The Kings Fund -Our response to Don Berwick's report on patient safety

“We welcome this strong and insightful report. Many of the principles and recommendations are not new and echo the findings of previous reviews - the question remains how to make a patient-centred culture that takes safety seriously a reality.

“National bodies can help create the right environment for improvement, and effective regulation is an important backstop against failure.  However, the kinds of change that will make the NHS the safest and most effective health care system in the world, as Don Berwick believes we can achieve, happen within teams and organisations and take commitment on the ground over many years.

“We know from Mid Staffordshire hospital and elsewhere the importance of maintaining adequate staffing levels. We welcome the recommendation that NICE should interrogate the available evidence to develop guidance for the NHS. Staffing levels are likely to be too complex for a nationally mandated minimum staff-to-patient ratio to be set. Hospital boards should use good evidence in deciding on the right staffing level for different services, and indicative staffing ratios could be used to highlight cause for concern, but feedback from patients and staff is just as important, if not more so.

“We welcome the report’s emphasis on continued learning and improvement. People will not change the way they behave by being told to develop a different culture of care − they need to be provided with the tools, training and development, ideally within the teams they work with, to help them achieve this shift.

“We also need to provide ongoing support and model learning and openness from board to ward.  Staff throughout the health service should be supported to do the right thing, be honest when they make mistakes, which they sometimes will, and speak out where they are concerned about quality of patient care.”