One year on – reflections from the Berwick advisory group

The Berwick advisory group was set up in 2013 to support Professor Don Berwick to review patient safety in the NHS in England, following the publication of the Francis Inquiry report into failings in care at Mid Staffordshire NHS Foundation Trust between 2005-09. Its resulting report in August 2013, A promise to learn – a commitment to act, set out principles and recommendations for a whole-system approach to continually reduce harm throughout the NHS in England.

The Health Foundation’s Director of Strategy Jo Bibby, was a member of the advisory group. Commenting at the time of the report’s launch, she said: 'It is imperative that the government and the NHS act on the report’s recommendations. We must not let this opportunity to improve the safety of patients’ care pass.'

In November 2013 the government responded to both the Francis Inquiry and the Berwick reports in Hard Truths. It outlined plans for a number of initiatives, including proposals for greater data transparency and some changes to regulation.

From the continuing focus on safety by the Secretary of State for Health over the last year, it’s clear that reducing harm to patients remains a political imperative. We spoke to members of the Berwick advisory group about where we are one year on from the publication of its report.

Jan Gould, a patient representative at Asthma UK, is optimistic. ‘My sense is that there have been more positive news items about the NHS and a rising confidence that measures are being put in place to secure safe and appropriate health care,’ she says. ‘I know that [the NHS] is a big machine to move but I believe that the right priorities have been set and personally remain respectful of the hard work and commitment of the vast majority of NHS staff.’

Creating a system devoted to continual learning

The Berwick review set out a vision for the NHS to become ‘a system devoted to continual learning and improvement of patient care, top to bottom and end to end’.

In direct response to the recommendations in the review, NHS England is now finalising plans for regional patient safety collaboratives. ‘It’s good to see that trusts and trust boards have used [Berwick] as a guide to the future and a statement of principles,’ says Professor Charles Vincent, Director at Imperial College Centre for Patient Safety and Service Quality. ‘It has certainly influenced the NHS safety strategy and the direction of the collaboratives.’ 

In addition, Health Education England is currently conducting a review into the education and training of nurses and health care assistants, taking on board recommendations from the Francis, Berwick and Cavendish reviews. The Shape of Caring Review will publish its report in February 2015. 

Changes to regulation

The Berwick report called for a simple and clear approach to supervisory and regulatory systems and there has been some progress in this area. The Care Quality Commission has made big changes to how it regulates health and adult social care over the last year. Its new inspection framework sets out five ‘domains’, assessing providers on whether they are: safe; effective; caring; responsive to people’s needs; and well-led.

Mary Dixon-Woods, Professor of Medical Sociology at the University of Leicester, comments: 'Some of the improvements made by the CQC are an achievement, and the new modes of working adopted by the NHS Litigation Authority also seem good. The focus of attention still needs to be on reducing the level of complexity in the system. I still think providers are answerable to too many masters.’

Adequate staffing 

The Berwick report said that staffing levels should be consistent with the scientific evidence on safe staffing (which would include an assessment of staff numbers, skills and the level of treatment required to care for patients) and adjusted to the local context.

NICE is currently working on safe staffing levels for nursing care in wards, and has recently issued new guidance setting out ‘red flag events’ which warn when staffing levels mean patient needs are not being met. Publication of this guidance has led to much debate on how effective it will be and how much it will cost.

On the issue of cost, Mary Dixon-Woods agrees that this needs more careful thinking. ‘I think the most progress has been made in recognising staffing levels as a safety issue, though I don’t see any sensible consideration at policy level of how this will be funded,’ she told us.

Transparency and openness

The government is introducing a statutory ‘Duty of Candour’, which all NHS providers will be required to comply with from October this year. This means that providers must be open and transparent with service users about their care and treatment, including when it goes wrong.

‘There has been considerable work done particularly on transparency around whistleblowing,’ says Jason Leitch, Clinical Director for the Health and Social Care Directorate at NHS Scotland. Mary Dixon-Woods sounds a note of caution though, highlighting how far there is still to go: ‘Despite all the rhetoric about whistleblowers I still think there is a distaste for uncomfortable knowledge and a default to blaming.’ 

Another move aiming to create a more transparent NHS has been the publication of new patient safety data on the NHS Choices website, launched in June this year. This covers various aspects of safety at individual organisations, making large amounts of data available to the public.

Growing impact over time

While a year on from Berwick is a natural point to reflect on progress, it may take some time for the true impact to show. As Jean Hartley, Professor of Public Leadership at the Open University, puts it: ‘the ripples continue to spread’. 

However, to begin to understand the impact of recent safety initiatives and reports, Charles Vincent points out that ‘our attention should, as so often, be on measurement and evaluation.’

Without this knowledge, he wonders ‘how will we know if we have made progress?’

We’d love to hear your views on how the safety landscape has changed over the last year, do share your comments below.