Intended for healthcare professionals

Rapid response to:


UK patient safety is improving

BMJ 2005; 331 doi: (Published 10 November 2005) Cite this as: BMJ 2005;331:1100

Rapid Response:

NAO analysis puts positive gloss on CNST ineffectiveness in raising safety standards

It does seem clear that patient safety in the NHS is improving for
various reasons but for the NAO to state on page 4 of its report,
paragraph 13, that "Assessment of trusts' risk management systems
undertaken on behalf of the NHS Litigation Authority has also provided a
strong incentive for trusts to improve their reporting and learning
systems" is not supported by the evidence. The Clinical Negligence Scheme
for Trusts (CNST) was introduced in 1995 and the figures in the table on
page 19 of the NAO report show that after 10 years only 26% of trusts have
advanced beyond the most basic level, level 1. In light of the 2004-5
figures, Sir Nigel Crisp, Chief Executive of the NHS, was probably right
to be cautious when asked by Committee of Public Accounts MP, Mr Osborne,
on 17 October 2001 to speculate on whether at some date in the future the
National Audit Office would publish a report showing 0% of trusts on
level 0 and 100% of trusts achieving level 3[1]; the former 0% figure has
been hit but in 2005 only 4% of trusts are on level 3. Is the CNST a
"strong incentive" for safety improvement? - not on the figures and length
of time to achieve better.

Like the NAO, the NHSLA (National Health Service Litigation
Authority) itself likes to put a positive gloss on the CNST figures and in
its 2004 annual report it stated that there was a 74% reduction in the
number of trusts on level 0 (from 53 in 2003 to 14 in 2004) but failed to
mention so few trusts moving to levels 2 or 3[2]; that is hardly a
balanced view of the "strong incentive" to improve patient safety provided
by the CNST. Trust managers possibly do not feel the carrot on offer is
large enough in terms of policy premium reductions for the effort required
to move to higher levels of the scheme.

It is most likely that improvement in patient safety in the NHS over
the last 10 years has been less to do with schemes such as CNST and more
to do with a reaction of the public and professions to events and
individual failures such as Bristol, Ledward, Neale, Shipman and others, a
number of publications including "An Organisation with a Memory" and
"Building a Safer NHS For Patients", as well as the more recent and
welcome introduction of the NPSA and the promotion of a fair blame

[1] Committee of Public Accounts. Handling Clinical Negligence Claims
in England. Thirty-Seventh REport of Session 2001-02. Minutes of evidence
taken on Wednesday 17 October 2001 - at paragraph 85.
(accessed 22.3.05)

[2] NHSLA. Reports and Accounts 2004 - at page 13.

[3] Department of Health. Learning from Bristol: the report of the
public inquiry into children's heart surgery at the Bristol Royal
Infirmary 1984 - 1995. London: Stationery Offfice, 2001 (Cm 5207)

[4] Department of Health. An Organisation with a Memory. London:
Stationery Office, 2000.

[5] Department of Health. Building a Safer NHS For Patients. London:
Stationery Office, 2001.

Competing interests:
None declared

Competing interests: No competing interests

11 November 2005
Nigel Dudley
Consultant in Elderly Medicine
St James's Univeristy Hospital LEEDS LS9 7TF