Examination of Witnesses (Questions 160-161)
DEPARTMENT OF
HEALTH AND
NATIONAL PATIENT
SAFETY AGENCY
16 JANUARY 2006
Q160 Jon Trickett: I was hypothesising
three possibilities on the facts of the case. This has happened
and it does happen from time to time, but how would the incident
be reported? At what point would blame be attributed, if blame
was to be attributed? It seems to me it has not been regarded
as an incident really.
Professor Sir Liam Donaldson:
Such an incident—again not talking about the specifics of
this one—should be identified locally, reported locally
and it should then be investigated and the causation of it analysed
and conclusions drawn and changes implemented to prevent such
an incident in the future.
Q161 Greg Clark: A question to Sir
John. The National Patient Safety Agency now costs £44 million
and some of us have been a bit concerned about some of the practices
we have heard about. Have you been able to come to a view through
this study whether as an organisation it offers value for money?
Sir John Bourn: I think the view
we have come to so far is that you can certainly identify some
trusts where there is what I might call a fearless yet sensitive
analysis of accidents and improvements have been made, so you
can find individual cases of value for money. It is also true
that in terms of the Agency we have not yet reached a point where
you can say value for money is being secured by it because we
do not yet have a national system of analysis and sharing lessons
which is fully used, so we have not yet got to the point where
we are getting full value for money from the money that is going
on the system.
Greg Clark: Thank you very much.
Chairman: I think that is an appropriate
place to end. I am afraid I have to say to you, Ms Williams and
Ms Osborn, that it is very likely when we produce our Report we
will be issuing a question mark about whether your organisation
does provide value for money, given it was set up in 2001 and
the delays there have been in bringing in the system. Thank you
very much.
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