Monthly column for providers and professionals working in healthcare from Professor Ted Baker, Chief Inspector of Hospitals.

This month has seen the publication of two reports, which, while looking at very different subjects on the surface, both highlight the importance of learning from good practice to help improve the quality and safety of services.

The state of care in independent ambulance services

The independent ambulance sector is a significant and growing area of health care and it is important that patients who use services in this sector receive safe, high-quality care. The state of care in independent ambulance services report is an analysis of the findings from our comprehensive inspection programme of independent ambulance services in England. It reveals that the quality and safety of independent ambulance services varies greatly.

Inspectors saw some good practice and improvements over time in areas such as infection control, however, there are ongoing concerns with poor recruitment and training, medicines management, and poorly maintained vehicles and equipment. We also found that checks to make sure staff had the appropriate employment references, Disclosure and Barring Service (DBS) certificates, and driving licence categories were not being enforced consistently.

There is a complex range of commissioners for the sector, which include NHS trusts as well as others such as NHS England, clinical commissioning groups and local authorities. As well as improvement from providers, we are calling on those commissioners to ensure they make safety and quality a priority, and that they use the quality ratings that CQC can now award to independent ambulance services to help them make robust commissioning decisions.

We will be strengthening our assessment of how NHS trusts that have a subcontracting arrangement in place ensure they have continued oversight of performance and quality.

The report also raises concerns about those independent ambulance services that are not subject to CQC regulation, such as where medical cover is provided at temporary events. We believe that the current lack of oversight is putting people at risk, and we are working closely with local authority licensing boards and other relevant bodies to ensure they understand their responsibility for the safety of patients in such circumstances. We have highlighted these concerns to the Department of Health and Social Care, recommending that the regulations are reviewed to address this regulatory gap.

I would encourage those providing or commissioning independent ambulance services, including NHS trusts that sub-contract such services, to read the report and consider the findings.

Learning from deaths

In December 2016, our report Learning, candour and accountability detailed our concerns about the way NHS trusts investigate and learn from the deaths of people in their care, and the extent to which families and carers are involved in the investigation process.

Following this, the National Quality Board published guidance for NHS trusts on learning from deaths in 2017, which was followed by further guidance on working with families in 2018.

Earlier this month, we published a review of our inspectors’ observations from the first year of implementation of this guidance. We found that good progress is being made by some NHS trusts, however, failure to fully embrace an open, learning culture may be holding organisations back from making the required changes at the pace needed.

Overall, we found that the following factors can help support trusts to implement the guidance well:

  • Values and behaviours that encourage engagement with families and carers
  • Clear and consistent leadership
  • A positive, open and learning culture
  • Staff with the resources, training and support to carry out reviews and investigations
  • Positive working relationships with other organisations

These factors are not new, and reinforce the findings of our original report. Where we found examples of good practice, trusts had been able to build on existing strengths to integrate the national guidance. This echoes the findings of our thematic review of Never Events, Opening the door to change, which found that the culture of an organisation could affect how well an organisation was able to implement safety guidance.

We are concerned that we’re seeing the same issues persist in some NHS trusts more than two years on, with involvement and engagement with bereaved families and carers an area with which some trusts continue to struggle. Issues such as fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers, suggest that problems with the culture of some organisations may be a barrier to putting the guidance into practice. Cultural change is not easy and will take time, however the current pace of change is not fast enough.

We also acknowledge that to make the required changes, there needs to be continued support from the centre, including support for behaviours that encourage more openness and learning across the NHS. CQC also has a role in supporting this change, and we will continue to strengthen how we look at and assess the issues identified in our report as part of our focused well-led inspections.

We have included examples of good practice to inspire NHS trusts staff to continue to improve how they review and learn from deaths. I would urge you to use these examples to help identify the key drivers to improve learning from deaths, to build on the progress you have made so far, and to accelerate the changes needed.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

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