Health and Social Care Select Committee Expert Panel: Evaluation of the Government’s progress on meeting patient safety recommendations (22 March 2024)

Summary

This is the report of a review conducted by the Health and Social Care Select Committee’s Independent Expert Panel, examining progress the UK Government has made against accepted recommendations from public inquiries and reviews on patient safety. It focuses on five recommendations, giving the Government for each a rating in the style used by national bodies such as the Care Quality Commission. The overall rating across all recommendations is ‘requires improvement’.

Content

The report notes that the overall rating of Government progress in the area of patient safety as ‘requires improvement’ reflects:

• The length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer.
• While progress is imminent in several areas, the Expert Panel remain concerned about the time it has taken for real action to be taken.
• In two cases, the promised guidance or legislation to implement the recommendation has been delayed.

In the area of maternity and leadership, the Expert Panel chose to look at a recommendation challenging the lack of independent oversight of perinatal deaths. Connected to this recommendation is the extension of the powers of medical examiners. They rated the implementation of the recommendation as ‘good’.

The other four recommendations in the areas of leadership, training and establishing a culture of safety were rated as ‘requires improvement’. The recommendations were to:

• Establish and enforce an effective common code of ethics, standards and conduct for senior board-level healthcare leaders and managers.
• Introduce targeted interventions on collaborative leadership and organisational values, and new entry-level induction for all staff joining health and social care.
• Create a culture of safety for all organisations providing NHS healthcare, with a specific emphasis on boards creating a safe environment where staff feel able to speak up, and effectively monitor progress.
• Ensure all staff working in primary care similarly feel safe to speak up and highlight poor practice, and that appropriate processes are in place for staff to raise concerns.