Learning not blaming set out the government’s responses to three reports:
- The Freedom to Speak Up review by Sir Robert Francis that looked at how the NHS could create an open and honest reporting culture
- Investigating clinical incidents in the NHS, a report by the Public Administration Select Committee
- Dr Bill Kirkup’s independent report on the Morecambe Bay Investigation.
The document contained responses to each report in turn, but also identified key themes running through all three, including the importance of:
- openness, honesty and candour
- listening to patients, families and staff
- finding and facing the truth
- learning from errors and failures in care
- people and professionalism.
In his forward to the document, the Secretary of State said:
‘I was thrilled to return as Health Secretary, and I will continue to support the NHS on the journey it began after the publication of the Francis Inquiry into Mid Staffordshire NHS Foundation Trust. A journey about facing up to hard truths when care falls short. A journey about putting patients and their loved ones at the heart of care. A journey about a culture of learning not blame; and of improving services for patients, not defending the system. The three documents published today help to show why this journey matters so much.”
The Freedom to Speak Up review
The government outlined the outcome of a consultation on a package of measures to implement the principles and actions recommended in the Freedom to Speak Up report.
It stated that an Independent National Officer (INO) would be appointed to act as a key leader in ‘national renewal and reinvigoration of an open and learning NHS culture’. The INO would be hosted by the Care Quality Commission (CQC) and appointed by December 2015.
The response also said that each trust would appoint a ‘Freedom to Speak Up Guardian’ and, once in place, the INO would publish guidance on local implementation of the guardian role. Health Education England would produce guidance and a curriculum to help NHS organisations ensure that training around raising concerns was of a sufficiently high standard.
The Public Administration Select Committee’s report on investigating clinical incidents in the NHS
The government’s response outlined the need to improve the quality of NHS organisations’ investigations into serious incidents, observing significant variation in the way NHS providers handled such incidents and investigations.
It agreed with the Public Administration Select Committee’s recommendation that a new, independent patient safety investigation body should be established for the NHS. The Independent Patient Safety Investigation Service (IPSIS) would conduct expert-led investigations into patient safety incidents that signalled systemic or apparently intractable risks within the local health care system. It was expected to be in place from 1 April 2016.
The response stated: ‘The government concur[s] that there should be a capability at national level to offer support and guidance to NHS organisations on investigations, and to carry out certain investigations itself. The government believe[s] that through a combination of exemplary practice and structured support to others, such a capability could make a decisive difference to the NHS, promoting a culture of learning and a more supportive relationship with patients, families and staff.’
The Morecambe Bay Investigation report
The government’s response stated that it had accepted all the recommendations made by Dr Bill Kirkup in his report. It said that a number of these actions were already underway, including NHS England’s review of maternity care chaired by Baroness Cumberlege. This review would consider proposals for safe and efficient models of maternity care, as well as work by Health Education England to review how to best use smaller units in training programmes for staff in order to minimise isolation.
The government outlined the need to reform the regulatory regime for midwives since statutory supervisory functions encouraged confidentiality at the expense of improving practice and systems. Having committed in March to removing the Nursing and Midwifery Council’s oversight of midwifery supervision, the government stated that it would work with the UK chief nursing officers to develop a new system. These changes were intended to ensure a separation between the regulation of midwives and the supervision of midwives.
In addition, the response stated that the Secretary of State had asked Professor Sir Bruce Keogh, NHS England’s Medical Director, to review the professional codes for all regulated staff in the NHS and ensure that the right incentives were in place to encourage reporting and learning from mistakes. It said that the Secretary of State would review regulations setting out statutory requirements for notifying regulators to ensure that trust boards were required to openly report the findings of any reviews of care quality.