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Found 150 results
  1. Content Article
    The Protection for Whistleblowing Bill takes this agenda forward in a meaningful and measurable way. An Office of the Whistleblower will help everyone who has an interest in removing barriers to safe care. An Office of The Whistleblower will help confirm, identify, promote and follow up on actions to resolve root causes of systemic patient safety failings. This includes building on what is already in place. Some of the benefits of the Protection for Whistleblowing Bill, from a healthcare perspective, include that the Office of the Whistleblower will be: Accessible to members of the public who blow the whistle. Providing support for genuine whistleblowers whoever they are e.g., clients, patients, carers, relatives, contractors. Providing mechanisms to ensure that the substance of whistleblowing reports is investigated. Ensuring the failings identified by the whistleblower are followed up with action. Provision so that the whistleblower knows the outcome. Scrutiny of the regulators’ approach to whistleblowing and related actions. Ensuring consistent use of accredited investigators and appropriately skilled expert witnesses. Enforcement powers.
  2. Content Article
    A high resolution image of the poster with full references can be downloaded by clicking on the attachment below. Organisational culture and patient safety (ver 2) (2).pdf
  3. Content Article
    In 2015 the Government introduced a Freedom to Speak Up Guardian and a system of Local Speak Up Guardians in response to the recommendations made by Sir Robert Frances following the scandal at Mid Staffordshire. From the outset, this system has attracted significant criticism and the APPG has heard from whistleblowers who have been failed by local guardians sharing their experiences that included the disclosure of their identity to hospital management and boards – resulting in retaliation. The APPG has also heard from Local Guardians who were not supported and themselves the target of retaliation after supporting whistleblowers. Local Guardians in East Kent were described as, “dishonest” and that the Guardian system had failed in every case that had been investigated throughout the UK. Further evidence was provided of a tick box approach to the Duty of Candour introduced by the former Secretary of State for Health. The APPG was told that both the Guardian and Duty of Candour systems are beyond resurrection and that across the NHS there is no ownership of problems. All attempts to encourage speaking up have been hindered by a failure to introduce an effective and safe whistleblowing regime across the NHS, resulting in the NHS being unsafe for whistleblowers, making it unsafe for patients. The APPG were told that, in over 50 years of investigation experience, little has changed, and that “these issues are not new, nor are they confined to a small number of rogue hospitals”. That league table results are inaccurate because of a flawed regulatory system with no ownership of the problems and where the regulators are “caught up in the fraud”. The APPG was provided with a series of examples of what were described as “deep seated problems” relating to teamwork and culture, which resulted in the failure to join up clinical and ethical responsibilities. These responsibilities were described as being on separate tracks and a failure by the regulatory regime to identify or report on the impact of this has significant consequences for patients, whistleblowers and the future of the NHS, as demonstrated by the case of the Bristol Children’s Heart scandal brought to light by Dr Steve Bolsin 30 years ago. Dr Bolsin was shunned for exposing the failures that resulted in the death of so many babies because funding the unit was more of a priority that the lives of the babies (he has since made a successful career in Australia). In every case, a failure to listen to whistleblowers, followed by attempts to discredit the whistleblowers, and a deliberate cover up has proved in many cases fatal for patients. What has been proved time and time again is that The Public Interest Disclosure Act (PIDA) has made little or no difference to this failure to protect patients or whistleblowers or to learn and improve our NHS. Evidence provided to the APPG is of a lack of system-wide action and an absence of commitment to speaking up beyond excellent PR. It is unclear who, if anyone, is responsible for the monitoring and reporting on recommendations contained in investigation reports. In addition, there is no coherent process for triggering high-level independent reviews of major patient safety failings. This causes confusion, suffering and leads to missed opportunities. Mary Robinson MP, chair of the APPG for Whistleblowing, said: “We have a duty to support and protect whistleblowers because without them we cannot prevent more deaths like those in East Kent. My APPG is committed to making whistleblowing safe and will continue to press the Government to introduce the Whistleblowing Bill which will incentivise and normalise speaking up. I encourage everyone to write to their MPs and ask them to join the APPG and support the Whistleblowing Bill.” The Right Hon. Baroness Susan Kramer, said: “Doing nothing is not an option that we can afford. It’s time to put an end to ‘tick box culture’ and turning a blind eye to whistleblowers. Whistleblowing law must be meaningful, easily understandable and enforceable. The Whistleblowing Bill will do this and in doing so will save lives and protect our NHS.” Wendy Morden MP, member of the APPG for Whistleblowing, said: “I hear about problems when I am at the hairdresser because people are too afraid to speak up in their place of work. The Office of the Whistleblower will be the catalyst for meaningful change.” Dr Bill Kirkup, author of Reading the Signals Report, said: “I support the proposals set out in the Whistleblowing Bill because the NHS urgently needs an effective early warning system.”
  4. News Article
    German public research funder Deutsche Forschungsgemeinschaft (DFG) is conducting an audit of the clinical trials it has supported in the past. The audit was announced in response to a request from TranspariMED asking DFG for a list of all its trials completed between 2009 and 2017, to which DFG replied that it currently has no such comprehensive dataset. DFG stated that it is "currently preparing an evaluation of its clinical trials programme. In the framework of this evaluation the data you requested will be collected and analysed, as the outcomes of trials supported by DFG is of high interest including for DFG itself." TranspariMED, an organisation which aims to end evidence distortion in medicine, sees this development as a good opportunity for DFG to check whether and when clinical trials were registered and their results made public. Previous research has shown that nearly a third of German academic trials never make their results public. This not only wastes public money, but also harms patients because it leaves gaps in the evidence base on the efficacy and safety of drugs, medical devices, and non-drug treatments. Due to gaps in German law, there is still no legal obligation to make the results of many German clinical trials public. Read full story Source: TranspariMed, 20 December 2022
  5. Content Article
    The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem. A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where this gap acts as a barrier to patient safety improvement: Public inquiries and reviews Healthcare Safety Investigation Branch reports Prevention of Future Deaths reports When patients and families take legal action Patient complaints Incident reports Having considered these six areas where the policy implementation gap undermines our ability to translate patient safety insights and learning into practical improvements, the report highlights four common underlying themes: Absence of a systemic and joined-up approach to safety Poor systems for sharing learning and acting on that learning Lack of system oversight, monitoring, and evaluation Unclear patient safety leadership It calls on the Government, parliamentarians and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare, and invites them to engage in a system-wide debate about how healthcare can reshape its approach to learning and safety improvement. Recommendations The report details six recommendations relating to the areas of the implementation gap that it highlights: Patient safety inquiries and reviews need system-wide commitment and resources, with effective and transparent performance monitoring to ensure that the accepted recommendations translate into action and improvement. HSIB reports and their recommendations need system-wide commitment and resources, with effective and transparent performance monitoring to ensure that their recommendations translate into action and improvement. The Coroner’s Prevention of Future Deaths system needs to be improved so that recommendations for patient safety improvements and organisational responses to the reports can be easily accessed. Processes need to be in place to provide assurance that learning from causal factors of avoidable deaths is captured consistently and the insight from these cases is disseminated and acted upon across all healthcare organisations. NHS England and NHS Improvement and NHS Resolution need to work together to improve the process for identifying the causal factors of unsafe care identified through litigation, ensuring this can be disseminated widely and acted on to improve patient safety. The introduction of the new NHS Complaints Standards needs to be closely monitored, with clear guidance for organisations on how to implement this and clarity on who is responsible for this within the organisation. This should be accompanied by public transparent reporting by organisations on the rollout of the new standard, allowing for consistent monitoring and comparison. NHS England and NHS Improvement and the MHRA must ensure that the development of the new PSIRF and changes to the Yellow Card scheme have a core focus on learning for action and improvement to tackle the implementation issues highlighted in this report.
  6. Content Article
    You can access the following videos of conference sessions: Welcome remarks from Caroline Corby, the PSA's Chair and Alan Clamp, PSA Chief Executive Is regulation keeping people safe? Health and Social Care Safety Commissioners: a solution to bridge the safety gaps in all UK countries? Are learning cultures compatible with individual accountability and candour? Should health and care professionals have a duty to tackle health inequalities? Parallel session A: Does regulation need to change to deliver the workforce of the future? Parallel session B: Are commercial interests in health and care harming people? The role of the Patient Safety Commissioner Closing remarks and next steps from Alan Clamp
  7. News Article
    A former chief executive of the NHS has said most data collected about hospital discharges by NHS England is ‘useless’ and biased against social care. Sir David Nicholson, who was chief executive of the NHS from 2006 to 2013, and of NHS England until 2014, has said “almost all” of the data around delayed discharges “is designed to show how bad social care is”. Sir David, who is now chair of Worcestershire Acute Hospitals Trust and Sandwell and West Birmingham Trust, added that data on the number of patients with the “right to reside” in hospital is “wholly useless” when trying to improve discharge rates. NHSE publishes figures on the numbers of patients who “no longer meet the criteria to reside” in hospital – and during the winter months will publish this every week. NHSE has said the data collected on discharges helps to improve patient care and flow. In an interview with HSJ editor, Sir David said: “The problem we have with a lot of the data we collect [is that] it is designed for accountability reasons, not operational reasons. “And if you want a good example of that, have a look at the debate around discharge at the moment. There is a myriad of data, almost all of it is useless […] and almost all of it is designed to show how bad social care is. It’s extraordinary". Read full story (paywalled) Source: HSJ, 30 November 2022
  8. Content Article
    91% of female doctors have experienced sexism at work, according to a survey published by the BMA in August 2021. 56% of female respondents have experienced unwanted verbal conduct and 31% have experienced unwanted physical conduct.[1] These numbers prove that there is a culture of sexism and misogyny within healthcare. To clarify those terms, sexism is defined as prejudice, stereotyping or discrimination based upon an individual’s sex, whereas misogyny has a more sinister edge, defined as a dislike of, contempt for or ingrained prejudice against women.[2] It is important to highlight the distinction here as the perpetrators of sexist attitudes and behaviours often do not believe that they hate women – after all they have wives, mothers, daughters or sisters. However, whether or not the intention behind treating women differently to men is one coming from a place of kindness or contempt does not matter. Treating women differently to men disadvantages everyone as we all end up consigned to limited gender roles. So what does this look like within healthcare? “I am in a management role and lead a large team. I have had several experiences of men within my team who are much more junior than me being invited to represent our discipline in senior meetings or on interview panels instead of me… despite them not being qualified enough to take on those tasks.” Testimony from Surviving In Scrubs campaign website. “When I was an FY1 working in orthopaedics my supervisor told me that I should go into primary care because as a female that was the best career choice for me. It would make life easier to have children and I would be able work part time to look after them. We had previously never discussed my career options/aspirations or whether I wanted/could have children.” Testimony from Surviving In Scrubs campaign website. These incidences of undermining the authority and expertise of female healthcare workers, favouring less qualified men and making assumptions about a woman’s perceived desire for a ’traditional‘ family life over career aspirations are commonplace in healthcare. They are by no means the only examples of how women are treated as less valuable employees within the healthcare system. “As a house-officer I was groped whilst assisting a mastectomy. The consultant anaesthetist slid his hand under the drapes and groped me between my legs. I was so shocked I froze." Testimony from Surviving In Scrubs campaign. website “A patient threatened to rape me. My (male) manager laughed and said ’well what do we expect, bringing a beautiful woman on the ward?’” Testimony from Surviving In Scrubs campaign website. Sexual harassment and sexual assault occur within healthcare. A paper published in 2021 authored by Simon Fleming and Becky Fisher has shone a light on the issue within surgical training.[3] Again more work needs to be done on defining the prevalence of these criminal behaviours throughout the whole of the healthcare workforce. This is where the Surviving in Scrubs campaign comes in. This campaign was set up by myself and Dr Becky Cox earlier this year. We are currently collecting anonymous testimonies from ANY healthcare professional who has experienced sexism, misogyny, sexual harassment, sexual assault or even rape whilst in work. This can be at the hands of colleagues or patients. So far, we have over 120 testimonies and we have more coming in every day. We are collecting this data to show the human cost of these cultural problems. But also, to demonstrate the strength and power that each individual voice and testimony can have in bringing about change. The collective narrative that we have already established from a variety of healthcare backgrounds – doctors, nurses, physiotherapists, clinical psychologists, administrative staff, paramedics, etc – has already led to key stakeholders taking notice. We have had meetings with the GMC, NHS England, representatives from royal colleges, the BMA and other unions and governing bodies. There is buy in, and a drive to bring about change. But we need to keep pushing! We need more stories and voices so that we are able to represent survivors of this terrible culture within healthcare. Every voice that speaks up makes a difference. If you’ve experienced issues like these, we need your voice too! Email Surviving in Scrubs with your story or use one of the following social media platforms: Website: www.survivinginscrubs.co.uk Twitter: @scrubsurvivors @ByChelcie Instagram: @scrubsurvivors References 1. BMA. Sexism in medicine. British Medical Association, 2021. 2. Wolf N, Bindel J, Power N, et al. Sexism and misogyny: what's the difference? The Guardian, 2012. 3. Fleming S, Fisher RA. Sexual assualt in surgery: a painful truth. The Bulletin of the Royal College of Surgeons of England, 2021; 103 (6): 272-322.
  9. Event
    From July 2022, all NHS trusts providing acute and mental health services will need to join a provider collaborative, with these collaboratives forming a universal part of the provider landscape. Working within a challenging NHS environment – struggling with record high waiting lists and a limited workforce – provider collaboratives offer an opportunity to make efficiencies whilst improving service delivery. As providers move from a mindset of competition to one of collaboration, they must come together to deliver better services and improve care pathways. However, the purpose and form of these collaboratives can vary considerably across England and important decisions remain over the governance and accountability arrangements of these new collaboratives. Join the King's Fund for this digital virtual conference bringing together leaders from across collaboratives to explore this new approach to service delivery. The event will explore what collaboration models have been successful before and the barriers they overcame. What can we learn from these as new collaboratives are set to take shape? Register
  10. Event
    The free, one-day, virtual conference will explore the themes and issues arising from the report recently published by the Authority, Safer care for all – solutions from professional regulation and beyond. It will be an opportunity to hear a range of views, debates and discussions about some of the issues in the report with the aim of moving towards solutions to support safer care for all. Safer care for all – solutions from professional regulation and beyond is the Authority’s contribution to the debate on some of the key patient and service user safety challenges within health and social care, drawing on insights from our role overseeing the ten health and care professional regulators and the Accredited Registers programme. Topics that we focus on within the report include: tackling inequalities regulating for new risks facing up to the workforce crisis accountability, fear and public safety. Register