Jump to content

Search the hub

Showing results for tags 'Commissioner'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous


  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Learning news archive
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous


  • News

Find results in...

Find results that contain...

Date Created

  • Start

Last updated

  • Start

Filter by number of...


  • Start



First name

Last name


Join a private group (if appropriate)

About me



Found 42 results
  1. Content Article
    Slow, siloed, disjointed, dismissive. The Cumberlege review heard from patients who had been campaigning for years or decades without being heard, or their concerns acted upon. InFact raised concerns about sodium valproate being dispensed in plain white packaging without warning labels in 2013. Ten years later, the Government has just published the response to a consultation on white boxes. The plans will improve information and safety for patients taking sodium valproate, but also enable pharmacists and pharmacy technicians to use their discretion when there is a mismatch of 10% between the prescription (often in multiples of 28) and the pack size. Good news, but also a stark reminder of how slow the response is to the very people who are impacted by harm. What will it take for the evidence that patients raise to be seen as important as other sources in the hierarchy as evidence? Why is it that when thousands of patients are all saying the same thing, that the system is so slow to react? It’s clear that participants in clinical trials do not mirror the intended population whether for medicines or medical devices, so post marketing surveillance is particularly important, and we all have a responsibility to keep our minds open when patients give feedback or raise concerns. Patients describe being ignored, dismissed and ‘gas lighted’ when describing symptoms and signs, being told it’s all in their head, that they are hysterical, not to believe everything they read on social media. And yes, they are mainly women. We need to hear the early signals of harm and to act on these swiftly and in a co-ordinated way. This is particularly important with the recent Budget announcement that the MHRA will be able to rely on licensing of medicines and medical devices in trusted jurisdictions. We need a listening culture that values the voices of patients and families and that can translate the feedback into action. Patients should not have to push this information to providers and regulators – we need a system that draws the feedback into the centre. Instead of relying on the traditional hierarchy of evidence when identifying harm, we need a feedback loop as exists when we introduce quality improvements and for this feedback to be escalated directly to MHRA using the yellow card system. Without this the same problems will persist and we will look back in a further ten years and say: we were responsible – what did we do to stop harm? @InFactUK @KathSansom @meshcampaign @carlheneghan @MHRA #patientvoice This article was first published on LinkedIn.
  2. News Article
    The patient safety commissioner has complained to MPs that she does not have enough staff to cope with her ‘significant workload’, it has emerged. Henrietta Hughes’ concerns are revealed in a letter from Commons health and social care committee chair Steve Brine to health and social care secretary Steve Barclay. Mr Brine asks for assurances over the commissioner’s resources and says he was “concerned” Dr Hughes had told him her current funding was “too little to make the necessary improvements” to safety oversight. Mr Brine wrote on 6 March: “I am in regular contact with Dr Hughes and the matter of resources for her office is something that she has raised with me. She tells me that her office is under extreme pressure, with a significant workload, including correspondence from patients.” Mr Brine told Mr Barclay he shared Dr Hughes’ concerns that without “sufficient resourcing” there was a risk that the safety commissioner role would – according to Dr Hughes – “let down the hopes of patients that were raised by the publication of Baroness Cumberlege’s report”. Read full story (paywalled) Source: HSJ, 14 March 2023
  3. News Article
    Source: The Times. 5 March Shared on Twitter @ShaunLintern
  4. News Article
    A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published. In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. "Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition. "I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm." Read full story (paywalled) Source: HSJ, 2 February 2023
  5. Content Article
    The Patient Safety Commissioner outlines the range of different stakeholders she has met within her first 100 days in office, including patients, healthcare staff, patient safety specialists and healthcare providers. She also details the number of different areas of concern that have been raised with her in this period, including: pelvic mesh complications isotretinoin side effects painful gynaecological investigations Covid vaccination concerns mental health difficulties fluoroquinolone side effects Yellow Card scheme reporting concerns about electroconvulsive therapy. The report then sets out in more detail her reflections on patient safety concerns relating to the three medical interventions covered by the Independent Medicines and Medical Devices Safety Review: pelvic mesh, Sodium valproate and Primodos. She also highlights some positive areas of patient safety work she has encountered in her first 100 days in office, including the Scan 4 Safety initiative, NHS Resolution’s work on consent resources and how the new Patient Safety Incident Response Framework (PSIRF) is seeking to ensure that patients’ voices are included in incident investigations. The report concludes by setting out her top three priorities: 1. Culture Change The Patient Safety Commissioner plans to: hold a public consultation on the Principles of Better Patient Safety for the Patient Safety Commissioner work with healthcare leaders to put patient voice at the core of their activity and reporting amplify patients’ voices in all parts of the health system to ensure they are heard identify and highlight where patient voice is neglected challenge organisations to identify a named patient voice on all Boards and to place patient stories at the top of their meeting agendas campaign to improve the use of Yellow Card reporting campaign to see the NHS number used as the default and unique identifier ·work to ensure patients are engaged in the development of all national specifications develop the Patient Safety Commissioner website as a hub of best practice in championing patient voice. 2. Pelvic mesh The Patient Safety Commissioner plans to: co-produce resources for patients and GPs about side effects from pelvic mesh surgery work with NHS England to provide patients choice of access to specialist mesh centres work with the health system to ensure that information is available to all patients on national registries. 3. Sodium valproate The Patient Safety Commissioner plans to: support the health system to include the views of all stakeholders including patients to reduce harm from sodium valproate to the lowest possible level work with health leaders to ensure that all relevant patients are on a Pregnancy Prevention Plan (PPP) and given the necessary information collaborate with partners to ensure annual reviews are carried out by specialist prescribers work with partners across health to eliminate dispensing of sodium valproate in unlabelled white boxes work with professional regulators to streamline the advice to their registrants on sodium valproate and contraception raise patient awareness through charity collaboration.
  6. Content Article
    I love and support the NHS. But when things go wrong for patients and service users, the system is often too slow to change or respond effectively. I have been through complaints, the Ombudsman and Inquest processes around the poor end of life care of my late mother. Those processes took years and were almost as stressful as those last few days of my mother’s life. I would not do it again. At the time, I reported the incident in detail to the CQC (inspectors), to the CCG (commissioners), to Healthwatch (local and national), but I noted no evidence of change. In fact, the CQC continued for years to report similar failings at the same hospital. Too many other patients and service users say the same thing. I met many of these patients/users when I was part of the user/patient led group PHSOthefacts. Then, my elderly friend and neighbour asked me to be their advocate around their wishes for end of life care and unfortunately things were not perfect at all. I was able, through connections I had made from the previous experiences I mention above, to get a meeting with senior managers involved with her care. However, sadly I do not think much came of that either. I believe others could go through the same suffering my friend experienced. There are immense pressures on the NHS. Hospitals have budgets to operate within, reputations to manage and targets to meet, as well as keeping patients and staff safe. While the system is under huge pressure, and many of the known ‘complaint’ processes are not designed to improve patient safety, the good news is there is a growing awareness of the need to listen and learn from patients and service users, drawing on the best safety science and using independent experts. Safety improvement rather than simply complaining (often seen as an administrative process) is what so many patients and families most want to see so others do not suffer the same way as their loved one. Fortunately, via a convoluted route, I did discover the Patient Safety team of NHS England who was able to take one of my concerns about care very seriously. I also learned about the development of the Healthcare Safety Investigation Branch (HSIB). So the good news is that as well as traditional routes like Complaints, the Ombudsman (PHSO) and reporting to formal bodies (perceived as inadequate by too many patients/users who have been through this process), there are four developments to note of NHS dealing with events when patients suffer harm or potential harm: 1. New guidance is being developed by NHS England to help hospitals and health services address safety concerns and involve patients in this. 2. HSIB, who carry out up to 30 independent investigations a year, is developing an exemplar model of involving the patient and family perspective in these investigations. It offers an exciting, new, more change-focused, learning-focused and system-focused way of understanding and addressing many of the harmful incidents patients' experience, aligned with service users and families who wish to embark on a journey resulting in learning. Watch this HSIB video 'Why it's important that we learn from incidents'. 3. There is increasing recognition of the role of patients in all health decision-making, which is well covered in the Patients Associations' 'Shared decision making: a reality for everyone'. In fact, I recently wrote a blog for the hub on a particular patient harm issue: 'Please don't undermine my pain relief! A call for learning and respect for patients with long tern needs', which I then shared via ENGLAND.shareddecisionmaking@nhs.net and I was put in contact with a relevant Clinical Improvement Team in NHSE/I who were interested to learn more. 4. Finally, patients, service users and families can log issues on the NHS England NRLS reporting tool – although no one will get back to you personally, the information you share could be used to improve safety for future patients. However currently it is vastly under used (50 patient/family reports a year) compared to the general NHS complaints system (over 100,000 a year). In contrast, the system also logs and analyses nearly 2 million NHS staff-reported harm or potential harm incidents a year, examined by a team of NHS-employed independent patient safety experts. It may contribute to vital learning in the future and it is currently reviewed and upgraded, but to my mind the process is going too slow with regard to patient and family reporting. I think the patient, service user and family voice should be heard loud and strong. There should be a reporting option for where patients and users can go if they do not want to go through complaints, Ombudsmen, Inquest, legal or other processes (e.g. to CQC or CCG), or indeed want to do something alongside these processes and want to ensure independent health safety experts are made aware of concerning incidents. Please let me know if you are interested about developments in this latter area as there will be working groups wanting to hear the patient, service user and family experience, and I will be involved and want to ensure other harmed patient voices and their advocates are heard. The patient, service user, family and carer voice must be heard and acted on to improve patient safety at these difficult times.
  7. News Article
    Ambulance trusts should review their ability to respond to mass casualty incidents and press commissioners for any additional resources they need, the report into the Manchester Arena bombing has said. Only 7 of the 319 North West Ambulance Service Trust vehicles available on the night of the attack, in 2017, were able to deploy immediately, the report said. It said experts believed that “such a situation would almost inevitably be replicated if a similar incident were to occur again anywhere in the country”, given current resources and demand. Ambulance trusts are now hugely more stretched than in 2017, with response times having significantly lengthened due to lack of resources. The second volume of the report from the inquiry, chaired by Sir John Saunders, published today, is critical of the emergency services’ response to the bombing which killed 22 people. NWAS “failed to send sufficient paramedics into the City Room [an area adjoining the Arena]” and did not use available stretchers to remove casualties in a safe way, it says. A key role for managing the incident – that of ambulance intervention team commander – was not allocated for half an hour. But it also raised issues of ambulance capacity and availability for major incidents involving mass casualties. “Around the UK, ambulance services are always ’playing catch up,’” it said, with no spare frontline capacity. With demand doubling over the last 10 years, the inability to respond to such incidents is only going to get worse – and lives will be lost if they do not attend the scene quickly and in sufficient numbers, the report said. Read full story (paywalled) Source: HSJ, 3 November 2022
  8. Content Article
    This week I had the pleasure of meeting with Janet Williams MBE who with EMMA M. and INFACT have done so much to provide information and support to patients taking Sodium Valproate. Women are still not getting the information needed to make the choices that are right for them at different stages of their lives. Despite regulators advice patients continue to be dispensed sodium valproate in plain white boxes with no warning labels or patient information leaflets. Janet shared a devastating story with me about a patient who was only told about the harmful effects of sodium valproate after she had conceived. There are many complex and interdependent factors and a huge amount of work needed to get this right. So I was very pleased to meet with David Webb Chief Pharmacist and Aidan Fowler to get a deeper understanding of the barriers and how I can help to overcome them. It can be done - national safety systems have led to rapid identification and remediation of problems such as with ventilators during the pandemic. When information is available and people work collaboratively the system can respond swiftly , compassionately and in a joined up way. Information and data was central to my discussion with Scott Pryde and the Outcomes and Registries team at NHS England. When we have access to outcomes data including patient reported outcomes and experience (also known as PROMS and PREMS) then it will be possible to have more meaningful conversations about choosing the right treatment, possible side effects and other treatment options. It also relies on high quality and complete data and we discussed barriers to sharing data and helpful innovations to overcome this. Patient voice and how this is heard and acted on was the theme of my meeting with Helen Hughes. I met Sean O’Kelly, Chief Inspector of Hospitals at Care Quality Commission and talked about Safe and Well Led organisations. Leaders who actively listen and join the dots between safety, culture, patient and worker voice know more, know sooner and can take remedial action to keep people safe. My question to healthcare providers is ‘Who is the voice of patients at Board?’ Meeting the needs of all patients is key and in my call with Dr Habib Naqvi MBE of the NHS Race & Health Observatory we discussed the risks to patients when medical devices such as pulse oximeters work less effectively on patients from black or minority ethnic backgrounds. Let’s make sure that patients views are central to design and delivery - that’s how we will get it right for everyone. I’m pleased to see the NHS England Operating Framework has a key objective to ‘Strengthen the hands of the people we serve’ Mark Cubbon. For this to become a reality we need to have meaningful conversations with people, patients and everyone who works in the healthcare system to lift these words off the page and into our everyday experience. #patientsafetycommissioner #patientvoice #data #sodiumvalproate This article was first published on LinkedIn.
  9. Content Article
    Thank you to everyone who has shared your powerful stories with me about your own experiences and those of family members. Your testimonies are both heartfelt and heart breaking, a very emotional read. I cannot think of a greater motivation for decision makers to do what is right, without delay. I was very privileged to meet Yasmin Golding and to hear about the #SaferMumSaferBaby campaign by the Epilepsy Society. It was humbling to hear directly from Yasmin about her hopes and fears for the future and why having information to help minimise risk would make the world of difference. Thank you Yasmin 🙏 It’s so vital that patients can get the right information about medicines to be able to make the decisions which are the safest for themselves and their families. I met with Mid and South Essex Integrated Care System and Karen Flitton for a World Patient Safety Day webinar. The theme was Medication Without Harm and it was wonderful to see so many people with a passion for patient safety. I was also very pleased to meet with the team at Healthcare Safety Investigation Branch for a morning webinar to talk about patient safety and inclusion. Thanks very much James Titcombe for the kind invitation and to everyone for your insightful questions. Patient safety in a world of ransomware attacks was part of my conversation with Nicola Byrne the National Data Guardian. With more electronic patient records and electronic prescribing, there is a risk that patients can be harmed when we don’t have timely access to information. Cyber security is key to keeping patients safe by ensuring that access to information is protected. The Speak Up Month podcast I recorded with Jayne Chidgey-Clark and the National Guardian's Office has a theme of speaking up for safety and why psychological safety is so important Listen here: https://lnkd.in/enBsUx7w Psychological safety for all was also a topic of conversation when I met with Professional Standards Authority CEO Alan Clamp. Their recent publication Safer Care for All highlights the need for a swift and coordinated system response which tackles inequalities. We can only get this right if we get it right for everyone. Such a thought provoking week- thank you to everyone who has been in touch to help me have a greater understanding about your concerns and what needs to be done to get this right. *This article was first published on LinkedIn.
  10. Content Article
    Patient Partnership was the theme last week. I met with Rachel Power and we discussed the great value of shared decision making and the Patients Association strategy of Patient Partnership in the design and delivery of healthcare. I spoke at Royal College of Anaesthetists and had fantastic engagement from the delegates about improving patient safety. I heard Annie Hunningher speak about patient partnership as part of NatSSIPs2 This is the start of Speak Up Month I spoke with Jayne Chidgey-Clark about Speaking Up for safety and why it’s so important that patients, families and workers are able to ask questions, speak up and be heard, knowing that the right actions will follow. Thank you to everyone who has been in touch. I am listening and will follow up with you to bring about the changes that we need to see so that: Patients get the information to make the right choices about treatment. Patients can easily ask questions, speak up and be heard. The system responds in a swift, joined up and compassionate way. *This article was first published on LinkedIn.
  11. Content Article
    The safety of medicines and medical devices is everybody’s business and we all have a part to play The Patient Safety Commissioner is a new role and, with my small team, we are setting up the office. Thanks very much for your patience while we get up and running. Thanks very much to everyone who has been in touch this week. My contact details are commissioner@patientsafetycommissioner.org.uk. With many patient safety events in England being postponed I’ve reflected that World Patient Safety Day will be celebrated and prioritised for many weeks this year. With medication safety as this year’s theme it will help to embed the aims of the WHO campaign Know, Check and Ask before you give or receive medicines This week I was really pleased to meet June Raine to discuss patient safety and patient voice and learn more about how MHRA are responding to the recommendations from IMMDS. I also met with Rosie Benneyworth and the team at HSIB. With joint ambitions for improving patient safety there are lots of opportunities to listen and learn from patients and families and embed system improvements. Today I am heading to Leeds Teaching Hospitals NHS Trust to see how Scan4Safety delivers safer patient care as part of the Leeds Way and the Leeds Improvement method. *This article was first published on LinkedIn.
  12. Content Article
    I am honoured to start my role as the first Patient Safety Commissioner for England. Patients’ voices need to be at the heart of the design and delivery of healthcare but there are many examples where patients have not been listened to leading to untold harm to themselves and their families. I would like to pay tribute to the incredible courage, persistence and compassion of all those who have campaigned for many years and gave evidence to First Do No Harm. I will work collaboratively with patients and others to challenge the healthcare system to make improvements: All patients must receive the information they need to make a choice about treatment with medicines and medical devices. All patients’ voices are heard. The system responds quickly to keep people safe. This is a huge undertaking and builds on the work of many deeply committed people including patients, patient groups, professionals and organisations. I look forward to meeting and hearing from patients and patient groups, learning from their experience and working with the system to make improvements. With my small team we are setting up the office of the Patient Safety Commissioner. Please get in touch here: commissioner@patientsafetycommissioner.org.uk *This article was first published on LinkedIn.
  13. News Article
    Dr Henrietta Hughes was appointed as the first ever Patient Safety Commissioner for England in July. She began her role on 12 September. Dr Hughes is an independent point of contact for patients so that patients’ voices are heard and acted upon. She will use patients’ insight to help the government and the healthcare system in England listen and respond to patients’ views and promote patient safety, specifically with regard to medicines and medical devices. For more information on the role of the Patient Safety Commissioner see the fact sheet and the government’s response to a consultation regarding the post. The privacy notice sets out how the Patient Safety Commissioner collects and uses personal data to fulfil the role. Please contact the Patient Safety Commissioner at commissioner@patientsafetycommissioner.org.uk. Source: Department of Health and Social Care, 28 September 2022
  14. News Article
    A new patient safety chief should be appointed in each of the four UK nations to oversee health and social care and tackle the currently “fragmented and complex” system, experts have urged. The Professional Standards Authority for Health and Social Care (the body that oversees the 10 statutory bodies that regulate health and social care professionals in the UK, including the General Medical Council) has called for what it described as a radical rethink to improve safety in care. In a report published last week, it recommended the appointment of an independent health and social care safety commissioner (or equivalent) for each UK country. These commissioners would identify current and potential risks across the whole health and social care system, it said, and instigate necessary action across organisations. Read full story (paywalled) Source: BMJ, 6 September 2022 Related reading Working together to achieve safer care for all: a blog by Alan Clamp (chief executive of the Professional Standards Authority) Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (a blog from Patient Safety Learning
  15. Content Article
    The Professional Standards Authority for Health and Social Care (PSA) is an independent body which oversees the ten statutory bodies that regulate healthcare professionals in the United Kingdom and social care in England. Its aim is to protect the public by improving the regulation and registration of people who work in health and social care.[1] In its new report, Safer care for all – solutions from professional regulation and beyond, the PSA set out their view of the main unresolved challenges which impact the quality and safety of health and social care.[2] This is structured around four main themes: Tackling inequalities – considering the persistence of unequal and unfair outcomes for protected groups in aspects of professional regulation. Regulation for new risks – noting the need to adapt to both the risks and opportunities posed by rapidly developing and increasingly accessible new technologies and approaches in health and care. Facing up to the workforce crisis – considering the impact of workforce shortages on patient safety and the capacity of healthcare professionals. Accountability, fear and public safety – looking at the balance that needs to be struck between making individual accountability work in a system that is safe for patients and fair to healthcare professionals. The report also highlights a sector-wide issue which it describes as “structural flaws in the safety framework”.[2] This concerns the fragmentation and complexity of our current system-wide approach to safety in health and social care. The report highlights that no one organisation currently takes an overarching view of this, noting that instead this is only looked at through individual organisational remits. In this blog, we will consider the four main themes highlighted in this report from a patient safety perspective and reflect on the sector-wide issue of structural flaws in the safety framework. Tackling inequalities Health inequalities pose a serious threat to patient safety, with poorer outcomes for specific patient groups presenting themselves in a variety of different ways.[3] This report highlights some specific examples of this, such as abuse and neglect of people with learning disabilities, highlighted by reviews such as the Muckamore Abbey Hospital Public Inquiry, and people from specific ethnic and racial backgrounds being disproportionately affected by certain types of patient safety incidents.[4] [5] The PSA make a number of recommendations in this area, emphasising the importance of collecting appropriate health and social care data relating to people with protected characteristics, reducing barriers to raising complaints and identifying issues that disproportionately impact particular groups. We welcome the proposals set out in the report and also what appears to be a growing acknowledgement more broadly of the patient safety concerns raised by health inequalities, as evidenced by the recently announced Government call for evidence on the potential racial and gender bias of medical devices.[6] However, much more work is needed to ensure this becomes a key focus for all health and care organisations. To date, the most thorough work in this area has often been carried out either by tenacious patient campaigning groups, such as FIVEXMORE on disparities in maternal outcomes for Black women, or very specifically tasked bodies, such as the NHS Race and Health Observatory. Regulation for new risks The second key theme this report focuses on changes to how health and care is funded and delivered, including the use of new technologies. The PSA stresses the importance of the Government and regulators being ahead of the curve on such changes, ensuring they identify emerging risks and protect the public. We agree with this view and believe it is vital that we ensure that patient safety considerations are at the heart of new healthcare innovations and technologies, from the point of development through to their deployment. We also need to ensure there is a direct role for patients in the development and implementation of new innovations, and consistent use of Patient Reported Outcome Measures (PROMS) and Patient Reported Experience Measures (PREMS) to monitor their safety in use. Facing up to the workforce crisis There is a wide body of research highlighting the negative impacts on patient outcomes as a result of insufficient staffing levels.[7] [8] In addition, reports into major patient safety scandals, such as the Francis report on the Mid-Staffordshire NHS Foundation Trust, have made clear the link between patient safety incidents and safe staffing levels.[9] It is about having the right numbers of staff, with the right skills, in the right place at the right time.[10] PSA rightly identifies the serious workforce shortages we currently face in both health and social care in the UK as a key challenge to the quality and safety of care. We welcome their recommendation that the four UK governments should work together to develop a coherent strategy for the regulation of professionals, to support delivery of the national workforce strategies. Accountability, fear and public safety The fourth theme of this report is focused on striking the balance between making individual accountability work in a system that is safe for patients and fair to healthcare professionals. The PSA emphasise the importance of ensuring that workplace cultures do not unfairly punish healthcare professionals for mistakes when things go wrong whilst also retaining the importance of individual accountability. At Patient Safety Learning we believe it is vital that we create an environment in health and social care organisations with an open and fair culture that enables patient safety issues to be raised, discussed and resolved, ensuring incidents of avoidable harm are responded to with empathy, respect, rigour and action for improvement. To achieve this, patient safety incidents must be reported consistently, and staff and patients feel safe and supported in doing so. Related to this, we would agree with the PSA’s recommendation that professional regulators are seen to be fair and transparent, with clear explanations of how and why decisions are taken. This section of the report also considers the issue of ‘safe space’ principles in patient safety investigations by the Healthcare Safety Investigation Branch. This is where, as part of safety investigations, material such as transcripts, witness statements from staff and patients involved in the incident, notes written by investigators, electronic recordings of interviews and other information generated by the investigation are non-disclosable and inadmissible, except on the order of the High Court. The report raises concerns that this approach may run counter to the professional duty of candour that requires professionals to be open and honest when things have gone wrong. They suggest that: “The UK Government should ensure that the ‘safe spaces’ investigation approach being implemented in England does not cut across the duty of candour or otherwise negatively impact on transparency or accountability.”[2] Structural flaws in the safety framework Considering the health and social care landscape more broadly, the PSA highlights that the current approach to safety across health and social care is too complex and fragmented. It points out that while many individual organisations take a view on safety, they all do so only through the lens of their own remit, with no one taking an overarching overview. They also note this occurs in the case of public inquiries too, which can often vary considerably and are not necessarily looked at in a joined-up way. In response to this, the report makes a core recommendation that: “Each UK country has a Health and Social Care Safety Commissioner, or equivalent function, with broad responsibility for identifying, monitoring, reporting, and advising on ways of addressing patient and service user risks. The commissioners should sit above all other health and care organisations, spanning public as well as private provision. They would also be independent of Governments, and transparent in both their approach and outputs.”[2] We agree with the PSA’s diagnosis of this issue. In our recent report, Mind the implementation gap, we highlighted that part of the difficulty in implementing improvements in patient safety in the UK lies in absence of a systematic and joined-up approach to these issues and unclear leadership at a system level.[11] This is not a new problem, previously identified in a 2018 report by the Care Quality Commission, Opening the door to change, which stated: “Arm’s-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what.”[12] The PSA’s proposals for independent commissioners have significant merit and are worth further exploration as part of an effective Safety Management System. However, the introduction of a Health and Social Care Safety Commissioner, while potentially bringing significant benefits of coordination and oversight at a system level for patient safety, will not alone bring about a significant improvement in patient safety. In our view, any such change must be part of a wider transformation in our approach to patient safety, placing this at the heart of our healthcare system. This cannot just be limited to the most senior levels of health and social care, we need everyone – politicians, policymakers, patients, families and communities, clinicians, managers, system and professional regulators, researchers and academics, and health and social care system leaders – involved in this effort. References PSA., Who we are. Last Accessed, 6 September 2022. PSA. Safer care for all – solutions from professional regulation and beyond. 6 September 2022. Patient Safety Learning., Health inequalities and patient safety. 15 December 2021. Muckamore Abbey Inquiry. About the inquiry. Last Accessed 7 September 2022. Chauhan A, et al. The safety of health care for ethnic minority patients: a systematic review. Int J Equity Health 2020: 8;19(1):118. Department of Health and Social Care. Equity in medical devices: independent review call for evidence. 11 August 2022. Rafferty AM. Research proves we need safe staffing. RCN Bulletin, 23 July 2019. National Institute for Health and Care Excellence. Safe staffing for nursing in inpatient mental health settings. Last Accessed 22 August 2020. Robert Francis QC. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. February 2013. Royal College of Nursing. Safe and Effective Staffing: Nursing Against the Odds. 2017. Patient Safety Learning. Mind of the implementation gap: The persistence of avoidable harm in the NHS. 7 April 2022. CQC. Opening the door to change: NHS safety culture and the need for transformation. 2018.
  16. Content Article
    Working together to achieve safer care for all There are some big challenges ahead that need us all to work together to solve them. In our new report, 'Safer Care for All: solutions from professional regulation and beyond', we set out four key challenges for patient and service user safety: Tackling inequalities. Keeping pace with changes to technology and the delivery of care. Facing up to the workforce crisis. Addressing issues of accountability, fear and public safety. We suggest possible solutions as well as one major overarching recommendation: that each UK nation should have a Health and Social Care Safety Commissioner. These Commissioners would have broad responsibility for identifying, monitoring and advising on ways of addressing patient and service user risks. Tackling inequalities in health and care professional regulation Inequalities in the health and care sector affect both patients and registrants (healthcare professionals). For patients, this can result in significantly worse outcomes, such as black women being four times more likely to die in childbirth than white women in the UK.[1] For registrants, inequalities affect career attainment and experiences of disciplinary processes. In England, amongst NHS staff as a whole, black, Asian and minority ethnic (BAME) staff are more likely to enter local disciplinary processes and, according to General Medical Council (GMC) research, are twice as likely to be referred to the GMC by employers compared to white doctors; and international medical graduates face an increased likelihood of receiving a serious sanction.[2] This is echoed in the findings of other regulators, which indicate that BAME professionals are overrepresented at all stages of the fitness to practise process. Regulators and employers need to work together to tackle this issue. There is also a lot we still do not know about how inequalities affect all-important complaints mechanisms when care has gone wrong, which is crucial to addressing health inequalities for patients and service users. We recommend a range of actions to help tackle inequalities, and for our part have committed to ensuring that our equality, diversity and inclusion (EDI) standards for regulators are stretching and stimulate continuous improvement. Keeping pace with changes in how care is delivered and funded Health and care is changing, with more care being delivered by the private sector and online. Technology is being used increasingly to diagnose and treat conditions, presenting both opportunities and risks to patient care. Regulation can be slow to adapt; instead it needs to keep pace and be agile enough to adapt quickly to new delivery models and emerging risks to patient care. Some of the issues we examine in the report are the interplay between profit and the best interests of patients and staff, individual conflicts of interest, online care provision and new technologies. We recommend a cross-sector review of arrangements to address financial conflicts of interest among healthcare professionals and that regulators do more to tackle any business practices that fail to put patients first. We also highlight the opportunity to give regulators greater agility to address new and developing risks through the Government’s reform programme for professional regulation. Facing up to the workforce crisis It is estimated that the UK needs over a million extra health and care workers in the next decade. But it takes time to train healthcare professionals and we fear it will be too little too late without some radical change. We consider what might be done differently to grow the workforce and adapt to new ways of working, and how professional regulation might help. Our recommendations include considering whether regulated professionals can be trained faster. We believe that the risks posed by the lack of staff is now so severe that a new approach is required. This means regulators, educators and professional bodies exploring whether there are opportunities for accelerating training safely. We also recommend that better and smarter use be made of unregulated roles. We propose a new strategy for the regulation of health and care professionals to be developed by the four UK Governments to support delivery of their national health and social care workforce strategies. Accountability, fear and public safety The report considers how to make individual accountability work in a system that learns from mistakes, is safe for patients and service users, and fair to professionals. We ask whether professional regulation can do more to explain its role in keeping people safe so that professionals are not practising in fear of unfair sanctions. We raise questions about how to ensure that the ‘safe spaces’ approach to safety investigations doesn’t cut across the professional duty of candour and individual accountability mechanisms. Regulators may have to investigate and take action relating to individuals involved in a safety incident, and individual accountability plays a key part in keeping people safe in health and care. Further, and understandably, when care has gone wrong, victims and families typically want the truth about what happened. Candour and transparency are key to this. In order to ensure that ‘safe spaces’ approaches address more risks than they create, we recommend that the UK Government should build in a review of the policy and assess how compatible it is with the professional duty of candour. The way forward There have been improvements in health and care regulation, but the patient safety landscape is still fragmented and complex. Concerns often fall between organisations or are left unaddressed due to jurisdiction issues or insufficient powers. Large-scale failures of care still occur frequently, as repeated inquiries testify. That’s why we think a new role is needed to oversee patient safety. The Health and Social Care Safety Commissioners would help to identify current, emerging and potential risks across the whole health and social care system, and bring about the necessary action across organisations. They would also coordinate public inquiries and reviews, and monitor how recommendations are addressed. In the meantime, there is action we, the regulators and registers we oversee, the four UK Governments, workforce bodies, employers, registrant organisations, health and social care services, and education bodies, can take to help make the system safer and more coherent. However, it is essential this is done hand in hand with patients, service users and organisations like Patient Safety Learning. I hope you will read the report and join us in working together towards safer care for all. References NHS Race and Health Observatory. Ethnic Inequalities in Healthcare: A Rapid Evidence Review. February 2022. Atewologun D, Kline R, Ochieng M. Fair to refer? Reducing disproportionality in fitness to practise concerns reported to the GMC. 2019.
  17. Content Article
    The report considers four main themes: 1) Tackling inequalities The report sets out that there are persistent, major inequalities in access to and experience of healthcare services. To help tackle this, it states that the system as a whole needs to improve the way it collects data about the protected characteristics of complainants, so that we can see start to identify any differences in how care is delivered, and how complaints are handled. 2) Regulating for new risks It highlights that the way health and care are funded and delivered is changing. There is an increase in ‘high street’ provision and the use of technology; disrupting factors, such as commercial and financial interests, can interfere with professional judgement, and put patients at risk. Governments and regulators must be ahead of the curve as delivery changes, to identify emerging risks and protect the public. It suggests that they should use the current reforms to healthcare professional regulators to ensure they have the agility to address new challenges. 3) Facing up to the workforce crisis The report states that the UK is facing a serious workforce shortage in health and social care, which must be addressed to avoid services suffering and patients and service users being at risk from harm. It calls for the four UK governments should work together to develop a coherent strategy for the regulation of professionals, to support delivery of the national workforce strategies. 4) Accountability, fear and public safety It notes that individual accountability plays a key role in keeping people safe in health and care. The Professional Standards Authority states that it has concerns about the safe spaces approach in England (where the law may prevent the disclosure of information that staff provide to safety investigations). They state that UK government should ensure that this approach does not undermine existing public protection mechanisms or reduce transparency when things have gone wrong. Structural flaws in the safety framework The report also identifies a sector-wide problem of structural flaws in the safety framework, stating that the patient and service user safety landscape is fragmented and complex. Concerns raised often fall between organisations, or are left unaddressed due to jurisdiction issues or insufficient powers. Large-scale failures of care still occur frequently, and inquiries and reviews highlight similar themes and issues, with the system seemingly unable to prevent their recurrence. Each body looks at the problems principally through the lens of its own remit, often prejudging the nature of the solutions as a result. We need a new framework focused on safety that spans organisational and sectoral boundaries. In response to this, its core recommendation is the appointment of an independent Health and Social Care Safety Commissioner (or equivalent) for each UK country to identify current, emerging, and potential risks across the whole health and social care system, and bring about the necessary action across organisations. Related reading Working together to achieve safer care for all: a blog by Alan Clamp (chief executive of the Professional Standards Authority) Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (a blog from Patient Safety Learning
  18. Event
    With general practice in crisis due to workforce shortages, an increasingly complex workload, rising public expectations, and further pressures caused by the Covid-19 pandemic, The King's Fund are providing the time and space for you to reflect, think differently, share and learn. Join peers and experts from The King’s Fund to explore: what the future of general practice looks like how the experience for patients and staff can be improved how to ensure those actions are building blocks towards the future. This event is for GPs, commissioners, nurses, practice managers, allied health professionals, Additional Roles Reimbursement Scheme (ARRS)-funded roles, and other professionals working in multidisciplinary general practice teams and those responsible for general practice at place or neighbourhood level. Register