Berwick report: 8 key things in major patient safety review and 2 that are not
Professor Don Berwick’s report makes eight key recommendations for improving NHS patient safety but does not call for rumoured measures on mandatory minimum staffing levels or a legal duty of candour.
Eight key recommendations in Berwick report:
- The NHS needs to adopt a culture of learning – this must come from “countless, consistent and repeated” messages to staff so that goals and incentives are clear and in patients’ best interests
- Staffing levels must be adequate, based on evidence – boards and local leaders should take responsibility for ensuring that clinical areas are adequately staffed
- Connecting with patients and the frontline – leaders need first-hand knowledge of the reality of the system and the patient voice must be heard and heeded at all times
- Complaints systems need to be continuously reviewed and improved.
- Transparency must be complete, timely and unequivocal
- There is no single measure for safety – the NHS should continue to use mortality rate indicators to detect potentially severe problems, but these indicators remain a “smoke alarm”
- Supervisory and regulatory systems should be clear – an in-depth, independent review of the structures and the regulatory system should be completed by the end of 2017
- New criminal offences should be created around recklessness or wilful neglect or mistreatment by organisations or individuals, and for organisations that withhold or obstruct relevant information
Two recommendations not in the Berwick report that were rumoured to be:
- A statutory duty of candour for healthcare workers should not be introduced – it claims professional codes of conduct and guidance are adequate
- Mandatory minimum levels for nurses and other NHS staff – it claims staffing levels cannot be dictated from the centre
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