Abstract
Following the public administration select committee (PASC) investigation looking at the investigation of safety incidents and its recommendation of an independent incident investigation service for the NHS, the Secretary of State quickly accepted the recommendation in principle. An ‘expert advisory group’ was set up with a view to a new service being established by April 2016. At the time of writing (October 2015), the expert advisory group was still in the middle of its deliberations. However, some important themes had already emerged which are vital to how the new service will be received and how effective it will be, which are worth exploring.
There was a great deal of consensus amongst those who gave evidence to the select committee that the standard of NHS investigations was very varied, and in some cases woefully inadequate. In our daily work at AvMA, we see poorly conducted investigations. Not infrequently, these almost completely by-pass the patients and families involved and are conducted by staff who lack the specialist skills and experience necessary to do the job. However, there were mixed views about the way that any new independent patient safety investigation service (IPSIS), to give it its temporary working title, should work.
The select committee was very taken by the approach taken with regard to incidents in the airline industry. One issue they were ambivalent about was whether to adopt the approach adopted there which leans towards confidentiality and where full disclosure to the public, passengers and their families is sometimes sacrificed in order to give witnesses the confidence they need to give evidence. The approach to openness with patients/families about evidence gleaned through IPSIS investigations is one of the major debates that the designers of IPSIS need to tackle. There are those who would sacrifice the principle of full disclosure to patients/families based on their view that without protection, health professionals simply will not give full and open evidence. Some have suggested putting conditions on what patients/families can do with the information that is gleaned about their treatment. AvMA’s strong view, shared by many others, is that such an approach would not only drive a coach and horses through Government policy such as the Duty of Candour and NHS Constitution, but that it would doom the service to failure from the outset. It would not be possible for a service to enjoy public confidence if it reserved the right to cover up. It is important to remember some fundamental differences between NHS incidents and air accident investigations. In the NHS, there is an historical commitment to the principle (if not always the practice) of ‘nothing about me without me’, as well as openness and honesty with patients/families. Information about your or your loved one’s treatment belongs to you – it’s not for the NHS to decide what can be done with it. The ‘contract’ you have with your health provider is personal and specific to your treatment in a way that agreeing to get on a plane simply isn’t. None of that is to say that IPSIS should not give the support and protection it can to witnesses, within ethical parameters. Of course, its aim should be about learning for patient safety – definitely not about apportioning individual blame or hanging people out to dry. If it is seen to follow all these principles, it will win the confidence of health professionals as well as the public.
Another key issue is the degree of independence IPSIS should enjoy. There is a very widely held view that in order to be effective and enjoy public confidence, IPSIS needs to be fully independent. However, there was clearly a view in government that IPSIS should be part of the new arms-length body, NHS Improvement. There is an argument that embedding the service in that body would provide a more joined up approach, with IPSIS directly being able to access data and intelligence from NHS Improvement’s other work on patient safety, including the national reporting and learning system. It is also arguable that this would mean that lessons from investigations would more easily find their way into NHS Improvement work. A lot will depend on how much independence the Secretary of State is prepared to give IPSIS; just how ‘arms-length’ NHS Improvement will be; and whether independence for IPSIS within NHS Improvement could realistically be achieved.
The third big issue is just how much IPSIS will be able to achieve with the resources it is allocated. It is likely that those who held big hopes for the impact of IPSIS will end up being disappointed, at least at first. It will only be able to handle a tiny proportion of serious incidents that occur in the NHS. Furthermore, its potential impact on improving the standard of local NHS incident investigations is likely to be modest. In my view, improving the standard of local investigations and bringing them up to a consistently high standard is the biggest priority. One way that IPSIS could help in that regard is by being a model of good practice and an exemplar for all those conducting NHS incident investigations. That is why it is so important that it guarantees full and unconditional disclosure to patients/families concerning information about their treatment.