Inspection and Regulation


Resounding calls to legislate HSIB as NHS still not learning from whistleblowers

Despite repeated promises from NHS England, NHS Improvement and the CQC to transform the investigative culture in the NHS into one that fosters learning-focused investigations – as well as numerous reports on the “critical issue” facing complaints handling and clinical incident probes – the investigative processes in the health service remain “obscure and difficult to navigate”.

The Public Administration and Constitutional Affairs Committee (PACAC) reinforced this issue in a new report today, which follows closely similar findings from the PHSO, that concluded there is “precious little evidence” that the NHS in England is learning from its mistakes at all.

PACAC’s chairman, Bernard Jenkin MP, stressed that there is “an acute need for the government to follow through on its commitment to turn the NHS in England into a learning organisation”, one where staff can “feel safe to identify mistakes and incidents without fearing the finger of blame”.

But while several initiatives exist to improve the investigative culture in the NHS, there is nevertheless a “distinct lack of co-ordination and accountability for how these initiatives might coalesce”.

The PHSO Dame Julie Mellor agreed with these findings, arguing that the NHS “still has a long way to go to provide staff with the relevant skills to carry out fair, high-quality investigations into avoidable harm”.

“The government and NHS leaders must commit to providing training, national standards and accountability for the NHS, to make it safer for all,” she added.

But a Department of Health spokesman insisted that it was already committed to ensuring the NHS “becomes an organisation that learns from its mistakes”.

“That's why from April this year, all NHS trusts will be required to publish how many deaths they could have avoided had care been better, along with the lessons that they have learned,” he added.

Healthcare Safety Investigation Branch

The committee also considered the impact of the new Healthcare Safety Investigation Branch (HSIB) on this culture, the creation of which was recommended by PACAC’s predecessor committee, PASC, in 2015. The branch, announced last year by health secretary Jeremy Hunt, was established to conduct investigations where people involved in the most serious clinical incidents are able to speak “honestly and openly”.

The group tasked with advising the government on how to establish the HSIB warned shortly after its announcement that the current system is failing patients, families and staff, with evidence pointing to a pattern of delayed, protracted and poor-quality investigations.

One month later, PACAC warned that the branch would fail unless stronger safeguards were established to strengthen its powers and autonomy. It had also previously insisted that the HSIB must remain independent.

In its report today, the committee stressed that is still “deeply concerned” that HSIB is being asked to begin operations without important necessary legislation to secure both its independence and the “safe space” for its investigations. Health minister Philip Dunne admitted late last year that there is indeed a “strong argument” for primary legislation to support the branch, but said introducing it was out of his control.

Today, Jenkin argued that the government “must cease to defy the consensus” established by Parliament, the HSIB and its chief investigator Keith Conradi that the branch requires legislative underpinning.

“Without such legislation, its ability to contribute to the development of a learning culture in the health system will be crippled,” he added. “This is not acceptable.”

As well as bringing forward such legislation as soon as possible, the government was asked to firstly stipulate in the legislation that HSIB “has the responsibility to set the national standards by which all clinical investigations are conducted”.

Secondly, it must ensure local NHS providers are responsible for delivering these standards and, thirdly, the CQC should continue to be responsible as the regulator in assessing the quality of clinical investigations according to those standards at a local level, argued the PACAC.

“The intention for HSIB to share learning will not alone guarantee the improvement of investigations across the NHS in England. HSIB’s role as an exemplar can only be effective if its relationship to other bodies is clear,” added the committee’s report.

“There must also be a well-defined process so that HSIB’s best practice is respected and shared across the system, including at local level. In order for this to happen, existing investigations and investigative bodies need to understand what to expect from HSIB when it starts operating, and how they are meant to respond to its findings.”

The DH spokesman agreed that the HSIB will help the NHS learn from mistakes “in the same way that the airline industry does”.

“As the health secretary said last year, we completely agree that it should be as independent as possible which is why we are committed to pursuing legislation,” he added.


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