Health Committee Recommendations: Progress - Procedures related to Adverse Clinical Incidents and Outcomes in Medical Care
Sixth Report: Procedures related to Adverse Clinical Incidents and Outcomes in Medical Care (HC 549) Published: 23/11/99
Government Reply: Cm 4698Published: 04/2000
Government Response and Action
We recommend that the DoH reviews and reports on the implementation of clinical governance (paragraph 23).
Regional Offices are monitoring the implementation and development of Clinical Governance in the NHS on an ongoing basis and the Commission for Health Improvement has begun its rolling programme of reviews. The first reviews are complete and the reports will be made public in due course, as will the reports of the investigations the Commission has undertaken so far.
We recommend that the DoH issues guidance to NHS regional offices, health authorities and trusts giving clear advice as to which adverse incidents should be reported, to whom and when and that regional offices should ensure that this guidance is being followed. We also recommend that the DoH maintains a central, national database of adverse incidents (paragraph 34).
The Chief Medical Officer's expert group on learning from adverse events published its report, An organisation with a Memory on 13 June 2000. The report recommends the setting up of a new national mandatory reporting system that will ensure that lessons learnt in one part of the NHS are properly shared with the whole of the Service. The expected roll out of the system is by the end of 2001.
We recommend that the Government takes action to ensure that staff who comply with their professional duty to report concerns about colleagues, are not victimised (paragraph 44).
The draft protocol has been developed and the Regional Offices, particularly those with recent experience of "Whistleblowing" cases, are being consulted.
It is our view that the disciplinary procedures, in particular for suspension, should be refined to ensure they are fair, transparent and consistent. It is clear that trusts must adhere much more firmly to the guidelines. We recommend that there should be improved training for managers in dealing with the disciplinary process for clinicians (paragraph 52).
Agrees; current guidance will be reviewed. Proposed Assessment and Support Service will have an important role to help managers deal with professional issues.
We consider that doctors should be responsible for maintaining their professional skills. However they should not be deterred from retraining where this is necessary and we recommend that the DoH contributes towards funding of such training in appropriate circumstances (paragraph 57).
The original response referred to proposals for an assessment service for addressing concerns about an individual's professional skills. The NHS Plan announced the establishment of the National Clinical Assessment Authority from 1 April 2001.
We consider, however, that when a claim is made against a doctor or healthcare professional, the health authority or trust should initiate an inquiry into why such circumstances arose and whether patient safety is at risk. This inquiry should include an examination of the performance of any doctors or clinicians involved. We note that health authorities and trusts have a duty to report any concerns about the performance of clinicians to the relevant professional regulatory bodies. As part of clinical risk management, trusts and primary care groups should closely monitor claims, adverse clinical incidents and complaints, and should ensure that appropriate follow up action is taken. We recommend that responsibility for this should lie at a senior level. We recommend that the Commission for Health Improvement should ensure that effective sanctions are imposed on health authorities and trusts which do not fulfil these responsibilities (paragraph 60).
NHS Boards and Chief Executives have ultimate responsibility for clinical governance, including monitoring and acting on adverse clinical incidents and complaints.Regional Offices and CHI will monitor clinical governance.
We recommend that the DoH consults with professional regulatory bodies, the Health Service Commissioner, patients and carers, and others, on ways of clarifying the links between bodies and reducing the complexity of the system. At the very least the variety of mechanisms and the links between them should be explained to patients, their relatives and carers at the outset of their complaint. We recommend that trusts and health authorities should provide leaflets which describe the various avenues for complaint and how they inter-relate. They should also give details of where they can obtain help, for example the Community Health Councils, Citizens Advice Bureaux or other bodies, such as patient support groups, where relevant (paragraph 62).
The liaison group mentioned the original response has continued to meet on regular basis with an expanded membership that now includes a range of professional bodies and patient interest groups, as well as the Health Service Commissioner's office. A new Guide to the NHS will replace the current Patient's Charter in the autumn.
Whilst recognising the importance of a strong professional input, we recommend that the constitution of the GMC and the UKCC is amended to increase the lay membership to a bare majority and that health authorities and trusts are encouraged to involve local communities in monitoring and maintaining standards (paragraph 65).
Recent legislation (SI 2000 No 1803, the Medical Act 1983 (Amendment) Order 2000, which became effective from 3 August 2000, enables the GMC to co-opt non-members on to any of its committees. This is chiefly to help tackle the backlog of cases, but also to open up the Council to wider public involvement in its committee work, and bring in wider views and experience. As for the UKCC, the consultation exercise involving a range of stakeholders mentioned in the original response is due to end on 31 October 2000 and this will be followed up by a wider public consultation.
We welcome the DoH's review of the NHS complaints procedure but recommend that the DoH addresses any early indications of problems as quickly as possible (paragraph 75).
Need to ensure changes made in properly considered way. The evaluation team will report early in 2001 and the NHS Plan made it clear that the Government will act on the outcome to make the complaints procedure more independent and responsive to complainants' needs. The Department of Health will, of course, continue to advise the NHS on any concerns that arise in relation to the procedure as it currently operates.
It is clear that the initial investigation of a complaint needs to be much more thorough and should be carried out by well-trained, dedicated staff. We believe that the report from investigations relating to adverse clinical incidents or potential adverse clinical incidents must contain a detailed account of events and be robust enough to be used by other bodies, such as the GMC and UKCC, NHS disciplinary committees, or the courts. It should also contain a recommendation for further action. The implementation of its recommendations should be monitored as part of clinical governance. We recommend that the DoH provides a proforma to trusts and health authorities encompassing all the steps which need to be completed as part of the investigation (paragraph 79).
The Committee's recommendation will be given consideration during the implementation of the report of the Chief Medical Officer's expert group, An Organisation with a Memory.
We recommend that trusts be encouraged to appoint a quality and risk manager with sufficient training, authority and personal skills to deal with complaints and bring these issues to Board level where the appropriate action can be taken (paragraph 80).
NHS organisations must have designated complaints manager of sufficient seniority. Boards already responsible for statutory duty of quality.
We recommend that the complaints manager in charge of the initial investigation sifts complaints to ensure that those which may contain serious allegations about staff performance and which could endanger future patient care are dealt with speedily and passed to an appropriate authority where necessary. The DoH should issue guidance on the types of complaints which would need to be passed on quickly (paragraph 82).
Already required to consider whether matter may merit disciplinary action or referral to other body. Will consider whether guidance would be useful. The Committee's view on guidance on the types of complaints which might merit onward referral will be considered in the context of the wider reform of the complaints procedure following the report of the evaluation project.
We recommend that existing conciliation practices are evaluated to enable good practice to be identified and disseminated (paragraph 83).
The use of conciliation in handling complaints is something that the Government has always encouraged. The independent evaluation of the NHS complaints procedure is considering the effectiveness of conciliation as one of the options available for resolving complaints at an early stage. The project will report early in 2001.
We consider that it is vital that the NHS complaints procedure is made more open and transparent and that the system is seen to be fair and independent. We make recommendations on how this might be done at the independent review stage in paragraphs 89 to 96. We recommend that the role of convener as it currently stands be abolished. Patients, their relatives and carers who would like an independent review of their complaint should apply directly to the IRP for "leave to appeal". This is similar to those going through the legal process who apply to the court of appeal (paragraph 88).
Conveners should act fairly and impartially and are not NHS employees. IRPs are not standing committees and therefore complainant could not apply to them. Will take Committee's views into account when considering complaints system evaluation. The independent evaluation has been examining all aspects of the NHS complaints procedure and will report early in 2001. The Government will consider any changes to the complaints procedure in the light of any recommendations made. The NHS Plan, published in July, commits the Government to acting on the evaluation report with a view to changing the complaints procedure to make it more independent and responsive to complainants needs. However, in the meantime the complaints procedure will continue to operate within the scope of the current legislation and guidance and the Government expects the NHS to do this in an open, honest and thorough manner with the primary aim of resolving the complainant's concerns.
We recommend that Independent Review Panels (IRPs) should consist of a majority of lay members and should not be connected with the trust or health authority which is subject to complaint. We recommend that IRPs should be funded by and accountable to the regional offices of the NHS Executive (paragraph 91).
IRPs are sub-committees of NHS trusts or HAs for a variety of legal reasons.
We consider that IRPs should be conducted in a more formal manner, with all parties present, and act as adjudicatory bodies (paragraph 92).
Believes that a non-adversarial (thus not quasi-judicial) system is best. Will consider further guidance on conduct of IRPs.
We recommend that IRPs should be chaired by people with the appropriate background and experience, recruited by the regional office of the NHS Executive. Common standards should apply throughout the country and staff should be properly trained and resourced. Chairs should be fewer in number and operate across the region so that they can build up expertise (paragraph 93).
Aim to have large pool of lay Chairs to prevent over-familiarity with NHS bodies. Will consider recommendation alongside evaluation findings.
We recommend that IRPs should have the power to summon witnesses and take evidence. Trusts and health authorities should be required to make a formal response to the panel recommendations. IRPs should refer any major concerns to the Commission for Health Improvement and report annually to the Health Service Commissioner. They should also be able to recommend that disciplinary action may be necessary (paragraph 94).
IRPs will be able to recommend that the NHS body involved consider inviting CHI to examine issues. It would compromise HSC's impartiality to receive reports on complaints he may subsequently be asked to investigate. Believe complaints and discipline should be separate.
We recommend that the regional offices of the NHS Executive take greater responsibility for independent review, including issuing guidance on good practice. This should include, for example, circulation of the clinical assessors' report to all parties before the panel hearing, that all parties should be present at the hearing, that all parties should receive a copy of the IRP report (including Community Health Councils (CHCs) who should receive an anonymised version), and that patients and relatives should be advised of the role of the Health Service Commissioner (paragraph 95).
Will consider whether further guidance is required.
We recommend that the clinical assessors' report is made available to the IRP and the complainant prior to the panel hearing (paragraph 98).
Does not agree. However, the evaluation may well comment on the issue of clinical assessors reports in which case the Government will give careful consideration to any recommendation made.
We suggest that patients should have as speedy a resolution as possible to their complaint, but we consider that the current time limits for NHS organisations and for patients and relatives should be evaluated and, where appropriate, changed to make them more realistic. We recommend that the NHS regional offices monitor the management of complaints, and emphasise the importance of trusts and health authorities maintaining those deadlines for their overall quality performance (paragraph 101).
Time scales are being examined; will take recommendation into account.
We recommend that methods for recording data from complaints, and reporting these, should be clarified as a matter of urgency. We also recommend that GP practices should be required to provide more information to health authorities on how they handle complaints, what the complaints concern, how they are resolved and what action has been taken in response (paragraph 102).
The Government recognises that information is important if patients are to be empowered to make informed choices. The NHS Plan commits the Government to ensuring that patients can, as of right, access more information about each GP practice. This would include list size, accessibility, performance against National Service Frameworks, and the numbers of patients removed from practice lists. The Government will consider whether more information about complaints, and the underlying monitoring arrangements, is needed in the light of the evaluation of the NHS complaints procedure.
We recommend that the NHS regional offices provide adequate training for IRP chairs and members and that the trusts and health authorities provide resources for the training of all staff in complaint handling with special training for complaints and risk managers. Our comments in paragraph 102 on the economic benefits of learning from complaints are relevant here (paragraph 104).
Expect staff to be adequately trained. However, the Government will consider the issue of training again in the light of the evaluation and any subsequent changes to the complaints procedure when it will be clearer what training is required.
The Select Committee on Public Administration recently commented on this issue "we believe that GPs should only be permitted to remove patients from their lists as a last resort, and that an account be provided to the patient of the reasons for the removal". We strongly agree and we hope that having received this recommendation from two select committees the Government will act (paragraph 105).
The survey mentioned in the Government's original response is expected to report in December 2000. The Government will then consider what action is necessary.
We recognise that the reason why patients are expected to take their complaint to the primary care practice is that this provides an opportunity for the matter to be sorted out. However, we believe that there should be an alternative route for complainants through the primary care group, trust or health authority, and recommend that this should be addressed as a matter of urgency (paragraph 106).
The current arrangements, which allow health authorities to act as "honest brokers" to facilitate resolution of complaints about primary care services, are being considered as part of the evaluation of the NHS complaints procedure.
We recommend that CHCs should have a clearer remit for giving support and advice to patients and relatives with complaints. This could be achieved through issuing guidance, and would tie in with our recommendation in our report on independent healthcare that CHCs remit be extended to the independent sector to allow them to assist patients with complaints in that sector (paragraph 110).
The NHS Plan, launched in July, describes a comprehensive new package of measures to ensure that patients, users and carers have more power over their own health; that patients are full partners in their own healthcare, and that members of the public have a greater say in health care policy.This new package of measures supplants the role and functions currently carried out by CHCs, and the Plan announced that when the new system is established Ministers have decided that, subject to legislation, CHCs will be abolished.Specifically on future handling of complaints, The NHS Plan outlines a new NHS-wide Patient Advocacy and Liaison Service (PALS) which will be established in every Trust. This will act as a source of information on services and treatment available. It will also be charged with supporting patients who have problems or concerns both by providing an independent advocacy service for formal complaints, and informally liaising with relevant NHS organisations to negotiate immediate remedial action where possible.
We recommend that trusts and health authorities should:_at a minimum, provide everyone who is bereaved with the Department of Social Security booklet What to do after a death and information on local bereavement services.
_provide all nursing and medical staff with some training in dealing with distressed and bereaved people, with role play and follow up.
_consider developing an integrated model where the specialist patients affairs officer is linked with other clinical staff.
_establish agreements with local voluntary agencies on support for bereaved relatives (paragraph 111).
Guidance has been issued to trusts requiring them to have procedures in place to deal with deaths of patients in hospital and the bereaved friends or relatives of the deceased.
The Department of Health has been involved over the last year in a multi-agency approach to reviewing services across Government for those dealing with bereavement. Examples of best practice by trusts is being disseminated across the NHS via the Service Delivery and Practice Database on the NHS Learning Zone, currently available on the NHS Web, but shortly to be launched on the Internet.The Department of Health is shortly to be actively involved in UK Online, a multi-disciplinary project, also involving non-governmental organisations, to provide accessible information on how to cope with death and bereavement.
We recommend that regional offices of the NHS Executive establish patients' advocates based in every CHC. The advocates should be accountable to the regional office through the CHC. It is crucial that they are properly recruited and trained. They should develop links with, but maintain their independence from, the trust and health authority complaints managers (paragraph 114).
See response on paragraph 110. Modernisation Action Team members and other stakeholders are working with the Department of Health to set out the principles and operational guidelines for PALS. Guidance will be issued to the NHS early in 2001.
We consider that INQUEST's recommendations relating to coroners' courts are sensible and recommend that the SofS consults with his counterpart in the Home Office on their implementation (paragraph 118).
The Department of Health is in intense dialogue with the Home Office at Ministerial and senior official level on all aspects of post mortem examination. The Chief Medical Officer is reviewing this whole area in the light of growing public concern about the need for post-mortem autopsy and the Bristol and Alder Hey Inquiries.
It is rare for coroners' post-mortems to be carried out without informing bereaved families, relatives or partners. Coroners' officers make every attempt to do so and to inform relatives of their rights within the law and regulations. Coroners' officers in general have close contact with NHS trusts and bereavement staff and good training in managing the bereaved. The Department is actively developing proposals relating to the registration of death and the coronial system in response to the on-going Home Office review of death certification. The recommendations on financial support for legal representation at inquests held before a jury, relatives having the opportunity to call witnesses, extending the remit of coroners' inquests and family access to the coroners documents are all matters directly for Home Office Ministers. They would all require substantial change to current regulations and the law and will need to be considered carefully in the context of the coroner's responsibility to provide impartial decisions on the cause of death.
Department of Health Ministers and the Chief Medical Officer share the concerns about the quality and indeed the conduct of coroners' post-mortems especially as these comprise over 95% of all post mortems. The professional guidelines from the Royal College of Pathologists should apply equally to coroners' cases as well as to those requested by hospital clinicians. The Chief Medical is addressing these issues with the Home Office in the context his investigation into the retention of organs and tissues at post-mortem.
We recommend that the Lord Chancellor's Department keeps under review the impact on clinical negligence of the civil justice reforms in Lord Woolf's report (paragraph 124).
The Department of Health, in conjunction with the NHS Litigation Authority, is continuing to monitor the effect on the NHS of the new Civil Procedure Rules. Indeed, the Litigation Authority, which handles clinical negligence claims for the NHS, was already using the tighter time scales for handling claims imposed by the new rules. In addition, the Authority provided training for all NHS trust and health authority claims managers so that they were aware of the implications of the new rules.
We recommend that the Government reviews, clarifies and improves the funding, and other, arrangements relating to mediation and acts on the findings of the pilot mediation scheme (paragraph 130).
The Government has always supported and encouraged the use of mediation as an alternative to court action in resolving clinical negligence claims and the report the Committee mentions has been made available to the NHS. In addition the NHS Litigation Authority has asked all its Panel Solicitors to seek to mediate cases and to provide a monthly return to the Authority as to whether this had been successful. This initiative is on going and will provide robust evidence as to whether mediation is a viable proposition in clinical negligence cases and if not, the reason why people do not wish pursue this option. The Department of Health will continue to work closely with the Authority on this issue.
We recommend that the DoH reviews the issues and publishes a consultation document on the possible introduction of no-fault compensation within the NHS (paragraph 133).
The Government is considering the issue of compensation and redress in the context of the NHS and how best to ensure that appropriate mechanisms are in place.