Clarify oversight responsibilities
Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: NHS England
Source — verbatim from the inquiry
●Inquiry recommendation
The division of responsibilities between the Care Quality Commission and other parts of the NHS for oversight of service quality and the implementation of measures to correct patient safety failures was not clear, and we are concerned that potential ambiguity persists. We recommend that NHS England draw up a protocol that clearly sets out the responsibilities for all parts of the oversight system, including itself, in conjunction with the other relevant bodies; the starting point should be that one body, the Care Quality Commission, takes prime responsibility. Action: the Care Quality Commission, NHS England, Monitor, the Department of Health.
Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The National Quality Board was re-established to provide leadership for quality across the NHS, with a network of regional and local Quality Surveillance Groups in place since April 2013 (Learning Not Blaming, Cm 9113, Department of Health, July 2015).
- The NHS Oversight Framework (updated annually) sets out how NHS England monitors and supports NHS trusts, including clear escalation thresholds and the role of the CQC (NHS England).
- The Health and Care Act 2022 consolidated oversight arrangements, merging NHS Improvement into NHS England and clarifying the CQC's role (Health and Care Act 2022, c.31).
Response — verbatim from government
●NHS England
92. We accept this recommendation in principle. Patient safety is a critical element
of an effective, patient-focused health system and we agree that it is important to be
clear about who is responsible for patient safety. The onus on ensuring quality sits
primarily with provider Trusts themselves; although commissioners and regulators
also have an important role.
93. In “Culture Change in the NHS”21 the Government agreed that it would be
sensible to concentrate and consolidate national expertise and capability on safety
within a single organisation that can provide strategic leadership across the whole
healthcare system. The Government intend to bring under the single leadership of
Monitor and the NHS Trust Development Authority the responsibility for leading the
patient safety functions that currently sit with NHS England.
94. Through the newly re-established National Quality Board we will continue to
improve both the operation of the oversight arrangements in place at present and the
understanding of those arrangements by NHS organisations and the public. A
network of regional and local Quality Surveillance Groups has been in place since
April 2013 to ensure effective intelligence sharing and action on quality concerns
between all partners.
21 https://www.gov.uk/government/publications/culture-change-in-the-nhs
95. Where Trusts, for whatever reason, are not able to provide the quality of care
required, other parts of the system have a role to play in helping them improve. The
Care Quality Commission has been established as the independent inspector of
quality and has clear processes in place to identify issues that are brought to light
through the inspection process.
Where Trusts are unable to rectify identified
problems themselves Monitor or the NHS Trust Development Authority provides
support to enable the provider Trusts to improve – in UHMB’s case through the
special measures regime.
96. The Care Quality Commission is inspecting University Hospitals of Morecambe
Bay NHS Foundation Trust in July this year to assess its progress against the
agreed action plan, and its report will be published in the autumn.
Organisational change: 36-37
NHS England · 16 Jul 2015 Written response →
Evidence trail — what's actually happened since
- 31 Dec 2015 NHS Oversight Framework clarifies roles and responsibilities of NHS England and CQC in quality oversight. Source →
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
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Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.