The must-read stories and debate in health policy and leadership.

Unintended consequences

Last week, HSJ revealed NHS England’s attempt to impose stricter conditions on the publication of national clinical audit reports. This week, clinicians have told HSJ patients are being put at risk by the subsequent delays.

At least one national clinical audit has been delayed for more than two months — its publication was only granted this week after HSJ put questions to NHS England to seek an explanation for the hold up.

Why are patients at risk because of a report being unpublished, some might ask? Clinical audits draw on real data from the frontline, with doctors and other staff putting in huge amounts of effort to ensure a full national picture of the care provision is available.

The audits are then able to analyse outcomes and performance, and reveal the variations in care and substandard practice in some locations.

Publication means local trusts can focus efforts on improving and have an awareness of where they are falling short. Delays mean the NHS is aware of these variations and problems, but no action is being taken to communicate that to the service.

Royal colleges – which were initially reluctant to put their heads above the parapet – have now found their voice and the Academy of Medical Royal Colleges council will discuss the “significant concerns” later this month.

NHS England insists its new process is designed to improve the audit process and quality of reports. The effect of this heavy handed control of the message may be an unintended consequence, but it’s one NHS England needs to seriously address as the UK’s reputation for clinical audit is being seriously put at risk.

Playing it safe

Taking an organisation out of special measures is a finely balanced decision. Many will still be in the early stages of improvement with little evidence that change has been embedded consistently across the organisation. At the same time, leaving special measures can be a significant morale booster and may drive further improvements.

Unfortunately, in recent years, a number of organisations have fallen back into special measures. Norfolk and Suffolk Foundation Trust slipped back in last year, as did Northern Lincolnshire and Goole Hospitals FT and United Lincolnshire Hospitals FT. Arguably, there are others which should never have been allowed to exit the regime in the first place and remain perilously close to the edge.

So the Care Quality Commission may be playing it safe with South East Coast Ambulance Service FT. It has raised its rating to “requires improvement” but said more time is needed to see if changes are embedded before deciding on whether to take it out of special measures.

There have certainly been improvements at SECAmb, especially around organisational culture. It has a permanent board in place after a period where every post seemed to be filled by an interim. It is recruiting more staff and getting more ambulances. Its performance against many indicators is improving.

But challenges remain: the emergency operations centre still faces staffing issues and struggles to answer all calls promptly. People who are not critical emergencies still wait too long for an ambulance. And the cultural change is not evenly spread across the organisation.

The CQC is well aware winter tends to test ambulance services as much, if not more, than other parts of the health service. It should be no surprise it has erred on the side of caution at this point in the year. Next summer, if it reinspects, it may feel differently.