Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH AND
NATIONAL PATIENT
SAFETY AGENCY
16 JANUARY 2006
Q20 Chairman: Lastly, Sir Nigel,
did you see the front page of the Daily Telegraph today?
"£235,000 lavished on slipper safety advice. A £235,000
scheme advising the elderly on how to wear slippers is among the
array of examples of wasteful government spending in this area.
They include £40,000 spending by the NHS on a 46-word patient
experience definition that required two £8,000 workshops,
£4,000 of public meetings, two £1,600 meetings with
children, three £600 in-depth interviews. Among the aspirations
established by the exercise was that patients wished to be treated
with both honesty, respect and dignity", which we would have
hoped would be obvious.
Sir Nigel Crisp: I have not seen
the Daily Telegraph.
Q21 Chairman: On slipper safety.
Sir Nigel Crisp: I do note from
the figures in this Report that the biggest area of reports of
incidents is people falling. I cannot remember where it is in
the document. It is something like 31.5% are about falls. We do
know that in areas where people have set up what are called falls
clinics—they are as simple as that—we are seeing some
improvement in the reduction of fractured femurs and so on. Whether
that particular expenditure was justified or not, reducing falls
amongst elder people is undoubtedly justified.
Q22 Mr Khan: Can I say how reassured
I am that you do not read the Daily Telegraph. I am pleased
to hear that. I am afraid I have got to leave shortly for another
meeting, so apologies, no discourtesy is intended. My first question
is do you think it is realistic and reasonable for one in 10 patients
who are admitted to NHS hospitals to be unintentionally harmed?
Sir Nigel Crisp: No, I do not.
As a patient, this is something I want to know that we take extremely
seriously.
Q23 Mr Khan: What are the experiences
of other countries?
Sir Nigel Crisp: Broadly similar.
I think it is worth drawing out, as it does in this Report, that
two-thirds of that 10% do not experience any harm, so we are lumping
everything together in that. Again, Sir Liam is the international
expert on this and he could talk more about that.
Q24 Mr Khan: What I am interested
in is 10% is not realistic and it should be lower—the obvious
thing is to say it should be zero of course—if you were
to come back here in a year's time or 24 months' time, what would
that figure be?
Sir Nigel Crisp: I doubt in that
sort of period that it would shift, but I do not like using an
argument that we are just as bad as everyone else.
Q25 Mr Khan: How long do patients
have to wait before they see an improvement that is noticeable?
Sir Nigel Crisp: You will see
certain categories where we have got improvements. I could have
said in response to an earlier comment that the National Patient
Safety Agency has sent out 15 safety alerts in the last three
years about specific devices or use of drugs or whatever; and
that compares with 10 in America over the same period, for example.
We are actively trying to focus down on individual issues and
make sure that those particular sorts of incidents never reoccur.
We have got the IT system. A lot of these incidents were about
slightly wrong levels of medication and when we are not relying
on people's handwriting we will get better at that as well, so
you will see some changes.
Q26 Mr Khan: How soon before we see
changes on the ground?
Professor Sir Liam Donaldson:
Could I add a comment? I think in most developed countries the
ballpark figure is similar. The comparison should be with other
high risk industries, like the airline industry who have systematically
improved safety. It has taken several decades or more to get to
where they are, in fact even longer than that in some industries,
but we have some of the key ingredients in place that have been
shown from evidence from other industries to work. We are seeing
cultural change which is probably the most important thing, more
safety awareness in local services, and that is acknowledged in
the Report. We are seeing more reporting and analysis of reports,
which was also a way in which the airline industry changed. We
are seeing specific solutions coming through to reduce risk. Those
are not working as well as they could be yet but, as Sir Nigel
said, there are more of them coming through and certainly the
advent of the electronic patient record will benefit safety of
medication which accounts for 25% of the harm worldwide, medication
errors, and it will also reduce some of the problems that result
from poor communication and fragmented clinical information.
Q27 Mr Khan: So a noticeable change
a decade from now?
Professor Sir Liam Donaldson:
Absolutely, yes, but with incremental change over that period.
Q28 Mr Khan: One of the things you
referred to was the culture. In the context of enhancing the safety
culture within NHS trusts, there are comments made in the Report
about having an open and fair employer so that staff feel confident
coming forward. Can I ask you what further actions you expect
the NPSA to take to improve the culture in the NHS so that staff
feel they have an open and fair employer?
Professor Sir Liam Donaldson:
I think they have already put out guidance to good practice that
staff should not be suspended unless there is evidence of negligence
or careless conduct. On the majority of occasions when something
goes wrong there is an error but it is a failure provoked by weak
systems supporting the practitioner concerned, so just by careful
monitoring. We do live in a blame culture society, as is the case
in many Western countries, where scapegoats are looked for and
individuals are blamed for mistakes but as we have seen in other
industries, like the airline industry, that blame culture can
be rolled back but it requires effort not just within the service
concerned but by society as a whole and in particular the media.
Q29 Mr Khan: In particular, in your
answer a knock-on effect that will have on clinical negligence
cases is if you are admitting your mistakes that may have an impact
on the number of cases that are settled.
Ms Williams: The programme we
have to support a culture of change is we have trained 8,000 staff
in root cause analysis, which is a particular technique which
seeks to look at the contributory factors that lie behind an incident
which starts to move people away from individual blame. At our
conference next month we are launching a cultural assessment tool
so that trusts themselves, whether at unit team level or strategic
health authority level, can assess the level of maturity against
a well recognised and used tool in other industries. We have trained
and worked with 113 boards to talk through the issues of open
and fair culture. We have issued a chief exec checklist so that
chief execs themselves know the role that they can play to promote
safety. Also, we have run leadership courses through the lens
of patient safety to introduce them to some of these concepts.
In terms of your last question, I am sorry I lost the—
Q30 Mr Khan: The impact on settlements
in cases.
Ms Williams: Just recently we
issued a Being open policy and teaching materials. This
involves apologising and giving a full explanation involving the
patient and their relatives in working through what actions might
prevent harm in the future. We built that policy from experience
both in Australia but particularly in Veterans' Health Services
in the USA where they have run this policy for a number of years
and their negligence bill has not increased during this time.
Q31 Mr Khan: At the beginning of
your answer you referred to your 8,000 staff who have been trained
on the forms. How will the NPSA be able to identify learning when
it says in paragraph 2.38 that trusts "are not required to
provide information on contributory factors"?
Ms Williams: A number of trusts
are using the form that—
Q32 Mr Khan: They are not required
to, are they?
Ms Williams: Not at the moment
because we are reliant on seven or eight commercial vendors and
not all of those systems collect contributory factors. The numbers
where we are getting this information is increasing. What we would
like to see over time, as people become familiar with these terms—these
are very new ways of looking at incidents—as trusts become
more familiar is their internal forms changing.
Q33 Mr Khan: Do you envisage it being
a requirement to provide those?
Ms Williams: I think in time,
yes, it will be.
Q34 Mr Khan: This is probably a question
for Sir Liam. Most countries favour a confidential rather than
anonymous service for reporting because it means that you can
learn from the information you are given. Why is the National
Reporting and Learning System that we have anonymous?
Professor Sir Liam Donaldson:
Only one aspect of it is anonymous. The confidentiality code can
be broken in circumstances where there is a very serious cluster
of cases that needs to be investigated further. By and large,
the majority of reports are made through local risk managers,
the clinicians giving their reports to the local risk managers.
They are being open about it anyway. It is important to emphasise
that a lot of learning needs to take place at local level, it
is not just a case of looking at reports at national level, those
incidents need to be used at local level to introduce safer systems
in the hospital.
Q35 Jon Trickett: I want to reflect
on patient choice since we are now offering a choice of hospitals
to patients. What information is provided to patients about the
level of accidents, say per thousand staff, so they choose which
hospital they would prefer to go to?
Ms Williams: At the moment there
are a number of trust boards who do put papers on their public
part of the agenda which show the number of incidents by specialty
and what action they are taking as a result. The work that we
have done with groups of patients to discuss this issue to feed
into the patient choice agenda is the issue for us is that more
reports is a sign of a healthy environment in which incidents
are raised and action can be taken and, therefore, it seems more
counterintuitive but more reports is a good thing for patients
to be looking for. In fact, to choose a hospital where there were
very few reports might be a concern because it might show that
there might be a level of cover-up.
Q36 Jon Trickett: Does the GP provide
to the patient the number of accidents in the four hospitals which
are being offered to the patients?
Sir Nigel Crisp: No. The two things
that the patients will get are the MRSA rate, which is one of
the issues here, and that is published by the hospital, and the
second thing that is also available to patients is the Healthcare
Commission's Report on the hospital. We do not have a figure of
accidents per so many staff.
Q37 Jon Trickett: I will ask you
about the two tables in here in a second. What monitoring do we
do? If I go to my GP and I am referred to three NHS trusts and
a BUPA hospital and I ask what information he or she has about
the number of accidents across the four sites, is that information
available to him or her?
Sir Nigel Crisp: There is not
information that is systematically available about accidents across
sites. There is about the things that we collect and publish,
and I deliberately say MRSA and I do deliberately pick out the
Health Care Commission's Report which will be made public. Those
are in the public domain. As you know from the earlier discussion
and the points that Ms Williams has just been making, there is
not a simple definition of what are accidents as opposed to anything
else.
Q38 Jon Trickett: You have signed
the paper off. Do we collect information about hospitals in the
independent sector, the number of accidents?
Sir Nigel Crisp: We do not. What
we are doing with the NPSA is first of all starting with the hospitals
physically within the NHS with the intention of then moving on
to deal with the independent sector of whatever sort.
Q39 Jon Trickett: Do you have statutory
powers to receive the information from the independent sector?
Sir Nigel Crisp: The Healthcare
Commission does.
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