A Health System with a Memory for Adverse Events, but at what Cost? An Economic Analysis of the UK's National Reporting and Learning System (NRLS)

Since the publication of ‘To Err is Human: Building a Safer Health System’ in the US and ‘An Organisation with a Memory’ in the UK soon-after, the UK’s National Health Service (NHS) and many other health systems have made concerted efforts to place patient safety at the heart of care delivery, with the aim of minimising the harmful effects of iatrogenic care. In the wake of recent highly public failings in patient safety and care quality, these issues are of highest priority for policy-makers.

There is limited evidence on the economic implications and the societal costs and benefits of patient safety initiatives. Therefore, policy-makers have relatively little guidance as to which existing or prospective quality improvement programs they should invest taxpayer’s contributions, and it is unclear which policies are most likely to lead to marked improvements in service quality and thus maximise societal welfare.

The objective of this paper is to analyse the costs of one of the most important UK patient safety initiatives, the National Reporting and Learning System (NRLS), which was set up in 2003. The NRLS is a central database of patient safety incident reports that are voluntarily reported by frontline healthcare providers. Analysis of these incidents leads to feedback and guidance reports for national learning, in the form of urgent patient safety alerts or lower priority publications.   The main objective of this pilot study is to provide guidance to policy-makers on the resources required to maintain a central adverse event (AE) reporting system. As such, we address a significant gap in health policy evaluation.

We use a mixed method approach to evaluate the annual operating costs of the NRLS, incorporating several cost variables, including: personnel, equipment and IT, office space and general administrative costs. Data sources include accounting reports, semi-structured interviews to derive personnel time, and Department of Health administrative resources. We estimate annual operating costs of the NRLS of around £1,100,000, of which >90% account for personnel time. We also derive the annual cost of feedback or guidance using the average number of reports produced annually since 2003. We estimate an average cost per report of around £26,000, but depending on the type of report, costs range from £18,000 to £53,000. The main limitation of our research is the lack of full cost information, including frontline time costs of reporting AEs.

In order to decide on the societal worth of the NRLS, policy-makers need to consider whether the benefits in terms of improvements in care quality and prevention of patient safety events exceed the costs of collecting and managing incident reports. We lay out an agenda for future research and propose a framework of evaluating economic benefits across five categories: care practice change, patient safety culture change, benchmarking and monitoring of performance, risk assessment, and international and national peer regard for data.    Economic evaluations in these areas are needed to support our understanding of the value of reporting and learning systems and to inform their development as a means of improving the safety of patients.