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It has been just over a year since Professor Don Berwick produced his review of patient safety in England. The review offered a distinct shift in emphasis from the focus of the Francis Inquiry. Most notably, it stated that 'rules, standards, regulations and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning'.

The review team was specifically asked how the NHS can 'make zero harm a reality'. They came back and said sorry, not possible (my paraphrasing), but instead filled the report with broader ambitions which would enable the NHS to achieve the 'continual reduction of harm'.

So what impact has the Berwick review had on the NHS?

In conjunction with Monitor and the Trust Development Authority, the Health Foundation sent a survey out to every NHS provider in England. We received anonymised responses from 99 organisations – a 40% response rate – including acute, mental health, community and ambulance services. The headline results are set out in our infographic.

Two thirds of respondents told us that the report had a ‘high’ or ‘very high’ impact on their safety improvement agenda. We heard many examples of action that they directly attribute to the report. From the ward – where it improved incident reporting and spreading learning – to the board – where it informed strategies, policies and governance structures.

Respondents told us that action in areas such as monitoring safety and embracing transparency was already underway before Berwick, but that the report gave an endorsement or legitimacy to it, and the motivation to do more. Crucially, more than 9 out of 10 respondents thought that they were making progress towards the continual reduction of harm.

Not a bad result then for a report which was only 46 pages long (even including annexes), which contained only a handful of 'commitments', and where the NHS isn’t being formally assessed against it. Although we don’t know what the other half think (the non-responders), it seems that the NHS has responded well to being praised for its efforts rather than being criticised for its 'failings'.

But despite there being cause for optimism, it is this concept of 'failure' which suggests that the NHS hasn’t yet taken up perhaps the most critical recommendation from the report – to 'abandon blame as a tool'. For instance, we have just seen the Heart of England NHS Foundation Trust criticised for a ‘clear failure in leadership’, following concerns about waiting times and mortality rates. This led to the resignation of its Chief Executive Dr Mark Newbold.

Mike Farrar, former Chief Executive of the NHS Confederation, came to speak to Health Foundation staff a few weeks ago, and he made the point that we have seen 'responsibility [for safe care] increasingly externalised' to regulators and national bodies. So if this is the case, have we created a system where oversight bodies end up apportioning blame as part of their efforts to diagnose and remedy safety problems (whatever we think of those efforts)? 

In our survey, we asked what role national bodies should play in improving safety. Respondents told us they want practical and moral support. Practical support in the form of sharing learning, evidence and best practice on what works, and making improvement tools and resources available. And moral support in terms of greater acknowledgement of where improvements have been made, and recognising that lasting change takes time to achieve.

Is it time, then, to rethink the role of national bodies in supporting improvement? From one which focuses on assuring the quality of care to one which creates the conditions to allow improvement to flourish at the front line? After all, our survey showed that the commitment where providers are making the least progress is in supporting and training staff to improve the processes of care.

The manufacturing sector is an example of an industry which has pursued quality by moving away from external assurance to empowering frontline staff to act when things go wrong. Inspections and audits play their part, but these are largely to help the operators deliver the best quality possible, not to take responsibility for it. Similarly, our research on safety cases illustrates how it is the primary responsibility of operators in other safety critical industries, such as nuclear power and commercial aviation, to make the case themselves for the safety of its services.

Whatever the landscape for improvement will resemble in future, this survey has given us cause for optimism about how organisations at the local level are pursuing safer care, and cause for thought at the national level as to how we can best support this to happen.

John is a Policy Manager at the Health Foundation.

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