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Good morning and welcome to my latest Patient Safety Update. In a week of confusion over lockdown rules and parliamentary debates on the removal of liberties we started the Select Committee inquiry into maternity safety to make the point that pandemic or not lots of other things need fixing. Not that the pandemic doesn't intrude even into that as Alice Thompson points out that less than a quarter of English hospitals are allowing a partner to be present for the duration of labour. My calculation is that testing them would be an extra 2000 tests a day - surely we could find the capacity to do that? Today’s big event will be the launch of the select committee's written report into the delivery of regular NHS and core services throughout the pandemic. This will come against a backdrop of recently surfaced figures from SAGE that suggest that for every Covid death we have had one additional indirect death caused by the disruption to normal services. My concern is why when Chris Whitty told the Select Committee in July that he would support weekly testing of staff in hotspot areas it is still not happening. Given that we know that one hospital had 40% of its staff infected and around half of transmission is asymptomatic the case for weekly testing of NHS staff - as we now do care home staff - is unanswerable. Maternity Safety 1 If you haven’t already then I would urge you to watch Michelle Hemmington's evidence to the Select Committee yesterday. Patient safety campaigners constantly amaze me with their courage in being prepared to re-live tragedies, in her case over the loss of her son Louie. I was most struck by her comments that without an independent investigation into his death she felt litigation was the only option. Unsurprisingly there was strong support for the new HSIB investigations from Chief Inspector of Hospitals Ted Baker which have 'really progressed well' and 'gained the confidence of clinicians.' Depressingly Michelle says the hospital concerned has still not apologised for what happened despite accepting responsibility for 19 clinical errors after four and half years of litigation. There has to be a better way if we are to avoid the same thing being repeated. Maternity Safety 2 Also in this first session of the inquiry we heard from Dr Bill Kirkup who is leading the independent investigation into what happened at East Kent Hospitals NHS Trust. Along with Ted Baker, he argued that culture, leadership and training are vital if things are going to change at the small number of units where things are going badly wrong. Ted summed this up with a useful summary of the three common factors behind good quality care in maternity. To stop repeated failures he called for an end to the "culture within healthcare that is defensive and not willing to learn when things go wrong". Powerful stuff. Maternity Safety 3 Finally in this session the two people I appointed to lead the 'halve it' campaign to reduce stillbirths, neonatal deaths, brain injuries and maternal deaths, Dr Matthew Jolly and Professor Jacqueline Dunkley Bent, the Chief Midwifery Officer. Both said progress was being made towards the target of halving stillbirths and neonatal baby deaths by 2025. My summary of it would be great progress on stillbirths (down 25%) and on maternal deaths but the jury is out on neonatal deaths and brain injuries where the numbers don't appear to be budging. They both strongly supported the impact of the now stopped maternity safety training fund. Can’t help but feel Shaun Lintern has a point here. £16m is a drop in the ocean of the DHSC/NHS budget that will save many babies’ lives. Research Roundup...As we’ve focused mainly on maternity safety this week here is an interesting piece of research led by academics from The Healthcare Improvement Studies Institute at Cambridge and sent to me by James Titcombe. They have tried to distil what exactly makes safe maternity care into a guiding framework and come up with ‘Seven Features of Safety in Maternity Services’. Training, teamwork and a culture of safety are the ones that stand out to me and chime with what we heard at the Select Committee on Tuesday. Any Bright Ideas...a good response to my call for bright ideas last week on maternity issues but most notable was the suggestion from Cyril Chantler to look at legal reforms based on the Swedish system, something I’m definitely going to do. Patient Safety Movement Foundation boss Joe Kiani called me last night from the US where they are continuing to do great work. His big focus is ensuring financial incentives are aligned to patient safety goals, something that may become harder in England as we move to system level budgeting rather than payment by results. I do support system level budgeting because it moves incentives from cure to prevention but it is important not to lose sight of patient safety objectives. The Migration Advisory Committee has announced that senior care workers and nursing assistants should be added to the Shortage Occupation List to help ease pressures on recruiting those positions when freedom of movement with the EU ends. This is welcome but will they go further and add lower paid care workers? The call by the Committee for the social care sector to make jobs “more attractive to UK workers by increasing salaries rather than relying on migrants” is more controversial and I suspect we will only know the answer to the question when we see what levels of domestic unemployment we end up with post-pandemic. The Health Foundation has estimated that increasing pay in the social care sector to improve retention and recruitment - alongside demographic pressures - would cost around £4bn and that's before any Dilnot-style reforms. Going to be pricy to fix social care. Stat of the week...the NHS has spent £200m on clinical negligence claims related to medication error over the last 15 years. Worryingly the amount spent has doubled in the last six years.. As always please feel free to share this email with friends/colleagues who can sign up here and if you are a new subscriber you can catch up on old editions here. Jeremy Hunt
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