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18 Mar 2010 : Column 340WH—continued
3.34 pm
Sandra Gidley (Romsey) (LD): It is a pleasure to serve under your chairmanship, Mr. Russell.
I am here today in a dual role; as well as a member of the Select Committee, I am speaking broadly on behalf of the Lib Dems. I was mindful of the little anecdotes that my medical colleagues were recounting earlier. Certainly, my best man, who was a doctor, was told exactly the same as other Members here today-that he would kill somebody at some stage and the only question was when. As a pharmacist, I was always told that doctors buried their mistakes and pharmacists conducted post-mortems on them. I do not know how true that expression was, but I suspect that little has changed since I heard it.
This report is one of the Select Committee's best reports in this Parliament, because it has attempted to take an overarching and quite analytical look at the problem of patient safety. Very often we look at something in retrospect, and it is a credit to the Committee that it realised that there was a potential problem in this area and that it wanted to do something a little more proactive. I hope that the Government will act on most of the recommendations in the report.
It is fair to say that, in the past, financial concerns have been put ahead of patient safety concerns. That has not been the case everywhere, but there has been a lot of research of documents such as board minutes, which show that many items on board meeting agendas relate to finance, whereas not all such boards have an agenda item on patient safety. Clearly, not all boards take patient safety seriously. That can lead to catastrophic failures, such as those in the Mid Staffordshire NHS Trust and in the Maidstone and Tunbridge Wells NHS Trust.
Unusually for our Committee, we examined the problems in the Mid Staffordshire NHS Trust in an evidence session. Usually we avoid examining individual examples of where things have gone wrong, because it does not seem to be fair to do so. However, this inquiry coincided with the incident in Mid Staffordshire. What seemed to be clear in Mid Staffordshire was that everybody was blaming everybody else and that nobody was taking responsibility for any of their actions. My feeling was that people can blame targets if they want to make a political point, but we had a number of people in Mid Staffordshire who should have had a code of professional ethics that would have prompted them to act differently.
I will return to the broader question of boards and direction from boards. I think it was Lord Patel who suggested that one non-executive director from each board should have special training and take a particular responsibility for patient safety. Our Committee's report
highlighted the fact that many managers and non-executive directors with some responsibility for this area of patient safety have had little or no grounding in the subject. If we also consider the training of our health professionals, there is a great deal of evidence to show that patient safety is not part of that training. I will return to that issue shortly. Clearly, patient safety needs to be more ingrained into the life and soul of the NHS. It should be there; currently it is not.
Safety can improve only if there is an open culture of reporting, so that we can all learn from our mistakes. It is very important to have a "no-blame" culture. The Government response to our report actually recognises that
"removing the 'blame culture' around making mistakes is essential to improving NHS patient safety."
The Government response goes on to express support for the National Patient Safety Agency and it also mentions the Care Quality Commission. The new CQC regulations come into force in April, but regulation 18 of the current draft CQC regulations-that is S.I. 2009/3112, for those who want to rush and look up the regulations at the end of the debate-places a statutory duty on registered organisations to report patient safety incidents to the CQC or to the NPSA, in the case of NHS bodies. That is fine, but there is no requirement to inform patients or their next of kin. That is particularly disappointing, because the Government's current approach seems to fly in the face of the Committee's recommendation that
"further consideration be given to the CMO's proposal"-
that is, the chief medical officer's proposal-
"for a statutory duty of candour".
It is not enough to include a responsibility in the NHS constitution, which seems to have disappeared almost without trace. The Government response says:
"There is ongoing work to consider other ways that the registration requirements could be used to further clarify the requirement for information to be made available to service users when things go wrong."
It would be helpful if the Minister explained that apparent backtracking, because one change that we made to the NHS Redress Bill when we discussed it provided for a report to be published and made available on any incident that came under the scope of the Act. It is a shame that no progress seems to have been made in enacting that legislation. There is a certain inconsistency in the Government's approach in relation to what it is right and proper to do.
From personal casework and professional experience, I strongly believe that advising patients and relatives is crucial and usually causes far less hassle in the long run. There will always be the occasional person set on litigation and getting the best for themselves, but I wish that I had a fiver-only a fiver-for every time somebody has come to me with a problem and said, "If only they had explained to me at the time, said sorry and told me what they were doing so it wouldn't happen again, I would be happy." MPs' time and the time of chief executives of trusts is being wasted producing reports, all because some hospitals have a culture of covering up.
I pay tribute to the chief executive of Winchester hospital. Every time he receives a complaint, he will offer to meet the complainant personally. As a result of his proactive approach, the number of complaints that come to me has plummeted. It can be done. Openness, honesty and the willingness to check and review events even after they have happened go a long way with patients.
Complaints are still dealt with poorly in too many places. Complaints are a learning opportunity, but we should not rely on them. Again I pay tribute to those at Luton and Dunstable hospital, who have taken patient safety to heart and have plenty of examples of good practice. However, as the hon. Member for Wyre Forest (Dr. Taylor) said, they regularly sample case note reviews to see what lessons can be learned. It seems essential to embed that procedure more firmly in all our NHS trusts, as well as in our primary care trusts. Reporting of incidents in secondary care is now good, but I do not believe that primary care is very much safer. I believe that incidents in primary care generally go unreported. We must examine the reporting culture there as well.
I will give one example to stress how open reporting can benefit us. A few years ago, when I was working as a pharmacist, I worked as a locum, which gave me experience of different firms. One firm had an open reporting culture. In another, those who reported mistakes would receive a nasty letter telling them not to do it again. Consequently, not many mistakes were reported there. However, the company with an open learning culture realised that 90 per cent. of mistakes were simple and involved two drugs in two strengths with similar names, all of which came in the same type of pot. It was a simple matter to ensure that a system was put in place to highlight the difference between those four products. Problems were reduced at a stroke, and patients were better off. It is much better to foster open reporting.
Information technology was mentioned. I will not repeat what other Members have said, but I endorse fully the comments made by the hon. Members for Dartford (Dr. Stoate) and for Wyre Forest. The decision on who should have access to the summary care record should not be in the hands of doctors; it should certainly be in patients' hands. To some extent, that would avoid the read-write access problem, as the patient could say, "Yes, I want you to have my records and be able to update them." If the matter is handled properly, the vast majority will want to ensure that all their health needs have been taken into account.
We need to put the patient at the heart of the process, rather than any of the misguided interests of some-although not all-sectors of the medical profession, because better continuity of care is essential. Also, mistakes in electronic records are difficult to change. I have had constituency casework involving allegations that paper notes were changed after an incident. It was difficult to prove, and the story was harrowing. Electronic communication makes such behaviour a lot more difficult. An audit trail in medical care is essential.
The part of the inquiry that I found fascinating dealt with human factors. Improving recognition of the role that human factors play in errors is an issue that risks being ignored, but to me, it was one of the most important parts of our inquiry. Brian Capstick carried out research in 2006 to assess the extent to which human error was responsible for incidents serious enough
to give rise to litigation claims. He found that human error was the proximate cause of 97 per cent. of them. He also claimed that there were numerous systems
"whose shortcomings create enlarged spaces for human error".
The hon. Member for Dartford mentioned that that was true of approximately 50 per cent. of the cases that he looked at.
Brian Capstick, putting together considerations by other people, went on to identify the types of process failure most commonly involved in mistakes. The first was
"delays in making a primary diagnosis...or in recognizing the severity of the patient's condition generally".
That usually comes down to training, which is often ignored or cut back when budgets are tight. He also cited
"the omission to act on adverse results",
which again relates to a culture of open reporting and learning,
"the lack of an adequate management plan for high risk cases that have been identified"
"the omission to allocate known high-risk cases to a reliable pathway or person".
Some of the evidence that we took from Staffordshire, where blame was shifted, showed that clearer responsibilities are needed in the health service.
Interestingly, another type was
"allowing or encouraging clinicians to work outside or beyond their skill set".
That is crucial. We heard of the horrifying case of Bethany Bowen, a five-year-old with a condition requiring her spleen to be removed and who died of uncontrolled bleeding. The reason was that the surgeon used a device called a morcellator, which sounds awful. It is an instrument with rotating blades that is usually used in gynaecology. The people using that instrument had no experience of using it on an adult, let alone a child, and the results were horrific. It was clearly beyond the skill set of those surgeons.
"the unavailability of skilled supervision, guidelines or protocols; shortcomings in clinical leadership; shortcomings in the recruitment or induction processes; and deficiencies in educating the patient to deal with his or her own condition."
If we are serious about reducing errors and improving patient safety in the health service, we need to consider how those eight factors can be minimised in all areas of clinical practice.
The submission by the Clinical Human Factors Group made many similar points. It stated that training in human factor skills
"such as teamwork and communication is virtually absent in healthcare."
Such skills should be drilled into doctors, nurses, pharmacists, physiotherapists and so on from day one. It also mentioned that
"teamwork training may reduce technical errors".
Interdisciplinary training, which has been mentioned, is good in theory, but in practice some of it is very bad. It is clear why we need it: it challenges the perceived norm that doctor knows best. However, it is often organised so that people at the same stage of training
work together, with the medics, nurses, pharmacists and social workers all being first-year students. At that point, such attitudes are becoming ingrained in the students.
We saw a cleverly thought out scheme in New Zealand in which the doctors were in their first year of training and the other health professionals had two or three years' more training. The trainee doctors had to rely on the nurses, pharmacists and other health workers to support them and give them the information they needed to complete the tasks satisfactorily. Until we review the way in which training is carried out in many places, it will not be as good as it should be. I say that somewhat advisedly, because my son is training to be a nurse in Southampton and he whinges like mad about the training. When I had the opportunity to talk to some medical students in Southampton, to my surprise they whinged like mad about the training as well. They said that they thought it would improve because in the review of training they all complained and said that it was not very good. We have to learn from the best, because although training is essential, if it is done poorly it is counter-productive.
I want to mention briefly the National Patient Safety Agency, which seems to be collecting a huge amount of data through the national reporting and learning system. However, the NPSA seems to have relatively few teeth. The Chair of the Select Committee gave the example of the syringe fittings on spinal needles from 2001. I was amazed that the Government response said that
"solid progress is being made".
After nine years, "solid progress" would mean that the devices are in place to prevent further occurrences of the mistake. One idea put to us was that although the NPSA has a lot of data, perhaps it should concentrate on finding more detail in fewer areas. There is a need to review what it does.
On whistleblowing, it was scandalous that the private Member's Bill promoted by the hon. Member for Wyre Forest was objected to. As constituency MPs with an interest in health, I am sure we have all had the experience described by the hon. Member for Dartford of someone coming to us with their problem but saying that we cannot use their name because they do not think they should be speaking to us and are worried about getting into trouble. Lots of people come to speak to us off the record. If systems are going wrong, there needs to be an adequate system so that people feel they can report it. I hope the Government will look at that matter.
There are only eight never events, which were chosen by the NPSA. Clearly wrong site surgery should be a never event. I think that the list should be added to and beefed up. Such events should not be looked at in isolation and more attention should be paid to whole procedures. I welcome the work of surgeons on the pre-operation checklists. I hope that such approaches will benefit patients and staff. In evidence, we heard that checklists are not adhered to in some places. If consultants do not go through the process with staff and enable them to comment, it should be a disciplinary matter.
While I am talking about surgeons, I want to mention the European working time directive. The Royal College of Surgeons has always been against the reduction to 48 hours. I accept the point that I do not want to be operated on by a tired doctor who has worked over
100 hours, which is what used to happen. However, I also want the person working on me to have quite a few hours' experience of what they are doing. There are serious concerns that the focus on 48 hours in the European working time directive makes it impossible to produce an adequate rota that provides sufficient and appropriate training for surgeons. Last week, Sir Bernard Ribeiro, the former president of the Royal College of Surgeons, told me that when a consultant surgeon qualified a few years ago, they would have had about 30,000 hours under their belt-that sounds like a lot and I have not worked out how many days it is. It is now 8,000 hours. That is a huge difference in experience.
Dr. Richard Taylor: Does the hon. Lady agree that if we both get back on the Health Committee after the election, we should push for an examination of the way in which the European working time directive is being applied and its effects?
Sandra Gidley: That is a good idea. Some hospital trusts claim to have achieved the 48 hours. As far as I can see, this is a tick-box exercise. Some students are complaining that they are not getting the experience and there are concerns among senior and experienced surgeons that standards will slip. We cannot afford to take that risk. I was a panellist on a British Medical Association question time at Southampton university where Sir Bernard Ribeiro advised all the students to opt out of the European working time directive. I thought that was slightly unhealthy and that it put unfair pressure on some students for various reasons. It would be helpful to review the situation, as the hon. Gentleman said, with a view to working towards a derogation. That should not be impossible.
In conclusion, there are some easy things that can be done, such as making a board member in each trust responsible for patient safety. Those things are likely to happen. However, some fundamental factors at the heart of improving patient safety, such as training and emphasising human factors, will be more difficult to achieve. As the NHS is going to be financially constrained and these matters are not even on the agenda yet, a big push is needed to ensure that they are at the forefront of everybody's thinking, because that would benefit all of our constituents in the long run.
3.59 pm
Anne Milton (Guildford) (Con): It is a pleasure to serve under your chairmanship, Mr. Russell. I congratulate the right hon. Member for Rother Valley (Mr. Barron), the Chairman of the Health Committee, on his opening remarks. I also congratulate the Committee on producing yet another balanced report. Having been a member of the Health Committee myself, it feels a bit like old times-we could be back there today.
Some 10 per cent. of patients admitted to hospital suffer some sort of harm. That is a substantial number, because the NHS treats around 1 million people every 36 hours. There is a huge raft of issues to consider, as the matter is extremely complex. A number of issues have been mentioned: data collection, the regulation of professions and organisations, staff and professional skills, education and training, continuing professional
development, the role of targets, the systems that we need to have in place to ensure that accidents do not happen and that harm is prevented, audit-including the audit of complaints-and the role of management. The list could go on.
At the end of the day, some form of harm will always happen, and no system can absolutely guarantee 100 per cent. safety, as I think the hon. Member for Dartford (Dr. Stoate) mentioned. The Committee report states:
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