Watchdog calls for safety culture

The Healthcare Commission has urged the NHS to generate better comparative information on safe care and outcomes and to set up a national database of serious untoward incidents.

In its final report on the State of Healthcare in England and Wales, the Commission says there is much about the health service that is positive and that it has improved dramatically in some areas, such as access to services.

However, it also says that “what gets measured gets done” and that its successor, the Care Quality Commission, should focus on measuring the safety and quality of care, outcomes and patients’ experiences.

Sir Ian Kennedy, the Commission’s chair, said: “It’s clear that safety is higher on the agenda that ever, but we are also a long way from an NHS that hungrily and systematically examines its own performance, gathers in and learns from mistakes, reinforces good practice and does things differently for the future.”

The Commission is concerned about the ability of healthcare providers to collect good information on the safety of care and to use it to improve services and protect patients. Only around half of English trusts comply with all the government’s core standards relating to patient safety.

The Commission says trust boards need to become more involved in the safety of care and that more should be done to involve patients.

It recommends that new registration requirements for health and social care should include ensuring that systems are in place to understand safe care and risk, report and act on individual incidents, and analyse and act on wider lessons.

The Commission says “a particular effort” needs to be made to increases the focus of safe care in primary care and claimed that up to 600 errors a day occur in diagnosis and treatment in general practice.

The error figure was disputed by the British Medical Association, which said it was a misleading suggestion, based on data mainly gathered outside the UK.

Dr Hamish Meldrum, BMA Council chair, said: “Doctors want to get rid of unacceptable variations in quality, but we need to be careful to analyse and learn from the causes of low performance rather than jumping to conclusions or simply adopting a blame culture.”

Sir Ian said a small number of trusts were “trapped at a level of performance that is unacceptably poor” and that the NHS was still “playing catch-up” which it came to consistently providing patient-centred care. He also said there were concerns about continuing inequalities in health status and about the quality of commissioning.

The Commission carried out in-depth reviews of healthcare in a variety of settings. Its final report says its reviews of maternity, mental health and urgent care services have all showed a wide variation in performance.

It identified maternity as an area generally lacking good IT and urgent care as an area in need of more joined up information.

The report notes that there is a “great deal of work underway” to correct the general shortage of information about outcomes and patient experiences , and says: “We look forward to seeing it have an impact on the quality of healthcare.”

The Healthcare Commission will cease to exist on 31 March 2009 after five years regulating the healthcare sector.

Link

State of Healthcare in England and Wales 2008