'Learning not blaming': What NHS boards need to know

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20 / 07 / 2015

Learning not blaming, the Government’s response to three reports on patient safety, contains several new requirements, structures and arrangements for NHS boards to be aware of and act on. They are summarised below and should be considered alongside announcements made by the health secretary on 16 July to 'profoundly change the culture of the NHS'.

The report details the Department of Health’s response to the Freedom to Speak Up Review consultation, the Public Administration Select Committee’s report Investigating clinical incidents in the NHS and Dr Bill Kirkup’s report on failings in care at Morecambe Bay. 

It also provides an update on progress against report recommendations and next steps.

For action

  • All trusts in England are to appoint a Freedom to Speak Up Guardian, to encourage and enable staff to raise concerns over patient safety in a confidential setting.  
  • The guardian should be appointed by the chief executive and will act as a “genuinely independent figure.” 
  • The guardian will raise concerns with the chief executive or board. If they have lost confidence in how the organisation is handling concerns, they are also able to raise concerns with a national guardian.

For information

Raising concerns

  • A national guardian – the independent national officer (INO) – will be appointed to act as a key leader in a “national renewal and reinvigoration of an open and learning culture.” 
  • The INO will provide an independent role to review the handling of concerns raised by NHS workers and/or the treatment of people who speak up where there is cause for concern.
  • The position will be based at the Care Quality Commission (CQC) and will be appointed by December 2015.
  • Once in place, the INO will produce guidance on local implementation of the Freedom to Speak Up Guardian role and how this role will develop. 
  • Some trusts have already taken the role forward and have a guardian in place; the INO is expected to take account of good practice already in place before publishing guidance.
  • If trusts feel confident to appoint a guardian without this guidance, they are encouraged to do so. Any appointments should be made within the principles set out in the Freedom to Speak Up review.
  • Health Education England will work with CQC and INO on guidance on training for the Freedom to Speak Up Guardian role.
  • By September 2015, NHS England will produce guidance on how to implement the principles and actions of the Freedom to Speak Up report in primary care.
  • NHS England, Monitor and the NHS Trust Development Authority (TDA) will establish a support scheme for whistleblowers who can demonstrate that they are having difficulty finding employment as a result of raising concerns.
  • The three organisations will produce a standard integrated policy and procedure for reporting incidents and raising concerns.
  • Health Education England will make recommendations in the autumn on ways in which education and training can be used to improve patient safety.
  • Further organisations will be added to the Prescribed Persons Order of the Small Business, Enterprise and Employment Act 2015 (SBEEA), requiring them to report annually on whistleblowing disclosures made to them. 
  • The Government intends to extend the definition of "worker" within the whistleblowing statutory framework in the Employment Rights Act 1996 to include all students studying for a career in healthcare, "when parliamentary time allows."

Patient safety

  • An Independent Patient Safety Investigation Service (IPSIS) will be created, to conduct independent, expert-led investigations into patient safety incidents. 
  • IPSIS will be brought under the single leadership of Monitor and the NHS Trust Development Authority.
  • IPSIS will be in place from 1 April 2016. It will be centrally funded initially with the expectation it moves towards a mixed-funding model “with a significant proportion of its income being derived from NHS trusts.” 
  • The Government will bring under the single leadership of Monitor and the TDA the responsibility for leading the patient safety functions that currently sit with NHS England, led by Dr Mike Durkin.
  • HEE’s Commission on Education and Training for Patient Safety will set out comprehensive proposals for enhancing safety training for all health and care professionals


  • The Parliamentary and Health Service Ombudsman (PHSO)will be reformed to simplify and modernise its existing structures.
  • NHS England is taking forward a number of actions to improve complaints handling over the coming months, including developing a toolkit for commissioners and working with the PHSO to pilot ways of surveying patients about their experience of complaining.
  • Late summer 2015 will see the publication of the first round of hospital complaints data collected quarterly, rather than annually.
  • As part of the establishment of the Independent Patient Safety Investigation Service, the Government will also seek further expert advice on how local organisations can align their processes for handling complaints and investigations into serious incidents.

Maternity services

  • The Government's response to Dr Bill Kirkup's report into Morecambne Bay reflects the actions taken by the trust and progress against the system-wide recommendations.
  • The Nursing and Midwifery Council (NMC)’s oversight of midwifery supervision will be removed and replaced with a more “robust system” that separates the regulation of midwives (NMC's role) from supervision. This will be done via legislation, with the Government intending to introduce an Order in Council under section 60 of the Health Act 1999.
  • Clear standards will be drawn up for incidents reporting and investigations in maternity services.

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