18 March - non-executive directors - with Helen Hughes

18 March 2022

This week’s non-executive directors webinar opened in conversation with Helen Hughes, Chief Executive of Patient Safety Learning.

Helen said: “If you go to big conferences you hear about the enormous scale of unsafe care and its causes but how to deliver is a complex problem that we’ve worked on for 20 years.”

“One of the big things we do is create this knowledge platform/hub for learning which is free to use. It's got three quarters of a million views from 200 countries around the world – 60% of which are from the UK – and it's designed for and by a wide range of people.”

“I don’t think we have the data and insight systems to understand the full scale [of the patient safety challenge]. Much of our knowledge comes from research work. Our kind of operational insight into it is very informed by reactive instant reporting systems that are voluntarily reported on. They’re not comprehensive so collectively we don’t actually know for sure but from the work that WHO has done we are looking at the same scale of harm probably as about 20 years ago, despite the best efforts.”

“There’s a much greater understanding of the scale of harm – and globally that’s 3 million avoidable deaths a year. Some initiatives are undoubtedly making a difference, such as the safe surgery initiative about checklists. This is a tool for collaboration and planning. There are huge opportunities with ICSs looking at patient safety not just organisationally but through care pathways.”

“One of the things I think we’ve created in healthcare was that we took the learning from aviation’s reporting systems. We thought if we really focused on our reporting systems that would really give us the answer. A lot of what staff do is capture incidents and analyse them, with very little time spent on learning and applying learning. NHS improvement is introducing PSIRF (the patient safety incident reporting framework). The principle is, rather than focusing on the process, let's look at the behaviour and insights to understand what goes on and to move to improvements and learning. It’s a huge culture change. NEDs should be being briefed to the impact of this. We need to make sure we don't just replace one set of initiatives with another.”

“Since the beginning of the pandemic there is has been an 80 percent increase in the number of referrals to secondary care that are being refused. Patients are not getting onto outpatient lists because the lists are full. There sems to be a change in criteria so GPs are referring elsewhere so patients are being dotted around. The consequence is that there are huge inefficiency and a lower quality and safety of care.”

These meetings are by invitation and are open to all NHS non-executives directors, chairs and associate non-executive directors of NHS providers. Others may attend by special invitation.

If you have any comments, questions or suggestions about these webinars, please contact: events@good-governance.org.uk