Health and Social Care Bill

Debate between Baroness Hussein-Ece and Baroness Finlay of Llandaff

Monday 13th February 2012 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I considered long and hard whether to add my name to this amendment. The gagging orders to which the noble Baroness, Lady Williams, has just referred run completely counter to openness and candour, and there has to be candour. I hope that the Government will take away from this debate the fact that, first, something has to be done to stop people being gagged; and secondly, whether it is in guidance or on the face of the Bill, there must be a way to ensure that there is candour throughout the whole system and that it applies to everyone. The implication that general practitioners, dentists and so on are not on an equal footing with other organisations is invidious.

Patients need to know what has happened. I admire my noble friend Lady Masham for persevering with her research into this issue and presenting it to us today. The tension arises between an individual, a doctor registered with the GMC, on whom there is a duty of candour as an individual to be open and honest with patients if things go wrong—indeed, in the relevant paragraph in Good Medical Practice 2012, the word “must” appears, which means what it says, as opposed to “should”, which is advisory—and organisations. When things go wrong, there is often a series of errors that become compounded, along with other events that may seem insignificant. For example, a patient’s notes were not available on one occasion when they were seen so the wrong investigation was ordered, and things went on from there. Another difficulty is that it is sometimes the patient’s own behaviour which contributes to the cascade. It can be difficult to confront a patient who is already distressed with the fact that the way in which they have behaved—perhaps by discharging themselves or by going off to some alternative practitioner—has contributed to the way in which things have gone wrong. Another simple example is, if you do not know that a patient is taking a certain medication, it can be very difficult to predict an interaction with a prescribed medication.

I should declare my interests, which I did not do earlier in our debates—I hope that the House will forgive me—as a fellow of the Royal College of Physicians, a fellow of the Royal College of General Practitioners, a member of the British Medical Association and a practising clinician. I will always remember as a medical student meeting a general practitioner who took me for a walk in a small village on a Welsh hillside. He took me to the churchyard and said, “I want to walk you around the churchyard”. I asked him why, and he replied, “Because I want to introduce you to my errors”. He had been working in the village for many years. Sadly, as a junior doctor I was in a hospital where there was a catastrophic medical error. What that taught me more than anything is that you have to be open from the first moment you realise that an error has been made. Anything other than openness fails.

To reinforce the remarks made by the noble Lord, Lord Newton, and the noble Baroness, Lady Pitkeathley, whenever I have had to tell patients that something has gone wrong, however minor it may be, I have been astounded at how grateful both they and their families have been for the fact that I have told them. They are also grateful when we institute intensive monitoring procedures, which can mean that patients are woken every hour through the night, and express relief touched with a sense of humour when such intensive monitoring is no longer required. Time and time again when things have gone wrong, there is an overwhelming sense that whatever it was should not happen to anyone else, along with the realism of knowing that you cannot put the clock back, and that medicine is about not absolutes but all shades of grey.

The difficulty with having this clause in the Bill is the potential for unintended consequences. That is why I hesitated about adding my name to it. I hope the Minister will take the matter forward, because this has been a very powerful debate, and put something in guidance. In 2009, the CMO recommended a duty of candour. We really must make it a reality if the implication of “nothing about me without me” is to be honoured. We need to be open, honest and realistic with our patients.

[Baroness Hussein-Ece]

My Lords, I, too, had no intention to speak on this amendment, having spoken on and supported the proposal for a duty of candour in Committee. Patients and public quite rightly have higher expectations of the services they receive from the NHS, both for themselves and their families. They are also better informed, and they expect NHS clinicians, carers and nursing staff to respond to that. This is not just about graveyards, as mentioned in the rather alarming story recounted to us by the noble Baroness, Lady Finlay, but also about care. Patients might not have received the quality of care that they expected. I have had experience of that with my late father. When he was terminally ill, the standard of nursing care was so poor and so distressing that the onus was on me, on behalf of my family, to take it up with the chief executive or whomever I could find and say that things were just not good enough. Even as someone who had worked in the health service and spent time as a chief officer for a community health council representing patients, I still found it hard to know who was the right person to take a complaint to. It was not a serious complaint—about medication, for example—it was just about the standard of care. In fact, the consultant on the ward asked me to take up the matter because he was so concerned and could not do anything about it himself.

What worries a lot of trusts, and I came across it in my career in the NHS, is that an apology might somehow be taken as an admission of guilt. They were therefore reluctant just to give a straightforward apology. In my case, I had to complain about a particular member of the nursing staff, with the case continuing after the death of my father and disciplinary action being taken against the individual concerned, but I still did not receive an apology. Even after my complaint was upheld, there was no apology. There was no sense of, “Yes, we realise things went wrong”; rather, it was, “Yes, this person did something wrong and she is going to be dealt with”. There was no apology, no statement of how things would change and how the culture in that particular ward in terms of caring for older patients would improve. A basic apology should be the very least thing that could happen, without there necessarily being an admission of liability or of guilt. At the human level, an apology should be made to somebody who has suffered, or to their family.

People also want a simple explanation. They do not want an incomprehensible letter about treatment; they want a step-by-step, basic explanation of what should have happened but did not—just to give someone some background. This should be done very quickly. Trusts should also offer a face-to-face meeting, which not all of them do, particularly early on. It may already be offered further down the track.

Those two or three simple measures should be put in place and become the norm. We have heard in this very interesting debate that there are variations, and there probably always will be, but we should expect a minimum standard when things go wrong or when services are perhaps not what they should be.

Health and Social Care Bill

Debate between Baroness Hussein-Ece and Baroness Finlay of Llandaff

Wednesday 2nd November 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, it may help the Committee if I explain how the GP contract is being renegotiated; I hope that I get this right. Instead of a GP contract covering a rigidly defined area, as now, there will be an outer ring as well. If patients move a bit further away but stay within that outer ring area, instead of being forced to change their GP, they will be able to remain with their current GP. Therefore, I think that the problem of choice, to which the noble Baroness, Lady Cumberlege, alluded, should in large part be solved by the negotiations that the Government have just had with GPs. There is of course a difficulty in defining any area but to date the areas have been defined by GPs, and they will still have to define the outer area or outer ring to which it is practical for them travel to carry out home visits and so on.

As I understand it, a decision has not yet been taken on what will happen with people who, like most of your Lordships, are classified as temporary residents. Many of us live a long way from here and, if we need to see a GP, we register as a temporary resident with one somewhere in Westminster. I am not sure how those arrangements will work in the future but they have served us reasonably well until now. The danger in relation to allocation relates precisely to those patients to whom the noble Baroness, Lady Tonge, referred—those who have been thrown off GP lists or cannot get themselves signed on to a GP list for whatever reason but still have healthcare needs. If those needs are not met, that will impact on the very social fabric of our society. I hope that I have clarified some of the points.

[Baroness Hussein-Ece]

I should like to ask a couple of questions to clarify where the debate is going. As my noble friend Lady Tonge said, for a number of years some groups have found it almost impossible to get a GP. It is almost a case of GPs selecting the people they want on their lists; it is an unwritten code. That is why asylum-seeking families, refugee families and others with very high needs will always find it difficult to get a GP, and I want to ask the noble Baroness, Lady Finlay, how her amendment will assist that.

Equally, as has already been mentioned, areas of high need have in my experience always been in inner cities, where it has been difficult for some people to register with a GP. We know that attendance at A&E departments has become extremely high in some areas—almost unsustainably so—and I want to ask how the amendment will address that too.

There are also families who are placed by local authorities in temporary accommodation in other areas. Currently, a local authority is responsible for such a family—for example, social services or family support may be involved with the children. However, if that family is placed in another borough way out of the catchment area, I am not sure who their GP will be. Perhaps the Minister can respond to that as well and say how that would work with a local authority having responsibility for a family placed well outside the area. Would that family still be able to get support by going on to a GP list in the new area? Would that connection be made? Over the years we have worked very hard to make sure that social care, healthcare and local authorities all work together in partnership. Perhaps we could have an explanation of how it is going to work when families with very high needs are spread around.