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18 Mar 2010 : Column 334WH—continued
"Nurses and midwives must renew their pledge to society and service users to tackle unacceptable variations in standards and deliver high quality, compassionate care."
It was a nurse who said that the girl who was dying could go home. Where are the good, old-fashioned matrons and ward sisters, who sail round in proper uniforms, know when people are ill and actually tell the doctors when they are missing something?
Two of the cases that I mentioned in fact involved rare diagnoses, and I am not saying that everybody should be able to make a rare diagnosis. However, people must be able to spot whether somebody is ill. In a very good article in The Times on 15 March, Liam Donaldson drew attention to the poor awareness of rare diseases. Again, we are not all expected to make the best diagnosis in the world, although it is very exciting when we do, but doctors and nurses must have the basic ability to know when somebody is ill, and then jump up and down until something is done about it.
Recommendations 44 and onwards are about Staffordshire and the inability of so many people there to spot what was going on. There has been a valuable spin-off from the Stafford disaster, in that great interest is now focused on patient safety. There are now open board meetings, board members are involved with safety and there is an awareness of the importance of whistleblowers and their problems. On 12 March, an article in The Times said:
"The Toyota Way is famous...In reality, the Toyota Way is to ignore warnings from within the firm".
It was clear from the report that workers at Toyota had pointed out the deficiencies in quality control as long ago as 2006, but their whistleblowing had been completely ignored.
Two things led me to use my opportunity to introduce a private Member's Bill to support whistleblowers. I wanted to call my Bill the "NHS Whistleblowers Support Bill", but I was not allowed to, because the word "whistleblower" is apparently non-parliamentary language. Instead, my Bill was called the National Health Service Public Interest Disclosure Support Bill, which is a mouthful.
There were two reasons why I pushed for the Bill. The first was obviously Stafford. As our Chair said, there were whistleblowers there, but their whistleblowing was blocked before it got to board level, and they did not know what to do. The first thing, therefore, is to give them a system that allows them to go higher when they get blocked. My second reason for pushing for the Bill
was that whistleblowers have come to me at home about the out-of-hours care service. They were frightened for their jobs, so they could not go through the normal channels. They came to me because they trusted me to keep their anonymity and to have the clout to do something, which I certainly did.
The aims of my Bill were to publicise the Public Interest Disclosure Act 1998 and the work of Public Concern at Work, as well as to introduce support officers who would act as accessible and independent listeners, advisers and supporters. That is why I was pleased by the Committee's recommendation 56 and the Government's response. Our recommendation said:
"We recommend that Annex 1 of the Health Service Circular..."The Public Interest Disclosure Act 1998-Whistleblowing in the NHS" be re-circulated to all Trusts for dissemination to all their staff as a matter of urgency."
The Government responded by saying:
"We accept that proposals should be brought forward as recommended to improve protection for whistleblowers. We will consider the practicalities of establishing a model whereby whistleblowers can complain to an independent statutory body."
They are on exactly the same wavelength as my private Member's Bill, so perhaps it does not matter that it was filibustered out of existence a few days ago.
Nurses have started really to push for quality. A little time ago, they produced a marvellous document called "Dignity in Care", and I have already referred to the little booklet called "Front Line Care". The Royal College of Physicians is also at work and has produced a booklet called "Leading for Quality", which says:
"At the heart of quality rests safety. Many clinical errors could be avoided if the right information was shared at the right time."
However, errors and safety are not yet recognised widely enough. I dropped into the Library a few minutes ago and looked at the latest medical dictionary-the 41st edition of "Black's Medical Dictionary", which appeared in 2005. Look up "safety", and the only thing that it mentions is the safety of drugs. Look up "error" and the entries go straight from "eroticism" to "eructation". It does not even recognise that there could be errors.
I leave the House with my four Cs for quality, and hence safety: care, compassion, communication and continuity.
3.19 pm
Dr. Howard Stoate (Dartford) (Lab): I want to start by echoing your sentiments, Mr. Russell, about the quality of this afternoon's debate. As you have already pointed out, the Government and Opposition leads are nurses, and a pharmacist is leading for the Liberal Democrats. An illustrious retired physician is speaking for the Independents, and we also have an immunologist present. In addition, my right hon. Friend the Member for Rother Valley (Mr. Barron), the Chair of the Select Committee, was a member of the General Medical Council for many years. That shows how important the debate is.
I am particularly pleased that my right hon. Friend managed to secure the debate, because there can be no Members of the House who have not had cases in their work load related to patient safety incidents, mistakes and other problems caused by medical treatment. As my right hon. Friend has already pointed out, something like 10 per cent. of people who go to hospital suffer some type of medical error. Many of those can be
unpleasant and some are fatal, and half of them at least are avoidable. The issue is clearly of great importance to all Members of the House and of even greater importance to the people who have suffered such problems.
It is worth asking why the rate of patient safety incidents in the national health service is so high. The short answer must be that patient safety is not given the priority it deserves. I remember having only one lecture on the subject as a medical student, from the dean of the medical school. I had just arrived there-brand new; I think it was my first or second week and we had an introductory course by the dean, who said, "I'd just like to tell everyone in this room you're all going to kill somebody sooner or later, so you might as well get used to it." He made us all extremely concerned and most of us never forgot that lecture. He may have been harsh, but it stood us in good stead, and we realised that medicine is a dangerous as well as a healing art. The dean woke us up and stopped us short, but did not go much further about how to avoid such things. He just left it at that. Nevertheless it was a useful lesson.
In addition to being a practising GP I chair the all-party parliamentary group on patient safety, so it is particularly pleasing for me to take part in the debate. Much of the problem, as Suzette Woodward of Patient Safety First explained to the all-party group last year, is that trusts face a huge range of competing responsibilities, and find it hard to give patient safety the attention it deserves. I have discovered that patient safety does not even feature among the seven principal assessment domains drawn up by the Care Quality Commission. It is relegated to the status of a sub-category of quality, whereas financial management has a category all of its own. Consequently, many trust chief executives spend a vast amount of time thinking about finance, and little time thinking about patient safety-unless, of course, they are forced to react to a problem that has occurred in their trust.
Research by Patient Safety First, for example, found that 26 per cent. of trusts did not do leadership walkabout checks in hospitals, and that only 18 per cent. of trust boards had patient safety as the first item on their agenda. This week I had a meeting with Mark Devlin, the chief executive of the acute trust in my constituency, Dartford and Gravesham NHS trust, and put that point to him. I breathed a huge sigh of relief when he produced two board agendas and I noted that patient safety was item 1 on both. I am pleased that at least my local trust can show a clean bill of health on patient safety, putting it at the top of its agenda.
Patient Safety First also suggested that there was a lack of clarity about the principles behind patient safety, and a failure to disseminate best practice. One of the problems of the NHS is that it lacks a coherent overall strategy for promoting patient safety. As I have pointed out, medical training is an issue. There are thousands of doctors working in the NHS today who have gone through six years' medical training with no real formal training on patient safety at all. At the same all-party group meeting I mentioned before, Oliver Warren, a general surgical registrar at the North West London Hospitals NHS Trust, and a member of the National Leadership Council, admitted to us that he had never been given so much as a lecture on patient safety while at medical school. I am sure there are generations of NHS doctors who could tell the same story.
That helps to reinforce the view that patient safety seems to be too mundane an issue for highly qualified clinicians to trouble themselves with. It is a cultural issue that I hope is beginning to fade, and I am pleased that our patient safety report is beginning to move the agenda on. The Government response to many of the points that have been raised shows that the issue is finally taking the central role it deserves. For example, the emphasis on addressing MRSA and clostridium difficile has not only led to a significant drop in the number of cases; it has also forced trusts to think more seriously about disease control. The safer patient initiative is another positive step. The national reporting and learning programmes, which my right hon. Friend has already mentioned, have also been very welcome.
There remains much to be done, however. First, leadership at all levels of the NHS is crucial. Until clinical leads and managers are prepared regularly to spend time hammering home the importance of patient safety it will be hard to move forward. We also need far more transparency and reliable patient safety measurement processes. At present there is a tendency in the NHS not to report incidents, or concerns about colleagues, because of the blame culture that still exists. A formal and, above all, constructive mechanism for reporting errors and concerns needs to be built into the NHS. We need a learning culture, not a finger-pointing culture.
A more open and constructive approach would also help to encourage front-line health professionals and managers to become more proactive about patient safety. Instead of the cautious and guarded approach to patient safety that is taken now in many places, where it is seen primarily as a burden or a potential banana skin, a new approach will hopefully lead to a more positive culture, in which it is seen as a means of driving up standards across the board.
We also need greater continuity of care throughout the NHS, which would also help us to improve patient safety. Patient handovers are particularly important in that respect. A lack of communication between clinicians can easily lead to processes being repeated or, more worryingly, forgotten entirely. It is important, too, that clinicians involved in each step of the patient pathway through the NHS should have an awareness of each other's working processes. A better working knowledge of the patient journey as a whole would help clinicians to spot potential problems that could have an impact on safety and provide an opportunity for them to work collaboratively to address the issue. A more integrated care model, which would allow primary practitioners and secondary specialists to work alongside one another, could provide real benefits for patient safety.
It has already been mentioned that technology could help to improve continuity of care. Some trusts, for example, have been making use of virtual desktops that enable clinicians to access patient records using interactive bedside systems. That reduces the need for staff to log in and out of numerous systems, and has dramatically improved the risk of clinical error. However, in most parts of the country front-line professionals are not able to get such patient safety access quite so easily.
I have said many times in the House that the fact that pharmacists still cannot get electronic read-write access to the relevant part of the patient record is absurd. I do
not know how a pharmacist can carry out a meaningful patient medication review without knowledge of the patient's history-their medication and allergy history and other important aspects of their care. Nor do I see how they can properly advise GPs how to make sensible medication changes and checks if that information cannot be passed back electronically straight into the patient record. Those parts of the record are essential.
We have already heard that one of the BMA's objections to the electronic patient record is to do with confidentiality. Of course that is a major issue, but the hon. Member for Wyre Forest (Dr. Taylor) has already addressed it. Surely there must be ways nowadays, with modern computing, to improve confidentiality and safety. We do not often hear of banks losing data wholesale, or of people's credit card details being bruited about, and if the banks and building societies can introduce safe mechanisms to ensure that there is reliability and confidentiality, surely so can the national health service.
We raised the issue on a visit to the United States to see what happened there. The attitude was completely different. The view was that electronic records were at least as safe as the old, traditional paper records, and the issue, largely, was not taken too seriously. Those we spoke to said that it is possible to break into a surgery and steal patient records, so electronic records must be safer than that, and we should stop getting quite so hung up about the small chance that someone might find out my blood pressure. Frankly, I would not be particularly worried if they did.
If we wish to improve patient safety, the other thing that we must do is listen to patients. They are the only people who see the patient journey right the way through from start to end, and it is a serious mistake to ignore their experiences and insights when building patient safety into clinical practices. We simply cannot afford to continue the "them and us" attitude that has dogged the relationship between patients and clinicians for far too long.
As has already been mentioned, we need to look very seriously at the way that patient safety is addressed in medical training. Teamwork and communication skills are not taught well enough to medical students, even though those skills are vital in promoting safety. NHS employers are also guilty in that regard; most of them do not offer any kind of training in collaborative working or teamwork. That must change. During our inquiry, for example, we heard that teamwork training has the potential to reduce errors by between 30 and 50 per cent.
We should also provide more opportunities for students from different medical fields to train alongside each other. For example, some of our schools of pharmacy and of medicine have experimented with interdisciplinary training. That opportunity has given pharmacy and medical students valuable insights into each other's professions, which can only help to improve patient safety. Clinical pharmacology and therapeutics are crucial areas of study, but they have long been neglected at medical school. They are obvious examples of subjects that medical and pharmacy students could usefully take together. The failure in recent years to teach medical undergraduates about the appropriate use of medicines, and about prescribing them, has significantly increased the risk of error and patient harm. That failure must be addressed.
The most important thing that needs to happen is for patient safety to be made explicitly, rather than implicitly, part of the national curriculum, at both undergraduate and postgraduate level. It needs to be the first and last thing that doctors in training are taught, and it needs to inform every single course-both core and optional courses-that they take during training.
We have heard this afternoon that other industries take these matters more seriously than the NHS. The airline industry is often used as an example of how safety issues are taken much more seriously in other industries than in the NHS. However, it would be wrong to extrapolate directly across from the airline industry into medicine. I do not mean to belittle the airline industry, but aircraft tend to behave relatively predictably; if someone can fly one large jet, then broadly speaking they can probably fly another large jet.
As I say, I do not wish to undermine pilot training. However, patients do not behave relatively predictably; they do not necessarily respond to the "controls" in the way that doctors might like them to. It would be rather naive to assume that introducing airline-style systems into the health service would solve the problem; it clearly would not. However, in the airline industry, when something goes wrong, the industry's instant response is not to say, "That's somebody's fault." The industry's instant response is to say, "The system has somehow failed this person. How can we change the system to reduce the risk of it happening again?" That culture would easily transfer across from the airline industry to the health industry, and it is one that we could take seriously.
I want to talk about primary care, which is, after all, my special subject. Remarkably little is known about patient safety incidents in primary care, because information on them is not systematically collected. It is very difficult to make any meaningful study of how GPs report such incidents, how frequently they occur and how many are simply not picked up by anybody at all. That needs to be addressed.
However, such incidents are being looked at. For example, on the latest appraisals for GPs, it is now expected that GPs will look very carefully at critical incidents in their practice, and that they will use examples of any such incidents in their appraisal documents, saying where the incident happened in the practice and the steps that the practice took to reduce the risk of such an incident happening again. That is extremely welcome.
I am sure that this is true of the vast majority of general practitioners, but if we have a critical safety incident in my practice, we immediately raise the matter at the next practice meeting. We examine what has happened, we see what we can learn from it and nearly always-well, without exception-introduce changes to reduce the risk of such an incident happening again. I am sure that that is happening around the country. The problem is that we do not have any systematic way of collecting that data, and we do not really know what is going on.
It would be very useful if the Minister would consider how we could make use of better reporting in general practice, and how we could encourage GPs, hopefully on a non-blame basis, to be more up front about the systems that fail and the things that go wrong. I say that because when something happens in one practice, it is
pretty obvious that it will be happening in other practices around the country. If we can learn from each other, we can reduce the risk of our colleagues making the mistakes that we have perhaps made ourselves.
Those are the aspects of the report that I want to concentrate on. Producing the report has been a very useful exercise, and I hope that the Government have found our recommendations useful. I have certainly been very encouraged by the response that the Government have given to our report, and I await the Minister's comments in response to my suggestions.
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