Good morning and welcome to the first one-handed edition of my patient safety update. As many of you will have seen I broke my arm last week whilst out running in icy conditions and had an operation yesterday to reset my fractured elbow so I want to repeat my thanks to the amazing NHS who looked after me so brilliantly. As someone who nerdishly knows there are 4 wrong site surgeries every week it was a genuine pleasure to have my arm written on with an arrow and to be asked my name, DOB and purpose of operation repeatedly. This week I set out what I hope to see from the PM’s plan for easing restrictions due next Monday; what we really need from the Health and Care Bill; worrying research on nosocomial infections and have an interview with NHS National Patient Safety Director, Aidan Fowler.

COVID LATEST Cases, hospital admissions and deaths all continue to decline. The HSJ reports that the decline in hospital admissions is speeding up which is great, although there are still about the same number of people in hospital with COVID as there were at the peak in April. Today’s REACT study is very encouraging as it shows a “strong decline” in infection levels since lockdown began.

HOSPITAL ACQUIRED COVID A truly shocking study has found that up to 40% of patients who had the virus in the first wave of the pandemic probably caught the infection at their hospital,  accounting for up to 8,000 deaths. Along with Alastair McLellan I’ve been highlighting this issue and this new paper shows why. I suspect the Select Committee will recommend brand new pandemic protocols are developed by the NHS as - aside from early PPE issues - social distancing guidelines for hospital staff were not introduced quickly enough. It is striking how few Covid casualties there have been amongst ICU staff in Covid wards where strong efforts were made compared to less stringent efforts to prevent asymptomatic transmission in other areas of hospitals.

VAX THE WAY TO DO IT None  of which should detract from fantastic news that the NHS hit the target of offering a first dose to the top four priority groups slightly ahead of schedule. It also looks like we’re motoring ahead with the next target of doing the same for the rest of the most vulnerable people by May, with speculation this may be achieved sooner. Actual take up has also been remarkably high with 93% of those over 75 receiving a dose. The government is surely right though to roll out a new plan to target those in under-served groups to deal with some clear issues in certain groups.

ANTIBODIES AND THERAPUTICS Two more pieces of good news for the long term in that a RECOVERY trail has shown that Tocilizumab reduces deaths in patients hospitalised with the virus and a study shows a rise in antibodies in the over 80s. Less good news for us politicians who are going to have to learn how to pronounce the damn word.

BACK TO SCHOOL? Research published earlier in the week shows that schools didn’t drive infection rates during the autumn but rather followed the case rate in the community. This has led to some people immediately calling for them all to be reopened. The authors though warn that reopening them is likely to result in an increase in the R rate and this article features worrying evidence from Italy and Israel that schoolchildren are catching the new variants. Big debate now is whether teachers should get the jab early. The JCVI will balance the potential benefits of stopping spreading in the classroom with vaccinating more of the 50-70 year olds currently filling up our ICUs and after their brilliance in recommending delaying the second jab, now vindicated by the WHO, I am inclined to listen to them carefully on this before taking a strong public line.

PROCEED WITH CAUTION As clearly will the Prime Minister ahead of his lockdown exit plan next Monday. There seems to be a consensus that reopening schools will increase the rate of infection in the community, but the question is by how much? If cases continue to come down we’ll hopefully buy ourselves some more wriggle room which will mean we can phase schools back gently from 8th March and monitor the impact before pressing ahead with more easing. Rather than specify dates where other restrictions might be lifted I hope the PM talks more about the key data milestones, including when we can introduce enhanced contact-tracing (backwards, forwards, genomic  sequencing) for every new case. Mass testing is also likely to play a key role as are vaccine passports although government spin doctors will now be frantically trying to find a new name for them having ruled them out so many times before. Thankfully, the PM looks like he’s proceeding along these lines with his call for the easing to be “cautious but also irreversible”.

PROVIDER TAKE Chris Hopson has sensibly written to the Prime Minister with four key tests that he would like to be met before restrictions are eased. These are for cases and R to have dropped significantly, hospital capacity to be at manageable levels, the vaccine roll out well advanced and plans in place to tackle future outbreaks of new variants. Sounds pretty reasonable to me.

NO WHITE PAPER SURPRISES Looks like the leaked version we reported on last week was pretty much the same as the version that was published last Thursday. Whilst these proposals are welcome as far as they go I really do think the Bill will need to do more to tackle the three big challenges facing healthcare in this country – workforce shortages, social care reform and persistent safety and quality issues. You can read more on this in my piece in the guardian here. I also asked the Health Secretary about whether he wants the CQC to inspect Integrated Care Services here and got a mildly encouraging response.

CQC/RCP AGREEMENT Good to see patient safety at the heart of this new agreement between the CQC and Royal College of Pathologists.

RESEARCH CORNER A couple of interesting pieces this week. Firstly, this article in the BMJ looks at the lessons we can learn from successful HIV harm prevention strategies in tackling COVID-19. And Patient Safety Watch Trustee James Titcombe has a typically powerful piece on the dangers of the ‘normal’ birth ideology.

INTERVIEW WITH AIDAN FOWLER

JH: So first of all, what is your role because we haven’t had one before?

AF: I’m the National Director for Patient Safety. This means I have the responsibility for making sure that the systems we have in place for treating patients safely is as strong as it could be. We haven’t had one before not because we weren’t interested in patient safety but because we recognised we hadn’t had the whole strategic structural approach to making the system as safe as it could be.

JH: Your background was in healthcare in Wales. What are the differences between Wales and England on patient safety?

AF: My three years before this role was but before that I had always been based in England. Over time my journey has become more international. The main differences are that Wales is of a different scale. They have integrated health systems and a scale that means you can wrap your arms around things more easily. Scotland is similar in many ways. The learning from there is that they have focused on safety continuously for a long period of time without structural reform. They’ve also invested proportionally more than other nations.

JH: Size gives you nimbleness but what is done better in England, where does scale help?

AF: Sometimes with a smaller scale you miss things. You don’t see the volume or numbers to see clear warning signs.  In England we get signals you wouldn’t see at smaller scale through our national reporting systems. Then on the economics – there are things we do that are of better value at scale. Even if I could I wouldn’t want to reproduce some of our central functions across the country.

JH: What impact do you expect the new health and care bill to have on patient safety?

AF: Well harm doesn’t always occur in the neat silos we currently have. We know of cases where there is diagnostic harm, someone is seen in primary care, then referred to secondary care, but things get lost in the gaps. The Bill will mean we’ll now have a system that looks at the pathway in a more cohesive fashion. It will make the whole pathway of care safer, which is very important.

JH: Are you positive about the indications that CQC inspections of ICSs will include a safety domain?

AF: I think that that makes sense. I can see a logic to quality being looked at, at an ICS level. You will remember we’ve discussed pressure ulcers in the past and whether they were community acquired or hospital acquired – that was distracting. Having the debate about where they arose was distracting because for the patient that doesn’t matter. So looking at safety as a whole is important.

JH: Would you see one of the key jobs of the ICS to strengthen collaboratives in maternity and cancer?

AF: Yes, I think they can do both of those. As you know in maternity we’ve had a maternity transformation programme running for four years. And the change in outcomes shows there has been good progress. But there are more things that we want to do. We’re looking at a revised way of working and looking forward to how that will work across ICS level.

JH: I often compare us with other countries on patient safety and think about the impact having the NHS has. The advantage of a national health service is that with the absence of a profit motive in large parts of the system you can focus people on quality and safety. And secondly, your data should be superior because someone like you can require the frontline to provide that data. Do we fully take advantage of that? In ten years could we be by the far safest system in the world?

AF: I see absolutely no impediment to us being as safe as anywhere in the world if not safer. I don’t look at it as a competition though - what we learn we should share for obvious reasons. But you are right, incentives are important. If what we ask of our system is that they get operational and financial targets right that’s all they will do. So it is important we say, here is important safety data and we want you to focus on that. With our strategy we’re trying to build in that structure and resource so it isn’t sporadic but it becomes a normal part of the system that there are people with dedicated time and training that look at harm.

JH: What is on your personal wish list for the next couple of years?

AF: if we look at our three key themes. Insight, infrastructure and improvement. We’ll join up the data much more and have a clearer signal of what’s going on in the system. People will be less afraid to speak up. Whether that’s patients, or staff. We’ll have a structure in place to train people on how safety works, what makes a safe system, human factors and so on. And we will keep improving our models of transformation.

JH: How central is it to get the right staffing levels for safe maternity care?

AF: It is recognised throughout the maternity system that we haven’t got sufficient numbers in some units and that has an impact. We have a better understand of the right number in midwifery than on obstetricians so we need to work on that too. I think there are often over used comparisons with aviation but in maternity it is one that works – airlines always have the right number of staff.

JH: Do you think attitudes to patient safety have changed over the last few years.

AF: I think it is changing all the time. When I qualified in 1990 you did not talk about patient safety as a concept. We all thought we were doing our best and the safest thing. I remember one of the first projects I did as a consultant was on infection rates. With focus on some changes we managed to halve our infection rates. Knowing what I know now we could’ve halved them again. With the right training and skill set we could have done so much better. That’s what I want to make sure everyone has now. 

Jeremy Hunt