I have published today “Learning not blaming” (CM9113), which sets out the Government’s position on the freedom to speak up consultation, the Public Administration Select Committee report “Investigating Clinical Incidents in the NHS”, and Dr Bill Kirkup’s independent report on the Morecambe Bay investigation; and, in a separate document, Lord Rose’s report on NHS leadership.
The three reports cover distinct areas, and the accompanying document addresses the points and recommendations raised in each report. The “freedom to speak up” review by Sir Robert Francis QC, focused on whistle blowing; the Public Administration Select Committee report “Investigating Clinical Incidents in the NHS”; and, the investigation into university hospitals Morecambe Bay NHS Foundation Trust, conducted by Dr Bill Kirkup CBE. There are, however, some themes common to each report, including the importance of:
openness, honesty and candour;
listening to patients, families and staff;
finding and facing the truth;
learning from errors and failures in care;
people and professionalism.
In considering points made in these reports, the Government have been guided by the need to build on the work we and the NHS have done in recent years to improve the way in which the NHS treats patients and families, by developing capabilities locally to respond to patients’ and families’ concerns and to exercise proper oversight of care quality.
In recognition of this, the NHS’s own Five Year Forward View emphasises the need for care to be both safe and sustainable over the long term. For each of the reports, we therefore propose specific actions to address the immediate issues they raise, and in doing so make clear that the NHS must develop an improved approach to patient safety and complaints. Our response therefore sets out a strong expectation that we want nothing less than a renewed culture that values learning, not blaming; compassion, not defensiveness; and putting patients and families before systems and institutions.
In summary, we will:
put in place freedom to speak up guardians in each trust to build up capability and capacity locally, at the frontline of service provision;
ensure that every local NHS provider provides training in raising and listening to concerns;
remove the Nursing and Midwifery Council’s current responsibility and accountability for statutory supervision of midwives in the United Kingdom. (The NMC will of course remain responsible for the regulation of midwifery, but the supervision of midwives will be brought into line with the arrangements for other clinical professions);
review the professional codes of doctors, nurses and midwives and ensure that the right incentives are in place to encourage people to report openly, and to learn from mistakes;
set up a new patient safety investigation function to be fully operational from 1 April 2016—the independent patient safety investigation service. An expert advisory group will convene shortly in order to develop the structure, governance and operating model of this new service.
Freedom to Speak Up
The Government have consulted on a package of measures to implement the principles and actions set out in Sir Robert Francis QC’s report. In light of the consultation responses, I can now announce that the role of independent national officer will be hosted by the Care Quality Commission, who intend to have them in place by December 2015. I can also announce that freedom to speak up guardians will be appointed in all NHS Trusts, to build up capability and capacity locally, at the frontline of service provision, following guidance published by the independent national officer.
Robert’s report also called for training on raising and hearing concerns in every local NHS provider organisation. The relevant national bodies will now be working on a package that would include the following content:
the inclusion of content on raising concerns in induction training for all staff;
the inclusion of good practice regarding the raising of concerns for healthcare professionals as part of their professional codes, followed up through continuing professional development;
the regular use of reflective practice, through for example team meetings or Schwartz rounds, to review particular examples when concerns have been raised or not raised and how this might be improved in future;
the inclusion of content on raising concerns in other specific packages of training that NHS workers are expected to undertake or which NHS employers have included in annual training priorities; and
the inclusion of content on raising concerns in initial education and training undertaken by those learning to become healthcare professionals. This is already being considered and developed by health education England.
Morecambe Bay investigation
The Government have accepted all the recommendations of this report.
The recommendation for an independent patient safety investigation service is explained in more detail in our response to the Public Administration Select Committee report.
We will use secondary legislation to remove the Nursing And Midwifery Council’s current responsibility and accountability for statutory supervision of midwives in the United Kingdom. The NMC will of course remain responsible for the regulation of midwifery, but the supervision of midwives will be brought into line with the arrangements for other clinical professions. This will improve the local oversight and accountability for midwifery. Existing arrangements will remain in place until alternative arrangements are introduced.
In addition, I have asked Professor Sir Bruce Keogh to review the professional codes for all regulated staff in the NHS and to ensure that the right incentives are in place to encourage reporting and learning from mistakes, and prevent covering up.
In response to recommendations 25 and 42 in the report, I am proposing to review the regulations that set out statutory requirements for notifications to the Care Quality Commission and Monitor during 2015-16 with the intention of addressing Dr Kirkup’s recommendation that trust boards should openly report the findings of any reviews of care to relevant external bodies.
We would also like to extend this to the commissioning of any such reviews. We will consult on any changes.
In response to recommendation 20, NHS England has established a national review of maternity services, independently chaired by Baroness Cumberlege. It is anticipated that the review will publish proposals on safe and efficient models of maternity care at the end of the year. The review will pay particular attention to the challenges of achieving this objective in more geographically isolated areas.
Public Administration Select Committee report
We accept the recommendations of this report.
Our response sets out the Government’s decision to set up a new independent patient safety investigation service, to be operational from 1 April 2016. IPSIS will operate independently and it will be brought under the single leadership of Monitor and the NHS Trust Development Authority.
We have also set up an expert advisory group to advise on the scope, governance and operating model of this new service. The membership of this group includes:
Dr Mike Durkin, National Director for Patient Safety
Keith Conradi, Chief Inspector of the Air Accidents Investigations Branch
James Titcombe OBE, Morecambe Bay campaigner and currently working as a patient safety adviser to CQC
Prof Jonathan Montgomery, Professor of Healthcare Law at University College London
Julian Brookes, advisor on clinical governance for the Morecambe Bay Investigation, deputy chief operating officer Public Health England
Carl Macrae, Independent Quality Improvement Expert
Prof Martin Marshall CBE, Professor of Healthcare Improvement at University College London
Dame Eileen Sills DBE, Chief Nurse and Director of Patient Experience, Guy’s and St Thomas’ NHS Trust
Dr Bill Kirkup CBE, Chairman of the Morecambe Bay Investigation
Kate Lampard CBE, barrister and NHS strategic health authority chairman who provided oversight on the NHS’s Savile investigations.
PASC also recommended that, “draft legislation should be published for scrutiny early in the next Parliament” as part of the establishment of this new function. We will ask the expert group to consider whether the work of the independent patient safety investigation service would benefit from having any legal powers to fulfil its duties effectively.
I am confident that the new service will help to transform the state of patient safety.
I have today also published the report of Lord Rose’s review of National Health Service (NHS) leadership, “Better leadership for tomorrow”. A copy can be found online at: http://www.parliament.uk/writtenstatements. This is an important report making recommendations for the creation of a single NHS vision, improving training, performance management, reducing bureaucracy and improving management support.
I asked Lord Rose early in 2014 to consider what might be done to attract and develop talent from inside and outside the health sector into leading positions in the NHS and to recommend how strong leadership in hospital trusts might help transform the way things get done. Following the publication of the NHS’s Five Year Forward View, I requested him to extend his remit to consider how best to equip clinical commissioning groups to deliver the vision outlined within that report.
I welcome Lord Rose’s report and his 19 recommendations, all of which I have accepted in principle.
I am announcing today that the Government accept fully the recommendation to transfer responsibility for the NHS leadership academy from NHS England to health education England (HEE).
The Government also accept the need to do more to manage talent in the NHS and I can announce today that talent management for our brightest and best will become a formal responsibility for the single leadership of Monitor and the NHS Trust Development Authority.
My Department will work with the health and care system to develop plans to implement each of the other recommendations to the extent possible, subject to an assessment of proportionality, cost-effectiveness and affordability.