Published: 20/06/2002, Volume II2, No.5810 Page 4 5
The first major conference held by the National Patient Safety Agency has been overshadowed by a row over the handling of potentially explosive data, with accusations that ministers showed a 'lack of political courage' by trying to suppress figures on adverse incidents.
The report, seen by HSJ, says that based on the findings of electronic submissions from 18 of the pilot sites, it would not be unreasonable for the NPSA to receive details on 200,000 adverse incidents a year, which 'may result in excess of two million incidents being received after a period of five years'.
HSJ understands that the NPSA had intended to publish in full the findings from 28 pilots on adverse incidents and near-misses at the conference on Tuesday, but at the end of last week the Department of Health ordered the agency to keep the findings under wraps.
One senior communications official for the NHS told HSJ he understood that Mr Milburn's special advisers 'had gone apeshit' when they learned of the NPSA's plans to publish both headline and detailed figures on the scale of adverse incidents and near misses.
On Monday, London's Evening Standard broke the story that health secretary Alan Milburn had banned publication of figures which showed that more than 20,000 adverse incidents and near misses had taken place at the pilots over the last nine months.
That figure comes from annexes to a 150- page report on the pilots.
Following publication of the story, the DoH and the NPSA agreed to reveal some of the figures at the conference.
And NPSA joint chief executive Sue Osborn insisted that the full data had been held back simply because it was not robust, and would be published in due course with the proper context.
At the conference, Ms Osborn and chief medical officer Professor Sir Liam Donaldson revealed several key findings, including a total figure of 27,110 adverse incidents and near-misses collated by the trusts.
The report from which the figures come does describe 'substantial data quality issues. . . including some incomplete or inconsistently applied data fields' and points out that some trusts do not collect information on the likely outcome of an adverse event.
It points out that 57.6 per cent of reported incidents did not specify the severity of harm to patients, and the severity of 60.9 per cent of incidents was not classified.
Nonetheless, it actually says 'the frequency for catastrophic events was lower than expected'.
It points out that the late shift is 'the most risky period for patients when it comes to significant adverse incidents'.
The report also points out that the greatest number of problems appear to be occurring in medicine, mental illness and the elderly.
But some communications officials accused the NPSA of naivety for the part they played in the saga, which has overshadowed the launch.
One said the NPSA had displayed 'an incredible naivety in thinking that these figures were palatable, politically'.
Many others senior officials said the DoH had displayed 'a lack of political courage' and created a negative story through its intervention.
'We could do with a bit less panic and paranoia. They should have had the courage to publish the information, stand back and take it on the chin, ' one senior communications official said.
Romola Christopherson, former director of communications for the DoH, said she was not convinced that either the DoH or the NPSA went far enough 'to prepare the ground to ensure a piece of work which was entirely for the good but was clearly vulnerable to being turned into a 'panic bomb in the streets' sort of story'.
And she suggested that 'the DoH made a rod for its own back' by intervening in the furore.
And Ms Christopherson said the role of the DoH and ministers should be 'to lay out the parameters of an agency like the NPSA - not get involved in the news management of it'.
But NHS Confederation policy manager Alistair Henderson laid the blame clearly at the door of the press for reacting 'irresponsibly' in their treatment of the figures.
'Either they didn't read the figures, in which case they were ignorant, or they didn't understand them, in which case they were stupid, or they wilfully misinterpreted them - in which case it was malice.'
The DoH said: 'Ministers and the NPSA decided not to publish information about the number of adverse incidents at this stage because the raw figures are unreliable and not sufficiently robust for an official government publication.
However, there is nothing to hide and we are committed to publish audited figures when they are available.'