[Relevant documents: Sixth Report from the Health Committee, Session 2008-09, HC 151, and Government Response, Cm 7709.]
Motion made, and Question proposed, That the sitting be now adjourned.—[Mr. Watts.]
May I say how pleasant it is to serve under your chairmanship for the first time, Mr Russell? Just before close of play in terms of the parliamentary timetable, I am pleased that we have the opportunity to discuss our patient safety report and the Government’s response. I intend to give a broad-brush speech explaining why we took up the report, some of the evidence that we took and some of the recommendations in the Government’s response.
“Do no harm” is a fundamental principle of medical practice that goes back many thousands of years, but there has always been scope for patients to be harmed accidentally. That is an issue in all areas of clinical practice and all types of health care systems around the world, however they are funded or organised. Reviews of patients’ case notes indicate that in health care systems across the developed world, about 10 per cent. of people admitted to hospital suffer some form of harm, much of it avoidable. Indeed, the report states that 50 per cent. of harm created in our health care system is avoidable.
The national health service in England treats huge numbers of people—1 million every 36 hours—and the vast majority receive safe and effective care. Over the years, however, notorious cases have illustrated how badly things can go wrong. In the 1990s, patient safety became an important issue in the NHS following the inquiry into the Bristol Royal Infirmary, where unsafe heart surgery on young babies had had fatal consequences. In 2000, an expert group convened by the chief medical officer published “An organisation with a memory”. That document acknowledged that in most cases when patients are unintentionally harmed, the harm is not down to negligence or serious incompetence on the part of individuals, but to unsafe systems and ways of working.
The expert group recommended that patient safety in the NHS be improved by the creation of a national patient safety incident reporting system, so that lessons could be learned and repeat incidents avoided. The group recognised that the system needed to be underpinned by a culture of openness and “fair blame”, allowing people to report incidents without fear of being unfairly made to shoulder all the responsibilities when systems were at fault.
The Government accepted the expert group’s recommendations and created the national reporting and learning system and the National Patient Safety Agency. That made the Government one of the first in the world to attempt to address patient safety systematically across an entire health care system.
Despite nearly a decade of emphasis on patient safety as a policy priority, major lapses in safety have continued to come to light in recent years. At Stoke Mandeville hospital, and at Maidstone and Tunbridge Wells NHS Trust, there were stark failures in preventing and controlling health care associated infections, with, sadly, some disastrous consequences. At Mid Staffordshire Foundation Trust, wholly inadequate accident and emergency care led to unnecessary deaths and suffering, while at Basildon and Thurrock University Hospitals NHS Foundation Trust, poor hygiene and unacceptably high death rates also came to light. Against that background, we must ask how far the Government’s policy has succeeded in reducing harm to patients and what more needs to be done, and we decided to conduct our inquiry on that basis.
We found that although reporting is useful for learning from incidents, it is not a reliable way of measuring the extent of harm. Judging the overall effectiveness of patient safety policy is made difficult because of the failure by the Department of Health to collect adequate data. Despite all the policy innovations of the last decade, it is apparent that there has been insufficient progress in making services safer. Indeed, underlying Lord Darzi’s emphasis on quality and safety in the next stage review of 2008 was a tacit admission by the Government that not all services are safe enough yet.
Patient safety is a multifaceted issue that touches on many aspects of the NHS, and we examined in some detail those we regarded as the most important. We concluded that there were significant deficiencies in current policy, and we recommended several changes that were needed to bring about further progress in tackling unsafe care. To monitor whether services are being made safer, data on the incidence of harm must be systematically collected. The best available means of doing that is to review samples of patients’ case notes at periodic intervals in order to calculate a rate of harm. We concluded that such a review should be undertaken by all hospitals, and that data produced in that way should be gathered together by the NPSA.
In their response, the Government told us that the high cost of large-scale record reviews, and the need for extensive involvement in them of people with clinical expertise, meant that they could not be conducted frequently. However, they did agree that small-scale, local case note reviews were vital in helping NHS organisations to measure their performance.
When patient safety incidents occur, harmed patients and their families or carers are entitled to receive information, an explanation, an apology and an undertaking that the harm will not be repeated. We found that too often that does not happen and we felt that recent changes to the NHS complaints system were unlikely to improve how the service treats complainants. Patient advice and liaison services should be provided independently of the NHS organisations to which they relate, and not by in-house staff, as happens at present. The independent review stage of the complaints process, which the Government abolished nearly a year ago, should be reinstated—the Committee has said that before. However, once again, the Government failed to agree with those recommendations.
Harmed patients are currently forced to endure often lengthy and distressing litigation to obtain justice and compensation. There will not be many hon. Members of the House whose case work does not suggest that; I have a case in my constituency that has lasted for more than a decade, and it has still not been resolved. At the same time, NHS organisations are obliged to spend considerable sums on legal costs, and are encouraged to be defensive when harm occurs. Four years ago, Parliament passed legislation to enable the Department of Health to introduce the NHS redress scheme, removing the need for litigation in many cases. However, the Department has not implemented the scheme, and seems not to have a timetable for doing so.
In responding to our report, the Government insisted that their reforms of the NHS complaints system had made the NHS redress scheme unnecessary. However, I say to my hon. Friend the Minister that that prompts the question as to why the Government bothered to take up Parliament’s time putting through legislation that now seems to be unnecessary.
The NRLS is collecting significant amounts of data that are being used to help make services safer, but significant underreporting remains, particularly for incidents in primary care, medication incidents, serious incidents and reporting by doctors. We found that a major reason for underreporting is the persistent failure to eliminate the blame culture. Another important factor is fear of litigation or prosecution, which underlines the need for the Government to address the medico-legal aspects of patient safety. We particularly recommended the decriminalisation of dispensing errors on the part of pharmacists. The apparently now redundant NHS redress scheme also seems relevant to that issue.
The one-size-fits-all nature of reporting systems seems to be a significant cause of underreporting, for example by GPs. We thought that as much as possible of the data collected by the NRLS should be published, and we welcome the decision to start publishing reported data broken down by individual NHS organisations. We had some criticisms of the policy on data collection; we thought there had been too much emphasis on gathering summary data on common or less serious incidents.
The NRLS should be gathering more in-depth information on serious and sentinel events—those needing an immediate investigation and response, as they involve death or serious injury, or the risk thereof. We thought that that particularly applied to the less common types. Also, there must be much wider and better use of root-cause analysis, which is an investigative method designed to identify the underlying causes of an incident, with a view to preventing its repetition. Although the patient safety observatory, which is a part of the NPSA, was already collating data from a variety of sources other than incident reports, we thought that doing so should become a key priority for the NPSA.
We found that, too often, although patient safety solutions were well known, there was a failure to adopt them where they were needed—on the front line of the NHS. Solutions are handed down from on high as diktats—if they are passed on at all—without clinicians being convinced of their effectiveness. We had a number of clear examples of that. Moreover, a culture persists in which various types of easily avoidable harm are seen as inevitable risks of treatment.
However, safety improvements can be fully integrated into front-line services by engaging and involving clinicians and other health care workers. That has been shown in schemes such as the safer patients initiative and the productive ward programme, which have been successfully adopted at a number of hospitals. We made visits to a number of hospitals to look at that issue. We were particularly impressed when we visited Luton and Dunstable hospital, which is an exemplar of good practice on patient safety in the NHS. We heard that central venous line infections, which clinical staff had previously regarded as a normal risk of that type of treatment, were now very rare and seen as exceptional occurrences.
We were particularly struck by the fact that the NHS lags unacceptably behind other safety-critical industries in recognising the importance of effective teamworking and other non-technical skills. Health care clearly has much to learn from other industries such as aviation in that regard. We took evidence from a person who has worked as an adviser to the aviation industry. When things go wrong in that industry, they are reported and lessons are learned immediately. Although we cannot do a complete read-over on that, the NHS and its health professionals could do far worse than accepting that when things go wrong, we should learn the lessons, and we do not learn the lessons if they are not brought to the fore.
We found that inadequate staffing on the front line had been a major factor in undermining patient safety in a number of notorious cases. Given the recent huge increases in funding and staffing overall in the NHS, it seems inexcusable that some services have ended up being run with too few doctors or nurses, to the extent that safety has been compromised and patients harmed.
A number of years ago, the Committee produced a report on NHS work force planning, and found that when there were overshoots, in terms of taking people on, or when there were major increases in the NHS work force, that was not necessarily related to service improvement. Targets for more doctors and nurses were set centrally, and I am very pleased that the Government provided exactly that, but we need to look at where that takes place.
We heard that several technologies could make significant improvements to care, but were being implemented far too slowly. Examples include automated decision support systems, including electronic prescribing support systems—that seems a pretty obvious one to us—and automatic identification and data capture technology, such as barcoding. We have heard in different parts of not just this country but the world about exactly how barcoding can ensure that people do not suffer any harm. The most classic example that we saw was at Charing Cross hospital. It had a system whereby patients were barcoded, so that when people went to the patient’s bed and scanned the barcode, information immediately came up on what medication the patient needed at that time of the day, and on the right quantity as well.
It is extraordinary that medication error causes a lot of harm in the acute sector of the NHS. When people take a prescription home from the pharmacist, they might misuse the medication, but medication being misused in the acute hospital sector is not acceptable. In the case of Charing Cross, two individuals watch each other as they put the medication in the right quantity into the—I was going to say “contraption”, but that is not the word. They put the medication into a dispenser, which they take on to the ward. It was shown that that system, which was an attempt to avoid medication error in that hospital, had reduced and further reduced human error. Another example is the electronic patient record. You will know, Mr. Russell, that we have commented on that before in our reports.
We were alarmed at the lengthy delay in developing spinal needles that cannot be connected to a Luer syringe, which is a simple technical solution to a known and potentially lethal problem. It is unacceptable that the NHS does not have a mechanism to ensure that such changes, which impact seriously on patient safety, occur in a timely fashion. It is not the first time that the Health Committee has considered that particular issue and made recommendations on it. Since we published our report, significant progress has been made on non-Luer spinal connectors. In November, the NPSA issued a patient safety alert, which I am told should mean that the new connectors are in commercial production soon and in use across the NHS by next year. We will all be very pleased that that is happening, but it makes us wonder how long we have to keep making the call before someone takes action to try to avoid the situations that we have found.
We found serious deficiencies in the undergraduate medical curriculum, “Tomorrow’s Doctors”, which were detrimental to patient safety, in respect of training in clinical pharmacology and therapeutics, diagnostic skills, non-technical skills and root-cause analysis. We said that those issues should be addressed in the next edition of “Tomorrow’s Doctors”, and we understand that that is in hand and will happen.
We concluded that patient safety must be fully and explicitly integrated into the education and training curriculums of all health care workers. In addition, there should be much more interdisciplinary training; those who work together should train together. That is important. I have knowledge of medical training from the time when I was a lay member of the General Medical Council, and what is rightly being said to trainee doctors and others is that we cannot avoid all aspects of harm to patients. However, because we cannot avoid all harm, I wonder whether it is being said that some of it is inevitable, and that nothing can be done about it. We believe that through the consideration of systems, something can be done about it.
Each time that a major patient safety scandal has come to light, the Government have assured us that it is a unique case and that no other NHS bodies are in the same situation—and then, normally, within about three to six months, we get an example that seems to disprove that. Such cases are extremely rare, but we thought that there were too many gaps in the current arrangements for commissioning, performance management and regulation to be able to say with certainty that there are not further, as yet undiscovered, cases. That is probably a good maxim for everyone to use in the health care system. The case of Basildon and Thurrock University Hospitals NHS Foundation Trust, which I have mentioned, and which emerged after we published our report, seems to prove the point. People said, “Well, things are okay now,” but clearly they were not.
A key role for primary care trusts in commissioning services is to ensure the quality and safety of those services. However, we have had grave doubts about whether all PCTs are doing so. We welcomed the principle of linking payment by PCTs to the quality of care, but recommended that that be piloted first. We supported the use of never events by PCTs, but had doubts about whether they should involve a financial penalty. We recommended that that be piloted, too. We shall pass further comment on that in the next few days, with the publication of a report on an inquiry that we have undertaken in relation to commissioning.
We found that the performance management role of strategic health authorities appeared to be a bit ill defined and to vary between SHAs. We recommended that the Department of Health produce a formal definition of that role. In their response, the Government said that the new SHA assurance framework would clarify the SHAs’ role. We welcome that.
We found that the regulation of health care has been too rule-based, looking at processes and procedures rather than outcomes and consequences or professional competence. Consequently, the annual health check did not pick up major failings in some cases. We believe that the Care Quality Commission’s registration system, which is to be introduced this year, should focus on the outcomes being achieved by NHS organisations rather than on formal governance processes.
There remains concern about the role of self-assessment in regulation. That was undoubtedly a weakness in the annual health check. Indeed, that was confirmed this week by the widespread lapses in hygiene standards that the Care Quality Commission uncovered when inspecting 167 trusts on that aspect of care as part of the transition to the new registration system.
We felt strongly that the relationships between bodies responsible for commissioning, performance management and regulating NHS service providers were not sufficiently defined. Baroness Young, then chair of the Care Quality Commission, told us that there were
“a lot of players on the pitch”.
We thought that the rules of the game were none too clear. In particular, there was a lack of clarity about the role of Monitor, the foundation trust regulator. It is rather like a moving picture, and I know that the Minister will want to bring us up to date.
We told the Department of Health that it should produce a succinct statement on how commissioning, performance management and regulation are defined, and how they, and the organisations responsible for them, relate to each other. The Department said in its response that that would be included in the next NHS operating framework.
The report on the Mid Staffordshire NHS Foundation Trust by Robert Francis QC was published last month. It seems to vindicate our concerns. Mr. Francis recommended that the Department
“should consider instigating an independent examination of the operation of commissioning, supervisory and regulatory bodies in relation to their monitoring role at Stafford with the objective of learning the lessons about how failing hospitals are identified.”
I am pleased to say that the Department accepted that recommendation. Mr. Francis has agreed to chair the new inquiry.
We took evidence not only about Mid Staffordshire but about management and governance in other places. We found disturbing evidence of catastrophic failure on the part of some senior managers and boards, including at Mid Staffordshire. Although other boards are not failing as comprehensively, there is substantial room for improvement. Boards too often believe that they are discharging their responsibilities in respect of patient safety by addressing governance and regulatory processes, but we believe that they should be promoting tangible improvements in services.
We believe that there is a case for providing specialist training in patient safety issues, particularly to non-executive directors, in order to help them scrutinise their executive colleagues and hold them to account. Patient safety must be the top priority for boards; to show that that is the case, it should without exception be the first item on every agenda of every board. It is remarkable that that was not the case when we investigated the situation. It is difficult to comprehend why that should be so, in view of the harm that is done to patients.
We recommended to NHS organisations the measures that were piloted as part of the safer patients initiative. They included implementing tried and tested changes in clinical practice in order to ensure safe care; banishing the blame culture; providing the leadership to harness the enthusiasm of staff to improve safety; and changing the way in which they identify risks and measure performance, using information about actual harm done to patients, such as data from sample case note reviews.
I remember very well our visit to Luton and Dunstable hospital. I was interested to note that when something had gone wrong no one thought to consider what had happened in order to find out what lessons could be learned. They undertook systematic reviews of patient case notes to ensure that patients going through their hospital were getting the best and safest care. It is not only about investigating something when it goes wrong but about considering the system as a whole, including the management of patients, to ensure that nothing more can be done to lessen potential harm.
We strongly endorsed the Department’s view that NHS boards should not always meet behind closed doors. We urged the Government
“to legislate as necessary to ensure that Foundation Trust Boards meet regularly in public”.
The Government said in their response that they were
“considering what legislative or other changes may be necessary or desirable in the light of recent events in Mid-Staffordshire”.
Since then, the Francis report has concluded that the board at Mid Staffordshire discussed “far too much” business in private, giving the impression
“that only good news is discussed in public while the bad is hidden behind a curtain of secrecy.”
The Secretary of State responded by telling the House that there is a “strong presumption” that foundation trust board meetings
“should be held in public and that governors should have access to all papers”.—[Official Report, 24 February 2010; Vol. 506, c. 312.]
However, he did not mention any plans for new legislation, instead invoking the spirit of the existing law on foundation trust status. I would be interested to hear the Minister’s comments on that, and if we are not to have new legislation, how that change can be implemented.
We said in our report that the NHS remains largely unsupportive of whistleblowing, with many staff fearful of the consequences of going outside official channels to bring unsafe care to light. We recommended that the Department should bring forward proposals on how to improve the situation. Here too, we had Mid Staffordshire very much in mind.
The previous Secretary of State told the House last year that it was a mystery why no one had blown the whistle at Mid Staffordshire, given the existence of legal protection for whistleblowers. However, our evidence led us to conclude:
“Many healthcare workers remain fearful…that if they whistleblow they will be victimised.”
Indeed, that conclusion was made also by the Francis report.
We recommended that the Department should
“bring forward proposals on how to improve this situation and that it give consideration to the model operated in New Zealand, where whistleblowers can complain to an independent statutory body.”
The Government, I am pleased to say, accepted that recommendation. It is no good our passing laws in our legislative Chamber to protect whistleblowers if they are still fearful. The Francis report again vindicated our conclusions, finding that the Mid Staffordshire Trust had not offered the support and respect due to those brave enough to become whistleblowers. In response, the Secretary of State announced that a group had been established to advise him on updating NHS whistleblowing guidance.
We thought that the Government should be praised for being the first in the world to adopt a policy that makes patient safety a priority. However, Government policy has too often given the impression that other priorities—notably hitting targets for waiting lists and accident and emergency waiting times, achieving financial balance and attaining foundation trust status—are more important than patient safety. Everyone will say that that is the impression being given, but it is not so. Reading such stories in the media over the past few years, that often seems to have been the case for the defence. I hope that that is not so. No case can be made for the neglect of patients, whether in the acute sector or even the primary sector. I hope that the Government are conscious of the fact that there are some basic principles when it comes to ensuring that we look after our patients as safely as we can.
All Government policy in respect of the NHS must be predicated on the principle that the first priority, always and without exception, is to ensure that patients do not suffer avoidable harm. The key tasks of the Government, we said, were to ensure that the NHS
“develops a culture of openness and ‘fair blame’”—
we all make mistakes; indeed, incidents from this House reported in the media over the past 18 months show that many here make mistakes from time to time—
“strengthens, clarifies and promulgates its whistleblowing policy”—
I am pleased that that will happen—
“and provides leadership which listens to and acts upon staff suggestions for service changes to improve efficiency and quality and, by the provision of examples and incentives, encourages and enables staff to implement practical and proven improvements in patient safety.”
In addition, we argued that the Government should examine the contribution that deficiencies in regulation make to failures in patient safety. I am pleased to note that the Government again seem to be acting on some of the issues raised in the Francis report.
Finally, there is no health care system in the world that can be said to have completely solved the issue of patient safety. We can be proud of the fact that over the past decade, the NHS has been a pioneer in developing policies and systems to address patient safety. However, many things still need to be put right before the whole NHS—not just its best parts—is ensuring that patients are not avoidably harmed. I hope that our report can be said to have made a contribution to bringing that about.
I thank the Chair of the Select Committee for introducing the debate. The House has allocated us three hours—or until 5.30—in which to discuss the report. There is no requirement for us to fill those three hours. There is sufficient time for everybody to have their say. Let me inform Members that we have two doctors, two nurses, a pharmacist and a research immunologist among us, so we can safely say that the expertise and experience of the outside world is brought into this Chamber.
It is a pleasure to serve under your encouraging and benign chairmanship, Mr. Russell, and to follow the Chair of our Health Committee. I am pleased, too, that five of the really active members of our Committee are present in the Chamber.
I am accused at home of doing this job as a hobby. If someone’s hobby is something that really interests them and it is their job as well, it is marvellous. One of my hobbies for years and years has been to try to improve the national health service for the patient, and that is exactly what this report is about. I shall speak very briefly about a few of the recommendations and then concentrate on three of them. I will try not to overlap too much with our Chair. The first recommendation draws attention to the use of the words “safety” and “quality” in the Darzi review, and the second to the safer patients initiative, to which our Chairman referred and which we went to see in Luton and Dunstable. The Government welcomed both recommendations.
Recommendations 5 and 41 reminded the Department of the value of random case note review. When I was a practising physician some years ago, we used to dread the visits of the royal colleges to examine our wards and our care because they would look in the note trolley and pick out any note, so we had to have all the notes written up without any gaps. The Committee wanted to emphasise the importance of such a review and, as part of the safer patients initiative, Luton and Dunstable had taken it on board.
Recommendation 41 said:
“We recommend the DH consider how to reinstate the best aspects of the Royal Colleges’ inspections in the new system.”
The Government’s response stated:
“The Government agrees that the new system of registration could usefully take account of previous experience in related fields, including the Royal Colleges’ inspection of hospital training posts. We will draw this recommendation to the attention of the CQC.”
That was excellent.
Recommendations 9 to 11 talk about the NHS complaints process, which the Chairman also mentioned. The loss of the independent review of a complaint before it goes to the ombudsman is, as far as I am concerned, pretty much a disaster. If I am lucky enough to be back here in the next Parliament and back on this Committee, one of the things that I will be pushing for is an inquiry into the NHS complaints process, because it needs yet another review. Recommendation 24 emphasises the importance of training in non-technical skills, such as teamwork, communication and leadership, all of which are vital and should be taught.
There are three areas that I want to cover at greater length: the electronic patient record in recommendation 32; human factors and error, which are covered by recommendations 34 and 35; and, inevitably, Staffordshire and whistleblowing, which the Chair of the Select Committee also mentioned.
In recommendation 32, we deplored the delays in the electronic patient record and welcomed, of course, the marvellous success of the picture archiving and communication systems. We particularly deplored the delays in the summary care record, although the Government response said that
“good progress is now being made in delivering the Summary Care Record.”
The Committee heard about varying numbers of general practices that have the summary care records up and working. We asked for details of those practices to see whether any were in our home areas, so that we could visit them to see how they were getting on.
I have been very surprised by the complaints that have come out recently, from the British Medical Association in particular, about confidentiality, because it is a matter that should have been sorted out ages ago. In France—I will not attempt to use a French accent here—the patient owns their summary care record and can therefore censor whatever is on it. If a person writes their own summary care record with their GP, they will only put on the things that are essential for safety in the middle of the night, and I see nothing wrong with that. We also saw the ideal summary care record in Canada. Called the patient lifetime record, it was designed by Infoway on a single computer screen. I have said many times that the Department of Health is making the summary care record too complex.
On our visit to the US, concerns were expressed about the idea of trying to introduce a huge computer system with a big bang approach. Clinicians need to be involved in the design, and patients must be made to understand the huge advantages of having a summary care record, especially if they are taken unconscious into an accident and emergency department in the middle of the night.
Moving on to recommendations 34 and 35, which cover human factors, it is quite obvious that patient safety should be in postgraduate training. Our Chairman went back several thousand years to “First, do no harm” or “primum non nocere”, and I can go back to 500 BC to Aeschylus, who had a very reassuring quote:
“Even he who is wiser than the wise may err.”
That gives us all some encouragement. In 1690, in an essay concerning human understanding, John Locke said:
“All men are liable to error”
and very worryingly, he added:
“and men may be as positive in error as in truth.”
Even now, we can see people trying to defend the indefensible. I shall come to that a bit later. Let me refer Members to a post note, written in June 2001, called “Managing Human Error”. The overview is so good that I will have to read it.
“Human error is inevitable. Reducing accidents and minimising the consequences of accidents that do occur is best achieved by learning from errors, rather than by attributing blame. Feeding information from accidents, errors and near misses into design solutions and management systems can drastically reduce the chances of future accidents. Hence, studying human error can be a very powerful tool for preventing disaster.”
That is a very good summary.
Let me broaden the debate and talk about medical errors because they are a bugbear to patient safety. I shall mention just four complaints that have come across my desk relatively recently. First, let me say that I am not perfect; I have admitted in this Chamber to a desperate mistake that I made as a junior houseman, and there were certainly other errors. However, I take encouragement from Aeschylus, who said that even the
“wisest of the wise may err.”
The four complaints that I want to draw attention to provide absolute lessons. The Minister will remember from her nurse’s training that a patient losing their false teeth or glasses in hospital is an absolute disaster, because such things can never be found or replaced. In the first of my four cases, an elderly patient with mild dementia lost his false teeth. Despite his complaining of difficulty swallowing, it took three weeks and a request for an endoscopy for staff to discover that the false teeth were stuck within sight at the back of his throat. Nobody had done a proper examination or even looked down his throat, which is appalling.
In another case, nobody recognised that a small boy was ill, purely because nobody had taken a proper history or done a proper physical examination. The defence—the case went to the Care Quality Commission, and we got a whitewash report—was that doctors do not examine the chest now. The hon. Member for Dartford (Dr. Stoate) will remember that we were taught that physical examination consists of inspection, palpation, percussion and auscultation.
I remember that one entirely; we were all told that.
Inspection, palpation, percussion and auscultation are absolutely crucial, but nobody had listened to this kid’s chest or tapped it, which is what Auenbrugg, the inventor of percussion, did on beer barrels. I am afraid that poor little kid died after several apparent examinations by the NHS.
In the third case, there was a failure to recognise that a patient who could not stand up because his blood pressure fell every time he did so was actually having a gastrointestinal haemorrhage, which proved fatal. The failure to spot it was the result of total diagnostic incompetence, but so far it has been defended through a whitewash, and I am fighting for an external inquiry.
The last case, which is very current and very sad, involves a girl of 15 with glandular fever who also had a fatal septicaemia that killed her. Nobody had sufficient experience to recognise that people do not die of glandular fever and that something else must have been going on. The attending doctors had inadequate experience, and nobody with experience intervened.
That gives me a chance to mention a booklet called “Front Line Care”, which is dear to the Minister. Its first recommendation is:
“Nurses and midwives must renew their pledge to society and service users to tackle unacceptable variations in standards and deliver high quality, compassionate care.”
It was a nurse who said that the girl who was dying could go home. Where are the good, old-fashioned matrons and ward sisters, who sail round in proper uniforms, know when people are ill and actually tell the doctors when they are missing something?
Two of the cases that I mentioned in fact involved rare diagnoses, and I am not saying that everybody should be able to make a rare diagnosis. However, people must be able to spot whether somebody is ill. In a very good article in The Times on 15 March, Liam Donaldson drew attention to the poor awareness of rare diseases. Again, we are not all expected to make the best diagnosis in the world, although it is very exciting when we do, but doctors and nurses must have the basic ability to know when somebody is ill, and then jump up and down until something is done about it.
Recommendations 44 and onwards are about Staffordshire and the inability of so many people there to spot what was going on. There has been a valuable spin-off from the Stafford disaster, in that great interest is now focused on patient safety. There are now open board meetings, board members are involved with safety and there is an awareness of the importance of whistleblowers and their problems. On 12 March, an article in The Times said:
“The Toyota Way is famous…In reality, the Toyota Way is to ignore warnings from within the firm”.
It was clear from the report that workers at Toyota had pointed out the deficiencies in quality control as long ago as 2006, but their whistleblowing had been completely ignored.
Two things led me to use my opportunity to introduce a private Member’s Bill to support whistleblowers. I wanted to call my Bill the “NHS Whistleblowers Support Bill”, but I was not allowed to, because the word “whistleblower” is apparently non-parliamentary language. Instead, my Bill was called the National Health Service Public Interest Disclosure Support Bill, which is a mouthful.
There were two reasons why I pushed for the Bill. The first was obviously Stafford. As our Chair said, there were whistleblowers there, but their whistleblowing was blocked before it got to board level, and they did not know what to do. The first thing, therefore, is to give them a system that allows them to go higher when they get blocked. My second reason for pushing for the Bill was that whistleblowers have come to me at home about the out-of-hours care service. They were frightened for their jobs, so they could not go through the normal channels. They came to me because they trusted me to keep their anonymity and to have the clout to do something, which I certainly did.
The aims of my Bill were to publicise the Public Interest Disclosure Act 1998 and the work of Public Concern at Work, as well as to introduce support officers who would act as accessible and independent listeners, advisers and supporters. That is why I was pleased by the Committee’s recommendation 56 and the Government’s response. Our recommendation said:
“We recommend that Annex 1 of the Health Service Circular…“The Public Interest Disclosure Act 1998—Whistleblowing in the NHS” be re-circulated to all Trusts for dissemination to all their staff as a matter of urgency.”
The Government responded by saying:
“We accept that proposals should be brought forward as recommended to improve protection for whistleblowers. We will consider the practicalities of establishing a model whereby whistleblowers can complain to an independent statutory body.”
They are on exactly the same wavelength as my private Member’s Bill, so perhaps it does not matter that it was filibustered out of existence a few days ago.
Nurses have started really to push for quality. A little time ago, they produced a marvellous document called “Dignity in Care”, and I have already referred to the little booklet called “Front Line Care”. The Royal College of Physicians is also at work and has produced a booklet called “Leading for Quality”, which says:
“At the heart of quality rests safety. Many clinical errors could be avoided if the right information was shared at the right time.”
However, errors and safety are not yet recognised widely enough. I dropped into the Library a few minutes ago and looked at the latest medical dictionary—the 41st edition of “Black’s Medical Dictionary”, which appeared in 2005. Look up “safety”, and the only thing that it mentions is the safety of drugs. Look up “error” and the entries go straight from “eroticism” to “eructation”. It does not even recognise that there could be errors.
I leave the House with my four Cs for quality, and hence safety: care, compassion, communication and continuity.
I want to start by echoing your sentiments, Mr. Russell, about the quality of this afternoon’s debate. As you have already pointed out, the Government and Opposition leads are nurses, and a pharmacist is leading for the Liberal Democrats. An illustrious retired physician is speaking for the Independents, and we also have an immunologist present. In addition, my right hon. Friend the Member for Rother Valley (Mr. Barron), the Chair of the Select Committee, was a member of the General Medical Council for many years. That shows how important the debate is.
I am particularly pleased that my right hon. Friend managed to secure the debate, because there can be no Members of the House who have not had cases in their work load related to patient safety incidents, mistakes and other problems caused by medical treatment. As my right hon. Friend has already pointed out, something like 10 per cent. of people who go to hospital suffer some type of medical error. Many of those can be unpleasant and some are fatal, and half of them at least are avoidable. The issue is clearly of great importance to all Members of the House and of even greater importance to the people who have suffered such problems.
It is worth asking why the rate of patient safety incidents in the national health service is so high. The short answer must be that patient safety is not given the priority it deserves. I remember having only one lecture on the subject as a medical student, from the dean of the medical school. I had just arrived there—brand new; I think it was my first or second week and we had an introductory course by the dean, who said, “I’d just like to tell everyone in this room you’re all going to kill somebody sooner or later, so you might as well get used to it.” He made us all extremely concerned and most of us never forgot that lecture. He may have been harsh, but it stood us in good stead, and we realised that medicine is a dangerous as well as a healing art. The dean woke us up and stopped us short, but did not go much further about how to avoid such things. He just left it at that. Nevertheless it was a useful lesson.
In addition to being a practising GP I chair the all-party parliamentary group on patient safety, so it is particularly pleasing for me to take part in the debate. Much of the problem, as Suzette Woodward of Patient Safety First explained to the all-party group last year, is that trusts face a huge range of competing responsibilities, and find it hard to give patient safety the attention it deserves. I have discovered that patient safety does not even feature among the seven principal assessment domains drawn up by the Care Quality Commission. It is relegated to the status of a sub-category of quality, whereas financial management has a category all of its own. Consequently, many trust chief executives spend a vast amount of time thinking about finance, and little time thinking about patient safety—unless, of course, they are forced to react to a problem that has occurred in their trust.
Research by Patient Safety First, for example, found that 26 per cent. of trusts did not do leadership walkabout checks in hospitals, and that only 18 per cent. of trust boards had patient safety as the first item on their agenda. This week I had a meeting with Mark Devlin, the chief executive of the acute trust in my constituency, Dartford and Gravesham NHS trust, and put that point to him. I breathed a huge sigh of relief when he produced two board agendas and I noted that patient safety was item 1 on both. I am pleased that at least my local trust can show a clean bill of health on patient safety, putting it at the top of its agenda.
Patient Safety First also suggested that there was a lack of clarity about the principles behind patient safety, and a failure to disseminate best practice. One of the problems of the NHS is that it lacks a coherent overall strategy for promoting patient safety. As I have pointed out, medical training is an issue. There are thousands of doctors working in the NHS today who have gone through six years’ medical training with no real formal training on patient safety at all. At the same all-party group meeting I mentioned before, Oliver Warren, a general surgical registrar at the North West London Hospitals NHS Trust, and a member of the National Leadership Council, admitted to us that he had never been given so much as a lecture on patient safety while at medical school. I am sure there are generations of NHS doctors who could tell the same story.
That helps to reinforce the view that patient safety seems to be too mundane an issue for highly qualified clinicians to trouble themselves with. It is a cultural issue that I hope is beginning to fade, and I am pleased that our patient safety report is beginning to move the agenda on. The Government response to many of the points that have been raised shows that the issue is finally taking the central role it deserves. For example, the emphasis on addressing MRSA and clostridium difficile has not only led to a significant drop in the number of cases; it has also forced trusts to think more seriously about disease control. The safer patient initiative is another positive step. The national reporting and learning programmes, which my right hon. Friend has already mentioned, have also been very welcome.
There remains much to be done, however. First, leadership at all levels of the NHS is crucial. Until clinical leads and managers are prepared regularly to spend time hammering home the importance of patient safety it will be hard to move forward. We also need far more transparency and reliable patient safety measurement processes. At present there is a tendency in the NHS not to report incidents, or concerns about colleagues, because of the blame culture that still exists. A formal and, above all, constructive mechanism for reporting errors and concerns needs to be built into the NHS. We need a learning culture, not a finger-pointing culture.
A more open and constructive approach would also help to encourage front-line health professionals and managers to become more proactive about patient safety. Instead of the cautious and guarded approach to patient safety that is taken now in many places, where it is seen primarily as a burden or a potential banana skin, a new approach will hopefully lead to a more positive culture, in which it is seen as a means of driving up standards across the board.
We also need greater continuity of care throughout the NHS, which would also help us to improve patient safety. Patient handovers are particularly important in that respect. A lack of communication between clinicians can easily lead to processes being repeated or, more worryingly, forgotten entirely. It is important, too, that clinicians involved in each step of the patient pathway through the NHS should have an awareness of each other’s working processes. A better working knowledge of the patient journey as a whole would help clinicians to spot potential problems that could have an impact on safety and provide an opportunity for them to work collaboratively to address the issue. A more integrated care model, which would allow primary practitioners and secondary specialists to work alongside one another, could provide real benefits for patient safety.
It has already been mentioned that technology could help to improve continuity of care. Some trusts, for example, have been making use of virtual desktops that enable clinicians to access patient records using interactive bedside systems. That reduces the need for staff to log in and out of numerous systems, and has dramatically improved the risk of clinical error. However, in most parts of the country front-line professionals are not able to get such patient safety access quite so easily.
I have said many times in the House that the fact that pharmacists still cannot get electronic read-write access to the relevant part of the patient record is absurd. I do not know how a pharmacist can carry out a meaningful patient medication review without knowledge of the patient’s history—their medication and allergy history and other important aspects of their care. Nor do I see how they can properly advise GPs how to make sensible medication changes and checks if that information cannot be passed back electronically straight into the patient record. Those parts of the record are essential.
We have already heard that one of the BMA’s objections to the electronic patient record is to do with confidentiality. Of course that is a major issue, but the hon. Member for Wyre Forest (Dr. Taylor) has already addressed it. Surely there must be ways nowadays, with modern computing, to improve confidentiality and safety. We do not often hear of banks losing data wholesale, or of people’s credit card details being bruited about, and if the banks and building societies can introduce safe mechanisms to ensure that there is reliability and confidentiality, surely so can the national health service.
We raised the issue on a visit to the United States to see what happened there. The attitude was completely different. The view was that electronic records were at least as safe as the old, traditional paper records, and the issue, largely, was not taken too seriously. Those we spoke to said that it is possible to break into a surgery and steal patient records, so electronic records must be safer than that, and we should stop getting quite so hung up about the small chance that someone might find out my blood pressure. Frankly, I would not be particularly worried if they did.
If we wish to improve patient safety, the other thing that we must do is listen to patients. They are the only people who see the patient journey right the way through from start to end, and it is a serious mistake to ignore their experiences and insights when building patient safety into clinical practices. We simply cannot afford to continue the “them and us” attitude that has dogged the relationship between patients and clinicians for far too long.
As has already been mentioned, we need to look very seriously at the way that patient safety is addressed in medical training. Teamwork and communication skills are not taught well enough to medical students, even though those skills are vital in promoting safety. NHS employers are also guilty in that regard; most of them do not offer any kind of training in collaborative working or teamwork. That must change. During our inquiry, for example, we heard that teamwork training has the potential to reduce errors by between 30 and 50 per cent.
We should also provide more opportunities for students from different medical fields to train alongside each other. For example, some of our schools of pharmacy and of medicine have experimented with interdisciplinary training. That opportunity has given pharmacy and medical students valuable insights into each other’s professions, which can only help to improve patient safety. Clinical pharmacology and therapeutics are crucial areas of study, but they have long been neglected at medical school. They are obvious examples of subjects that medical and pharmacy students could usefully take together. The failure in recent years to teach medical undergraduates about the appropriate use of medicines, and about prescribing them, has significantly increased the risk of error and patient harm. That failure must be addressed.
The most important thing that needs to happen is for patient safety to be made explicitly, rather than implicitly, part of the national curriculum, at both undergraduate and postgraduate level. It needs to be the first and last thing that doctors in training are taught, and it needs to inform every single course—both core and optional courses—that they take during training.
We have heard this afternoon that other industries take these matters more seriously than the NHS. The airline industry is often used as an example of how safety issues are taken much more seriously in other industries than in the NHS. However, it would be wrong to extrapolate directly across from the airline industry into medicine. I do not mean to belittle the airline industry, but aircraft tend to behave relatively predictably; if someone can fly one large jet, then broadly speaking they can probably fly another large jet.
As I say, I do not wish to undermine pilot training. However, patients do not behave relatively predictably; they do not necessarily respond to the “controls” in the way that doctors might like them to. It would be rather naive to assume that introducing airline-style systems into the health service would solve the problem; it clearly would not. However, in the airline industry, when something goes wrong, the industry’s instant response is not to say, “That’s somebody’s fault.” The industry’s instant response is to say, “The system has somehow failed this person. How can we change the system to reduce the risk of it happening again?” That culture would easily transfer across from the airline industry to the health industry, and it is one that we could take seriously.
I want to talk about primary care, which is, after all, my special subject. Remarkably little is known about patient safety incidents in primary care, because information on them is not systematically collected. It is very difficult to make any meaningful study of how GPs report such incidents, how frequently they occur and how many are simply not picked up by anybody at all. That needs to be addressed.
However, such incidents are being looked at. For example, on the latest appraisals for GPs, it is now expected that GPs will look very carefully at critical incidents in their practice, and that they will use examples of any such incidents in their appraisal documents, saying where the incident happened in the practice and the steps that the practice took to reduce the risk of such an incident happening again. That is extremely welcome.
I am sure that this is true of the vast majority of general practitioners, but if we have a critical safety incident in my practice, we immediately raise the matter at the next practice meeting. We examine what has happened, we see what we can learn from it and nearly always—well, without exception—introduce changes to reduce the risk of such an incident happening again. I am sure that that is happening around the country. The problem is that we do not have any systematic way of collecting that data, and we do not really know what is going on.
It would be very useful if the Minister would consider how we could make use of better reporting in general practice, and how we could encourage GPs, hopefully on a non-blame basis, to be more up front about the systems that fail and the things that go wrong. I say that because when something happens in one practice, it is pretty obvious that it will be happening in other practices around the country. If we can learn from each other, we can reduce the risk of our colleagues making the mistakes that we have perhaps made ourselves.
Those are the aspects of the report that I want to concentrate on. Producing the report has been a very useful exercise, and I hope that the Government have found our recommendations useful. I have certainly been very encouraged by the response that the Government have given to our report, and I await the Minister’s comments in response to my suggestions.
It is a pleasure to serve under your chairmanship, Mr. Russell.
I am here today in a dual role; as well as a member of the Select Committee, I am speaking broadly on behalf of the Lib Dems. I was mindful of the little anecdotes that my medical colleagues were recounting earlier. Certainly, my best man, who was a doctor, was told exactly the same as other Members here today—that he would kill somebody at some stage and the only question was when. As a pharmacist, I was always told that doctors buried their mistakes and pharmacists conducted post-mortems on them. I do not know how true that expression was, but I suspect that little has changed since I heard it.
This report is one of the Select Committee’s best reports in this Parliament, because it has attempted to take an overarching and quite analytical look at the problem of patient safety. Very often we look at something in retrospect, and it is a credit to the Committee that it realised that there was a potential problem in this area and that it wanted to do something a little more proactive. I hope that the Government will act on most of the recommendations in the report.
It is fair to say that, in the past, financial concerns have been put ahead of patient safety concerns. That has not been the case everywhere, but there has been a lot of research of documents such as board minutes, which show that many items on board meeting agendas relate to finance, whereas not all such boards have an agenda item on patient safety. Clearly, not all boards take patient safety seriously. That can lead to catastrophic failures, such as those in the Mid Staffordshire NHS Trust and in the Maidstone and Tunbridge Wells NHS Trust.
Unusually for our Committee, we examined the problems in the Mid Staffordshire NHS Trust in an evidence session. Usually we avoid examining individual examples of where things have gone wrong, because it does not seem to be fair to do so. However, this inquiry coincided with the incident in Mid Staffordshire. What seemed to be clear in Mid Staffordshire was that everybody was blaming everybody else and that nobody was taking responsibility for any of their actions. My feeling was that people can blame targets if they want to make a political point, but we had a number of people in Mid Staffordshire who should have had a code of professional ethics that would have prompted them to act differently.
I will return to the broader question of boards and direction from boards. I think it was Lord Patel who suggested that one non-executive director from each board should have special training and take a particular responsibility for patient safety. Our Committee’s report highlighted the fact that many managers and non-executive directors with some responsibility for this area of patient safety have had little or no grounding in the subject. If we also consider the training of our health professionals, there is a great deal of evidence to show that patient safety is not part of that training. I will return to that issue shortly. Clearly, patient safety needs to be more ingrained into the life and soul of the NHS. It should be there; currently it is not.
Safety can improve only if there is an open culture of reporting, so that we can all learn from our mistakes. It is very important to have a “no-blame” culture. The Government response to our report actually recognises that
“removing the ‘blame culture’ around making mistakes is essential to improving NHS patient safety.”
So far, so good.
The Government response goes on to express support for the National Patient Safety Agency and it also mentions the Care Quality Commission. The new CQC regulations come into force in April, but regulation 18 of the current draft CQC regulations—that is S.I. 2009/3112, for those who want to rush and look up the regulations at the end of the debate—places a statutory duty on registered organisations to report patient safety incidents to the CQC or to the NPSA, in the case of NHS bodies. That is fine, but there is no requirement to inform patients or their next of kin. That is particularly disappointing, because the Government’s current approach seems to fly in the face of the Committee’s recommendation that
“further consideration be given to the CMO’s proposal”—
that is, the chief medical officer’s proposal—
“for a statutory duty of candour”.
It is not enough to include a responsibility in the NHS constitution, which seems to have disappeared almost without trace. The Government response says:
“There is ongoing work to consider other ways that the registration requirements could be used to further clarify the requirement for information to be made available to service users when things go wrong.”
It would be helpful if the Minister explained that apparent backtracking, because one change that we made to the NHS Redress Bill when we discussed it provided for a report to be published and made available on any incident that came under the scope of the Act. It is a shame that no progress seems to have been made in enacting that legislation. There is a certain inconsistency in the Government’s approach in relation to what it is right and proper to do.
From personal casework and professional experience, I strongly believe that advising patients and relatives is crucial and usually causes far less hassle in the long run. There will always be the occasional person set on litigation and getting the best for themselves, but I wish that I had a fiver—only a fiver—for every time somebody has come to me with a problem and said, “If only they had explained to me at the time, said sorry and told me what they were doing so it wouldn’t happen again, I would be happy.” MPs’ time and the time of chief executives of trusts is being wasted producing reports, all because some hospitals have a culture of covering up.
I pay tribute to the chief executive of Winchester hospital. Every time he receives a complaint, he will offer to meet the complainant personally. As a result of his proactive approach, the number of complaints that come to me has plummeted. It can be done. Openness, honesty and the willingness to check and review events even after they have happened go a long way with patients.
Complaints are still dealt with poorly in too many places. Complaints are a learning opportunity, but we should not rely on them. Again I pay tribute to those at Luton and Dunstable hospital, who have taken patient safety to heart and have plenty of examples of good practice. However, as the hon. Member for Wyre Forest (Dr. Taylor) said, they regularly sample case note reviews to see what lessons can be learned. It seems essential to embed that procedure more firmly in all our NHS trusts, as well as in our primary care trusts. Reporting of incidents in secondary care is now good, but I do not believe that primary care is very much safer. I believe that incidents in primary care generally go unreported. We must examine the reporting culture there as well.
I will give one example to stress how open reporting can benefit us. A few years ago, when I was working as a pharmacist, I worked as a locum, which gave me experience of different firms. One firm had an open reporting culture. In another, those who reported mistakes would receive a nasty letter telling them not to do it again. Consequently, not many mistakes were reported there. However, the company with an open learning culture realised that 90 per cent. of mistakes were simple and involved two drugs in two strengths with similar names, all of which came in the same type of pot. It was a simple matter to ensure that a system was put in place to highlight the difference between those four products. Problems were reduced at a stroke, and patients were better off. It is much better to foster open reporting.
Information technology was mentioned. I will not repeat what other Members have said, but I endorse fully the comments made by the hon. Members for Dartford (Dr. Stoate) and for Wyre Forest. The decision on who should have access to the summary care record should not be in the hands of doctors; it should certainly be in patients’ hands. To some extent, that would avoid the read-write access problem, as the patient could say, “Yes, I want you to have my records and be able to update them.” If the matter is handled properly, the vast majority will want to ensure that all their health needs have been taken into account.
We need to put the patient at the heart of the process, rather than any of the misguided interests of some—although not all—sectors of the medical profession, because better continuity of care is essential. Also, mistakes in electronic records are difficult to change. I have had constituency casework involving allegations that paper notes were changed after an incident. It was difficult to prove, and the story was harrowing. Electronic communication makes such behaviour a lot more difficult. An audit trail in medical care is essential.
The part of the inquiry that I found fascinating dealt with human factors. Improving recognition of the role that human factors play in errors is an issue that risks being ignored, but to me, it was one of the most important parts of our inquiry. Brian Capstick carried out research in 2006 to assess the extent to which human error was responsible for incidents serious enough to give rise to litigation claims. He found that human error was the proximate cause of 97 per cent. of them. He also claimed that there were numerous systems
“whose shortcomings create enlarged spaces for human error”.
The hon. Member for Dartford mentioned that that was true of approximately 50 per cent. of the cases that he looked at.
Brian Capstick, putting together considerations by other people, went on to identify the types of process failure most commonly involved in mistakes. The first was
“delays in making a primary diagnosis…or in recognizing the severity of the patient’s condition generally”.
That usually comes down to training, which is often ignored or cut back when budgets are tight. He also cited
“the omission to act on adverse results”,
which again relates to a culture of open reporting and learning,
“the lack of an adequate management plan for high risk cases that have been identified”
“the omission to allocate known high-risk cases to a reliable pathway or person”.
Some of the evidence that we took from Staffordshire, where blame was shifted, showed that clearer responsibilities are needed in the health service.
Interestingly, another type was
“allowing or encouraging clinicians to work outside or beyond their skill set”.
That is crucial. We heard of the horrifying case of Bethany Bowen, a five-year-old with a condition requiring her spleen to be removed and who died of uncontrolled bleeding. The reason was that the surgeon used a device called a morcellator, which sounds awful. It is an instrument with rotating blades that is usually used in gynaecology. The people using that instrument had no experience of using it on an adult, let alone a child, and the results were horrific. It was clearly beyond the skill set of those surgeons.
Other factors included
“the unavailability of skilled supervision, guidelines or protocols; shortcomings in clinical leadership; shortcomings in the recruitment or induction processes; and deficiencies in educating the patient to deal with his or her own condition.”
If we are serious about reducing errors and improving patient safety in the health service, we need to consider how those eight factors can be minimised in all areas of clinical practice.
The submission by the Clinical Human Factors Group made many similar points. It stated that training in human factor skills
“such as teamwork and communication is virtually absent in healthcare.”
Such skills should be drilled into doctors, nurses, pharmacists, physiotherapists and so on from day one. It also mentioned that
“teamwork training may reduce technical errors”.
Interdisciplinary training, which has been mentioned, is good in theory, but in practice some of it is very bad. It is clear why we need it: it challenges the perceived norm that doctor knows best. However, it is often organised so that people at the same stage of training work together, with the medics, nurses, pharmacists and social workers all being first-year students. At that point, such attitudes are becoming ingrained in the students.
We saw a cleverly thought out scheme in New Zealand in which the doctors were in their first year of training and the other health professionals had two or three years’ more training. The trainee doctors had to rely on the nurses, pharmacists and other health workers to support them and give them the information they needed to complete the tasks satisfactorily. Until we review the way in which training is carried out in many places, it will not be as good as it should be. I say that somewhat advisedly, because my son is training to be a nurse in Southampton and he whinges like mad about the training. When I had the opportunity to talk to some medical students in Southampton, to my surprise they whinged like mad about the training as well. They said that they thought it would improve because in the review of training they all complained and said that it was not very good. We have to learn from the best, because although training is essential, if it is done poorly it is counter-productive.
I want to mention briefly the National Patient Safety Agency, which seems to be collecting a huge amount of data through the national reporting and learning system. However, the NPSA seems to have relatively few teeth. The Chair of the Select Committee gave the example of the syringe fittings on spinal needles from 2001. I was amazed that the Government response said that
“solid progress is being made”.
After nine years, “solid progress” would mean that the devices are in place to prevent further occurrences of the mistake. One idea put to us was that although the NPSA has a lot of data, perhaps it should concentrate on finding more detail in fewer areas. There is a need to review what it does.
On whistleblowing, it was scandalous that the private Member’s Bill promoted by the hon. Member for Wyre Forest was objected to. As constituency MPs with an interest in health, I am sure we have all had the experience described by the hon. Member for Dartford of someone coming to us with their problem but saying that we cannot use their name because they do not think they should be speaking to us and are worried about getting into trouble. Lots of people come to speak to us off the record. If systems are going wrong, there needs to be an adequate system so that people feel they can report it. I hope the Government will look at that matter.
There are only eight never events, which were chosen by the NPSA. Clearly wrong site surgery should be a never event. I think that the list should be added to and beefed up. Such events should not be looked at in isolation and more attention should be paid to whole procedures. I welcome the work of surgeons on the pre-operation checklists. I hope that such approaches will benefit patients and staff. In evidence, we heard that checklists are not adhered to in some places. If consultants do not go through the process with staff and enable them to comment, it should be a disciplinary matter.
While I am talking about surgeons, I want to mention the European working time directive. The Royal College of Surgeons has always been against the reduction to 48 hours. I accept the point that I do not want to be operated on by a tired doctor who has worked over 100 hours, which is what used to happen. However, I also want the person working on me to have quite a few hours’ experience of what they are doing. There are serious concerns that the focus on 48 hours in the European working time directive makes it impossible to produce an adequate rota that provides sufficient and appropriate training for surgeons. Last week, Sir Bernard Ribeiro, the former president of the Royal College of Surgeons, told me that when a consultant surgeon qualified a few years ago, they would have had about 30,000 hours under their belt—that sounds like a lot and I have not worked out how many days it is. It is now 8,000 hours. That is a huge difference in experience.
That is a good idea. Some hospital trusts claim to have achieved the 48 hours. As far as I can see, this is a tick-box exercise. Some students are complaining that they are not getting the experience and there are concerns among senior and experienced surgeons that standards will slip. We cannot afford to take that risk. I was a panellist on a British Medical Association question time at Southampton university where Sir Bernard Ribeiro advised all the students to opt out of the European working time directive. I thought that was slightly unhealthy and that it put unfair pressure on some students for various reasons. It would be helpful to review the situation, as the hon. Gentleman said, with a view to working towards a derogation. That should not be impossible.
In conclusion, there are some easy things that can be done, such as making a board member in each trust responsible for patient safety. Those things are likely to happen. However, some fundamental factors at the heart of improving patient safety, such as training and emphasising human factors, will be more difficult to achieve. As the NHS is going to be financially constrained and these matters are not even on the agenda yet, a big push is needed to ensure that they are at the forefront of everybody’s thinking, because that would benefit all of our constituents in the long run.
It is a pleasure to serve under your chairmanship, Mr. Russell. I congratulate the right hon. Member for Rother Valley (Mr. Barron), the Chairman of the Health Committee, on his opening remarks. I also congratulate the Committee on producing yet another balanced report. Having been a member of the Health Committee myself, it feels a bit like old times—we could be back there today.
Some 10 per cent. of patients admitted to hospital suffer some sort of harm. That is a substantial number, because the NHS treats around 1 million people every 36 hours. There is a huge raft of issues to consider, as the matter is extremely complex. A number of issues have been mentioned: data collection, the regulation of professions and organisations, staff and professional skills, education and training, continuing professional development, the role of targets, the systems that we need to have in place to ensure that accidents do not happen and that harm is prevented, audit—including the audit of complaints—and the role of management. The list could go on.
At the end of the day, some form of harm will always happen, and no system can absolutely guarantee 100 per cent. safety, as I think the hon. Member for Dartford (Dr. Stoate) mentioned. The Committee report states:
“All Government policy in respect of the NHS must be predicated on the principle that the first priority, always and without exception, is to ensure that patients do not suffer avoidable harm.”
That is a worthy ambition, but to some extent, such a statement might disappoint the public, who would be utterly appalled to think that they could come to any harm when being treated by the NHS. As the hon. Gentleman said, medicine in its widest sense—I include all the professions allied to medicine—is an art, not a science. There is a mismatch between public perception and what actually happens regarding the treatment of people.
The right hon. Gentleman talked about the need to convince professions of the need for, and purpose of, data collection. I completely agree with that. The danger with professional staff—this includes professions outside medicine—is that they do not understand why they are being asked to do what they do, and if they do not understand why, they do not do it. I recently had the privilege of spending a day on a shift with charge nurse Nathan Askew on Sky ward at Great Ormond Street hospital. I would like to put on the record my thanks to the staff for putting up with me. I would also like to put on the record that all the children received absolutely fantastic care during that day. I have no doubt they receive such care every single day. The wonderful thing about NHS staff, particularly nurses, is that they will have gone to no exceptional lengths to please me on that occasion; they will have simply been doing their routine work. As I say, I was hugely impressed by them.
There is no doubt that NHS staff feel that some of the systems in place are not useful. At times, I think they feel that such systems are designed to frustrate them in their delivery of care. Many NHS staff say that nobody asks those on the front line how data should be collected and what will or will not work. In addition, there has been no explanation of why such systems have been put in place. Yesterday, the Royal College of Nursing bus was in New Palace Yard, and I said to the nurses there that nurses are particularly inventive at working around obstacles that get in their way. If we come up with a system that nurses do not like, they are far more inventive than doctors—I point this out to the hon. Member for Dartford in particular—in finding a way around it. If nurses come up against a system that they do not like or do not understand the point of, they will get around it to ensure that their patients get the best possible care. That does not necessarily work to the benefit of patients or the benefit of attempts to drive up patient safety. We absolutely must explain why such systems are put in place.
That leads me to the issue of education and training. The armed forces have moved away from talking about training, to talking about education. There is a drive throughout many of the professions involved in NHS care to move towards education rather than training. Doing so is vital. I remember from many years ago, when I was a nurse, an agency nurse on a ward who did exactly what she was told to do. Throughout the night, she observed the patient and recorded various vital signs every quarter of an hour. In the morning, at 6 o’clock, the patient had a cardiac arrest. Fortunately, the patient was resuscitated. On looking at the patient’s charts, one could see that the nurse had been absolutely faithful in the tasks that she had been asked to do. However, she had not understood the purpose of what she was doing or when she should alert medical staff or senior nurses that things were going wrong. She was not educated; she was trained to do what she was told to do.
Such a situation can be applied to every level of staff and every profession. Everyone involved in patient care needs to have a sense of ownership—for example, the person who cleans the ward and dilutes the cleaning chemicals needs to know why those dilutions are important, so that they know that if they get to the end of the bottle of concentrate, it is worth going down the corridor to get a new bottle. That person needs to know that they must not skimp on cleaning chemicals, because they are contributing to the cleanliness of the ward and the reduction in health care associated infections. As I say, it is extremely important that we move from training to education.
Continuing professional development improves the understanding of why certain things are necessary, and is absolutely vital. That is an ongoing issue for medical staff. One of the dangers is that the people who are vigilant about continuing professional development and who attend the training courses actually do not need to attend, and the people who should attend such training courses often do not turn up. That situation possibly also occurs in this place. For example, if one attends seminars designed to help Members of Parliament with their constituency work, when one looks around the room, one knows that none of the people present needs the help. The same is true in medicine, and indeed in other professions.
There is a lot of talk about regulation. One hears that we need regulation, because it will sort the problems out. However, regulation needs to be effective—it is not, in itself, necessarily effective—and evidence-based. We do not need knee-jerk reactions to concerns and disasters; we need careful, considered thought and, as I say, evidence-based solutions. We do not need regulation to cover—I cannot think of an acceptable parliamentary word—the rears of senior managers, Department of Health officials or Ministers. I do not mean current Ministers in particular; I mean Ministers in general. We do not need defensive regulation; we need regulation that is balanced with risk.
I was recently approached by a number of ophthalmic organisations—the Association of British Dispensing Opticians, the Association of Optometrists and the Federation of Ophthalmic and Dispensing Opticians—who said:
“The General Optical Council has dramatically increased their level of activity over the last three years or so in a way which might be acceptable if we had the levels of risk of, say, GPs and were paid at the same level”—
we could perhaps put that bit in brackets. The organisations continued:
“this activity is very expensive for smaller and lower paid professions such as ours. This appears, in part, to be driven by a wish to comply with requirements imposed by the regulator’s regulator the CHRE. Often there is no evidence base for what is proposed, but it seems to be driven more by political correctness than genuine patient protection. We would like to see a far greater emphasis on evidence-based patient protection and value for money in regulation.”
That important point will be echoed by many. As I said, regulation must be effective, evidence-based and proportionate; otherwise, the whole system completely seizes up.
I shall also mention targets. It is not a political matter that the hon. Member for Romsey (Sandra Gidley) talked about that subject. The word “target” has been hijacked by party politics, but I do not want to mention it in a party political way. We need to think about what we measure in the NHS, which again relates to the evidence base. We must ask what is effective and what we want to achieve. I have a feeling that although we measure a great deal of things, the one thing we do not measure is whether anyone got better. There is a tendency to measure many processes but not necessarily the outcomes. Many targets have worthy motivations, as no one wants to spend four hours in accident and emergency, but we must distinguish between process and outcome and ensure that process-driven targets do not get in the way of clinical outcomes.
I visited an A and E a year ago, and one of the senior physicians explained that if he had a very sick patient in A and E and wanted them to go up to intensive care, but intensive care was full, they would have to be looked after somewhere else for five or six hours. He said that he would like them to be looked after in A and E, because he felt that the nurses there had the expertise and experience to deliver that sort of care, but the manager of A and E would not want the patient there because he was acutely aware of his targets, so there is a clash between a process target and a clinical outcome. As with many things, that is about balance. I would like to quote something that has been said about Mid Staffordshire NHS Trust:
“The Trust Board placed a high priority on compliance with nationally set targets, and, in particular, the four-hour waiting time target for A&E. The pressure to comply with such targets came from the Department of Health (DH), the strategic health authorities (SHAs) and the primary care trusts (PCTs)”.
In that case, the chief operating officer described the sort of pressure that he was under to comply with targets. That is fine, so long as clinical outcomes are not put at risk.
Nursing Times recently surveyed more than 900 nurses and found that
“nearly two thirds said patients at their hospital were being treated in areas not designed for clinical care. They highlighted threats to safety, including patients having no access to call bells… Of those nurses who had seen the practice, nearly 60 per cent said it happened more than once a week. Two thirds said patients were left in the areas for more than 12 hours—for some the areas are used for days at a time…Eighty-three per cent”,
which is a huge number,
“said they had raised it with senior nurses or managers but, of those, only 4 per cent said it had then been stopped. They were commonly told that all other space was full, accident and emergency was under pressure, the move was authorised by senior managers, or the A&E waiting time target was at risk.”
Again, we are talking about a matter of balance. No one wants to keep people waiting. We need good performance and we need people to be treated effectively, efficiently and in good time, but we also need to ensure that clinical care is the first priority.
The role of managers and boards was touched on in the debate. The Mid Staffordshire NHS Trust report undoubtedly makes absolutely dreadful reading. I recommend that many people read it to see how complex failure can be. It is not just the managers and boards that need to be looked at. The Health Committee’s report states:
“There is disturbing evidence of catastrophic failure on the part of some senior managers and Boards in cases such as Mid-Staffordshire NHS Foundation Trust. While other Boards are not failing as comprehensively, there is substantial room for improvement. Boards too often believe that they are discharging their responsibilities in respect of patient safety by addressing governance and regulatory processes, when they should actually be promoting tangible improvements in services.”
In the past there has been much talk of a “ward to board” approach, and such an approach would eventually drive up standards. The boards will have to look at more than just the bits of paper dealing with finance that are in front of them. They absolutely must understand their core business, which is to treat patients safely.
The group Action against Medical Accidents has conducted some interesting research, based on freedom of information requests to the Department of Health. The research revealed that
“large numbers of trusts were failing to implement the alerts, some stretching back five years.”
That is interesting, because data collection in itself is not enough. It is what is done with the data once we have them that is important. The group continued:
“Even more worryingly, the research revealed that even though this information was available to the DoH, CQC, SHAs and NPSA, absolutely no system was in place to ‘chase up’ those trusts, even those with large number of alerts outstanding. The Government’s response seeks to give the impression that there was a robust system in place. Clearly, there is not. As far as we know, even following publication of our report, no action has been taken to find out what is going on in even the worst performing trusts. It is this kind of complacency which could allow another Stafford to happen under our noses.”
That is well put.
We could have a separate debate on a huge number of concerns that have been raised, and on some that have not even come up. We could have separate debates on health care acquired infections, no-blame reporting, the need for effective communication, which was highlighted in relation to maternity services in particular, drug errors and the role of pharmacists in reducing them, and problems arising as a result of the free movement of labour in cases where English might not be a professional’s first language. The hon. Member for Dartford mentioned a matter that is dear to my heart—the fact that although banks can transfer massive amounts of money at the touch of a button, we cannot get clinical records online. It feels as though we cannot use even the simplest computerised system. If all that information is available on a computer, why is someone not acting on that?
As for whistleblowing, anyone who has worked in the NHS—we have two nurses, two doctors, a pharmacist and a scientist in this Chamber—would find the Maidstone and Tunbridge Wells NHS Trust report staggering. Why did no one tell someone what was going on, and why did action not follow? I cannot understand why nothing happened. There is a lack of faith in whistleblowing policy, and a lack of action resulting from it, and there are ineffective means of auditing complaints from patients, relatives and staff. I must mention professional standards, because I am a former nurse, as is the Minister, and I am sure that I speak for her on this point. No one has mentioned professional standards today.
The hon. Lady says that she did. We should fly the flag for driving up standards, and that is about clinical leadership across all the professions.
I finish by again congratulating the Health Committee, and those members of it who have contributed to the debate. They have demonstrated a wealth of proper, front-line expertise. My concern is not only about the complexity of the issues that are in play when it comes to increasing patient safety, but about the gap between government, meaning Ministers and officials in Whitehall, and what happens on the front line. People at the top might think that something is happening at the bottom when it is not, so there is a gap in communications, and policies do not necessarily follow as a result. Many of the strings between Whitehall and the front line have been cut.
Lack of patient safety costs lives. Every Member will have constituents who have suffered because of a lack of patient safety, and some families will never recover from their loss. Despite the sometimes defensive nature of chief executives of various trusts, my experience is that families often do not want any compensation. Indeed, often they do not even want an apology. They want to know, above all else, that their experience will not be repeated, that lessons have been learned, and that no further loss will happen to other families. I am pleased that the debate has not been party political, and I look forward to hearing what progress the Minister feels can be made.
It is a pleasure to serve under your chairmanship for the first time, Mr. Russell.
I am grateful to my right hon. Friend the Member for Rother Valley (Mr. Barron), who is the Chair of what is undoubtedly a prestigious Committee in the House of Commons. The Health Committee has held many inquiries. I gave evidence to this one, and was pleased to do so. As a practising nurse for more than 28 years, I was pleased to have openness at last as to what takes place in our health service, and I am pleased that we are having this debate on the important subject of patient safety.
I congratulate my right hon. Friend and his colleagues on the excellent report that they produced last year on this subject, and for the contribution that they have made to the provision of safe services for patients. The first Committee on which I served when I was elected to the House was the Health Committee, and I know of its importance and the difficult work that it has to take on.
Fortunately, the vast majority of people treated by the national health service receive high quality and efficient treatment. They recover and have their confidence and control restored, in whatever capacity they enter the NHS.
The hon. Member for Guildford (Anne Milton) acknowledged the expertise in the Room, and mentioned that I share her profession, which was nursing. I am sure she would admit that we never practised in a golden age, regardless of the matrons that the hon. Member for Wyre Forest (Dr. Taylor) wants back. They are back—we have brought our matrons back—and ward sisters are firmly in place. They were highlighted in the report on the Prime Minister's Commission on the Future of Nursing and Midwifery. I have no doubt that, had we practised together, we would have had some interesting times and provided very safe patient care.
Would the Minister agree that the concept of the matron has been watered down by having rather a lot of them, instead of one figurehead who really could move around the hospital like a galleon in full sail and frighten people into doing what was right?
It is very brave of the hon. Gentleman to go down that path. I know that across the river at St. Thomas’ hospital there are quite a number—more than 50—of modern matrons. I challenge him to debate with them at any time to see whether there is agreement on that. Many women and men perform an excellent function as matrons across the NHS.
The hon. Lady mentioned targets. We must be aware that they are based on clinical decisions. I do not want to be party political either, but I know that in her party’s manifesto in 1992, the patients charter mentioned four-hour targets for accident and emergency that were to be reduced eventually to two hours. Sadly, that was not achieved, but today’s targets have improved patient care and have undoubtedly saved lives.
One million people are treated by the NHS every 36 hours, and nine out of 10 people see their family doctor in any given year. The NHS is a successful, internationally regarded institution of which we can all be justly proud. However, we must recognise that in a system as big as the NHS, which provides treatment and care to so many people, sadly mistakes and unforeseen incidents can and will happen.
Mistakes and errors in other service sectors may not result in harm to a person’s health, but that is not the case in health care. A relatively small error can result in severe harm or even death. Although human nature and the risks associated with the provision of complex treatment mean that some errors are inevitable, we must work towards preventing and reducing as many avoidable errors as we can. An error in the NHS may not itself cause harm, but if we can understand the reasons for the error occurring and put in place actions that militate against its occurring again, we might be able to prevent someone from being harmed at a later date.
I recently had the great privilege of meeting Mrs. Lisa Richards-Everton and her brother-in-law, Stephen Richards. Sadly, a drug was administered to Mr. Paul Richards in error, which created a fatality. I do not profess that I would ever be able to measure the impact that that tragedy has had on family and friends. In this case, much of what could have been done to reduce the risk of the incident happening was done, but a renewed focus has taught us that much more can always be done to reduce risk further.
I was humbled by the meeting and by the positive way in which Mrs. Richards-Everton chose to deal with the tragedy. We discussed ideas and suggestions for improving the information systems underpinning patient safety development. Those suggestions were not only helpful but full of common sense. Her straightforwardness enabled us to see through her eyes how a bureaucracy deals with risk and sometimes overcomplicates what should be simple. Having petitioned the Prime Minister, and having met with me and my officials, she has, without hesitation, accepted an invitation to become involved in a forthcoming patient safety conference that will continue to raise the profile of safety in the administration of medicines.
Mrs. Richards-Everton’s experience has also called into question how professional regulators deal with clinical staff when things go wrong. In particular, that has helped the Nursing and Midwifery Council to review how it writes to complainants to explain decisions about investigations and the outcomes of fitness-to-practise hearings, to ensure that letters are clearer and much more sensitive. Her ideas and suggestions will contribute significantly to safer services and, importantly, ensure that others do not have to go through what she went through.
The lesson that we must learn from that experience is that managers and clinicians cannot by themselves shape and deliver safe services. The engagement of patients, families and carers is important if we are to get this right. As well as understanding and trying to make provision for the tragic personal consequences that unavoidable errors can lead to, reducing and preventing mistakes generally is a mammoth challenge. The Committee’s report has reminded us of some key things that we need to get right if patient safety is to be embedded effectively into health care planning, development and delivery.
First, there needs to be a culture of openness. No one should argue with that, but sadly, some recent reports show that there is not a culture of openness throughout our health care systems. What do we mean by a culture of openness? What did it mean to practise with certain clinicians, or to be with certain managers who bullied, and who undoubtedly brought about a culture in which one stayed quiet and did not admit to mistakes?
As the hon. Gentleman said, we all make mistakes at some stage, and the Select Committee Chair said that it happens in the House. In all areas of life, mistakes are made. How do we manage mistakes? How are we treated? How do we expect to be treated when we are open and above board with people? This is so important to the culture of an organisation. Successful organisations are open and efficient. They manage their finances well, and they train, develop, care for and look after their staff. That is the key to much of our success, along with the all-important communications.
It is important to be open and candid with patients, families and carers when things go wrong, and to ensure that staff are part of a culture that supports them in dealing with incidents that have harmed, or may harm, patients. A blame culture has pervaded some parts of the NHS for far too long, and I would be foolish if I were to say that it no longer exists anywhere.
I have the privilege of being the Minister responsible, but, as Aneurin Bevan asked when he was the Health Minister, was he to get the blame in Whitehall when a bedpan fell off a trolley in Tredegar? I have the title, so I have to accept some of that responsibility, but I know that all NHS staff are involved, from the senior managers down, including the chief executive.
The hon. Member for Romsey (Sandra Gidley) mentioned a chief executive being able to sit and listen to complaints, which is a first-class example of how people should behave. We know that that would make a difference. They should be walking the floor, being visible. We must do all that we can to change any practice that creates a culture that is not open. We should stop looking for scapegoats and consider what lessons can be learned from patient safety incidents to avoid them in future. One key element of this is the freedom for staff to raise any concerns that they may have about patient safety.
The hon. Member for Wyre Forest and I were in the House on the Friday that his private Member’s Bill, about which there was expectation and hope, might have gone through. The way that the House deals with private Members’ Bills has always been a mystery to me, and is a mystery to most people in the House on the day. We did not reach the hon. Gentleman’s private Member’s Bill, but we had the opportunity to discuss in the Department some days beforehand what we could take from it and what we could learn from his experience. Those discussions will continue, so that we can find out how we can work with some of the recommendations. It would be foolish to ignore those.
I worked with my right hon. Friend the Member for Holborn and St. Pancras (Frank Dobson) when he was Secretary of State for Health in 1997 on the first opening up of our NHS culture to enable whistleblowers to be protected. I have been a whistleblower. As a district nurse I reported an incident that I witnessed in a private nursing home. It took courage to continue with that complaint, but courage I had, and it was eventually dealt with and the nursing home lost its licence. That was in the 1980s.
Hon. Members might remember a nurse called Graham Pink, who in the ’80s exposed the care of elderly people in his area. I was pleased to be part of the group of 20 nurses that was acknowledged by Nursing Times. Graham was acknowledged as one of the most influential nurses of his time, and in the past 60 years of the health service. In the ’80s, people did not say anything: the fear about what would be likely to happen if they reported something was serious.
I am pleased with the progress. We have established a working group with Public Concern at Work, the trades unions and NHS employers to update the guidance on whistleblowing and to identify what further measures can be taken to give a louder voice and stronger protection to staff who speak up. The NHS constitution gives a clear set of rights to staff: to be treated well, to be supported properly in a rewarding job and to blow the whistle without fear of repercussions. The Care Quality Commission and Monitor are listed as prescribed bodies in the Public Interest Disclosure Act 1998 to receive concerns raised by staff. All NHS providers of regulated activities are required to register with the CQC.
Secondly, although patient safety relies on the conscientiousness of individuals, organisational robustness and clear leadership is needed if a consistently high level of patient safety is to be achieved. The Committee also emphasised that local services need to be provided with relevant and effective information, support and advice from central Government and their agencies. Also, it said that a robust monitoring and regulation process needs to be in place to ensure that all NHS organisations, not just some, reach the standards we all expect of them.
I am pleased that the Committee’s report praises the Government for being first in the world to adopt policies that make patient safety a priority, and that it welcomed the creation of the National Patient Safety Agency. I pay tribute to all who work in such an important area. We are seen as one of the world leaders in the international drive to improve the safety of health care. We were one of the first countries to give priority to tackling patient safety by focusing on a whole-system approach. The 2000 report, “An organisation with a memory”, which has galvanised action on patient safety, is still regarded internationally as a seminal document.
The NPSA was set up in 2001, and its reporting and learning system is the most comprehensive national incident-reporting system in the world. Every NHS staff member in every type of organisation—acute, primary care, mental health and ambulance trust—can report patient safety incidents. Patients themselves can also report directly to the NPSA. The reporting and learning system received nearly 3.9 million patient safety incident reports between October 2003 and 30 September 2009.
What the NPSA does with that information is regarded most highly. As well as sharing regularly with the NHS information on trends in respect of types of incident and levels of harm, it provides information, guidance, alerts and tools to highlight the safety risks in general and specific areas and supports the NHS in heading off potentially harmful practices. We are grateful to the Committee for acknowledging the valuable work carried out by the NPSA, an organisation that we are proud of.
“Safety first” was published in 2006, setting out the chief medical officer’s vision for furthering patient safety and leading to a number of national initiatives, not least the patient safety first campaign that has brought together a number of national stakeholders working to a common aspiration.
My hon. Friend the Member for Dartford (Dr. Stoate) has done so much as a Member of Parliament, not only as a member of the Health Committee but in many other areas of work that he has promoted or has been involved with as a chair. I am sorry that he is standing down at the election. We should acknowledge his work today, with your permission, Mr. Russell. In respect of some of the matters that my hon. Friend raised, it might help if I said that the NPSA now has an e-form for general practitioners that was launched in November last year, which is used for reporting and learning from any mistakes and for spreading information. Safety and safeguarding is one of the CQC’s priorities. Such matters are raised separately, so perhaps we could look further at that matter and discuss it another time.
Lord Darzi, in his NHS next stage review report, “High quality care for all”, reminded us all what patient safety means in the context of providing quality services and of the importance that patient safety should be accorded. Safety is a core dimension of quality and relies on a whole-system approach, so that patients are able to receive the highest level of care.
“High quality care for all”, and Lord Darzi’s interim report, introduced a number of new policy developments for patient safety. For example, from April 2010 a service commissioner will be able to retrieve from a hospital the cost of any treatment that leads to a never event. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventive measures have been implemented. PCTs are required to monitor the occurrence of never events within the services they commission and publicly report them annually. This is such a change in the way that we practise health care: it is open and transparent, not like the secret ways of the past. The more that figures are published on when harms take place, the better. It is those areas where nothing seems to take place that cause me some concern still, because, health care being so complex, it is difficult to accept that there has not been some evidence that there has been harm, so people are perhaps practising in a secret way.
The role of the regulator in achieving safe services cannot be underestimated. The establishment of the Care Quality Commission and the introduction of registration requirements for all health and social care organisations will be a powerful tool for us to use in the furtherance of patient safety. The regulations underpinning the registration system, which are currently going through the parliamentary process, contain some specific requirements for patient safety. Until now, unlike the requirements for the social care and private health care sector, the reporting of serious patient safety incidents in the NHS has been voluntary. The registration requirements that are due to become operational on 1 April will make it mandatory for serious patient safety incidents to be reported to the NPSA, which will share the information with the CQC. We must also recognise that patient safety involves a diverse range of stakeholders with different skills, training, experience and knowledge, and working in different service sectors.
I will mention that when I draw my comments to a conclusion.
My Department must do what it can to corral the interests in patient safety to ensure that each complements the other. As well as clinical care, there are other areas that the Committee said we must not forget. For example, there is no doubt about the potential for information technology to bring significant patient safety benefits. Medication errors, record documentation error and communication failure feature among the most common major causes of patient safety incidents. The Department of Health recently established a national stakeholder group to consider how best to facilitate the acceleration of implementation of such technologies in the NHS. It cannot come soon enough as far as this Minister is concerned.
We promised the Committee a review on the implementation of “Coding for Success”, which is a policy document from 2006. It focuses on the use of barcoding and other auto-identification technology to make services safer. That policy document dates from 2006, and we need to fast-track it. The review is in progress, and we will share the outcome with the Committee shortly.
We must continue to ensure that as well as listening to patients and their families and carers, we include patient safety champions in our national dialogue. The National Patient Safety Forum was established for exactly that purpose. It is linking into the work of the recently established National Quality Board to ensure that patient safety is not seen as an afterthought, but is promoted as an integral part of health care delivery.
I will try to address some of the points that were raised during the debate, including the recent one raised by the hon. Lady will not constrain me because the debate may continue, but my eyesight may constrain me in fully delivering all the answers that my dedicated and hard-working officials have prepared for me. I will do my best.
On the NHS Redress Act 2006, changes in arrangements by the NHS Litigation Authority have resulted in quicker settlement of claims, particularly when they are small and straightforward. Case note reviews are a central feature of the patient safety first campaign, and not a one-off. They are carried out regularly every month with lessons learned and improvements made.
On NHS foundation trusts, the Secretary of State said that it is absolutely essential that FT board meetings are held in public. There is absolutely no need for such meetings to be held in private, and we will monitor that. The purpose of the legislation on foundation trusts was to make boards more accountable; foundation trusts were brought into being so that they would be more accountable to the public. Mid Staffordshire NHS Foundation Trust did not hold board meetings in public. It should have done, but it chose not to. There is clear guidance that all foundation trusts should hold board meetings in public, and the Secretary of State gave a clear reminder of that recently.
On the summary of care records, this major initiative is being rolled out nationally. The BMA only recently raised concerns. The work is still in progress, but I am assured that progress is being made.
The hon. Lady asked why there was no requirement for patient incidents to be reported to the CQC—
Or patients. Such incidents have caused serious harm or even death, and it is almost inconceivable that they would not be reported. They could not be covered up from patients. It would be totally inexcusable, and similar to reporting an infectious disease to the Health Protection Agency but not informing the patient that they have an infectious disease. I am happy to discuss the matter outside the debate.
The national reporting and learning system is the largest and most comprehensive anywhere in the world. It is the envy of many other countries, and has been further developed and improved to make reporting easier and learning from it much quicker.
Patient safety as a discipline is about 10 years old. It has taken time—perhaps a little too much time—to develop sound principles, but they are now in place, and are part of the curriculum for many health care undergraduates. The Government have frequently stressed that it must be a mainstream, key priority for all NHS staff. It certainly features in front-line care and strongly in patient safety with the deans of all the nursing and medical colleges.
Comments were made about civil aviation, and I have been reminded that we have been active in transferring some of the culture and lessons of civil aviation to the NHS. The Committee took evidence from Martin Bromiley, a practising airline pilot. We are grateful for the insight that he is giving us on the human factors in particular. We continue to work with him.
On extending and expanding the list of never events, the National Patient Safety Agency is considering adding to the existing list, and any addition will be evidence-based. There have been suggestions in the press recently that the Government are not serious about being open and candid with patients, families and carers when things go wrong, and the subject was raised during the debate. Nothing could be further from the truth, and I want to make it clear today that under the NHS constitution all NHS staff have a duty to be open and honest with patients at all times, particularly in these difficult situations. A statutory duty of candour is being sought by some individuals and organisations, and on the face of it a legal duty on staff to be open looks attractive. I have often said that we must do what we can to ensure that organisations and individuals take their duties in this respect seriously. In my view, a statutory duty, if it could be made workable, is not the key issue to focus on initially; it would be the icing on the cake.
Before considering whether a statutory duty is necessary or workable, we must do what we can to ensure that a culture of candour develops, giving staff the confidence to be open, safe in the thought that they will not be scapegoated for an error that might not be of their making. That would close down communications rather than open them up. A lot of work is being done in this area, and we should consider whether more can or should be done. I have asked officials to set up a small stakeholder meeting giving proponents and opponents of a statutory duty the opportunity to put their views on record, and to use that as a starting point for a defensive policy review.
I am pleased to say that organisations such as Action against Medical Accidents, the National Association of LINks Members, the Council for Healthcare Regulatory Excellence, the Medical Protection Society, the British Medical Association, the NHS Confederation and the Royal College of Surgeons, together with a number of clinicians with key interests in that area, have already agreed to take part in the initial meeting.
I feel confident that I will be able to say yes to the hon. Lady. I hope to be in regular contact with her for some time, and I know that she will pursue the matter. Those clinicians, with the possible inclusion of pharmacists who have a key interest in this area, have agreed to take part, and we will ensure that it is the start of a wider consultation process as our ideas progress. I have also asked for further discussions with the Care Quality Commission and the National Patient Safety Agency on the practicalities of introducing a statutory duty, if that is the way people feel we need to go.
The Health Committee’s report has reminded us that we still have much to do to ensure that as many patients as possible receive the safest possible care. My conversations with people such as Mrs. Richards-Everton tell me that all our systems can be improved. It would be wrong of me to claim today that we will be putting in place nationally a rigorous process to ensure full compliance with every safety alert issued, although I wish that could be the case. However, I assure hon. Members that we will continue to strive to do everything that we can, and work with and listen to everyone who is able to help us. If we are leading internationally at the moment, other countries will learn from us, but we must always remember that our first duty to our patients, and our first duty as guardians of the NHS, in whatever way and capacity we perform that role, is to put safety first, for quality and patient care.
I am not tempted to fill in the remaining time available for the debate, but perhaps you would allow me to respond to the debate, Mr. Russell, and to thank everybody who has taken part. The Minister spoke about the impending retirement of my hon. Friend the Member for Dartford (Dr. Stoate), who has played a solid role on the Health Committee for many years. May I also mention my hon. Friend the Member for Bristol, North-West (Dr. Naysmith), who is present this afternoon but has not spoken in the debate? Both will be retiring at the next election, and from my perspective as quite a green Chair of a Select Committee when I moved to the Health Committee in 2005, they have been of enormous use, not only for the report, but to me as an individual. Their experience has helped me on many occasions to chair the Committee and to bring reports such as this to the House. I wish them both well in whatever they plan to do once they leave the House.
The Minister has mostly responded positively to the outcome of our inquiry into patient safety, both this afternoon and in her written responses. I would like to address three areas, one of which was mentioned by the hon. Member for Romsey (Sandra Gidley) and relates to the evidence we took about the European working time directive. I do not want to rehearse the issue now, but there was concern about the ability of young surgeons to get appropriate experience and training.
When the Committee looked at independent sector treatment centres, phase 1, which took uncomplicated orthopaedic cases, we found an absence of training for our young surgeons in those establishments. At the time, it was said that the surgeons would be trained in phase 2 of the ISTCs, although we know that many of them have not taken part. I emphasise to my hon. Friend the Minister that we must seize such opportunities. No matter what is happening with the working time directive and changing hours, we must seize opportunities to train young surgeons, so that they can go into such institutions and train on a daily basis. Someone in the Committee mentioned practice, but intense training in doing that type of surgery is the best way. We did not serve those young surgeons well by agreeing to have the ISTCs and an absence of training. That was one area I wanted to mention, because the real issue is what will happen in the future, and whether there will be any diminution in the quality of our surgeons. I am sure that all future Health Committees will want to look into the matter.
One issue that all speakers mentioned during the debate, which I touched on too, was the use of technology, particularly information technology. Everybody who spoke in the debate agreed that we need to use such technology. The summary care record was mentioned, and there have been recent BMA outpourings on that. The issue is not new. About three years ago when we began to look at IT in the national health service, I visited a local GP surgery in a village that I represent, and I was told that there were great issues of confidentiality. I was told that a pass card was needed to get into the system. I asked how many people had a pass card, and found that although there were five GPs in the practice—it was quite large—there were 11 pass cards. I asked who had the other six cards if there were only five GPs, and I was told, “Well, the people who do the letters have got the other six.” I said, “It doesn’t seem to me that there is a great concern about confidentiality in your practice, if six non-clinical people have access to your electronic records”.
The BMA must get a grip on that issue. Everybody knows about the potential not only for summary care records but for other records to improve patient safety and look after patients, but some people have had their heads in the sand for a number of years. The hon. Member for Romsey said that we cannot alter patient records, but it is possible to trace who opens an electronic record. We can go back and see whether anybody has gone into it who should not have done, but who knows who looks into the paper records in a GP’s surgery—the Lloyd George records as they are called? There is no trace of who does that.
There is also the issue of patients’ records being altered when things have gone wrong. I have personal experience of that from when I sat on the General Medical Council as a lay member and looked at fitness to practise many years ago. There were occasions when people altered records because something had gone wrong with a patient. That is wholly unacceptable, and a way of getting round it is to introduce proper electronic records together with confidentiality.
My hon. Friend the Member for Dartford mentioned the time we went to the USA. We visited the veterans agency that looks after ex-service men and women. It has a database of 4 million people. During the hurricane in New Orleans, all the local records were lost, but the records of the ex-service men and women were still there because they were held on a central database. If those records had not been held in that way, it would have been a catastrophe for the management of some of those people. That has been well written about since, but the Health Committee knew about it then. Everybody who has attended the debate will see the point of that—I am looking at the hon. Member for Guildford (Anne Milton) because one or two of her colleagues have questioned this issue on occasion. If millions of people can have individual banking records, why can we not have that for public sector records, certainly for the management and the safety of patients? I hope that people will read and listen to this debate, and take that into account.
I agree with the Minister not only about the work of the NPSA up to now, but about the potential for that work to bring in more data and for people to learn from such data. I am sure that in a decade’s time—even I will not be in this place talking about health and patient safety then—we will be far more knowledgeable.
I want to finish on what is in part a negative note. None the less, I think that I should bring this up, because the Minister brought up the fact that the culture of openness was lacking and the challenge back in the 1980s by Nurse Pink. I have the press report that came out when the final report of the independent inquiry into the events at Mid Staffordshire NHS Foundation Trust was published and I shall read out one paragraph from it. Speaking at the publication of his final report, Robert Francis, QC, said:
“The Inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care. Morale at the Trust was low, and while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion towards their patients. Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear and bullying.”
That is not acceptable in any health care system. It certainly is not acceptable in a 21st century health care system that is more than 60 years old, as the NHS is now. We have a long way to go to improve our health care system if reports such as that are now and again coming before us. I hope that the Health Committee report and what has been said about it in today’s debate go some way towards improving patient safety in this country. We need to get away from the blame situation. We need to be more open. We need to learn what aviators learn. When there is a near miss, everyone should know about it, so that if such an incident can be avoided, it will be avoided in the future.
I thank all hon. Members for taking part and you, Mr. Russell, for giving us the opportunity to debate the report. This will be the last debate that we have on a Health Committee report in this Parliament.