NHS KNOW-NOTHINGS

Thousands of lives are being put at risk every year in the NHS because of the Government's failure to set up an effective system to monitor patient safety and prevent mistakes recurring, an influential cross-party committee said yesterday. A report by the Committee of Public Accounts, the parliamentary spending watchdog, describes the performance of the National Patient Safety Agency, which was set up to improve safety in health settings, as "extremely weak" and "dysfunctional".

In 2004-05 there were more than 1.2 million safety incidents and near-misses, half of which could have been avoided if health trusts had learnt from past mistakes. The report, which is based on work by the National Audit Office and evidence from the Department of Health, the safety agency and the Chief Medical Officer, concludes that a culture of secrecy and inadequate safety regulation is preventing error reduction in the NHS.

A total of 974,000 incidents were reported to the agency in 2004-05, but these represented only about three-quarters of the actual total, the committee found. It said that an average of 22 per cent of incidents go unreported, most of which were medication errors and incidents leading to serious harm.

Edward Leigh, chairman of the committee, said that arguably the most worrying finding was the apparent inability of the health service to reduce avoidable and recurring mistakes. "These statistics would be terrifying enough without our learning that there is undoubtedly substantial under- reporting of serious incidents and deaths . . . The NHS simply has no idea how many people die each year from patient safety incidents," Mr Leigh said. "What this points to are two related and deep-seated failures. One is the failure of the NHS to secure accurate information on serious incidents and deaths. The other is the failure on a staggering scale to learn from previous experience."

The report, A Safer Place for Patients: Learning to Improve Patient Safety, said estimates that one in ten patients admitted to hospitals in developed countries is unintentionally harmed showed the urgent need for an effective system. The errors are costing the health service about o2 billion a year in extra bed days and o400 million in settled clinical negligence claims. The report said that the safety agency had "provided only limited feedback to NHS trusts on solutions to reduce serious incidents". Underreporting by staff, particularly doctors, also remained a problem.

It added that "few trusts have formally evaluated their safety culture" and "insufficient progress" had been made on achieving targets set out by the Department of Health. The report also refers to data showing that less than a quarter of trusts routinely inform patients involved in a reported incident and 6 per cent do not involve patients at all. It noted that the size and complexity of the NHS workload, which treats a million people every 36 hours, meant that errors were inevitable. Peter Walsh, of the patient safety charity Action against Medical Accidents, called for urgent action as a result of the report.

Susan Williams, joint chief executive of the safety agency, said that progress had been made, but more was needed to ensure "even safer healthcare".

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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