How do we prevent ‘never events’ in the NHS?

At the 2017 GS1 UK Healthcare Conference, the delegates attending were set a challenge by Professor Terence Stephenson: to prevent the 400 ‘never events’ that take place in the NHS every year. Glen Hodgson, head of Healthcare at GS1 UK, explores what is meant by the term a ‘never event’, how can these be prevented and what role does GS1 standards have to play

2017 has been a significant year for GS1 standards in healthcare. More trusts and healthcare suppliers are GS1 members than ever before and momentum is building behind the next phases of the Scan4Safety programme. The 2017 GS1 UK Healthcare Conference is an important landmark in our calendar and this year’s event – taking place over two days on 21 and 22 November – saw more than 400 attendees, including senior NHS and Department of Health leaders, programme leads, suppliers and technology providers, discuss how GS1 standards could be adopted by even more healthcare suppliers and providers.

How do we prevent ‘never events’
The first day of the conference kicked off with Professor Terence Stephenson, chair of the General Medical Council. We were pleased to welcome back Professor Stephenson, who in 2016 had set the audience the challenge of sourcing real clinical evidence to demonstrate how GS1 standards in healthcare increase efficiencies, while improving patient safety.

Why did he set this challenge last year? While Professor Stephenson was a firm believer in the effectiveness of GS1 standards, he said that securing clinical data rather than concentrating on inventory stock – albeit fundamentally important – was going to secure better buy-in from senior NHS management to unlock funding.

Thankfully Professor Stephenson has been able to move on from this challenge as there has been substantial progress in this area. So at this year’s conference, Professor Stephenson turned his attention on the challenge of reducing ‘never events’.

To describe exactly what ‘never events’ are, Professor Stephenson began by offering many examples to demonstrate where human error was affecting the NHS. Many came from cases where he had treated patients himself or major news stories, such as the PIP breast implant scandal. But it was Professor Stephenson’s own back surgery that helped illustrate to the audience the importance of GS1 standards in healthcare.

Earlier this year, Professor Stephenson had two screws fixed into his spine. After five hours being unconscious during surgery, he wanted to know that the right screws had been inserted, in the right place and fundamentally, in the right person. Through no fault of any person, medical procedures can be beset by human error and Professor Stephenson said every week there are on average at least two operations where the wrong kit has been left inside the patient. He called these instances ‘never events’ and said there were 400 cases in 2016/17.

400 doesn’t sound a lot but for Professor Stephenson he said even one was too many. Having completed a secondment on an oil rig, where health and safety was at the heart of everything Shell did, Professor Stephenson was inspired about how he could apply this safety-focused culture to the NHS.

Implementing GS1 standards was vital to achieve this strong safety culture in the NHS and while Chair of the Medicines and Healthcare products Regulatory Authority, Professor Stephenson was instrumental in the adoption of Unique Device Identification (UDI) numbers. This saw everyone’s NHS number associated with a barcode to help identify, track and trace every patient who had interacted with the NHS.

He closed the session, with his challenge to the audience to prevent the 400 instances of ‘never events’ every year. And the message was clear: if the audience could demonstrate real success after implementing GS1 standards then these standards would be adopted more universally across the NHS. Ultimately, increasing efficiencies while improving patient safety.

Spreading success throughout the NHS
Matthew Swindells, national director of Operations and Information at NHS England, has worked in the NHS for 20 years. His first role was centralising Bolton Hospital’s store room’s supplies and procurement procedures. He is a firm believer in the importance of delivering an NHS that is safe, with high-quality services and is cost effective.

Speaking on the first day, Swindells assumed the audience was of the same mindset but admitted that generally people struggled to get their heads around the fact that the NHS can simultaneously be safe, efficient and provide value for money. He said that the NHS’s performance needed to be put into context as it is fairing better than the UK services sector in terms of driving productivity.

Nonetheless, age and changing lifestyles has put increased pressures on the NHS and Swindells stressed that the tax payer needs to be confident further levels of funding will increase efficiencies rather than paper over the cracks.

Swindells also admitted that there are regular achievements in the NHS, but for him, the key to achieving real long-term success was to spread best practice. While this was being done locally and across individual trusts, Swindells said it was important that all parts of the NHS knew what success looked like.

Like Professor Stephenson before him, Swindells challenged the audience to spread their pilot successes with the Scan4Safety programme so that it becomes the norm rather than the exception. But to convince the NHS, which isn’t the easiest customer, then the Scan4Safety pioneers had to convince their colleagues in other institutions that GS1 standards are a solid investment at a time when so much is going on.

Using lessons learnt from the United States and their approach to electronic medicine during the Obama presidency, Swindells suggested that the audience needed to demonstrate that projects that had adopted GS1 standards were connected, could demonstrate effective implementation between different institutions and that they could join-up different systems and services.

Our role at GS1 UK is to help the Scan4Safety demonstrator sites illustrate success, while connecting different trusts and we hope to meet Swindells’ mission to help spread best practice right across the NHS.

Bringing the industry together
Over the next two days, there was a whole raft of presentations, workshops and Q&A sessions which brought together healthcare providers, suppliers and thought leaders so they could network and make firm connections, while all learning from each other.

Bob Alexander, deputy chief executive at NHS Improvement, gave an impassioned account of how the NHS suffers from unprecedented levels of ‘never events’ which could be mitigated by universal adoption of GS1 standards. He stressed there shouldn’t be differences in how GS1 standards are implemented before challenging senior decision-makers to change their thinking from when are they going to adopt GS1 standards to why they aren’t doing this already.

Dr Andrew Goddard, a consultant gastroenterologist at Derby Teaching Hospitals NHS Foundation Trust, and registrar for the Royal College of Physicians, helped bring to life how GS1 standards in clinical procedures brought successful results. At the conference, Dr Goddard presented findings from a landmark bit of research he has been conducting where he demonstrated how barcodes in endoscopy procedures were improving patient safety, patient flow and reduce resource wastage.

On both days, delegates were treated to panel sessions which included lively Q&As with several NHS trust chief executives, including Alan Foster, CEO at North Tees and Hartlepool NHS Foundation Trust, Gavin Boyle, CEO at Derby Teaching Hospitals NHS Foundation Trust, and Cara Charles-Barks, CEO at Salisbury NHS Foundation Trust.

Each chief executive was able to provide their own experiences of implementing GS1 standards in their hospitals and what they envisaged would be the next steps and challenges when it came to seeing further adoption of barcodes in their trusts and beyond.

The solution to ‘never events’
Most of the audience agreed that GS1 standards have an important role in increasing efficiencies and improving patient safety but were asking where GS1 UK and the standards we promote are providing that much needed added-value. And the final session of the second day addressed exactly where GS1 UK might be able to help.

Currently, NHS trusts are using GS1 standards to capture data after clinical procedures happen. But GS1 standards don’t have to always look back and what healthcare would really benefit from is an intelligent point of care scan to provide healthcare professionals with real-time decision support to avoid causing harm to their patients.

And that’s the potential of using GS1 standards as they can provide real-time event data or as Lord Hunt put it “better outcomes for patients from big data.”

When Professor Stephenson challenged the audience to completely eliminate ‘never events’ he was also challenging GS1 UK to help the healthcare industry do exactly that. EPCIS is just one of the solutions that will help drive a patient-centric and efficient NHS and our challenge over the next year is to use the lessons learnt from the conference to go out to healthcare providers and suppliers and really demonstrate the importance of GS1 standards in healthcare.

Professor Stephenson

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