Health and Social Care (Safety and Quality) Bill

David Nuttall Excerpts

Friday 7th November 2014 Commons Chamber

[Jeremy Lefroy (Stafford) (Con)]

I beg to move, That the Bill be now read a Second time.

This Bill is all about patients—their care and safety. My commitment to that comes directly out of the findings of the Francis report, particularly the second Francis report, following the public inquiry into the instances of dreadful care at the Mid Staffordshire NHS Foundation Trust in my constituency. The work of Cure the NHS, led by Julie Bailey, who challenged that care, and supported by a group of my constituents and those of my hon. Friend the Member for Stone (Sir William Cash), has brought us to today’s Bill.

Sir Robert Francis, in the letter to the Secretary of State for Health presenting his report, wrote:

“In introducing the first report, I said that it should be patients—not numbers—which counted. That remains my view. The demands for financial control, corporate governance, commissioning and regulatory systems are understandable and in many cases necessary. But it is not the system itself which will ensure that the patient is put first day in and day out. Any system should be capable of caring and delivering an acceptable level of care to each patient treated, but this report shows that this cannot be assumed to be happening.”

The Prime Minister, in his reply to the Francis report, said:

“Quality of care means not accepting that bed sores and hospital infections are somehow occupational hazards—that a little bit of these things is somehow okay. It is not okay; they are unacceptable—full stop, end of story. That is what zero harm—the jargon for this—means.”—[Official Report, 6 February 2013; Vol. 558, c. 281.]

The Prime Minister’s words captured the essence of this issue precisely.

Most of the Francis report recommendations have been accepted, and many have already been implemented. In addition, other very important decisions have been taken by my right hon. Friend the Secretary of State for Health, such as the appointment of chief inspectors of hospitals, general practice and social care. Those are already having a profound effect on improving the safety and quality of care that patients receive.

Our NHS, using the best medical science and skills, combined with professionalism and compassion, delivers extraordinary repair treatment and healing to the vast majority of its patients. Yet, it can also forget that and cause completely avoidable harm to sick patients. The Bill intends to reduce, and, I hope, eliminate, its ability to do that. The Bill arises out of a determination to ensure that what happened at Stafford, and indeed elsewhere, should not be repeated. It seeks to ensure that the focus on safety and quality of care we are seeing is not only maintained, but strengthened, and, most importantly, it seeks to ensure that it cannot be reversed. Of course, legislation on its own will not guarantee safe and high-quality care—leadership, culture and resources are all vital elements—but by making it clear in law what is expected of those providing health care, the Bill will go a long way to doing so.

First, the Bill, in clause 1, changes the Secretary of State’s power to a duty, moving from a “may” to a “must”, to ensure that all those providing health and social care make zero avoidable harm their target. Patient safety is therefore put at the top of the list of what must be inspected for. One important way of ensuring that patients receive the safe and high-quality care we would all wish to see is through better integration between services, both health and social care. That is why clauses 2, 3 and 4 seek to give an impetus to integration through the requirement for a single patient identifier and a responsibility to share information. Professional bodies play a vital role in improving safety and quality of care by setting standards.

[Mr David Nuttall (Bury North) (Con)]

My hon. Friend will be aware of small concerns raised by the British Medical Association about some of the detail of his Bill. Is he confident that those will be able to be dealt with in Committee?

[Jeremy Lefroy]

I thank my hon. Friend who has shown a strong, keen and sincere interest in this Bill. Yes, I have just seen the BMA’s submission, and I recognise the concerns that have been raised. Those concerns should be listened to, addressed, and dealt with in detail in Committee. Perhaps what I am coming on to say will address some of them now. We must take extremely seriously the views of the BMA, which represents doctors.

As I was saying, professional bodies play a vital role in improving safety and quality of care by setting standards of practice and ensuring that high standards of conduct are maintained. Clause 5 and the schedule to it ensure that the professional bodies within the medical, nursing and care professions have the same overarching objectives that will benefit patients.

I propose to set out the context of the Bill and then to go into the detail of each of its three parts. In doing so, I will seek to address points that have been raised with me, especially whether we need legislation to achieve the aim of the Bill—patient safety and quality of care.

I am grateful to the team at the Department of Health that has helped in the preparation of the Bill and to the Minister, whose earlier proposals in his ten-minute rule Bill have informed the measures on the integration of services. I also thank the shadow Secretary of State and the Opposition health team for their interest in the Bill, the Chair of the Health Committee and other colleagues who have taken the time to discuss it with me, and to those in the health and social care professions who have contributed their thoughts.

I am also grateful to Ken Lownds whose work on patient safety has been fundamental to my work on this Bill and to my hon. Friend the Member for Stone who first called for a public inquiry and who has supported this work all along. I wish to thank my staff: James Cantrill, Pauline Ingall, Hetty Bailey, Alex Simpson, and Emily Mills, all of whom, but especially James and Pauline, have contributed in many ways. Above all, I wish to thank my wife, Dr Janet Lefroy, who has patiently discussed with me over many years the theory and reality of patient safety and care.

In 1863, in her preface to her notes on hospitals, Florence Nightingale wrote:

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do no harm to the sick.”

That principle, extended to all health and social care services, lies behind the whole Bill, but particularly clause 1, to which I will now turn.

We are in a time where, quite rightly, there is increasing scrutiny of the safety and quality of care in our health and social care services. There are no accurate figures of how many people die avoidably while in the care of health or social care services in England. A recent study estimated that perhaps 12,000 people a year die from avoidable causes in hospitals alone. That is more than four times the annual number of deaths on roads in the UK. This is about not just those who die avoidably, but those who live but whose lives are profoundly affected by the avoidable errors—perhaps they are left with disability or mental scars. It is also about those who care for them who may have caused the avoidable harm and for whom it casts a shadow over their entire life.

In many cases, straightforward patient safety concern, procedures and practice would have protected both the patients and the members of staff from the consequences of avoidable harm. No patient wants to be harmed, and no one in the NHS would willingly harm them. The essence of zero avoidable harm is for the professionals and the organisations for which they work to convey to the patients, “We are health care providers because we want to treat and cure people. This is our contribution to humanity. We owe it to you, the patient, when you submit to our treatment not to harm you by being unprofessional, inattentive or negligent and also to have made all possible preparations in case we make an error so that it will not harm you. We will of course advise you of all risk inherent in what we are going to do for you.” When I speak of zero avoidable harm, that is the culture I mean.

These principles, procedures and practices for zero avoidable harm are in place in many hospitals and other care providers across the country, but they are neither universal nor standard. This is about not bureaucracy, but ensuring that health and social care has the same approach to safety as other activities in which safety is critical, such as air travel or the nuclear industry. Just last weekend, I noticed at one of the manufacturing sites in my constituency, which deals in chemicals, a board prominently displayed that said that the site had gone for more than 1,000 days without an accident. I fully acknowledge that health and social care is highly complex, and becoming increasingly so. But to those who use complexity as an excuse not to draw lessons from other professions that have had to make safety a priority, I would simply say: that is not good enough.

There is much excellent work going on in safety science, systematising and standardising many elements of health care, and indeed social care, to ensure that variability can be eliminated. Safety-critical sectors in the UK and elsewhere have for years been using what are called human factors to enable all staff to perform at their best, not only technically but also in communicating with patients and colleagues. Human factors are the key to building a culture of safety, or an open culture in which staff are able to speak up about safety—a just culture, in which blame is absent but fair accountability is the norm.

I shall now explain the detail of clause 1. At the moment regulated activities, which are defined by clause 8(2) of the Health and Social Care Act 2008 as activity involving, or connected with,

“the provision of health and social care”,

are regulated through regulations that are made under section 20 of that Act. That section provides that the Secretary of State

“may impose in relation to regulated activities any requirements which the Secretary of State thinks fit”.

Such regulations

“may in particular make provision with a view to…securing the health, safety and welfare of persons for whom any such service is provided.”

So the Secretary of State has the power—a “may”—but not the duty—a “must”—to impose regulations regarding the safety of patients. The message that this could send out is that patient safety is not essential. Of course, Secretaries of State, and most recently heads of the Care Quality Commission, have made it clear that patient safety is of vital importance, but that did not apply at Stafford hospital or, indeed, in many other places.

Clause 1 of my Bill amends the 2008 Act by substituting the following for subsection (1) and part of subsection (2) of section 20:

“The Secretary of State must by regulations impose requirements that the Secretary of State considers necessary to secure that services provided in the carrying on of regulated activities cause no avoidable harm to the persons for whom the services are provided.”

So it is now incumbent on the Secretary of State specifically to require that those providing health and social care services cause no avoidable harm. The Care Quality Commission will therefore need to assure itself, when inspecting those providers, that they have the policy systems and procedures in place that tackle avoidable harm.

As the explanatory notes to the Bill state, current Care Quality Commission registration requirements, which the Government are introducing, which will introduce new fundamental standards of care, would not be changed as a result of clause 1, as the new regulations satisfy the new duty. But the clause ensures that those regulations could not be watered down in future to reduce the emphasis on patient safety.

The Bill defines harm as being avoidable,

“unless the person providing the service cannot reasonably avoid it (whether because it is an inherent part or risk of a regulated activity or for another reason).”

It may be argued—this is one of the concerns that have been expressed by the BMA—that it is impossible precisely to define avoidable harm in every instance, and therefore that we should not attempt to do so. However, the very fact that so many cases of avoidable harm, sometimes leading to death or other serious consequences, manifestly do occur is a reason to ensure that it receives the highest possible priority, even if there may be arguments over the definition at the very margins.

Some may understandably raise the concern that the desire to tackle avoidable harm might lead to professionals simply not taking any risks. The Bill covers that by excluding from the definition harm that cannot be reasonably avoided. As in many instances, a test of reasonableness, which is included in the Bill, is a sensible way to address that.

Instances of avoidable harm would include, for instance, operations being performed on the wrong limb; patients being left without adequate hydration or nutrition; patients being left alone in A and E for long periods without any attention; poor records resulting in the wrong drugs being administered; and neglect as a result of wards being staffed below safe levels. In my experience, and I am sure in that of other hon. Members, the vast majority of instances of avoidable harm would come under one of those, or similar, categories.

There would be no questioning whether such instances had arisen because professionals were afraid to take risks; they would come from poor clinical skills, faulty record keeping, inefficient administration or a lack of care and compassion. The fact that the instances of avoidable harm vary so much across the health and social care sectors in itself shows that the problem can be tackled. How many lives would be saved if all providers had the same standards as the best in class? That is why it is so important to address avoidable harm through legislation.

I now turn to clauses 2, 3 and 4. These clauses are about continuity of information, which must be used

“to facilitate the provision to the individual of health services or adult social care in England, and…in the individual’s best interests.”

Again, this is all about the patient. There are two provisions: the first is for use of a consistent identifier for a person by the provider of health or social care; the second is to ensure that relevant information is shared in support of people’s direct care by the introduction of a duty to share information. Both provisions are designed to help with the integration of health and social care, which is greatly needed and which the Government and the Opposition have said is essential for the future.

Before I turn to the details, I should like to quote from a letter sent to me by my constituent, Mrs Janet Powell, who was delighted to hear about the Bill. She describes two recent experiences of the lack of integrated information, explaining:

“After breaking her femur in November 2013, my mother was admitted to the Manor Hospital, Walsall. In February 2014, she was admitted to Stafford Hospital suffering from heart failure. In July 2014, she went to New Cross Hospital, Wolverhampton for her cataract operation. For each of these admissions, she has a different hospital number. We have had to repeat vital information about her medical conditions each time she has been dealt with by different teams.”

Mrs Powell’s mother was fortunate to have relatives who were able to be with her on each occasion and give the vital information about her conditions, but for many people that is not the case, and even if it were, the process would still be inefficient and leave open the possibility that vital information regarding the patient and their care would be omitted.

The requirement for the use of a consistent identifier would make the accessing of accurate and timely information about a patient’s condition much easier, but clause 2 stresses in proposed new section 251A(5)(a) to the Health and Social Care Act 2012 that the requirement to use a consistent identifier would apply only if it was

“likely to facilitate the provision to the individual of health services or adult social care in England, and…in the individual’s best interests.”

As one would expect, the Bill contains provisions for the identifier not to be used in certain circumstances, including when the individual objects or would be likely to object and when the information concerns the provision of services by an anonymous access provider—for instance, sexual health services. The Bill makes it clear that the professional must still comply with the Data Protection Act 1998 and with any common law duty of care or confidence.

The introduction of a duty to share information for an individual’s care and treatment—again, only if in the person’s best interests—is aimed at ensuring that medical records are shared appropriately between the professionals in the NHS and care sectors who are responsible for the care of the patient. That is especially important when patients move between organisations along their care pathway.

The 2013 Caldicott review of information governance, “To Share or not to Share”, found that a culture of anxiety prevents information from being shared between organisations and that the legislative landscape contributed to this, with staff saying that a risk-averse attitude to sharing was a barrier to sharing in caring for people. The review said that the duty to share information in such circumstances can be as important as the duty to protect patient confidentiality. Dame Fiona concluded that health and social care organisations should have the confidence to share information in the best interests of patients within the essential broader framework of protecting personal patient data. Again, the Bill will provide the same important safeguards as those in respect of the consistent identifier.

I do not for one moment pretend that these provisions alone will make fully integrated health and social care a reality, but I believe that they will certainly help to remove some of the obstacles.

The final part of the Bill—clause 5 and schedule 1 —sets out three objectives of regulation: public protection, maintaining public confidence in the professions and upholding standards. Again, the driver for this is the safety and care of patients.

The long title of the Bill states that it would

“make provision about the disposal of cases concerning a person’s fitness to practise a health or social care profession”.

That was indeed my intention. Some of the regulatory bodies have been frustrated by the limitations on their ability to deal with a person’s fitness to practise. However, I have subsequently learned that such was the level of detail required to introduce the provisions that they would have made the legislation too long and complex for a private Member’s Bill. This Bill therefore concentrates on the vital overarching duty to protect the health, safety and well-being of the public.

When the serious failures set out in the second Francis report were debated in the other place, the noble Lord Hill, then Leader of the House, said:

“the regulatory bodies in particular have difficult questions to answer. The Nursing and Midwifery Council and the General Medical Council need to explain why, so far, no one has been struck off. The Secretary of State for Health has today invited them to explain what steps they will take to strengthen their systems of accountability in the light of this report, and we will ask the Law Commission to advise on sweeping away the Nursing and Midwifery Council’s outdated and inflexible decision-making processes.”—[Official Report, House of Lords, 6 February 2013; Vol. 743, c. 320.]

The Law Commission, to which we are greatly indebted, has produced an excellent draft Bill with an accompanying report, “Regulation of Health and Social Care Professionals”, dealing with these matters. It states:

“Given the importance of health and social care professionals regulation, it is a matter of some concern that its UK legal framework is fragmented, inconsistent and poorly understood.”

It describes the piecemeal growth of that regulation since the establishment of the General Medical Council in 1858, which has become a framework that

“is neither systematic nor coherent and contains a wide range of inconsistencies and idiosyncrasies.”

As part of its work, the Law Commission therefore proposed in recommendation 13 that an overarching duty to protect the public should be established in a single statute for all the regulatory bodies. The recommendation states:

“The main objective of each regulator and the Professional Standards Authority should be to protect, promote and maintain the health, safety and well-being of the public. The regulators and the Authority also have the following general objectives: to promote and maintain public confidence in the profession and to promote and maintain proper professional standards and conduct for individual registrants.”

It is that recommendation that will be given effect by clause 5 of my Bill.

It might reasonably be asked why we do not simply wait for the entire Bill, with all the details of changes to regulatory body powers, and introduce the overarching duty then. Let me be clear that I am a very strong advocate of introducing the Law Commission’s entire Bill at the earliest opportunity; indeed, I would urge the next Government to do so. However, I believe—this is supported by regulators who have written to me—that introducing the overarching duty to protect the public, together with maintaining public confidence in the professions and promoting and maintaining proper professional standards and conduct, is a very important matter. It should not be left any longer. The commission’s report explains why:

“fitness to practise panels have, in some cases, adopted an overly restrictive approach to the test of fitness to practise impairment… In particular, the concern is that in cases of clinical misconduct or deficient professional performance they are more likely to look at whether the instances of clinical misconduct or performance are remediable than to fully consider all of the factors, including the public confidence in the profession.”

It concludes:

“If this concern is correct, then we think that the panels in question have misunderstood the correct legal position—namely that regard must be had to all of the factors reflected in the objectives when deciding impairment, irrespective of the particular grounds being considered. Our intention is that the wording of the general objectives in the draft Bill and duties to have regard to them should help to clarify the existing legal position.”

I have enormous respect for the health care professions—in fact, three members of my closest family work in or are training for them. These professions have led the world in many ways. Indeed, hundreds of health care professionals are at this very moment showing their courage and commitment by volunteering to tackle the Ebola epidemic in west Africa. One of the most important things that we as legislators can do is to provide them with the framework they need so that poor practice will not be tolerated and the public will have the highest degree of confidence in them. Clause 5 will help to achieve this.

I said at the beginning that this Bill is all about patients. It will put safety at the heart of health care by making the Secretary of State responsible for bearing down on avoidable harm. It will help the vital integration of health and social care services, thereby improving both quality and safety by introducing a consistent identifier and a duty to share information. It will make it clear that the main objective of each regulator of the health care professions is the promotion, protection and maintenance of the health, safety and well-being of the public.

None of this will absolutely guarantee that the failure of safety and care described in Sir Robert Francis’s first report, and the failure of the NHS and regulators set out in his second, will not happen again. That depends on other things that cannot be legislated for, such as culture and leadership, and those that can, such as the commitment of resources. However, it is my belief and hope that it will make a recurrence much less likely. My constituents in Stafford, and those of my hon. Friends the Member for Stone, for Cannock Chase (Mr Burley) and for South Staffordshire (Gavin Williamson) will then know that all they have gone through over so many years will not have been in vain.

[Mr David Nuttall (Bury North) (Con)]

I congratulate my hon. Friend the Member for Stafford (Jeremy Lefroy) on introducing this Bill. He has set out its content comprehensively, in great detail and with great clarity. I also congratulate him on having the foresight to include as one of the sponsors of the Bill my hon. Friend the Member for Mid Norfolk (George Freeman), who is now of course the Minister speaking for the Government on it. That was a smart move.

Perhaps everyone in this country sometimes takes our national health service for granted as something that is always there. Whatever the political arguments may be about the NHS, we all know that it is part of the bedrock of British society—part and parcel of the fabric of this country. In essence, it boils down to two things. First, there is the scientific element: the technical expertise of the scientists, the doctors, and the people who put the drugs together and study the biology of the human body and the interaction of drugs within it.

There is also the human side—the care side. When someone is ill, they rely on the scientists to come up with a solution, but sometimes there is no solution and the scientists say, “We’re sorry—we can’t help you.” Sadly, even after decades of advances, there are still all too many ailments that afflict the human condition. In those cases, and in those where people, for whatever reason, may be nearing the end of their lives, it comes down to the human touch—the care and the everyday things that are not really related to science at all, just to common humanity. Regrettably, as seen most notably in the constituency of my hon. Friend the Member for Stafford—the reasons have been well explored—sometimes that care is not there. I am not going blame A, B or C for what happened—whatever happened has happened and we are where we are. Terrible things have happened and care has not been up to standard—we all accept that.

What we must now consider is whether it is possible to redesign the regulatory framework in such a way as to try to reduce the risk of what has happened in the past ever happening again. I do not pretend that this Bill will achieve that 100%. My support for it is based not on that premise, but on the premise that, on balance, it will be an improvement.

The Bill’s first proposed provision for a duty—an obligation—to inspect care makes absolute sense. Millions of people outside this Chamber will, frankly, be amazed that that is not already the case. It would be entirely uncontroversial to enshrine in law that requirement of the NHS regulator.

Secondly, the proposal for a common identifier is common sense. When members of my own family have had to go into hospital—this has happened recently and, sadly, it happens on too many occasions—they tell me, time and again, “The only thing that really annoys me is that I constantly have to give information.” Surely a common identifier would save time for our NHS. I am pleased that the professional bodies support the proposal. There are one or two technical and minor concerns, and clause 2 goes a long way to dealing with them. I am sure that any further concerns can be dealt with in Committee.

On balance, this is a sensible Bill, which has been very carefully explained to us this morning. I wish it a speedy passage through this House and the other place.