Examination of Witnesses (Questions 60-79)
DEPARTMENT OF
HEALTH AND
NATIONAL PATIENT
SAFETY AGENCY
16 JANUARY 2006
Q60 Mr Bacon: You are saying the
nature of the report is such that there is a local identifier
of who it is?
Ms Williams: Yes.
Q61 Mr Bacon: I think the very first
committee meeting I attended of this Committee some years ago,
certainly if not the first one of the very earliest, was on the
NHS Litigation Authority. I remembered that meeting when reading
this statement on page 55 where it says in paragraph 3.36: "the
prevailing legal system does not encourage health professionals
to be open after an adverse patient safety incident..." What
have you done, Sir Nigel, to try to suggest policy changes to
the prevailing legal system as it relates to medical error and
as far as it relates to litigation since October 2001 when we
had that hearing?
Sir Nigel Crisp: Some very specific
things, but can I ask Sir Liam, who has been the architect of
these, to address it.
Professor Sir Liam Donaldson:
Apart from the measures that have been taken to encourage reporting
and which have been pretty successful given the level of reporting
that we have seen over the last couple of years. I also produced
for the Government a report on reforming the medical litigation
system called Making Amends which is about to work its
way through the House towards a Bill. That firmly places emphasis
on trying to get blame and retribution out of the litigation system,
allowing patients, not just with small claims, to have compensation
but also to ensure they have an apology, an explanation of what
has happened and a report from the local health service telling
them what action will be taken as a result of the incident that
harmed them and how it might prevent harm to another patient.
That is another strand of action which tries to improve the climate
and stop us going down the American path of very confrontational
and costly litigation.
Q62 Mr Bacon: This is a question
for Ms Williams. It relates to paragraph 2.38 and the follow-up
work to the An Organisation with a Memory report, and it
says halfway down that paragraph: "Despite the existence
of well-developed international incident classification, the National
Patient Safety Agency decided to define its own taxonomy for national
reporting and produce tailored versions for use in nine different
healthcare settings." Why did you not follow the widely used
international incident classification?
Ms Williams: We could not find
any widely used international incident taxonomies.
Q63 Mr Bacon: You did not find anyone
who used them?
Ms Williams: Not an international
taxonomy. What we found was a number of state-wide taxonomies
in Australia or in the United States, very often uni-functional,
so only concerned with a particular type of speciality.
Q64 Mr Bacon: So is this paragraph
wrong?
Ms Williams: No, it is not wrong.
There are a number of taxonomies around the world which we did
review and what we found was there was very little for mental
health, in fact none, for learning disability, primary care or
ambulance services. There was some work done in some states in
some countries that looked at acute services.
Q65 Mr Bacon: So you constructed
a new classification?
Ms Williams: So we worked with
clinicians to construct something that was relevant for the UK.
Q66 Mr Bacon: Can you tell me whether
the next sentence is correct. It says: ". . . reporting fields,
which identify the contributory factors to the incident, are optional,
and compliance is variable, even though the learning of lessons
is most likely to come from this information." Is that sentence
in all its particulars correct?
Ms Williams: Yes, it is correct.
As I was explaining earlier, not all the commercial risk systems
that the trusts have purchased collect contributory factors. We
have thousands of reports which do have contributory factors on
but this is an area where we want to make changes over the next
year or so. We are going to be reviewing our data set, we gave
a commitment to review it once we have rolled it out to all the—
Q67 Mr Bacon: Do you mean the fields
will be obligatory rather than optional?
Ms Williams: I think they need
to be because that is where the—
Q68 Mr Bacon: Is it not rather obvious
to make them obligatory if you want to have complete data to work
with? You do not need thousands of consultants to tell you that.
Ms Williams: The free text in
the reports that we currently get reveal an enormous amount and
we are able to use that for learning. Certainly ideally we would
like the contributory factors but it would mean commercial systems
making a change. One of the things that we have been doing is
working with Connecting for Health and one of the solutions to
this would be a national specification for risk management systems.
Q69 Mr Bacon: Is this yet another
bell and whistle added on to the original Connecting for Health
specification?
Ms Williams: I think it is something
that we could very closely work with them on. It is a specification
that would be tendered but it would give that mandatory flavour
which I think we are all asking for.
Sir Nigel Crisp: We are holding
off the bells and whistles at the moment.
Q70 Mr Bacon: May I ask about the
Department of Health's identification of the Australian patient
safety system which is called AIMS, Advanced Incident Monitoring
System? The Department of Health identified that as a workable
system but when the responsibility was transferred to the NPSA
you did not go with that, as it were, an off-the-shelf working
system. You started from scratch. Can you say why?
Ms Williams: The Department of
Health tendered for a system and when we arrived in post there
was a consortium in place between the company that operated the
AIM System and a UK-based software system. We decided to let the
pilot run. We evaluated it in April 2002 and we found that there
were a number of problems. There were technical difficulties and
we learned a huge number of lessons but it was not a system that
at that time we felt could be rolled out to the whole of the UK.
Q71 Mr Bacon: Could I just check that
Mr Stuart Emslie, who wrote to this Committee[5]
with a note about this system and indeed about what he feels was
a waste of money which the Department of Health was engaged in
on this procurement, is the same Stuart Emslie who was reported
on 2 December 2001 in The Sunday Times as having given
an internal briefing to the Department of Health the previous
month, in November 2001, that 16-20% of your budget disappeared
through waste, fraud and mismanagement?
Sir Nigel Crisp: I do not know.
Q72 Chairman: I understand that this
is a matter which is sub judice. Under the rules of the
House, as our Clerk advises us, it might be difficult to pursue
this matter. I understand there is a writ against this man. Is
that right?
Sir Nigel Crisp: Yes, that is
right.
Q73 Mr Bacon: I am not wishing, Chairman,
to stray into anything that might come before the court. I am
simply trying to identify if this is the same person who was referred
to in the article in The Sunday Times on 2 December 2001.
Sir Nigel Crisp: Frankly, I do
not have a memory for everything that has appeared in The Sunday
Times in the last five years, but I would request the Chairman
that we do not go into this area, for the reasons that the Chairman
has stated.
Q74 Mr Bacon: I would just like to
know if it is the same person. I think it is right that you can
confirm whether it is the same person or not.
Sir Nigel Crisp: I suspect it
is.
Q75 Mr Bacon: Can I ask you one more
question, and this may be for Ms Williams again? It is about power
generators. In an Adjournment Debate the other day there was an
answer by the Minister of State concerning medical injury, the
Sarah Lynch brain damage case, a very sad case. One of the problems,
and it is arguable to this day, 20 years later, whether this was
a contributory factor, was that there was a power cut and the
back-up generator also did not work. What data do you keep centrally
on the state of back-up generators and whether they are all in
good condition and maintained regularly? In this particular incident
the back-up generator log book was destroyed. Do you keep data
centrally on that?
Ms Williams: No, we would not
keep data about individual pieces of equipment or estate at the
NPSA.
Q76 Mr Bacon: It would be at the
trust level, would it?
Ms Williams: That would be at
the trust level. There will have been guidance from NHS Estates
in the past requiring trusts to make sure that there were suitable
back-up arrangements.
Q77 Mr Mitchell: Can I carry on with
the National Patient Safety Agency and ask Sir Nigel how he rates
the success of the agency in meeting its key target of improving
the culture of the NHS? Would you say it was stunning? Would you
say it was mediocre? Would you say, in a civil servants' phrase,
it was disappointing, or lousy?
Sir Nigel Crisp: I would say good
and more to do. I think we have come quite a long way but there
is an enormous amount further that needs to be done. Why I say
good is because we do have this reporting system that is at the
level of other people around the world or where we are perhaps
leading the way. We do have the 15 safety alerts that I referred
to and so on, so I think it is fair to say good but I do think,
as this Report reveals, we have got a lot further to go to see
improvements, so I am going wider than just the NPSA, but I think
they have played a significant part in this.
Q78 Mr Mitchell: But come a long
way more slowly than everybody would have hoped?
Sir Nigel Crisp: I think that
is true but I do think that it is a very strong point that they
took over a piloting system from the Department of Health, evaluated
it, found it wanting and then went on to develop a full Business
Case for an in-house developed system, which required Treasury
approval. You hope pilots work but if they do not you want proper
evaluation. I am pleased that the board and the chief executive
had a proper evaluation. That is disappointing but I think we
have come a long way.
Q79 Mr Mitchell: Can I ask Ms Williams
why it took such a long time to get the National Reporting and
Learning System off the ground? This was presumably a key task
and yet you were messing about for ages.
Ms Williams: We could not proceed
with the first pilot and therefore we had to ascertain whether
it would be possible to roll out a system with just the Australian
company that we mentioned earlier. That was also found not to
be possible. We also discovered during that period in 2002 that
the scale of the enterprise was such that we needed to seek Treasury
approval for a full business case. That was done and from receipt
of approval it has taken two years to roll out to 607 organisations,
which I think is a major task. Of course we would like to have
done it more quickly. However, we did not wait until we had rolled
it out before starting work on a range of solutions. We had a
number of issues that were raised with us by patients or by members
of staff, we worked on those and we issued guidance to try to
prevent harm, so we did not wait for the reporting system to get
going before we started work on our solutions.
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