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This is the website of the independent public statutory Inquiry established to examine the circumstances in which patients in the UK were given infected blood and blood products, in particular since 1970. The Inquiry is Chaired by barrister Keith Langstaff, who has experience of health-related public inquiries. The website contains information on: public hearings and meetings evidence latest news on the Inquiry how to get support if you have been affected by infected blood products. The Inquiry team is also inviting patients and family members of patients who received infected blood or infected blood products to give evidence to the Inquiry, either as a written statement or by speaking to an intermediary. Evidence given to the Inquiry will contribute to its findings and recommendations.

This briefing paper by thinktank The Centre for Mental Health explores evidence about the links between factors that worsen mental health, showing that living in poverty increases people’s risk of mental health difficulties, and that more unequal societies have higher overall levels of mental ill health. It also demonstrates that poverty and economic inequality intersect with structural racism to undermine the mental health of racialised and marginalised groups in society. Among other things, it highlights inequalities in access to primary care and mental health services across the UK.

The Covid-19 pandemic presented the need for fast decision-making in a rapidly shifting global context. This article in BMJ Evidence Based Medicine looks at the limitations of traditional evidence-based medicine (EBM) approaches when investigating questions in the context of complex, shifting environments. The authors argue that it is time to take a more varied approach to defining what counts as ‘high-quality’ evidence. They introduce some conceptual tools and quality frameworks from various fields involving what is known as mechanistic research, including complexity science, engineering and the social sciences. The article proposes that the tools and frameworks of mechanistic evidence, sometimes known as ‘EBM+’ when combined with traditional EBM, may help develop the interdisciplinary evidence base needed to take us out of this protracted pandemic.

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 blog by the charity Picker explores concerns about the safety of staffing levels in the NHS, highlighted by the 2021 NHS Staff Survey. It talks about the potential impact of a recent drop in staff morale. The blog draws out these key findings from the survey: The proportion of staff who felt unwell as a result of work-related stress in the last 12 months rose to 46% – almost half. This was an increase of nearly 3% from the 2020 figure (44%) and continued a trend: the figure has risen each year since 2017, when 38% of staff reported work-related stress. Almost one-in-three staff members say they “often think about leaving” their organisation – an increase of 4% points vs the 26% recorded in 2020. And one-in-six (16%) say they will leave their organisation “as soon as I can find another job” – a 2% point increase from 2020. Only 52% of NHS staff say that they look forward to going to work – a decline of more than 6% points from 58% in 2020. New questions in the survey suggest that many staff are experiencing burnout. Overall, more than a third of staff (34%) said that they ‘always’ or ‘often’ “feel burnt out because of [their] work”. The proportion was even higher for staff in patient facing roles (for example, 41% of registered nurses and midwives) and especially for ambulance personnel (51%).

The consultancy firm McKinsey & Company explored the effects of the Covid-19 pandemic on the nursing workforce in a global survey that included nurses from United States, the United Kingdom, Singapore, Japan, Brazil and France. The survey findings show a consistency around how nurses feel in their roles today, despite the different healthcare systems and delivery networks in each of the six countries. A substantial population of nurses are expressing a desire to leave direct patient care, with between 28% and 38% of nurse respondents in the United States, the United Kingdom, Singapore, Japan and France indicating that they were likely to leave their current role in direct patient care in the next year. This article explores in detail some of the reasons why nurses are choosing to leave direct patient care, and highlights approaches that might encourage retention, including positive leadership initiatives.

Complexity is often talked about in health services research, but it has not been sufficiently studied. In this article in the journal BMC Medicine, the authors argue that in open systems characterised by dynamically changing inter-relationships and tensions, conventional research designs must be augmented by the study of how we can best deal with uncertainty, unpredictability and emergent causality. They propose an agenda for future research and invite researchers to contribute to the conversation.

Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.

This thesis by Suzette Woodward describes a project that aimed to identify how the National Patient Safety Agency (NPSA) could support improvement in implementing patient safety guidance. It explored the factors that help or hinder successful implementation and its findings led to the design and development of an implementation toolkit, initially targeted at NPSA staff and other national bodies responsible for issuing guidance about safer practices.

The poor treatment of autistic people and people with learning disabilities has been a long-standing problem for the NHS and care system. Although successive governments have focused on supporting autistic people and people with learning disabilities to live independent and fulfilled lives in the community, over 2,055 people remain in secure institutions where they are unable to live fulfilled lives and are often subject to unacceptable and inhumane treatment. This report by the Health and Social Care Select Committee chaired by Jeremy Hunt MP outlines the finding of the committee's Inquiry into the treatment of autistic people by health and care services.

The Better End of Life programme is a collaboration between Marie Curie, King's College London Cicely Saunders Institute, Hull York Medical School, the University of Hull and the University of Cambridge. It's first research report outlines key findings of the programme relating to the experience of death and dying during 2020, at the height of the Covid-19 pandemic. This interactive webpage presents graphics which highlight the key findings of the research.

This guidance from The Royal College of Radiologists aims to provide radiologists with guidance on how to implement the duty of candour, recognising the unique circumstances they face. It includes real-world examples and provides an approach which will help radiologists navigate an unfamiliar process in the best possible way. The guidance covers: The principles of candour Why this can be difficult in a radiological context Candour in different situations (reactive and proactive candour) and departmental disclosure policies Candour processes in practice The difference between discrepancy assessment and education/Radiology Events and Learning Meetings (REALM) Specific considerations (interventional radiology and remote reporting within an imaging network).

This retrospective cohort study in the British Journal of General Practice aimed to identify opportunities for timely investigations or referrals in patients presenting with potential symptoms of colon and rectal cancer, or abnormal blood tests. The study found evidence that patients with these cancers presented with low haemoglobin, high platelets and high inflammatory markers as early as nine months pre-diagnosis, and the authors suggest that starting cancer-specific investigations or referrals earlier may be beneficial in patients with some of these diagnostic markers.

This report outlines the results of a survey of 10,000 nursing staff in the UK carried out by the Royal College of Nursing (RCN). The survey highlighted stark differences in career progression and treatment in the workplace between White nurses and those from a mixed ethnic background, and Black and Asian nurses. In the 35-44 age group, 66% of White and 64% of respondents from mixed ethnic backgrounds said they’d been promoted. This dropped to just 38% of Asian and 35% of Black respondents. Black respondents working in both hospital (39%) and community (32%) settings are more likely to report having experienced physical abuse than respondents of other ethnic backgrounds. In response to these findings, the RCN is calling on the UK Government to reform human rights law to help tackle workplace racism, including introducing a legal requirement to eliminate disparities in recruitment, retention and career progression. They also want employers to have greater responsibility to protect minority ethnic groups from racism in all its forms.

In 2020, the Independent Medicines and Medical Devices Safety (IMMDS) Review made specific recommendations that the government provide justice and redress to thousands of women who have been harmed by surgical mesh implants. Surgical mesh, also known as transvaginal tape, is a medical device surgically implanted to support organs and tissue. It is primarily used to treat urinary incontinence in women, but is also used to treat hernias and to reinforce abdominal areas where women have had tissue removed to reconstruct their breasts after mastectomy. In this article for the Mail Online, John Naish highlights that two years after the IMMDS, none of its recommendations have been implemented properly and surgical mesh is still being used. He examines the case of Kelly Cook, a 37 year-old mother who has been left with constant pain, nerve issues and incontinence after mesh surgery in 2018. In spite of the impact the mesh is having on her life, she has been told she may not be seen at one of the new specialist mesh centres for two years due to the length of the waiting list. The article also highlights the fact that no financial redress has yet been offered to mesh victims, that women's pain is still not being seen as a serious issue, and that there is a concerning lack of research into the safety of mesh devices.

This study in Clinical Epidemiology aimed to investigate the long-term complications associated with surgical mesh devices used to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP). The authors looked at rates of diagnoses of depression, anxiety or self-harm (composite measure) and sexual dysfunction, and rates of prescriptions for antibiotics and opioids in women with and without mesh surgery, with a diagnostic SUI/POP code, registered in the Clinical Practice Research Datalink (CPRD) gold database. The study found that mesh surgery was associated with poor mental and sexual health outcomes, alongside increased opioid and antibiotic use, in women with no history of these outcomes and improved mental health, and lower opioid use, in women with a previous history of these outcomes. The authors highlight the need to carefully consider the risks and benefits of mesh surgery on an individual basis.

The pandemic led to major disruption to services right across health and social care, as well as a huge shift in where patients are dying, with more than 105,000 extra deaths at home in the UK over the first two years of the pandemic. The reasons for this are not fully understood, but have profound implications for the experience of people dying and their families and carers, and for the type and quality of care they receive.  There is currently a large gap in our understanding of the services that the hospice sector provides across the UK. This report by the Nuffield Trust seeks to begin to close that gap by analysing the important role of hospices in supporting people at the end of life and their families, both in hospice settings and at home.

This analysis from the European Observatory on Health Systems and Policies provides a review of developments in financing, governance, organisation and delivery, health reforms and performance of the health systems in the United Kingdom.

Safety voice is the act of speaking up about safety in order to prevent accidents and physical harm. This systematic review in the journal Safety Science aimed to determine how safety voice differs conceptually from employee voice, is described across levels of analysis and could be best investigated. The authors found that there are important challenges for safety voice in terms of developing methodologies and interventions.

Anaphylaxis is a severe and often sudden allergic reaction that occurs when someone with allergies is exposed to something they are allergic to (known as an allergen). Anaphylaxis is potentially life-threatening, and always requires an immediate emergency response. Between 10 May 2017 and 10 May 2019, 55 hospital trusts reported 77 incidents relating to allergens in hospital, three of which involved the patient going into anaphylaxis, a severe and potentially life-threatening condition. This e-learning course is for nurses, healthcare assistants, ward managers, staff educators, directors of nursing, dieticians and anyone else involved in patient care on the ward. It has been designed to equip participants with knowledge and understanding about food allergies so that they can ensure the necessary processes are in place to keep inpatients with food allergies safe.

The Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.

The UK Government has announce a statutory public inquiry into the handling of the Covid-19 pandemic - the Hallett inquiry. However, in light of the wide-ranging impact of the pandemic, the inquiry faces a huge task to decide on the highest priority areas for investigation. This long read by Tim Gardner, Senior Policy Fellow at The Health Foundation, aims to examine what the parameters and structure of the UK Covid-19 Inquiry could be, and set out what it might realistically cover.