Health Management and Policy Alert

Responding to challenge

Patient Experience Library -
This report aims to demonstrate what the warning signs of harmful cultures look like. It looks at ten years of avoidable harm inquiry reports, and the organisational and professional cultures that lie at the heart of harm. It then tries to find patterns of behaviour that crop up time and again in health care disasters through the themes of teamwork, compliance, accountability, organisational learning and more.

• Report
• Patient Experience Library - publications

Workforce and patient safety: primary and community care co-ordination for people with long-term conditions

Health Services Safety Investigations Body -
This report finds that a lack of co-ordination of care for people with long-term health conditions is taking a toll on patients and carers, leading to burnout, distress and harm. It also outlines the impact of being unable to navigate the health and care system. A focus of the investigation was on the role of the ‘care co-ordinator’ – someone who is able to connect patients/carers with the right care and support.

• Report
• Health Services Safety Investigations Body - news

Nursing associates in maternity settings: position statement

NHS England - 

Nursing associates are members of the nursing team in England who help bridge the gap between health and care assistants and registered nurses. This position statement outlines challenges to deploying nursing associates in maternity settings, including issues with profession-specific education and training, delegation of tasks, accountability, and scope of practice. It concludes it does not support nursing associates working in maternity services. The Royal College of Nursing and the Royal College of Midwifery have also published separate statements in support of this position.

• Position statement
• More detail

National mandatory learning people policy framework

NHS England - 

This policy is for NHS organisations to adopt and adapt to help them meet their statutory obligation to ensure a safe and inclusive work environment. It is intended to reduce or prevent incidents, near misses, risks and connected loss of productivity. It also aims to increase efficiency by ensuring learners do not need to repeat learning unnecessarily.

• Policy framework

The safety gap: safety and accessibility of medicines and medical devices for people with sensory impairment

Patient Safety Commissioner -
This report presents the results of a short-term study to explore the challenges experienced by patients with sensory impairment in relation to their safe and effective access to and use of medicines and medical devices. It explores the barriers to patient safety that exist for patients with sensory impairment, particularly those patients who have diabetes and are visually impaired, and discusses what the health system could do to overcome these barriers. 

• Report
• Patient Safety Commissioner - publications

BMA reporting portal submissions: physician associates and anaesthesia associates

British Medical Association -

The BMA has submitted this response document and associated appendices to the ongoing government-commissioned Leng Review. The response is based on the views and experiences of the medical profession, obtained through dedicated surveys, and through individual submissions to a collection portal. It covers the key areas of the review’s terms of reference - selection and recruitment, training, day to day work and scope of practice, oversight and supervision, and addresses the role and views of the GMC throughout. It also addresses the international experience of assistant/associate roles, and importantly, provides a comprehensive list of recommendations to assist the review team.

• Submission document
• Associated appendices
• British Medical Association - press release

Report for the Thirlwall Inquiry: analysis of questionnaires from 120 NHS trusts

Nuffield Trust -
The Thirlwall Inquiry was set up to examine events at the Countess of Chester Hospital following the trial and subsequent convictions of Lucy Letby for the murder and attempted murder of babies at that hospital. This report was commissioned by the Thirlwall Inquiry. It summarises key themes from responses to a questionnaire sent by the Inquiry to all other NHS trusts with maternity and neonatal units in England.

• Report
• Nuffield Trust - publications

Safety management: accountability across organisational boundaries

Health Services Safety Investigations Body -
This report is intended for health care organisations, policy-makers and the public to help improve patient safety in relation to the management of patient safety risks across organisational boundaries. This has been explored through an understanding of the pathways of care for patients whose care involves engaging with providers in primary, secondary and community care and with integrated care systems. It makes reference to processes which exist within the health and care system relating to the management of safety.

• Report

Mental health inpatient settings: creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge

Health Services Safety Investigations Body -
This report finds that systemic issues, lack of patient and family involvement and cultures of fear and blame contribute to mental health services not learning from inpatient deaths. The findings evidence challenges in maintaining safety, conducting effective and timely investigations and ensuring system wide learning. It identifies that, whilst investigations and patient safety event analysis aim for transparency and learning, they are often of variable quality.

• Report
• Health Services Safety Investigations Body - news

Commission on Human Medicines report on proposed permanent order to restrict the sale and supply of gonadotrophin-releasing hormone agonists in children and young people under 18 years of age for the purpose of puberty suppression in gender incongruence a

Commission on Human Medicines - 

This independent report considers the safety implications of a proposal to restrict the availability of puberty blockers for under 18s. The report is technical and may not be easily interpreted by non-experts so an accompanying factsheet is designed to help readers interpret the report.

• Report
• More detail