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Policy Protecting patients from avoidable harm

Issue

A million people use healthcare services every 36 hours, and the vast majority of them receive safe and high quality care. But things do go wrong, and mistakes are made. Recent high profile cases (such as the neglect of patients at Stafford Hospital) show that there is still a lot to do to make sure that everyone is treated safely when they use healthcare services.

Actions

From April 2013, patient safety will be the responsibility of NHS England, but we will continue to help set the standards that NHS services must meet.

Measuring how successfully the NHS protects patients

The NHS Outcomes Framework sets out how we will measure the success of NHS services, including how well they treat and care for people in a safe environment and protect them from avoidable harm.

Working with NHS England, we will strengthen these indicators by adding a new measure that reviews individual cases to identify how many patients had problems in their healthcare. Other indicators include the number of:

  • patient safety incidents reported (which we want to increase, as reporting incidents shows that the NHS is open and learns from mistakes)
  • serious patient safety incidents reported (which we want to decrease, to show that there are fewer risks to patients)
  • healthcare associated infections (for example superbugs like MSRA)
  • incidents in which children are harmed because of a failure to monitor them properly

Preventing inexcusable health and social care

The NHS has a list of 25 ‘never events’ - incidents that can cause severe harm or death and that should never happen because we already have guidance and tools to prevent them. Examples include operating on the wrong part of a patient’s body and leaving objects in a patient’s body after an operation.

In 2011 to 2012, 326 never events were reported to strategic health authorities.

We want to reduce the number of never events to zero. We have recently updated the never events policy to make it clearer what staff should do to stop never events happening and to respond to them when they do happen. NHS England is taking on responsibility for the never events policy and is creating a surgical never events task force to set out what else the NHS needs to do to prevent surgical never events.

We also want to protect adults who may be vulnerable to abuse and neglect. Under the Care and Support Bill (which will soon be laid before Parliament), local councils will have to create a ‘safeguarding adults board’. These boards must produce a plan for protecting adults who may be vulnerable to abuse or neglect and who have care and support needs.

Learning from mistakes

It is important to learn from mistakes in health and social care and to prevent them happening again.

We have already set out the actions we will take after the Winterbourne View scandal. For example, people with learning difficulties, autism or mental health problems will get more support in the community rather than in hospital, where appropriate. We have also published our initial response to the Mid Staffordshire NHS Foundation Trust Public Inquiry report.

We are also:

  • giving doctors regular assessments (medical revalidation) to ensure that their training and expertise are up to date and they are still able to provide high quality care for patients
  • examining what changes we need to make to improve the Care Quality Commission’s capacity to hold organisations to account when they fail to treat patients with respect and dignity
  • introducing a ‘duty of candour’ for NHS organisations – this means they must tell patients if their safety has been compromised, apologise and make sure that they learn lessons so that mistakes don’t happen again

Making it easier for staff to report their concerns

We expect all NHS organisations to have ‘whistleblowing’ policies and procedures. These allow staff to raise concerns about issues that are in the public interest without the risk of suffering at work - for example, victimisation or losing the chance to be promoted. We have therefore:

  • strengthened the NHS Constitution by including an expectation that staff will raise concerns and that their employers will support them, and by providing greater clarity about how the law protects them
  • funded a helpline for health and social care staff who want advice on how to raise their concerns and employers who want to know how to meet their whistleblowing obligations

Making sure cosmetic surgery is safe

Many people think that the cost of cosmetic surgery is more important than the qualifications of the person doing it and the quality of care they provide.

Following the recent scandal over the quality of breast implants, we are deciding on how the cosmetic surgery industry should be regulated to keep patients safe. We consulted the public, cosmetic surgery providers and patient groups, and have published their responses, which we will use to come up with recommendations in 2013.

Background

In 2010 the coalition government published its plans for reforming the NHS. ‘Equity and excellence: liberating the NHS’ stressed the importance of increasing safety in health services.

In 2012, patient safety became one of the priorities in DH’s corporate plan for 2012/13 and the mandate for NHS England.