Independent Review into Thomas Oliver McGowan’s LeDeR Process Phase two

All those who are new to the role of lead reviewer, or local area contact (LAC), must be allocated a ‘buddy’ who is experienced in the LeDeR process.

There should be clear guidance on the roles of buddy and second reviewers.

There must be a transparent process for LeDeR in each locality, with robust governance and appropriate resources to ensure that each review is properly monitored in terms of procedure and outcomes.

Governance of LeDeR should be appropriately embedded into emerging new structures, such as sustainability and transformation partnerships (STPs) and integrated care systems (ICSs), from the onset.

The LAC and the lead reviewer should confirm at the onset of the LeDeR process how much support is needed and what it should look like. Guidance for reviewers should emphasise that when undertaking a LeDeR, there is an onus on a team responsibility to complete the process to the required standards, rather than it falling to an individual (the lead reviewer, in this case).

Each CCG must identify an executive lead to be responsible for the LeDeR programme and for ensuring that the board has full sight of progress.

The CCG executive lead for LeDeR will ensure that LeDeRs are completed in a timely and correct manner and will intervene where problems are escalated, such as the inability to obtain critical information from the relevant agencies.

When a multi-agency review (MAR) is indicated, it is important that the correct process and outcomes are achieved. It is therefore expected that where the reviewer and the LAC have no previous experience of a MAR, they will seek support from a ‘buddy’ who does.

One of the requirements for a MAR is determined by an initial scoring system of 1–6, with a score of 6 indicating that ‘care fell short of current best practice in one or more significant areas resulting in the potential for or actual adverse impact on the person’. Currently, this scoring is not carried forward into the main report. It is recommended that there is a review of this scoring process and that the initial score is retained as a record in the main report.

Appropriate support should be available to reviewers, along with strong governance, to ensure that all LeDeR recommendations are robust and actioned in a timely manner, and that lessons learnt are shared nationally.

Each CCG must formally undertake and document and review its own systems and processes against the learnings and recommendations arising from Oliver’s re-review. This review and the accompanying action plan must be submitted to, and monitored by, the local integrated care system (ICS), giving feedback to the national LeDeR team around progress. The panel wishes for a senior, single point of contact from NHS England and NHS Improvement to ensure all actions are taken and progress monitored.