Public Administration and Constitutional Affairs Committee

Bernard Jenkin Excerpts

Thursday 2nd February 2017 Commons Chamber

[Mr Bernard Jenkin (Harwich and North Essex) (Con)]

I am grateful for the opportunity to present to the House the seventh report of PACAC this Session, “Will the NHS Never Learn?”, a follow-up to the Parliamentary and Health Service Ombudsman report on the NHS in England, “Learning from Mistakes”.

Over the past decade, written complaints regarding NHS services have doubled, from just over 95,000 in 2005-06 to more than 198,000 in 2015-16. Investigations into such complaints have frequently failed to identify the root causes of any mistakes that occurred. Even more frustrating is that they have failed to prevent the same mistakes from being repeated over and over again, despite multiple reports highlighting that as a critical issue from both the Parliamentary and Health Service Ombudsman and the Public Administration and Constitutional Affairs Committee, which I chair.

In its report “Learning from Mistakes”, which was published last year, the PHSO highlighted the fear of blame that is pervasive throughout the NHS. That fear drives defensive responses and inhibits open investigations, which in turn prevents NHS organisations from understanding what went wrong and why. That also undermines public trust and confidence, because the public can see that NHS organisations are failing to learn from mistakes—if they did, that would drive improvement. A combination of a reluctance on the part of citizens to express their concerns or to make complaints, and a defensiveness on the part of services to hear and address concerns, has been described by the PHSO herself, Dame Julie Mellor, as a “toxic cocktail” that is poisoning efforts to deliver excellent public services.

To further understand the issues and what more needs to be done to tackle them, PACAC recently undertook its inquiry, which followed up on the PHSO’s “Learning from Mistakes” report. In PACAC’s report, which was published earlier this week, we conclude that if the Department of Health is to achieve its policy of turning the NHS into a learning organisation, it must integrate its various initiatives to tackle the issue and come up with a long-term and co-ordinated strategy. That strategy must include a clear plan for building up local investigative capability, as the vast majority of investigations take place locally. We will hold the Secretary of State for Health accountable for delivering the plan.

PACAC’s report also considered the potential impact of the new healthcare safety investigation branch, which is in the process of being set up. The creation of HSIB, as it is known, originates from our recommendations as the Public Administration Committee in 2015. The Government accepted our recommendation, and HSIB is due to be launched in April. It will conduct investigations into the most serious clinical incidents, and is intended to offer a safe space to allow those involved in such incidents to speak openly and frankly about what happened. In so doing, it is hoped that HSIB will play a crucial role in transforming the expectation and culture in the NHS from one that is focused on blame to one that emphasises learning. It should be a key part, albeit only a part, of the wider strategy that we want the Government to adopt.

Unfortunately, there is still a long way to go if the Department of Health’s aim of turning the NHS into a learning organisation is to be achieved. Most importantly, HSIB is being asked to begin operations without the legislation necessary to secure its independence and ensure that the safe space for its investigations is indeed safe. That undermines the whole purpose of HSIB. It is essential that the Government introduce the necessary legislation as soon as possible.

To ensure that the learning produced from HSIB’s investigations leads to an improvement in standards, PACAC also reiterates its previous recommendations, made in our 2016 report, “PHSO review: Quality of NHS complaints investigations”, that the Government should stipulate in the HSIB legislation: first, that HSIB has the responsibility to set the national standards by which all clinical investigations are conducted; secondly, that local NHS providers are responsible for implementing those standards according to the serious incident framework; and, thirdly, that the Care Quality Commission should continue to be responsible, as the regulator, for assessing the quality of clinical investigations at local level according to those standards.

The purpose of complaints is not just the redress of grievances—which I must say is extremely unsatisfactory in the NHS anyway—although that is clearly important; complaints are a tool by which public services can learn and improve. When medical professionals are forced primarily to be concerned with avoiding liability and responsibility and are trapped in a culture of blame, there can be no learning. There is an acute need for the Government to follow through on their commitment to promote a culture in which staff feel able to speak out and in which the emphasis is placed on learning, not blame. I very much hope that they will implement PACAC’s recommendations as a step towards achieving that as soon as possible.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I congratulate my hon. Friend for his work, and that of his Committee, on producing the report. He is absolutely right about HSIB and the need to underpin it properly. The Government have said that they would cap litigation costs at £100,000. I think my hon. Friend would accept that there will always be litigation, even if we get a more satisfactory means of redressing grievance, in the way he has suggested. Does he think that that cap would be appropriate, particularly since motor costs, for example, are capped at that level? Would that mean that people with grievances would be properly compensated while, sadly, their lawyers would not be?

[Mr Jenkin]

I confess I am not sighted on the proposal to cap litigation costs, but people resort to litigation only because they feel that their complaints are not being heard and that the problems they have identified in the service are not being addressed. People resort to litigation because they do not feel they are being told the truth. We know from our surgeries that most people who complain come in and say, “I only want to make sure this doesn’t happen to somebody else. I don’t want compensation.” Nevertheless, because that public-spirited attitude to complaining is so often rebuffed in the health service, people resort to litigation because they feel there is a cover-up.

In other fields, such as aviation and marine investigations, where this kind of investigative process is already established and is designed to find the causes of accidents without blame, there is far less resort to litigation at the outset. That does not preclude litigation in the final analysis, but discovering the truth without blame is the first step towards reconciliation.

[Glyn Davies (Montgomeryshire) (Con)]

I, too, greatly welcome this report, as do my constituents. That may seem surprising to some of my colleagues, as, of course, my constituency is in Wales, but all my constituents use hospitals in England for elective care and specialist care, so this is as important to the people of Wales as it is to the people of England. I have also been involved in many of the complaints. Does the Chair of the Committee acknowledge that, in the debates that he has had and in any follow-up debate that he might have, the position of Welsh constituents is key, because, although they are in another Administration as far as health is concerned, they depend on hospitals in England for treatment?

[Mr Jenkin]

I am most grateful to my Welsh hon. Friend for his question. It gives me an opportunity to highlight not only my agreement with the point that he makes, but that this is just about healthcare safety investigations in England. By pursuing this policy to set up HSIB, the Government have embarked on a very, very major and significant reform, which the health services in Scotland, Wales and Northern Ireland are certainly watching. I can assure my hon. Friend that they are being watched all over the world. Different countries in different jurisdictions have tried using various bodies to deal with this question. I do not think that any country before England has embarked on a reform of this scale and nature that has the capacity to transform safety investigation in a health system. I very much hope that Wales, Scotland and Northern Ireland will either set up their own equivalent of HSIB, or employ HSIB as the pinnacle of their investigation system as well. This matter is not something that necessarily needs to be devolved any more than the Air Accidents Investigation Branch of the Department for Transport.

[Sir Peter Bottomley (Worthing West) (Con)]

Does the Chairman agree that each of us receives from our constituents many more golden letters about their treatment in the health service than letters of complaint? When there are complaints or questions, openness and responsiveness matter most, and most of our constituents are satisfied with that. HSIB will be for the pinnacle of the hardest cases, but most cases should be resolved locally by the GPs or the hospitals.

[Mr Jenkin]

I certainly agree that the vast majority of our constituents who experience the care of hospitals or GP practices are extremely grateful for the quality of care that they receive. However, we cannot underestimate how corrosive the blame culture has been throughout our health system. Crises such as those at Mid Staffordshire and at the Morecambe Bay maternity unit arise from the defensive culture that exists in the NHS. If we are to change that into a much more open and collaborative system of learning from mistakes, we need HSIB to set the tone throughout the entire organisation. It is not just about dealing with a few complaints, but about setting a whole new standard for a whole new profession in the NHS about how complaints and clinical incidents are investigated. I am most grateful to have the opportunity to present this report.

[Justin Madders (Ellesmere Port and Neston) (Lab)]

Labour welcomes this constructive report and thank all of those involved in producing it. It highlights some worrying statistics, including the fact that the most recent NHS staff survey found that 43% of staff thought that their organisations treat staff involved in near misses, errors and incidents fairly. Clearly, from the Chairman’s candid contribution today, there is a long way to go before we eradicate the culture of defensiveness that he has described. To give HSIB the strongest start, it was the clear view of the Committee, HSIB, the Expert Advisory Group, HSIB’s chief investigator and even the Minister himself that legislation is needed, but, as of today, no legislation has been forthcoming. Given that, does the Chair of the Committee agree that it might be better to delay implementation to allow time for legislation?

[Mr Jenkin]

I am most grateful to the hon. Gentleman for his question and for his support. I am also extremely grateful to my Committee for its work on this report.

I hesitate to lose the progress that we have made. We have approved the appointment of the chief investigator of HSIB, who spent 25 years as chief investigator of the Air Accidents Investigation Branch of the Department for Transport. He brings with him that wealth of experience and perspective about how this organisation should work. The answer is, as the hon. Gentleman suggests, for the Government to bring forward the legislation as quickly as possible. I know that efforts are being made in that direction, but perhaps the Minister will have something to tell us.

[The Minister of State, Department of Health (Mr Philip Dunne)]

I wish to add my thanks to my hon. Friend and members of the Committee for their considered report. He has succinctly described to the House what more needs to be done systematically to transform the way in which the NHS learns from errors to improve patient safety. We support the main thrust of the Committee’s recommendations and will offer a detailed response to the report in due course. Like the Committee, we put this matter right at the top of our agenda to change the culture within the NHS, of which he has spoken so eloquently today.

We are committed to making our hospitals and GP surgeries the safest in the world, supported by the NHS as the world’s largest learning organisation. The only way in which we will achieve that is through a learning rather than a blame culture characterised by openness, honesty and candour; listening to patients, families and staff; finding and facing the truth; and learning from errors and failures in care.

As my hon. Friend has indicated, the Government have accepted the recommendation of PACAC’s predecessor Committee to establish an independent healthcare safety investigation service. The Healthcare Safety Investigation Branch will be up and running from April. I join him in welcoming the appointment of Keith Conradi, the former chief inspector of the Air Accidents Investigation Branch, who has a strong track record of delivering high-quality investigations in aviation.

The hon. Gentleman’s Committee has again called for HSIB to be statutorily independent, and we agree that it should be as independent as possible if it is to discharge its functions fully and effectively, and we would not rule out the option of legislation. His Committee has also raised, in this week’s report, various suggestions for HSIB and its potential role in setting standards. We will be responding to that formally in due course.

We are committed to ensuring that the NHS becomes an organisation that learns from its mistakes. In response to the Care Quality Commission’s report, “Learning, Accountability and Candour”, from April this year all NHS trusts will be required to publish how many deaths they could have avoided had care been better, along with the lessons that they have learned.

Before I pose my question, I should like to thank the Committee for its response to the Government’s recent consultation, “Providing a Safe Space in Healthcare Safety Investigations”, and we will be responding to it shortly.

Improvements in safety, incident handling and learning in the NHS will not happen overnight, but does my hon. Friend agree that the shared programme of work demonstrates a commitment, across the care system, to improve the way in which all serious patient safety incidents are viewed and treated, and is that not a crucial foundation for lasting change?

[Mr Jenkin]

I am most grateful to the Minister for his question and for the fact that he has personally appeared at the Dispatch Box today with his opposite number from Her Majesty’s Official Opposition. I know that his presence here underlines the commitment of the Secretary of State to this programme of change.

I very much welcome the shared programme of work to which my hon. Friend refers, but, in taking evidence for this particular report, we found that there was some dislocation between the various bodies involved in it. We conclude that it is only Ministers, and probably only the Secretary of State, who can draw this together to ensure that there is a coherent strategy and a plan, which is what we emphasise in this report.

Finally, my hon. Friend refers to legislation in passing, but I hope that valiant efforts are being made in that regard. Perhaps something can be included in Her Majesty’s Loyal Address later this year. I must point out that it is not just about statutorily underpinning the independence of HSIB, but the safe space to which he refers and on which he thanks the Committee for its contribution. The safe space has to be legislated for. Without legislation, there is no safe space. The AAIB, the Marine Accident Investigation Branch of the Department for Transport and equivalent bodies could not possibly function unless they can provide people with protection, so that those people can come and talk openly and off the record about what has happened. That has transformed the safety culture in other areas, and it is the transformation that we need in the health service. I leave with the Minister the word “legislation” echoing in his ears, and I very much look forward to making further progress with him on these matters.

[Madam Deputy Speaker (Mrs Eleanor Laing)]

The House is grateful to the Chair of the Public Administration and Constitutional Affairs Committee for bringing his report before the House this afternoon and for taking questions.