Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern.

My tough second album…

Welcome to the second edition of Lintern’s Risk Register. Thank you to everyone who took the time to send me some feedback on what you’d like to see me cover in these regular briefings. I hope to reply to everyone who got in touch but if you want to add your voice to what you think I could be doing better or fancy tipping me off to stories I have missed you can contact me in confidence here.

This week’s briefing brings you some reflections on last week’s international patient safety summit in London, the continuing crisis enveloping the health service ombudsman and how the crisis in workforce planning and heavy handed approaches are playing out on the frontline. 

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Shaun Lintern, patient safety correspondent

A meeting of minds

Health secretary Jeremy Hunt’s “Global Patient Safety Summit” last week gathered eminent delegates from across the world to the elegant surroundings of Lancaster House, a stone’s throw from Buckingham Palace. The event brought together some of the biggest names in safety – Darzi, Berwick, Kaplan and Gawande, to name a few – with thought-provoking presentations from people like Martin Bromiley (read his piece for HSJ here) and Black Box Thinking author Matthew Syed.

The summit explored the challenges involved in learning how and why errors happen in healthcare, and looked at the ways providers must engage staff if they are to understand the systemic causes of many incidents.

It looked at emerging trends in research on patient safety and had notable nods to anti-microbial resistance (a crisis that is already here) culminating with a speech by Mr Hunt that is actually one of the best I think he has made on patient safety since he arrived at Richmond House. Read it here.

All of this is of course welcome. But is it new? The influential To Err is Human was published 15 years ago and Liam Donaldson, who I spotted in the crowd at Lancaster House, published his report An Organisation With A Memory, in 2000.

On Wednesday I had the pleasure of listening to a presentation by Professor Mary Dixon-Woods, who warned against the temptation of “magical thinking” when people in the NHS evaluate their own quality improvement projects and claim progress where there is none. I think there were quite a few magicians wandering the corridors of Lancaster House last week.

Workforce shortages bite

No service can guarantee patient safety without enough staff with enough time to care.

Sadly the health service seems unable to dig itself out of the hole it dug itself into with workforce planning. Indeed it seems intent to keep filling and excavating the same hole on a 5-10 year cycle.

HSJ has highlighted some concerning developments showing the consequences for the frontline. At Basildon and Thurrock University Hospitals, the foundation trust has been forced to reduce night shift cover on its general medicine rotas because it can’t recruit doctors.

Meanwhile, Oxford University Hospitals Foundation Trust has seen its training of doctors suffer due to staffing shortages and a backlog of ultrasound work heaping pressure on those who remain.

HSJ has heard of many more examples of this than we have so far published.

It is true that workforce numbers are growing – data from the Health and Social Care Information Centre can’t be argued with– but that growth is not keeping pace with demand. The workforce plans of many years ago woefully failed to predict this so we are stuck with increasing gaps in rotas and pressure on staff, while at the same time the government can crow that its employing more clinical staff than ever before.

And there’s an elephant in the room here: the junior doctors’ contract row which rumbles on and Monitor’s latest drop in the agency cap rate which comes into force on 1 April.

Ombudsman faces second investigation

In the latest twist to the increasingly convoluted story of the Parliamentary and Health Service Ombudsman, the watchdog’s board has ruled that an independent investigation should be commissioned into its own response to revelations that her deputy was involved in a cover up.

This will look at what Dame Julie Mellor and the organisation knew about her deputy’s involvement in covering up the sexual harassment of an NHS director, and what they did in response. As HSJ has reported, Dame Julie was informed about Mick Martin’s history in July last year, but only took action after HSJ highlighted it last month.

These latest developments make it seem even more strange that MPs on the public administration and constitutional affairs committee – which oversees the PHSO – are apparently content to be silent on the issue.

Chief investigator of investigators

For anyone brave enough to take on all of these system errors and make a potentially big impact for healthcare quality, the new chief investigator role for the Healthcare Safety Inspection Branch is now out for applications. The salary is pegged at £131,000, and they’re looking for a “national or international expert in carrying out rigorous investigations, and experienced in leading a team of authoritative investigators”.

As I have mentioned before, HSIB has huge potential…but also faces gigantic risks with detractors on all sides. Who will be willing to step into such a role?

Is it magical thinking to believe HSIB can work?