How to Improve Safety for Patients in Scotland
The Scottish Executive Health Department's Consultation Paper

The UNISON Scotland Response

February 2003

Executive Summary

UNISON Scotland welcomes the opportunity to respond to the consultation paper on improving patient safety in Scotland.

UNISON Scotland welcomes the establishment of the new Health Board ‘NHS Quality Improvement Scotland' and believes that in addition to removing unnecessary duplication of effort in respect of clinical governance in Scotland, the creation of this body can also help restore public confidence in the ability of the NHS to deliver patient care of the highest quality.

UNISON Scotland is encouraged by the executive's commitment to improving patient safety in Scotland and is supportive of the executive's aim to promote awareness of risk and patient safety amongst ALL health workers who assist in the provision of services for patients.

UNISON Scotland is supportive of the executive's drive to encourage a ‘reporting' and a ‘safety culture' amongst NHS Scotland staff. UNISON Scotland believes that improving the care of patients requires the development of a blame-free culture in the Scottish health service where lessons are learned from both good and bad experience. However, UNISON Scotland believes that to enable a ‘reporting' culture to work effectively within the NHS, steps have to be taken to ensure that staff are able to work without fear of intimidation or harassment as a result of their willingness to report adverse incidents.

UNISON Scotland also believes that staff must have confidence that lessons will be learned and changes enacted following the investigation of incidents. UNISON Scotland believes that the NHS will only benefit from the adoption of a reporting system if staff in the frontline of patient care have complete confidence in the ability of the reporting system to produce results.

In the main, UNISON Scotland believes that the key proposals outlined in the document will provide a good starting point to improving patient safety in Scotland. However, UNISON Scotland believes that the overall strategy to improve patient safety could be reinforced if the Scottish Executive was willing to act on trade union concerns in relation to hospital cleanliness and its impact on rates of HAIs.

UNISON Scotland believes that the Scottish Executive should afford a higher priority to combating HAIs and ensuring that adequate cleaning and hygiene standards are maintained in the NHS. In addition, it should remove all private contractors from cleaning responsibilities within the Scottish Health Service and show a greater willingness to involve health service trade unions in the strategy to reduce patient harm in Scotland.

Introduction

UNISON is Scotland's biggest health union representing thousands of NHS staff throughout the country. Our members include nursing, ancillary and clerical staff, whom the NHS depends upon to ensure the safe and effective functioning of the NHS.

This paper constitutes UNISON Scotland's response to the consultation document issued by the Scottish Executive entitled: ‘Learning from experience' How to improve safety for patients in Scotland.

Background

The document sets out the Scottish Executive's proposals for improving patient safety in Scotland. The document also sets out the Executive's plans for making Quality Improvement Scotland the lead agency for patient safety issues in Scotland with responsibility for developing an agreement with the National Patient Safety Agency (NPSA) on behalf of NHS Scotland.

In addition, the document sets out the key elements of the Scottish Executive's strategy to reduce harm in NHS Scotland and pinpoints five key areas of clinical governance, which it considers important in its drive to improve patient safety in NHS Scotland. These are:

• Implementing a reporting and learning system
• Developing an open and fair culture in the NHS and skills for analyzing incidents
• Developing solutions
• Disseminating Patient Safety Alerts
• Investigating issues of serious concern.

The main thrust of the consultation is concerned with the way in which Quality Improvement Scotland will manage, monitor and co-ordinate with the NPSA to improve patient safety in relation to the five key areas of action highlighted in the document.

Responses

Q1 Do you agree that Trusts in Scotland should begin to send adverse incident data to NPSA when the Agency is ready to implement its reporting and learning system?

UNISON Scotland agrees that it would be beneficial for Trusts in Scotland to send adverse incident data to NPSA at the earliest date. UNISON Scotland believes that the contribution of NHS Scotland experiences to the NPSA database will facilitate the process of learning and change within the NHS and enhance the NHS bank of knowledge on controlling risk.

However, UNISON Scotland has reservations regarding the timetable for implementation of the reporting system. UNISON Scotland believes that NHS Trusts should only begin providing data to the NPSA when adequate numbers of staff have been properly trained, to do otherwise would only put extra pressure on staff and bring into question the validity and usefulness of the data collected.

In addition, UNISON Scotland believes that NHS Quality Improvement must ensure the reliability and compatibility of the computer systems before implementing the reporting and learning system and the transfer of data to the NPSA. Only last year the NPSA were forced to concede that there were significant problems in relation to "data capture, data transfer and data transmission" within the reporting system. In addition it was found that computers in primary care centres and in mental health services did not integrate well with the NPSA system.

UNISON Scotland believes that NHS Quality Improvement must seek assurances from the NPSA that these technical problems have been resolved before implementing the new system and beginning the transfer of data to the NPSA.

Q2 Do you have any comments on these approaches to implementing educational support on patient safety in Scotland?

UNISON Scotland welcomes the move to take forward and develop within NHS Scotland many of the NPSA educational and support initiatives currently underway in England and Wales. UNISON Scotland believes that an approach similar to that of the NPSA, with adjustments suited to Scottish needs, offers the best opportunity to effectively develop the capacity to report and learn from adverse incidents and to implement an open and fair culture in NHS Scotland.

In recognition of the fact that the number of adverse incidents increases when there are more temporary staff employed, UNISON Scotland would encourage NHS Scotland to ensure that temporary and agency staff working in the NHS Trusts are provided with induction training in patient safety.

Q3 How else should the education and training initiatives to build capacity and change the culture be taken forward in Scotland?

UNISON Scotland believes that trade unions have a clear role to play in ensuring the success of the strategy to reduce patient harm in NHS Scotland. UNISON Scotland would like to see this role developed to enable trade unions to work in partnership with NHS Scotland.

UNISON Scotland has recently published a practical guide for its members on how to use the duty of care to ensure safe healthcare services and a safe working environment for healthcare staff. It has been published to assist stewards and members in raising concerns about excessive workloads, poor staffing, inappropriate grade mix, and a bullying culture, which may prevent concerns being raised. It also provides practical advice on how to positively influence service changes and modernisation of services.

UNISON Scotland is disappointed therefore that the document does not envisage a greater role for trade unions in the development of the support initiatives and educational tools needed to encourage reporting and safety conscious working in NHS Trusts.

Q4 Do you have any comments on this approach to the development of solutions to problems of patient safety in Scotland?

UNISON Scotland welcomes the new approach which emphasises a more co-ordinated and Scotland wide approach to implementing solutions to patient safety. UNISON Scotland also welcomes NHS Quality Scotland's commitment to tackling the "root causes" behind incidents and the plans to produce guidance and patient safety alerts where needed to improve patient safety.

UNISON Scotland also believes that in addition to developing these practical solutions to the problem of patient safety in Scotland the executive should also take immediate action to bring to an end the privatisation of hospital cleaning services. UNISON Scotland believes that until the Scottish Executive starts putting the issue of patient safety before profits the practical solutions to improve patient safety currently being developed will not realise their full potential.

UNISON Scotland has had long held concerns about hospital cleanliness and its impact on rates of Hospital Acquired Infections. The recent Audit Scotland report into Hospital Cleaning showed that 38% of hospitals and wards cleaned by private contractors were in the category of greatest concern as opposed to only 14% of those hospitals and wards cleaned by directly employed NHS staff.

We believe that the Scottish Executive should consider adopting the UNISON Scotland three-point action plan to tackle Hospital Acquired Infections (HAI). This plan would establish agreed minimum staffing levels for domestics for every ward and department in the Scottish Health Service. It would ensure that the day to day management of domestics is returned to Ward Sisters and Charge Nurses and also that all private contractors are removed from the National Health Service. UNISON Scotland believes that only by adopting this action plan will the NHS be able to demonstrate significant improvement in the cleanliness of the NHS hospitals and facilities.

Q5 Are there other ways that Scottish interests should be involved in the development of ‘solutions'?

As stated previously, UNISON Scotland believes that there is a greater role for health service trade unions in the development of solutions to patient safety than is outlined in the document. UNISON Scotland believes that the input of practical advice from our members who work at the frontline of patient care in the NHS can play an important role in the development of solutions to patient care.

In addition, UNISON Scotland is concerned that the NPSA has failed to provide assurances that Scottish expertise in the field of clinical governance and patient safety will be fully utilised as a key element within the wider UK research strategy. Scottish academic institutions and researchers have a proven R&D track record in these fields which UNISON Scotland believes should be fully utilised to contribute to the development of solutions not only in Scotland but in the UK as a whole.

UNISON Scotland agrees with the principles for disseminating Patient Safety Alerts developed by the NPSA. We are pleased that the alerts are being issued simultaneously to NHS Scotland and to the NHS in England and Wales and that differences in the nature of Scottish NHS service arrangements have been recognised and taken into consideration by the NPSA.

Q7 Do you have any comments on this approach to investigating issues of serious concern in Scotland?

UNISON Scotland welcomes the new arrangements that will give NHS Quality Improvement the power to investigate issues of serious concern on its own initiative. UNISON Scotland anticipates that this will strengthen the current arrangements in place and hopefully ensure a fully impartial and independent process of investigation and reporting of patient safety issues within NHS Scotland.

UNISON Scotland believes that if NHS Quality Improvement is seen to be free from external influences that this will encourage NHS staff to develop a wider reporting culture within their own working environments within NHS Scotland. It will also help assure an increasingly sceptical public of the Scottish Executive's determination to improve patient safety in Scotland.

 UNISON Scotland also welcomes the Scottish Executive's commitment to review current arrangement to ensure all staff in clinical professions have the skills and capabilities to fulfil their clinical roles effectively. However, UNISON Scotland believes that continuing development and training should be available for all NHS staff. The ability of the NHS to improve patient safety will depend upon all grades of staff being given the opportunity to access relevant training and knowledge on hazards to patient safety, not just the select few.

For Further Information Please Contact:

Matt Smith, Scottish Secretary
UNISONScotland
UNISON House
14, West Campbell Street,
Glasgow G2 6RX

Tel 0141-332 0006 Fax 0141 342 2835

e-mail matt.smith@unison.co.uk