07.08.13
NHS needs to focus on learning, not blame – Berwick review
Doctors found guilty of neglect should face criminal sanctions, a new review into patient safety has recommended. Professor Don Berwick (pictured above) was commissioned by the Prime Minister to conduct an inquiry in response to the Mid Stafford scandal.
He has recommended that clinicians who act with “recklessness and wilful neglect” should be disqualified from future leader roles, be publicly reprimanded and for the most extreme cases face financial sanctions for organisations and up to five years prison for individuals.
But Berwick, previously a member of the Obama administration as head of Medicare and Medicaid, also stressed the need to move away from blame and for the NHS to become “a learning organisation”. It was “systems, procedures [and] conditions” that led to patient safety problems, rather than specific individuals, he added.
The review called for NICE to determine safe nurse-to-patient ratios that could be applied, but did not go as far as legal minimum staffing levels.
The NHS must create a new culture of openness, Berwick said, with greater transparency, more patient involvement and regulators avoiding a diffusion of responsibility.
Berwick said: “In any organisation, mistakes will happen and problems will arise, but we shouldn’t accept harm to patients as inevitable. By introducing an even more transparent culture, one where mistakes are learned from, where the wonderful staff of the NHS are supported to learn and grow in their capacity to improve the NHS, and patients and are always put first, the NHS will see real and lasting change.”
He added: “The NHS in England can become the safest health care system in the world. That will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. 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.”
Health secretary Jeremy Hunt said: “This is a fantastic report. For too long, patient safety and compassionate care have become secondary concerns in parts of the NHS and this has to change.”
Patients’ organisations have warned that the recommendations do not go far enough, and others say there was not enough focus on staffing levels.
More reaction to the review here.
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Image: PA Wire