital mortuaries by maintenance supervisor and convicted murderer David Fuller. A progress report published this month by the inquiry highlighted “responsibilities between trusts and contractors” as an area of concern. The report said expectations around information sharing should be made clear in policy and, if sharing is deemed necessary, consideration should be given to what checks and evidence is needed to show this is taking place. HSJ understands that Mr Fuller did not declare previous convictions for burglary when he was first employed at the Kent and Sussex Hospital in Tunbridge Wells in 1989. Other issues flagged to NHS England by the inquiry included how access to “high-risk areas” is monitored and who requires access to these areas. It added that consideration should be given to monitoring access, involving a review of CCTV and swipe card use. Read full story (paywalled) Source: HSJ, 20 May 2022
  8. Content Article
    There are too many integrated care systems (ICSs) in some parts of the country, especially the South West and Midlands, writes Alastair McLellan and Dave West in this HSJ article. This means that effective integration will struggle due to limited resources, leadership capacity and ability to influence large providers. It is also a problem widely acknowledged at the centre and within the regions.  The proposed structure for ICSs is overly complex, consisting of a partnership board with little statutory power, which is meant to give strategic direction to an executive board which in practice will be held accountable for all decisions, but which is also meant to give up as much power and money as possible to “place based” entities which remain ill defined and have no statutory standing.
  9. Content Article
    This webpage contains information from the Royal College of Anaesthetists (RCOA) on coroners' reports that have been sent to the RCOA so that action can be taken to prevent future deaths. The webpage contains: information about the latest reports received. links to articles relating to the patient safety issues identified. information on multidisciplinary team training. training videos.
  10. Content Article
    This study in the Journal of Patient Safety aimed to assess the impact of a pro forma that standardises medical record-keeping on ward rounds. The pro forma was developed by analysing notes entered in patient charts and comparing them with standards set out by the Royal College of Surgeons of Ireland and England, as well as Medical Council guidelines from the two countries. The authors found that the pro forma improved compliance of ward round notes when compared with internationally recognised guidelines, with no additional time required during ward rounds.
  11. Content Article
    This article, published in the American Journal of Medical Quality, examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the Covid-19 era.
  12. News Article
    West Suffolk Foundation Trust’s investigation to find a whistleblower was “intimidating…flawed and not fit for purpose”, according to a damning review which is highly critical of the organisation’s leadership. The long-awaited review, published today, was triggered by ministers back in January 2020 following allegations that trust directors had ordered staff to give fingerprints and handwriting samples during a “witch hunt” for a whistleblower. The review, led by Christine Outram, has corroborated many of the allegations. It concluded trust leaders’ investigation to uncover the identity of the author of an anonymous letter sent to a patient’s family was “intimidating, flawed and not fit for purpose… impractical and unwise.” It said: “The decision to use fingerprinting and handwriting analysis in an NHS hospital, in the context of an anonymous letter and where no crime has been committed, was highly unusual and without doubt extremely ill-judged.” Read full story (paywalled) Source: HSJ, 9 December 2021
  13. Content Article
    Findings from an independent review, commissioned by NHS Improvement in February 2020, at the request of the Department for Health and Social Care, into the handling of whistleblowing at West Suffolk NHS Foundation Trust.
  14. Content Article
    This survey for health and care staff looks at how quickly staff are aware of alarms emitted by bedside monitoring equipment in single patient rooms, and their ability to respond. Doors to single patient rooms are often kept shut for long periods of time for reasons of privacy, dignity and (at the moment especially) infection control. With the UK Government targeting a growth in the proportion of NHS hospital rooms which have a single bed, is this a risk to the health and wellbeing of patients? This is not a specific issue where data is collected, so an online survey has been created to gather feedback and opinions.
  15. Content Article
    This is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user David at North West Boroughs Healthcare NHS Foundation Trust, published in June 2020.
  16. Content Article
    This article, published in the BMJ Quality & Safety, discusses the value of incident reporting systems. Reporting systems, both local and national, are overwhelmed by the volume of reports they receive and fall short in defining recommendations for improving healthcare safety. Focusing incident reporting systems on the local learning process of healthcare providers could mitigate many of the problems that have been attributed to reporting systems.
  17. Content Article
    An examination of how humans interact with their environments and each other led a team at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, USA, to question one of its long-standing medication safety practices and change how they work.
  18. Content Article
    This study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
  19. Content Article
    This article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.
  20. News Article
    ‘Very heavy-handed, laborious and expensive’ inspections ‘have not been the right way’ of regulating hospitals, according to the Care Quality Commission’s (CQC) former chair. Speaking at a Royal Society of Medicine event on Wednesday, Lord David Prior, who is now the chair of NHS England, said “very few” physicians will have improved their work after reading a report from the regulator. He added that there is a role for the CQC to move in when “things are going wrong” although he is “sceptical” the regulator can actually drive improvement in hospitals. Lord Prior said: “I am highly sceptical as to whether or not CQC or any regulator can really drive improvement and drive the top hospitals to make them better. “And certainly I think there’ll be very few physicians who will say that their clinical work has improved as a result of reading a CQC report. “I think the sadness I have about CQC is that we have not been able, or it has not been able, to develop a series of predictive metrics that could replace these very heavy handed, very laborious and very expensive visits that we used to do.” Read full story (paywalled) Source: HSJ, 9 September 2021
  21. Content Article
    This competency framework has been developed and updated to support prescribers in expanding their knowledge, skills, motives and personal traits, to continually improve their performance, and work safely and effectively.
  22. Content Article
    This toolkit, produced by the Canadian Patient Safety Institute, is intended to support healthcare leaders and policy makers to develop, implement or improve healthcare worker support models. It includes tools, resources and templates from organisations across the globe who have successfully implemented their own healthcare worker support models, such as peer support programs for healthcare providers.
  23. Content Article
    This manuscript provides a comprehensive overview of what healthcare worker support models are available in Canada and internationally. It outlines best practice guidelines, tools and resources that policy makers, accreditation bodies, regulators and healthcare leaders can use to assess the support needs of healthcare workers. The Canadian Peer Support Network is intended as a forum for healthcare organisations seeking guidance in the development of their Peer Support Programs to assist providers who have experienced a patient safety incident. These interventions aim to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients.
  24. Content Article
    Health workers are at the front line of the COVID-19 outbreak response and as such are exposed to different occupational hazards that put them at risk, including exposure to SARS-CoV-2 and other pathogens, violence, heavy workload and prolonged use of personal protective equipment (PPE). This document, produced by WHO, provides specific measures to protect occupational health and safety of health workers and highlights the duties, rights and responsibilities for health and safety at work in the context of COVID-19.
  25. Content Article
    This guide, published by WHO, consolidates COVID-19 guidance for human resources for health managers and policy-makers to design, manage and preserve the workforce necessary to manage the COVID-19 pandemic and maintain essential health services. The guide identifies recommendations at individual, management, organisational and system levels.
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