The review into patient safety, commissioned by the Secretary of State for Health and Social Care, Wes Streeting, and led by Chair of NHS England, Dr Penny Dash, makes a range of recommendations, including a revamped and revitalised National Quality Board, with enhanced responsibilities, that is directly accountable to the Health Secretary.
The ’Review of patient safety across the health and care landscape’ finds a system with considerable duplication and overlap, that requires streamlining and simplifying as well as a strategic approach to address gaps in functions. The many reviews, enquiries and resulting recommendations lack impact because too many functions sit outside of the commissioners and providers of care who are responsible for improving quality. Those same commissioners and providers need a greater focus on effective governance, building skills and establishing clear accountability for quality – including safety – of care.
Whilst the primary remit of this review was on safety of care, and the role of six organisations established to assure, or contribute to improving safety of care, it was also tasked with looking at the wider landscape, of organisations influencing quality of care. Safety is defined as one aspect of a multi-dimensional concept of quality of care, which needs to also consider effectiveness and patient or user experience, accessibility, equity and efficiency.
The Dash review found that: “poor management of care contributes to unsafe care, ineffective care and poor user experience.” Research from 2019 estimates that poor or inadequate management results in a 5% efficiency gap, which when applied to NHS Trusts, equates to a cost in excess of £5 billion each year.
Findings
• There has been a shift towards safety (vs other areas of quality of care) over the last 5 to 10 years, with considerable resources deployed, but relatively small improvements have been seen.
Concerns over safety have led to an increase in staffing levels, particularly nursing staff, but this has not necessarily led to improved safety. “It appears that the focus on safety has been at the expense of other aspects of quality of care.”
• There has been limited strategic thinking and planning with regard to improving quality of care.
Previous strategies to improve quality of care are few and far between, however, the impact of improving effectiveness of care for those with long-term conditions and frailty has been recognised, but not acted upon. “This should have led to a shift in resources (money and staff) away from acute hospital care and towards primary and community (neighbourhood) care, but the opposite has happened.”
• A large number of organisations carry out reviews and investigations resulting in a very high number of recommendations being made to the NHS, most of which lack any cost-benefit analysis.
This situation is confusing for staff and often results in clinical staff moving into supervisory roles to check the recommendations are being followed. “Recommendations are often focused on inputs, rather than outputs or outcomes, and fail to recognise the balance of risks within organisations and across systems.”
• A large number of organisations look at user experience or advocate on behalf of the 'voice of the user', yet few boards in the NHS have an executive director for user or customer experience
Multiple surveys and action groups cause confusion for patients and users and result in inefficiencies. “Their distance from the commissioners and providers of health and care risks a lack of action and change.”
• The current system for complaints and concerns is confusing and may lack responsiveness.
The fragmented system means there are over 20 different organisations where patients or service users can share feedback, including concerns and complaints about serious harm or side effects, which again causes confusion. “Complaints and concerns are often poorly handled with patients, users and patient and user groups describing delays and poor-quality responses.”
• Some of the organisations under review have expanded their scope.
This might have happened with the best of intentions, but it creates further complexity, recommendations and confusion.
• A greater strategic focus on care delivery and management is needed to improve quality of care.
Whilst providers and their boards take responsibility for delivery, management and improvement of care, less attention has been paid to associated guidance structures resulting in wide variation across the system, from understanding of risks, effectiveness of boards, accountability for high-quality care, lack of incentives to support high-quality care, lack of detailed performance appraisals for staff and inconsistent role modelling of behaviours that embed high-quality care.
• The National Guardian's Office duplicates work carried out by providers.
The review questions the effectiveness of the National Guardian’s Office – with its responsibility for leading, training and supporting Freedom to Speak Up Guardians – being hosted within CQC, saying it creates distance between the role and the people it needs to support and influence. “Placing the responsibility for Freedom to Speak Up Guardians firmly within commissioners and providers should raise the profile and importance of staff voice and allow a more rapid response.” As the regulator, CQC needs to ensure these functions are happening within all commissioners and providers.
• Insufficient use is made of the NHS's data resources to generate insights and support improvement.
The NHS is said to be “data-rich” and more could be done to share that data, use advanced analytics and AI to generate greater insights, thus helping organisations to identify and focus on the most significant issues and challenges to improve care.
• There is insufficient focus on developing a national strategy for quality of social care.
This is outside the scope of the review, but the lack of national attention to the quality of social care is nevertheless commented upon.
Nine recommendations
• Revamp, revitalise and significantly enhance the role of the National Quality Board (NQB), which could be co-chaired by the chairs of CQC and NHS England, transitioning over time to the lead non-executive director for quality on the board of DHSC, and be directly accountable to the Secretary of State for Health and Social Care.
• Continue to rebuild the CQC with a clear remit and responsibility
• Continue the Health Services Safety Investigation Body’s role as a centre of excellence for investigations and clarify the remit of any future investigations
• Transfer the hosting arrangement of the Patient Safety Commissioner to the Medicines and Healthcare products Regulatory Agency and broader patient safety work to a new directorate for patient experience within NHS England, transferring to the new proposed structure within DHSC
• Bring together the work of Local Healthwatch and the engagement functions of Integrated Care Boards and providers to ensure patient and wider community input into the planning and design of services
• Streamline functions relating to staff voice
• Reinforce the responsibility for and accountability of commissioners and providers in the delivery and assurance of high-quality care
• Technology, data and analytics should be playing a far more significant role in supporting the quality of health and social care
• There should be a national strategy for quality in adult social care, underpinned by clear evidence.
What does this mean for the six organisations that were under review?
Care Quality Commission (CQC) – should remain as the independent regulator and oversight body across the health and social care system. It needs to rebuild public, professional and political confidence, and house functions where independence is required.
Health Services Safety Investigations Body (HSSIB) – the functions of HSSIB should be transferred to CQC. HSSIB should continue to operate as a discrete branch within CQC and retain its independence for providers.
Patient Safety Commissioner – the original function of this body, to promote the safety of and enable the user voice to feed back on adverse impacts of medicines and medical devices, should sit with the Medicines and Healthcare products Regulatory Agency (MHRA). Its wider remit should be integrated into DHSC.
NHS Resolution – its role as already established should continue.
Healthwatch England – the strategic functions should be transferred to the new directorate for patient experience at DHSC. The functions of Local Healthwatch should be combined with the involvement and engagement functions of Integrated Care Boards (ICBs).
National Guardian’s Office – incorporating its responsibilities within providers, with responsibility for ensuring these functions are happening falling to CQC, means this body will no longer be required.
