NHS England and NHS Improvement
HSIB recommends that NHS England and NHS Improvement urgently issue definitive guidance on the role, function, and key attendees of the medical gas committee. This guidance should identify and encourage key multidisciplinary relationships and board level reporting of medical gas issues.
The NHS Estates team within NHS England and NHS Improvement has been and continues to be committed to supporting the NHS response to the COVID-19 pandemic. Our priority is to ensure that NHS estates and facilities meet the needs of patients and front-line staff during the pandemic and longer term. NHS estates and facilities has made strides since the start of the pandemic. This includes updating the primary guidance to the NHS oxygen and other related gases: “Health Technical Memorandum (HTM) 02-01 NHS estates guidance for medical gas pipeline systems” which is currently ongoing. This will reflect the recommendations raised by the Healthcare Safety Investigation Branch in this report including in relation to the qualification and experience of staff and the role, functions, and key members of the medical gas committee.
In addition we are looking at how we can better centrally support the provision of medical gases in the NHS both locally and nationally, drawing on the experiences and lessons learned from the NHS response to the COVID-19 pandemic.
The updated version of “Health Technical Memorandum (HTM) 02-01 NHS estates guidance for medical gas pipeline systems” will include more detail on the membership of medical gas committees and their responsibilities.
The Terms of Reference for such committees are included in the “Performance of healthcare cryogenic liquid oxygen systems – mitigating the effects of current and future pandemic demand” document.
Response received on 17 September 2021.
NHS England and NHS Improvement
HSIB recommends that NHS England and NHS Improvement review and further specify the key roles, responsibilities and competencies of individuals identified in the health technical memorandum (HTM) for medical gas pipeline systems, including identifying how the appointment and training of designated officers may be supported.
The current version of “Health Technical Memorandum (HTM) 02-01 NHS estates guidance for medical gas pipeline systems” includes the identification of key personnel in relation to medical gas systems e.g. Authorising Engineer (MGPS).
The revision of this document will explore this area further including identifying how the appointment and training of designated officers may be supported.
Response received on 17 September 2021.
NHS England and NHS Improvement
HSIB recommends that NHS England and NHS Improvement implement a process to provide ongoing assurance on the qualifications and experience of individuals identified in the health technical memorandum (HTM) for medical gas pipeline systems (MGPS), including how MGPS Authorising Engineers, or their subcontractors, are appointed by NHS trusts.
This issue is being explored partly through the updating of the HTM, but also more widely. The approach of creating an assured and certified central register of appropriately qualified and experienced MGPS Authorising Engineers is being developed and will be launched in parallel with the publication of the HTM.
Response received on 17 September 2021.
NHS England and NHS Improvement
HSIB recommends that NHS England and NHS Improvement completes ongoing work to review, revise and reissue the health technical memorandum (HTM) for medical gas pipeline systems (MGPS). An updated HTM should reinforce multidisciplinary team working and include:
- Updated advice on the type and design of MGPS infrastructure recommended for NHS trusts.
- Enhanced processes to encourage shared working between clinical and nonclinical teams on MGPS issues.
- Specifications for the relevant levels of competence and training for NHS staff on MGPS.
- Any updated processes or guidance generated in response to the other safety recommendations specified in this report (R/2021/120, R/2021/132, R/2021/133).
The update of the “Health Technical Memorandum (HTM) 02-01 NHS estates guidance for medical gas pipeline systems” has started and it will include consideration of all the recommendations raised by the HSIB in this report.
Response received on 17 September 2021.
Care Quality Commission
HSIB recommends that the Care Quality Commission reviews and adapts its assessment model for NHS hospital estates to ensure greater scrutiny of estates related safety concerns.
We welcome this report, which shines a light on an estates issue that can have a significant impact on patient safety. We are committed to working with partners, including NHS Estates, to ensure that where there are concerns about the management and governance of estates issues, we can act upon these in a timely and effective manner.
As we develop our new regulatory model, we will ensure that the management and governance of estates issues is reflected in our trust level well-led framework. We will explore ways of working with NHS Estates (and other relevant partners such as the Health and Safety Executive) that enable them to raise with us any assurance concerns they have, and provide the technical expertise to help us respond to such risks appropriately.
Establish contact with the NHS Estates team with regards to the recommendations made to our respective organisations in this report . Timeline: September 2021 complete.
Develop options with NHS Estates for how the data and assurance gained through the NHS Premises Assurance Model (PAM) can be utilised in our new regulatory approach. This will focus on:
- How the analysis NHS Estates carries out on the PAM can be shared with us, so that there is clear and early identification of possible risks
- What specialist support and advice NHS estates can provide inspection teams in responding to these risks.
Timeline: December 2022.
Response received on 17 September 2021.