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18 Mar 2010 : Column 346WH—continued
"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."
That is a worthy ambition, but to some extent, such a statement might disappoint the public, who would be utterly appalled to think that they could come to any harm when being treated by the NHS. As the hon. Gentleman said, medicine in its widest sense-I include all the professions allied to medicine-is an art, not a science. There is a mismatch between public perception and what actually happens regarding the treatment of people.
The right hon. Gentleman talked about the need to convince professions of the need for, and purpose of, data collection. I completely agree with that. The danger with professional staff-this includes professions outside medicine-is that they do not understand why they are being asked to do what they do, and if they do not understand why, they do not do it. I recently had the privilege of spending a day on a shift with charge nurse Nathan Askew on Sky ward at Great Ormond Street hospital. I would like to put on the record my thanks to the staff for putting up with me. I would also like to put on the record that all the children received absolutely fantastic care during that day. I have no doubt they receive such care every single day. The wonderful thing about NHS staff, particularly nurses, is that they will have gone to no exceptional lengths to please me on that occasion; they will have simply been doing their routine work. As I say, I was hugely impressed by them.
There is no doubt that NHS staff feel that some of the systems in place are not useful. At times, I think they feel that such systems are designed to frustrate them in their delivery of care. Many NHS staff say that nobody asks those on the front line how data should be collected and what will or will not work. In addition, there has been no explanation of why such systems have been put in place. Yesterday, the Royal College of Nursing bus was in New Palace Yard, and I said to the nurses there that nurses are particularly inventive at working around obstacles that get in their way. If we come up with a system that nurses do not like, they are far more inventive than doctors-I point this out to the hon. Member for Dartford in particular-in finding a way around it. If nurses come up against a system that they do not like or do not understand the point of, they will get around it to ensure that their patients get the best possible care. That does not necessarily work to the benefit of patients or the benefit of attempts to drive up patient safety. We absolutely must explain why such systems are put in place.
That leads me to the issue of education and training. The armed forces have moved away from talking about training, to talking about education. There is a drive throughout many of the professions involved in NHS care to move towards education rather than training. Doing so is vital. I remember from many years ago,
when I was a nurse, an agency nurse on a ward who did exactly what she was told to do. Throughout the night, she observed the patient and recorded various vital signs every quarter of an hour. In the morning, at 6 o'clock, the patient had a cardiac arrest. Fortunately, the patient was resuscitated. On looking at the patient's charts, one could see that the nurse had been absolutely faithful in the tasks that she had been asked to do. However, she had not understood the purpose of what she was doing or when she should alert medical staff or senior nurses that things were going wrong. She was not educated; she was trained to do what she was told to do.
Such a situation can be applied to every level of staff and every profession. Everyone involved in patient care needs to have a sense of ownership-for example, the person who cleans the ward and dilutes the cleaning chemicals needs to know why those dilutions are important, so that they know that if they get to the end of the bottle of concentrate, it is worth going down the corridor to get a new bottle. That person needs to know that they must not skimp on cleaning chemicals, because they are contributing to the cleanliness of the ward and the reduction in health care associated infections. As I say, it is extremely important that we move from training to education.
Continuing professional development improves the understanding of why certain things are necessary, and is absolutely vital. That is an ongoing issue for medical staff. One of the dangers is that the people who are vigilant about continuing professional development and who attend the training courses actually do not need to attend, and the people who should attend such training courses often do not turn up. That situation possibly also occurs in this place. For example, if one attends seminars designed to help Members of Parliament with their constituency work, when one looks around the room, one knows that none of the people present needs the help. The same is true in medicine, and indeed in other professions.
There is a lot of talk about regulation. One hears that we need regulation, because it will sort the problems out. However, regulation needs to be effective-it is not, in itself, necessarily effective-and evidence-based. We do not need knee-jerk reactions to concerns and disasters; we need careful, considered thought and, as I say, evidence-based solutions. We do not need regulation to cover-I cannot think of an acceptable parliamentary word-the rears of senior managers, Department of Health officials or Ministers. I do not mean current Ministers in particular; I mean Ministers in general. We do not need defensive regulation; we need regulation that is balanced with risk.
I was recently approached by a number of ophthalmic organisations-the Association of British Dispensing Opticians, the Association of Optometrists and the Federation of Ophthalmic and Dispensing Opticians-who said:
"The General Optical Council has dramatically increased their level of activity over the last three years or so in a way which might be acceptable if we had the levels of risk of, say, GPs and were paid at the same level"-
we could perhaps put that bit in brackets. The organisations continued:
"this activity is very expensive for smaller and lower paid professions such as ours. This appears, in part, to be driven by a wish to comply with requirements imposed by the regulator's regulator the CHRE. Often there is no evidence base for what is proposed, but it seems to be driven more by political correctness than genuine patient protection. We would like to see a far greater emphasis on evidence-based patient protection and value for money in regulation."
That important point will be echoed by many. As I said, regulation must be effective, evidence-based and proportionate; otherwise, the whole system completely seizes up.
I shall also mention targets. It is not a political matter that the hon. Member for Romsey (Sandra Gidley) talked about that subject. The word "target" has been hijacked by party politics, but I do not want to mention it in a party political way. We need to think about what we measure in the NHS, which again relates to the evidence base. We must ask what is effective and what we want to achieve. I have a feeling that although we measure a great deal of things, the one thing we do not measure is whether anyone got better. There is a tendency to measure many processes but not necessarily the outcomes. Many targets have worthy motivations, as no one wants to spend four hours in accident and emergency, but we must distinguish between process and outcome and ensure that process-driven targets do not get in the way of clinical outcomes.
I visited an A and E a year ago, and one of the senior physicians explained that if he had a very sick patient in A and E and wanted them to go up to intensive care, but intensive care was full, they would have to be looked after somewhere else for five or six hours. He said that he would like them to be looked after in A and E, because he felt that the nurses there had the expertise and experience to deliver that sort of care, but the manager of A and E would not want the patient there because he was acutely aware of his targets, so there is a clash between a process target and a clinical outcome. As with many things, that is about balance. I would like to quote something that has been said about Mid Staffordshire NHS Trust:
"The Trust Board placed a high priority on compliance with nationally set targets, and, in particular, the four-hour waiting time target for A&E. The pressure to comply with such targets came from the Department of Health (DH), the strategic health authorities (SHAs) and the primary care trusts (PCTs)".
In that case, the chief operating officer described the sort of pressure that he was under to comply with targets. That is fine, so long as clinical outcomes are not put at risk.
Nursing Times recently surveyed more than 900 nurses and found that
"nearly two thirds said patients at their hospital were being treated in areas not designed for clinical care. They highlighted threats to safety, including patients having no access to call bells... Of those nurses who had seen the practice, nearly 60 per cent said it happened more than once a week. Two thirds said patients were left in the areas for more than 12 hours-for some the areas are used for days at a time...Eighty-three per cent",
"said they had raised it with senior nurses or managers but, of those, only 4 per cent said it had then been stopped. They were commonly told that all other space was full, accident and emergency was under pressure, the move was authorised by senior managers, or the A&E waiting time target was at risk."
Again, we are talking about a matter of balance. No one wants to keep people waiting. We need good performance and we need people to be treated effectively, efficiently and in good time, but we also need to ensure that clinical care is the first priority.
The role of managers and boards was touched on in the debate. The Mid Staffordshire NHS Trust report undoubtedly makes absolutely dreadful reading. I recommend that many people read it to see how complex failure can be. It is not just the managers and boards that need to be looked at. The Health Committee's report states:
"There is disturbing evidence of catastrophic failure on the part of some senior managers and Boards in cases such as Mid-Staffordshire NHS Foundation Trust. While 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, when they should actually be promoting tangible improvements in services."
In the past there has been much talk of a "ward to board" approach, and such an approach would eventually drive up standards. The boards will have to look at more than just the bits of paper dealing with finance that are in front of them. They absolutely must understand their core business, which is to treat patients safely.
The group Action against Medical Accidents has conducted some interesting research, based on freedom of information requests to the Department of Health. The research revealed that
"large numbers of trusts were failing to implement the alerts, some stretching back five years."
That is interesting, because data collection in itself is not enough. It is what is done with the data once we have them that is important. The group continued:
"Even more worryingly, the research revealed that even though this information was available to the DoH, CQC, SHAs and NPSA, absolutely no system was in place to 'chase up' those trusts, even those with large number of alerts outstanding. The Government's response seeks to give the impression that there was a robust system in place. Clearly, there is not. As far as we know, even following publication of our report, no action has been taken to find out what is going on in even the worst performing trusts. It is this kind of complacency which could allow another Stafford to happen under our noses."
We could have a separate debate on a huge number of concerns that have been raised, and on some that have not even come up. We could have separate debates on health care acquired infections, no-blame reporting, the need for effective communication, which was highlighted in relation to maternity services in particular, drug errors and the role of pharmacists in reducing them, and problems arising as a result of the free movement of labour in cases where English might not be a professional's first language. The hon. Member for Dartford mentioned a matter that is dear to my heart-the fact that although banks can transfer massive amounts of money at the touch of a button, we cannot get clinical records online. It feels as though we cannot use even the simplest computerised system. If all that information is available on a computer, why is someone not acting on that?
As for whistleblowing, anyone who has worked in the NHS-we have two nurses, two doctors, a pharmacist and a scientist in this Chamber-would find the Maidstone
and Tunbridge Wells NHS Trust report staggering. Why did no one tell someone what was going on, and why did action not follow? I cannot understand why nothing happened. There is a lack of faith in whistleblowing policy, and a lack of action resulting from it, and there are ineffective means of auditing complaints from patients, relatives and staff. I must mention professional standards, because I am a former nurse, as is the Minister, and I am sure that I speak for her on this point. No one has mentioned professional standards today.
Anne Milton: The hon. Lady says that she did. We should fly the flag for driving up standards, and that is about clinical leadership across all the professions.
I finish by again congratulating the Health Committee, and those members of it who have contributed to the debate. They have demonstrated a wealth of proper, front-line expertise. My concern is not only about the complexity of the issues that are in play when it comes to increasing patient safety, but about the gap between government, meaning Ministers and officials in Whitehall, and what happens on the front line. People at the top might think that something is happening at the bottom when it is not, so there is a gap in communications, and policies do not necessarily follow as a result. Many of the strings between Whitehall and the front line have been cut.
Lack of patient safety costs lives. Every Member will have constituents who have suffered because of a lack of patient safety, and some families will never recover from their loss. Despite the sometimes defensive nature of chief executives of various trusts, my experience is that families often do not want any compensation. Indeed, often they do not even want an apology. They want to know, above all else, that their experience will not be repeated, that lessons have been learned, and that no further loss will happen to other families. I am pleased that the debate has not been party political, and I look forward to hearing what progress the Minister feels can be made.
4.19 pm
The Parliamentary Under-Secretary of State for Health (Ann Keen): It is a pleasure to serve under your chairmanship for the first time, Mr. Russell.
I am grateful to my right hon. Friend the Member for Rother Valley (Mr. Barron), who is the Chair of what is undoubtedly a prestigious Committee in the House of Commons. The Health Committee has held many inquiries. I gave evidence to this one, and was pleased to do so. As a practising nurse for more than 28 years, I was pleased to have openness at last as to what takes place in our health service, and I am pleased that we are having this debate on the important subject of patient safety.
I congratulate my right hon. Friend and his colleagues on the excellent report that they produced last year on this subject, and for the contribution that they have made to the provision of safe services for patients. The first Committee on which I served when I was elected to the House was the Health Committee, and I know of its importance and the difficult work that it has to take on.
Fortunately, the vast majority of people treated by the national health service receive high quality and efficient treatment. They recover and have their confidence and control restored, in whatever capacity they enter the NHS.
The hon. Member for Guildford (Anne Milton) acknowledged the expertise in the Room, and mentioned that I share her profession, which was nursing. I am sure she would admit that we never practised in a golden age, regardless of the matrons that the hon. Member for Wyre Forest (Dr. Taylor) wants back. They are back-we have brought our matrons back-and ward sisters are firmly in place. They were highlighted in the report on the Prime Minister's Commission on the Future of Nursing and Midwifery. I have no doubt that, had we practised together, we would have had some interesting times and provided very safe patient care.
Dr. Richard Taylor: Would the Minister agree that the concept of the matron has been watered down by having rather a lot of them, instead of one figurehead who really could move around the hospital like a galleon in full sail and frighten people into doing what was right?
Ann Keen: It is very brave of the hon. Gentleman to go down that path. I know that across the river at St. Thomas' hospital there are quite a number-more than 50-of modern matrons. I challenge him to debate with them at any time to see whether there is agreement on that. Many women and men perform an excellent function as matrons across the NHS.
The hon. Lady mentioned targets. We must be aware that they are based on clinical decisions. I do not want to be party political either, but I know that in her party's manifesto in 1992, the patients charter mentioned four-hour targets for accident and emergency that were to be reduced eventually to two hours. Sadly, that was not achieved, but today's targets have improved patient care and have undoubtedly saved lives.
One million people are treated by the NHS every 36 hours, and nine out of 10 people see their family doctor in any given year. The NHS is a successful, internationally regarded institution of which we can all be justly proud. However, we must recognise that in a system as big as the NHS, which provides treatment and care to so many people, sadly mistakes and unforeseen incidents can and will happen.
Mistakes and errors in other service sectors may not result in harm to a person's health, but that is not the case in health care. A relatively small error can result in severe harm or even death. Although human nature and the risks associated with the provision of complex treatment mean that some errors are inevitable, we must work towards preventing and reducing as many avoidable errors as we can. An error in the NHS may not itself cause harm, but if we can understand the reasons for the error occurring and put in place actions that militate against its occurring again, we might be able to prevent someone from being harmed at a later date.
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