I slogged my way through the main body of the report. It’s
probably the shortest of the recent studies, with the fewest boring footnotes,
addendums and figures. It’s also perhaps the least helpful. There’s not much
data there and as you should know from me by now, original data is like finding
a vein of ore in rock.
It seems to be a selection of powerpoint presentations and
flipchart images. I can see these being ‘cascaded down’ throughout the NHS in
the months to come.
That’s the correct managementspeak, I think.
I can also see tired and depressed people just turning off as
one page merges into another.
Here are the good intentions, nothing anyone could disagree
with here;
“Place the
quality of patient care, especially patient safety, above all other aims.
Engage,
empower, and hear patients and carers at all times.
Foster
whole-heartedly the growth and development of all staff, including their
ability and support to improve the processes in which they work.
Embrace
transparency unequivocally and everywhere, in the service of accountability,
trust, and the growth of knowledge.”
Here a fine sentiment, again no problem with that;
“At its
core, the NHS remains a world-leading example of commitment to health and
health care as a human right – the endeavour of a whole society to ensure that
all people in their time of need are supported, cared for, and healed. It is a
fine institution. But the events at Mid Staffordshire have triggered a need to
re-examine what the NHS does and determine how it can improve further. The only
conceivably worthy honour due to those harmed is to make changes that will save
other people and other places from similar harm.”
Here are the problems;
“The
following are some of the problems we have identified:
●Patient
safety problems exist throughout the NHS as with every other health care system
in the world.
●NHS staff
are not to blame – in the vast majority of cases it is the systems, procedures,
conditions, environment and constraints they face that lead to patient safety
problems.
●Incorrect
priorities do damage: other goals are important, but the central focus must
always be on patients.
●In some
instances, including Mid Staffordshire, clear warning signals abounded and were
not heeded, especially the voices of patients and carers.
●When
responsibility is diffused, it is not clearly owned: with too many in charge,
no-one is.
●Improvement
requires a system of support: the NHS needs a considered, resourced and driven
agenda of capability-building in order to deliver continuous improvement.
●Fear is
toxic to both safety and improvement.”
Here the solutions;
“To address
these issues the system must:
●Recognise
with clarity and courage the need for wide systemic change.
●Abandon
blame as a tool and trust the goodwill and good intentions of the staff.
●Reassert
the primacy of working with patients and carers to achieve health care goals.
●Use
quantitative targets with caution. Such goals do have an important role en
route to progress, but should never displace the primary goal of better care.
Executive
Summary
●Recognise
that transparency is essential and expect and insist on it.
●Ensure
that responsibility for functions related to safety and improvement are vested
clearly and simply.
●Give the
people of the NHS career-long help to learn, master and apply modern methods
for quality control, quality improvement and quality planning.
●Make sure
pride and joy in work, not fear, infuse the NHS.The most important single
change in the NHS in response to this report would be for it to become, more
than ever before, a system devoted to continual learning and improvement of
patient care, top to bottom and end to end.
And here the recommendations;
We have
made specific recommendations around this point, including the need for improve
training and education, and for NHS England to support a network of safety
improvement collaboratives to identify and spread safety improvement approaches
across the NHS.”
Our ten
recommendations are as follows:
1. The NHS
should continually and forever reduce patient harm by embracing wholeheartedly
an ethic of learning.
2. All
leaders concerned with NHS healthcare – political, regulatory, governance,
executive, clinical and advocacy – should place quality of care in general, and
patient safety in particular, at the top of their priorities for investment,
inquiry, improvement, regular reporting, encouragement and support.
3. Patients
and their carers should be present, powerful and involved at all levels of
healthcare organisations from wards to the boards of Trusts.
4.
Government, Health Education England and NHS England should assure that
sufficient staff are available to meet the NHS’s needs now and in the future.
Healthcare organisations should ensure that staff are present in appropriate
numbers to provide safe care at all times and are well-supported.
5. Mastery
of quality and patient safety sciences and practices should be part of initial
preparation and lifelong education of all health care professionals, including
managers and executives.
6. The NHS
should become a learning organisation. Its leaders should create and support
the capability for learning, and therefore change, at scale, within the NHS.
7.
Transparency should be complete, timely and unequivocal. All data on quality
and safety, whether assembled by government, organisations, or professional
societies, should be shared in a timely fashion with all parties who want it,
including, in accessible form, with the public.
8. All
organisations should seek out the patient and carer voice as an essential asset
in monitoring the safety and quality of care.
9.
Supervisory and regulatory systems should be simple and clear. They should
avoid diffusion of responsibility. They should be respectful of the goodwill
and sound intention of the vast majority of staff. All incentives should point
in the same direction.
10. We
support responsive regulation of organisations, with a hierarchy of responses.
Recourse to criminal sanctions should be extremely rare, and should function
primarily as a deterrent to wilful or reckless neglect or mistreatment.”
My conclusions tomorrow.
Neil Harris
(a don’t stop till you drop production)
Home: helpmesortoutthenhs.blogspot.com
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