Gambling with your health
What the Government doesn’t want you to know about your NHS - from the office of the Rt Hon Andy Burnham MP
The NHS is facing the biggest financial challenge in its history. At the same time, the Government has launched the biggest top-down reorganisation since 1948.
It is widely acknowledged that this combination of events has exposed the NHS to greater risks. This was acknowledged by the Chief Executive of the NHS when speaking to the Public Accounts Committee. What we do not know is the Government’s own assessment of the precise nature and scale of the risks it is running with the quality, safety and efficiency of health services. The Information Commissioner has ruled that the Department of Health should release its risk register. However, the Government has refused to do so.
This dossier provides a glimpse of the information that the Government doesn’t want people to know about the scale of the risks it is running with their health. It is drawn from the Risk Registers of various PCTs and SHAs. It reveals widespread concerns held by senior management across the NHS that the disruptive effects of the Government’s reorganisation are jeopardising the quality and safety of essential services. The extracts below are taken from the Significant or High Risk gradings from the SHA and PCTs Risk Registers.
Petition calling for the release of the risk register
If you know of any more significant or high risk assessments by NHS organisations please let us know.
Delivery of major service changes
- London SHA: There is a risk that, during the transition to a new end-state for decision-making processes and accountability, there may be insufficient focus to deliver the necessary transformation at pace. The consequence of this risk could be that the transformational changes in health services envisaged in London's QIPP plans in response to the clear clinical case for change, may not be realised in full or are delayed, thereby undermining significant improvements in the health of Londoners.
- London SHA: There is a risk that planning for and implementing the Government’s White Paper reforms, including the transitional arrangements, may have a disruptive effect on the delivery of business across the system.
This includes risks to:
- maintaining a grip on financial and service performance during the period of change; and
- implementing agreed commissioner QIPP plans and provider savings plans.
The consequences of this risk could be patients receiving sub-optimal care and planned QIPP savings could be difficult to achieve which would place a strain on the financial performance of the NHS and reputational damage could be done to the NHS in London.
- East of England SHA: Progression management. Performance issues not addressed so patients harmed and legal risk from patients and trainees.
- Sussex PCT: PCT staff become distracted from managing delivery of current plans due to impending structural and organisational changes and impact on individuals (with the potential for increased stress and sickness absence, lower morale and an inability to retain staff), resulting in potential failure to deliver the Integrated Plan in 2011/12.
- Yorkshire and the Humber SHA: The potential for risks to be realised is heightened in the context of transition.
- Yorkshire and the Humber SHA: Organisation and system instability due to transition following publication of the White Paper. The risk is likely to remain high until new systems become fully established.
- East of England SHA: Consortia will not be developed quickly enough to take over from PCTs the mantle of delivering QIPP. The system becomes unable to improve quality and productivity as quickly as required to deliver necessary outcomes.
Safeguarding Children
- London SHA: There is a risk that any breach of compliance with the policy for safeguarding children, dilution of expertise within NHS London or wider workforce i.e. loss of substantive Designated/Named professionals, and weaknesses in information sharing systems and processes may increase or create a risk to children in London. The consequences of this may be preventable harm to children, damage to the reputation and loss of public confidence in NHS London and the NHS in London.
- Lambeth PCT: Failure to ensure that children and adults at risk of abuse are identified by our providers and independent contractors
- Devon NHS: Risk that there is a serious child safeguarding concern around inequity of provision across NHS Devon to provide safeguarding liaison services for vulnerable children admitted to RD&E, North Devon and DPS MIUs. The impact of not providing the paediatric posts could result in non identification of potential safe-guarding issues through lack of communication and lack of information sharing process between agencies. This is a recommendation following serious case reviews of 2007/08.
- Rotherham PCT: High profile lapses in Child Protection processes leading to a child suffering harm. National and local Serious Case Reviews demonstrate gaps in service.
- Great Western Hospitals: Health Visitors not always aware when children DNA appointments as letters no longer copied to Child Health notes (and notes becoming unavailable) - risk of HV not being aware of child protection issues and CP processes of child being less than optimal as a result.
Maternity Services
- London SHA: There is a risk that women may be exposed to unsafe services / systems/ processes which could cause them harm if NHS London fails to implement a comprehensive approach to planning the capacity of maternity services and capability of the workforce.
- East of England SHA: The number of midwives does not increase sufficiently and the target ratio is not met. Increase in adverse outcomes in maternity services. Women’s perception about 1:1 care in Labour.
- Outer North East London PCT: Assurance of safety and quality of maternity services.
Patient Safety
- London SHA: There is a risk that patients may be exposed to unsafe systems/processes which could cause them harm if NHS London fails to implement a comprehensive approach to patient safety, including the management of Serious Incidents. There is also a risk of failing to identify seriously under-performing organisations at an early stage, if a sufficient assessment and escalation framework is not managed by the NHS in London. The consequence of this could be poor or unsafe care for patients and loss of public confidence in healthcare in London.
- Sussex PCT: Ongoing lack of clarity regarding the procedures and processes for the future delivery of some key governance systems e.g. professional performance, potentially resulting in a reduction in the effectiveness of patient safety and accountability arrangements.
- Rotherham PCT: We fail to maintain improvements in quality of commissioned services. Pressures on commissioned services have increased due to the requirements for efficiency savings.
- Royal Surrey County Hospital: Failure to deliver required reduction in levels of Hospital Acquired Infections, or to comply with screening targets.
- NHS South Gloucestershire: As a result of below target performance by GWAS there is a risk that the Category Red (Emergency) and Category Green (Routine) Ambulance Standards will not be met in 2011/12, which may result in PCT failure to meet national targets, poor patient service and potential patient risk.
Waiting Times
- Sussex PCT: Capacity issues in neurosurgery and neurology are causing long waits for treatment (non urgent appointments up to 39 weeks from referral). Median waits and 18 week performance will be below target for quarter 4 and potentially quarter 1 in 2011/12.
- Surrey PCT: Performance measures as set out for 18 weeks are not met due to a loss of capacity or focus or availability of funding.
- South Gloucestershire NHS: A&E 4 hr waits: There is a risk that NBT/UHB (and consequently the PCT) may not achieve the national target for 4 hour waits which may result in poor service for patients and PCT failures to meet a national target and associated CQC rating.
Winter Plans
- London SHA: There is a risk that winter plans may not be sufficiently robust in order to ensure business continuity during pressure surges over winter 2011/12. This includes an additional aspect of the risk which is associated with a lack of clarity over the introduction of new clinical A&E indicators. The consequences could be compromised clinical care and patient safety, the failure of the 95% operational standard for A&E waits and a concomitant impact on other trust services, as well as considerable damage to the reputation of NHSL and the wider NHS in London in failing to manage the pressures of winter effectively.
Social care
- Lambeth PCT: Reduction in social care funding impacting on the ability to deliver required changes.
- Devon PCT: Risk of lack of appropriate staff and capacity to investigate cases identified by the serious case review group or individual whole home safeguarding alerts which could lead to severe risks for vulnerable adults and censure for NHS Devon. In particular capacity of community nurses an issue. Volume and severity of cases unpredictable.
- Rotherham PCT: High profile lapse in Adult Protection processes leading to an adult suffering harm. National and local Serious Case Reviews demonstrate gaps in service provision to protect adults.
- North Central London: Quality outcomes for end of life care not met; reputational risk; Avoidable admissions to hospital; Increased costs.
Commissioning
- Lambeth PCT: There is a risk that primary care professionals and the wider workforce may not engage in the development of the emerging GP consortia leading to failure to robustly prepare for clinically-led commissioning.
Quality
- Devon PCT: Limited staff transfer from Torbay and Plymouth commissioning teams to cluster team leading to inadequate support for patient safety and quality.
- Devon PCT: Risk that NHS Devon as leading commissioning authority cannot guarantee compliance of providers with redesign plans and initiatives which will adversely impact on the whole care delivery system. Financial benefit realisation will not be achieved so quality of care and health inequalities benefits will suffer. National and political uncertainty also clouds the issues.
- South Central SHA: Risk that the pace and scale of reform, if coupled with savings being achieved through cost reductions rather than real service redesign, could adversely impact on safety and quality; with the system failing to learn the lessons from Mid Staffordshire and Winterbourne View.
- Yorkshire and the Humber SHA: Productivity gains are at the expense of quality (as measured by safety, clinical effectiveness and patient experience) and safeguarding.
- East of England SHA: Loss of quality and quantity of services through period of transition and potentially thereafter.
- East of England SHA: Quality Assurance. Loss of training approval or trainee related safety issue.
- East of England SHA: GPs are not engaged in QIPP. The system becomes unable to improve quality and productivity as quickly as required to deliver necessary outcomes.
- Great Western Hospitals: Quality of care compromised due to deployment of extra bed spaces.
- South Gloucestershire NHS: Continuing Healthcare – as a result of CHC team capacity there is a risk that the backlog of CHC cases will increase and obligatory reviews are not undertaken, resulting in poor service for existing and potential patients, potentially unnecessary costs for placements no longer meeting patient need and potential complaints, litigation and reputation risk for the organisation.
Staffing
- Devon PCT: Risk that the full range of medicines management priorities will not be delivered due to staffing vacancies this may also compromise patient safety and NHS Devon's performance against CQC standards.
- Devon PCT: Risk that the Primary Care Support Service (PCSS) will be unable to provide all their expected functions due to low staffing levels.
- Manchester PCT: Workforce Development - Concern continues to be expressed across the PCT and CCGs that lack of capacity presents challenges to delivery.
- Yorkshire and the Humber: Uncertainty about the future affects the capacity and capability of SHA staff and undermines the SHA’s ability to deliver its objectives, sustain governance and accountability arrangements, remain fit for purpose and true to its corporate values.
- East of England: Emerging consortia will not have the right calibre of people to support them in their development. The system becomes unable to improve quality and productivity as quickly as required to deliver necessary outcomes.
- NHS Northamptonshire and Milton Keynes PCT: Failure to deliver NHSN objectives, business continuity and statutory functions due to lack of capacity, capability, retention and availability across the workforce resulting from the proposed Health & Social Care Bill.
- NHS Northamptonshire and Milton Keynes PCT: Local deployment plans are at risk due to uncertainty in the delivery of compliant systems by Connecting for Health (CfH) (IM&T) Lack of capacity to deliver financial management, skills and operations to the organisation (Fin) Capacity & capability is reduced due to loss of staff (PH) Failure of orthotics contract to meet clinical demand and address waiting list concerns (OP)
- Sussex PCT: Significant organisational changes lead to a potential loss of current relationships which have been established with local partners resulting in a lack of system leadership.
- East of England SHA: Mission critical staff in all disciplines will leave during the transition leading to system failures. Effect on delivery of QIPP and service delivery.
Children’s health
- Rotherham PCT: A generally poorer quality of life will be experienced if children are not supported to prevent overweight and obesity. Leading to long term health problems.
- Lambeth PCT: There is a risk that we will not meet the child obesity targets as set by the National Childhood measurement programme.
- Lambeth PCT: Risk of not meeting children's immunisation national targets and seasonal flu targets/ and risk of uptake rates decreasing. The majority of immunisation are delivered by primary care whilst the majority of risk assurance is around the community provider.
Real-terms funding cuts and efficiency
- Rotherham PCT: We fail to maintain improvements in quality of commissioned services. Pressures on commissioned services have increased due to the requirements for efficiency savings.
- Sussex PCT: Significant medium term financial challenge to the PCT caused by a reduction in real terms funding and a lack of an underlying surplus resulting in potential reductions in services or budgetary overspend.
Patient data
- Devon NHS: Risk that insufficient Information Governance training for all staff may lead to breaches in confidentiality, data integrity and loss of data. The use of the CfH IG Training Tool (IGTT) has become a mandatory requirement. The IGTT is not being used as a a matter of policy. A failure to use the IGTT and monitor staff completion of required IG training will result in a failure to meet the required scores in the annual IG Toolkit in 2010/11. Should NHS Devon suffer a breach in confidentiality, it would have no defence against accusations of negligence if the Trust has not complied with CfH IG training requirements.
Public health
- Rotherham PCT: Poor outcomes, early death due to current obesity services not having the capacity to make an impact proportionate to the scale of the problem.
- Rotherham PCT: Life expectancy of people living in deprived areas is significantly lower than these living in other parts of Rotherham.
- Rotherham PCT: Undiagnosed CVD leading to increased morbidity and premature death. High demand on primary & secondary care services.