Organisational duty of candour procedure: first year review

4. Findings from Annual Report Analysis  

This section describes this review's findings, which were informed by analysis of the annual Duty of Candour reports for the first year (2018/19). These sections reflect the structure of Part 2, Section 24 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016. The findings and associated observations are aimed at NHS Scotland rather than any particular Board. 

4.1. Analysis of First Year Annual Reports 

Duty of Candour Reports were initially analysed using a customised framework to map compliance with the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 - Part 2, Section 24: Reporting and Monitoring, which governs what an annual Duty of Candour report should include. A quick-check mapping table of the 2018/19 Board reports can be seen in Appendix 5.

4.1.1. Preparing and Submitting Report 

Part 2, Section 24: Reporting and Monitoring point 1 stipulates that "A responsible person who provides a health service, a care service or a social work service during a financial year must prepare an annual report on the duty of candour as soon as reasonably practicable after the end of that financial year."

For the majority of Boards point 1 was met within an adequate time frame. By November 2019 the majority of Boards had either contacted the dedicated Duty of Candour mailbox within the department to inform that their annual report had been published publically or was ready to view, or had published their report on their public website. However, one Board has yet to publish its report (see Appendix 5). It is also of note that the majority of Primary Care providers have not as yet published a report. Those that did notify the Scottish Government that they published represent a very small proportion of overall Primary Care providers in Scotland, and are skewed towards certain Boards (See Appendix 5). I understand that NHS Highland emailed a reporting template to all the GP practices that were contracted to them and that this worked well.

4.1.2. Report Information Required 

Part 2, Section 24: Reporting and Monitoring point 2 stipulates that "The report must set out in relation to the financial year— 
(a) information about the number and nature of incidents to which the duty under section 21(1) has applied in relation to a health service, a care service or a social work service provided by the responsible person,
(b) an assessment of the extent to which the responsible person carried out the duty under section 21(1),
(c) information about the responsible person's policies and procedures in relation to the duty under section 21(1), including information about –
(i) procedures for identifying and reporting incidents, and
(ii) support available to staff and to persons affected by incidents."

Most Board reports complied and met expectations in regards to point 2. However, there were some exceptions. Five Territorial Boards, three Special Boards, and one Primary Care Provider failed to comply with various sub-sections of point 2. This included several reports that did not include information on the number and type of incidents to which the Duty of Candour applied; assessments to the extent to which duty of candour was carried out, and the type of support available to staff and persons affects by incidents which triggered the duty of candour procedure. 

Of the reports that did not meet expectations under point 2 and its sub-sections, the most common exclusion was the type of support available to staff and persons affected by incidents, or if this information was included, it tended to cite staff undertaking the duty of candour e-module, instead of outlining practical or psychological support available for those members of staff affected. 

4.1.3. Report Confidentiality 

Part 2, Section 24: Reporting and Monitoring point 3 stipulates that "A report must not—
(a) mention the name of any individual, or
(b) contain any information which, in the responsible person's opinion, is likely to identify any individual."

Almost all submitted annual reports complied with point three and all sub-sections. The protection of patient confidentiality should be upheld continuously and when preparing the annual duty of candour reports, even more so. This was for the most part, upheld.  However, one report, from a Primary Care provider, did not fully meet expectations in regards to point 2, sub-section (b), in which a recommendation for further learning placed the onus of the incident occurring on the patient involved. If viewed by the patient in question, they could be identifiable. 

4.1.4. Appropriate Reporting 

Part 2, Section 24: Reporting and Monitoring point 4 stipulates that "The responsible person must publish a report prepared under subsection (1) in such manner as the responsible person thinks appropriate."

All annual reports that the Scottish government were notified about were prepared with sub-section one in mind, and were deemed by the responsible person to be appropriate for submission. However, the available report template provided to those preparing an annual report was only a suggestion. Following the provided template was not a requirement for the first year of reporting on duty of candour. As such, the overall quality of reporting varied quite widely, making standardised analysis difficult. 

4.1.5. Notification of Publication

Part 2, Section 24: Reporting and Monitoring point 5 stipulates that "On publishing a report, the responsible person must notify—
(a) Healthcare Improvement Scotland, in the case of a report published by a responsible person which provides an independent health care service (within the meaning of section 10F(1) of the 1978 Act),
(b) the Scottish Ministers, in the case of a report published by any other responsible person which provides a health service,
(c) Social Care and Social Work Improvement Scotland, in the case of a report published by a responsible person which provides a care service or a social work service."

Under point five, sub-sections (a) and (c) were not applicable to the annual report analysis due to only analysing annual reports published by the territorial Boards, special Boards, and Primary Care providers falling under GPs, Dentistry, Pharmacies, and Optometrists. Those providing independent health services as defined under sub-section (a), and those providing care or social work services defined under sub-section (c) were not captured for analysis this year. 

Of those services required to notify the Scottish Ministers as defined under sub-section (b), sixteen out of the twenty-three annual reports analysed met expectations by notifying the dedicated duty of candour email inbox. The others published their reports, but failed to report the publication to the dedicated inbox. 

4.2. Good Practice in the Annual Reports

There were several examples of good practice present in the annual duty of candour reports published for 2018/2019. This included; clear examples of what improved as a result of reviewing duty of candour incidents, and transparent reporting where the template was used. 

Reports produced by NHS 24, NHS Ayrshire & Arran, and Dumfries & Galloway include transparent, clear examples of incidents that triggered the duty of candour procedure, and the subsequent learning and improvement as a result. These examples illustrate a clear understanding of the duty of candour procedure and reporting requirements, as well as the expectations of an open and transparent culture in which learning can come from unintended incidents. An example includes NHS24 updating relevant clinical and operational processes, ensuring that NHS24 staff do not raise expectations when arranging an onward referral for patients.  This was implemented following an incident where a patient was told that they would be seen at out of hours by a doctor specifically. NHS24 have reviewed all guidance and processes to ensure that staff are instructed that when arranging an onward referral for patients not to set  expectations on the level of  health professional that will see them at the out of hours services. 

Several reports were also produced in a clear and transparent style. The reports that contained examples of good practice were those that followed the duty of candour report template and guidance booklet information. 

Another example of good practice to note was demonstrated by those Boards who were transparent as to the extent they followed the duty of candour procedure. Instead of treating this section as a closed question, they elaborated as to the extant or lack of in their opinion in which they met the stipulations as laid out in the duty of candour procedure, showing an alignment to a culture of openness and learning.