Source · Select Committees · Public Accounts Committee
Recommendation 13
13
Accepted
Health system overwhelmed by patient safety recommendations, hindering affirmative action.
Recommendation
In 2024, the Health Services Safety Investigations Body reported that the broader health system was drowning in patient safety recommendations rather than taking affirmative actions to improve it.26 NHS England told us that there are over 1,500 recommendations in the system and that managing those centrally is a huge task. NHS England told us that the new National Quality Board will look at how the NHS can access stronger, smarter recommendations.27 19 Qq 35-36 20 Q 38 21 C&AG’s Report, para 16 22 Switalskis Solicitors (CCN0014); Action against Medical Accidents (CCN0018); Slater & Gordon (CCN0023) 23 Q 83 24 Q 78 25 Q 99 26 C&AG’s Report, para 1.4 27 Q 80 12 Learning from available data
Government Response Summary
NHS England is required to collect information about what goes wrong in the health service and use this to provide advice and guidance and has introduced the Patient Safety Incident Response Framework (PSIRF) which is a contractual obligation for all Trusts.
Government Response
Accepted
HM Government
Accepted
2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2e. PAC recommendation: The Department and NHS England should have a clear system of accountability for patient safety, learning from mistakes and sharing what works, implementing best practice across the NHS streamlining patient safety alerts and recommendations from national bodies. 2.17 The government agrees with the Committee’s recommendation Recommendation implemented 2.18 NHS England is required to collect information about what goes wrong in the health service, using this to provide advice and guidance ‘for the purposes of maintaining and improving the safety of the services provided by the health service’ (Health and Social Care Act 2012). The Learn from Patient Safety Events service (LFPSE) now learns more from than 3 million patient safety incidents recorded each year through the development of machine learning and AI tools for analysis. LFPSE reviews hundreds of incidents weekly to look for new and under recognised risks that can be acted on including through issuing National Patient Safety Alerts, or developing national guidance in collaboration with partner organisations, such as royal colleges and the Medicines and Healthcare products Regulatory Agency. This saves an estimated 160 lives per year and £13.5 million in treatment costs per year through risk mitigation. 2.19 The way the NHS responds to patient safety incidents has been reformed through introducing the Patient Safety Incident Response Framework (PSIRF). The PSIRF is a contractual obligation for all Trusts, supporting safety learning with a reduction in bureaucracy, greater patient and family involvement and more effective, timely learning through proportionate responses focused on driving improvement. 2.20 The NHS has clear accountabilities for patient safety as set out in National Quality Board guidance. The changes the department is making as a consequence of the 10 Year Health Plan and Penny Dash’s review of patient safety across the health and care landscape will improve quality and safety by clarifying where responsibility and accountability sit at all levels of the system.