Health Service Safety Investigations Bill [HL]

Lord Turnberg Excerpts

2nd reading (Hansard): House of Lords
Tuesday 29th October 2019 Lords Chamber

[Lord Turnberg (Non-Afl)]

My Lords, I should declare my interest after a lifetime spent in the National Health Service and as a past president of a medical royal college, so of course I welcome a Bill on patient safety, even if it may be some time before we see it again. I am sorry to sound a rather negative note, but as I read the Bill, I did wonder how it would work in practice. I became increasingly concerned that, in its present form, it may not have the balance quite right between the major themes of investigation of serious qualifying incidents and the need to encourage local clinical staff involvement—and whether, because of that, it will frustrate its purpose of improving patient safety. This point has been made by several noble Lords who have spoken. So I thought it might be worth trying to see how the Bill would have worked if it had been in operation back in the 1970s, when I was involved in a rather tragic case of my own—I am afraid that I go back rather a long time.

I was a consultant physician in Manchester in 1978 or 1979 when we had an elderly patient in the ward with a gallstone stuck in her bile duct, blocking the flow of bile. She was in her 90s, frail and jaundiced and a very poor risk for an operation. So we decided on an experimental, non-invasive treatment in which we would try to dissolve the stone by infusing a solvent directly into the bile duct via a tube through her nose. All went well until one evening a junior doctor on my unit came in to inject the next dose of solvent. Instead of injecting it through the nasal tube, she put it into a drip going into the patient’s vein—a very big mistake, which, I am afraid, caused the tragic death of the poor lady. Noble Lords may imagine how devastated we all were when we realised what had happened.

Now the immediate question was how such a tragic event could happen and who was to blame. These are the questions that might be posed under this safety investigation Bill were it in operation, but then it was me and my team who tried to answer the questions. Was the junior doctor who gave the injection at fault? She might have known better if she had understood what we were doing when she came on our ward rounds. Or perhaps it was the registrar on call, who was not around at the time and should have supervised her in this new type of treatment. Or perhaps it was the nurse, who came with her and handed her the syringe. One might have expected her to have known something about it. Perhaps the pharmacy that sent up the injection was at fault. They should have labelled the solvent more clearly as not for intravenous injection, perhaps with a fitting that could not fit on to an IV line. Or of course perhaps the fault lay with me for not giving clear enough instructions to my junior staff. I was certainly the one who shouldered the burden of breaking the news to the relatives that we had made a huge error that caused the death of their loved one; and it was I who appeared before the coroner.

Forgive me for using this sad case, but it illustrates the catalogue of errors—a multi-system failure—that can have such devastating consequences and where ascribing blame to individuals is so fraught with difficulties. But more important than the blame game is what one should do when it happens to prevent it happening again. I can tell noble Lords what we did and ask what might have happened if the Bill in front of us had been enacted.

First, we did not try to make any excuses to ourselves or to the relatives. We were completely open. I said how sorry I was that it had happened, in the belief, like the noble Lord, Lord Hunt, that saying sorry that someone has suffered is never a mistake; it is an expression of sympathy, and the fear that saying sorry leaves one open to litigation is just untrue. I have never believed that a sense of compassion is a confession of guilt. Then we initiated a full inquiry with all the staff—the doctors, nurses, pharmacists and everyone who was engaged—into the causes of the tragedy, and we made a full set of recommendations that were applied at every level.

The question now is in what way this new Bill would have helped or hindered this process. It is very unlikely that it would have prevented that particular episode from happening, but would it make it any easier after the event? Would it have encouraged us to report to the new statutory body for investigation? And would that have improved patient safety? There was no criminal intent by anyone in our case, yet the Bill seems to hint at that sort of investigation rather than for errors of judgment. Perhaps more important is the question of whether it will inhibit medical and caring staff from disclosure of mistakes.

The Explanatory Notes start off in fine form talking of providing a safe place and the promotion of learning throughout the NHS. They talk of providing advice, guidance and training and of the need to learn from mistakes so that helpful information can be spread. All that sounds admirable and would no doubt have been helpful in our case, but when one reads the Bill itself the accent is on investigation by an external body with little sign of the encouragement that will be so essential if anyone is going to admit to their errors. If it is going to be effective, it will need to shift its focus from top-down, external, big-brother investigation to providing the safe place where practitioners can really feel free to come forward with their difficulties. Certainly it should be capable of thorough investigation where it is needed, but on many more occasions—we heard from the noble Lord, Lord O’Shaughnessy, about how many occasions—support is needed to help to ensure that the much more common errors of judgment are not penalised and that lessons can be learned from them. The emphasis in the Bill is, to my mind, too far over to the external investigation side and not enough to the encouragement of practitioners to come forward to engage with learning lessons from their errors. I am not convinced that I would have been more or less open than I was all those years ago.

I shall finish with a word about the role of the medical examiner proposed in the Bill. I presume that it is the same person whom the GMC talked of years ago. The important question has always been about where busy doctors will find the time to take on this role. If it becomes a statutory position, will it take, say, one session a week? It probably will not, but it might. If so, will we be able to fund 10% more staff simply to cope with this important duty? Perhaps it will take less time, but it will still take time and staff, and without the funds that will be necessary, it will not happen as we hope. Can the Minister explain?

I fear I may have sounded somewhat negative about this Bill, but that is not because I do not think we need to focus hard on improving patient safety now more than ever. However, I remain somewhat unconvinced that this Bill will fill that need sufficiently well. The accent here is on investigation of serious cases, and that is fine. There is some overlap with the GMC and other regulatory bodies which are doing a good job. What we need, and what I hope we will see in the Bill after the election, is a shift of focus to the encouragement, engagement, involvement and support of those who are directly responsible, at the coalface, across the field, for the safety of patients, so that they can freely admit when things go wrong and learn from their mistakes. It is because these words—encouragement, engagement and involvement—are missing that I fear the Bill will not achieve what we hope for. The Minister used the words “completely candid”; I remain to be convinced that this Bill will encourage candour in the way she hopes.

Vaccine Hesitancy

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Monday 1st April 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The noble Baroness raises a very important point which is that while social media can be used to spread disinformation or misinformation, it can also be used in a positive way to spread the positive value of vaccinations. That is why we want to work with those who have doubts about vaccination to highlight the benefits of vaccinations, the protection that they bring from the very serious diseases which she highlighted and how safe they are. A wealth of information is available online through trusted NHS channels which will enable parents to make well-informed decisions about getting their children vaccinated. I encourage the noble Baroness to highlight in her event next week some of the channels which are available and which we will continue to push.

[Lord Turnberg (Lab)]

My Lords, vaccination programmes are the most effective public health measures we can imagine. I have two questions. First, what are the Government doing to ensure that pharmaceutical companies are encouraged to develop new vaccines for diseases? Secondly, I understand that some schools have made it imperative for parents to ensure that their children are vaccinated before they can attend the school. Is this something that we can extend?

[Baroness Blackwood of North Oxford]

The noble Lord raises an important point. There are global shortages of some vaccines on occasion and, when that happens, discussions with manufacturers are ongoing. There is also ongoing work to develop new vaccines. That is part of the life sciences strategy and sector deal, which the noble Lord may be aware of. Public Health England advises clinicians on how to prioritise available vaccines when these situations occur.

I think that I covered the question of compulsory vaccinations and schools that restrict access to vaccinations in my first Answer. Public Health England and clinicians do not believe that this is the appropriate route, as medical care in the UK is delivered by informed consent. Generally, those who are hesitant about vaccinations respond better to people working closely with them to explain the benefits of vaccines and how safe they are; otherwise, the risk is that children will be withdrawn from schooling entirely, which would be a much worse outcome for the children involved.

Health: Pancreatic Cancer Treatment

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Wednesday 19th December 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Baroness makes a very important point. I am sure that she is aware of the 14 Be Clear on Cancer campaigns that have been run over the last eight years, which are absolutely about raising the salience of these issues and making sure that people know the signs they should be looking for and can come to GPs earlier. We are seeing fewer people presenting with cancer diagnosis through emergency departments, which have the worst outcomes, and more coming through GPs. Of course, as I said, we are investing in these rapid diagnostic centres as well.

[Lord Turnberg (Lab)]

My Lords, the problem with pancreatic cancer is that, by the time a patient has symptoms and a diagnosis has been made, it is almost always too late. It hides itself away for far too long. The only way to make a real impact is by having some sort of method of determining whether someone will get pancreatic cancer by having a screening programme. That depends very much on new research into the ways in which we can detect cancer cells from DNA and the peripheral blood. Research into that area is vital if we are to make any impact on pancreatic cancer. Does the noble Lord agree?

[Lord O’Shaughnessy]

I absolutely agree on that point. I hoped we would pass the “Lord Young test” with a jargon-free and, at least, succinct White Paper—the Life Sciences Sector Deal 2, which we published recently. It outlines some very important commitments to research in this area, including the creation of new early diagnosis cohorts, using a cohort of healthy people to look for early signs. That is one of the investments we are making, as well as investment through the National Institute for Health Research. We are looking for those exciting innovations, like liquid biopsies, that can help us get the signs earlier.

NHS: Specialist Services in Remote Areas

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Tuesday 11th December 2018 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, there is one important way in which patients in remote parts of the country can access specialist care: telemedicine. It is quite easy to send X-ray pictures, scans and blood test results online, and even to interview patients. I send things via WhatsApp to my children almost every other day. It is entirely possible for me to do that on my iPhone; surely the NHS can do it too. I understand that Wales has managed to do it quite well. Is it possible for us to do the same in England?

[Lord O’Shaughnessy]

The noble Lord is right. Of course it is possible for us to do it in England; it is happening all over the country. Telemedicine offers fantastic opportunities, such as Skype-based GP consultations. Indeed, there is the example of Morecambe Bay’s remote clinician pilots in a variety of specialisms, such as gastroenterology and mental health care. Clearly, that is important. I point the noble Lord to the tech vision published by my relatively new Secretary of State this autumn, which points out the massive potential for digital health in reducing these kinds of inequalities.

Adult Social Care

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Wednesday 11th July 2018 Lords Chamber

[Lord O’Shaughnessy]

The noble Lord is quite right that there is a need for more money in the social care system. That is why, in addition to the funding set out in the spending review, the Government have put £9.4 billion over three years into the system in the short term. The point he makes, which is right, is about the long-term sustainability of the settlement. I would point him to the seven principles underpinning the Green Paper, which my right honourable friend set out. One of those is a sustainable funding model—a model which, as we have said, cannot put pressure on the NHS. That means that we need to find the money to ensure that it can subsist.

[Lord Turnberg (Lab)]

My Lords, the noble Lord is well aware that we need more money for social care, and that integrated care is vital. He may also be aware that Salford has successfully integrated health and social care. I am sorry to keep banging on about Salford, but it is where I spent many happy years working. It has done it very successfully, and Sir David Dalton has led it wisely. What lessons are being learned centrally, not just from abroad but from the UK and similar experiments?

[Lord O’Shaughnessy]

The noble Lord speaks with great wisdom and he is absolutely right to highlight Salford, as he always does, because it is the root of the integrated care service being put in place in Greater Manchester with unique devolution powers, and we want to see that model rolled out across the country. Of course, the point of that is to ensure a better interface between the National Health Service and social care, so that one of the problems that bedevils us at the moment—delayed transfers of care—does not get in the way of proper care.

Branded Health Service Medicines (Costs) Regulations 2018

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Wednesday 20th June 2018 Lords Chamber

[Lord Borwick (Con)]

My Lords, I declare an interest in this debate, as I am a patron of both the British Thyroid Foundation and the Thyroid Trust. I have heard it said that, somewhere in the Lords, there is always an expert on any subject raised; all I can claim is personal experience. I have suffered from Graves’ disease, which results in an overactive thyroid gland. Once it has had one episode, the thyroid can have an increased incidence of repeated episodes, and I had three in increasing frequency. The cure used often in the UK is to surgically remove the thyroid completely. Suddenly, the patient moves from too much hormone to none at all.

The thyroid, which is a small butterfly-shaped gland in the front of the neck, produces two hormones—levothyroxine and liothyronine—known as T4 and T3. As the noble Lord says, it is much easier to use those words. As T4 is a base stage, T4 makes T3 and the vast majority of patients, perhaps 80% and including me, can convert T4, the inactive hormone, into T3, the active one. Some cannot do so or can only do so inefficiently. The level of research is so low that, alas, we do not know for sure why this is. It may well be a faulty gene.

The trouble with thyroid patients is that their experience of the disease is so varied and the effect on their bodies is sometimes so profound, that they can be “hard to treat”. This is a marvellous medical euphemism that carries a wide range of patients with it, from ones who feel well when they are actually quite close to death, like me, to those whose low thyroid level makes them apathetic, befuddled and exhausted. The latter are the most frequently occurring cases. The majority of them are female and they are often overweight, finding that diets tend not to work for them, however hard they try to lose weight. As the thyroid affects the speed of every single cell in the body, including the brain, a nasty aspect of the disease is known as “brain fog”. That is the inability to think anything through at all, let alone explain what is wrong with you. That aspect, coupled with hormone tests that can declare that everything is within normal limits when they are still wrong, makes some patients particularly “hard to treat”.

With a high level of thyroid activity, life may feel quite pleasant. Even Brexit seems to be simple. A high thyroid level has something in common with being mildly overserved, even tipsy, and yet I know someone who sadly died of this disease and, for a few, the symptoms can be dramatically unpleasant, even as severe as psychosis. With a low level of thyroid, everything can be too complex, too difficult, too depressing or gloriously clear but wrong. Endocrinologists are doctors with immense patience. Overall, any imbalance in thyroid hormones, which can occur rapidly or very slowly, from high to low or low to none, can trigger brain fog and a range of other debilitating and diverse symptoms.

This liothyronine problem affects a group of patients who may appear to have the right level of T4, but who cannot make sufficient quantities of T3 from it. T3 was made by a single supplier for a time, Concordia, a company that I have met and been impressed by. It deals with a wide variety of generic drugs to be supplied to the Department of Health. These drugs are subject to several layers of regulation, including on price and quality. Most important is consistency, as the thyroid patient is peculiarly sensitive to inconsistency. Consistency depends in part on modern methods of manufacture, and the problem that Concordia faced, it tells me, was a need to update the manufacturing equipment with a large capital investment for a small number of patients.

To put the problems into context, the Department of Health buys a vast number of generic drugs. Millions of different patients need thousands of different drugs, and it is amazing how few problems occur. This is because of the great work done by the unsung heroes of the department’s regulatory agencies. All this takes place without much political input, and probably is the better for that, but a price that goes up so much raises an eyebrow or two, particularly compared to a price that is so much lower abroad. Even if the price increases had been agreed with the department, as Concordia informs me they were, the solution is likely to involve negotiation between the manufacturer and the department. Competition is likely to play a part here, and I gather that there are now three manufacturers in the market to provide T3 for UK use and prices are falling.

The bottom line is that, where there is a portfolio of generic drugs, used by different patients for different syndromes, the marginal price of any one drug in any one quantity is somewhat arbitrary. Should it be a loss leader or priced as the star of the portfolio? It is clear to me that the pricing, like thyroid disease, only becomes noticeable when it varies quickly or goes out of control. What caused a problem was misinterpretation of health department advice into suddenly not prescribing T3 to patients who had been happily taking it for years. I am not sure that a referral to the Competition and Markets Authority did anything other than raise the stakes, when negotiation is surely the best way to deal with the problem.

While liothyronine is available at a lower cost from European suppliers, there have been calls for the NHS to source directly from overseas. This initially may seem appropriate, given that patients are currently being told to purchase directly from these overseas suppliers themselves, with a private prescription from their NHS GPs, who tell them that their practice or CCG will not pay.

The Thyroid Trust has given permission to me to share the alarming case of Maureen Elliott in South Thanet. Maureen was well for 10 years on liothyronine and agreed to stop taking it when her doctor flagged up the high cost to the NHS. Subsequently becoming very unwell without it, she was referred to an NHS endocrinologist, who confirmed that she should have it, yet the instruction she was given was to buy it herself from abroad. With prices from different suppliers varying wildly, from more than £600 to £50 a packet, and inconsistent quality, she has found the whole experience extremely stressful as well as expensive. Why should she and others have to do this as individuals, when the Department of Health could be doing it, presumably with the capacity to drive a better bargain?

However, if the quality control requirements of the UK’s Medicines and Healthcare products Regulatory Agency have triggered prices here to be higher than elsewhere, is the liothyronine from manufacturers that do not hold a UK marketing authorisation of questionable quality? Given the negative effect on patients such as Maureen, perhaps the Minister can help to stress to doctors that T3 has not been banned, that he agrees that some patients need it, that although it is expensive it is valuable to certain patients and that doctors should not restrict access for existing patients prior to clinical assessment by a specialist.

[Lord Turnberg (Lab)]

I want to restrict my observations to the case of the treatment of hypothyroidism, and elaborate just a little on the wise words of my noble friend Lord Hunt of Kings Heath.

We have here an unhappy coincidence of bureaucratic errors on the one hand and what can be described only as corporate greed on the other. The end result is that patients with hypothyroidism are suffering. I suppose that I should just say a little about this condition, in which these patients fail to produce enough of their own thyroid hormone, for one reason or another. Although I am no longer on the medical register, I do not feel too constrained: it causes a range of unpleasant symptoms and can be life threatening. It causes symptoms, some of which may sound familiar to your Lordships, including extreme tiredness and a general slowing down, which makes you gain weight, thickens your skin and makes you lose hair. It comes on insidiously, so that it can sometimes be difficult to diagnose. It is worth noting, as I think my noble friend said, that up to 5% of the population, or one in 20, are said to suffer from hypothyroidism—and, worst of all, it can cause heart attacks, if not treated.

Yet treatment is very easy indeed—just one tablet a day of the hormone thyroxine gets rid of all the symptoms and can make people normal again, which works for the vast majority. But here is the rub: a few patients do not feel better, and they need to take the more active metabolite of thyroxine, liothyronine, or T3, to make them well. There is some controversy over why some patients need that more expensive treatment. Do they have a problem with converting thyroxine to the active principle or not? That has not been resolved scientifically, but there is little doubt that, clinically, some patients get better only on the active metabolite, T3. That being so, clinicians should be able to prescribe it. Certainly, that is the case in many countries around the world.

Prescribing T3 here in the UK was never a problem until 2007, when the Canadian manufacturer, Concordia, got hold of it and was given the sole contract by the NHS to produce it. It was then that, as a monopoly supplier, it put the price up several-thousandfold, as we have heard, so that now the price has risen to over £900 for 100 tablets. Then, of course, NHS England found it increasingly unaffordable. So instead of trying to find cheaper suppliers, it put in draconian conditions on doctors under which it may be prescribed. On top of that, those conditions are so ambiguous that CCGs, GPs and consultants are fearful of prescribing it, so they have stopped. As we have heard, patients who have been on it for years now cannot get it and suffer the consequences. So what do the patients do? They go online and buy it privately in Europe for around €30, instead of £900 for 100 pills.

I have three questions for the Minister. Will the Government try to move the Competition and Markets Authority along after its preliminary hearing that the manufacturers should repay the several million pounds that they owe to the NHS? Will they consider purchasing the medicine from an alternative supplier, possibly elsewhere in Europe, for a fraction of the cost? Will he press NHS England to produce some straightforward, unambiguous guidance for patients and doctors about how it can and should be prescribed? I would be happy to help, if he would like that.

[Lord Lucas (Con)]

My Lords, I ask my noble friend to turn his intelligence and attention to how the NHS can get best value in the purchase of out-of-patent medicines, branded and generic. I have had the pleasure of reading the 2014 pharmaceutical price regulation scheme. If any noble Lord is in need of tickling his belly button with his jaw, I suggest that he does the same. It is the most astonishing system, guaranteed to produce lush profits for manufacturers, giving the NHS almost no purchase whatever on the price being charged. It is done in the name of promoting innovation and promoting the UK industry, but there does not seem to be the level of intelligence—meaning not mental intelligence but investigation and the understanding— that would be necessary to make sure that that was the case.

Long-term Plan for the NHS

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Tuesday 19th June 2018 Lords Chamber

[Lord O’Shaughnessy]

My noble and learned friend is quite right: these commissions do not always produce action. I realise that there is some frustration in the House over the delay to the social care Green Paper. I hope noble Lords will respect the fact that it is sometimes difficult to fight battles on many fronts. We have made some progress on the NHS and the army moves on to win the war on social care as well.

[Lord Turnberg (Lab)]

My Lords, I for one from these Benches welcome the influx of funds. We have been waiting quite a while for it so it is well received. Everyone knows, however—we have heard today—that without changes and improvement in social care, this 3.5% will go down the drain as well. It is not just that we need to do both together; we need provision for social care at the same time as, if not in front of, the influx of funds for the NHS.

[Lord O’Shaughnessy]

I agree with the noble Lord and thank him for his welcome. We all agree; indeed, the Statement sets out clearly that the two must go hand in glove. I should point out that additional money for social care in the short term was put in a previous Budget by the Chancellor—£2 billion extra over three years, a budget that is now growing. Clearly that was a short-term measure. Now we need to find that long-term settlement that goes hand in hand with the NHS and ensure that we have true service integration as well.

Children: Obesity

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Thursday 10th May 2018 Lords Chamber

[Lord O'Shaughnessy]

I am turning into the commissioner of children’s programming. I am trying to remember—I think that there is actually a CBBC programme that encourages children to cook. Its name has gone completely out of my mind but it was popular with my children. The noble Baroness raises an important point. Children learn to cook in primary schools, most of which have some sort of kit that allows them to do that. It is critical for them to understand that food does not just come from packets or shops but can be created by hand—and enjoyably, too.

[Lord Turnberg (Lab)]

My Lords, is the noble Lord aware that it has been shown that having a good breakfast, such as an egg or two in the morning, reduces one’s appetite for the rest of the day, and one’s weight? One of the problems for children is that many do not get a good breakfast. Can the Government do anything to encourage breakfast as a proper meal?

[Lord O'Shaughnessy]

It goes to show that public health campaigns can be effective. I remember the “Go to work on an egg” campaign—although I had a banana myself. The serious point is that too many children do not go to school after a proper breakfast, and one of the great advances with the sugar levy has been a commitment of around £26 million to support breakfast clubs in about 1,500 schools in areas that unfortunately have the worst outcomes for healthy children and obesity. That support will help those children go to school on a good breakfast and function properly.

Children: Obesity

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Thursday 19th April 2018 Lords Chamber

[Lord O'Shaughnessy]

All I can say is that both my noble friends are excellent examples of slim and fit young men.

[Lord Turnberg (Lab)]

I am sure that the Minister is aware that while exercise is very good for children and adults—it improves mental and physical health—it does not do much for obesity. It is food that does the worst. It is not just sugar, it is fat, and ice cream, crisps and chocolates are so appealing to children. Ice cream has twice the calories of sugar. Will he consider how to get that message across?

[Lord O'Shaughnessy]

One thing I noticed at Easter was that Easter eggs seem to have got bigger. I was counting the calories on the Easter egg that my children had. There is a serious point there. It is about reformulation, it is not just about reduced sugar, salt and so on; it is also about smaller portion sizes, and that is a measure that we are tracking as well.

General Practitioners: Workforce

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Monday 5th March 2018 Lords Chamber

[Lord O’Shaughnessy]

My noble friend is absolutely right. As well as our commitment to increase the number of GPs by 5,000, we also have a commitment to increase the number of GP practice staff by 5,000, including 1,500 pharmacists, who provide exactly the kind of support she outlined.

[Lord Turnberg (Lab)]

My Lords, one of the reasons why general practice is less attractive than it used to be is because of the enormous bureaucratic load that is placed on GPs nowadays. They have to sit on committees and on CCGs, and they rush around doing non-clinical work. Is there any way to reduce this non-clinical workload?

[Lord O’Shaughnessy]

That is an important issue. We know that workload is a problem. I point the noble Lord and other noble Lords to NHS England’s 10 high-impact actions. These are actions which all GP surgeries can take; for instance, using technology such as e-booking and e-prescribing to reduce the kind of workload he is talking about.