Examination of Witnesses (Questions 100-119)
DEPARTMENT OF
HEALTH AND
NATIONAL PATIENT
SAFETY AGENCY
16 JANUARY 2006
Q100 Greg Clark: Ms Williams, what
is the annual budget of your organisation?
Ms Williams: The original NPSA
budget was £15 million a year.
Q101 Greg Clark: The original one?
Ms Williams: From 1 April 2005
we took on a range of additional responsibilities following the
Government review of arm's length bodies and that added an extra
£20 million or so to our budget.
Q102 Greg Clark: So the budget for
next year is what?
Ms Williams: It is of the order
of £44 million.[6]
Q103 Greg Clark: How many employees do
you have working for you?
Ms Williams: With our new responsibilities
we have 316 whole time employees.
Q104 Greg Clark: How long have you
been Chief Executive of the organisation?
Ms Williams: Since its inception
in October 2001.
Q105 Greg Clark: During that time
have you identified any principles that would tend to make the
hospital more safe and less prone to these patient safety incidents?
Ms Williams: What we have identified,
having looked at other industries, is aspects of what we would
call a safety management system. There are certain things that
need to be in place that would tend to lead towards a safer environment.
Q106 Greg Clark: Can you give me
some examples?
Ms Williams: They are a reporting
system, an open and fair culture (which can be tested), a root
cause analysis of serious incidents when they occur, feedback
to staff, multidisciplinary teamwork, communications, work on
those particular areas, handovers, and then time for learning.
We found in some trusts that they had very well developed systems
where on a regular basis the multidisciplinary team sit down—and
it can happen in a GP practice or in a specialty—and discuss,
"What has gone well, what has not gone so well, what can
we put in place to prevent risk occurring?". It is that sort
of drive that we want to see extended right across.
Q107 Greg Clark: That seems very
sensible and I would expect that, but it strikes me, just reading
the Report, that some of those principles do not seem to apply
to the organisation itself. Take learning, for example. Mr Bacon
has already raised a point about international comparisons and
I detect a note of criticism in the NAO Report when it says, ".
. . and, despite the existence of well developed international
incident classification, the National Patient Safety Organisation
decided to define its own taxonomy and national reporting and
produce tailored versions for use in nine different healthcare
settings". For an organisation that is there to promote learning
it seems strange that you would ignore the international examples
and go for something that is entirely unique.
Ms Williams: We did not ignore
them. We went through a process of reviewing the classifications
that we could find internationally and, as I have previously said,
we could not find any taxonomies that related to mental health,
learning disability, the ambulance services, primary care. There
was some work done on acute services in some parts of the world.
Q108 Greg Clark: But just on acute
services is it not possible to take in that, which is, I would
imagine, a large portion of the incidents?
Ms Williams: Again, when you look
at any other national system, there is always a need to customise
it for the local language—
Q109 Greg Clark: Customise, yes,
but to start from scratch seems extreme.
Ms Williams: We felt that we needed
a system that had local clinician support and we went through
a process which involved several hundred clinical staff to reach
a taxonomy that learnt from others but actually met the requirements—
Q110 Greg Clark: It strikes me that
as an organisation you advocate learning but do not seem to have
done much learning yourself when it comes to this.
Sir Nigel Crisp: Can I just say
something there? I think that paragraph does say that there are
well developed international incident classifications, but the
point that Ms Williams and colleagues are making is that they
are not comprehensive and we wanted a comprehensive system that
covered all patients. Whilst it is appropriate to learn from other
people, we now actually have a system that does cover the whole
patient population.
Q111 Greg Clark: I would have thought
in the context of this organisation that learning implied sharing
best practice rather than adopting a unique approach. Let me move
on to another principle. It strikes me that it would be reasonable
to suppose in any discussion of safety that mistakes happen when
procedures are complex and unclear. I assume that would be a common
sense assessment. Would that be reasonable, that complexity is
an area of safety?
Ms Williams: Yes, complexity is
plainly going to create a more difficult environment.
Q112 Greg Clark: But then we see
on page 34 of the Report, paragraph 2.30, that the NAO concludes
that trusts "face an extremely complex system of reporting
and investigation". For an organisation that is, one would
hope, aiming to promote simplicity and clarity that is a dreadful
conclusion from the National Audit Office surely.
Ms Williams: It is true to say,
as the Report makes clear, that there are a number of bodies to
which trusts should report and some of these are for very good
statutory reasons, whether it is for overdose of radiation or
whether it is the Health and Safety Executive, or whether it is
the Health Protection Agency which offers surveillance for—
Q113 Greg Clark: Surely, for an organisation
to be about simplicity and clarity, to have a conclusion from
the National Audit Office that described not just a complex system
but an extremely complex system of reporting and investigation,
that seems to be dysfunctional.
Sir Nigel Crisp: To be fair, if
I may come in, if I am reading paragraph 2.30 properly, I do not
think that is purely about the NPSA. I think that is about the
fact that trusts do have to report to a lot of people.
Q114 Greg Clark: Shall we read it
out: ". . . the National Reporting and Learning System added
to the list of organisations to which trusts were already required
to report and trusts still face an extremely complex system of
reporting and investigation. Figure 14 overleaf", it goes
on to say, "shows the main national reporting systems, but
around 30 routes still remain." That seems extraordinary.
Sir Nigel Crisp: The point I was
making was that I am not sure that is entirely fair to lay that
at the door of the NPSA because if you look at those if you look
at those other agencies, police and coroners and other people,
they require information as well, and it is not surprising that
they do. What we have discussed is—
Q115 Greg Clark: The problem is,
is it not, that the way the NPSA has gone about its work has duplicated
the systems in place rather than added to them? For example, if
we take Appendix 5, page 71, the final bullet point says that
"trusts that were visited felt that the local systems were
more important for learning lessons". As far as I understand
it, one of the objectives of this organisation, the National Patient
Safety Agency, is to promote learning and yet we find that their
own systems are not, practitioners find, the best place to promote
learning; it is the local systems that have been added to. That
again is not a happy conclusion, Ms Williams.
Sir Nigel Crisp: I think there
are two points here.
Q116 Greg Clark: Ms Williams' perspective
is the one we would like to have.
Ms Williams: Of course, local
learning is absolutely vital and it is the building block on which
any national system will sit. However, what a local system cannot
do necessarily is pick up themes and trends that are applying
across systems. They will only know of the incidents that they
report locally. They will not know that actually it is part of
a trend that is quite widespread. Only a national system can do
that.
Q117 Greg Clark: Just on that point,
Ms Williams, paragraph 2.37 says that the National Patient Safety
Agency "could have collected aggregate information on commonly
occurring incidents that trusts knew about and used it to promulgate
learning nationally".
Ms Williams: We did look as part
of our business case at a range of options and one of them was
aggregate collection of data. This would not have allowed us to
pick up the individual reports on a particular issue. It would
have provided summaries of information, statistical information.
It would not have yielded the richness of the reports that we
have received and that we are able to take action on. On our very
first alert, if I could give you that example, we had 40 individual
reports on a particular drug which meant that we were able to
take action. If it was aggregated information all we would be
able to receive would be something like 2,000 medication incidents.
That is not a basis on which we could have taken action.
Q118 Greg Clark: Your organisation
had an objective to be a leader in this field, to promote the
profile of patient safety. You were established in 2001. In 2005
77% of junior doctors said that they needed more information on
what your agency was about and 60% have never heard of you. Is
that a good performance?
Ms Williams: We know that doctors
internationally, not just in this country, are a particularly
hard group to reach in relation to patient safety and reporting.
That is precisely why we mounted a campaign this year to increase
the knowledge. We have, through doctors.net.uk, which is a web-based
organisation that many thousands of junior doctors in training
are members of, found that now 10,500 doctors in training have
been through that programme.
Q119 Greg Clark: I was interested
in the results of that. I agree this seems a commendable thing
but, having gone through this programme of creating awareness,
initially 13% thought the organisation would improve patient safety.
As a result of people going through the process it rose to 34%.
In other words, having been made aware, having been briefed and
having gone through a course, 66% of doctors still thought that
this was not going to make a difference.
Professor Sir Liam Donaldson:
If I could just add on that, we have put into the training programme
for all junior doctors from now on a competency on patient safety,
so I think that situation will dramatically improve over the next
few years.
6 Correction by witness: The NPSA budget for
2005-06 is £35.154 million. Also see Ev 19-21 Back
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