Safety on board – reducing risk

NHS England | February 2019 | Safety on board – reducing risk

A new case study on NHS England’s Atlas of Shared Learning looks at how a  Ward Sister at Solent NHS Trust led the implementation of a Patient Safety Board on a neuro-rehabilitation ward which has significantly improved staff accessibility to patient information relating to risk.


Staff on the neuro-rehabilitation ward at Western Community Hospital care for patients who have a variety of neurological conditions and support needs. These patients are often at risk of falling, have swallowing problems and are under The Deprivation of Liberty Safeguards(DoLS) which is the procedure prescribed in law when it is necessary to deprive of their liberty a resident or patient who lacks capacity to consent to their care and treatment in order to keep them safe from harm.

The necessity for staff to check information on computer systems and notes was observed to be having an impact, delaying the right care being delivered and causing some near miss incidents. The Ward Sister identified that as well as being an inefficient use of staff time, there were significant issues with accessibility of patient information. Patient records were not always in the same place reducing ease of access for staff and sometimes leading to risk factors not being recorded which could impact on quality of care delivery.

At the Nursing and multidisciplinary team (MDT) meeting, discussions identified that the accessibility of important information was an issue and the need to make changes  was agreed. This led to the introduction of  patient information relating to swallowing problems, fall risks and DoLS on the existing white board in the ward office. The board was chosen because it was well utilised by the entire MDT, kept up-to-date, and in a central accessible position in the ward office. It was also considered a pragmatic approach.

Magnets were used on the board to identify the risk issues with a reminder colour-coding key for staff:

  • yellow for swallowing problems;
  • blue for fall risks;
  • black for DoLS; and,
  • red for do not resuscitate.

It was easy for staff to update the board using the magnets and enabled any rotational or agency staff to easily see and understand the new system. After two weeks of testing, changes were made to the board template. It is still being used daily and the change is embedded in the ward routine (Source: NHS England).

Read the case study Safety on board – reducing risk

Shared Decision Making: Summary Guide

NHS England | January 2019 | Shared Decision Making: Summary Guide

Shared Decision Making: Summary Guide from NHS England is intended for people leading local implementation of shared decision making.



This guide is intended for people leading local implementation of shared decision making. It enables:

  • increased understanding of what good shared decision making looks like and how it ensures that we commission and provide systems and services that informed individuals want
  • commissioning of local shared decision making initiatives and embedding them in care pathways
  • providers to have better conversations with people using services, thereby supporting them to make more informed choices based on their personal values and preferences and what is known of the risks, benefits and consequences of the options available to them.

Shared Decision Making: Summary Guide

Suicide death numbers fall by a third globally over past 30 years

Naghavi, M. | 2019|Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016 |BMJ |364 |l94 |doi:

An international team of researchers conducted an analysis of  data from the 2016 Global Burden of Disease Study, a project that tracks all known causes of death by country, the experts found that the total number of deaths from suicide increased by 6.7% globally between 1990 and 2016 to 817,000 deaths in 2016. The results of the study have now been published in the BMJ. 


Objectives To use the estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and Socio-demographic index, and to describe temporal trends between 1990 and 2016.

Design Systematic analysis.

Main outcome measures Crude and age standardised rates from suicide mortality and years of life lost were compared across regions and countries, and by age, sex, and Socio-demographic index (a composite measure of fertility, income, and education).

Results The total number of deaths from suicide increased by 6.7% globally over the 27 year study period to 817 000 (762 000 to 884 000) deaths in 2016. However, the age standardised mortality rate for suicide decreased by 32.7% worldwide between 1990 and 2016, similar to the decline in the global age standardised mortality rate of 30.6%. Suicide was the leading cause of age standardised years of life lost in the Global Burden of Disease region of high income Asia Pacific and was among the top 10 leading causes in eastern Europe, central Europe, western Europe, central Asia, Australasia, southern Latin America, and high income North America. Rates for men were higher than for women across regions, countries, and age groups, except for the 15 to 19 age group. There was variation in the female to male ratio, with higher ratios at lower levels of Socio-demographic index. Women experienced greater decreases in mortality rates  than men.

Conclusions Age standardised mortality rates for suicide have greatly reduced since 1990, but suicide remains an important contributor to mortality worldwide. Suicide mortality was variable across locations, between sexes, and between age groups. Suicide prevention strategies can be targeted towards vulnerable populations if they are informed by variations in mortality rates.

Read and download Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016 from the BMJ 

In the news:

OnMedica Suicide death numbers fall over past 30 years

Polypharmacy: new guidance available

Royal Pharmaceutical Society | February 2019 | Polypharmacy: new guidance available

Polypharmacy: Getting our medicines right provides a summary of the scale and complexity of the issue of polypharmacy. It outlines how healthcare professionals, patients and carers can find solutions when polypharmacy causes problems for patients and points to useful resources that can help.


The guidance recommends that all healthcare organisations have systems in place to ensure people taking 10 or more medicines can be identified and highlighted as requiring a comprehensive medication review with a pharmacist.

The benefits of such reviews include:

•           A reduction in problematic polypharmacy

•           Improved health

•           Patients more likely to take their medicines

•           Fewer wasted medicines

Polypharmacy: Getting our medicines right

 Polypharmacy: Getting our medicines right  [shorter version]

What people have told us about health and care: October – December 2018

Healthwatch | February 2019 |What people have told us about health and care: October – December 2018

Over 11,000 people shared their experiences and views with Healthwatch between October – December 2018. This briefing highlights what the public are saying about four main areas of care, and how Healthwatch are using this information to help shape health and social care policy and practice. Healthwatch also takes an in-depth look at why people are facing problems with their medication.

Carers UK Research: More than 600 people quit work to look after older and disabled relatives every day

Carers UK | February 2019 | Research: More than 600 people quit work to look after older and disabled relatives every day

Research released by Carers UK reveals that 2.6 million people have quit their job to care for a loved one who is older, disabled or seriously ill, with nearly half a million (468,000) leaving their job in the last two years alone – a figure that equates to more than 600 people every day.  Carers UK report that this is a 12 per cent increase since Carers UK and YouGov polled the public in 2013.


The findings also show that more people are caring than previously thought, with almost 5 million workers now juggling their paid job with caring – a dramatic rise compared with Census 2011 figures of 3 million.

  • 1 in 7 of the UK workforce caring for a loved one
  • 6 million have quit their job to care
  • Carers UK calls for better employment rights including five to 10 days paid care leave (Source: Carers UK)

Carers UK Research: More than 600 people quit work to look after older and disabled relatives every day

In the news:

BBC News Carers quitting jobs from pressure

Yorkshire Post More than 600 carers a day are being forced to quit work to look after loved ones

Sky News Hundreds forced to quit paid work every day to look after relatives


Investigation into the management of health screening

National Audit Office | February 2019 | Investigation into the management of health screening

There are currently 11 national screening programmes in England. During 2017-18, more than 7.9 million people were screened under the four programmes covered by this report: abdominal aortic aneurysm, bowel cancer, breast cancer and cervical cancer.

In 2018, two events (on the breast and cervical screening programmes) raised concerns about the management and understanding of screening programmes.

Now the National Audit Office has published Investigation into the management of health screening  


Content and scope of the report

The National Audit Office’s investigation focuses on:

  • delivery of health screening programmes (Part One);
  • performance of health screening programmes (Part Two);
  • oversight of health screening programmes (Part Three); and
  • progress in implementing change in screening programmes (Part Four).


Full Report – Investigation into the management of health screening

Summary – Investigation into the management of health screening

ePub – Investigation into the management of health screening

Press release 

In the news:

BBC Health screening ‘not meeting targets’, report finds

Guardian NHS England cervical screening backlog revealed by watchdog

The Telegraph Smear results for 150,000 women left in backlog amid NHS failings

Millennials getting worst asthma care in UK

Asthma UK | January 2019 | Millennials getting worst asthma care in UK

Asthma UK reveals that two-thirds of young people (those aged 18-29) with asthma are not getting basic asthma care, which is a figure far higher than in any other age group. 

The research charity’s  findings have been released in The reality of asthma care in the UK: Annual Asthma Survey 2018  Asthma UK surveyed more than 10,000 people with asthma reveal that:

  • Millennials are more likely to have uncontrolled asthma, putting them at a higher risk of an asthma attack
  • They are twice as likely to need emergency care compared to those over 60 years old
  • The National Review of Asthma Deaths found two thirds of asthma deaths would have been prevented if people had had basic asthma care
  • Basic care includes, among other things, a written asthma action plan, a yearly review with your doctor, and an inhaler check.


Asthma UK suggests there are a number of reasons why millennials may be getting worse asthma care, including a complacency around the seriousness of asthma or an inability to get a GP appointment.

They also explain that in general, there is a misconception that asthma is ‘not serious’, with around 1 in 6 people in the UK not knowing that asthma attacks can be fatal. In fact, every day three people in the UK die from an asthma attack.

Almost a third (28%) of millennials with asthma did not attend their asthma review. More than 1 in 10 (12%) said that their GP surgery was too busy, so they were unable to book a review. More than half (57%) said they did not receive a reminder that their review was due (Source: Asthma UK)

The reality of asthma care in the UK: Annual Asthma Survey 2018

See also:

Every 3 seconds a person in the UK could be having a life-threatening asthma attack, finds Asthma UK

NHS efficiency map

HFMA, NHS England & NHS Improvement| January 2019 | NHS efficiency map

The NHS efficiency map has been updated and revised by HFMA, NHS England & NHS Improvement; it is a tool that promotes best practice in identifying, delivering and monitoring cost improvement programmes (CIPs) and quality, innovation, production and prevention (QIPP) schemes in the NHS.

The map is split into three sections:

  1. enablers for efficiency,
  2. service efficiency
  3.  system efficiency.


Image source:

The map highlights the successes some NHS organisations have had in delivering specific efficiency schemes and provides sign-posts to existing tools and reference materials.

As well as additional provider efficiency material the map has now been updated with a number of tools and guidance suitable for commissioning organisations, reflecting increased collaboration and integration. Therefore, the provider efficiency section has been appropriately renamed as service efficiency. The map will continue to be updated as new tools and case studies are produced (Source: HFMA).

Download from HFMA