Some CCGs are failing to support NHS trusts in improving patient safety, a report has concluded.
The opening the door to change report – published by the CQC today – shows that a number of trusts do not feel they have the backing of their CCG when a ‘never event’ or other serious incident occurs.
The findings come after former health secretary Jeremy Hunt last year asked the CQC and NHS Improvement (NHSI) to carry out a review into the factors that contribute to never events in NHS trusts and what can be done to learn from them and address patient safety concerns.
Variation across the country
The CQC findings show a lack of consistency in the support trusts receive from CCGs when a safety alert or a never event is brought to their attention. The report said that this variation might be due to CCGs being unclear on what role they should play in patient safety.
The report said: ‘[CCGs] know, for instance, that [their role] include assurance and monitoring, but what this means in practice is not consistent
‘Some CCGs were comprehensive and collaborative in their approach, visiting trusts to observe how they implemented guidance, talking with staff and patients, and having frequent meetings with trust leaders.
‘Some saw assurance and monitoring as simply checking what trusts are doing administratively, without getting involved.’
In 2017/18, there were 21,500 serious incidents in the NHS, of which 500 were preventable, according to data from NHSI.
Greater clarity needed
The report called for greater clarity on the roles local and national organisations play in helping trusts learn from patient safety incidents and implement the measures to prevent these issues from occurring.
CQC’s chief inspector of hospitals Professor Ted Baker said everyone, including patients, ‘can play a part in making patient safety a top priority’ in the NHS.
He added: ‘Staff know that what they do carries risk, but the culture in which they work is one that views itself as essentially safe, where errors are considered exceptional, and where rigid hierarchical structures make it hard for staff to speak up about potential safety issues or raise concerns.
‘There is a wider challenge for us all to effect the cultural change that we need, to have the humility to accept that we all can make errors – so we must plan everything we do with this in mind.’
On Monday, NHSI announced a new patient safety strategy that will address safety incidents in key areas across the NHS and better support staff. It will be delivered in April 2019.