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Government still to fully implement agreed actions to improve patient safety after nine years, warns Committee’s Expert Panel

22 March 2024

Government action to improve patient safety ‘requires improvement’ warn independent experts in a report published today by the Health and Social Care Committee.

The overall ‘requires improvement’ rating applies to five recommendations made by independent inquiries and reviews into major patient safety issues going back to 2013, which the government has pledged to act upon. It covers recommendations to improve maternity care and leadership, staff training, and safety culture/whistleblowing. 

The rating reflects the fact that the government, in some cases, has taken too long to fully implement recommendations, which had been accepted nine or more years ago. While the government assured the Panel that some progress was “imminent”, the Panel said it remained concerned about the lack of ‘real action’. In two cases, the promised guidance or legislation to implement recommendations has been delayed.

The Panel noted progress on a recommendation to improve maternity care and leadership, made by the Morecambe Bay investigation, chaired by Dr Bill Kirkup CBE, to tackle the lack of independent oversight of perinatal deaths or maternal deaths. Though this recommendation was accepted by government in 2015, the Panel was concerned that it is still not fully implemented.

A recommendation from the 2013 Report of the Mid Staffordshire NHS Foundation Trust Public inquiry, chaired by Sir Robert Francis KC, would require improvement to be met. The recommendation required a common code of ethics, standards and conduct for senior board-level healthcare leaders and managers, with staff obliged to comply with the code and employers to enforce it. Tom Kark KC, who was the legal counsel to this inquiry, told the Panel that legislation rather than guidance would be necessary for the code of conduct to be ‘really effective’.

The Panel concluded that the two recommendations relating to safety culture across secondary and primary care, required improvement. In the report the Panel highlights a declining percentage of NHS staff who feel safe raising concerns about patient safety as worrying.

The Expert Panel rated funding for health and social care staff training to take up targeted interventions on leadership and organisational values as “inadequate”.

Please see pages 13&14 of linked Expert Panel’s report for detailed evaluation ratings

In compiling the report, the Panel heard from professionals, healthcare staff and members of the public in a series of roundtables, including Tom Kark KC, Chair of the Kark Review and Counsel to Sir Robert Francis' Mid Staffs inquiry, and Dame Linda Pollard, co-author of the independent Messenger review into leadership across health and social care in England (Roundtable 2 transcript). The Panel also heard from parents whose children died following failings in patient safety (Roundtable 3 transcript), and health and care professionals (Roundtable 1 transcript).

Chair of Expert Panel comment

Professor Dame Jane Dacre, Chair of the Expert Panel, said:

“Our evaluation has examined government progress to implement recommendations made by an independent inquiry or review when there’s been a major incident involving patient safety.

“We’ve looked at recommendations made by significant inquiries, Morecambe Bay and Mid-Staffs, both involving tragic loss of life. Nine or more years have passed since these recommendations were accepted by the government of the day. We are concerned about delays to take real action to implement them and rate overall progress by the government on this serious matter as requiring improvement.” 

Chair's comment

Steve Brine MP, Chair of the Health and Social Committee, said:  

“I welcome today’s report by our independent Expert Panel which we commissioned in the wake of the deep concern around the Letby case which gave rise to calls for another statutory inquiry. Investigations into major failures in the NHS, like the Thirlwall Inquiry into Letby, are vital but it’s equally important to hold the government and leaders of organisations responsible for actually implementing the recommendations that are made to improve patient safety. It was progress on a selection of such recommendations - each accepted by government - that our independent experts assessed. It is therefore disturbing to hear of delays in fully implementing the majority of them.

“The Health and Social Care Committee has now launched its inquiry into leadership, performance and patient safety in the NHS. The work of the Panel will provide valuable insights and an important foundation in support of our forthcoming public evidence sessions.”

Further information

Image: PA