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Patient Safety

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. Member for Guildford 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 mitigate against its occurring again, we might be able to prevent someone from being harmed at a later date. I recently had the great privilege of meeting Mrs. Lisa Richards-Everton and her brother-in-law, Stephen Richards. Sadly, a drug was administered to Mr. Paul Richards in error, which created a fatality. I do not profess that I would ever be able to measure the impact that that tragedy has had on family and friends. In this case, much of what could have been done to reduce the risk of the incident happening was done, but a renewed focus has taught us that much more can always be done to reduce risk further. I was humbled by the meeting and by the positive way in which Mrs. Richards-Everton chose to deal with the tragedy. We discussed ideas and suggestions for improving the information systems underpinning patient safety development. Those suggestions were not only helpful but full of common sense. Her straightforwardness enabled us to see through her eyes how a bureaucracy deals with risk and sometimes overcomplicates what should be simple. Having petitioned the Prime Minister, and having met with me and my officials, she has, without hesitation, accepted an invitation to become involved in a forthcoming patient safety conference that will continue to raise the profile of safety in the administration of medicines. Mrs. Richards-Everton's experience has also called into question how professional regulators deal with clinical staff when things go wrong. In particular, that has helped the Nursing and Midwifery Council to review how it writes to complainants to explain decisions about investigations and the outcomes of fitness-to-practise hearings, to ensure that letters are clearer and much more sensitive. Her ideas and suggestions will contribute significantly to safer services and, importantly, ensure that others do not have to go through what she went through. The lesson that we must learn from that experience is that managers and clinicians cannot by themselves shape and deliver safe services. The engagement of patients, families and carers is important if we are to get this right. As well as understanding and trying to make provision for the tragic personal consequences that unavoidable errors can lead to, reducing and preventing mistakes generally is a mammoth challenge. The Committee's report has reminded us of some key things that we need to get right if patient safety is to be embedded effectively into health care planning, development and delivery. First, there needs to be a culture of openness. No one should argue with that, but sadly, some recent reports show that there is not a culture of openness throughout our health care systems. What do we mean by a culture of openness? What did it mean to practise with certain clinicians, or to be with certain managers who bullied, and who undoubtedly brought about a culture in which one stayed quiet and did not admit to mistakes? As the hon. Member for Wyre Forest said, we all make mistakes at some stage, and the Select Committee Chair said that it happens in the House. In all areas of life, mistakes are made. How do we manage mistakes? How are we treated? How do we expect to be treated when we are open and above board with people? This is so important to the culture of an organisation. Successful organisations are open and efficient. They manage their finances well, and they train, develop, care for and look after their staff. That is the key to much of our success, along with the all-important communications. It is important to be open and candid with patients, families and carers when things go wrong, and to ensure that staff are part of a culture that supports them in dealing with incidents that have harmed, or may harm, patients. A blame culture has pervaded some parts of the NHS for far too long, and I would be foolish if I were to say that it no longer exists anywhere. I have the privilege of being the Minister responsible, but, as Aneurin Bevan asked when he was the Health Minister, was he to get the blame in Whitehall when a bedpan fell off a trolley in Tredegar? I have the title, so I have to accept some of that responsibility, but I know that all NHS staff are involved, from the senior managers down, including the chief executive. The hon. Member for Romsey (Sandra Gidley) mentioned a chief executive being able to sit and listen to complaints, which is a first-class example of how people should behave. We know that that would make a difference. They should be walking the floor, being visible. We must do all that we can to change any practice that creates a culture that is not open. We should stop looking for scapegoats and consider what lessons can be learned from patient safety incidents to avoid them in future. One key element of this is the freedom for staff to raise any concerns that they may have about patient safety. The hon. Member for Wyre Forest and I were in the House on the Friday that his private Member's Bill, about which there was expectation and hope, might have gone through. The way that the House deals with private Members' Bills has always been a mystery to me, and is a mystery to most people in the House on the day. We did not reach the hon. Gentleman's private Member's Bill, but we had the opportunity to discuss in the Department some days beforehand what we could take from it and what we could learn from his experience. Those discussions will continue, so that we can find out how we can work with some of the recommendations. It would be foolish to ignore those. I worked with the right hon. Member for Holborn and St. Pancras (Frank Dobson) when he was Secretary of State for Health in 1997 on the first opening up of our NHS culture to enable whistleblowers to be protected. I have been a whistleblower. As a district nurse I reported an incident that I witnessed in a private nursing home. It took courage to continue with that complaint, but courage I had, and it was eventually dealt with and the nursing home lost its licence. That was in the 1980s. Hon. Members might remember a nurse called Graham Pink, who in the '80s exposed the care of elderly people in his area. I was pleased to be part of the group of 20 nurses that was acknowledged by Nursing Times. Graham was acknowledged as one of the most influential nurses of his time, and in the past 60 years of the health service. In the '80s, people did not say anything: the fear about what would be likely to happen if they reported something was serious. I am pleased with the progress. We have established a working group with Public Concern at Work, the trades unions and NHS employers to update the guidance on whistleblowing and to identify what further measures can be taken to give a louder voice and stronger protection to staff who speak up. The NHS constitution gives a clear set of rights to staff: to be treated well, to be supported properly in a rewarding job and to blow the whistle without fear of repercussions. The Care Quality Commission and Monitor are listed as prescribed bodies in the Public Interest Disclosure Act 1998 to receive concerns raised by staff. All NHS providers of regulated activities are required to register with the CQC. Secondly, although patient safety relies on the conscientiousness of individuals, organisational robustness and clear leadership is needed if a consistently high level of patient safety is to be achieved. The Committee also emphasised that local services need to be provided with relevant and effective information, support and advice from central Government and their agencies. Also, it said that a robust monitoring and regulation process needs to be in place to ensure that all NHS organisations, not just some, reach the standards we all expect of them. I am pleased that the Committee's report praises the Government for being first in the world to adopt policies that make patient safety a priority, and that it welcomed the creation of the National Patient Safety Agency. I pay tribute to all who work in such an important area. We are seen as one of the world leaders in the international drive to improve the safety of health care. We were one of the first countries to give priority to tackling patient safety by focusing on a whole-system approach. The 2000 report, "An organisation with a memory", which has galvanised action on patient safety, is still regarded internationally as a seminal document. The NPSA was set up in 2001, and its reporting and learning system is the most comprehensive national incident-reporting system in the world. Every NHS staff member in every type of organisation—acute, primary care, mental health and ambulance trust—can report patient safety incidents. Patients themselves can also report directly to the NPSA. The reporting and learning system received nearly 3.9 million patient safety incident reports between October 2003 and 30 September 2009. What the NPSA does with that information is regarded most highly. As well as sharing regularly with the NHS information on trends in respect of types of incident and levels of harm, it provides information, guidance, alerts and tools to highlight the safety risks in general and specific areas and supports the NHS in heading off potentially harmful practices. We are grateful to the Committee for acknowledging the valuable work carried out by the NPSA, an organisation that we are proud of. "Safety first" was published in 2006, setting out the chief medical officer's vision for furthering patient safety and leading to a number of national initiatives, not least the patient safety first campaign that has brought together a number of national stakeholders working to a common aspiration. My hon. Friend the Member for Dartford (Dr. Stoate) has done so much as a Member of Parliament, not only as a member of the Health Committee but in many other areas of work that he has promoted or has been involved with as a chair. I am sorry that he is standing down at the election. We should acknowledge his work today, with your permission, Mr. Russell. In respect of some of the matters that my hon. Friend raised, it might help if I said that the NPSA now has an e-form for general practitioners that was launched in November last year, which is used for reporting and learning from any mistakes and for spreading information. Safety and safeguarding is one of the CQC's priorities. Such matters are raised separately, so perhaps we could look further at that matter and discuss it another time. Lord Darzi, in his NHS next stage review report, "High quality care for all", reminded us all what patient safety means in the context of providing quality services and of the importance that patient safety should be accorded. Safety is a core dimension of quality and relies on a whole-system approach, so that patients are able to receive the highest level of care. "High quality care for all", and Lord Darzi's interim report, introduced a number of new policy developments for patient safety. For example, from April 2010 a service commissioner will be able to retrieve from a hospital the cost of any treatment that leads to a never event. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventive measures have been implemented. PCTs are required to monitor the occurrence of never events within the services they commission and publicly report them annually. This is such a change in the way that we practise health care: it is open and transparent, not like the secret ways of the past. The more that figures are published on when harms take place, the better. It is those areas where nothing seems to take place that cause me some concern still, because, health care being so complex, it is difficult to accept that there has not been some evidence that there has been harm, so people are perhaps practising in a secret way. The role of the regulator in achieving safe services cannot be underestimated. The establishment of the Care Quality Commission and the introduction of registration requirements for all health and social care organisations will be a powerful tool for us to use in the furtherance of patient safety. The regulations underpinning the registration system, which are currently going through the parliamentary process, contain some specific requirements for patient safety. Until now, unlike the requirements for the social care and private health care sector, the reporting of serious patient safety incidents in the NHS has been voluntary. The registration requirements that are due to become operational on 1 April will make it mandatory for serious patient safety incidents to be reported to the NPSA, which will share the information with the CQC. We must also recognise that patient safety involves a diverse range of stakeholders with different skills, training, experience and knowledge, and working in different service sectors.