Patient Safety

Caroline Dinenage Excerpts

Wednesday 28th March 2018 Commons Chamber

[The Minister for Care (Caroline Dinenage)]

I wish to start by congratulating my hon. Friend the Member for Sleaford and North Hykeham (Dr Johnson) on securing this really important debate on patient safety. All patients have a right to expect care that is compassionate, effective and safe. The courageous testimonies of individuals such as Julie Bailey, who exposed the scandalous failings at Mid Staffordshire NHS Foundation Trust, and Sara Ryan, who campaigned fearlessly following the death of her son, Connor Sparrowhawk, while in the so-called care of Southern Health, show that safer care starts with listening to patients and their families.

It is important that we recognise that there are many victims when care fails—the families and the loved ones, of course, but also the healthcare professionals who carry the burden of their mistakes. The great majority of NHS patients receive effective and successful care. However, according to international studies, levels of healthcare harm range from 1% for the most “negligent” adverse events, to 8% to 9% for preventable adverse events. We are clear that any level of harm over 0% is unacceptable, and we believe that the route to a safer NHS is through transparency, learning and action. What is most frustrating is when harm persists, despite our having the knowledge and wherewithal to prevent it. There are approximately nine “never events” in the NHS every week—avoidable harms such as wrong-site surgery or foreign objects left after an operation.

Thirty years ago, the aviation industry stood at a similar crossroads. Since then, there has been a massive reduction in fatal accidents every decade, despite a huge increase in the number of passengers. According to the Civil Aviation Authority, there is an average of one fatality for every 287 million passengers carried by UK operators. Compare that with the 150 avoidable deaths every week across the NHS. That rate would potentially equate to the loss of 52 airliners per year.

How has the airline industry transformed its safety record so successfully? The key has been a “just culture” that recognises honest human error, but continues to hold people to account for criminal acts or wilful negligence. Creating a safe space that protects the evidence provided by pilots and air traffic controllers when there is an investigation is a cornerstone of the approach. It helps to create a culture in which people can be open about their errors and a system of learning from one’s mistakes, rather than blaming individuals.

[Jim Shannon (Strangford) (DUP)]

I congratulate the hon. Member for Sleaford and North Hykeham (Dr Johnson) on securing this debate on an important matter. NHS staff are greatly restricted by their work and the long hours they do. We all know that and pay tribute to them. Sometimes, however, we have to look at better ways of keeping records and at innovations to streamline things to make sure that the real focus of NHS staff is on the work that they do. Has the Minister looked at streamlining and innovations to take away the red tape that restricts the caring job that NHS staff do?

[Caroline Dinenage]

The hon. Gentleman is absolutely right. The more we can innovate and put in place the technology that helps to streamline day-to-day processes, the more that will help NHS staff, who do such a marvellous job, to do their job even more effectively and efficiently.

As my hon. Friend the Member for Sleaford and North Hykeham rightly said, to err is human. I am told that every year, 30,000 motorists put diesel fuel into their petrol cars—that is around 15 every hour. Those people are not intentionally destructive or feckless, they are human. Of course, I am not making an analogy with medical mistakes, which can be significantly more damaging and life-changing than the need to get a new engine, but in the same sort of way we need to move away from a blame culture in health—away from investigations that single out one individual rather than seeing their actions in the context of a complex overarching system.

[Rachael Maskell]

Robert Francis’s report included 290 recommendations to address these issues, not the least the duty of candour. However, people are still fearful to report—why is that?

[Caroline Dinenage]

I think it is for a variety of reasons. The hon. Lady is absolutely right to raise that issue; if she bears with me, I shall come to it a little later.

A first step in our new direction, based on an aviation model, is the Healthcare Safety Investigation Branch, which became fully operational in April last year and will independently investigate some of the most serious patient safety incidents every year. It is the first investigatory body of its kind in the world and demonstrates our commitment to learning and innovation. As part of the Government’s drive to make the NHS the safest place in the world to give birth, HSIB will standardise investigations of cases of unexplained severe brain injury, intrapartum stillbirths, early neonatal deaths and maternal deaths in England.

As an MP who represents a constituency in the area served by Southern Health, I am particularly aware that tragedy can spiral when an organisation loses sight of systematic problems in its provision of care. Our Learning from Deaths programme is a direct response to such events. Trusts are now expected to have proper arrangements for learning from the deaths of patients and are subject to new reporting arrangements, including evidence of learning and improvements. I should add that we are one of the first countries in the world to measure deaths in this way. Through Learning from Deaths, NHS England is supporting improved engagement across the NHS with bereaved families and carers.

As my hon. Friend the Member for Sleaford and North Hykeham rightly says, healthcare professionals need to feel safe to speak out about problems in the workplace. To support that, we have introduced an independent national officer for whistleblowing, and new regulations to prevent discrimination against whistleblowers who move jobs. Recent commentary in the media and among professionals has highlighted a possible brake on openness and transparency arising from high profile convictions of healthcare professionals for gross negligence manslaughter, which is exactly the same example as the one that she cited. That is why the Secretary of State for Health and Social Care announced in February that he was asking Professor Sir Norman Williams, former President of the Royal College of Surgeons, to conduct a rapid review into the application of gross negligence manslaughter in healthcare.

Absorbing the review’s recommendations into our healthcare system will be crucial to ensure that our healthcare professionals feel valued and secure, and that includes the GMC. The deadline for submitting evidence is April, and I encourage patients, families and professionals to contribute.

It is essential that infants have the best possible start in life, and the safety of mothers and their babies is a fundamental starting point for safer care. In November 2017, the Secretary of State announced his intention to bring forward the ambition to halve the rate of maternal deaths, neonatal deaths, birth-related brain injuries and stillbirths by 2025—a full five years ahead of our previous target. Pre-term birth is a major health inequality with mothers, and the Secretary of State has set an ambitious target to reduce the national rate of pre-term births from 8% to 6%.

Continuity of care is a key factor in a healthy pregnancy. Evidence shows that women who continue to receive care from the same midwives are 19% less likely to miscarry, and 16% less likely to lose their baby. That is why, yesterday, the Secretary of State announced important steps towards ensuring that the majority of women receive care from the same small team of midwives throughout their pregnancy, labour and birth by 2021. That announcement includes 650 new training places for midwives in 2019, which represents a 25% increase in the number of midwives in the UK.

We can never be complacent. Zero harm might sound impossible to achieve, but it should always be our aim. By learning lessons when things go wrong, listening to patients and their families, and working across the whole system to create a genuine culture of improvement, this Government are making a significant and lasting contribution to patient safety.

Question put and agreed to.