NHS staff should be supported to learn from mistakes and patients and carers must be put above all else in an attempt to make the NHS a world leader in patient safety, an independent report will say today. Professor Don Berwick, a renowned international expert in patient safety, was asked by the Prime Minister to carry out the review following publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.
The report, led by Professor Don Berwick, follows five months of intensive work to examine the lessons for NHS patient safety from healthcare and other industrial systems throughout the world.
His four key findings are that:
The quality of patient care, especially patient safety, should be paramount
Patients and carers must be empowered, engaged and heard
Staff should be supported to develop themselves and improve what they do
There should be complete transparency of data to improve care
Recommendations in the report include:
The NHS needs to adopt a culture of learning
this cannot come from regulation, but from “countless, consistent and repeated” messages to staff so that goals and incentives are clear and in patients’ best interests
Staffing levels must be adequate, based on evidence
the report echoes the Keogh review in saying that staffing levels cannot be dictated from the centre, but that boards and local leaders should take responsibility for ensuring that clinical areas are adequately staffed
Connecting with patients and the frontline
leaders need first-hand knowledge of the reality of the system and the patient voice must be heard and heeded at all times
Complaints systems need to be continuously reviewed and improved
Transparency must be complete, timely and unequivocal
There is no single measure for safety
the NHS should continue to use mortality rate indicators to detect potentially severe problems. But these indicators remain a “smoke alarm” and should not be used to generate league tables
Supervisory and regulatory systems should be clear
an in-depth, independent review of the structures and the regulatory system should be completed by the end of 2017, once recent changes have been operational for three years
New criminal offences should be created
around recklessness or wilful neglect or mistreatment by organisations or individuals and for healthcare organisations which withhold or obstruct relevant information. But the report emphasises that the use of criminal sanctions should be extremely rare and unintended errors must not be criminalised.
The report does not recommend that a statutory duty of candour for healthcare workers is introduced – instead it finds that this duty is adequately addressed in professional codes of conduct and guidance. Above all else, the report argues that cultural change is the most important factor in continuously reducing harm. In particular the report distinguishes clearly between mistakes and negligence and the need for a transparent culture where mistakes are reported and learnt from.
The report is clear that the most important task for the NHS is to build a culture of learning and improvement. It aims to complement rather than duplicate the Francis Inquiry, which has already made 290 concrete recommendations for change.
Professor Don Berwick said:
I am a great admirer of the NHS – it has been, and still is, very respected around the world. This report is one of a number of recent reports that, taken together, provide the NHS with a real opportunity to deliver the safest healthcare in the world.
In any organisation, mistakes will happen and problems will arise, but we shouldn’t accept harm to patients as inevitable. By introducing an even more transparent culture, one where mistakes are learnt from, where the wonderful staff of the NHS are supported to learn and grow in their capacity to improve the NHS, and patients are always put first, the NHS will see real and lasting change.
Secretary of State for Health, Jeremy Hunt said:
This is a fantastic report from a world renowned expert on patient safety. It is a strong endorsement of all that the government has delivered since the Francis report, including on transparency, putting patients first, duty of candour and CQC reform.
For too long, patient safety and compassionate care have been secondary concerns in parts of the NHS and this has to change. I want to get to a point where every patient has confidence that their care will be safe and where every member of NHS staff feels supported to make safe, high quality care the priority.
The report makes clear that the NHS could lead the world in patient safety. Nothing less is good enough for the patients and families who rely on it, and this government will back our hard-working NHS staff to make this a reality.
Jane Cummings, Chief Nursing Officer at NHS England, said:
Don Berwick’s report is landing at exactly the right time for the NHS. He has highlighted many of the key areas that the NHS is actively addressing to give our patients quality care every time and support our staff to work with the right conditions for success.
NHS England welcomes the focus on growing a culture which puts patients first, engages and empowers patients and carers, supports transparency and learning and takes responsibility for poor care. This is all underpinned by having the right staff with the right skills and knowledge. We are already tackling this through the actions set out in Compassion in Practice and by working with NICE and other key partners such as Health Education England.
This report demonstrates the passion for patient safety that so many in the NHS have and will be a touchstone for patient safety in the NHS for the next decade or more. NHS England accepts the challenges set in this report and will lead the way in responding.
Following the Francis Inquiry report in February 2013, the government has already acted to improve care, including introducing a new regulatory model under a strong, independent Chief Inspector of Hospitals, publishing more data on survival results for surgery, improving training and committing to fitness to practice tests for nurses, as well as becoming the first department where every civil servant will gain real and extensive experience of the frontline.
The government will now consider this report and respond in full to both it and the Francis Inquiry in the autumn.
Prior to his service in 2010 and 2011 as President Obama’s appointee to head the US Medicare and Medicaid programs, Dr Berwick was a paediatric consultant, Professor of Health Care Policy at the Harvard Medical School, and Professor of Health Policy and Management at the Harvard School of Public Health. He is world-renowned for his expertise in patient safety, and advised NHS Scotland in the development of its first national patient safety approach.
The solutions in the report are grouped under the following themes:
Recognise the need for systemic change
Abandon blame as a tool – distinguish between errors and misconduct
Reassert the primacy of patients and carers
Use targets with caution – they have a role en-route to progress, but they should never become the end in itself
Recognise that transparency is essential
Ensure that responsibility for safety is clear and simple, with cooperation among the agencies involved
Give NHS staff career-long help to learn, master and apply modern methods of quality control
Focus on pride and joy, not fear
The group that has conducted the report includes world-leading experts in all aspects of the culture and processes of minimising patient harm, from healthcare management and nursing to sociology and psychology. The team of 12 includes recognised experts from the US and the UK. It consulted with patients, clinicians and managers from across the NHS as part of this work.