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Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare

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Background Organisations involved Findings Further work

Background

This report is an output of the work commissioned by the Department of Health and Social Care (DHSC). At a meeting of the Arm’s-Length Body (ALB) Chief Executives and Chairs in November 2022, areas where joint work between DHSC’s ALBs would be valuable were identified. A series of workstreams were set up as a result.

Dr Rosie Benneyworth, the Chief Executive Officer of HSSIB, agreed to Chair the workstream on how ALBs and DHSC can better manage risks that the system is facing. This became known as the Recommendations to Impact Collaborative Group (referred to here as ‘the group’) and has been meeting virtually and at in-person workshops since March 2023. The group is a collection of organisations and individuals, including a panel of international academics and experts in collaborative governance and the role of evidence in developing policy. The purpose of these meetings is to look at ways in which to increase collaboration and efficiencies in how safety recommendations made to the healthcare system are developed, made and implemented.

Organisations involved

The following organisations and individuals have contributed to this work:

  • Academy of Medical Royal Colleges
  • Care Quality Commission
  • Department of Health and Social Care
  • National Institute for Health and Care Excellence
  • Health Research Authority
  • Human Fertilisation and Embryology Authority
  • Human Tissue Authority
  • Maternity and Newborn Safety Investigations
  • Medicines and Healthcare products Regulatory Agency
  • National Guardian’s Office
  • NHS Blood and Transport
  • NHS Confederation
  • NHS England
  • NHS Providers
  • NHS Resolution
  • National Quality Board
  • Parliamentary and Health Service Ombudsman
  • The Health Innovation Network
  • The Patient Safety Commissioner
  • UK Health Security Agency
  • Academic panel of international experts in patient safety, governance and policy
  • Provider representatives from acute and mental health trusts.

Findings

  • Failure to implement actions following recommendations can impact public confidence in the healthcare system and compound harm to patients.
  • The ‘noise’ created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement recommendations, concentrating on those which are addressed directly to the provider, or where there are immediate patient safety risks.
  • Some recommendations duplicate or contradict others. The development of a searchable repository which includes recommendations made across the healthcare system may help to reduce this.
  • It may reduce the ‘noise’ and help with prioritisation if organisations refer to each other’s recommendations, or group together in support of one organisation’s recommendation rather than repeating it. The development of an agreed system to identify recommendations for cross-referencing would assist this.
  • There is currently a lack of visibility of ongoing work across arm’s length bodies that would enable collaborative working on related workstreams. A searchable repository of ongoing work may assist this.
  • Recommendations differ in terms of the evidence on which they are based, and their structure and language. This can affect their relevance and how they are interpreted.
  • It is unclear how some recommendations are intended to impact the patient, which should be a key consideration in their development where possible.
  • Most recommendations made to the healthcare system are not costed, either in relation to the cost of implementing the proposed actions or their longer-term cost effectiveness. This may affect providers’ ability to implement them and means there is a lack of information to support prioritisation decisions.
  • Some recommendations may be of limited relevance to certain providers and could promote inequalities by negatively impacting certain patient groups if implemented. However, providers can feel they are not empowered to reject recommendations, especially those related to safety.
  • Few recommendations require a formal response from the recipient organisation, and there is a lack of monitoring of the actions planned or taken to address recommendations. A monitoring system could help to track actions and identify opportunities for escalation where changes have not been made.

Further work

The Recommendations to Impact Collaborative Group recommend further work in this area to develop:

  • guidance on the creation and implementation of recommendations
  • a proposal for a repository for recommendations
  • a proposal for a repository for ongoing workstreams
  • a proposal for a monitoring system with a multi-agency board feeding into the Department of Health and Social Care to provide oversight and a route of escalation for recommendations that are not implemented.
Report