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Monday, 5 September 2016

Committee of Public Accounts - Written evidence from the Chief Executive, Action against Medical Accidents (Part 4)

Over a series of Articles we intend to look at the Committee of Public Accounts - Written evidence from the Chief Executive, Action against Medical Accidents.

This is a Published Article taken directly from the Publications Page of www.parliament.uk

You can jump straight to the full publication here

We, at Edith Ellen HQ, have been very interested in the AvMA a national charity working towards Patient Safety and Justice for Patients when "things go wrong".


The main points of this Article are

  • whether the CQC should be more proactive in following up indicators of potential patient safety lapses, drawing on our research on implementation of Patient Safety Alerts issued by the National Patient Safety Agency (NPSA);
  • whether the CQC does enough to regulate openness and transparency, both with respect to promoting the protection and support of whistleblowers, and openness with patients/their relatives when things go wrong;
  • whether the CQC engages appropriately with the public; and
  • whether the CQC’s remit is too wide.

With these main points in mind we are jumping to Point 3 of the published article: 

Is the CQC proactive enough? The example of Patient Safety Alerts

"They cover issues which have been shown to repeatedly go wrong in the NHS causing harm or death to patients."

3.1 AvMA published its first report on the implementation of Patient Safety Alerts in February 2010, and followed this up with further reports in August 2010, February 2011 and August 2011. Copies of these reports are provided in the appendices.

3.2 Patient Safety Alerts are issued to NHS bodies by the NPSA. They cover issues which have been shown to repeatedly go wrong in the NHS causing harm or death to patients. They contain specific actions designed to avert these problems and a deadline by which these should be completed. It is meant to be a requirement for NHS bodies to complete the required actions by the given deadline.

3.3 AvMA found that the CQC were not initially taking implementation of patient safety alerts into consideration at all, in their monitoring and regulation of NHS bodies. Even after our report of February 2010 which exposed shocking rates of non-compliance, the CQC failed to do anything at all to chase NHS bodies up or ensure compliance. They admitted not to have written a single letter or made a single telephone call to trusts even where they had more than 10 alerts outstanding, and/or alerts which were outstanding years past the deadline. We found this a shocking oversight for a regulator who is supposed to have a key role in patient safety.

3.4 More recently, the CQC has acknowledged that it should have been taking implementation of patient safety alerts more seriously. It now says that it takes this into consideration in building the “Quality and Risk Profile” for each NHS body. However, it remains very unclear what this means in practice. We have been provided with no evidence of NHS bodies being taken to task by the CQC for being behind with implementing patient safety alerts.

3.5 In its evidence to the Mid Staffordshire NHS Foundation Trust public inquiry, the CQC remained vague about this. It appears to be entirely a matter for the discretion of regional managers. The CQC appears to have a blind spot as regards what it could and should be doing short of a full blown “responsive review” or taking action using its statutory powers.

3.6 AvMA believe that the CQC needs to be more proactive in encouraging compliance by taking simple common sense steps such as writing to NHS bodies who are known to be behind, warning them that they should ensure compliance within a given timeframe or face formal investigation or regulatory action. This would not be labour intensive and could have the same or more effect than AvMA publishing its six monthly exposés of the situation.

3.7 The CQC should also develop better links with commissioners to establish who is monitoring what and share information. We were amazed that this did not happen with regard to patient safety alerts.

3.8 Whilst we have concentrated on patient safety alerts and whilst timely implementation of these alerts is vitally important (literally a “life and death” issue), we believe that this is an indicator of how the CQC overall could be more effective.


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