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A promise to learn? A commitment to act? Improving the safety of patients in England

Following hard on the heels of the Francis Report, the Department of Health today published the Berwick review into Patient Safety. This independent review highlights what it considers to be the main problems affecting patient safety in the NHS, and makes recommendations to address them. Some recommendations have “the hard edge of requirement and enforcement” for example:

Providers should act on patient safety alerts, and regulators should ensure that they do.

Transparency ought not to be optional.

Staffing levels should be adequate, based on evidence.

Sanctions should apply to reckless and wilful neglect or mistreatment of patients.

In other recommendations the report says that the health 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 – they should never displace the primary goal of better care

recognise that transparency is essential and expect and insist on it

ensure that responsibility for functions related to safety and improvement are established clearly and simply

give NHS staff 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

These are fine and moving words and I eagerly turn to the “Moving Forward Section” where I expect these recommendations to be transformed into a plan for action, you know, with S.M.A.R.T. goals – specific, measurable, achievable, realistic and timed and targeted: a recommended plan for Who is to do What and by When.

It is therefore disappointing to find only yet another recommendation – albeit “the most important one of the review”. This is a recommendation to envision the NHS as a learning organisation, fully committed to the following:

Placing the quality of patient care, especially patient safety, above all other aims.

Engaging, empowering, and hearing patients and carers throughout the entire system and at all times.

Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work.

Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

No matter how many independent enquiries and published reports, bullet points, promises to learn or commitments to act, in my admittedly limited experience, nothing ever happens without a PLAN.

Jo is a Partner specialising in catastrophic personal injury and clinical negligence claims.

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