We need a sustainable solution to care failure investigations

How should the NHS deal with individual cases of poor care where those affected feel the provider involved has failed to resolve their concerns? After more than two years of focus on patient safety, one would forgive the public for being surprised that the answer is still not clear.

‘The task of NHS England should be to develop the most effective framework for the delivery of improving healthcare’

The lack of clarity about which organisation is responsible for investigating individual care failures was highlighted by the tragic case of Elizabeth Dixon.

The fact that after 13 years of fighting, the family are still unable to find anyone willing and able to carry out a full investigation is unacceptable. However, it would be very easy to knee jerk into accusations of uncaring NHS bureaucracy.

The circumstances that led to the family being informed of NHS England’s decision to withdraw from the investigation were unkind at best, but that should not disguise the honesty or logic of the decision.

Division of powers

The task of NHS England should be to develop the most effective framework for the delivery of improving healthcare outcomes and to oversee that framework’s effectiveness. NHS England’s founding chief executive Sir David Nicholson was keen on a broader set of responsibilities. His last few months in post were noticeable for his interest in care failures issues.

‘The NHS is working hard to become more accountable, to own up to mistakes and explore their causes’

His successor Simon Stevens arrived in post alive to the dangers of mission creep. He is, for example, determined not to see his senior management bogged down by time consuming exploration of historic care failings.

However, NHS England has specific powers to investigate individual care failings that other bodies do not. Specifically, the Parliamentary and Health Service Ombudsman can only take up cases that have happened in the last 12 months. The Care Quality Commission’s investigatory powers are restricted – in this case – to carrying out “thematic reviews” that consider broader system issues.

With NHS England now declaring it is “not an investigatory body”, it appears the only route left open to complainants like the Dixon family is to seek a specially created investigation, such as the one underway at University Hospitals of Morecambe Bay Foundation Trust.

The demands of being transparent

In other words, the situation promises more frustration for the public and greater expense and complication for the service.

The NHS is working hard to become more accountable, to own up to mistakes and explore their causes. One consequence of this is that those who feel failed by the service will be emboldened to seek answers.

‘The temptation will be to create a new body or share out responsibility among existing ones’

This is to be celebrated – but the demands it creates must be recognised and a solution rapidly devised to meet them.

To begin with, an assessment system must be created to determine which individual cases of care failure have not been satisfactorily investigated by other bodies and demand further scrutiny. The process would also, of course, need to allow for appeals against decisions.

This would hopefully create a manageable workload and allow investigations to be completed within acceptable and defined timeframes.

A new organisation is unnecessary

So who should take on this responsibility? The leadership of any organisation would understandably quail in the face of such a task – and the temptation will be to create a new body or, more likely, to share out responsibility among existing ones.

This temptation should be resisted and the CQC should be given the powers and resources to assume the task; providing clarity for the service and the public.

In the meantime NHS England and the CQC should develop an interim solution as quickly as possible to ensure the Dixons and others can be confident they will be listened to and, where appropriate, their concerns acted on.

It also makes senses to extend the period of time the ombudsman can investigate care failings to at least two years.