NHS building

The Long and Winding Road of NHS Complaints System Reform

By John Tingle

Sadly, the NHS (National Health Service) has not been able to get its complaint system right, even after decades of trying.

Despite several reports published over two and half decades detailing the challenges the complaint system faces, as well as potential solutions, it still is not fit for purpose. Most recently, the Parliamentary Health Service Ombudsman (PHSO) has produced a report on complaint handling with a focus on the NHS. It is a good, hard-hitting report, which spells out clearly the problems, difficulties, and opportunities to put things right with NHS complaints.

It is, however, another good NHS complaint system reform report in a long line of others. The other reports failed to change adequately the NHS complaints culture and there is little evidence to suggest that this one will succeed where the others have failed.

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UCL A&E entrance

The NHS Complaints System: Wither the Toxic Cocktail Image?

The National Health Service in England has been trying for many years to get its complaints system right, but it has never succeeded. A great number of reports have been published on the system over the years, some dating back for at least a quarter of a century.

The Care Quality Commission (CQC ) the independent regulator of health and social care in England have just published a report launching a “Declare Your Care” campaign, which raises several important issues about the NHS complaints system. Read More

The New NHS Never Events Policy and Framework

By John Tingle

In tort law we have a very well-known Latin phrase, ‘Res Ipsa Loquitur’ (the thing speaks for itself). An inference of negligence can be raised by the events that occurred. In the National Health Service (NHS) in England there is a similar concept,‘the Never Event’. The Never Event concept is a USA import into the NHS and was introduced  from April 2009. The list of what is to be regarded as a Never Event has been revised over the years in the NHS and is currently set out by NHS Improvement.

Never events include, wrong site surgery, wrong implant/prosthesis, retained foreign object post procedure, mis-selection of a strong potassium solution, administration of medication by the wrong route and so on. Never Events are defined in NHS policy documentation as:

“…patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers.  Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event.” (p.6) Read More

‘Safe spaces’ in adverse health incident investigation and patient complaints

By John Tingle

Two new reports, one by Action against Medical Accidents,(AvMA),the charity for patient safety and justice and the other by the Patient’s Association charity, (PA), highlight once again significant  problems with NHS (National Health Service) patient safety investigative and complaints structures and procedures.

The Department of Health, (DH) in 2016 produced a consultation paper which closed on 16th December 2016 on providing a ‘safe space’ in healthcare safety investigations.

This is linked to the new NHS, Healthcare Safety Investigation Branch (HSIB),operational from April 2016, and when fully functional will  offer support and guidance to NHS organizations on investigations, and carry out certain investigations itself.Current Government policy is to consider the development of a ‘safe space’ in serious adverse health incident investigations. The Consultation paper stated:

“…many believe that the creation of a type of ‘strong wall’ around certain health service investigations, so that information given as part of an investigation would only rarely be passed on, would provide a measure of ‘psychological safety’ to those involved in investigation, allowing them to speak freely. This will enable lessons to be learned, driving improvement and ultimately saving lives.” (p.8). Read More