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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