Health Protection Agency Coordination and publication of providers' information on healthcare associated infections
The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health and Social Care Information Centre.
- UKHSA operates the mandatory surveillance programme for healthcare associated infections (HCAI), publishing data on each NHS trust's performance in relation to MRSA bacteraemia, Clostridioides difficile infection, Escherichia coli bacteraemia, Klebsiella species bacteraemia, and Pseudomonas aeruginosa bacteraemia. Data is published at trust level and is publicly accessible (UKHSA HCAI mandatory surveillance, GOV.UK).
- The Health and Social Care Information Centre (now part of NHS England) collaborated with PHE (now UKHSA) on the publication and dissemination of HCAI data. HCAI data is published through the UKHSA data dashboard and Fingertips public health data tool, providing trust-level, ICB-level, and national-level analysis (UKHSA Fingertips, GOV.UK).
- NHS England includes HCAI reduction objectives in the NHS Standard Contract. Trusts are required to have infection prevention and control programmes and to report HCAI data through mandatory surveillance. CQC monitors compliance with Regulation 12 (safe care and treatment) which includes infection control requirements (NHS Standard Contract; SI 2014/2936, Regulation 12).
How was this evidence gathered?
Response
Accepted
Response
AcceptedThe government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS). NRLS fully decommissioned 30 June 2024. LFPSE has broader coverage including primary care, uses machine learning for analysis and improved trend identification.
Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework from Autumn 2023. Shifts from individual blame to system-based learning approaches. Mandatory for all NHS-funded secondary care providers. Part of NHS Patient Safety Strategy (July 2019).
HSSIB formally launched 1 October 2023 as independent statutory body under Health and Care Act 2022. Replaced HSIB (non-statutory, established 2016). Has statutory "safe space" protections, powers of entry, inspection and seizure. Conducts system-focused patient safety investigations.
Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.
Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.
Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.