Review of patient safety across the health and care landscape: terms of reference
Published 15 October 2024
Applies to England
Introduction
Quality is a critical issue for health and care services.
Using the definition from Lord Darzi in High quality care for all, quality needs to be seen as having 3 distinct, but closely interlinking components, namely:
- safety
- effectiveness
- user experience
The focus of this review will be safety, but it is important to recognise the links between these 3 domains, as safety does not stand alone.
This review will:
- map the broad range of organisations that impact on quality (and therefore have links to safety), but will not examine them in detail
- focus on 6 key organisations overseen by the Department of Health and Social Care, which have a significant impact on safety
Background
The Secretary of State for Health and Social Care has been clear about his commitment to improving quality of care, including safety. Through learning from user experiences and challenging poor culture and practice where it occurs, the Secretary of State intends to restore public confidence in our health and care system.
The landscape of bodies that impact on safety has changed significantly since the late 1990s. Recent commentary, for example in the final report of the Infected Blood Inquiry, highlights that the way the landscape has developed means multiple organisations are involved in related activities.
This may have limited, rather than supported, national system leadership in relation to patient safety and created an unquantified overhead on provider organisations.
Purpose
The primary task of this review is to assess whether the current range and combination of organisations delivers effective leadership, listening, learning (including investigations and their recommendations) and regulation to the health and care systems in relation to patient and user safety (and to what extent they focus on the other domains of quality).
Based on this assessment, the review should make recommendations on whether greater value could be achieved through a different approach or delivery model.
The review will set out the wider landscape of quality, looking at health and social care. The mapping work will provide context for the review of the specific organisations named below. This work will also be used to more widely inform the 10-year health plan.
Scope
The main focus of the review will be on the following organisations:
- Care Quality Commission (CQC) - including the Maternity and Newborn Safety Investigations programme
- National Guardian’s Office (NGO) – NGO is hosted by CQC and its work on staff experience should inform improvements in patient safety
- Healthwatch England (HWE) and the Local Healthwatch (LHW) network – HWE is also hosted by CQC. Its work, alongside LHW, on patient experience should inform improvements in safety
- Health Services Safety Investigation Body
- Patient Safety Commissioner
- NHS Resolution (patient safety-related learning functions only, not clinical negligence functions)
Where these organisations have functions related to health and social care, both will be in scope.
The review will also work closely with NHS England and the Parliamentary and Health Service Ombudsman, as well as the Local Government and Social Care Ombudsman, where this is relevant, to support recommendations related to the named organisations.
Approach
The wider quality landscape
In relation to the wider quality (including safety) landscape, the review will map the overall current landscape of bodies that:
- undertake regulatory or non-regulatory activity with respect to quality (including safety)
- set standards in respect of quality (including safety)
- handle quality (including safety) issues as part of their workload
The review will also:
- consider the breadth of bodies currently collecting ‘people’s experience’ feedback, and how this could be more effectively channelled and used as a basis for assessment and improvement
- make recommendations for further work based on the mapping of the wider landscape
Named organisations
Focusing on the named organisations, the review will:
- make recommendations on the ownership, execution and accountability of key functions, with the objective of ensuring responsibilities are clear and distinct across organisations and are transparent to service users and service providers
- make recommendations on how to maximise the collective benefit of the organisations and propose different delivery models if greater benefits could be achieved
- make recommendations on whether there are key functions across the 6 organisations that are duplicated or are missing
- make recommendations on the rationalisation of data collection and improvements in data sharing and measurement
- ensure there are mechanisms for clear system-wide priority-setting to help ensure recommendations deliver the greatest impact
- make recommendations on how to ensure that people’s experiences and staff voice - including but not limited to data on complaints - are effectively used to make improvements in safety
- set out legislative inconsistencies and overlaps - for example, ensuring enforcement powers are consistent with the mission to rebuild the health and care system