The current situation on recommendations for safety and quality in healthcare is untenable according to a new review.
The DHSC-commissioned review was published by HSSIB on behalf of a group of ALBs. It concludes that the substantial number of recommendations made to the healthcare system means providers struggle to prioritise and implement recommendations.
It found that the lack of structure around the creation and implementation of recommendations as well as the lack of monitoring of actions means many are not improving patient care while continuing to burden providers.
Some recommendations duplicate or contradict others and most are not costed, which may affect providers’ ability to implement them and means there is a lack of information to support prioritisation decisions. Some may be of limited relevance to certain providers and could promote inequalities by negatively impacting certain patient groups if implemented. There is a lack of monitoring of the actions planned or taken to address recommendations.
Welcoming the report, the PSC said: ‘It is becoming increasingly clear to the public that vital recommendations for urgent changes to be made to keep the public safe are simply not being acted upon, leaving persistent risks unaddressed and patients and staff vulnerable.
‘It is essential that the public can have the confidence that recommendations commissioned from independent safety bodies, reviews and Inquiries are properly co-ordinated and followed up with tangible actions. Patients deserve a healthcare system where safety is a top priority, where lessons are learned, and avoidable harms are removed. It is unacceptable that findings which could prevent harm or injury can be neglected for decades.’
The review recommends further work to look at setting up a repository for recommendations, a monitoring system and a route of escalation for recommendations that are not implemented.