Health Management and Policy Alert

Standing up for patient and public safety

Royal College of Nursing - 

This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services, and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. To resolve this, the RCN makes the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England.

• Report
• Press release

Caring, supportive, collaborative: doctors’ vision for change in the NHS

British Medical Association (BMA) -
This report draws on the experience and expertise of BMA members across all branches of medical practice in the UK. It outlines where the BMA believe changes are needed to ensure patient care is safe, makes the NHS a great place to work and transforms services for the better.

• Report
• BMA - publications

More harm than good: why more isn't always better with older people's medicines

Age UK -
This report calls for a more considered approach to prescribing medicines for our older population. It says too many older people in our society are on too many prescribed medicines, putting them at risk of side effects that in a worrying number of cases can lead to falls and a range of other serious harms. The report also provides evidence showing that prescribing more drugs isn’t always the best option, particularly when it comes to older people.

• Report
• Age UK - press release

Failures in communication or follow-up of unexpected significant radiological findings

Healthcare Safety Investigation Branch -
This report demonstrates where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiological findings. The investigation also makes three other recommendations in relation to following up unexpected significant radiological findings, to The Royal College of Radiologists, NHS England and NHS Improvement, and the Care Quality Commission.

• Report
• Healthcare Safety Investigation Branch - publications

The NHS patient safety strategy: safer culture, safer systems, safer patients

NHS - 

Patient safety is about maximising the things that go right and minimising the things that go wrong. It is integral to the NHS’ definition of quality in healthcare, alongside effectiveness and patient experience. This strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety. 

• Strategy
• More detail

Pounds for patients? How private hospitals use financial incentives to win the business of medical consultants

Centre for Health and the Public Interest - 

This report looks into how the private hospital sector uses financial incentives to attract NHS consultants to work for them. It argues that this could result in a potential conflict between consultants' income and patients’ best interests. The report was compiled between May 2018 and May 2019 using publicly available data on the websites of private hospitals, NHS trusts and Companies House.

• Report
• More detail

Medicines in health and adult social care: learning from risks and sharing good practice for better outcomes

Care Quality Commission - 

This report report describes lessons for better medicines optimisation across health and social care providers and the positive impact of involving pharmacy professionals in health and social care settings.

• Report
• Press rlease

Independent review of gross negligence manslaughter and culpable homicide

General Medical Council -
This independent review was commissioned following the death of Jack Adcock and the prosecution and conviction of Dr Hadiza Bawa-Garba for gross negligence manslaughter. This report is about how to achieve the aim of a just and fair culture in medicine and the need to learn, not blame, when things go wrong, for the benefit of both patients and the doctors who care for them.

• Report
• General Medical Council - news

Patient safety essentials toolkit

Institute for Healthcare Improvement - 

This toolkit includes documents on improving teamwork and communication, tools to help you understand the underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems. Each of the nine tools includes a short description, instructions, an example, and a blank template. Please note that free registration is required to access the toolkit.

• Toolkit

Learning Disability Mortality Review (LeDeR) programme: action from learning

NHS England - 
This report provides examples of the local changes that have been made to services so far and highlights the extensive work which is happening nationally in response to common themes raised through LeDeR reviews across the country.

• Report