Candour in Health Care

Debate between John Pugh and Anne Milton

Wednesday 1st December 2010 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to serve under your chairmanship for the first time Mr Gray congratulate my hon. Friend the Member for Poole (Mr Syms) on securing this debate. As Chairman of the Regulatory Reform Committee, he is no doubt acutely aware of some of the issues that exist around regulation, not least those that exist around the duty of candour. His humility and recognition of the impossible task that we face here today—to truly reflect the pain and suffering of those who have suffered as a result of medical harm—does him considerable credit.

We take candour and openness in the NHS extremely seriously. Everybody does, because it is a vital issue. As anyone who has ever been treated knows, a health care system is not just about how quickly someone is seen or how quickly their stitches come out; it is also about trust. Trust is fundamental—between patients, the patient’s family and health care professionals—and we must do everything we can to ensure that that trust is upheld.

As my hon. Friend may be aware, one of the early references to a statutory “duty of candour” was included in “Making Amends”, a 2003 report, which I know hon. Members have referred to. It was a consultation paper from the then chief medical officer, Liam Donaldson, and it set out proposals for reforming the approach to clinical negligence in the NHS, suggesting

“a duty of candour requiring clinicians and health service managers to inform patients about actions which have resulted in harm”.

The paper also proposed to foster an environment of openness and honesty among all NHS staff; it encouraged “integrity”, which is a word that we perhaps do not use often enough, and it proposed exempting those who report adverse events or medical errors from disciplinary action, unless there are serious extenuating circumstances. It is a key belief of the coalition, and I would hope all Members of the House, that the focus should be on the performance of the organisation rather than on penalising individuals who bring matters of concern out into the open. The hon. Member for Southport (Dr Pugh) has already mentioned whistleblowing. I think that the point is that this debate is not necessarily about the protection of whistleblowers or a right to whistleblow; it is perhaps about a duty to whistleblow.

It is important to note the good work that is currently being done to promote candour. The previous Government should be congratulated for providing staff with advice and support to help them to communicate with patients, their families and carers following harmful incidents. The Health Act 2009 requires all NHS organisations to be aware of the NHS constitution, which places a duty on NHS staff to acknowledge mistakes, apologise for them, explain what happened and put things right. The professional codes of practice for doctors and nurses contain a similar duty.

As somebody who trained as a nurse and worked in the NHS for 25 years, I think that professional codes of practice and professional standards are not talked about often enough. We look for someone to blame: we look for the organisation to blame; we look for the board to blame, and we look for the chief executive to blame. What we do not talk about is individual professional standards and I feel particularly strongly that we need to do everything that we can to raise those standards right up.

The National Patient Safety Agency has been running its own campaign to promote candour in the NHS, as the hon. Member for Leicester West (Liz Kendall) said. That campaign, entitled “Being Open”, is a long-term process rather than a short-term push. It encourages the provision of verbal and written apologies to patients, their families and carers; it promotes continual communication with those involved in incidents, and it requires thorough record-keeping of all “Being Open” discussions and documents.

However, we all know that still more needs to be done, as hon. Members have said and as I know myself from my own constituency casework; I have a number of people who have continually fought to try to get the truth about what happened to their relatives. The recent White Paper, “Liberating the NHS”, states that

“we will require hospitals to be open about mistakes, and always tell patients if something has gone wrong”.

It is quite simple: we expect the NHS to admit to errors; apologise to those affected, and ensure that lessons are learned to prevent errors from being repeated.

In one year, the NPSA receives notification of more than one million incidents. Most of those incidents result in no harm and we welcome the high level of reporting. However, the incidents that result in harm obviously cause distress and anguish for the patients and families involved. In those cases, it is even more important that the lessons are learned and that organisations are open with those who have been affected.

[Dr Pugh]

I want to ask about the future of the NPSA. If it is going to be brought within the national commissioning body, will a Chinese wall be established between the NPSA and the other operations of that body? It crosses my mind that risks can allegedly be increased or decreased by commissioning decisions themselves.

Under those circumstances, the NPSA has got to be free to impute itself, as it were, if the national commissioning body is going to be part and parcel of the same organisation. So, can the Minister assure me that there will be no conflict of interest when the NPSA is placed within the national commissioning body, which may itself—through its commissioning procedures—be one of the risk factors?

[Anne Milton]

The hon. Gentleman is absolutely right. That is terribly important. It is not only important to have Chinese walls and be seen to be separate; it is important to be separate. I will come to that point in detail in a minute.

Measuring openness is not as straightforward as measuring reporting. We welcome high levels of reporting, as they are an indicator of an open and supportive culture of patient safety, but there are still reasons why people within the NHS and organisations shy away from openness. Without a doubt, professionals who strive for excellence are reluctant to admit errors. The higher up the tree one is, the harder it is to say, “I’ve made a mistake.” All of us face that issue in our professional lives.

People may have unfounded concerns about possible admissions of liability, even though apologising when something has gone wrong is not in any way an admission of liability. The fine line between the two sometimes prevents people from saying what relatives want to hear: “I am so sorry this happened.” That is not necessarily saying, “I have made a mistake.” It is such a shame when professionals resort to a defensive stance, often encouraged by myths about where liability lies. Also, at times, they may fear reprisal, blame and even bullying.

We are considering options for introducing a requirement for openness and will make a decision in due course. The hon. Member for Southport felt that we were hesitating, and was concerned about possible evidence of Sir Humphreys in the Department. We are considering, not hesitating. It is important to get it right. Members have discussed the three options, but I will run through them quickly and mention a few relevant issues.

The first option is using what is in the existing Care Quality Commission registration requirement regulations. It is already mandatory for NHS trusts to report all serious patient safety incidents. We could also require organisations to demonstrate that they have met the openness requirement, which would not require new legislation. It makes sense to use existing means to detect and investigate trusts that are not as open as they should be. The counterargument is that that approach is not specific enough, and that the wording of the guidance would need to be made more explicit. We have seen many cases in which guidance has failed.

The second option involves introducing a new legal, statutory duty of openness explicit within the CQC regulations. That would send a clear signal about the importance of openness and provide patients and campaigners with a single clear duty that they could use to demand full disclosure. However, the Government want to create new legislation only when absolutely necessary, although when necessary, it should be done. We would need to ensure that any new legislation or new approach was not counter-productive. We want to make it easier for staff to come forward; we do not want new legislation to have unintended consequences.

The third option involves incorporating an openness requirement into the new NHS contractual, performance and commissioning processes, to which the hon. Members for Leicester West and for Southport referred. It certainly appears possible to pursue openness through the new commissioning arrangements. For instance, it could be written into standard NHS commissioning board requirements that providers commit to being open. The hon. Member for Leicester West asked whether the NHS commissioning board would have time to take a role on patient safety. In many ways, safety underpins all commissioning decisions. Any decision on any service commissioned should have safety wrapped around it. That is fundamental.

As with any complex matter, each of the options has its pros and cons. It is imperative that a decision on the issue is not rushed. I reassure the hon. Lady that campaigners and organisations have good access to officials within the Department, and I am sure that all their views will have been taken into account when a decision is made, because we are aware of the importance of getting it right. It is terrible to think that the first duty of the NHS is to do no harm. Safety wraps around everything that we do.

The hon. Lady also mentioned the decision to abolish strategic health authorities. I understand that SHAs are the performance managers of trusts, yet that did not help in Staffordshire. In many ways, bringing commissioning decisions closer to the patient within general practice will mean that decisions about care and its consequences rest where they should.

Contaminated Blood and Blood Products

Debate between John Pugh and Anne Milton

Thursday 14th October 2010 Commons Chamber

[Anne Milton]

The hon. Lady makes an important point that has crossed my mind already. I shall talk to colleagues and officials in the DWP to make sure that that issue is addressed.

It is important to put on record some relevant events. In the early 1960s, the life expectancy of someone with haemophilia was less than 40 years. In the early 1970s, the development of a revolutionary new treatment—clotting factor concentrates produced from large pools of human plasma—led to what was then considered an exciting new era of treatment. It offered the potential to extend significantly the length and quality of the lives of patients with haemophilia. The risk of viral transmission through blood and blood products was recognised at that time, particularly the risk of post-transfusion hepatitis. Generally though, the consensus within the scientific community was that the risk of using multiple donors was low and worth taking. Significantly, at that time, the Haemophilia Society said, in a bulletin published in September 1983, that

“the advantages of treatment far outweigh any possible risk”.

Sadly, we know how wrong that was. Tragically, the society was wrong and a devastating blow was dealt. The initial hope was ultimately replaced by the dreadful realisation that, although lives were extended, almost 5,000 patients with haemophilia in the UK and thousands more throughout the world had been infected with hepatitis C, HIV or indeed both.

Many of those people have since lost their lives to those conditions, and more continue to do so by the week, and we should pay tribute to the many campaigners who have died. I fully understand the sense of grievance and anger that people feel. I am not in that position, and it is impossible to know fully what it feels like, but I do understand some of it. I also know that for some time, whatever the Government do, sadly it will be far too little, far too late.

At the time, however, no other treatment was available. The UK blood supply and the only alternative, a product called cryoprecipitate, were both contaminated. The only real treatment, therefore, was no treatment at all, and that was the case not only in the UK, but in countries throughout the world. At the time, France, Germany, Japan and the United States all took a similar view, which was widely held by the scientific community throughout the world.

When those treatments were first introduced, we had a very different view also of the risks from hepatitis C. It was not until the mid-1980s that scientific and medical literature began to reflect increasing concern about the seriousness of disease associated with hepatitis C, and I, as somebody who was working as a nurse at the time, remember it well.

[Dr Pugh]

The Minister will be aware that in the Government’s response to the Archer report, certain documents are described as “misplaced”—they no longer exist or can be found. Do they have any bearing whatever on the analysis, and if they were discovered would they correct it in any way?

[Anne Milton]

I thank my hon. Friend for his question. We are talking about a long time ago; that is the trouble. I know that campaigners have been concerned about cover-ups, and that not all the documents have been released. I assure him that officials have told me that all documents have been released, but somewhere in the back of a cupboard, somebody at some point might discover more. It is a mistake to think that there is any conspiracy, however. I do believe, in all honesty, that previous Governments and the current Government have done, and continue to do, all that they can to ensure that all information is in the public domain.

As the consensus on the virus developed and technological advances occurred, the Government and the NHS moved quite quickly to address the risks. Heat treatment was introduced in 1985, and that effectively killed the hepatitis and HIV viruses. Validated tests for screening blood donations were also introduced. Since then, Governments have introduced a number of important safeguards to protect the blood supply, not least, as we heard today, from newer risks such as new variant CJD. We carefully assess, and shall continue to assess, all new evidence as it comes to light, and we now have EU directives that set standards of quality and safety.

I fully understand again the financial difficulties that many of those affected by contaminated blood products face. I have met some of them, and they have told me in some detail of their extraordinary experiences of living with the aftermath of infection. Not only were many of them infected, but they went on to infect their partners. They are, understandably, very concerned about their own and their family’s financial security, and they look to the Government to provide a degree of certainty in the years ahead.

Going—what may feel like—cap in hand to the state is demeaning, I know, but it is worth laying out the financial settlements that are currently available. Those infected with HIV receive a flat-rate payment of £12,800 per year, and they may also be eligible for additional discretionary payments. In the year ending April 2010, the average total payment to an individual infected with HIV was £17,400, although of course some received less and some received more. Those infected with hepatitis C are eligible to receive an initial one-off lump sum payment of £20,000 when they develop chronic infection. Despite contracting the virus, some people will make a full recovery, but many do not and go on to develop serious liver disease. For that group, there is a second one-off payment of £25,000. All those payments are tax-free and not used when calculating an individual’s eligibility for state benefits. Therefore, if they were unable to work for health reasons they would receive those benefits, but I take the point made by the hon. Member for Kingston upon Hull North (Diana R. Johnson).

The independent public inquiry on NHS-supplied contaminated blood and blood products, chaired by Lord Archer of Sandwell, investigated the circumstances surrounding the supply of blood products. It made several recommendations, the majority of which are in place in one way or another. However, a small number of recommendations have not been implemented. These primarily relate to aspects of the ex gratia payments, free prescriptions in England, and access to insurance.

I have instigated a review of those recommendations to see what more can be done. I know that hon. Members would love me to finish that review before Christmas. I will do what I can in the time available; I know that time is of the essence. The review will be conducted by Department of Health officials, but with the support of relevant clinical experts and external groups. The terms of reference should be in the Library. At this stage, let me put on record that I will place in the Library how the costs of implementing the Irish scheme in the UK were arrived at. I know that that has caused some concern, but I will come back to it, because time is very short.

I do not have time to go into detail on what happened in Ireland, but it is important to place on the record that in an article in The Irish Times—I will ensure that this is also in the Library—Brian Cowen, then Minister for Health and Children in the Republic of Ireland, and currently Taoiseach, confirmed that the Irish Government knew in 1995 that the Blood Transfusion Service Board had been negligent and had attempted to conceal that fact.

Child and Adolescent Mental Health Services

Debate between John Pugh and Anne Milton

Wednesday 7th July 2010 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

I congratulate the hon. Member for Stalybridge and Hyde (Jonathan Reynolds) on securing both this debate and his seat. The subject is of huge importance to him, and he brought with him his invaluable personal experience, as indeed did the hon. Member for Manchester, Withington (Mr Leech) and my hon. Friend the Member for South Swindon (Mr Buckland). Those personal experiences are crucial to the debate, as are the contributions from those who are experienced in the provision of services. This debate is vital, and I will ensure that all the representations that have been made today are fed back into the policy process. Time is short, but I will just say to the hon. Member for Worsley and Eccles South (Barbara Keeley), who speaks for the Opposition, that some of us were fortunate enough to have listened to and participated in debates on the Autism Act 2009, promoted by my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan), as it made its passage through the previous Parliament. At the time, there was an increasing dislike of and disillusionment with politicians, so I mention that measure because it showed this place in its very best light. It was about cross-party working and building a consensus. It was a genuine attempt by Members from all parts of the House to work together to improve the lives of others—in this instance it was the lives of those with autism. I pay tribute to Angela Browning, the former Member for Tiverton and Honiton, who was sometimes a lone voice calling for services for people with autism. She, too, brought her own personal experiences to the debate thereby helping to raise us to the next level.

I echo the comments made by the Minister of State, Department of Health, my hon. Friend the. Member for Sutton and Cheam (Mr Burstow), at the recent National Autistic Society reception. He said that the standards of care highlighted by the society in its “You Need to Know” report are unacceptable. He was grateful to the society—as indeed we all are—for its tireless campaigning, and was struck by the particular contribution of the young campaigners group. I am sure that he would pay tribute to them were he able to be here today.

The coalition’s programme for government makes it clear that we are committed to supporting the most vulnerable and to tackling health inequalities. There is strong consensus on what needs to be done to improve the emotional well-being and mental health of children and young people. More work is needed on prevention, early diagnosis and early intervention. Those are the key things that are needed by people with autism and mental health problems. We need better integrated working and more evidence-based approaches. The work force must be developed, and, crucially, we must do more to tackle stigma for people not only with autism but with mental ill health.

The National Advisory Council for Children’s Mental Health and Emotional Wellbeing report earlier this year reinforced the scale of that challenge. It called for action to strengthen leadership, build a confident and skilled work force, improve commissioning and ensure real participation by children and young people in service development. For me, commissioning is a vital part of that. It has never been done that well, but there is a general acceptance of the fact that if we improve commissioning, the services will then follow. As has been mentioned during this debate, there are examples of best practice, which we need to be able to transport to other areas. We need to consider all those issues to get the services that we want.

The Government have also promised to deliver measures in “Fulfilling and rewarding lives: the strategy for adults with autism in England”. There are many areas in which improvement in adult autism services will yield benefits for children’s services, such as developing local autism teams, improving access to diagnosis, better planning and better commissioning of services. As several hon. Members have said, raising awareness of the issue and improving skills in the work force should go much wider than just those working in the autism field, and should include teachers and sports clubs and all those who are involved with young people.

Our focus must be on improving the quality of services that we provide to all children. We must ensure that no one suffers the indignities and difficulties that are sadly all too common. I am referring to the frightened young person who is restrained by police because crisis services were not available; the child who feels isolated and frustrated, only to find that health care staff are not trained to help or able to understand them; the parents who desperately want to see an improvement but feel let down by services that do not treat their children as people with individual needs; and parents who are desperate, isolated and at the end of their tether. That is why it is so important to improve the standard of care across the board.

We must plan and build on the work that has been done on integrating services so that local partnerships can work together to deliver what we want. It will require incredible commitment from local NHS providers to engage with the work force to resolve difficult issues such as training and service design. Improving the reach and quality of child and adolescent mental health care means looking carefully at the different services that make up the whole picture. I am referring to universal services that play a pivotal role in promotion for all children and young people; targeted services that provide early interventions for vulnerable children and young people; and specialist services, which the hon. Member for Stalybridge and Hyde mentioned, for young people with complex, severe or persistent needs.

[Dr Pugh]

rose—

[Anne Milton]

I am sorry, there is no time. I already have far too many questions to answer. If hon. Members feel that their questions have not be answered or addressed, I urge them to write to me and I will make sure that we respond.

Oral Answers to Questions

Debate between John Pugh and Anne Milton

Tuesday 29th June 2010 Commons Chamber

[Dr John Pugh (Southport) (LD)]

T10. I have here a letter from my local PCT indicating that the clinical review of the safety of a proposed children’s walk-in centre in Southport is to be conducted by Dr Sheila Shribman and the Minister’s Department. Will the Minister arrange to meet me and relevant officials to ensure that the Department is properly aware of the background to this vital access issue and that we have a clinical network suitable for patients, as well as for practitioners?

[Anne Milton]

I thank the hon. Gentleman for that question, of which he gave our office prior warning. It is important that decisions made locally focus on outcomes for people, that they are about choice, that they have support from local clinicians and commissioners, and that they are based on sound clinical evidence. I would be happy to meet him to discuss this further.