Written Ministerial Statement

The content of this written ministerial statement is as received at the time from the Minister. It has not been subject to the official reporting (Hansard) process.

Department of Health - RQIA Review of the Governance of Outpatient Services

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Published at 11.00 am on Friday 21 February 2020

Mr Swann (The Minister of Health):

Introduction

The clinicians and staff working in the health and social care sector have a critical role to play in improving and safeguarding the health and well-being of the people of Northern Ireland.  We rely and trust that the care provided is of the highest possible standard and that diagnosis and treatment are made in the best interests of the patient.

In the vast majority of cases, the care provided in the Northern Ireland Health & Social Care sector is compassionate and caring as well as being in line with professional standards and guidelines.

However, in the rare situations when the standard of care falls short it is critical that action is taken to correct the situation as quickly as possible.  In addition, it is also important to understand why the situation occurred to reduce the risk of it happening again in the future.

When the Department of Health was made aware by the Belfast Health & Social Care Trust (BHSCT) of the concerns over the standard of care provided by a consultant neurologist, the immediate need was to review the treatment of the patients who were under that consultant’s care.

In response, a recall of the consultant’s current patients was initiated in May 2018 followed by a further recall of his previous patients in high risk groups. Over 4,100 patients have had their treatment reviewed to date.

RQIA Review of Outpatient Services

Whilst the primary focus has been to ensure that patients are now receiving the right care it is important that there is a good understanding of what went wrong; to determine if it is currently going wrong elsewhere; and to ensure that the chances of it happening again can be reduced.

To this end, the Regulation and Quality Improvement Authority (RQIA) was commissioned in May 2018 to undertake a review into the governance arrangements for outpatient services in the BHSCT.

The review was taken forward by an Expert Review Team which met with staff from the BHSCT, the Health & Social Care Board (HSCB) and the Public Health Agency (PHA).  The review team also conducted unannounced multidisciplinary inspections, held focus group discussions and undertook a survey of General Practitioners (GPs).

The RQIA has now published the final report from the review which is available on the organisations website: https://www.rqia.org.uk/reviews/rqia-s-neurology-work-programme/

The key findings from the review are as follows:

Clinical Peer Review- the potential for isolation of medical and/or specialist nursing staff was identified as a particular risk.  The risk was greatest where there is lone working outside a multidisciplinary team context, perhaps due to the nature of the specialty, by the choice of the health professional or because of a lack of governing systems across the service in question;

Access and Organisation- there is a need for streamlining the mechanisms for referring patients to Belfast Trust with more robust validation of waiting lists and triaging of patient referrals also required.  There is also an opportunity to improve the written communication with patients following their visit;

Safeguarding- the levels of training, knowledge and awareness of staff across outpatient services in relation to safeguarding were a significant issue of concern.  In response the matter was escalated to senior management in BHSCT.  The RQIA continues to monitor the Trust’s delivery of improvements in this area in line with its escalation policy;

Medicines Management- while there is robust oversight of prescribing of specialist medicines there is only limited oversight of all other prescribing in outpatient services. Significant weaknesses were identified in the monitoring and oversight of medicines prescribed or recommended to be prescribed as the current system is based on hard copy advice to GPs which limits the ability of the Trust to identify unusual prescribing practices;

Governance Arrangements- while arrangements were clear, or in the process of being clarified through Directorate and Divisional structures, arrangements were not necessarily as clear for staff providing care and/or treatment in outpatient services.  The importance of Charge Nurses/Ward managers in providing stable effective leadership was highlighted although the review did not find evidence that they were sufficiently connected to the collective leadership structures or could affect improvements at a system level;

Patient engagement- although the opportunities in some services/locations for patients to provide real time feedback were encouraging, there is a need to have consistent mechanisms to ensure that patient views are harnessed across all outpatients services; and 

Information and Intelligence- use of data, information and intelligence could improve oversight of the activity and outcomes of consultants and specialist nurses in outpatient services.

The report concludes that the review team had observed many good examples of compassionate and patient centred care, and recognised the work undertaken by the Trust to implement a comprehensive governance structure and quality assurance framework.  However, the report also found that outpatient services span a range of Directorates and specialties which means that oversight arrangements can be complex, with the risk of poor cohesion.

There are 26 recommendations for BHSCT within the report including that the Trust should develop, implement and assure a systematic approach to clinical peer review across its outpatient services as well as that data on clinical activity and patient outcomes should be routinely collected, reported and shared.

Next Steps

Although the focus of the review was on BHSCT, the RQIA have identified that many of the findings are also potentially applicable to other Trusts.  In response, the HSCB and PHA have been commissioned to work with all the Health & Social Care Trusts to identify the findings and recommendations from the RQIA review that are expected to apply to all NI Health & Social Care (HSC) Trusts rather than BHSCT alone.  The HSCB and PHA will then work with the Trusts to develop an Action Plan by September 2020 to address the recommendations from the RQIA review.

During 2020 the RQIA will now evaluate the governance of outpatient services in the other Trusts.  The additional findings from the evaluation of the other individual Trusts that have regional implications will also be considered as part of the work being taken forward by the HSCB and PHA.

This is the first of the three reviews that the RQIA is undertaking as part of the response to the Neurology Recall.  In particular, the RQIA is also conducting an expert review of the clinical records of all patients or former patients of the consultant neurologist who have died over the past 10 years as well as a review of governance arrangements in independent hospitals and hospices.

The independent sector review is nearing completion whilst the review of deceased patients has been delayed due to the need to put the necessary legal arrangements in place to allow for the medical records to be examined.

In respect of the wider recall, the Outcomes Report from the first phase has shown that approximately one fifth of the active caseload had a not secure diagnosis.  The findings from the second phase of the recall are being analysed with a report expected to be published in the spring, at which time an announcement will be made in respect of the need for a further recall.