Select Committee on Public Accounts Minutes of Evidence


Examination of Witnesses (Questions 80-99)

DEPARTMENT OF HEALTH AND NATIONAL PATIENT SAFETY AGENCY

16 JANUARY 2006

  Q80  Mr Mitchell: You talk about the Australian system but Mr Emslie tells us that there was an existing NHS Safecode system which was a Crown product developed and funded in this country. Why did you not consider using that?

  Ms Williams: There are a number of risk software systems developed in this country. I do not believe it would be appropriate to comment further on an individual system.

  Q81  Chairman: Was it unsuitable?

  Ms Williams: I do not believe I can comment.

  Sir Nigel Crisp: The organisation carried out a rigorous evaluation, which is what we would want them to do, speaking for the Department of Health, and having done that evaluation, they carried out an options appraisal which resulted in an in-house system being chosen, following business case rules, in part because they needed to in Treasury terms. They made a judgment based on the evidence available to them at the time.

  Q82  Mr Mitchell: Did you even consider Safecode?

  Sir Nigel Crisp: I think this is all part of the issue you talked about earlier, Chairman, and I think we really should not get into this.

  Q83  Mr Mitchell: So we take it that it was not considered?

  Sir Nigel Crisp: I am happy at some other point if you want to send you a written note or something but I do not think I am prepared to discuss this particular issue further as this is a matter that is sub judice.

  Q84  Chairman: Would you be more happy giving evidence in private or would you rather not give any evidence at all?

  Sir Nigel Crisp: I would rather not give any evidence at all.

  Q85  Chairman: Because it is sub judice?

  Sir Nigel Crisp: Because it is sub judice.

  Chairman: That is our problem. That is the rule of the House. I am quite happy to take advice but under the rules of this House we are not supposed to take evidence on matters which are sub judice.

  Q86  Mr Mitchell: Why, at the end of the day, when you had devised a system, did you come up with one where the trusts questioned the value of sending data to the system, given the lack of feedback and the lack of emphasis on solutions and given its complications?

  Ms Williams: In terms of complications we had a choice. We could either create a system whereby trusts reported separately to us, which would have meant reporting once on their own system and separately to a national organisation. We took the view, and it did take longer, that we would integrate our requirements as far as we possibly could into the commercial systems. That has meant at the initial stages a mapping exercise which has caused additional problems for the trusts but once mapped it is very much easier for the trusts to send us information. On the whole question of feedback, we are very aware that unless there is regular feedback this does act as a barrier to reporting. We would argue that we have produced three reports from each of the two pilots that we had, plus the Observatory report last year. As Sir Nigel has said, we have had 15 solutions. We have had conferences, we have run training sessions for 47,000 staff over the period, and therefore in one sense there has been feedback. It is not sufficient and clearly this is something we need to do more of. We have agreed with the Department of Health that there will be quarterly reports coming from the Observatory, which is the term we use where we bring together information from the reporting system together with other information sources—litigation, complaints, et cetera. We will publish more regularly on a quarterly basis and we have been piloting an extranet with trusts so that they can get immediate feedback which will enable them to benchmark themselves against other organisations.

  Q87  Mr Mitchell: But it seems odd, having moved so slowly and looked at this system and rejected that system, for reasons we are not allowed to be told, that you came up with a system which did not satisfy the needs of learning because it does not tell us about the causes of whatever has happened. How can you identify learning when trusts are not required to provide information on contributory factors?

  Ms Williams: As I have previously answered, we would like to see in future more of this information coming in. Many of the systems do provide this. We have many thousands of reports which do include contributory factors. We do believe that ideally it should be a mandatory field and that is something we would be working on with Connecting for Health.

  Sir Nigel Crisp: May I make one point on this, which I hope is helpful, which is that the point there is about the feeder systems not requiring that rather than about how they can be collected centrally. That is about using the feeder systems in the trusts.

  Q88  Mr Mitchell: What we need at the end of the day is guidance on avoiding accidents and that is not what you are able to provide.

  Ms Williams: We have produced a major guidance document. It is called Seven steps for patient safety. It outlines for trusts a comprehensive range of policies which they would need to develop in order to build the infrastructure that would support safety at a local level. On its own it provides the framework within which they develop their systems but on top of that we produce seven or eight other tools and techniques that would support safety at the local level.

  Q89  Mr Mitchell: Yes, but at the end of the day patient safety incidents cost, it is estimated, a couple of billion in extra bed days, so why have you not done more to develop guidance on costing the patient safety incidents and listing the solutions to them? This seems to be a key weakness.

  Professor Sir Liam Donaldson: The agency has put out 15 alerts on different subjects. Over the same period of time the Joint Commission in the States, which is probably the international benchmark for putting out these sorts of solutions to reduce risks, put out ten, so they have put out very extensive guidance and several of them are in areas where the cost savings are very big. Sir Nigel mentioned the cleanyourhands campaign. There is the whole question of the infusion pumps which cost lives and cause harm, so there are some very significant steps that have been taken in my view, and once the analysis of these nearly a million reports is more fully developed I think the solutions will flow out even more swiftly. They have looked, for example, at misplacement of nasogastric tubes which cost the lives of children and babies. They have looked at wrong site surgery. All of these things are very important measures to reduce risk in specific areas as well as the general Seven steps type of approach which Ms Williams has mentioned.

  Q90  Mr Mitchell: Yes, but this is an agency which is our agency which is supposed to develop solutions to our problems in a field where you told us at the start of this that we were world leaders and doing very well, thank you very much, an agency which has already rejected Australian experience. Why should we be reliant on the Americans in this kind of field? Why is it not doing it itself?

  Professor Sir Liam Donaldson: If you look around the world we are one of the few countries to have a nationwide system. The Americans have only got systems in certain parts of the country, so have the Australians. Indeed, the number of incident reports we have already I do not think has been surpassed anywhere in the world. Proportionate to the size of the populations, we are level with the Veterans Administration which covers 7 million people in the States. We cover 53 million people, so both numerically and proportionately I think we are in the lead. Other countries, and indeed other industries, have shown that you have to get high quality data in before you can start analysing. As Ms Williams has said, even before the data are fully in they have put out 15 alerts, which I think is quite a strong record, certainly in comparison to the other example that I gave.

  Q91  Kitty Ussher: As somebody who is not expert in this particular field of policy, reading the brief and the NAO's Report for the first time, I must admit I was immediately rather scared. I think the number of one in 10 is much higher than members of the public would expect and is certainly way higher than they would hope for. The idea that when you go into hospital and your life and welfare is in someone else's hands and in one in 10 times it will be made worse in accidents rather than something internal is really quite terrifying. I have heard you say that you think things are improving but obviously there is a long way to go. Could you describe the situation before Ms Williams' agency was established so that we have some kind of benchmark about where it started from? Where were we 10 years ago, for example?

  Professor Sir Liam Donaldson: Perhaps I could start on that. Ten or 15 years ago many members of the medical profession would say there was no such thing as a bad doctor. Many would say that you could not measure quality so why bother to try and improve it. Over the last five or six years we have put in place a comprehensive quality framework in this country which is admired internationally, with clear national standards, with inspectorates. Safety is the first of those national standards that were issued a year ago on which the Healthcare Commission inspects. At local level every hospital has now a duty of quality, and again that is very unusual compared to other countries, and local programmes of what we call clinical governance (which is a way of ensuring that clinicians are involved in quality assurance), quality improvement and safety are in place, and indeed the NAO Report talks in positive terms about our clinical governance programme, so things have moved on a lot. This strand of safety has been added to that overall programme and I think has in place the ingredients necessary to improve safety very considerably: the cultural change, the technical support with reporting and learning systems, the area which we are working on at the moment to improve education and training. If you take the particular element about poor practice and bad doctors, as I was saying earlier, we have also moved forward very substantially on that in identifying bad doctors early, trying to rehabilitate where possible but ensuring that patients are protected at an early stage. There is more to do but the emphasis is very much on quality and safety in the NHS today.

  Q92  Kitty Ussher: What was the trigger for the establishment of the agency?

  Professor Sir Liam Donaldson: It was a report that I produced called An Organisation with a Memory. I had had a longstanding interest in and had read a lot about the work that was being done in the airline industry and the way that they had managed to improve safety over many years and I thought that there would be a comparable programme that could be launched in healthcare.

  Q93  Kitty Ussher: Was there any national budget stream for patient safety in the holistic rational sense prior to the establishment of the agency?

  Professor Sir Liam Donaldson: Not specifically, no, and one was created by the implementation of An Organisation with a Memory.

  Q94  Kitty Ussher: In your opening remarks in your conversation with the Chairman you suggested that you should write to the Committee with the international comparisons to make sure that we had up-to-date information. Since then you have mentioned a couple of other instances. Since members, if you will permit me, Chairman, keep saying, "How does our one in 10 stack up when compared internationally?", and you have mentioned that we are a world leader now, could you expand on that answer a little bit more and give us a quick indication of where we now stand compared to other countries?

  Professor Sir Liam Donaldson: In developed countries the ball park figure of one in 10 hospital admissions resulting in some form of error or mistake is probably comparable across all countries. We do not know what the position is in developing countries. One would assume that, because of their poor infrastructure and resources, the problems there would be more serious, but the World Health Organisation is currently researching that. As far as the scale of the problem is concerned we are probably broadly comparable with other developed countries and certainly there is a great deal of concern in the US about the level of inadvertent harm caused by their healthcare system. As far as making commitment to action is concerned, we are in the forefront, although commitment and enthusiasm are growing across many countries in the world now and I have talked to people in other countries about what they are doing. The area where we need to achieve more is in this area of implementing risk reduction measures because, aside from some limited evaluations of the benefits of introducing, for example, electronic medicine prescribing into some parts of the world, there are very few examples of where reductions in risk can be quantified and attributed to particular interventions. We are trying to learn as much as we can from the researchers and from what is happening elsewhere as well as implementing our own programmes.

  Q95  Kitty Ussher: Given that we had not done much until very recently and given, as you seem to imply, that many other countries are in the same situation, if we are all on a ratio of one to 10 what do you think potentially, hypothetically, that ratio can be reduced to once we all operate at the maximum of our potential? I am not talking about the timescale but if that could become in theory one in 15 or one in 20 do you have a sense of the potential improvement there?

  Professor Sir Liam Donaldson: Given the experience of other industries, those scales of reduction are achievable and I do not think there is any reason why healthcare could not achieve the same sort of record of year on year improvement.

  Q96  Kitty Ussher: One in 20 then would you consider?

  Professor Sir Liam Donaldson: It is difficult to put an exact figure on it.

  Q97  Kitty Ussher: But that order of magnitude?

  Professor Sir Liam Donaldson: Yes.

  Q98  Kitty Ussher: You mentioned the implementation mechanism for the things that you have found out, which was going to be my next question, and I presume Ms Williams is the most appropriate person to answer. You have described how incidents are reported and you obviously now have a large quantity of data. You have said that you have issued 15 alerts and have this training agenda and the cleanyourhands campaign. I launched our own cleanyourhands campaign in my constituency so I know it is there, but what kind of enforcement powers do you have and what kind of checking or accountability powers do you have to make sure changes are made?

  Ms Williams: The NPSA itself does not have enforcement powers. There are three ways in which it is possible, if you like, to find out whether anyone is taking any notice of what we are putting out. The first thing is that we do have our own evaluation programme where we look to see what are the barriers to implementing our suggestions because we ourselves want to learn for future products how we can make it easy for people to implement our solutions. Secondly, and very importantly, the alerts go out through an alert system which is monitored by strategic health authorities. It is called the SABS system, so when something goes out trusts are required to indicate whether they are taking action, whether it is appropriate to take action, and when they will take action, so there is that performance monitoring. The third important strand is that the Healthcare Commission, which, as well as self-assessment, will be undertaking random inspections, have agreed to include in their criteria a check on a random sample of alerts that we put out, so they will be absolutely able to see a demonstration that something has happened at the other end.

  Q99  Kitty Ussher: That is reassuring. Has any of that actually happened yet? Do you have any data as to how effective you are being?

  Ms Williams: We have some examples. One of the topics we took was the standardisation of the crash call number. Standardisation is a common safety solution. What we found before we standardised to four twos—this is where you call for help from a team if somebody is having a cardiac arrest—was that there were 27 different telephone numbers across the Health Service, so staff clearly moved from one to another site and very often agency staff would be working across different locations. As at the end of 2005 all trusts have standardised to the four twos, 2222, so this is the standard number that can be used right across. Another example would be one of our very early alerts. Potassium chloride has already been mentioned. We asked trusts to withdraw it from general ward areas. This is a very toxic drug in its undiluted form. Before we put out our alert we did a base line. 32% of ward areas had not got this drug on their shelves, as it were. We checked two years later and in fact we are up to 98% of wards that have now removed it from their ward areas. This reduces the likelihood of a member of staff in a hurry reaching for this drug and giving it in an undiluted form.


 
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