Monthly column for providers and professionals working in healthcare from Professor Ted Baker, Chief Inspector of Hospitals.

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Prof Ted Baker, Chief Inspector of Hospitals

To start off my final column of 2018, I would like to take the opportunity to thank everyone across health and care for your hard work and commitment.

Many of you will be working over the festive period, and I know a lot of effort goes into making sure Christmas is special for the patients and service users in your care. Over on Twitter, people are talking about what it’s like to work during Christmas, and members of the public are sharing their thanks using the hashtag #ThankYouNHS, and I’d encourage you to take a look and share your own messages.

The NHS celebrated its 70th birthday earlier this year. To mark the occasion we recognised the individuals making a difference in health and social care, and I think it’s a fitting time to revisit their stories and reflect on everything you do to make the health service what it is.

I hope you have seen that we have just published the findings of our review into the issues that contribute to the occurrence of never events and wider patient safety incidents in NHS trusts in England. The review was carried out at the request of the Secretary of State for Health and Social Care and sought to help understand the barriers to delivering safe care and to identify learning that can be applied to improve patient safety.

We gathered evidence for the review during visits to 18 NHS trusts, and through group discussions with frontline staff, patients, and experts from other safety critical industries.

We found that while NHS staff do a remarkable job to keep patients safe, despite their best efforts, never events and other patient safety incidents continue to happen. The report also highlights the complexity of the current patient safety system. Trusts receive guidance from a number of different bodies, leading to confusion and a lack of clarity on which external organisations can provide information and support. Added to this is the impact of increasing patient demand and staff shortages which leave little time for staff to implement safety guidance effectively.

The report’s recommendations aim to help make patient safety a top priority, and identify a need for a new programme of training to ensure the entire NHS workforce has a shared understanding of their role in patient safety from the moment that they start their first job in healthcare and throughout their careers, but as I say in the report mechanistic implementation of the recommendations alone will not be enough to achieve the change that is needed. A new era of leadership, focused on safety culture, engaging staff and involving patients is essential.

We all have a role to play in changing the safety culture, and I hope that you will reflect on the findings and recommendations and share them with your colleagues. Visit our website to read the report.

In September it was announced that the local system reviews programme would be extended, and we would be undertaking three new reviews and following up on progress made in three areas we visited in 2017/18.

We have recently published the first two reports of the new local system reviews, which took place in Staffordshire and Leeds.

Our review of Staffordshire found that older people living in the county had varied experiences of health and social care services. There were local variations in what was available to people depending on where they lived, resulting in inconsistent experiences of care and support.

Reviewers in Leeds found that system leaders had a shared vision that was supported an understood across health and social care organisations, with a shared understanding of the challenges ahead. However, pressure on the system was most apparent in the flow of patients in hospital. A shortage of suitable nursing care home places resulted in people often waiting to be discharged — putting further pressure on beds.

You can see these reports, and revisit our report setting out our key findings following the initial 20 reviews on our website.

And so it remains for me to wish you a very Merry Christmas and a Happy New Year, and I look forward to meeting many of you in 2019.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

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