The NHS health regulation and governance environment is set to be fundamentally changed. Wes Streeting, the Secretary of State for Health and Social Care, has ordered two independent reviews, one of which will look at several NHS organisations with patient safety and quality remits (Department of Health and Social Care (DHSC), 2024a). In his words:
‘An overly complex system of healthcare regulation and oversight is no good for patients or providers. We will overhaul the system to make it effective and efficient, to protect patient safety.’
The organisations under review are:
The first review will look at these organisations in order to ‘make recommendations on whether patient safety could be bolstered through a different approach’ (DHSC, 2024a). Another will focus on quality and its governance. Findings of the Safety Landscape Review are expected in the new year (DHSC, 2024a) – more details are contained in the terms of reference (DHSC, 2024b). The reviews are to be led by Dr Penny Dash, who undertook the recent review into the CQC. Her report (Dash, 2024) found major failings with the CQC, and important remediable recommendations were made.
Damaged confidence
Confidence in the NHS patient safety, health regulatory and governance framework has been, in my view, seriously damaged by the performance shortcomings of the CQC, and only time will tell whether it can redeem itself. The Dash Review findings and the evidence obtained from stakeholders all go to show that the CQC has a lot of work to do.
The NHS does, however, appear to be in a perpetual state of regulatory flux, upheaval and change. Major patient safety problems have beset care over the years and continue to do so, particularly in the area of maternity care. Patient safety errors can be seen to be repeated over time with clinical practice remaining unchanged in certain areas. The patient safety lessons identified from past reports of investigations into health quality crises are patently going unlearnt.
All this provides essential context and a backdrop for the forthcoming Dash reviews. The NHS patient safety organisations to be reviewed all have key responsibilities and inputs for NHS patient safety culture development. It will be interesting to see what the Dash review concludes on such matters as overlapping functions, complexity of framework, performance and resulting confusion for NHS staff and the public.
Overlapping functions
In my past columns I have regularly pointed out the urgent need to rationalise and review the NHS patient safety organisations. There are too many of them with overlapping patient safety and health quality remits, and this causes confusion throughout the NHS.
In its seminal publication, ‘Opening the Door to Change’, the CQC said:
‘Arm's-length bodies, including CQC, royal colleges and professional regulators, have a substantial role to play within patient safety, but the current system is confused and complex, with no clear understanding of how it is organised and who is responsible for what. This makes it difficult for trusts to prioritise what needs to be done and when.’
The report also stated that trusts receive too many safety-related messages from too many different sources. More recently, the Infected Blood Inquiry pointed to issues in achieving an NHS patient safety culture and what needs to happen (Langstaff, 2024). Three aspects that require action are set out: changing the culture, a more rational approach to regulation and safety management, and ensuring a coherent approach to data. On the second point, the inquiry report highlighted the need for:
‘… a more rational approach to regulation and safety management resolving the problems created by the current systems for trying to deliver safer care: which are fragmented, overlapping, confusing, and poorly understood.’
It should also be noted that the NHS patient safety organisations regularly produce reports and recommendations, and all this can leave NHS staff and patients confused in the organisational output wake. Which is the more authoritative guidance, and which must be followed? Where is the evidence that supports the recommendation, has it been costed and does anybody ever check trust compliance with it? What if the guidance conflicts with other guidance or is contradictory?
A meaningful appetite for change
All the above shows that there is a general recognition in the NHS patient safety environment that change must come. The NHS health regulatory, governance, patient safety framework must be rationalised and reformed with overlap removed as far as is possible. There is a need for more joined-up action between NHS patient safety organisations. A merging of functions and agendas is needed, along with a reduction in the piles of separate guidelines, reports, and recommendations.
Support for my view that there is a marked political, as well as a significant stakeholder appetite for change in NHS patient safety bodies and other related matters, can be seen in Streeting's comments made in an interview to Elanor Hayward for The Times:
‘Wes Streeting intends to streamline the six overlapping organisations that currently share responsibility for patient safety in England, in one of his first major acts. He said that the present system was overcomplicated and “has failed to detect a series of disgraceful scandals in health and care”. These have included misconduct in maternity units in east Kent, Shrewsbury, and Nottingham hospitals, as well as a series of cases of appalling neglect in care homes.’
The interview clearly shows that there is a determined political will to make substantial changes to the patient safety, health regulatory and governance landscape in the NHS. The interview talks about the Health Secretary ordering an overhaul of the ‘bureaucratic web of regulatory bodies’ that have failed to stop a string of deadly NHS scandals.
‘He said that this new review will “give me the ammunition I need to overhaul health and care regulation”, as part of Labour's plans to shake up the NHS.’
In my view, after reading the Hayward interview, and the findings of the Dash CQC review, some degree of change in the organisations that have a health quality and patient safety remit is going to be inevitable.
The Health Secretary speaks in strong, resolute terms in his call for change. Change could take the form of the merging of organisations or the consolidation of some activities such as patient safety training and education into one organisation. The NHS Resolution claims database is a valuable resource and commodity. The view might be that that could be more widely shared and accessed across the NHS?
Adding fuel to the fire
Another recent report compounds, in my view, the need for the rationalisation and reform of NHS patient safety organisations. The report was published by the HSSIB on behalf of all the arm's length body members of the Recommendations to Impact Collaborative Group. It is based on meetings that took place to look at ways to increase collaboration and efficiencies in how safety recommendations made to the healthcare system are developed, made, and implemented.
Sections in the report cover some of the problems the group found relating to recommendations:
The report points out that failure to implement actions following recommendations can impact public confidence in the healthcare system and compound harm to patients. Furthermore:
‘The “noise” created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement recommendations, concentrating on those which are addressed directly to the provider, or where there are immediate patient safety risks.’
The Collaborative Group pointed out that some recommendations duplicate or contradict others, and that there is currently a lack of visibility of ongoing work across arm's length bodies that would enable collaborative working on related workstreams. The impact of recommendations on the patient is not always clear; the costing of them and relevance to some providers can also be unclear. Recommendations made include a need for guidance on the creation and implementation of recommendations, and a proposal for a repository of recommendations and ongoing workstreams.
‘There is a determined political will to make substantial changes to the patient safety, health regulatory and governance landscape in the NHS ’
Conclusion
The government has announced an important review of patient safety across the health and care landscape. The outcome will inevitably result, in my view, in some marked degree of reform and organisational change to some current NHS patient safety organisations (arm's length bodies). There is a significant degree of consensus in achieving this. The Dash review is to be welcomed.
The report from the Recommendations to Impact Collaborative Group (2024) has shone an important light on the problems that exist, with recommendations regarding quality and safety, making some valuable suggestions for reform. These will need to be factored into the Dash review.