NHS 'just out of starting blocks'
Updated on 11 December 2008
The NHS is only just out of the "starting blocks" when it comes to ensuring patient care is as safe as it can be, the head of the Healthcare Commission said.
Sir Ian Kennedy said reporting mistakes and learning from them needed to be "internalised in the DNA" of NHS trust boards.
And he said there was a "black hole" in the information available about mistakes made in GP surgeries.
Sir Ian said the issue of patient safety had risen up the Government's and the NHS's agendas. "But in my view the NHS is really only just out of the starting blocks," he said. "There's a great deal to do before we can be confident that the care patients receive is as safe as it reasonably can be.
"We are a long way from an NHS which systematically and hungrily examines its performance, reinforces safe practice, gets in and learns from things that go wrong and does things differently and more safely as a consequence."
Sir Ian, who is chairman of the Commission, said very little was known about the number of errors in primary care. Research has suggested that medical errors occur in primary care up to 80 times per 100,000 consultations (up to 600 errors a day). Up to 20% of these are thought to cause harm.
According to the Healthcare Commission, just 0.3% of incidents occurring in England and Wales in 2007/08 were from general practice.
Yet the vast majority of the contact a patient has with the NHS is with a GP and the largest number of complaints (38% in 2006/07) reviewed by the Commission relate to primary care, it said.
Sir Ian added: "Information about things such as missed diagnoses or late diagnoses won't show up in any register of untoward events because there's no incident, there's just a black hole."
A report published by the Commission, State of Healthcare 2008, called for more coherent systems for reporting mistakes and said the priority given to safe care varies among NHS trusts.
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