In January (2014) I wrote a blog regarding the setting of the threshold for the ‘duty of candour’ suggesting Mr Hunt had ignored advice from David Behan on the inclusion of ‘moderate harm’. Since writing the Department of Health Media Centre contacted me, via Twitter, to tell me Mr Hunt had not, as I suggested, ignored David Behan. After several requests to the media centre for further clarification they have now sent me a link to a document published in March this year entitled ‘Introducing the Statutory Duty of Candour: A consultation on proposals to introduce a new CQC registration regulation’.
I think this was supposed to clarify the issue for me, instead it has left me somewhat perplexed. It appears health and social care will be using different thresholds.
In the regulations, the harm threshold for healthcare is set at the threshold recommended by Dalton/Williams to include ‘moderate’ harm. This means that all harm that is classified as moderate or severe or where ‘prolonged psychological harm’ has arisen gives rise to a Duty of Candour to the service user, or a person lawfully acting on their behalf. The Duty will also apply in cases of death, if the death relates to the incident of harm rather than to the natural course of the service user’s illness or underlying condition.
For Adult Social Care
‘……..we intend to use the existing CQC notification requirement for ‘serious injuries’ as the Duty of Candour harm threshold for adult social care. The notification requirement for serious injury is broadly similar in scope: CQC has indicated that it covers the ‘severe’ and some of the ‘moderate’ harm categories recommended by Dalton Williams. It also covers prolonged psychological harm. Thus for adult social care providers, the duty will apply to death, serious injury, some moderate harm and prolonged psychological harm, broadly consistent with the application in the NHS’.
So, there we have it. I wonder how the ‘some’ moderate harm threshold will be implemented in practice.
As this is a consultation document I thought I would respond with my thoughts on the matter, however, this document was sent to me on the day the consultation closed. The consultation period seems a tad short (26th March – 25th April), I wonder has anyone responded?
If I had responded I would have said in my view to really change the culture of care that currently exists in some areas of health and social care we need to take a zero tolerance approach to harm, whether its mild, moderate or severe, it has no place in health and social care . Thresholds that are confusing, and complexly defined, will do nothing to change organisational cultures. What they will do is send mixed messages to providers, managers and employees because basically they are saying a little bit of harm is acceptable and indeed, even ‘some’ moderate harm might be okay!
The truth is the type of harm that was perpetrated against patients at Mid Staffs and places like Winterbourne View did not start at the thresholds now being suggested, they started with low-level abuse and failures to address them, probably they did not meet a ‘threshold’ for intervention, and so a culture developed where many began to accept the unacceptable as ‘normal’ practice.
If we needed a lesson on how to take something positive that could bring about substantial change and make it so complex it is unworkable, this is probably it.