The BBC described it as “one of the biggest scandals in NHS history”[i], while the Independent said it was “one of the worst care disasters in the service’s history”[ii]. Both are referring to the Mid-Staffordshire NHS Foundation Trust scandal, where between 2005 and 2008, hundreds of people died as a result of poor care. The scandal not only exposed systemic flaws in leadership, but also a systematic failure to champion a culture of openness and transparency towards patients and their loved ones.
The inquiries and investigations that followed prompted much soul searching and sweeping changes in regulation. In 2014, the CQC introduced and brought in Duty of Candour protocols to ensure that an open, fair and transparent culture was deeply embedded in all health and care services.
In March, however, the CQC updated its guidance. Why it chose to do so is unclear, but a recent CQC board meeting provided some hints. In the meeting it was revealed that in the absence of face-to-face inspections over the past year, safety incidents, which were often being reported after the event has occurred, had increased.
Therefore, perhaps this was one of the reasons why the CQC decided to publish updated guidance – including examples – as to what constitutes a notifiable safety incident (NSI), and what doesn’t.
So, under the CQC’s updated Duty of Candour guidance, how do you define an NSI? The CQC states that an NSI “must have been unintended or unexpected”. Secondly, the CQC guidance says that the activity “must have occurred during the provision of an activity” it regulates. Thirdly, in the CQC’s words, in the opinion of the healthcare professional the NSI “already has, or might result in death, or severe or moderate harm to the person receiving care”. [iii]
CQC guidance updates
In addition to providing a clear explanation and examples as to what constitutes an NSI, I think the CQC’s decision to clarify the fact that making an apology is not the same as accepting liability is a highly significant and welcome step for providers.
That said, having worked as a Practice Manager for over 18 years, there is still a feeling in some surgeries, no matter how open and transparent the culture, that saying ‘sorry’ is an admission of guilt and liability. While the CQC has actively emphasised that the two are in no way connected, written apologies may often contain defensive language. There’s a big difference, for example, between offering up “a non–apology apology” to saying sorry for actually doing something wrong.
This doesn’t mean to say, however, that GPs will find it challenging to meet their Duty of Candour responsibilities. On the contrary, I think the CQC’s new guidance not only provides a clear roadmap to providers, but a robust scaffold on which to build a culture of Duty of Candour within their practices.
But what does that mean? Essentially, practices must be able to satisfy themselves that they have followed the correct procedures, and are able to evidence this to the CQC. If they have done so, then it is much easier to write the letter of apology because a Practice Manager can instantly see if the practice is in breach of its statutory responsibilities around Duty of Candour.
It may be, however, that it quickly becomes evident that an error has been made. That said, if the provider can demonstrate to the CQC that it has reflected on its mistake, rectified it and put corrective steps in place to prevent it from occurring again, the CQC is likely to be satisfied.
How QCS can help
It is something that QCS, a leading provider of content, guidance and policies for the healthcare sector, recognises. In response to the recent changes, our GP team has updated our Duty of Candour Policy and Procedure in line with updated CQC standards. We’ve also updated a number of policies, which are closely linked to Duty of Candour, including our Supervision Policy and Procedure, our Complaints, Suggestions and Compliments Policy and Procedure, our Audit Policy and Procedure, and our Accident and Incident Reporting Policy and Procedure. Finally, our GP team has produced a Significant Event Register with a drop down menu to indicate whether or not Duty of Candour applies, which can be used as evidence at a CQC inspection of openness and honesty when things go wrong.
GP leaders must implement a duty of candour culture
However, to really affect lasting change, the culture of openness that the CQC is championing should be replicated in GP practices. This requires Practice Managers, Registered Managers and Senior Clinicians to lead the way. The culture should enable staff to feel that they can share mistakes they have made with the rest of the practice without fear. They should feel supported to be open, no matter how big the error. QCS’s Supervision Policy and Procedure, which advocates a safe and confidential environment for staff to reflect upon and discuss their work, takes this open and inclusive culture to the next level.
When a rich culture of transparency and accountability has been instilled, accident and incident reporting policies and procedures often prove to be far more effective. Why? Well, with greater openness, the policy is designed not just to record accidents and incidents, but to identify potential safety issues before they impact negatively on patients and staff. But in order for it to really work well, it relies on staff coming forward and reporting all accidents and incidents. Where the culture in a practice is strong, they’re much more likely to do so, enabling lessons to be learned and improvements made before a member of staff or a patient is harmed.
The fewer incidents and accidents, the fewer Duty of Candour breaches there are likely to be. When you consider the huge fines that Practices could incur, not to mention the mental and physical trauma sustained by patients, it is wise to stay on the right side of regulation.
If you wish to find out more about QCS’s Duty of Candour policies, why not contact QCS’s compliance advisors on 0333-405-3333or email firstname.lastname@example.org? Or for more coverage on the Duty of Candour debate, please tune into our podcast.
On 11th March, the CQC updated its guidance in relation to meeting duty of candour regulations. The updated guidance makes it clear as to what providers need to do to meet the requirements of the regulation and also explains the circumstances in which it must be applied.
In this episode, Tracy Green and Alison Lowerson will be discussing CQC guidance, demonstrating how to instil a culture of duty of candour, and explaining why saying sorry is not admitting fault when something goes wrong.