Health and Social Care Committee
The work of the Healthcare Inspectorate Wales
Evidence from the Healthcare Inspectorate Wales – HIW 22
Health and Social Care Committee
Inquiry into the work of Healthcare Inspectorate Wales (HIW)
Evidence from Healthcare Inspectorate Wales
1. Introduction
HIW was established in 2004 as the inspectorate of healthcare in Wales. Since then it has taken on a range of new functions:
2006 Independent healthcare
Statutory supervision of midwives
2007 Clinical reviews of deaths in prison
Homicide investigations
Nurse agencies
Ionising Radiation (Medical Exposure) Regulations
Youth Offending Teams
2008 Substance misuse
2009 Responsibilities from MHAC
Registration of private dentists
Deprivation of liberty safeguards
2011 New regulations for independent healthcare
Each of these new functions has reinforced the fundamental role of HIW as the lead inspectorate for healthcare in Wales.
The existence of a dedicated healthcare inspectorate has a number of advantages
However, the model is not without its challenges as there will inevitably be interfaces with the responsibilities of other review bodies. Effective collaboration can overcome most of these challenges and a particular focus during the coming year will be on how future inspection arrangements might need to develop to reflect the direction of travel towards more integrated care.
The role and purpose (included at Annex A) on which HIW is based remains sound, but we have been reflecting on the Francis Inquiry into Mid Staffordshire NHS Trust; the Keogh Report; and the challenges facing healthcare in Wales to assess whether the expectations of what we should deliver are clear and are capable of being met. It is clearly important that HIW considers the implications for its activity and has begun to do so. It is planned to publish a business plan later in the autumn for public consultation that will set out our response.
2. The effectiveness of HIW in undertaking its main functions and statutory responsibilities
3. The investigative and inspection functions of HIW, specifically its responsibility for making sure patients have access to safe and effective services and its responsiveness to incidences of serious concern and systemic failures
The approach taken by HIW to delivering its functions is rooted in a strong values and ethics base which has led to some clear strengths. In particular:
· Our inspection activity is clearly focused around the needs of priority issues and vulnerable groups, for example our inspections of Dignity and Essential Care (DECI), Cleanliness and Infection Control, Mental Health and Learning Disability services
· We use a range of approaches to inspection and review which enable us to get to the heart of the issues, ranging from the use of validated self-assessment, direct inspection, through to supported peer review
· Our teams of reviewers are designed to be appropriate to the issue being examined and can include a mix of HIW Inspectors, lay reviewers and specialist peer reviewers. This helps to ensure that the interests of patients are reflected and that the findings of the review have professional credibility
· We test what we are told through direct observation and through discussions with relatives, patients and staff
· We ensure that we get a full and accurate picture of the care received by patients by conducting inspections unannounced, out-of-hours and at weekends
· Where appropriate we undertake joint reviews with other inspectorates to ensure efficiency and effective utilisation of skills; for example our work with the Prison and Probation Ombudsman to undertake clinical reviews of deaths in custody and our work with Her Majesty’s Inspectorate of Probation to review health aspects of Youth Offending Teams.
· We are commissioned by the Welsh Government to review the circumstances where service users known to mental health users are involved in a homicide
We also adapt our work programme to accommodate targeted reviews where concerns are identified; for example the programme of reviews of independent learning disability and mental health providers following Winterbourne View, and governance reviews such as that of Betsi Cadwaladr University Health Board. In undertaking such reviews we work jointly with other regulators and inspectors where it is appropriate to do so.
Our business plan in the autumn will also identify areas for further development.
4. The overall development and accountability of HIW, including whether the organisation is fit for purpose
HIW has been particularly effective in maximising the impact of its capability and capacity through collaboration; drawing on the work of others where appropriate; and more recently through supporting the introduction of peer review in cancer and palliative care services. The utilisation of panels of lay and peer reviewers has also provided a cost-effective way of ensuring that patients are kept at the heart of our work and that specialist expertise informs the work that we do.
However, in line with other parts of the public sector HIW has faced financial challenges. The organisation has also experienced high levels of vacancies which have proved difficult to fill. This has made it difficult for HIW to contribute as consistently and effectively across the full range of responsibilities as it might.
The role and purpose of the organisation remains sound and the organisation is already employing approaches which draw directly on the experiences of patients. However, the environment in which HIW operates is undergoing significant and rapid change. The scale of the challenges facing healthcare in Wales, the rising expectations and scrutiny of healthcare regulators and inspectors, has led to a fundamental stocktake of the capability and capacity required by HIW to deliver against its range of functions. This stocktake is being captured in the business planning process and as stated above the results will be published later in the Autumn. This will show the organisation’s strengths as well as areas where it needs to develop further.
Although technically part within the Local Government and Communities Department of the Welsh Government HIW is, quite rightly, independent from Ministers, particularly those responsible for Health and Social Services. This independence is protected by a protocol between Welsh Ministers and the Chief Executive of HIW. This arrangement has so far proved effective. An area where governance could be strengthened is by the addition of a Strategic Advisory Board which would provide scrutiny and challenge to the work of HIW as well as acting as a champion for HIW where appropriate. There are plans to develop proposals for such a Board in the coming months.
5. The effectiveness of working relationships focusing on collaboration and information sharing between HIW, key stakeholders and other review bodies
HIW has a strong history of close and collaborative working with others. Within Wales, HIW is a signatory to the Concordat for Health and Social Care and the Working Collaboratively to Support Improvement : A Strategic Agreement. More broadly across the UK and beyond, HIW maintains good links with UK and European regulatory bodies, helping to ensure our work is both informed by and influences the development of effective inspection, investigation and regulatory practice.
Within this framework, HIW:
§ Contributes to the further development of the professional practice of inspection, audit and regulation by sharing inspection tools and other resources; jointly developing and accessing shared learning and development provision; and participates in peer review activity;
HIW also works together with NHS local health boards and trusts; independent healthcare providers and Welsh Government policy officials to create a common understanding of what we can do collectively to improve healthcare in Wales by:
§ Encouraging healthcare organisations to strengthen their own governance and assurance arrangements so that they ‘get things right’ first time through better self assessment and targeted self improvement
§ Engaging and involving clinicians and other healthcare professionals directly in our work programmes, eg., as ‘peer’ members of our review teams or by providing advice on the scope and approach to our work programmes. In this way we hope to contribute to healthcare professionals ‘continuing professional development’ and facilitate the transfer of learning back into healthcare organisations.
§ Leading the development of more effective peer review arrangements. The introduction of Peer Review ‘lite’ in Wales has involved working with senior cancer and palliative acre clinicians from across Wales to identify the fundamental standards against which the approach should be developed
HIW considers these arrangements to be generally well developed overall
6. Consideration of the role of HIW in strengthening the voice of patients and the public in the way health services are reviewed.
HIW aims to work closely with patients, service users, carers, their families and the public more generally. This helps us to understand people’s needs and preferences, to learn from their experiences of health services and to promote openness and transparency about the quality of healthcare. We involve citizens directly in our work by:
§ Providing information on the quality and safety of healthcare through the publication of our reports.
However, there is a need to build upon and further strengthen our existing arrangements. For example, action is underway or has been planned, to:
§ complete a recruitment, induction and training process for new lay reviewers
§ further develop our links with third sector organisations to cover the widest range of participation, including older people, people with a disability, carers and children’s services
§ establish improved ways of working directly with carers, service user and patient representatives to ensure we are better able to gain their views and further strengthen their participation in our work
§ further enhance our working relationship with Community Health Councils nationally and locally
§ improve our website and the accessibility of information to the public and stakeholders.
7. Safeguarding arrangements, specifically the handling of whistleblowing and complaints information.
HIW recognises the potential vulnerability of anyone accessing healthcare services and we have a specific statutory responsibility to safeguard and promote the rights of children. Our work programmes, inspection tools and work practices focus on the extent to which healthcare service organisations provide appropriate support to individuals during their involvement with health services. We deliver a number work programmes that focus on ensuring the well being and human rights of individuals from specific service user groups are safeguarded; such as our mental health act monitoring service; as well as focused work programmes designed to respond to concerns in key service areas, e.g., services for people with learning difficulties and services for older people.
We are a “prescribed body” under UK whistle blowing laws.
HIW’s statutory role does not routinely include investigating individual concerns or complaints received by patients or the wider public about the particular circumstances of an individual patient’s care and treatment. Nor does it have a specific role with regard to individual complaints about professional misconduct, change to service configurations or specific matters which are subject to legal process.
The exception to this may be complaints from people (or their representatives) whose rights are restricted under the Mental Health Act and other relevant laws about the way healthcare staff have used their powers.
HIW may also receive information on complaints from other agencies/bodies with a role in the review of healthcare provision, for example the Public Services Ombudsman for Wales and Community Health Councils.
However, even though we cannot normally investigate an individual concern or complaint about health services, we may follow up issues raised by an individual concern if there is a possibility of wider, systemic issues within an organisation.
HIW takes very seriously any concerns raised with us that indicate the decisions and actions of a healthcare provider may have an adverse impact on the quality and safety of healthcare provision. Where this is the case, we determine what action may be needed (taking account of the nature of the disclosure or concern or the number of similar concerns received about a health service) and whether or not we are best placed to take forward any such action. In making such a determination, we take into consideration whether the concerns raised may have already been subject to earlier scrutiny by other public bodies.
We will be developing our arrangements in this area to foster a greater public awareness of our role in relation to concerns and complaints; and to ensure that our intelligence systems provide sufficient early warning of themes and trends that may require specific action.
Annex A
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Purpose HIW is the lead independent inspectorate for healthcare in Wales. Its purpose is To provide independent and objective assurance on the quality, safety and effectiveness of healthcare services making recommendations to healthcare organisations to promote improvements |
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Our role § To independently inspect and report on the quality and safety of the provision of healthcare by NHS bodies in Wales § To inspect and regulate independent healthcare providers in Wales § To discharge specific statutory responsibilities on behalf of Welsh Ministers § To provide independent and objective information to patients and the public |
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The outcomes we seek to influence § Citizen experience of healthcare is improved § Citizens are able to access clear, timely, honest information on the quality, safety and effectiveness of healthcare services in Wales § Citizens are confident that inspection and regulation of the healthcare sector in Wales is sufficient, proportionate, professional, co-ordinated, and adds value |
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Our values Central to everything we do, our values establish the fundamental principles that govern the way we carry out our work. They are: § Centred on patients, service users and citizens § Openness and honesty § Collaboration, sharing our experiences amongst ourselves and with other review bodies § Efficiency, effectiveness and proportionality in our approach § Supporting and encouraging learning, development and improvement
§ Professionalism
§ Driven by intelligence |