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18 Mar 2010 : Column 328WH—continued
We took evidence not only about Mid Staffordshire but about management and governance in other places. We found disturbing evidence of catastrophic failure on the part of some senior managers and boards, including
at Mid Staffordshire. Although other boards are not failing as comprehensively, there is substantial room for improvement. Boards too often believe that they are discharging their responsibilities in respect of patient safety by addressing governance and regulatory processes, but we believe that they should be promoting tangible improvements in services.
We believe that there is a case for providing specialist training in patient safety issues, particularly to non-executive directors, in order to help them scrutinise their executive colleagues and hold them to account. Patient safety must be the top priority for boards; to show that that is the case, it should without exception be the first item on every agenda of every board. It is remarkable that that was not the case when we investigated the situation. It is difficult to comprehend why that should be so, in view of the harm that is done to patients.
We recommended to NHS organisations the measures that were piloted as part of the safer patients initiative. They included implementing tried and tested changes in clinical practice in order to ensure safe care; banishing the blame culture; providing the leadership to harness the enthusiasm of staff to improve safety; and changing the way in which they identify risks and measure performance, using information about actual harm done to patients, such as data from sample case note reviews.
I remember very well our visit to Luton and Dunstable hospital. I was interested to note that when something had gone wrong no one thought to consider what had happened in order to find out what lessons could be learned. They undertook systematic reviews of patient case notes to ensure that patients going through their hospital were getting the best and safest care. It is not only about investigating something when it goes wrong but about considering the system as a whole, including the management of patients, to ensure that nothing more can be done to lessen potential harm.
We strongly endorsed the Department's view that NHS boards should not always meet behind closed doors. We urged the Government
"to legislate as necessary to ensure that Foundation Trust Boards meet regularly in public".
The Government said in their response that they were
"considering what legislative or other changes may be necessary or desirable in the light of recent events in Mid-Staffordshire".
Since then, the Francis report has concluded that the board at Mid Staffordshire discussed "far too much" business in private, giving the impression
"that only good news is discussed in public while the bad is hidden behind a curtain of secrecy."
The Secretary of State responded by telling the House that there is a "strong presumption" that foundation trust board meetings
"should be held in public and that governors should have access to all papers".-[Official Report, 24 February 2010; Vol. 506, c. 312.]
However, he did not mention any plans for new legislation, instead invoking the spirit of the existing law on foundation trust status. I would be interested to hear the Minister's comments on that, and if we are not to have new legislation, how that change can be implemented.
We said in our report that the NHS remains largely unsupportive of whistleblowing, with many staff fearful of the consequences of going outside official channels to bring unsafe care to light. We recommended that the Department should bring forward proposals on how to improve the situation. Here too, we had Mid Staffordshire very much in mind.
The previous Secretary of State told the House last year that it was a mystery why no one had blown the whistle at Mid Staffordshire, given the existence of legal protection for whistleblowers. However, our evidence led us to conclude:
"Many healthcare workers remain fearful...that if they whistleblow they will be victimised."
Indeed, that conclusion was made also by the Francis report.
We recommended that the Department should
"bring forward proposals on how to improve this situation and that it give consideration to the model operated in New Zealand, where whistleblowers can complain to an independent statutory body."
The Government, I am pleased to say, accepted that recommendation. It is no good our passing laws in our legislative Chamber to protect whistleblowers if they are still fearful. The Francis report again vindicated our conclusions, finding that the Mid Staffordshire Trust had not offered the support and respect due to those brave enough to become whistleblowers. In response, the Secretary of State announced that a group had been established to advise him on updating NHS whistleblowing guidance.
We thought that the Government should be praised for being the first in the world to adopt a policy that makes patient safety a priority. However, Government policy has too often given the impression that other priorities-notably hitting targets for waiting lists and accident and emergency waiting times, achieving financial balance and attaining foundation trust status-are more important than patient safety. Everyone will say that that is the impression being given, but it is not so. Reading such stories in the media over the past few years, that often seems to have been the case for the defence. I hope that that is not so. No case can be made for the neglect of patients, whether in the acute sector or even the primary sector. I hope that the Government are conscious of the fact that there are some basic principles when it comes to ensuring that we look after our patients as safely as we can.
All Government policy in respect of the NHS must be predicated on the principle that the first priority, always and without exception, is to ensure that patients do not suffer avoidable harm. The key tasks of the Government, we said, were to ensure that the NHS
"develops a culture of openness and 'fair blame'"-
we all make mistakes; indeed, incidents from this House reported in the media over the past 18 months show that many here make mistakes from time to time-
"strengthens, clarifies and promulgates its whistleblowing policy"-
I am pleased that that will happen-
"and provides leadership which listens to and acts upon staff suggestions for service changes to improve efficiency and quality and, by the provision of examples and incentives, encourages and enables staff to implement practical and proven improvements in patient safety."
In addition, we argued that the Government should examine the contribution that deficiencies in regulation make to failures in patient safety. I am pleased to note that the Government again seem to be acting on some of the issues raised in the Francis report.
Finally, there is no health care system in the world that can be said to have completely solved the issue of patient safety. We can be proud of the fact that over the past decade, the NHS has been a pioneer in developing policies and systems to address patient safety. However, many things still need to be put right before the whole NHS-not just its best parts-is ensuring that patients are not avoidably harmed. I hope that our report can be said to have made a contribution to bringing that about.
Bob Russell (in the Chair): I thank the Chair of the Select Committee for introducing the debate. The House has allocated us three hours-or until 5.30-in which to discuss the report. There is no requirement for us to fill those three hours. There is sufficient time for everybody to have their say. Let me inform Members that we have two doctors, two nurses, a pharmacist and a research immunologist among us, so we can safely say that the expertise and experience of the outside world is brought into this Chamber.
3 pm
Dr. Richard Taylor (Wyre Forest) (Ind): It is a pleasure to serve under your encouraging and benign chairmanship, Mr. Russell, and to follow the Chair of our Health Committee. I am pleased, too, that five of the really active members of our Committee are present in the Chamber.
I am accused at home of doing this job as a hobby. If someone's hobby is something that really interests them and it is their job as well, it is marvellous. One of my hobbies for years and years has been to try to improve the national health service for the patient, and that is exactly what this report is about. I shall speak very briefly about a few of the recommendations and then concentrate on three of them. I will try not to overlap too much with our Chair. The first recommendation draws attention to the use of the words "safety" and "quality" in the Darzi review, and the second to the safer patients initiative, to which our Chairman referred and which we went to see in Luton and Dunstable. The Government welcomed both recommendations.
Recommendations 5 and 41 reminded the Department of the value of random case note review. When I was a practising physician some years ago, we used to dread the visits of the royal colleges to examine our wards and our care because they would look in the note trolley and pick out any note, so we had to have all the notes written up without any gaps. The Committee wanted to emphasise the importance of such a review and, as part of the safer patients initiative, Luton and Dunstable had taken it on board.
"We recommend the DH consider how to reinstate the best aspects of the Royal Colleges' inspections in the new system."
The Government's response stated:
"The Government agrees that the new system of registration could usefully take account of previous experience in related fields, including the Royal Colleges' inspection of hospital training posts. We will draw this recommendation to the attention of the CQC."
Recommendations 9 to 11 talk about the NHS complaints process, which the Chairman also mentioned. The loss of the independent review of a complaint before it goes to the ombudsman is, as far as I am concerned, pretty much a disaster. If I am lucky enough to be back here in the next Parliament and back on this Committee, one of the things that I will be pushing for is an inquiry into the NHS complaints process, because it needs yet another review. Recommendation 24 emphasises the importance of training in non-technical skills, such as teamwork, communication and leadership, all of which are vital and should be taught.
There are three areas that I want to cover at greater length: the electronic patient record in recommendation 32; human factors and error, which are covered by recommendations 34 and 35; and, inevitably, Staffordshire and whistleblowing, which the Chair of the Select Committee also mentioned.
In recommendation 32, we deplored the delays in the electronic patient record and welcomed, of course, the marvellous success of the picture archiving and communication systems. We particularly deplored the delays in the summary care record, although the Government response said that
"good progress is now being made in delivering the Summary Care Record."
The Committee heard about varying numbers of general practices that have the summary care records up and working. We asked for details of those practices to see whether any were in our home areas, so that we could visit them to see how they were getting on.
I have been very surprised by the complaints that have come out recently, from the British Medical Association in particular, about confidentiality, because it is a matter that should have been sorted out ages ago. In France-I will not attempt to use a French accent here-the patient owns their summary care record and can therefore censor whatever is on it. If a person writes their own summary care record with their GP, they will only put on the things that are essential for safety in the middle of the night, and I see nothing wrong with that. We also saw the ideal summary care record in Canada. Called the patient lifetime record, it was designed by Infoway on a single computer screen. I have said many times that the Department of Health is making the summary care record too complex.
On our visit to the US, concerns were expressed about the idea of trying to introduce a huge computer system with a big bang approach. Clinicians need to be involved in the design, and patients must be made to understand the huge advantages of having a summary care record, especially if they are taken unconscious into an accident and emergency department in the middle of the night.
Moving on to recommendations 34 and 35, which cover human factors, it is quite obvious that patient safety should be in postgraduate training. Our Chairman went back several thousand years to "First, do no harm" or "primum non nocere", and I can go back to 500 BC to Aeschylus, who had a very reassuring quote:
"Even he who is wiser than the wise may err."
That gives us all some encouragement. In 1690, in an essay concerning human understanding, John Locke said:
"All men are liable to error"
and very worryingly, he added:
"and men may be as positive in error as in truth."
Even now, we can see people trying to defend the indefensible. I shall come to that a bit later. Let me refer Members to a post note, written in June 2001, called "Managing Human Error". The overview is so good that I will have to read it.
"Human error is inevitable. Reducing accidents and minimising the consequences of accidents that do occur is best achieved by learning from errors, rather than by attributing blame. Feeding information from accidents, errors and near misses into design solutions and management systems can drastically reduce the chances of future accidents. Hence, studying human error can be a very powerful tool for preventing disaster."
Let me broaden the debate and talk about medical errors because they are a bugbear to patient safety. I shall mention just four complaints that have come across my desk relatively recently. First, let me say that I am not perfect; I have admitted in this Chamber to a desperate mistake that I made as a junior houseman, and there were certainly other errors. However, I take encouragement from Aeschylus, who said that even the
"wisest of the wise may err."
The four complaints that I want to draw attention to provide absolute lessons. The Minister will remember from her nurse's training that a patient losing their false teeth or glasses in hospital is an absolute disaster, because such things can never be found or replaced. In the first of my four cases, an elderly patient with mild dementia lost his false teeth. Despite his complaining of difficulty swallowing, it took three weeks and a request for an endoscopy for staff to discover that the false teeth were stuck within sight at the back of his throat. Nobody had done a proper examination or even looked down his throat, which is appalling.
In another case, nobody recognised that a small boy was ill, purely because nobody had taken a proper history or done a proper physical examination. The defence-the case went to the Care Quality Commission, and we got a whitewash report-was that doctors do not examine the chest now. The hon. Member for Dartford (Dr. Stoate) will remember that we were taught that physical examination consists of inspection, palpation, percussion and auscultation.
Dr. Howard Stoate (Dartford) (Lab): When I was a medical student, the registrar who taught us about the rectal examination-the per rectum-always said that, "If you don't put your finger in it, you'll certainly put your foot in it," and I have never forgotten that.
Bob Russell (in the Chair): Dr. Taylor-this is getting interesting.
Dr. Taylor: I remember that one entirely; we were all told that.
Inspection, palpation, percussion and auscultation are absolutely crucial, but nobody had listened to this kid's chest or tapped it, which is what Auenbrugg, the inventor of percussion, did on beer barrels. I am afraid that poor little kid died after several apparent examinations by the NHS.
In the third case, there was a failure to recognise that a patient who could not stand up because his blood pressure fell every time he did so was actually having a gastrointestinal haemorrhage, which proved fatal. The failure to spot it was the result of total diagnostic incompetence, but so far it has been defended through a whitewash, and I am fighting for an external inquiry.
The last case, which is very current and very sad, involves a girl of 15 with glandular fever who also had a fatal septicaemia that killed her. Nobody had sufficient experience to recognise that people do not die of glandular fever and that something else must have been going on. The attending doctors had inadequate experience, and nobody with experience intervened.
That gives me a chance to mention a booklet called "Front Line Care", which is dear to the Minister. Its first recommendation is:
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