Inspection and Regulation

31.01.17

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.

Comments

There are no comments. Why not be the first?

Add your comment

 

national health executive tv

more videos >

latest healthcare news

NHS England’s chief nurse to take up role as London regional director

21/08/2017NHS England’s chief nurse to take up role as London regional director

England’s chief nurse Professor Jane Cummings will take charge of the London region until a permanent regional director is found, NHS Engla... more >
Risk assessments not carried out before teenager’s death at Southern Health

21/08/2017Risk assessments not carried out before teenager’s death at Southern Health

Regular risk assessments were not carried out by the psychiatrist responsible for Connor Sparrowhawk when the teenager died in 2013, a tribunal h... more >
Too many older patients ‘suffering in silence’ over complaint concerns

21/08/2017Too many older patients ‘suffering in silence’ over complaint concerns

Concern has been raised by the families of older patients this week who say that it is too difficult to complain about the hospital care or treat... more >

editor's comment

13/06/2017Tackling the major challenges facing the NHS

As you will have gathered from the front cover, a theme that runs throughout this edition of NHE is about empowering and involving the workforce in order to deliver innovative change across the system.  Professor Jane Dacre, president of the Royal College of Physicians, highlights on page 16 the importance of sustainability and trans... read more >

last word

Your personality, your leadership

Your personality, your leadership

Deirdre Wallace, clinical skills manager at UCL Medical School, discusses the importance of learning about leadership and self while at medical school. Approximately five years ago, I was ch... more > more last word articles >
681 149x260 NHE Subscribe button

the scalpel's daily blog

We need your Health Heroes!

21/08/2017We need your Health Heroes!

We are once again delighted to be the official media partner for the Our Health Heroes Awards, working alongside Skills for Health to celebrate those in our healthcare workforce who go above and beyond the call of duty. It’s important that the fantastic contributions healthcare workers are making across the UK every day don’t ... more >
read more blog posts from 'the scalpel' >

comment

Changing our digital culture and safeguarding patient data

08/08/2017Changing our digital culture and safeguarding patient data

Joanna Smith, chief information officer at Royal Brompton & Harefield NHS FT (RBHT), says that as the NHS becomes more digital it has to get ... more >
A centre for medicines optimisation research and education

04/08/2017A centre for medicines optimisation research and education

Dr Yogini Jani, a consultant pharmacist at University College London Hospitals NHS FT (UCLH), discusses a collaboration with UCL School of Pharma... more >
Unlocking the benefits of age-friendly cities

04/08/2017Unlocking the benefits of age-friendly cities

Stefanie Buckner, Calum Mattocks and Louise Lafortune from the Cambridge Institute of Public Health, alongside Melanie Rimmer from the School of ... more >
A community service

04/08/2017A community service

Louise Watson, NHS England director of the New Care Models programme, discusses the emerging success stories from the vanguard areas across the c... more >

interviews

Improving care at the touch of a screen

08/08/2017Improving care at the touch of a screen

When it comes to dementia, having a calm and safe environment can have a substantial impact on a patient’s quality of life. NHE’s Jos... more >
A new approach to talent management

25/07/2017A new approach to talent management

Martin Hancock, national lead for talent management at NHS Leadership Academy, and Gill Rooke, the organisation’s senior operations manager... more >
Enabling greater integration through ACSs

25/07/2017Enabling greater integration through ACSs

At this year’s NHS Confed, Simon Stevens revealed the first wave of accountable care systems (ACSs). NHE speaks to Ian Dodge, the director ... more >
How NHS organisations can protect themselves against cyber crime

25/07/2017How NHS organisations can protect themselves against cyber crime

On 12 May, a global cyber-attack occurred on an unprecedented scale. It affected organisations across the globe and, though it did not specifical... more >

health service focus

View all News