GOVNET'S PATIENT SAFETY
2011 CONFERENCE


Murray Devine, Head of Patient Safety, Department of Health spoke of the new regulatory system and the never events that would result in Trusts being penalised financially if they failed to deliver on the standards of care in the new framework. Professor Janice Stevens spoke of the progress so far on reducing MRSA bacteraemias and Clostridium difficile, it was felt there was a need to get back to the essential elements of nursing and move toward the system of conducting 'back rounds' which meant a focus on the patient, keeping a constant check on them to make sure they had been fed and they were comfortable, surely care bundles were not the only answer, the essential elements of care had to be implicit to avoid patient harm. 

Delivering the keynote address Professor Sir Bruce Keogh, Medical Director of the NHS, referenced Sir Liam Donaldson's report An Organisation with a Memory. He spoke about two key issues identified in the report, starting with a culture that inhibited reporting: "I invite you to think about how many of you can say that in your organisations, if somebody reports an incident, that within 24 hours they get an acknowledgment, a thank you, and a reassurance that something will be done about it?". Next, the absence of a cohesive national system for identifying and sharing lessons, which led to the creation of the National Patient Safety Agency. Sir Bruce went on to comment on the future of the NPSA: "The NPSA will be dissolved, but its functions will be preserved, and not only will they be preserved, they will be integrated seamlessly into the work of the national commissioning board". 

Professor Keogh then went on to look at medical errors in more detail, stating that "errors in healthcare often share root causes, making them amendable to system analysis, to modification, and to resolution". This being the case, Sir Bruce questioned why practices that have been shown to help reduce instances of harm to patients have not been adopted across the whole of the NHS: "Why is it that, despite now increasing evidence that the surgical checklist will reduce complications and death, it is not in place in every hospital?".

Dr Suzette Woodward, Director of Patient Safety at the NPSA, gave the closing morning address, taking a systemic look at patient safety: "We need to think a little bit more about prioritising action on the main causal contributory factors that lead to instances which cause harm". Echoing Sir Bruce, Dr Woodward's key message was that, useful though they are, it is not specific safety campaigns and initiatives that get results; improvement stems from the fact that a campaign directs healthcare professionals to look more closely at the root causes of medical errors. Citing a common example, Dr Woodward questioned why poor communication remains a causal factor in patient safety incidents. 

As General Practitioners begin taking over the reins of commissioning health services, Dr Clare Gerada, Chair of the Royal College of General Practitioners, spoke about the implications of these bold reforms for patient safety: "Most of the problems with respect to errors happen at transitions". Dr Gerada used a video to illustrate the point that patient safety is about spotting important things that stand out from the normal running of things. "It is vital, therefore, that in shifting the building blocks of the NHS we do not create gaps through which growing numbers of patients can fall". In keeping with earlier presentations, Dr Gerada advocated a systems view of patient safety: "Most threats to patients don't come from negligent staff, but from poorly performing systems". Taking the search for efficiency savings across the NHS as an example, Dr Gerada warned of taking the wrong approach to cost-cutting: "We must focus on increasing value, and not necessarily reducing cost".

The conference heard from Baroness Thornton, Lords Shadow Health Minister. Baroness Thornton spoke in the context of the Health and Social Care Bill, which she would have to leave the conference to vote on following her presentation. On the basis that the Care Quality Commission exists to provide minimum standards for quality and safety in health and adult social care, rather than raising standards, Baroness Thornton asked the question "who are going to be the future drivers of patient safety?" 

There were some challenges put to Baroness Thornton on her criticism of the NHS reforms, asking if it was not disingenuous to criticise areas where the Shadow cabinet had made cuts during their term, Derek Butler cited the reduction in the National Patient Safety Agency support to Trusts in the Cleanyourhands campaign, disbanding of Improvement Teams set up to help NHS Trusts with improvements in infection prevention and control that needed it, and the reduction in the Health Protection Agency microbiology funding during their term in Government, he said "it's time that politics in health were put to one side and that it was in the interests of everyone for the politicians to work together to improve the healthcare in this country, and that whilst they squabble those in the NHS and the patients suffer".  The comments were met with applause.
 
Derek's presentation was well received and delivered in 2 breakout sessions of an hour in length reaching the audience of 500 delegates.  Delegates were moved by the stories of our members' experiences.

Echoing Sir Bruce Keogh's challenge for organisations on hearing reports of an incident, that within 24 hours there is an acknowledgment, a thank you, and a reassurance that something will be done about it, Derek gave real examples of incidents where these should not have happened and where feedback had landed on deaf ears, and without doubt in at least six of the cases the failures would have resulted in the contraction of avoidable healthcare associated infections that were contributory factors, and in some cases the cause of their premature deaths.  

As Sir Bruce had cited errors in healthcare often share root causes, making them amendable to system analysis, to modification, and to resolution, yet for the people who had suffered unnecessary harm in the seven patient stories, there was little acknowledgment when desperate relatives tried to raise issues of concern, and a fear from the patients themselves of saying too much, for those that were able, as all too often if a patient is not conscious it is the family and friends that become the guardian when the system has failed them.

From our efforts to influence we can be proud that we are having an impact, not just by meeting healthcare professionals in this environment, but also by influencing those who make decisions and make a difference.  A lot of what was said in this conference about the future regulation and patient safety has come about as a direct result of the outcry from patients and patient organisations such as ourselves.  During Lord Ara Darzi's review of our healthcare system we did indeed make strident representation on the need to act on incidents when they were reported in the same way that other industries do, such as the nuclear and airline industries.

 View Derek's presentation here (PDF file 2.8MB)