Promoting safety, honesty and openness in the NHS Professor Alan Glasper discusses recent initiatives to promote safety in the NHS including a new review of the NHS reporting culture being conducted by Sir Robert Francis QC over the next 5 months, which is designed to make it easier for NHS staff to speak up when things go wrong.
Background A million people use healthcare services every 36 hours, and the vast majority of them receive safe and high-quality care. Despite this, things can go wrong and mistakes are made. Recent high-profile cases such as that of the Mid Staffordshire NHS Foundation Trust, which exposed the serious
814
neglect of patients there, show that there is still much to be undertaken to ensure that everyone is treated safely when they use healthcare services. The contractual ‘duty of candour’—which forms part of the government’s plans to modernise the NHS in the wake of these failings by making it more accountable and transparent—is an enforceable duty on providers. The government now has an explicit expectation that the NHS must be a service that is fully transparent in how it deals with patient safety concerns. In particular, there is an expectation that the service should be able to ‘apologise’ to those affected when something goes wrong and that this is a key component of promoting a safety culture; a culture where all incidents are reported, discussed, investigated and learned from (Glasper, 2013). Since April 2013, patient safety has been the responsibility of NHS England. These latest initiatives are part of the government’s quest to reduce avoidable harm to patients. In addition to commissioning Sir Robert Francis QC to review reporting, NHS England has also launched the ‘Sign up to Safety’ campaign, which is designed to help realise the ambition of making the NHS the safest healthcare system in the world by creating a system devoted to continuous learning and improvement (NHS England, 2014). Sign up to Safety’s 3-year objective is to reduce avoidable harm by 50% and save 6000 lives. To focus this work, five Sign up to Safety pledges have been developed, and organisations and individuals who sign up to the campaign commit to setting out actions they will undertake in response to these: ■■ Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally ■■ Continually learn. Make their organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are
Be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong ■■ Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use ■■ Support. Help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress. ■■ Honesty.
Measuring safety Although the NHS has come under much criticism of late, many nurses will be gratified to learn of a report featured in a Guardian newspaper commentary (Campbell and Watt, 2014) that found ‘The United Kingdom ranks first overall, scoring highest on quality, access and efficiency’. The report in question ranked the UK first in the world for quality of care, including safety. As important as this endorsement is, healthcare systems around the world continue to have high levels of avoidable harm. Tackling unsafe care and avoidable harm such as medication errors, deep vein thrombosis and pressure ulcers will not only improve patient outcomes but will save the NHS money that can be reinvested into patient care. To illustrate this, a National Patient Safety Agency report (2007) estimated the cost of adverse events due to medication errors at £774 million per year with the NHS spending around £1.3 billion per year on litigation claims. Going further than any other healthcare system in the world, the NHS Choices (2014) safety website aspires to offer an unprecedented amount of patient safety information to allow patients, regulators and staff to see safety performance across a range of indicators. The seven indicators are: ■■ Care Quality Commission (CQC) standards ■■ Patient safety reporting—‘open and honest’ reporting ■■ Safe staffing—percentage of nursing and
© 2014 MA Healthcare Ltd
I
n June 2014, the Department of Health and NHS England announced a raft of initiatives to enhance safety in the NHS including a new review into the NHS reporting culture. Sir Robert Francis QC will lead this, and it aims to make it easier for NHS staff to speak up when concerns are identified. Simultaneously the government has published pertinent data on a new safety section on the NHS Choices website, which will display how well NHS institutions are meeting key safety measures and is similarly intended to ensure that the NHS remains a world leader on safety (NHS Choices, 2014) Furthermore the launch of the new ‘Sign up to Safety’ campaign (NHS England, 2014) is one of the new initiatives that are part of the existing campaign by the government to protect patients in the NHS from avoidable harm (Department of Health and Poulter, 2013). Perhaps the flagship of these new initiatives is the new Francis review, entitled ‘Freedom and Responsibility to Speak Up: An Independent Review into Creating an Open & Honest Reporting Culture in the NHS’ (Gov.UK, 2014). This review aims to provide independent advice and recommendations to ensure that: ■■ NHS workers can raise concerns in the public interest with confidence that they will not suffer detriment as a result (this is crucial) ■■ Appropriate action is taken when concerns are raised by NHS workers ■■ Where NHS whistle-blowers are mistreated, those mistreating them will be held to account.
British Journal of Nursing, 2014, Vol 23, No 14
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
healthcare policy midwifery hours filled as planned control and cleanliness ■■ Patients assessed for risk of blood clots ■■ Responding to patient safety alerts ■■ Recommended by staff to their relatives and friends (i.e. staff confidence in their own institutions). The data are gathered from a variety of sources including the CQC and the Picker Institute. It is important to stress that this is work in progress and not all data for every trust are currently displayed. However, such data, when populated for each trust, will be a powerful tool for members of the public who wish to see how their local hospitals compare with other similar institutions elsewhere. Published on the NHS Choices website in June 2014, the data will, for the first time, allow the public the opportunity to compare key safety measures across hundreds of NHS trusts in England. An examination of these data shows that a large percentage of NHS hospitals have been rated as ‘good’ or ‘satisfactory’ for their reporting culture. Worryingly, about 20% of acute care NHS trusts have been rated as ‘poor’ for open and honest reporting, underlining the continual need to support NHS staff to report and raise safety concerns. ■■ Infection
© 2014 MA Healthcare Ltd
Freedom to speak up It is against this backdrop that the new Francis review will be conducted. The independent review will look at what further action is necessary to protect NHS workers who speak out in the public interest and help to create the kind of open culture that is needed to ensure safe care for patients. It will issue a call for evidence from NHS whistleblowers, NHS frontline staff, NHS employers, trade unions, professional and systems regulators, among others, and will use this evidence to learn lessons from historic cases so the NHS can learn for the future. It will provide independent advice and recommendations to the Secretary of State for Health on measures to: ■■ Build confidence to speak out ■■ Prevent mistreatment ■■ Consider independent dispute resolution ■■ Separate out concerns about care, malpractice or wrongdoing at work from personal grievance disputes ■■ Seek out and learn from best practice. The ultimate aim is to ensure that NHS staff in England can raise concerns about any aspect of the quality of care, malpractice or wrongdoing at work and be sure that they will be listened to and that appropriate action will
British Journal of Nursing, 2014, Vol 23, No 14
be taken. Staff should not suffer detrimental treatment as a result of raising concerns and the review will explore whether there are appropriate remedies so that those mistreating can be held to account. The review will consider whether new and/or independent mechanisms are needed to resolve disputes in the NHS that involve whistleblowers; and consider options so that where tribunals or courts find in favour of individuals who have raised concerns, arrangements are in place to help them go back to work in the NHS. In the context of personal grievance disputes, however complex cases become, in future, concerns about care need to be pulled out and dealt with separately. Sir Robert believes that the NHS fundamentally needs a culture where staff should be empowered to develop an ‘I need to report this’ mindset, one where concerns are listened to and acted on. His review will consider independent mediation and appeal mechanisms to resolve disputes on whistleblowing fairly and he and his team will engage closely with individual NHS workers who say they have suffered detriment as a result of raising legitimate concerns, as well as with employers, trade unions, professional and system regulators and professional representative bodies.The review will therefore consider, in light of recent policy measures in response to the public inquiry into Mid Staffordshire NHS Foundation Trust, what further action is necessary to protect those individual NHS workers who speak out and, in doing so, make a significant contribution to the open culture that is needed to ensure safe care for patients. This review will complete its work by the end of November 2014. The UK is part of the European Union Network for Patient Safety and Quality of Care (PaSQ) (www.
pasq.eu), which has a mandate to improve patient safety and quality of Care through the sharing of information, experience, and the implementation of good practices. Importantly, this activity is organised around PaSQ National Contact Points in all the countries of the network, who are also the contacts for PaSQ concerns in their respective countries. The primary objective of this network is to support the implementation of the European Council Recommendation on Patient Safety. PaSQ unites representatives of the European medical community with the institutional partners involved in patient safety and quality of care in the member states of the European Union.
Conclusion The independent review on whistleblowing wants to hear from frontline staff, trade unions and NHS employers among others. Information about how NHS staff such as nurses can contribute will be made available shortly on the webpage for the independent BJN review (Gov.UK, 2014).
Campbell D, Watt N (2014) NHS comes top in healthcare survey. The Guardian 17 June. http://tinyurl.com/ o4spkmn (accessed 15 June 2014) Department of Health, Poulter D (2013) Protecting patients from avoidable harm. 25 March. http://tinyurl.com/ cl7detn (accessed 15 July 2014) European Union Network for Patient Safety and Quality of Care (2014) Glasper A (2013) Making the NHS develop a culture of openness. Br J Nurs 22(6): 346-7 Gov.UK (2014) Whistleblowing in the NHS: independent review. http://tinyurl.com/q3k3ydg (accessed 15 July 2014) National Patient Safety Agency (2007) Safety in doses: medication safety incidents in the NHS: The fourth report from the Patient Safety Observatory. March. Appendix 5: 59 NHS Choices (2014) Patient safety in the NHS. http:// tinyurl.com/l9ej3gw (accessed 15 July 2014) NHS England (2014) Sign up to Safety: Listen, Learn, Act. http://tinyurl.com/ocnbhbg (accessed 15 July 2014)
Key points n In June 2014 the Department of Health and NHS England announced a raft of initiatives to enhance safety in the NHS n A new review into the NHS reporting culture led by Sir Robert Francis QC is to be launched, which aims to make it easier for NHS staff to speak up when concerns are identified n The independent review will look at what further action is necessary to protect NHS workers who speak out in the public interest and help to create the kind of open culture that is needed to ensure safe care for patients n Sir Robert Francis believes that the NHS fundamentally needs a culture where staff should be empowered to develop an approach of ‘I need to report this’
815
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
Background A million people use healthcare services every 36 hours, and the vast majority of them receive safe and high-quality care. Despite this, things can go wrong and mistakes are made. Recent high-profile cases such as that of the Mid Staffordshire NHS Foundation Trust, which exposed the serious
814
neglect of patients there, show that there is still much to be undertaken to ensure that everyone is treated safely when they use healthcare services. The contractual ‘duty of candour’—which forms part of the government’s plans to modernise the NHS in the wake of these failings by making it more accountable and transparent—is an enforceable duty on providers. The government now has an explicit expectation that the NHS must be a service that is fully transparent in how it deals with patient safety concerns. In particular, there is an expectation that the service should be able to ‘apologise’ to those affected when something goes wrong and that this is a key component of promoting a safety culture; a culture where all incidents are reported, discussed, investigated and learned from (Glasper, 2013). Since April 2013, patient safety has been the responsibility of NHS England. These latest initiatives are part of the government’s quest to reduce avoidable harm to patients. In addition to commissioning Sir Robert Francis QC to review reporting, NHS England has also launched the ‘Sign up to Safety’ campaign, which is designed to help realise the ambition of making the NHS the safest healthcare system in the world by creating a system devoted to continuous learning and improvement (NHS England, 2014). Sign up to Safety’s 3-year objective is to reduce avoidable harm by 50% and save 6000 lives. To focus this work, five Sign up to Safety pledges have been developed, and organisations and individuals who sign up to the campaign commit to setting out actions they will undertake in response to these: ■■ Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally ■■ Continually learn. Make their organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are
Be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong ■■ Collaborate. Take a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use ■■ Support. Help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate the progress. ■■ Honesty.
Measuring safety Although the NHS has come under much criticism of late, many nurses will be gratified to learn of a report featured in a Guardian newspaper commentary (Campbell and Watt, 2014) that found ‘The United Kingdom ranks first overall, scoring highest on quality, access and efficiency’. The report in question ranked the UK first in the world for quality of care, including safety. As important as this endorsement is, healthcare systems around the world continue to have high levels of avoidable harm. Tackling unsafe care and avoidable harm such as medication errors, deep vein thrombosis and pressure ulcers will not only improve patient outcomes but will save the NHS money that can be reinvested into patient care. To illustrate this, a National Patient Safety Agency report (2007) estimated the cost of adverse events due to medication errors at £774 million per year with the NHS spending around £1.3 billion per year on litigation claims. Going further than any other healthcare system in the world, the NHS Choices (2014) safety website aspires to offer an unprecedented amount of patient safety information to allow patients, regulators and staff to see safety performance across a range of indicators. The seven indicators are: ■■ Care Quality Commission (CQC) standards ■■ Patient safety reporting—‘open and honest’ reporting ■■ Safe staffing—percentage of nursing and
© 2014 MA Healthcare Ltd
I
n June 2014, the Department of Health and NHS England announced a raft of initiatives to enhance safety in the NHS including a new review into the NHS reporting culture. Sir Robert Francis QC will lead this, and it aims to make it easier for NHS staff to speak up when concerns are identified. Simultaneously the government has published pertinent data on a new safety section on the NHS Choices website, which will display how well NHS institutions are meeting key safety measures and is similarly intended to ensure that the NHS remains a world leader on safety (NHS Choices, 2014) Furthermore the launch of the new ‘Sign up to Safety’ campaign (NHS England, 2014) is one of the new initiatives that are part of the existing campaign by the government to protect patients in the NHS from avoidable harm (Department of Health and Poulter, 2013). Perhaps the flagship of these new initiatives is the new Francis review, entitled ‘Freedom and Responsibility to Speak Up: An Independent Review into Creating an Open & Honest Reporting Culture in the NHS’ (Gov.UK, 2014). This review aims to provide independent advice and recommendations to ensure that: ■■ NHS workers can raise concerns in the public interest with confidence that they will not suffer detriment as a result (this is crucial) ■■ Appropriate action is taken when concerns are raised by NHS workers ■■ Where NHS whistle-blowers are mistreated, those mistreating them will be held to account.
British Journal of Nursing, 2014, Vol 23, No 14
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
healthcare policy midwifery hours filled as planned control and cleanliness ■■ Patients assessed for risk of blood clots ■■ Responding to patient safety alerts ■■ Recommended by staff to their relatives and friends (i.e. staff confidence in their own institutions). The data are gathered from a variety of sources including the CQC and the Picker Institute. It is important to stress that this is work in progress and not all data for every trust are currently displayed. However, such data, when populated for each trust, will be a powerful tool for members of the public who wish to see how their local hospitals compare with other similar institutions elsewhere. Published on the NHS Choices website in June 2014, the data will, for the first time, allow the public the opportunity to compare key safety measures across hundreds of NHS trusts in England. An examination of these data shows that a large percentage of NHS hospitals have been rated as ‘good’ or ‘satisfactory’ for their reporting culture. Worryingly, about 20% of acute care NHS trusts have been rated as ‘poor’ for open and honest reporting, underlining the continual need to support NHS staff to report and raise safety concerns. ■■ Infection
© 2014 MA Healthcare Ltd
Freedom to speak up It is against this backdrop that the new Francis review will be conducted. The independent review will look at what further action is necessary to protect NHS workers who speak out in the public interest and help to create the kind of open culture that is needed to ensure safe care for patients. It will issue a call for evidence from NHS whistleblowers, NHS frontline staff, NHS employers, trade unions, professional and systems regulators, among others, and will use this evidence to learn lessons from historic cases so the NHS can learn for the future. It will provide independent advice and recommendations to the Secretary of State for Health on measures to: ■■ Build confidence to speak out ■■ Prevent mistreatment ■■ Consider independent dispute resolution ■■ Separate out concerns about care, malpractice or wrongdoing at work from personal grievance disputes ■■ Seek out and learn from best practice. The ultimate aim is to ensure that NHS staff in England can raise concerns about any aspect of the quality of care, malpractice or wrongdoing at work and be sure that they will be listened to and that appropriate action will
British Journal of Nursing, 2014, Vol 23, No 14
be taken. Staff should not suffer detrimental treatment as a result of raising concerns and the review will explore whether there are appropriate remedies so that those mistreating can be held to account. The review will consider whether new and/or independent mechanisms are needed to resolve disputes in the NHS that involve whistleblowers; and consider options so that where tribunals or courts find in favour of individuals who have raised concerns, arrangements are in place to help them go back to work in the NHS. In the context of personal grievance disputes, however complex cases become, in future, concerns about care need to be pulled out and dealt with separately. Sir Robert believes that the NHS fundamentally needs a culture where staff should be empowered to develop an ‘I need to report this’ mindset, one where concerns are listened to and acted on. His review will consider independent mediation and appeal mechanisms to resolve disputes on whistleblowing fairly and he and his team will engage closely with individual NHS workers who say they have suffered detriment as a result of raising legitimate concerns, as well as with employers, trade unions, professional and system regulators and professional representative bodies.The review will therefore consider, in light of recent policy measures in response to the public inquiry into Mid Staffordshire NHS Foundation Trust, what further action is necessary to protect those individual NHS workers who speak out and, in doing so, make a significant contribution to the open culture that is needed to ensure safe care for patients. This review will complete its work by the end of November 2014. The UK is part of the European Union Network for Patient Safety and Quality of Care (PaSQ) (www.
pasq.eu), which has a mandate to improve patient safety and quality of Care through the sharing of information, experience, and the implementation of good practices. Importantly, this activity is organised around PaSQ National Contact Points in all the countries of the network, who are also the contacts for PaSQ concerns in their respective countries. The primary objective of this network is to support the implementation of the European Council Recommendation on Patient Safety. PaSQ unites representatives of the European medical community with the institutional partners involved in patient safety and quality of care in the member states of the European Union.
Conclusion The independent review on whistleblowing wants to hear from frontline staff, trade unions and NHS employers among others. Information about how NHS staff such as nurses can contribute will be made available shortly on the webpage for the independent BJN review (Gov.UK, 2014).
Campbell D, Watt N (2014) NHS comes top in healthcare survey. The Guardian 17 June. http://tinyurl.com/ o4spkmn (accessed 15 June 2014) Department of Health, Poulter D (2013) Protecting patients from avoidable harm. 25 March. http://tinyurl.com/ cl7detn (accessed 15 July 2014) European Union Network for Patient Safety and Quality of Care (2014) Glasper A (2013) Making the NHS develop a culture of openness. Br J Nurs 22(6): 346-7 Gov.UK (2014) Whistleblowing in the NHS: independent review. http://tinyurl.com/q3k3ydg (accessed 15 July 2014) National Patient Safety Agency (2007) Safety in doses: medication safety incidents in the NHS: The fourth report from the Patient Safety Observatory. March. Appendix 5: 59 NHS Choices (2014) Patient safety in the NHS. http:// tinyurl.com/l9ej3gw (accessed 15 July 2014) NHS England (2014) Sign up to Safety: Listen, Learn, Act. http://tinyurl.com/ocnbhbg (accessed 15 July 2014)
Key points n In June 2014 the Department of Health and NHS England announced a raft of initiatives to enhance safety in the NHS n A new review into the NHS reporting culture led by Sir Robert Francis QC is to be launched, which aims to make it easier for NHS staff to speak up when concerns are identified n The independent review will look at what further action is necessary to protect NHS workers who speak out in the public interest and help to create the kind of open culture that is needed to ensure safe care for patients n Sir Robert Francis believes that the NHS fundamentally needs a culture where staff should be empowered to develop an approach of ‘I need to report this’
815
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
