Our recommendations
The issues we have identified are complex. They reflect the fact that healthcare is a web of interactions, behaviours and processes, underpinned by deeply ingrained cultures. If there were readily available, easy solutions to tackle clinical failures and end compounded harm, they would have been implemented long ago.
Facing up to this complexity, we have focused on two themes in our recommendations.
1. Accountability for a robust and compassionate response to harm, which supports learning for systems and healing for families
Our casework shows that many local investigations are not good enough. It cannot be right that in so many instances, the Ombudsman finds errors that the Trust has not identified at an earlier stage. The gap between the findings of local investigations and the findings of our investigations
suggests how defensive some NHS cultures can be. In some Trusts, there is still an embedded lack of curiosity about what has happened and what can be learnt.
It is important to recognise that our evidence base is just one snapshot in a much bigger picture. We understand that few people will have the energy to keep going and bring their case to the Ombudsman, having been through the trauma of grief, an investigation and a complaints process. This means what we see through our casework is likely to be the tip of the iceberg.
We must improve investigation quality and practices so they aid learning and promote healing, rather than adding to compounded harm. The HSIB has done important work to upskill NHS staff in best practice investigation methodologies, and the PSIRF is an excellent framework to take this
even further. There is a lot to welcome in the framework’s systems-based approach and emphasis on compassionate engagement.
While we want to endorse the approach the PSIRF outlines, we need to be realistic about how far there is still to go. There is a gap between the welcome rhetoric in PSIRF guidance documents and the defensive behaviours from some NHS leaders we still see in our casework, as evidenced in this report.
The additional flexibility the PSIRF offers (giving Trusts more autonomy to decide when a safety investigation is needed) might present a risk that Trusts with poor cultures do not carry out safety incident investigations when they should. This possibility is not acknowledged in the PSIRF
oversight guidance. Rather, the emphasis on ‘proportionate responses’ focuses more on making sure unnecessary investigations are not conducted if they would repeat old ground or would not lead to learning.
The PSIRF needs to be accompanied by sufficient monitoring and support for families.
We recommend that:
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Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is needed. This should include paying special attention to the balance of patient safety investigations versus other learning responses in Trusts (or service areas of a Trust) where there are poor CQC ratings for safety and leadership, or where other national bodies have raised concerns (recommendation 1).
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As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local investigations did not take place, or did not find that things went wrong, but PHSO or another independent oversight body later identified failings (recommendation 2).
The PSIRF recognises that genuine apologies are critical to avoid compounded harm. As we found in cases we analysed, apologies are often still not good enough and duty of candour is not always implemented as it should be. It is unacceptable that Trusts still fail in this duty nearly a decade after it was introduced. Again, this is symptomatic of a defensive culture in some Trusts. Duty of candour is the right policy, but it needs more attention and monitoring.
We recommend that:
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The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement (recommendation 3).
We welcome the model of family engagement outlined in the PSIRF. But we know that, for the foreseeable future, it will continue to be very challenging for families affected by safety incidents to navigate the complex NHS landscape when they raise concerns and seek answers. They are often very aware of the power imbalances in dealing with professionals who are familiar with the processes and systems that they are coming to for the first time. In this context, advocacy is an essential service, not a ‘nice to have’.
While there is a statutory duty for local authorities to commission NHS complaints advocacy, these services are often limited to helping people navigate the NHS complaints process. As we noted in ‘Making Complaints Count’, there are concerning gaps in access to more specialist services that may be important for families affected by patient safety incidents.
We recommend that:
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The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident (recommendation 4).
2. Evidencing that patient safety is a top Government and NHS priority
The right patient safety framework is not enough on its own to drive change. NHS leaders and frontline staff need to be in no doubt of the priority placed on patient safety.
In some ways it is strange that this should need emphasis: patient safety is about the NHS’ core purpose to do no harm. But there are clear signs that patient safety is not prioritised at the moment, however much rhetoric there is to suggest otherwise.
First, we are becoming too used to seeing repeated failings. This is especially stark in maternity services. In his inquiry in East Kent, Bill Kirkup acknowledged the disappointing familiarity of the findings to those he made in Morecambe Bay seven years earlier. The fact that inquiries many years apart find the same failings is met with dismay, but not always outrage or even surprise. There
is almost an acceptance that this is ‘how things are’. This inertia undermines the difficult work underway to change cultures and manage patient safety more effectively.
Second, political leaders have created a confusing landscape of organisations, often in knee-jerk reaction to patient safety crisis points. HSIB, the Patient Safety Commissioner, PHSO, NHS England, NHS Resolution and more than a dozen different health and care regulators all play important roles in patient safety. But there are significant overlaps in functions, which create uncertainty about who is responsible for what. This means patient safety voice and leadership are fractured. This is not due to a lack of dedication and professionalism from those tasked with championing patient safety. The problem is structural.
The Government must consider the case for streamlining some of these functions, for the benefit of people who use the NHS, their families and carers. This is not about reducing investment in patient safety. It is about creating a system that is coherent and easier to navigate, based on evidence and engagement with patients, families, NHS staff and leaders. We recommend that:
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The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families (recommendation 5).
Patient safety must be a consistent priority over the long term. It must not be subject to changes of emphasis or importance each time there is a new minister or leadership change in the NHS. We recommend that:
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The Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority (recommendation 6).
Third, it is not possible to claim to prioritise patient safety while avoiding difficult political decisions about the workforce the NHS needs. Patient safety will always be at risk in environments that are understaffed and where staff are exhausted and under unsustainable pressure. No matter how effective the safety systems and process, it is not possible to run a safe service without the right numbers of staff. Many patient safety commentators draw parallels between the NHS and aviation. In aviation, a plane would not take off without the right number of staff, with the rights skills, who have had enough rest, support and training to be able to operate safely.
Tackling workforce shortages goes beyond political decisions about resourcing. It is about making the NHS a place where people want to work and stay because it is somewhere they feel valued, not just because it is a vocation. We must break down the false dichotomy between the interests of patients and staff, recognising that a system that does not treat its workforce with humanity and compassion will struggle to extend these qualities to patients and families.
We recognise the Government has promised to publish a new NHS workforce strategy. At the time of writing, this is expected ‘shortly’. But for this to properly address the underlying causes of NHS staffing pressures, it needs cross-party consensus. In a sector where it can take nearly two decades to train a consultant doctor, a workforce strategy will only succeed if there is support from across the political spectrum, and far beyond one parliamentary term.
We recommend that:
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The Government should urgently produce its long-awaited long-term workforce strategy, with cross-party support, to increase the numbers entering and staying in the workforce across clinical and non-clinical roles. This strategy must:
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include independent, evidence-based and fully costed projections of future workforce requirements
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include detailed plans for training and recruiting new staff, retaining staff already working in the NHS and attracting those who have left to return
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take account of the mix of different professional skills required, rather than just total numbers in the workforce, and how existing professional skills can be deployed where they are most needed (recommendation 7)
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The Department of Health and Social Care should write to the Health and Social Care Select Committee and the Public Administration and Constitutional Affairs Committee within six months of the publication of this report to provide an update on progress against recommendations 3, 4, 5, 6 and 7.
NHS England should write to the Health and Social Care Select Committee and the Public Administration and Constitutional Affairs Committee within six months of the publication of this report to provide an update on progress against recommendations 1 and 3.