Contents
Foreword by the Secretary of State for Health 6
Statement of Common Purpose 10
Executive Summary 16
Introduction 22
Action Since the First Inquiry 23
Chapter One - Preventing Problems 26
Summary 26
Achieving Culture Change 26
Common Values - the NHS Constitution 27
The Board - Critical for a Compassionate Culture 28
Clinically-Led Commissioning, Focused on Outcomes 28
Extending the Statutory Role of Local Authorities 30
Actions for Cultural Change 30
Supporting Staff to Care 32
The Emotional Labour of Care 32
Measuring Culture 34
Creating Time to Care, Creating Time to Lead 34
Safety in the DNA of the NHS The Berwick Review 36
Zero Harm 36
Conclusion 38
Chapter Two - Detecting Problems Quickly 40
Summary 40
Introduction 41
A Chief Inspector of Hospitals 41
Chief Inspectors 42
Expert Inspectors 42
Ratings - A Single Balanced Version of the Truth 42
Working Together to Focus on Quality 43
Care and Support 44
Transparency 45
Mortality indicators 46
Quality and Risk Profiles 46
Duty of Candour 46
Criminal Sanctions 47
A Ban on Clauses Intended to Prevent Public Interest Disclosures 48
Engaging and Involving patients 51
Patient and Staff Feedback 52
Complaints 53
Healthwatch 54
Sharing Information 55
Chapter Three - Taking Action Promptly 56
Summary 56
Fundamental Standards 56
Time Limited Failure Regime for Quality as Well as Finance 57
Foundation Trust Status 59
Chapter Four - Ensuring Robust Accountability 62
Summary 62
Introduction 62
Health and Safety Executive to use Criminal Sanctions 63
Faster and Proactive Professional Regulation 63
Directors and Senior Leaders 65
Barring System for Healthcare Assistants Enforced by Chief Inspectors 65
Clear Responsibilities for Tackling Failure 65
Chapter Five - Ensuring Staff areTrained and Motivated 68
Summary 68
Treating staff well 68
Staffing Levels 69
Making Time to Care 70
Rewarding High Quality Care 70
Listening to Staff 71
Recruitment and Training Health Education England 71
Revalidation for Nurses 72
Nursing Supervisory Ward Managers 72
Health and Care Support Workers 73
Caring for Older People 75
Attracting Professional and External Leaders to Senior Management Roles 76
Frontline Experience for Department of Health Staff - Culture Change Within The Department of Health and Across the System 78
Conclusion 80
References 82