Health Management and Policy Alert

Hiding in plain sight: tackling malnutrition as part of the prevention agenda

Future Health - 

This report reveals that an estimated 464,000 people who are admitted to hospital have disease related malnutrition each year in England. This is the equivalent to over 50 people admitted to hospital every hour. People with malnutrition are more likely to visit their GP, be admitted to hospital and recover from treatment more slowly. The research estimates that the additional cost of a person with malnutrition is £7,775 per person per year at a total cost to the healthcare system in England of £22.6 billion. The report sets out a series of recommendations to tackle the issue of disease related malnutrition.

• Report
• Press release

Access to urgent and emergency care

Public Accounts Committee - 

This report warns of wide regional variations in the quality of patients’ access to urgent and emergency care. It finds that ambulance services covering large rural areas, for example services in the South-West and East of England, were particularly challenged and disproportionately affected by problems stemming from the flow of patients elsewhere in the system. The report further warns that not enough is being done to tackle delayed discharges, with beds unable to be released for new patients.

• Report
• Press release

Spotlight on sepsis: your stories, your rights

Parliamentary and Health Service Ombudsman - 

Despite some progress on diagnosis and treatment of sepsis since the publication of the PHSO's report, Time to act in 2013, lessons are not being learned and repeated mistakes are putting people at risk. This report highlights that the same serious failings are still happening, and that significant improvements are urgently needed to avoid more fatalities. Failings include delays in diagnosis and treatment, poor communication and record-keeping, and missed opportunities for follow-up care.

• Report
• Press release

Saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21

MBRRACE-UK - 

This report, the tenth MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2019 and 2021 in the UK. In addition, it also includes confidential enquiries into the care of women who died between 2019 and 2021 in the UK and Ireland from obstetric haemorrhage, amniotic fluid embolism, anaesthetic causes, infection, general medical and surgical disorders and epilepsy and stroke. The report also includes a Morbidity Confidential Enquiry into the care of women with morbidity following repeat caesarean birth.

• Report
• More detail

Martha’s rule: a new policy to amplify patient voice and improve safety in hospitals

Demos -
Martha Mills died aged 13 in the summer of 2021 and the inquest into her death heard that she would likely have survived the sepsis that killed her had consultants made a decision to move her to intensive care sooner. This report is a response to a call from Martha Mills’s parents to rebalance the power between patients and medics to improve patient safety. It outlines evidence that shows that failing to properly listen to patients and their families contributes to safety problems in the NHS, along with public awareness among citizens that the NHS can feel unresponsive at times.

• Report
• Demos - publications

Quality and safety of maternity care (England)

House of Commons Library - 

This briefing details government and NHS policies on the quality and safety of maternity care in England.

• Briefing
• More detail

Harm caused by delays in transferring patients to the right place of care

Healthcare Safety Investigation Branch -
This national investigation seeks to examine the systems that are in place to manage the flow of patients through and out of hospitals and considers the interactions between health and social care systems. It finds that issues relating to patient flow affect ambulance crews’ ability to hand over patient care to emergency department (ED) staff. It also finds that EDs are routinely at, or exceeding, their maximum capacity and this has an impact on their ability to provide safe care. This report brings together the findings from the investigation’s three interim reports and provides an update since they were published.

• Report
• Healthcare Safety Investigation Branch - publications

Diagnostic imaging reporting turnaround times

NHS England - 

Turnaround time (TAT) in imaging is the interval between an imaging examination and a verified report being made available to the referring clinician. Keeping TATs as short as possible is essential for the timely diagnosis and treatment of patients. Developed in consultation with and supported by the Royal College of Radiologists and The Society of Radiographers, this document sets out national turnaround time (TAT) guidance in England for imaging reporting TATs across clinical pathways, including the maximum timeframe within which all imaging must be reported.

• Guidance
• More detail

 

Government response to the Independent Pregnancy Loss Review: care and support when baby loss occurs before 24 weeks' gestation

Department of Health and Social Care - 

The government’s response to the Independent Pregnancy Loss Review sets out the immediate action the government is taking to prioritise the recommendations that it can begin to implement in the short term, while continuing to work with its system partners on those that need more time and planning to progress.

• Response
• Press release

The Independent Pregnancy Loss Review: care and support when baby loss occurs before 24 weeks gestation

Independent Pregnancy Loss Review Group - 

The Pregnancy Loss Review Group was commissioned to consider the registration and certification of pregnancy loss occurring before 24 weeks’ gestation, and the quality of National Health Service care. The review looks at options to improve NHS gynaecology and maternity care practice for parents who experience a miscarriage, ectopic pregnancy, molar pregnancy or termination for medical reasons. It makes 73 recommendations, which are intended to support the government and the NHS in creating a forward-looking approach to improve the safety and care experience for all those who have a pre-24-week baby loss.

• Report
• More detail
• Government response