Government action to improve patient safety ‘requires
improvement’ warn independent experts in a report published today
by the Health and Social Care Committee.
The overall ‘requires improvement’ rating applies to five
recommendations made by independent inquiries and reviews into
major patient safety issues going back to 2013, which the
government has pledged to act upon. It covers recommendations to
improve maternity care and leadership, staff training, and safety
culture/whistleblowing.
The rating reflects the fact that the government, in some cases,
has taken too long to fully implement recommendations, which had
been accepted nine or more years ago. While the government
assured the Panel that some progress was “imminent”, the Panel
said it remained concerned about the lack of ‘real action’. In
two cases, the promised guidance or legislation to implement
recommendations has been delayed.
The Panel noted progress on a recommendation to improve maternity
care and leadership, made by the Morecambe Bay investigation,
chaired by Dr Bill Kirkup CBE, to tackle the lack of independent
oversight of perinatal deaths or maternal deaths. Though this
recommendation was accepted by government in 2015, the Panel was
concerned that it is still not fully implemented.
A recommendation from the 2013 Report of the Mid Staffordshire
NHS Foundation Trust Public inquiry, chaired by Sir Robert
Francis KC, would require improvement to be met. The
recommendation required a common code of ethics, standards and
conduct for senior board-level healthcare leaders and managers,
with staff obliged to comply with the code and employers to
enforce it. Tom Kark KC, who was the legal counsel to this
inquiry, told the Panel that legislation rather than guidance
would be necessary for the code of conduct to be ‘really
effective’.
The Panel concluded that the two recommendations relating to
safety culture across secondary and primary care, required
improvement. In the report the Panel highlights a declining
percentage of NHS staff who feel safe raising concerns about
patient safety as worrying.
The Expert Panel rated funding for health and social care staff
training to take up targeted interventions on leadership and
organisational values as “inadequate”.
Please see pages 13&14 of attached Expert Panel’s
report for detailed evaluation ratings
In compiling the report, the Panel heard from professionals,
healthcare staff and members of the public in a series of
roundtables, including Tom Kark KC, Chair of the Kark Review and
Counsel to Sir Robert Francis' Mid Staffs inquiry, and Dame Linda
Pollard, co-author of the independent Messenger review into
leadership across health and social care in England (Roundtable 2
transcript). The Panel also heard from parents whose children
died following failings in patient safety (Roundtable 3
transcript), and health and care professionals (Roundtable 1
transcript).
Professor Dame Jane Dacre, Chair of the
Expert Panel, said:
“Our evaluation has examined government progress to implement
recommendations made by an independent inquiry or review when
there’s been a major incident involving patient safety.
“We’ve looked at recommendations made by significant inquiries,
Morecambe Bay and Mid-Staffs, both involving tragic loss of life.
Nine or more years have passed since these recommendations were
accepted by the government of the day. We are concerned about
delays to take real action to implement them and rate overall
progress by the government on this serious matter as requiring
improvement.”
ENDS
, Chair of the Health and
Social Committee, said:
“I welcome today’s report by our independent Expert Panel which
we commissioned in the wake of the deep concern around the Letby
case which gave rise to calls for another statutory inquiry.
Investigations into major failures in the NHS, like the Thirlwall
Inquiry into Letby, are vital but it’s equally important to hold
the government and leaders of organisations responsible for
actually implementing the recommendations that are made to
improve patient safety. It was progress on a selection of such
recommendations - each accepted by government - that our
independent experts assessed. It is therefore disturbing to
hear of delays in fully implementing the majority of them.
“The Health and Social Care Committee has now launched its
inquiry into leadership, performance and patient safety in the
NHS. The work of the Panel will provide valuable insights and an
important foundation in support of our forthcoming public
evidence sessions.”
ENDS
The Expert Panel’s evaluation covered
recommendations made by: the inquiry into Morecambe Bay
Investigation, (March 2015); the Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry (February 2013); The Health
and Social Care Review: Leadership for a collaborative and
inclusive future report (June 2022); The Freedom to Speak Up
Review (February 2015).
Expert Panel Chair: Professor
Dame Jane Dacre, Emeritus Professor of Medical
Education at University College London, a consultant physician
and rheumatologist, and past President of the Royal College of
Physicians.
Expert Panel
members: Professor
;
Professor Stephen Peckham; Professor Emma Cave; Sir David
Pearson. Sir Robert Francis KC is also a member of the
Expert Panel but did not take part in this evaluation due to his
involvement in some of the public reviews and inquiries which the
Expert Panel examined.
