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Good morning and welcome to our many new subscribers since last week. Special mention to Shaun Lintern for a nice write up of last week’s email. Shaun is the local journalist who helped uncover Mid Staffs and has a campaigning pedigree second to none. 'Patient safety' can seem a technical term - I had never heard of it when I became Health Sec and initially thought it was about ‘elf and safety,’ not a favourite topic for Tory ministers. Far from pettifogging bureaucracy patient safety campaigners focus on one simple thing: reducing the large amount of avoidable harm and death in healthcare. There are about 150 avoidable deaths a week in the NHS in England according to the Hogan and
Black research. Soberingly it is likely to be even worse in other countries given the Commonwealth Foundation rate the NHS as the safest healthcare system in the world. Which is why we need it to stay that way in a pandemic....where the big health story of the last few days was the deadpan presentation by Chris Whitty and Patrick Valance on Tuesday on the increase in COVID-19 cases in the UK and the PM's announcement of new restrictions yesterday. There is a big debate raging between pro-economy libertarians who hate it all and health hawks who would like to go even further. All should look at the evidence from South Korea, Taiwan, Singapore and Hong Kong, whose model we are now following (but did not in the Spring). No more than 9 deaths on any one day in Korea, not a single care home death in Hong Kong and no national lockdowns in any of those countries. Which shows this economy vs public health debate is really phoney. The British public largely seem to agree with the measures announced yesterday although we do need to sort out testing urgently as I asked Boris. World Patient Safety Day no 2 was last Thursday with the 'theme' being the protection of healthcare workers. I launched the day virtually with Dr Tedros alongside a new WHO Health Worker Charter. This highlights, amongst other things, the need for staff to access proper PPE, to look after staff’s mental wellbeing to prevent burnout and the importance of a zero tolerance approach to violence against staff. The WHO are encouraging all institutions, health care settings and countries to sign the Charter…. ….a World First? Which is exactly what I asked the Health Secretary to do and he was only too happy to commit to here. I believe makes us the first country to do so. We will no doubt come back to staff wellbeing issues in the Select Committee inquiry into Health and Care Staff Burnout for which we will shortly be calling for evidence. Less positively on those avoidable deaths the UK was also the first country in the world to require hospitals to publish data on the number of avoidable deaths they have each year. But a survey I did of around 60 NHS trusts has found that very few are complying with these rules. Only one quarter published meaningful stats whereas about a fifth refused to publish anything, and another fifth said they had no avoidable deaths which given what we know about the number of such cases overall seems extremely unlikely (to put it politely). If we are going to create a proper learning culture within the NHS we need to start by being honest about the level of harm that currently exists within all modern healthcare systems. That means finding a way for all Trusts to consistently publish - and commit to learn from - the number of avoidable deaths they experience each year. Patient Safety Watch will be publishing research on the amount of preventable harm in the NHS shortly. Maternity lawsuits As part of my research into maternity care for the select committee inquiry I uncovered the fact that maternity lawsuits now cost more than the combined cost of every doctor and nurse working in NHS maternity units, currently about £1bn per year. Behind every one of these lawsuits is a family that has been irreparably hurt by unsafe care. Think how much more logical it would be if that money was instead being spent on making care safer - something my select committee will be looking into in its maternity safety inquiry for which the first evidence session is this coming Tuesday. We will be hearing from Bill Kirkup, who having done the Morecambe Bay inquiry is now leading an inquiry for NHS England into East Kent and other places with recurring maternity issues and Ted Baker, Chief Inspector of Hospitals. Any bright ideas? Yesterday I spoke to both Bill and James Titcombe, perhaps our highest profile campaigner for maternity safety following the tragic loss of his son Joshua. They talked about legal reforms. improvements to training and continuity of care as key issues. BAME mothers appear to have a higher than average risk of a complicated pregnancy according to an excellent presentation by MBRRACE at the Baby Loss APPG last week so that too needs careful investigation. 111 Sepsis training The government is investing £24m into NHS 111 call handling capability as part of moves to change A & Es to a 111 first model. I welcome this following the powerful evidence by Dr Katherine Henderson (Royal College of Emergency Medicine) that going back to crowded A & E waiting rooms would literally cost lives. But if we do change the model it is vital 111 call handlers are trained to recognise the potential signs of sepsis which our A & E departments are now getting pretty good at screening for. For the data on just how much of a hidden killer sepsis it is worth checking out what the Sepsis Trust say – their numbers show it’s a bigger killer than both cancer and Covid-19. Electronic prescribing boost I was really pleased to see Nadine Dorries, the Minister for Patient Safety, use World Patient Safety Day to announce £8.7m to help hospitals move to electronic prescribing. Medication error is a much bigger issue than most patients realise, and electronic prescribing can cut it by about a third. I will never forget the roundtable I hosted at DHSC with families affected by it, some of whom I am still in touch with today. I met one lady who was wrongly kept on a heavy steroid prescription for six years, after which she was totally unable to eat normally. Which leads to the... Shocking stat of the week fromresearchers at Manchester, Sheffield and York universities that medication errors could be a factor in up to 22,000 deaths a year - roughly half of our Covid death toll. National Patient Safety Strategy Also on World Patient Safety Day, NHS England published its first annual progress report for its Patient Safety Strategy. Lots of good progress even if the COVID-19 pandemic has impacted some areas of work. And as a reminder please do share this email with friends/colleagues who can sign up to it here. Jeremy Hunt
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