Comment

Learning from clinical correspondence failures

Ashley McDougall, director of Local Service Delivery value for money studies at the National Audit Office, on what healthcare organisations can learn from the NHS Shared Business Service (SBS) backlog of unprocessed clinical correspondence fiasco.

From 2008, NHS SBS, a joint venture between the Department of Health (DH) and Sopra Steria, was contracted by PCTs in three areas (south west, East Midlands and north east London) to redirect clinical correspondence. This amounted to an estimated 700,000 items of mail a year. 

In March 2016, NHS SBS informed NHS England and the DH that it had discovered a backlog of approximately 435,000 items of unprocessed clinical and other correspondence. The backlog eventually grew to almost 709,000 items after NHS SBS found more boxes of unprocessed clinical correspondence in its archives. 

To date, NHS England’s clinical review of the unprocessed correspondence has found 1,788 cases of potential harm to patients, but no case of actual harm has been identified yet. 

Our report set out the facts about the failures in correspondence handling and how the NHS and NHS SBS responded to the service failure. Although we did not make recommendations, our previous work on contracting and commercial services does suggest relevant lessons: 

• Understand risks: When PCTs were abolished in 2013, NHS England took over their contracts with NHS SBS for handling misdirected correspondence. NHS England told us it considered that there was no opportunity to review, amend or renegotiate the terms of those contracts before the contracts were transferred to it. It did not review the contracts later
• Ensure shared understanding: NHS SBS accepts that processing misdirected correspondence was a contracted activity for 21 of the 26 contracts with PCTs. NHS England, on the other hand, told us that it believed NHS SBS accepted that the service was being provided under the contracts to all of the 26 areas covered by the contracts
• Design performance measures that work: None of the contracts contained key performance indicators (KPIs) to measure how well NHS SBS was delivering the mail redirection service, and there were no direct financial incentives or penalties attached to NHS SBS’s performance in redirecting mail. NHS SBS told us that it concluded the absence of KPIs reflected the understanding of original commissioners and NHS SBS that this was a low-priority mail redirection service rather than a priority clinical task
• Respond appropriately to service issues: Senior managers within the NHS SBS primary care services business unit knew about the clinical risk to patients from not processing misdirected mail in January 2014, but did not develop a plan to deal with the backlog. The final internal audit report commissioned by NHS SBS into the incident found weaknesses in oversight at NHS SBS, a lack of awareness of the importance of correspondence redirection and a lack of urgency in dealing with the incident once it was escalated to senior management
• Know what suppliers are doing: NHS England was dissatisfied with NHS SBS’s co-operation in understanding the facts and causes of the incident. The main report by NHS SBS’s internal auditors in May 2016 on the effectiveness of the internal investigation, root cause analysis and management response to the incident did not provide NHS England with the level of assurance it required that the incident had been appropriately investigated and the causes clearly established
• Understand suppliers’ motivation: An internal investigation found that NHS SBS staff had considered the misdirected clinical correspondence a lower priority than other work as there were no performance indicators attached to it. The NHS SBS chief executive reported that staff considered this work to be ‘just filing’, although he stressed that this did not excuse the backlog 

NHS SBS is a key part of the back office of the NHS, working with one-third of trusts and 209 CCGs. It is worrying that NHS England was dissatisfied with NHS SBS’s co-operation in understanding the facts and causes of the incident and there is, as yet, no resolution of who pays the £6.6m in investigation and remediation costs. 

The Public Accounts Committee will be considering our report this autumn.

FOR MORE INFORMATION

W: www.nao.org.uk/reports

Top Image: © FabioBalbi