With the future of the National Patient Safety Agency in the balance, Joanna Lyall looks at its track record and examines the criticism it has attracted from many quarters

With the future of the National Patient Safety Agency in the balance, Joanna Lyall looks at its track record and examines the criticism it has attracted from many quarters

It has certainly grown, but what has it learned?

The future of the five-year-old National Patient Safety Agency is under review and a slimming down of its central function seems likely following critical reports from the National Audit Office and the Commons public accounts committee. Last month, both of its joint chief executives, Sue Osborn and Sue Williams, were sent on 'extended leave'.

This was followed by the appointment of an acting chief executive, Bill Murray, chief executive of South Tees Hospitals trust.

A review of national safety in the NHS by NHS South West chief executive Sir Ian Carruthers is expected to report next month and to recommend an increasingly devolved approach to patient safety.

Speaking at an HSJ conference on patient safety in June, Sir Ian, then acting chief executive of the NHS, acknowledged the work of the NPSA, which he said had done a 'fantastic job' in raising the issue of safety up the agenda, but said 'wholesale system change' was needed to produce recognisable improvements.

A lot had been accomplished by NHS trusts with support from national bodies and there was a much greater awareness of safety among health professionals and managers, he said.

'But it is hard to escape the conclusion that patchy improvements have been the order of the day. Excellent and important projects have failed to be sustained and incorporated into lasting system improvements,' he said, while sustainable improvements at the frontline were not yet embedded.

This was echoed in a speech by Healthcare Commission chair Professor Sir Ian Kennedy a month later. He said more needed to be done to reduce avoidable deaths.

The NPSA was launched in August 2001, partly in response to the Bristol Royal Infirmary inquiry, chaired by Professor Kennedy, which called for a single reporting system for adverse incidents and a culture in which all staff could learn from failures. The agency's functions were to collect and analyse information on adverse events from local organisations, NHS staff and patients and provide feedback to inform practice.

In April 2005, following the government's review of arm's-length bodies, which reduced their numbers, the agency's remit was extended to include the work of the National Clinical Assessment Services, national confidential inquiries and the Central Office for Research Ethics Committees. Its annual budget rose from£17m to£35m and the number of employees to 316.

But a report from the NAO, A Safer Place for Patients, published in October 2005, found 'limited progress on assimilating and disseminating lessons'. The NPSA had published its first feedback report in July 2005, the NAO noted. While the safety culture in trusts was improving, this was largely due to the Department of Health's clinical governance initiative and the response to incentives developed under the NHS Litigation Authority's clinical negligence scheme for trusts, it suggested.

'Trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture,' the report concluded.

In July this year, the Commons public accounts committee criticised the NPSA for delays in delivering the national reporting system and for providing limited feedback to trusts on solutions to reduce serious incidents. 'The NPSA has also failed to evaluate and promulgate solutions that have been developed at trust level,' said the report. 'As a result the agency has yet to demonstrate value for money.'

'A key target for the NPSA was to develop a national reporting system by December 2001, with all trusts to provide information to it by the end of 2002. The system was three years late in being linked to trusts' own reporting systems and was overspent by approximately£1m,' the report noted.

Doctors were less likely than other groups of staff to report incidents and 'doubts remain among healthcare workers as to whether the agency can really make a difference,' said the PAC report.

While the NPSA's reporting and learning system received 60,000 reports a month - 'proportionally greater than any other system in the world' - it had 'yet to demonstrate that it is using the information and knowledge effectively to change healthcare practices rather than simply collecting statistics', the PAC concluded.

Some believe that lack of visibility, and demonstrable effectiveness, at local level mean the agency has essentially failed. 'It's rather like the Modernisation Agency, which did a lot of good work but lost the confidence of strategic health authorities and didn't establish itself with trusts,' says Kieran Walshe, professor of health policy and management at the Centre for Public Policy and Management at Manchester Business school.

The NPSA has done some good work, such as establishing a check list to avoid wrong-site surgery, but made a strategic mistake in not providing early feedback and practical solutions for trusts and frontline staff, he believes.

'There was a huge concentration on gathering data, a very complicated collection system, and no quick wins at local level,' he says.

Professor Walshe believes any reconfiguration of the agency's responsibilities should focus on the collection of data at trust level rather than nationally. He believes the present model of central collection is not appropriate to an NHS with an increasingly diverse range of service providers.

A lack of demonstrable success has not helped the agency's profile.

Minutes of its April meeting, record two non-executives, Laurie Goldberg, a former NHS pharmacist, and Jeremy Butler, a former general manager at British Airways, raising concerns about evaluation. Mr Butler noted an absence of targets in the agency's business plan for 2006-07 for numbers of lives saved and associated cost savings.

NPSA director of epidemiology and research Richard Thomson told the meeting that evaluation work was in progress, but it would be 'two to three years before there was clear evidence of the impact of individual programmes of work'.

The PAC report noted that despite the NPSA's objective to promote the profile of patient safety, in 2005

60 per cent of junior doctors questioned had never heard of the agency.

It also questioned the agency's success in producing a more open culture in incident reporting. Most trusts stated that their culture had become more open and fair but less than half had assessed their progress, it noted.

'The perception among nursing and other non-medical staff is that they risk suspicion if they report a serious incident,' the report said.

Is it reasonable to expect a new agency to create a substantial culture change within five years?

Tony Giddings, Royal College of Surgeons council member with responsibility for patient safety, says: 'The NPSA has tried hard but come up with the difficulties we all have in this area. It's a continual struggle to translate good intentions into safe practice.

'The NPSA concentrated on volume data without telling us enough about how we might fix things. I think they could have been more visible in the frontline and given feedback at earlier stage. The real issue is capturing hearts and minds and I hope a reborn NPSA will help us do that.'

Jenny Firth-Cozens, retired professor of psychology and a member of the expert committee chaired by chief medical officer Professor Sir Liam Donaldson which led to the establishment of the NPSA, believes the agency has played a part in raising the issue of patient safety.

'Progress has been hampered by trusts having to contend with deficits and concentrate on targets. But the reporting system is acknowledged around the world.'

The decision last year to bring the NCAS, which supports underperforming doctors, into the NPSA offered the possibility of a much more co-ordinated approach to patient safety, she said.

'I think they could do an awful lot more if they had real clout and could tell trusts what to do,' she said.

Action against Medical Accidents chief executive Peter Walsh also believes the agency could have achieved more if it had been given more powers. 'If there are problems they are more about the way the DoH set it up. We would like there to be more emphasis on practical solution work rather than the national reporting system.

'It is simply unacceptable that the NPSA can only recommend safety improvements and that NHS bodies are not required to implement them.'

'However,' he adds, 'the last thing we would like to see is the baby thrown out with the bath water. The NPSA has done some great work and has the potential to make a massive contribution to patient safety if it is given the tools it needs. Uncertainty over its future is destabilising for staff and puts progress at risk.'

At the NPSA, interim communications director Ruth Davison is confident that the agency is on the right track: 'The way forward for patient safety is under review by the DoH and we are not in position to second guess what recommendations may be forthcoming. However, as

the important thing is not the organisation but patient safety, whatever it concludes we will work with all those concerned with quality and safe patient care to make its vision a reality.

'Meanwhile, under interim chief executive Bill Murray we are already refocusing our efforts following the early years of the NPSA when the first job of work was connecting people to the national reporting and learning system, and conversations were necessarily with risk and clinical governance managers.

'We are now beginning to engage with the real drivers for change in the NHS - clinicians - and to make the business case for patient safety with senior managers. We will also - review allowing - work alongside the new strategic health authorities and primary care trusts to ensure effective commissioning for patient safety.'


Governance gripes

Stuart Emslie, Department of Health former head of controls assurance, now a visiting fellow at Loughborough University, says that NPSA's slowness in delivering on its principal objective of setting up a national reporting and learning system represents a lack of effective governance.

When head of controls assurance, a post he left in December 2002, Mr Emslie was involved in the launch of the NPSA.

He believes its decision to develop its own recording system at a cost of some£10m, rather than adopt an existing system, was a waste of money.

The 2001 vision of an internationally regarded body identifying solutions to improve patient safety locally had not been delivered, he said.

He is fiercely critical of the approach taken by the NPSA. 'The whole board appears to have failed to ensure the

NPSA achieved its principal objective. There has been a lack of effective governance.'