A National Guardian for the NHS – your say: Improvement through openness

Royal College of Physicians of Edinburgh Care Quality Commission A National Guardian for the NHS – your sayThe Royal College of Physicians of Edinburgh (“the College”) is pleased to respond to the Care Quality Commission consultation on “A National Guardian for the NHS – your say”.Question 1: Do you agree with the proposed scope for the National Guardian? Generally yes.  It is however vital that the individual in post needs to have enough independence to challenge situations where care has been compromised.  The proposals for handling staff concerns seem appropriate.Given the CQC’s current remit and extensive work in primary care, the proposed limitation to NHS Trusts and NHS Foundation Trusts would need to be clearly articulated and advice made available for those in primary care settings who have concerns.Question 2: Do you agree that these principles are the rights ones? Are there any missing? Taking each principle in turn:

1. The independence of the National Guardian is crucial.  The College suggests adding “including government” after “national bodies” in order to emphasise the full independence of the role.
2. It is not clear as to the basis on which the National Guardian will exercise their discretion to become involved – there will need to be a high degree of clarity to those with concerns as to whether or not the National Guardian would have a role.  Otherwise there is the potential for whistleblowers to feel their concerns are ignored.
3. The division of responsibility between local and national guardians need to be clear.
4. Whilst it may be straightforward to identify where there are distinctions between the legal remedies, it may not be so easy to distinguish when and why the National Guardian may become involved.  It needs to be very clear to everyone when the National Guardian will be the relevant “person” for resolving issues and when local processes should instead be engaged.
5. To ensure the independence aimed at in (a) there will need to be clearly defined roles and relationships so that the backing described in (e) is not seen to, or perceived to, compromise this independence.
6. This needs further clarification.  It is not clear how this will be achieved without a degree of investigation into how the issues raised have been dealt with.  It may be very difficult not to appear to be passing judgment.
7. Again this needs further clarification – what are the timescales for something being regarded as “historic” (there is a reference to “current” or “ongoing issue” being regarding as from April 2016 onwards on page15)?  Also the nature of the concerns likely to warrant consideration will probably relate to issues that are not isolated incidents so there would need to be flexibility over the timescales.

Question 3: Do you agree that the proposed arrangements will be enough to effectively ensure the National Guardian’s independence, and provide effective governance? It is difficult to tell from the information provided.  The Board would need to be very clear about how it separates its obligations to the National Guardian from its primary function overseeing the CQC.  There may be potential difficulties if the different arm’s length bodies have alternative approaches.If in the future the National Guardian does have oversight of primary care etc, this may not be an appropriate model.Question 4: How should communications from the National Guardian be branded? Branding should be approached with care – it needs to be clearly “stand alone” without giving a misleading impression about the extent to which it is independent of the CQC.Question 5: Do you agree with our proposal that the National Guardian should build a strong network of Local Freedom to Speak Up Guardians, and do you have additional ideas for how this should be delivered? In principle, yes.  However, further work will need to be done to clarify lines of reporting, the circumstances when someone with concerns should go the local or National Guardian etc.Question 6: Do you agree with our proposal that the National Guardian should review how concerns have been handled in individual cases, where serious issues appear to exist, and do you have additional ideas for how this should be delivered? Yes; however the timescales need to be clear and it is also unclear as to any circumstances where it might be necessary to make the information (albeit not specific details) public, for example to triangulate information or to highlight trends etc.  In addition to single cases, the National Guardian should also be looking at patterns of reporting.The document states that the National Guardian has no statutory powers, therefore clarifying exactly where they fit in and what they may do if an organisation “refuses to listen” may be helpful.Question 7: Do you agree with our proposal that the National Guardian should support and advise providers, and do you have additional ideas for how this should be delivered? Yes.  However, there will need to be a balance struck between when a provider needs supported and advised and when to refer to the arm’s length bodies.Question 8: Do you agree with our proposal that the National Guardian should provide support and challenge to the system, and do you have additional ideas for how this should be delivered? The College agrees that the National Guardian should provide support and challenge to the system and has no further comment on the delivery of this.Question 9: Do agree that the four functions described are the right ones to enable the National Guardian to discharge its role, as described in the Freedom to Speak Up review? Although support for staff is extremely important, as is ensuring consistency as to the way in which concerns are investigated and addressed, it should also be made explicit that the role is about ensuring an improved and safer environment for patients and their families/carers.  Although page 19 mentions it, the document does not make this clear enough and this could be highlighted in the functions of the National Guardian.Question 10: Do you have any further views on how the National Guardian should discharge its role? Liaison with other independent agencies such as Royal Colleges should be considered.Question 11: Do you agree with the assessment of drivers of costs and benefits of the National Guardian and its functions? Can you provide further examples of likely drivers of costs and benefits?No specific comment.