Parliamentary Committees and Public Enquiries
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Still no open culture of learning in NHS in England, say MPs

The government must do more to coordinate its efforts to establish a culture of open-minded learning and investigation within the NHS in England, says the Public Administration and Constitutional Affairs Committee in its report.

Systemic problems with clinical incident investigations

The Committee inquiry followed the PHSO report, "Learning From Mistakes", which highlighted systemic problems with clinical incident investigations, where a fear of blame inhibited open investigations, learning, and improvement.
 
The Department of Health, NHS Improvement, and Care Quality Commission all acknowledged the need for the investigative culture to be transformed into one in which learning-focused investigations can routinely take place. However, despite repeated reports, both from PHSO and from PACAC, highlighting this as the critical issue facing complaint handling and clinical incident investigations in the NHS in England, there is precious little evidence that the NHS in England is learning. 
 
The Public Administration and Constitutional Affairs Committee (PACAC) found that, while a number of initiatives exist to improve the health service's investigative culture, there was also a distinct lack of coordination and accountability for how these initiatives might coalesce.

Turn the NHS in England into a learning organisation

Chairman of PACAC, Bernard Jenkin MP says:

"There is an acute need for the Government to follow through on its commitment to turn the NHS in England into a learning organisation; an organisation where staff can feel safe to identify mistakes and incidents without fearing the finger of blame."

Healthcare Safety Investigation Branch

The report also considered the proposed impact of the new Healthcare Safety Investigation Branch (HSIB) on the investigative culture in the health service. The creation of such a Branch was recommended by PACAC's predecessor Committee PASC in 2015. HSIB will conduct investigations where people directly involved in the most serious clinical incidents can speak honestly and openly in the interests of learning. However, PACAC is deeply concerned that HSIB is being asked to begin operations without the necessary legislation to secure its independence and the 'safe space' for its investigations.  
 
Chairman of PACAC, Bernard Jenkin MP, says:

"The Government must cease to defy the consensus now established by Parliament, the HSIB, and HSIB's Chief investigator Keith Conradi that the new 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. This is not acceptable."

The Committee calls on the Government to bring forward primary legislation for HSIB as soon as possible. Furthermore, the Government should stipulate in the HSIB legislation that, first, HSIB has the responsibility to set the national standards by which all clinical investigations are conducted; secondly, that local NHS providers are responsible for delivering these standards, according to the Serious Incident Framework; and thirdly, the Care Quality Commission should continue to be responsible as the regulator in assessing the quality of clinical investigations according to those standards at a local level.

Further information

 

Channel website: http://www.parliament.uk/

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