The remit of NCEPOD

The Company's objects are to assist in maintaining and improving standards of healthcare for the benefit of the public (such term to include members of the public for the time being serving a term of imprisonment) by reviewing the care of patients, by undertaking confidential surveys, and by publishing and generally making available the results of such activities.

How do NCEPOD studies work?

Typically there are not always agreed standards with which NCEPOD can compare current practice. If there were an agreed standard then all our work could be defined as audit, where the question to be answered would be "Does this service reach a predetermined standard?". Usually we are asking a question more akin to: "What standard does this service achieve?". In order to assess the standard, NCEPOD initially uses a technique to identify the key components of a service and their importance.

NCEPOD can therefore state that its work:

  • Does not involve new treatments
  • Does not involve additional therapies or investigations
  • Does not involve allocation to treatment groups
  • Does not involve randomisation.
In general, therefore, ethical research approval is not required for its studies. For each study it undertakes NCEPOD will ask the following questions to ensure that this remains the case:
  1. Does this study involve a new treatment?
  2. Does this study involve an additional therapy or investigation(s)?
  3. Does this study involve allocating patients to different groups not chosen by the healthcare practitioner/patient?
  4. Does this study involve randomisation?
  5. Is there any other reason why the Steering Group think advice should be sought?
If any of the answers to these questions are 'yes', then advice will be sought from the Health Research Authority (HRA) before proceeding. HRA have agreed the above approach.

(To read more about the work programme we submit to the Health Research Authority (HRA) and ethical approval please click here.)
How does NCEPOD select studies?

Each year, NCEPOD invites organisations or individuals to submit original study proposals for consideration as possible forthcoming studies. Proposals should be relevant to the current clinical environment and have the potential to contribute original work to the subject. Organisations or individuals wishing to submit a study proposal are required to complete a Study Proposal Form, which is available to download from this website.

How do we disseminate our findings and recommendations?

All reports are created as a full version and as a summary. These reports and summaries are sent to Local Reporters and Ambassadors for onward dissemination to consultants and other healthcare professionals within their hospitals.

During the year NCEPOD staff visit hospitals (by invitation) and give presentations as part of multidisciplinary meetings such as audit days. This provides an excellent opportunity to discuss the ways in which clinicians participate in morbidity and mortality audit and to examine the ways in which recommendations made by NCEPOD should be addressed within the local setting.

What happens if we find a case that gives us cause for concern?

Cases that cause NCEPOD concern are referred back to the Medical Director of the Trust/Health Board concerned in order that appropriate action may be taken. Consultants involved with the case are also notified. This approach was given support by the GMC in 1998 and 1999 and was ratified by the NCEPOD Steering Group in March 2001, April 2005, and agreed by HQIP in 2013.

How are we governed and funded?

NCEPOD is independent of Government bodies and the professional associations. NCEPOD is both a charity and a company limited by guarantee.

NCEPOD has a board of directors that are referred to as the NCEPOD Trustees. This board oversees the charitable and corporate governance of the organisation. The members can be seen on the Trustees page In addition, we also have the NCEPOD Steering Group. Members are nominated representatives of the various medical Royal Colleges and Associations and lay representation. There are also observers on the group from HQIP, the Coroners Society, the Royal College of Surgeons of Edinburgh, and the Royal College of Physicians of Edinburgh. This board ensures the clinical integrity of the work that NCEPOD undertakes.

The work is commissioned by the Healthcare Quality Improvement Partnership HQIP on behalf of the funding bodies listed below and additional funding by  independent sector hospitals.

CPD Accreditation for completing NCEPOD Questionnaires

Consultants who complete NCEPOD questionnaires make a valuable contribution to the investigation of patient care. Completion of questionnaires also provides an opportunity for consultants to review their clinical management and undertake a period of personal reflection. These activities have a continuing medical and professional development value for individual consultants. Consequently, NCEPOD recommends that consultants who complete NCEPOD questionnaires keep a record of this activity which can be included as evidence of internal/self-directed Continuous Professional Development in their appraisal portfolio.

Can an individual refer a case to NCEPOD?

NCEPOD is an organisation in which currently practising clinicians review the management of patients undergoing medical and surgical care by undertaking confidential surveys and reviewing care provision and resources in the units carrying out the care. The surveys cover all units which provide the care being considered and the results are promulgated in regular reports in which comments and recommendations are made to suggest ways in which healthcare practice can be improved to the public benefit.

Primarily, the organisation exists to alert clinicians and hospital management to practice which may not have been of the best quality and to recommend improvements. It does not audit individual clinician's performance and it has no direct involvement in individual patient care and is not able to provide medical opinions or to recommend specialists. If you require help in these matters please contact your general practitioner who will be able to direct you appropriately.

The requirement to participate in the work of NCEPOD?

Under the National Clinical Audit and Patient Outcome Programme (NCAPOP) participation in the Clinical Outcome Review Programme into Medical and Surgical Care, and Child Health Review is mandated. The GMC states that clinicians should take part: Good Medical Practice states "You must take part in systems of quality assurance and quality improvement to promote patient safety". In particular Item (a) states "To help keep patients safe you must contribute to confidential inquiries". (Para 23 Good Medical Practice 2013). Additional guidance from the GMC on confidentiality also states that "There are circumstances in which you should disclose relevant information about a patient who has died" Para 137 states that this should be disclosed "when it is necessary to support the reporting or investigation of adverse incidents, or complaints, for local clinical audit, or for clinical outcome review programmes." The documents cover clinicians working in both the NHS and the independent sector.

The NHS Quality Accounts in England have classified participation in our work as a requirement.

The Scottish Government request participation by Scottish Health Boards.

Guidelines on Compliance with NCEPOD

NCEPOD regards compliance for individual clinicians as: completing NCEPOD questionnaires when requested to do so, and taking cognisance of recommendations arising out of our reports which are relevant to their practice. Clinicians may also wish to use our audit tools in order to facilitate local audits. This activity should be considered during their annual appraisal.

Trusts/Health Boards should:

  1. Provide support for the NCEPOD Local Reporters and individual clinicians in order to permit them to contribute to NCEPOD studies.
  2. Appoint an NCEPOD Ambassador to support the Local Reporter where necessary.
  3. Consider all NCEPOD recommendations, and record an action plan detailing how those recommendations of relevance to their Trust/Board are to be or not to be implemented, with reasons.
  4. Support those clinicians who are appointed as advisors or experts to participate in NCEPOD studies.