Recommendation 102

Patient safety data should be open for analysis

Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others facilitated in that task.

In its response to the Caldicott Review, Information: To Share or Not to Share , the Department of Health stated that health and care professionals must make decisions about how information is shared and used in the best interests of people and patients using the five rules of confidentiality set out in new Health and Social Care Information Centre guidance, Guide to Confidentiality in Health and Social Care.  This guidance provides a balance between confidentiality and information sharing and states that, ‘people using services deserve a lot more than just information security.  Individuals need the teams of professionals who are responsible for their care to share information reliably and effectively. Confidential information about an individual must not leak outside of the care team, but it must be shared within it in order to provide a seamless, integrated service.’

Greater sharing of NRLS information is a stated aim of NHS England, within the bounds of an information governance framework. NHS England publishes patient safety incident data from the National Reporting and Learning System including information on levels and severity of harm to patients. NHS England is exploring the extent to which information on Serious Incidents can be disclosed in more detail without breaching the Data Protection Act. As part of the review of the National Reporting and Learning System, NHS England is considering how greater access can be provided to others for the purposes of analysis of patient safety incident data. Fundamentally NHS England is of the view that improving patient safety is more important than preserving unnecessary confidentiality.

The National Clinical Assessment Service, previously a division of the National Patient Safety Agency, was transferred to the NHS Litigation Authority in April 2013. The release of information relevant to this service is consistent with the NHS Litigation Authority’s approach to making information and data available which is not subject to data protection legislation and regulation, and would not result in breach confidentiality and/or rules of the court or litigation practice.

The Care Quality Commission and NHS England will develop a dedicated hospital safety website for the public which will draw together up to date information on all the factors, for which robust data is available, that impact on the safety of care. This will include information on staffing, pressure ulcers, healthcare associated infections and other key indicators, where appropriate, at ward level. The website will aim to begin publication from June 2014.  This will over time become a key source of public information, putting the truth about care at the fingertips of patients. NHS England will begin to publish never events data quarterly before the end of 2013. In addition, new patient safety collaboratives will be created, which will bring together expertise on learning from mistakes, encourage open reporting of safety incidents and near misses, and support NHS organisations to take a rigorous approach to transforming patient safety. Initial priorities will include tackling pressure ulcers, hospital associated infections, falls and medication errors. The National Director of Patient Safety, Dr Mike Durkin, will lead the work to develop the collaboratives.

Update

On 24 June 2014, a new NHS Choices microsite was launched which for the first time brings together a range of meaningful patient safety data that can be used by patients and the public to understand more about the safety of services. The data includes information on incident reporting, infection control and cleanliness, staffing levels, patient safety alert compliance, risk assessment for blood clots, data on pressure ulcer and harmful fall prevalence from the NHS Safety Thermometer, the Care Quality Commission’s assessment of compliance with their national standards, and data on the proportion of staff who would recommend the organisation if their family or friends needed treatment. These are now incorporated on My NHS, which alongside other data allows for greater scrutiny and comparison of the performance on similar organisations in terms of quality and safety.

NHS England began the monthly publication of never event data from April 2014.

NHS England makes data on patient safety incidents available to a wide range of patient safety researchers, academics and improvement specialists via the form of Data Sharing agreements. This data is used as the source material for published studies, supports innovation in safer care and tackles key themes and areas of risk identified by professionals outside of NHS England. The Care Quality Commission also has unfettered access to all patient safety incidents reported to the National Reporting and Learning System.