Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern

Welcome to another Risk Register. This week we finally have some insight into safe staffing work by NHS Improvement, more leaks on junior doctors contracts, CQC budget cuts and some good news for mental health.

Contact me in confidence here.

Shaun Lintern, patient safety correspondent

Doing the same thing over and over…

It is almost a year since NICE was told to suspend its safe nurse staffing programme and despite promises of new guidance by December nothing has so far emerged from NHS England or NHS Improvement. Speaking with HSJ last week Dr Ruth May, NHS Improvement’s executive nurse director, said she wanted to move away from giving guidance to the NHS and instead return to an era of local discretion albeit with regulators measuring a number of indicators to safeguard quality of care.

Dr May deserves credit for engaging on this issue, which has left the reputations of both the government and NHS England bruised after their actions last year. But NHS Improvement’s approach has real risks. We have been here before: at a time of a national nursing shortages and serious financial constraints, local discretion on nurse staffing translates into unacceptable variation. The NHS has always had local discretion, and the results have been wards where nurses are expected to care for far more patients than is safe and where HCAs are routinely swapped for nurses despite research evidence showing both approaches are associated with poor care and higher mortality.

That is a real situation in parts of the NHS today. Let’s have evidence based guidance, developed by experts, and let’s be honest about how far we are from an acceptable standard and seek a plan to close that gap. Local discretion shifts the responsibility and blame on local trusts – but national nursing shortages, policy distractions and underinvestment are not of their making.

NHS industrial relations reaching new low

Another week, another leak. Insiders are continuing to send us revealing information from both sides of the junior doctors’ contract dispute. It is clear that not everyone in Tavistock House supports the approach being taken by the British Medical Association’s junior doctors. Earlier this month we revealed Dr Johann Malawana’s pleas to exclude paediatrics from this week’s emergency care had been rejected. And a new leak last week showed junior doctors’ leaders considering the unthinkable: an indefinite strike.

But within the NHS support for the government is fast waning too as the costs of the strike action continue to mount. It is approaching millions of pounds in lost elective activity for some NHS trusts. So unsurprisingly I have also received leaks from the NHS side – notably one from a trust leader unhappy at an attempt by NHS Improvement to obtain evidence that junior doctors are refusing to engage with trusts.

Leaving aside the rights and wrongs of the dispute - the undercurrent of mistrust, anger and frustration on both sides will have long term consequences.

Maybe if we could find a way to put the unhappy BMA insiders in a room with the unhappy NHS managers we might actually end up with a solution to this mess.

The CQC must not lose its focus

It is intellectually lazy to say regulation doesn’t work and the NHS would be better off without the CQC. Such commentators play to the crowd of healthcare professionals and managers who understandably don’t enjoy the accountability regulation brings, but it also ignores the evidence that CQC inspections, while far from perfect, are publicly revealing some unpalatable truths about the NHS and forcing them to be tackled.

There have been some embarrassments – long delays in its inspection programme and the recent predictable trouble in recruiting a national whistleblower guardian. Still, under David Behan the CQC has improved dramatically and we have been approaching an appropriate and effective model of regulation.

But the CQC, as an arm’s length body, is now seeing its budget being cut by £13m. It has now said it will need to rely on more intelligence and self-assessment by providers – something that has been tried before and that has failed to spot serious problems.

This year the CQC’s leaders are tasked with the challenge of maintaining its improved standard of inspection while dealing with shrinking resources. While they do, the service will need the regulator to keep its focus on its fundamental role: to maintain the safety of care for patients.

Go get ’em, Claire

I have long been a fan of Central North West London Foundation Trust chief executive Claire Murdoch – a widely respected registered mental health nurse running one of the largest community and mental health providers in the country.

So it was with some delight that the news of her appointment as NHS England’s national mental health director was received this week. It is an astute move by Simon Stevens to give one of the mental health sector’s leading lights a chance to nudge the Skipton House behemoth in the right direction on mental health – something that has been long promised, yet remains to be delivered.

Claire has a reputation for being an outspoken advocate for mental health services and patients, and also for being balanced and realistic in her criticisms of system leaders that have so often failed to deliver. She will need to marshal all her skills in the new role to ensure CCGs deliver on the commitment to invest in mental health, and to focus national leaders on the sector at a time when acute care seems to have such a monopoly on attention.

The Risk Register wishes her well.