Health and Social Care

Jeremy Hunt Excerpts

Thursday 16th January 2020 Commons Chamber

[Jeremy Hunt (South West Surrey) (Con)]

Let me start by saying that it is wonderful to see you in the Chair, Mr Deputy Speaker, and that your presence there is a signal to every new Member that it is possible to undergo the ups and downs of politics and come through on the other side.

I thank the Health Secretary for his personal commitment to patient safety in including the Health Service Safety Investigations Bill in the Queen’s Speech, and I thank the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Mid Bedfordshire (Ms Dorries), for her personal commitment in ensuring that it featured in both last year’s Queen’s Speech and the current one, despite many competing pressures. It is about patient safety that I wish to talk in my brief six minutes. When I became Health Secretary in 2012, I had not heard the phrase.

The first crisis with which I had to deal was the one at Mid Staffs. I remember the then chief executive of the NHS, Sir David Nicholson, taking me aside and saying, “You just need to understand, Jeremy, that in healthcare we harm 10% of patients. That is what happens all over the world.” I then asked the awkward question about how many people actually died because of mistakes in healthcare.

It is important to point out that this is not about the NHS; it is about how healthcare is practised everywhere. However, being the good old NHS, we have carried out endless academic studies on this. The Hogan and Black analysis shows that, at that time, 4% of hospital deaths had had a 50% or more chance of being preventable. If we do the maths, that works out at about 150 preventable deaths every single week—the equivalent of an aircraft falling out of the sky every single week.

Then I met a group of people who persuaded me that this issue should be my main focus as Health Secretary. I met Scott and Sue Morrish, a young couple from Devon who lost their son Sam to sepsis when he was three because it was not picked up early enough; James Titcombe, who lost his son Joshua at Morecambe Bay when he was nine days old; Deb Hazeldine, who lost her mother in a horrible death at Mid Staffs; Martin Bromiley, who lost his wife Elaine because of a surgery error at a hospital in Milton Keynes; and Melissa Mead, who lost her son William when he was just 12 months old—in December 2014, when I was Health Secretary—again because sepsis was not picked up.

Those people all did something that most of us would never do. Most of us, when we have a tragedy in our lives, want to close the chapter and move on, but they chose to relive their tragedy every single day because they wanted to tell their story and make the NHS change so that other families did not go through what they had been through. They paid a terrible price for doing that. James Titcombe had to write more than 400 emails over several years before we were prepared to admit why Joshua died. Martin Bromiley sacrifices 40% of his salary as an airline pilot so that he can go round the NHS talking in hospitals free of charge about what happened to Elaine. Melissa Mead carries William’s teddy everywhere. She goes into TV studios to try to alert people to the dangers of sepsis, and she brought it to her first meeting with me. Inside that teddy were William’s ashes. That is a meeting I will never forget as a Minister.

We must not let this blind us to the fact that the vast majority of NHS care is absolutely brilliant. I have three beautiful healthy children, thanks to the NHS. About a year before I was Health Secretary, I was in the Cabinet and I had a basal cell carcinoma removed from my head. A local anaesthetic was administered, and the surgeon had his scalpel out. The head nurse looked at me and said, “By the way, Mr Hunt, what is it you do for a living?” This was a time of austerity and cuts, and I froze before giving the answer to that question. But thanks to substantial additional funding by the last Labour Government and by this Government, the NHS has improved dramatically, and we now have record survival rates for every major disease category.

[Yasmin Qureshi (Bolton South East) (Lab)]

I thank the right hon. Gentleman for giving way. Three years ago my mother died of sepsis, and sepsis is still a big problem that needs to be addressed in hospitals.

[Jeremy Hunt]

I thank the hon. Lady for raising that. We have made huge progress in sepsis care, and the vast majority of people who go to A&E now are checked for sepsis, but mistakes still happen, and I am sure that it affected her as it affected the families of the people I have talked about.

We must not be complacent about the things that go wrong. In the NHS, we talk about “never events”—the things that should never happen. Even now, after all the progress on patient safety, we operate on the wrong part of someone’s body four times a day. It is called wrong site surgery. When I was Health Secretary, we amputated someone’s wrong toe, and a lady had her ovary removed instead of her appendix.

[Dr Whitford]

I know that the right hon. Gentleman visited the Scottish patient safety programme to see in action the WHO checklist, which is designed precisely to prevent such events, so can he explain why the checklist was never introduced during his time as Secretary of State?

[Jeremy Hunt]

Actually, we do have WHO checklists throughout the NHS in England—I think they were introduced under Lord Darzi in the last Labour Government—but the truth is that even with those checklists, which are an important innovation, mistakes are still made because sometimes people read through lists and automatically give the answer they think people want to hear. This is why we have to be continually vigilant.

What is the solution? It is to ask ourselves honestly, when a mistake happens and when there is a tragedy, whether we really learn from that mistake or whether we brush it under the carpet. To understand how difficult an issue that is, we have to put ourselves in the shoes of the doctor or nurse when something terrible happens, such as a baby dying. It is incredibly traumatic for them, just as it is for the family. They want to do nothing more than to be completely open and transparent about what happened and to learn the lessons, but we make that practically impossible. People are terrified about being struck off by the Nursing and Midwifery Council or the General Medical Council. They are worried about the Care Quality Commission and about their professional reputation. They are worried about being fired. In order for a family whose child is disabled at birth to get compensation, they have to prove that the doctor was negligent, but any doctor is going to fight that.

The truth is that many of the mistakes that are made are not negligence, but we make it so difficult to be open about the ordinary human errors that any of us make in all our jobs. As we are not doctors and nurses, people do not generally die when we make mistakes. That shows the courage of entering that profession, and if we make it difficult for people to be open, we will not learn from those mistakes. That is why we need to change from a blame culture to a learning culture. That is also why, as we reflect on the devastating news that the Under-Secretary of State for Health and Social Care, my hon. Friend the Member for Mid Bedfordshire (Ms Dorries), gave the House last night that the Shrewsbury and Telford Hospital NHS Trust is now examining 900 cases dating back 40 years, we realise that the journey that the NHS has started on patient safety must continue. We should take pride in the fact that we are the only healthcare system in the world that is talking about this issue as much as we are, and if we get this right, we can be a beacon for safe healthcare across the world and really turn the NHS into the safest and highest-quality healthcare system anywhere.