Use of information about compliance by regulator from: Serious untoward incidents

Accepted.
Information on serious untoward incidents is shared routinely with the Care Quality Commission, and Quality Surveillance Groups have been established to support the sharing of information and intelligence more generally at a local level.
NHS England is the relevant successor to Strategic Health Authorities. It continues routinely and regularly to share with the Care Quality Commission information on serious untoward incidents reported to the Strategic Executive Information System and the National Reporting and Learning System.
The Care Quality Commission has direct access to the Strategic Executive Information System, and is able to view all the information submitted to that system regarding serious incidents. Information on National Reporting and Learning System reported incidents is shared on a weekly basis with the Care Quality Commission.
The Care Quality Commission is reviewing how it uses incident data in its new surveillance and monitoring approach to support inspections carried out on behalf of the new Chief Inspector of Hospitals, looking at both incident severity and levels/consistency of reporting. The Care Quality Commission and NHS England are working closely on these developments and have agreed to use the same indicators and approach to their analyses where this is possible.
Quality Surveillance Groups have been established from April 2013 in each area and in each region. These groups actively share between commissioners, regulators, all local NHS organisations and others, information and intelligence on the quality of care being delivered, including on untoward incidents and how they are managed. The National Quality Board is currently conducting a review of how the Quality Surveillance Group network is operating, and what support it needs to be as effective as possible. It will publish revised guidance and support materials by the end of the 2013 to support all Quality Surveillance Groups to reach their full potential.

Serious Untoward Incidents no longer exist due to the changes made by NHS England in the transition to the Patient Safety Incident Response Framework. Therefore, recommendation superseded.

Strategic Health Authorities ceased to exist from April 2013. Since July 2022, Integrated Care Boards have been responsible for planning health services for their local population.

Incident reporting

This recommendation precedes the Patient Safety Incident Response Framework (the NHS approach to developing and maintaining effective systems and processes for responding to patient safety incidents) and the Learn from Patient Safety Events (LFPSE) service (a national NHS system for the recording and analysis of patient safety events).

PSIRF is a contractual requirement under the NHS Standard Contract and puts a strong focus on compassionate engagement and involvement of those affected by patient safety incidents, including patients, families and staff. Guidance is available.

The Intelligent Monitoring tool analyses a range of information including information from the National Reporting and Learning System, as well as people’s experiences of care, staff experience and analysis of statutory returns to the Care Quality Commission (for example, notifications of serious incidents).

The indicators raise questions about the quality and safety of care but are not used on their own to make final judgments. These judgments will always be based on what the Care Quality Commission finds at inspection, which is informed by Intelligent Monitoring data and information from the service provider and other local sources.

Since April 2013, a network of Quality Surveillance Groups has been established at a local and regional level across the country. Quality Surveillance Groups regularly bring together organisations from across the health economy to share information and intelligence on the quality of care being provided to their communities. Regional Quality Surveillance Groups share reports with key issues and concerns with each other and to the NHS England Executive Group on a regular basis so that any issues that need national attention and action can be escalated. To support Quality Surveillance Groups to be as effective as possible in fulfilling their role and potential, a review has been undertaken by the National Quality Board along with all organisations represented on the Quality Surveillance Groups. This has resulted in the publication of revised guidance for Quality Surveillance Groups, ‘How to run an effective Quality Surveillance Group’.

This recommendation was accepted by the Government.

In the January 2014 Hard Truths report, the Government said that information on serious untoward incidents was shared routinely with the Care Quality Commission and Quality Surveillance Groups had been established in April 2013 to support the sharing of information at local level. Quality Surveillance Groups shared information and intelligence on the quality of care between commissioners, regulators and all local NHS organisations, including untoward incidents and their management. The Government also said that NHS England (the relevant successor to Strategic Health Authorities in this context) continued to share with the Care Quality Commission information on serious untoward incidents reported to the Strategic Executive Information System and National Reporting and Leaning System.

In the February 2015 Culture Change report, the Government referred to the Care Quality Commission’s Intelligent Monitoring tool, which would analysis information including that from the National Reporting and Learning System and statutory returns to the Care Quality Commission.