Corporate report

Clinical Governance Annual Report 2024 to 2025

Updated 29 July 2025

© Crown copyright 2025

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This publication is available at https://www.gov.uk/government/publications/clinical-governance-annual-report-2024-to-2025/clinical-governance-annual-report-2024-to-2025

Published July 2025

List of abbreviations

Abbreviation Definition
CAT Clinical Authorship Team
CGEB Clinical Governance and Excellence Board
CMPD Contract Management and Partnership Delivery
CPBPG Clinical Policy and Best Practice Group
CPD Continuous Professional Development
CTGM Core Training and Guidance Material
DWP Department for Work and Pensions
EB Editorial Board
FAS Functional Assessment Service
GMC General Medical Council
GPhC General Pharmaceutical Council
HCPC Health and Care Professions Council
HAAS Health Assessment Advisory Service
HTA Health Transformation Area
HTP Health Transformation Programme
IPR Internal Process Review
NICE National Institute for Health and Care Excellence
NHS National Health Service
NMC Nursing and Midwifery Council
PfDR Prevention of Future Death Reports
RO Responsible Officer
OSEF DWP Operational Stakeholder Engagement Forum
TAG Training and Guidance

List of figures

Figure 1: Proportion of clinicians registered with each professional body in March 2025

Figure 2: Breakdown of clinical incidents by type, September 2024 to March 2025

Figure 3: Summary of key actions implemented to improve services

Figures 4: Path to achieving a gold standard in clinical governance

Chief Medical Advisor foreword 

Dr Gail Allsopp 

I am delighted to present the first Department for Work and Pensions clinical governance report to share the progress the department has made to improve the clinical standards for clinicians and people who use our clinical services. 

However, we have only just begun our journey. Continuous improvement is essential and a core principle of clinical governance. By learning from the data and implementing change, we will strengthen policies, guidance, education and training and we will continuously strive to improve not only the clinical services people receive, but also the experience of our clinicians. 

We have made huge progress over the past year, aligning clinical governance within the department to NHS best practice, strengthening our training for clinicians and improving the oversight of all policies and procedures relating to clinical governance. We will not stop here though. Improvement work continues and includes a departmental review of safeguarding processes to compliment the work we have already undertaken in the clinical teams.  

Publishing this report demonstrates our aim for transparency in the clinical processes that we undertake, which is essential to building trust in our clinicians and in the department. We will aim with subsequent reports to include more data as our processes improve.

Introduction 

Welcome to the Department for Work and Pensions (DWP) Clinical Governance Annual Report for 2024/2025. This is the inaugural performance report, which will subsequently become a routine annual publication.  

Definition 

Clinical governance is the system by which DWP can continuously monitor and improve the clinical quality of its services and safeguard high standards of clinical care. It provides a structured approach to ensure all clinical activities are conducted ethically, legally and professionally. It supports the department’s commitment to delivering high-quality clinical services and become a clinical learning organisation. It emphasises the importance of maintaining high standards of clinical care, protecting claimants, ensuring accountability and promoting trust between the public, the clinical profession and the department. 

Background 

Following an external review of the department’s clinical governance in 2023, the report, Department for Work and Pensions: Development of a new approach to clinical governance (December 2023) made numerous recommendations and was a key driver for making improvements to the department’s clinical governance approach. Following the report, we accepted all recommendations and commenced implementation of a new approach to clinical governance in 2024, based upon NHS best practice, which is now almost complete. (See Tracking progress).  

We will continue to improve our services and go further to ensure we can provide the best clinical service we are able to, aiming to ensure that our clinicians work as the advocate for people with health conditions and disabilities within the department. This first report demonstrates the progress we have made and covers all clinical teams working in or for DWP including:

  • DWP employed clinicians who work across the department in policy, innovation, research, transformation, audit and contract management 

  • Occupational Psychologists and Work Psychologists who undertake front line activity in job centres 

  • Clinicians[footnote 1] within the 4 health assessment providers[footnote 2] who provide the Health Assessment Advisory Service (HAAS) via the Functional Assessment Service (FAS) contracts. It is important to note that these providers all have their own clinical governance processes and policies in place. This work will ensure that DWP has full oversight of those processes aiming to align them with consistency of reporting. 

  • Clinicians employed by or contracted to the DWP Health Transformation Area (HTA) who undertake health assessments. 

Source of data for this report   

In response to the Department for Work and Pensions: Development of a new approach to clinical governance (December 2023) the recommendation that digital collection of standardised data from health assessment providers and DWP clinical teams has been implemented. The department has introduced 2 tools to standardise the collection of data, the clinical governance dashboard and the clinical significant event analysis tool. 

The data in this report, unless stated otherwise, are provided by the health assessment providers, including their partner organisations and DWP clinical teams via these 2 tools. It covers the period from the commencement of the new FAS contracts (9 September 2024) to the end of the reporting year (March 2025)[footnote 3]. Clinical governance data is provided monthly, and clinical significant event analysis data is provided quarterly.  

We took a phased approach to implementing these tools and collecting the data, to allow the department to test and learn and improve the quality of data. The initial phase started with DWP clinical teams in September 2024 and health assessment providers between January and February 2025. It is therefore a snapshot of where we are now, rather than a complete set of data. During the next reporting year (April 2025 to 2026), we will have full data which will enable us to ensure the health assessment providers, and our internal clinical teams, standardise their approach and we are able to learn from each other, striving to continually improve standards. 

The collected data passes through a quality assurance process. An initial review is carried out by the health assessment providers or internal team leaders, and a second quality assurance review by the department’s clinical governance team. In addition, a formal quality assurance check is undertaken at least annually.

Clinical governance 

Clinical governance is a system by which the Department for Work and Pensions can continuously monitor and improve the clinical quality of our services and safeguard high standards of clinical care.

  • Clinicians engage in assessing over 2 million citizens
  • Encompasses over 5000 registered clinicians
  • Provides strategic leaderships and performance management to ensure services are delivered effectively and efficiently
  • Works in partnership with our health assessment providers to ensure service users are assessed safely and professionally

Our approach to clinical governance is guided by the DWP Values. They are embedded in our day to day working practices with all our customers, colleagues and our partners, and they help us learn for the future.

  • We care
  • We deliver
  • We adapt
  • We work together
  • We value everybody

Clinical governance in DWP 

The Permanent Secretary has overall responsibility for clinical governance within the department and delegates this responsibility through the department’s Chief Medical Advisor. Governance is provided through the department’s standard governance processes complimented by the Clinical Governance and Excellence Board. 

DWP clinical governance structure

In the centre of the structure is the Clinical Governance and Excellence Board. This board reports to, and escalates concerns to, both the Department’s Executive Team and the Permanent Secretary, as well as to the Health and Disability and Health and Disability Outcome Boards. In the accompanying diagram, these latter boards are positioned above the Clinical Governance and Excellence Board.

Reporting into the Clinical Governance and Excellence Board are 5 key groups:

  • Clinical Policy and Best Practice Group
  • Responsible Officer Advisory Group
  • Caldicott Clinical Leadership
  • Safeguarding Clinical Leadership
  • Training and Guidance Editorial Board

Each of these groups includes representation from both contracted health assessment providers and internal clinical teams.

Clinical governance arrangements and key activities 

Clinical Governance and Excellence Board 

The Clinical Governance and Excellence Board (CGEB) is chaired by a DWP Non-executive Director.  This decision-making board includes a wide membership from across the department at director level to ensure that silo working is minimised. It connects the clinical leadership with policy, operations and customer experience teams. Key clinical members of the board include safeguarding leadership, Caldicott leadership, the Chief Medical Advisor and Chief Psychologist.  

CGEB guides the clinical governance strategy, monitors performance, advises on significant risks and provides assurance. It ensures appropriate risk escalation to Ministers and the Executive Team. The board includes an external member to provide independent scrutiny and to ensure our processes align with best practice. To ensure the voice of our service users is heard, CGEB is closely affiliated with the Departmental Operational Stakeholder Engagement Forum (OSEF). The Chief Medical Advisor attends OSEF biannually to update members and to ask for guidance on key decisions. 

CGEB has met 4 times since its launch in September 2024. The board has primarily focused on monitoring implementation of the new clinical governance framework to bring our standards and processes in line with NHS best practice. 

Clinical Policy and Best Practice Group 

The Clinical Policy and Best Practice Group (CPBPG) is a board that brings together the health assessment providers, internal departmental teams and colleagues from the Health Transformation Programme (HTP) to: 

  • ensure those who undertake health assessments adhere to the department’s clinical governance standards, aligning standards across health assessment providers and the department’s own provision of assessment services 

  • identify areas for clinical continuous improvement​ 

  • innovate and drive positive clinical change 

  • ensure the users of our clinical services are at the heart of the assessment process 

  • maximise the potential and effectiveness of the department’s clinical assessment test and learn capacity

CPBPG is convened and chaired by a senior clinician. Initially, at the implementation of the FAS contracts in September 2024 the board was held monthly, but this has now moved to a 6-weekly cadence. It provides a collaborative space to ensure stakeholders undertaking health assessments (whatever setting they are in) have a clear understanding of relevant changes to policy, processes and procedures. It enables a collaborative approach to innovation and improvements to clinical services and supports subsequent implementation of policy changes.  

There is a structured approach to scrutiny of clinical governance with each meeting focussing on a different pillar of clinical governance. This allows a well-rounded view of how clinical governance is implemented in practice across all health assessment providers and departmental clinical teams. Adherence to clinical governance is scrutinised, promoting two-way discussion. Best practice is shared with a strong focus on continuous improvement, aiming for all health assessment providers to work to a gold standard with service users at the heart of clinical decision making. CPBPG aims to support a culture of trust and transparency and provides onward assurances to the Clinical Governance and Excellence Board. 

Stakeholders include clinical directors and clinical leaders from the 4 health assessment providers alongside the department’s clinical leaders from all internal teams. Key clinical members of the board include Safeguarding leadership, Caldicott leadership, the Chief Medical Advisor and Chief Psychologist, alongside clinical policy advisors, and the departmental internal clinical audit team. This clinical collaboration is complimented with attendance by senior contract account managers and senior commercial, policy and operational managers to ensure that any decisions taken are multidisciplinary. 

Training and Guidance Editorial Board 

The purpose of the Training and Guidance (TAG) Editorial Board (EB) is to have oversight and responsibility for DWP-owned clinical Core Training and Guidance Materials (CTGM). The repository currently comprises approximately 700 CTGM documents, which make up the basis of training for clinicians employed by health assessment providers. There are an additional 200 documents managed by TAG EB, which are used by DWP decision makers to help determine eligibility to Attendance Allowance (AA) and Disability Living Allowance for children (DLAc). 

TAG EB convenes monthly to sign off products that have been produced by the Clinical Authorship Team (CAT) and have undergone clinical and policy quality assurance, subsequently distributing them to the end user. TAG EB functions as an escalation point for risks and concerns as well as approving the content of the clinical annual training programme and monitoring the progress of the CAT. 

TAG EB is chaired by the clinical training and guidance lead within Clinical Policy Group (CPG). The board is comprised of clinical education leads from the 4 health assessment providers alongside departmental representatives from clinical policy, Contract Management and Partner Delivery (CMPD), independent audit and policy teams. TAG EB aims to support a culture of trust and transparency and provides onward assurances to CGEB.

Responsible Officer  

The department is a designated body, which is an organisation that employs doctors and is responsible for supporting those licensed doctors with annual appraisals and revalidation. The Responsible Officer (RO) plays a critical role (defined in legislation The Medical Profession (Responsible Officers) Regulations 2010) in maintaining and improving the quality of care provided by licensed doctors to ensure all doctors work in a well-managed environment in which their performance, conduct and behaviour are monitored against agreed national standards.  

In 2024, our Chief Medical Advisor was formally appointed to the role as RO, bringing this crucial role in-house, as recommended in the independent clinical governance review (Department for Work and Pensions: Development of a new approach to clinical governance 2023).  

A RO advisory group meets quarterly. Membership includes a multidisciplinary team with external expertise who hold the department to account to ensure our processes align with best practice. The RO advisory group aims to support a culture of trust and transparency and provides onward assurances to CGEB. In addition, quarterly meetings are held with the ROs from the 4 health assessment providers to support openness, transparency, learning, continuous improvement and two-way feedback. 

To ensure all our clinicians are held to account to national standards relevant to their speciality, the RO advisory group was expanded in 2024 to support pharmacists and nurses. The aim is to expand this to include all clinicians in 2025, which will incorporate occupational psychologists, occupational therapists and physiotherapists. Further work is required to ensure that any clinician who is under investigation by the department is discussed with the profession lead to provide support and advice relating to regulatory body referrals. 

A full review of our first annual appraisal cycle (April 2024 to 2025) can be found in Annex A: Appraisals for doctors.

DWP Caldicott Guardian 

In April 2024, a senior clinician was appointed as the department’s first ever Caldicott Guardian, following recommendation and support from the National Data Guardian. The role of the Caldicott Guardian is to promote organisational and public trust by ensuring confidential clinical data is used ethically, legally and appropriately to improve outcomes, whilst putting the people who use our services first, protecting them and their confidential clinical data.  

The Caldicott Guardian is a member of CGEB, CPBPG and the DWP Data Board. During 2024, they have championed the 8 Caldicott Principles working closely with colleagues from data protection and legal teams.  

A quarterly meeting is held to bring together Caldicott Guardians from the health assessment providers and from across the departmental clinical teams. These meetings enable discussion about issues that may have arisen that required Caldicott input and encourage a two-way feedback process focused on continuous improvement. A log is kept of all issues, risks and concerns that require input from Caldicott leadership, aiming to support a culture of trust and transparency. The Caldicott Guardian provides onward assurances to CGEB and the Data Board. 

Caldicott Guardian awareness training forms part of the mandatory continuous professional development programme that all departmental and health assessment provider clinicians are expected to undertake. Members of CGEB have also committed to completing the training and work is ongoing to expand awareness to other teams across the department.  

DWP Clinical Safeguarding Lead 

In early 2024, a senior clinician was appointed as the department’s first Clinical Safeguarding Lead to create, implement and oversee a new clinical safeguarding policy, published in June 2024. They are trained to level 4 in safeguarding (executive leadership) and ensure the safeguarding training undertaken by our clinicians in the department and in the health assessment providers aligns to NHS best practice.  

The Clinical Safeguarding Lead is a member of CGEB, TAG EB and CPBPG. A quarterly cross-departmental meeting is held with safeguarding leads for each of the department’s clinical teams and health assessment providers, in order to ensure a two-way feedback process for continual improvement.

The Clinical Safeguarding Lead has also established links with the NHSE safeguarding lead and attends the cross-government safeguarding forum to ensure our standards align with best practice.  The Clinical Safeguarding Lead provides onward assurances to the Chief Medical Advisor and CGEB. 

Level 3 safeguarding training for adults and children forms part of the mandatory continuous professional development programme that all departmental and health assessment provider clinicians are expected to undertake, which is in line with best practice in the NHS. Departmental clinicians attended a mandatory ‘all ages safeguarding update’ delivered by the NHSE safeguarding lead in October 2024.  

In March 2025, the government announced a review of safeguarding within the department in its Green Paper – Pathways to Work. The consultation will last for 12 weeks. Insights from this consultation will inform the next steps for Safeguarding across DWP.

Clinical governance framework  

As part of the 2023 review, it was recommended that DWP simplify its approach to clinical governance and align it with NHS best practice.  Throughout 2024 we aligned our approach to the NHS using the 7 pillars of clinical governance, which are education and training, clinical audit and quality improvement, clinical effectiveness, clinical staffing and management, service user involvement, clinical information governance and clinical risk management.  

DWP published its Clinical Governance Standard in July 2024, which sets out the key policy alongside new organisational arrangements and governance. Assurance is provided to CGEB and onward to the executive team and ministers. 

Pillar 1: Education and training  

The first pillar aims to ensure that clinicians have appropriate education and training in place to allow them to maintain the competencies required for their role and to meet professional registration requirements. 

Core training and guidance material  

In September 2024, DWP took ownership of over 900 documents, which compromise clinical training and guidance documents for clinicians (who undertake Work Capability Assessments and health assessments for Personal Independence Payment and Specialist Benefits) and clinical support documentation for decision makers (in relation to Attendance Allowance and Disability Living Allowance for children). The documents for clinicians who undertake assessments are called the core training and guidance material (CTGM).  

All CTGM has been reviewed which has led to identification of bias and other inherent risks within the documentation. To fully mitigate all the risks a new departmental clinical education team has been designed and will be fully implemented by the end of 2025. This education team will ensure that there is a rigorous quality assurance process in place which occurs on an annual basis to ensure the material is unbiased and in line with best medical evidence.

From 2025, the material is now: 

  • written by expert clinical authors using live links to national guidance / best practice summaries (e.g. NICE / NICE Clinical Knowledge Summaries) where these exist. The department has a formal agreement in place to enable the use of these resources ensuring the guidance we use is always in line with the most current advice used in the NHS. Where no guidance is available, the authors will write condition specific advice based on best practice

  • quality assured externally, using an evidence-based approach by an independent team of clinical education experts 

  • quality assured internally by the departmental clinical education team who work closely with policy colleagues

Mandatory continuous professional development programme for clinicians 

In 2024, a new mandatory continuous professional development (CPD) programme was developed for all clinicians who are either directly employed, loaned to or contracted by the department, as well as for all clinicians who are employed by the health assessment providers. The mandatory CPD programme is based on best practice to ensure clinicians gain a wide range of appropriate knowledge relevant to their role, maintain core safety knowledge and satisfy requirements for their regulatory body. It will be reviewed and updated annually and includes:  

  • Adult Level 3 Safeguarding 

  • Child Level 3 Safeguarding 

  • Consent 

  • Mental Capacity Act  

  • Data Security Awareness 

  • The Role of the Caldicott Guardian 

  • Basic Life Support Level 1 

  • Equality and Diversity

  • The Oliver McGowan Mandatory Training on Learning Disability and Autism Part 1

The mandatory CPD programme is supplemented by additional continuous professional learning which is tailored to the needs of clinicians. From 2025, we aim to use more robust data to guide this programme including themes and trends identified from complaints, appeals, significant events, our internal process reviews and coroner reports.  

The clinical profession within the department 

In 2024, the clinical profession within the department was launched and aligned with best practice in other government departments aiming to support clinicians to feel part of a valued community, strengthening multidisciplinary working, promoting best practice and to ensure recruitment and retention is standardised. In the first year, the focus has been on bringing clinicians together from across the department and building the appraisal, revalidation and education offer for the profession. The intention is that the clinical profession offer will continue to strengthen as the team developed further. So far, the offer includes:  

  • The departmental ‘All Clinician Call’. This monthly hour-long session ensures external clinical experts from health, academia, stakeholder groups and charities are visible to the clinical profession and can provide regular educational sessions relating to the functional impacts of health conditions.

  • The ‘Annual Clinical Conference’. This all-day event brings departmental clinicians together in-person to learn from sessions led by national clinical experts. The focus is on multidisciplinary learning, sharing best practice, and networking. 

  • CPD learning resources for clinicians to use independently and within their teams to ensure they meet regulatory body requirements and stay up to date with changing clinical practice. This includes access to over 900 articles covering a huge range of medical topics and an online course that summaries the more relevant updates in clinical practice from the preceding year. 

  • A quarterly newsletter produced by clinicians for clinicians, focusing on increasing knowledge and awareness of work being undertaken in other departmental business areas, clinical topics relevant to functional impairment and resources to support with health and wellbeing.  

  • The ‘Clinician Hub’: An online space for the Clinical Profession to access information about clinical governance, a wide array of educational materials and any relevant news updates.

Pillar 2: Clinical audit and quality improvement  

The second pillar aims to ensure that an interaction between a clinician and the people who use our services is evidence-based, consistent and delivered right first time. The department has set standards for the quality of assessments for all health assessment providers and its own independent auditors. The department closely monitors all aspects of the process, including performance. 

Audit refers to a comprehensive check of the elements of the assessment, including how evidence is collected, what further medical evidence has been considered and how the assessment report has been completed by the assessing clinician. The check is completed against a set of guidelines to ensure a consistent approach is taken. This ensures that assessment reports are fit for purpose, clinically justified and sound, and provide sufficient information for the department to make an informed decision on entitlement to benefit.  

All health assessment providers work with the department on plans to continuously improve assessment quality through a range of measures including audit procedures, clinical observations (by the department in PIP), tailored training and development plans and through providing feedback and support to healthcare professionals. Assessment quality is a priority for both the health assessment providers and the department.  

The department works closely with health assessment providers to make improvements to guidance, training, and audit procedures through a continuous improvement approach to ensure a quality service is delivered. Quality performance is regularly reviewed at senior governance meetings held by both the department and the health assessment providers. 

Audit grading and the audit escalation process 

To ensure the quality and accuracy of assessment reports for health assessments, the department conducts a rigorous monthly audit of cases. The independent audit team meticulously reviews a randomly selected sample of assessment reports against established criteria, assigning grades to measure health assessment provider performance against defined standards. This process serves to verify compliance and provide valuable feedback to the health assessment provider, ensuring continuous learning and improvement.  

Assessment reports that undergo audit are graded based upon their quality by the departmental independent audit team. Should the health assessment provider contest an audit grade, a formal challenge process can be initiated. The independent audit team will review the case again and provide a written response aiming to provide more detailed learning. Grades may be adjusted, if appropriate, following a review.  

If, following review, the health assessment provider and the independent audit team disagree on the grading, the case can be escalated to the expert departmental clinical policy team for a senior, independent review. A comprehensive and detailed review of the case is undertaken, working with a multidisciplinary team, which includes policy experts if necessary. This process not only resolves disputes but also allows the clinical policy team to consider whether changes to guidance and training may be required to more clearly articulate what is required within the health assessment process, through a continuous learning process. 

On average, 19 escalations have been undertaken per month since September 2024. Of these, approximately 76% relate to PIP and 24% to WCA.  Around 71% of escalated cases result in the original audit grade being upheld.

Pillar 3: Clinical effectiveness  

The third pillar aims to ensure that processes and policies are designed to achieve optimum outcomes for people who use our services, whilst supporting clinicians to do the right thing, at the right time, with the right person, first time. It is a key component for improving safety. 

The department has reviewed and updated its clinical policies and procedures to ensure clinical governance processes are more robust. This includes introducing the Clinical Governance Standard, Clinical Safeguarding policy, Caldicott Guardian policy, Clinical Profession policy and Responsible Officer guidance. 

Pillar 4: Staffing and management  

The fourth pillar aims to ensure the department, and the health assessment providers, employ regulated clinicians in good standing with their regulator who are highly skilled, recruited in line with safer recruitment best practice and are working in a well-supported environment. 

There are over 5,400 clinicians working across the health assessment providers and 200 clinicians working for the department. As a requirement of employment, all clinicians must be registered with a regulatory body and in good standing with their regulator. Nurses are registered with the Nursing and Midwifery Council, doctors with the General Medical Council, pharmacists with the General Pharmaceutical Council, and physiotherapists, occupational therapists and psychologists with the Health and Care Professions Council. Registration status and any issues with regulator body status is monitored monthly.

Figure 1 Proportion of clinicians registered with each professional body in March 2025

Clinicians registered with professional body % registered in March 2025
NMC (Nurses) 76.9%
GMC (Doctors) 5.3%
HCPC (Healthcare Professionals) 17.3%
GphC (Pharmacists) 0.5%

Appraisal, revalidation and regulation 

Doctors are required by law to undertake an annual appraisal to maintain their licence to practice with the General Medical Council. There are 13 doctors who are directly employed by the department, 10 of whom have their appraisal completed annually at DWP via the appraisal process that can be seen in Annex A. Three doctors employed by the department have their appraisals completed externally due to other professional roles. Doctors who are employed by the health assessment providers undertake appraisals within their own organisation. Other clinicians have varying requirements to maintain their regulatory body status. This is all monitored via the clinical governance dashboard. 

Investigations 

When things go wrong, clinicians can be referred to their regulator for investigation. A referral can be related to a wide range of issues such as a complaint, a probity concern or a criminal investigation. The department has a process in place to monitor these issues and to ensure the users of our services are protected whilst investigations are ongoing. 

Safer recruitment 

The department is committed to safer recruitment in line with best practice. All clinicians undergo a security check before they can work with people who use our services.  

Indemnity 

Clinicians must have indemnity in place to undertake clinical work. Their indemnity cover is now monitored within the clinical governance dashboard to ensure this cover is in place and at the appropriate level for the service they provide. Clinicians directly employed by the department now have indemnity provided in line with NHS colleagues.

Pillar 5: External service user engagement 

The fifth pillar aims to ensure service users have a voice within the DWP Clinical Governance processes and policies. This ensures our clinical services involve those who use our services, which aims to improve transparency and build trust. With 2 million health assessments undertaken each year this is an important part of the clinical governance framework. 

Our formal service user involvement is through the DWP Operational Stakeholder Engagement Forum (OSEF). OSEF consists of over 50 national stakeholder organisations predominantly from charitable and welfare rights organisations who support the diverse range of people who use the department’s services on a non-contractual, non-payment basis. Through OSEF, members are updated on DWP initiatives and business change, and they can raise systemic issues across all benefit lines. Importantly, members can be involved in insight gathering and feedback sessions. The Chief Medical Advisor engages with this group by attending OSEF meetings on a 6-monthly basis, or more frequently if appropriate.  

Prior to September 2024, some charities and stakeholder organisations were closely involved in the writing and review of clinical guidance. This process has now been formalised with an independent quality assurance process in place. Therefore, a quarterly Training and Guidance Stakeholder Information Session is held for those who are interested in the clinical training and guidance processes, many of whom are OSEF members. 

It is important that people who use our services, and their representatives, have a voice within the process of educating clinicians who work for the department. Any stakeholder who wishes to have closer involvement can request to update the department’s clinicians at the monthly All Clinician Call. To ensure the quality of the information is in line with national standards and is unbiased, the material to be presented must be reviewed by a senior clinical policy advisor. It is also requested that the material is presented to the department’s clinicians by a clinical representative from the stakeholder organisation.  

Finally, there is a Disability Services Advocacy Team who support a quarterly National Advocacy Board, which is hosted by the 4 health assessment providers on a rotating basis. This board aims to capture the national voice of the customer, provide a forum for feedback, offer a mechanism to share accurate and timely updates and information on service delivery and drive service improvements. Minutes of this meeting will be shared with the Clinical Policy and Best Practice Group to ensure the feedback loop is completed and any recommendations can be considered within this multidisciplinary meeting.

Pillar 6: Clinical risk management including significant event tool  

The sixth pillar aims for teams to ensure that clinicians and their teams have the skills and capability to identify, assess, manage and monitor clinical risks with clear routes to report or escalate risks and incidents. The department provides high quality services that are person-centred. Clinical risk management means that with near misses, or when things do not go to plan, there is a robust process in place to identify issues and learn from them, which is a core part of the department becoming a clinical learning organisation. 

Each clinical team within the department and each of the health assessment providers reports their clinical incidents, which are then reviewed by the department’s clinical governance team. During 2024 to 2025 we are encouraging teams to report every incident, no matter how small. We want to encourage transparency and ensure that teams understand that highlighting near misses and issues is a good thing to do. Only by reviewing, investigating and reporting incidents can we learn and grow as a service.

Clinical significant event analysis summary 

As part of the department’s commitment to maintaining high clinical governance standards, incidents were reported between 9 September 2024 and 5 March 2025. These incidents were categorised as follows: clinician safeguarding incidents, clinician complaints, information governance incidents and other incidents which includes clinical operational issues such as equipment malfunctions and clinical system or process errors. The analysis has provided valuable insights, allowed us to identify early trends, and for the first time allows us to look across clinical teams from the department and the 4 health assessment providers to understand the risks that are present. As the data grows, the information will allow the department to drive change in education, training, policies and processes to continuously improve our clinical services.

Figure 2 Breakdown of clinical incidents by type, September 2024 to March 2025

Clinician complaints 31%
Information governance 39%
Safeguarding 20%
Others 10%

  • Information governance incidents represented the highest proportion at 39% of reported cases. These incidents involved data security breaches, documentation errors, and non-compliance with confidentiality protocols. The primary response to mitigate risks in this category was staff training on data protection and periodic compliance audits to ensure regulatory adherence. 

  • Clinician complaints accounted for the second highest proportion of reported incidents, making up approximately 31% of all cases. This category only includes those complaints that were upheld after investigation and primarily included concerns relating to professional conduct, clinical decision-making, and claimant interactions. The key governance action taken to address these incidents involved reflective learning for clinicians and compliance reviews to support continuous professional development. 

  • Safeguarding incidents made up 20% of the total incidents. These cases involved concerns about claimant safety, safeguarding procedures, and risk management. The predominant action taken in response was enhanced staff training on safeguarding policies and the implementation of stricter monitoring measures to reinforce best practices. 

  • Other incidents, including equipment malfunctions and system-related issues, accounted for approximately 10% of total reported cases. Governance actions in response to these incidents included technical reviews, system upgrades, and procedural refinements to minimise operational disruptions. 

Figure 3 Summary of key actions implemented to improve services

Key governance actions and learning

Figure 3 comprises of:

  • regulatory compliance checks
  • safeguarding related incidents
    • prioritisation of staff training in safeguarding contexts
  • staff training
  • clinician complaints
    • reflective learning crucial for addressing clinician complaints
  • reflective learning
  • information governance incidents
    • emphasis on compliance audits for information governance
  • compliance audits

The analysis highlights that staff training and compliance audits were the most frequently reported actions taken to address incidents across all categories. This allows employers to monitor more closely the clinician’s activity providing support and mentorship to improve clinical services. Reflective learning and professional development initiatives were emphasised in cases related to clinician complaints in line with NHS best practice, while regulatory compliance checks and refresher courses were prioritised for information governance and safeguarding-related incidents. There was a strong increased focus on systematic incident reporting and risk mitigation strategies to prevent recurrence.  

Next steps

Figure 4 Path to achieving a gold standard in clinical governance

Figure 4 consists of:

  • Supplier collaboration: essential partnership for safety

  • Commitment to reporting: ongoing event reporting

  • Face to face assurance visits: key action for improvement

The department recognises the importance of collaborating with the health assessment providers to maintain and improve clinical governance standards, with the end goal of improving clinical services. Face-to-face assurance visits involving two-way feedback will be completed during April to June 2025 to further improve reporting, collaboration and strengthen the clinical governance continuous improvement processes.  

Prevention of Future Death Reports 

Coroners have a duty to make reports to a person, organisation, local government or government department where the coroner believes that action should be taken to prevent future deaths. These reports are important within the clinical governance framework. 

The department’s customer experience team leads on any internal investigation when a Prevention of Future Death report is received. To ensure there is senior oversight of all responses, the Chief Medical Advisor cosigns all reports that are returned to the Chief Coroner.  

The numbers of reports received by the department are very small, with only 5 since the appointment of the Chief Medical Advisor in 2023. With small numbers it is difficult to identify trends, however reports are presented at the CGEB and learning is therefore shared across the department at director level. Coroner recommendations are tracked by the customer experience team to ensure actions and improvements are made where learning is identified. 

Internal process reviews  

Not all serious incidents or deaths are reviewed by a coroner. Internal process reviews (IPRs) are an opportunity for the department to understand customers’ experiences and to ensure that the department and its people have followed the correct processes. The IPR process looks to understand why to inform future learning activity and to improve services.  

The clinical team are involved in any IPR that involved a clinical team or clinical incident. From April 2025, as phase 2 of the clinical governance improvement process begins, learning from the quarterly IPR review recommendations will be formally embedded into the core training and guidance updates to continuously improve clinical governance processes and the department’s clinical services.  

Risk register 

The department’s Risk Management Strategy and Framework sets out the process for identifying, managing, and mitigating key risks. Clinical risks are held by the Chief Medical Advisor and reported to the CGEB on a quarterly basis. Risks are also highlighted at the Health and Disability Outcome Board quarterly and from April 2025 will be reviewed biannually by the Executive team.

Pillar 7. Clinical data and information governance 

The seventh pillar aims to ensure that confidential information about people who use our services is used ethically, legally and appropriately and that confidentiality is maintained. DWP takes its responsibility seriously and ensures that the right levels of security and protection are applied to information that it processes. Effective information management safeguards both our customers and our key corporate information, maintaining the department’s reputation and protecting the public purse. 

It is the responsibility of every clinician to ensure that confidential personal and clinical information is accurate, stored safely and securely, and yet accessible to those who need it. The Caldicott principles, the common law Duty of Confidentiality, and consent rules must be followed in addition to standard Information Governance and Data Protection requirements. All DWP employees are expected to complete Security training on an annual basis and a Data Security Awareness module is part of the mandatory CPD programme that clinicians must complete. 

The Caldicott Guardian champions the Caldicott principles across DWP and plays a key strategic role in ensuring that DWP satisfies the highest practical standards for handling confidential information.  

Clinical governance tracking progress 

Recommendations from the Department for Work and Pensions: Development of a new approach to Clinical Governance 2023 were all accepted by the department and we have continued to track progress. Most recommendations have been achieved and are detailed in this report. We continue to strive to complete the remaining recommendations in full with the aim to finish this by December 2025 and to add additional milestones to further improve the service and go beyond the recommendations in the report.

Recommendation Implementation Next steps
Develop and implement a new Clinical Governance framework, aligned to NHS best practice (7 pillars), consistent with regulatory body guidance coproduced with HAS Providers Complete Continue to monitor and improve data gathered, improve feedback loops.
Improve governance structure, leadership with clear accountabilities. Complete Maintain current structure.
Continuous improvement ensuring a shared risk meeting with providers, collaborative two-way feedback opportunities, and improved communication. Complete Maintain, aiming to continue to improve current status.
Set up a cross-departmental clinical profession ensuring cross-government alignment. Complete Maintain departmental engagement and continue to develop cross government clinical profession.
Appoint a Caldicott guardian, clinical safeguarding lead, and in-house the Responsible Officer. Complete Maintain competencies and promote best practice. Strengthen processes within the department to ensure clinicians under investigation are discussed with profession leads to provide support and advice on regulatory referrals.
Enhance clinical education and training offer. In progress Appoint full education team, secure on-going commercial engagement with independent educational provider, update all guidance to ensure full alignment to best practice and proceed to review all guidance annually, consider improved mandatory training for 2025/2026.
Digital collection of standardised data from HAS providers and departmental clinical teams. In progress Cleanse data and improve accuracy of reporting, commence assurance visits, promote data security review for all teams.
Use all available clinical evidence to improve services. Include IPR, PfDR, complaints, and appeals in clinical governance reporting to aid learning for providers and internal teams. In progress Work with customer experience to ensure all clinical incidents are considered within the clinical governance framework ensuring learning is embedded in clinical training and guidance.

Conclusions and the future  

As we move forward, we will:  

  • cleanse and improve the data we collect on clinical governance 

  • formally embed learning from coroner prevention of Future Death Reports and our Internal Process Reviews into the core training and guidance material for health care professionals 

  • complete face to face clinical governance assurance visits with all health assessment providers 

  • complete our review of Safeguarding and make recommendations on the Safeguarding Approach across DWP in collaboration with our Customer Experience team 

  • build and strengthen the clinical governance team 

We will continue to publish our report annually to ensure transparency in the processes we undertake aiming to build trust with the public, professionals and their representatives.

Annex A: Appraisals for doctors 

The department commissioned a comprehensive medical appraisal service for connected doctors for 2024 to 2025.  

  • Ten medical appraisals for the 2024 to 2025 year were commissioned, and 10 appraisals were facilitated and completed within year. Each lasted between 1.5 and 4 hours. 

  • Nine appraisals met all the previous NHS Category 1a standards. The documentation for 1 appraisal was returned after the 28-day deadline. 

  • Nine elite appraisers were engaged to facilitate the appraisals. 

  • The average QI score reviewing the appraisal summaries written by the appraisers was 19.1/20, which is outstanding, as 16 is considered satisfactory.  

  • Nine doctors returned feedback, a response rate of 90%. This is well above the NHS average and higher than the organisations average of 70%. 

  • 87% of the feedback regarding the appraiser’s skills was rated ‘Outstanding’ or ‘Very good’ by the doctors. 

  • One doctor reported their appraiser’s skills in providing appropriate support and constructive feedback as ‘Less than satisfactory’. This incident was investigated as a significant event.

Quality assurance 

At least 2 appraisal summaries per appraiser are assessed by a member of our team. When necessary, an external lay person independently calibrates our internal scoring. 

The mean score for appraisal summaries was 19.1/20, with the lowest score given being 17.5/20 and the maximum of 19.5/20. In comparison, the Wessex Appraisal Service Ltd. average for 2024 to 2025 across all quality assured summaries completed before 25 March 2025 was 18.6/20. 

Significant events and complaints 

There were 2 incidents relating to appraisals commissioned by DWP in 2024 to 2025: 

  • One doctor reported their appraiser’s skills in providing appropriate support and constructive feedback as ‘Less than satisfactory’. The doctor reported that there was a lack of understanding of their role and requested another appraiser for future appraisals, which was immediately accommodated. The incident was investigated and determined to be related to a new appraiser. Additional training and support was provided. 

  • Another doctor’s appraisal documentation was signed off after the 28-day deadline due to a life-event for the appraiser with no concerns/implications for the quality of the appraisal provided.  

Doctor feedback 

A 90% return rate was achieved. 87% of doctors rated the appraiser skill as ‘outstanding’ or ‘very good’.

Outstanding Very good Good Satisfactory Less than satisfactory % Outstanding % Very good % Good % Satisfactory % Less than satisfactory
Skill in establishing rapport 4 4 0 1 0 44.4% 44.4% 0.0% 11.1% 0.0%
Skills in facilitating your reflection on your achievements, challenges and aspirations. 4 4 0 1 0 44.4% 44.4% 0.0% 11.1% 0.0%
Skill in demonstrating thorough preparation for your appraisal 5 3 1 0 0 55.6% 33.3% 11.1% 0.0% 0.0%
Skill in listening to you and giving you time to talk 4 4 1 0 0 44.4% 44.4% 11.1% 0.0% 0.0%
Skill in giving constructive and helpful feedback 4 4 0 0 1 44.4% 44.4% 0.0% 0.0% 11.1%
Skill in providing appropriate support 4 4 0 0 1 44.4% 44.4% 0.0% 0.0% 11.1%
Skill in providing appropriate challenge 4 3 1 1 0 44.4% 33.3% 11.1% 11.1% 0.0%
Skill in helping you to review your practice 4 4 0 1 0 44.4% 44.4% 0.0% 11.1% 0.0%
Skill in helping you to identify gaps and improve your portfolio of supporting information for revalidation 4 4 0 1 0 44.4% 44.4% 0.0% 11.1% 0.0%
Skill in helping you to review your progress against your last personal development plan (PDP) 4 4 1 0 0 44.4% 44.4% 11.1% 0.0% 0.0%
Skill in helping you to produce a new PDP that reflects your development needs 4 3 1 1 0 44.4% 33.3% 11.1% 11.1% 0.0%
Skill in managing the appraisal process and paperwork 5 3 1 0 0 55.6% 33.3% 11.1% 0.0% 0.0%

  1. Clinicians: term used for GMC, NMC, HCPC and GPhC registered healthcare professionals ↩

  2. Functional Assessment Service is the name of the new contract awarded to health assessment providers Maximus, Ingeus, Capita and Serco ↩

  3. Note: Except for Maximus who started providing data from Dember 2024. ↩

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