Professor Don Berwick’s patient safety report, published on Tuesday, was commissioned by prime minister David Cameron to ‘make zero harm a reality’ following the failings at Mid Staffordshire NHS Foundation Trust.
A promise to learn – a commitment to act: Improving the Safety of Patients called for ‘systemic change’ and urged the government to use ‘quantitative targets with caution’ and to insist on transparency. It called on healthcare leaders to ‘abandon blame as a tool and trust the goodwill and good intentions of the staff’.
The 46-page report made a series of recommendations including for NICE to establish ‘what all types of NHS services require in terms of staff numbers and skill mix to assure safe, high quality care for patients’.
One of the recommendations said: 'Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well supported.'
Only last month, the RCGP warned that England was heading for a shortfall of 16,000 GPs by 2021.
The report said that ‘NHS England, CCGs and provider organisations should ensure that a specific, named and recognised clinician, known to the patient, is responsible for the coordination of care for every patient at every phase of treatment regardless of setting’.
The DH’s consultation on making GPs the named, accountable clinician for the vulnerable, elderly leaving hospital closes next month.
The government should create a new offence of ‘wilful or reckless neglect or mistreatment applicable both to organisations and individuals’, it said.
It rejected the Francis reports’ recommendation to create a ‘duty of candour’ for healthcare workers, because it said that this is already ‘adequately addressed in relevant professional codes of conduct and guidance’.
The BMA welcomed the move. Its chairman Dr Mark Porter said: ‘We need to examine further the proposals for new criminal offences and work with the DH to see if these add anything further to the existing sanctions. There are already a number of ways in which healthcare workers, including doctors, can be held to account for their actions and we support Professor Berwick’s decision not to call for a new statutory duty of candour for individuals.'
RCGP chairwoman Professor Clare Gerada said: 'This is a seminal report that has the potential to be a game changer for the NHS and we urge ministers to take heed and act on its recommendations.
‘To provide the best possible care to patients, we need to ensure that we have enough staff, funding and resources. General practice in England currently receives only 9% of NHS funding, despite family doctors carrying out 90% of the NHS contacts.
‘If patients are to have access to the care they need and deserve, we need to put the NHS of the future on a safe and sustainable footing, with more GPs and a reversal of the current workforce shortfall.
‘Don Berwick's report could be a major step forward towards achieving this and GPs and NHS staff everywhere will salute him.’
The MDU said that it was ‘uneasy’ about a new criminal sanction for doctors. Its chief executive Dr Christine Tomkins said: ‘Doctors who are accused of wilfully neglecting patients can already be reported to the GMC and face having their license revoked if found guilty.'