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Found 246 results
  1. Community Post
    Some years ago I stopped writing for journals, in favour of blogging & volgging. My reasons were: I specialise in patient involvement and inclusion, so I want the work of me and my colleagues to be easily found by everyone We didn't want our work to end up behind a paywall We work across disciplines and try to bypass hierarchies, especially in promoting action learning and patient led care I can see there are some really good Open Access Journals around. So my question for us all is: Which are the best Open Access Journals? Here a link to my digital profile: https://linktr.ee/stevemedgov This is our developing model of working, a away of working in healthcare that all use and participate in:
  2. Content Article
    In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.
  3. Content Article
    The aim of the Standard is to establish a framework and set a clear direction such that patients and service users (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss receive: ‘Accessible information’ (‘information which is able to be read or received and understood by the individual or group for which it is intended’). ‘Communication support’ (‘support which is needed to enable effective, accurate dialogue between a professional and a service user to take place’). Such that they are not put “at a substantial disadvantage…in comparison with persons who are not disabled” when accessing NHS or adult social services. This includes accessible information and communication support to enable individuals to: Make decisions about their health and wellbeing, and about their care and treatment. Self-manage conditions. Access services appropriately and independently. Make choices about treatments and procedures including the provision or withholding of consent.
  4. Content Article
    Positive results There are few results where the majority of people reported good experiences of mental health care. However, ‘organising care’ is an area where people were found to be more positive: 97% of people who have been told who is in charge of organising their care and services said they knew how to contact this person if they had a concern. 91% said the person that organised their care did so ‘very well’ (58%) or ‘quite well’ (33%). Another area where people were found to be more positive is ‘respect and dignity’: 73% reported that they were ‘always’ treated with dignity and respect. Key areas for improvement Crisis care 28% of people indicated that they would not know who to contact, out of office hours in the NHS, if they had a crisis. Of those who did try to contact this person or team, almost a fifth (17%) either did not get the help they needed or could not contact them (2%). Support and wellbeing 36% of people felt they had not had support with their physical health needs. 43% said they did not receive help or advice in finding support with financial advice or benefits. 43% of people did not get help or advice in finding support for keeping or finding paid or voluntary work, but would have liked this help. Accessing care 44% of people who had received NHS therapies in the last 12 months felt they waited too long to receive them. 24% of people felt they had not seen NHS mental health services often enough to meet their needs. 59% said they were ‘definitely’ given enough time to discuss their needs and treatment. Involvement 53% of those who had agreed with someone what care they will receive were ‘definitely’ involved as much as they wanted to be in the planning of their care. 52% of people who had been receiving medicines in the last 12 months were ‘definitely’ involved in making decisions about their medicines as much as they wanted to be. 50% of those who had received NHS therapies in the last 12 months were ‘definitely’ involved as much as they wanted to be in deciding which therapies to use. Communication 28% of people indicated that they had not been told who is in charge of organising their care. 24% of those who had been receiving medicines in the last 12 months for their mental health needs had no discussion about the possible side effects. 41% of people who had been receiving medicines had not had the purpose of discussed with them fully.
  5. Content Article
    The link below takes you to a Choosing Wisely UK webpage dedicated to resources on shared decision making. These include: Leaflet for patients to help them make the right choices for them at their healthcare appointment using the BRAN questions.Poster to be displayed to encourage the patients to ask the BRAN questionsGuidance on professional standards and ethics for doctorse-learning and video resources for cliniciansLeaflet for healthcare professionals to understand shared decision making.
  6. Content Article
    The CQC strategy is built on four themes that together determine the changes they want to make. Running through each theme is CQC's ambition to improve people’s care by looking at how well health and care systems are working and how they’re acting to reduce inequalities. It is not enough to look at how one service operates in isolation. It is how services work together that has a real impact on people’s experiences and outcomes. The four themes in our draft strategy are: People and communities: CQC want their regulations to be driven by people’s experiences and what they expect and need from health and care services. They'll focus on what matters to the public, and to local communities, when they access, use, and move between services. Smarter regulation: CQC want their assessments to be more flexible and dynamic. They'll be updating ratings more often, so everybody has an up-to-date view of quality. Being smarter with data means our visits will be more targeted, with a sharper focus on what they need to look at. Safety through learning: CQC want all services to have stronger safety cultures. They’ll expect learning and improvement to be the primary response to all safety concerns in all types of service. When safety doesn’t improve, and services don’t learn lessons, CQC will take action to protect people. Accelerating improvement: CQC want to do more to make improvement happen. They’ll target the priority areas that need support the most. They want to see improvement within individual services, and in the way they work together as a system to make sure people get the care they need. You can read the full strategy in the link below where you will find an online form to respond. Responses by 5.00pm on Thursday 4 March 2021.
  7. Content Article
    LATEST Patient Safety Weekly Update #15 (7 January 2020) Patient Safety Weekly Update #14 (17 December 2020) Patient Safety Weekly Update #13 (10 December 2020) Patient Safety Weekly Update #12 (3 December 2020) Patient Safety Weekly Update #11 (26 November 2020) Patient Safety Weekly Update #9 (12 November 2020) Patient Safety Weekly Update #8 (5 November 2020) Patient Safety Weekly Update #7 (29 October 2020) Patient Safety Weekly Update #6 (22 October 2020) Patient Safety Weekly Update #5 (15 October 2020) Patient Safety Weekly Update #4 (8 October 2020) Patient Safety Weekly Update #3 (1 October 2020) Patient Safety Weekly Update #2 (23 September 2020) Patient Safety Weekly Update #1 (17 September 2020)
  8. News Article
    Patient and Public Voice (PPV) partners play a crucial role in specialised services and are represented across the board on NHS advisory groups and governance structures to ensure that the views of patients, carers and the public are at the heart of what we do. Specialised Services are currently recruiting to a range of vacancies for PPV partners, all of which can be found here. NHS England and NHS Improvement are committed to promoting equality and inclusion to ensure that our PPV partners reflect and represent our diverse population, and particularly encourage people from Black, Asian and Minority Ethnic (BAME) backgrounds to apply. Read more Source: NHS England/Improvement
  9. Content Article
    There are a few key phrases that we may hear or read if we are told we need a surgical procedure: ‘shared decision making’, ‘consent to treatment’ and ‘informed consent’ to name a few. A common reaction is to see these processes as the small print, not dissimilar to ticking a box to agree to terms and conditions we almost certainly haven’t read. We all know deep down we should read them, but really, what’s the harm? And who has the time? When it comes to a surgical procedure, the implications can be significant, and in this blog post I will attempt to explain why. I will describe what those terms really mean, and why, as patients, we must all take some time to familiarise ourselves with anything we are putting our signature to. Anecdotally, surgeons tell me that many patients defer to their expertise when it comes to making a decision about a surgical procedure. They are, after all, trained to a very high level and, by definition, experts in their field. We are right to trust and rely on them to give us all the information we need. However, we also need to understand any potential consequences so we can make a decision. While it’s appropriate to defer to the experts for information, they are not the ones making the decision to go ahead or not. Moving away from a paternalistic relationship This brings me to my first definition, ‘shared decision making’. The National Institute for Health and Care Excellence (NICE) defines it as: ‘…when health professionals and patients work together. This puts people at the centre of decisions about their own treatment and care.’ You can read the full NICE definition here. This means that the relationship between the health professional (in most surgical cases, this is the surgeon) and the patient should not be paternalistic. While it is accepted that the health professional is the expert in this scenario, it is not appropriate for him or her to tell the patient what to do. We now have the Montgomery ruling, which transformed the patient consent journey, shifting the power from the clinician to the patient. I don’t have the space to describe this in detail, but I would recommend taking five minutes to read about the Ruling and to watch the short interview with Nadine Montgomery. The resultant ruling of this case acknowledged the importance of ‘material risk’, stating: ‘Material risk is a risk that is deemed to be of significance by an individual patient rather than by a body of doctors.’ So, what does all of this actually mean for patients? Well, most importantly, it means the conversation about treatment has gone from largely being one way, to an open, two-way discussion. The result of this conversation should hopefully be ‘consent to treatment’ – my next definition. It really is what it says on the tin. But it goes much further than ticking a box or signing on the dotted line. Making a decision to have surgery may be the biggest decision you make in your life. You may not feel that you have a choice, and in many cases, if you don’t go ahead with it, the problem will continue, worsen and it may be life-threatening. This, however, does not mean you should just say ‘yes’ without giving it due consideration. Have you been told about alternatives to the surgery being offered? What about the risks and potential complications? What would happen if you said ‘no’, both in the near and distant future? What information should patients be given? This is where ‘informed consent’ comes in. Informed consent means the patient has been made aware of the Benefits, Risks, Alternatives and doing Nothing by a qualified health professional. This is known among health professionals as ‘BRAN’. BRAN is essential for equipping us to make decisions about our treatment. But how is this information actually prepared and presented to us? In my role as Content Director at EIDO Healthcare, I am responsible for getting the written versions of this information from the surgeon who writes it to the health professional sharing it with patients. But what is that information, and what part does it play in shared decision making and informed consent? In short, it is written information about the procedure your surgeon has recommended. Many hospitals and/or surgeons write their own information, but at EIDO we maintain one version of each document that is used by hundreds of hospitals and surgeons both here in the UK and elsewhere around the world. Either option is fine, as long as the information is reviewed and updated regularly. Don’t be shy in asking your surgeon about how the information you’ve been given has been prepared. Helping patients access clear information At EIDO, all of our leaflets are written by specialists, reviewed by other clinicians and edited by experts in plain English. They are regularly updated and, because they are stored online, updates can be made almost immediately. We also have accreditation from the Patient Information Forum and work with the Patients Association to ensure they are accessible. We offer large and giant print versions, screen readers, ‘Easy Reads’ and a number of translations. Whether the leaflet you see is an EIDO one or not, it should contain relevant information relating to BRAN. This is vital in terms of patient safety. How can someone be expected to make a decision on something so important without knowing all the facts? Risks and benefits are subjective Arguably, the benefits will be of most interest to patients. There is a problem somewhere in your body and you need it to be fixed. But what about the risks? You need to think about how the operation will affect your life in the future. You need to measure the risks against the benefits. If you are a singer, for example, you may not want to risk an operation on your thyroid that could change your voice. Using the same analogy, if you’d like to protect your voice, are there any alternatives that would be preferable specifically to you? What if you did nothing, or waited for a few months, or even years? All of this information should be supplied by the health professional who is advising you to have the surgery. The pre-written information will go into general details, but this alone is not enough. It needs to be a two-way conversation with the opportunity for both of you to ask and answer questions. You can ask for a copy of any notes made about your treatment options, so you can refer back to that conversation. Some people find it helps to talk it through with a friend or loved one. You will have time before the actual procedure to digest this information before signing the consent form. Read the information You should be given information to take home (or it may be emailed to you). I cannot stress enough how important it is that you read this carefully, make notes if you need to, and think about questions you might want to ask your surgeon. The reason for this is twofold. The first, most obvious one, is that you need to know how to prepare for the procedure, what to expect afterwards, and how to take care of yourself in the following weeks. The second reason takes us back to those pesky terms and conditions… Legal implications When you sign the consent form, you are effectively saying you have read and you understand the BRANs for your procedure. This means that if something goes wrong and it was not mentioned or clearly explained to you, you are in a good position to make a claim against the hospital. It also means that if the risk was in the document, you will have a weaker claim. While it is hard to prove that someone has actually read a leaflet, and your signature is not the only consideration, signed consent forms have been used in such cases to dismiss claims made by patients. These documents exist to protect both the patient and the healthcare provider. Litigation against health professionals and providers has grown in recent years, demonstrating an increased understanding by patients of the care we should expect to receive. We are not merely recipients of care; we should also be involved in the direction it takes. The knock-on effect of this growing number of informed patients has resulted in better information. Many patients still choose not to engage fully, and some will even ask their surgeon to make the decision for them (although they will still need to sign a consent form). This is also perfectly acceptable, if that is their preference. The important thing is that they have been offered the information and have been given the opportunity to ask questions, digest the information and then make an informed decision. Julie Smith, Content Director, EIDO Healthcare.
  10. Event
    A move to personalised care means people having more control over the care and support they need to improve their own health and wellbeing. Personalised care is based on ‘what matters’ to people, not just what’s the matter with them. This event from the King's Fund will share the latest practice and learning on personalised care, bringing together people with lived experience, the NHS, local government and the voluntary community sector, to discuss what personalisation means in the context of COVID-19. With personalisation core to both social care and the NHS Long Term Plan, join us to explore the progress made in creating a new relationship between people, professionals, and the health and care system. Register
  11. Content Article
    View webinar Slideshow presentation Full responses to live questions from panelists and current research
  12. News Article
    Patient Safety Learning Press Release 10th December 2020 Today the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its first report on its findings.[1] The report made recommendations for actions to be implemented by the Trust and “immediate and essential actions” for both the Trust and the wider NHS. The Review was formally commissioned in 2017 to assess “the quality of investigations relating to new-born, infant and maternal harm at The Shrewsbury and Telford Hospital NHS Trust”.[2] Initially it was focused on 23 cases but has been significantly expanded as families have subsequently contacted the review team with their concerns about maternity care and treatment at the Trust. The total number of families to be included in the final report is 1,862. These initial findings are drawn from 250 cases reviewed to date. This is another shocking report into avoidable harm. We welcome the publication of these interim findings and the sharing of early actions that have been identified to make improvements to patient safety in NHS maternity services. We commend the ambition for immediate responses and action. Reflecting on the report, there are a number of broad patient safety themes, many of which have been made time and time again in other reports and inquiries. A failure to listen to patients The report outlines serious concerns about how the Trust engaged and involved women both in their care and after harm had occurred. This was particularly notable in the example of the option of having a caesarean section, where there was an impression that the Trust had a culture of wanting to keep the numbers of these low, regardless of patients’ wishes. They commented: “The Review Team observed that women who accessed the Trust’s maternity service appeared to have little or no freedom to express a preference for caesarean section or exercise any choice on their mode of deliver.” It also noted a theme in common with both Paterson Inquiry and Cumberlege Review relating to the Trusts’ poor response to patients raising concerns.[3] The report noted that “there have also been cases where women and their families raised concerns about their care and were dismissed or not listened to at all”. The need for better investigations Concerns about the quality of investigations into patient safety incidents at the Trust is another theme that emerges. The review reflected that in some cases no investigation happened at all, while in others these did take place but “no learning appears to have been identified and the cases were subsequently closed with it deemed that no further action was required”. One of the most valuable sources for learning is the investigation of serious incidents and near misses. If these processes are absent or inadequate, then organisations will be unable to learn lessons and prevent future harm reoccurring. Patient Safety Learning believes it is vital that Trusts have the commitment, resources, and frameworks in place to support investigations and that the investigators themselves have the right skills and training so that these are done well and to a consistently high standard. This has not formed part of the Report’s recommendations and we hope that this is included in their final report. Lack of leadership for patient safety Another key issue highlighted by the report is the failure at a leadership level to identify and tackle the patient safety issues. Related to this one issue it notes is high levels of turnover in the roles of Chief Executive, executive directors and non-executive directors. As part of its wider recommendations, the Report suggests trust boards should identify a non-executive director who has oversight of maternity services. Good leadership plays a key role in shaping an organisations culture. Patient Safety Leadership believes that leaders need to drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. Leaders need to be accountable for patient safety. There are questions we hope will be answered in the final report that relate to whether leaders knew about patients’ safety concerns and the avoidable harm to women and their babies. If they did not know, why not? If they did know but did not act, why not? Informed Consent and shared decision-making The NHS defines informed consent as “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[4] The report highlights concerns around the absence of this, particularly on the issue of where women choose as a place of birth, noting: “In many cases reviewed there appears to have been little or no discussion and limited evidence of joint decision making and informed consent concerning place of birth. There is evidence from interviews with women and their families, that it was not explained to them in case of a complication during childbirth, what the anticipated transfer time to the obstetric-led unit might be.” Again this is another area of common ground with other recent patient safety reports such as the Cumberlege Review.[5] Patient Safety Learning believes it is important that patients are not simply treated as passive participants in the process of their care. Informed consent and shared decision making are vital to respecting the rights of patients, maintaining trust in the patient-clinician relationship, and ensuring safe care. Implementation for action and improved patient safety In its introduction, the report states: “Having listened to families we state that there must be an end to investigations, reviews and reports that do not lead to lasting meaningful change. This is our call to action.” Responding with an official statement in the House of Commons today, Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, did not outline a timetable for the implementation of this report’s recommendations. In 2020 we have seen significant patient safety reports whose findings have been welcomed by the Department of Health and Social Care but where there has subsequently been no formal response nor clear timetable for the implementation of recommendations, most notably the Paterson Inquiry and Cumberlege Review. Patient Safety Learning believes there is an urgent need to set out a plan for implementing the recommendations of the Ockenden Report and these other patient safety reports. Patients must be listened to and action taken to ensure patient safety. [1] Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2020/12/ockenden-report.pdf [2] Ibid. [3] The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.serv...; The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf [4] NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ [5] Patient Safety Learning, Findings of the Cumberlege Review: informed consent, Patient Safety Learning’s the hub, 24 July 2020. https://www.pslhub.org/learn/patient-engagement/consent-and-privacy/consent-issues/findings-of-the-cumberlege-review-informed-consent-july-2020-r2683/