Patient Safety

Rachael Maskell Excerpts

Wednesday 28th March 2018 Commons Chamber

[Rachael Maskell (York Central) (Lab/Co-op)]

This issue is not just the preserve of doctors; it, of course, cuts across all health professionals. One of the biggest triggers is the pressure that NHS staff are put under, particularly in respect of their not being able to fulfil their duty of care. Does the hon. Lady recognise that when we have a staff crisis it creates the biggest risk to patients?

[Dr Johnson]

I thank the hon. Lady for her intervention, and I agree that this issue of accountability and blame applies equally to all professionals across the health service. Everyone makes mistakes; I was reading online the incident report for the serious investigation done into this young boy’s death and I noticed that, although no doubt all care and attention had been paid to ensuring that personal information was redacted, the child’s initials appeared in at least one place where someone had forgotten to do that. That is a sign that none of us is ever infallible.

Sanctioning doctors for honest mistakes also runs the risk of discouraging people from joining the profession. At a time when the Government are looking to increase the number of people entering medical careers, through the creation of more places at universities and the establishment of new medical schools, the perception that an honest mistake made later in someone’s medical career could end up with their being struck off the register, or even behind bars, risks alienating just the type of young, forward-thinking, ambitious students whom the NHS needs to pursue a career in medicine. It is a testament to the youth of today that medicine still continues to attract the brightest and the best. However, by the same token, these straight-A students have other, more lucrative career paths open to them, and those will become all the more attractive when the risks inherent in a medical career become too high.

This culture of fear not only risks discouraging people from joining the profession, but drives away highly skilled doctors already working in the NHS. As an NHS doctor, one is already expected to work in very challenging conditions, working long hours in an incredibly high-pressure environment. Again, if a perception develops among doctors that they may be treated as a criminal even if when working to the best of their ability, it will quite simply drive doctors away. The world-renowned medical schools we have here in the UK mean that British doctors are in high demand, and they may take their skills to the private sector or further afield to less litigious health services.

The Government recognise these problems and have commissioned an urgent review to look at the threshold for what constitutes gross negligence. This will report by the end of April. I understand that the GMC has also commissioned its own review, although it is not expected to report until the end of the year. Will the Minister tell the House how the Government will act in the meantime to reassure doctors, especially those in high-risk specialties such as paediatrics and obstetrics, that they will not be unduly punished for mistakes?

Overall, it is important that the Government act swiftly on the findings of this report, and consider carefully the impact of the threshold on both the recruitment and retention of medical staff, and safety and improvements to patient care. Doctors want to make people better—it drives all they do. We must stand with them and for them, for all our futures will depend on it.

--- Later in debate ---

[Caroline Dinenage]

The hon. Gentleman is absolutely right. The more we can innovate and put in place the technology that helps to streamline day-to-day processes, the more that will help NHS staff, who do such a marvellous job, to do their job even more effectively and efficiently.

As my hon. Friend the Member for Sleaford and North Hykeham rightly said, to err is human. I am told that every year, 30,000 motorists put diesel fuel into their petrol cars—that is around 15 every hour. Those people are not intentionally destructive or feckless, they are human. Of course, I am not making an analogy with medical mistakes, which can be significantly more damaging and life-changing than the need to get a new engine, but in the same sort of way we need to move away from a blame culture in health—away from investigations that single out one individual rather than seeing their actions in the context of a complex overarching system.

[Rachael Maskell]

Robert Francis’s report included 290 recommendations to address these issues, not the least the duty of candour. However, people are still fearful to report—why is that?

[Caroline Dinenage]

I think it is for a variety of reasons. The hon. Lady is absolutely right to raise that issue; if she bears with me, I shall come to it a little later.

A first step in our new direction, based on an aviation model, is the Healthcare Safety Investigation Branch, which became fully operational in April last year and will independently investigate some of the most serious patient safety incidents every year. It is the first investigatory body of its kind in the world and demonstrates our commitment to learning and innovation. As part of the Government’s drive to make the NHS the safest place in the world to give birth, HSIB will standardise investigations of cases of unexplained severe brain injury, intrapartum stillbirths, early neonatal deaths and maternal deaths in England.

As an MP who represents a constituency in the area served by Southern Health, I am particularly aware that tragedy can spiral when an organisation loses sight of systematic problems in its provision of care. Our Learning from Deaths programme is a direct response to such events. Trusts are now expected to have proper arrangements for learning from the deaths of patients and are subject to new reporting arrangements, including evidence of learning and improvements. I should add that we are one of the first countries in the world to measure deaths in this way. Through Learning from Deaths, NHS England is supporting improved engagement across the NHS with bereaved families and carers.

As my hon. Friend the Member for Sleaford and North Hykeham rightly says, healthcare professionals need to feel safe to speak out about problems in the workplace. To support that, we have introduced an independent national officer for whistleblowing, and new regulations to prevent discrimination against whistleblowers who move jobs. Recent commentary in the media and among professionals has highlighted a possible brake on openness and transparency arising from high profile convictions of healthcare professionals for gross negligence manslaughter, which is exactly the same example as the one that she cited. That is why the Secretary of State for Health and Social Care announced in February that he was asking Professor Sir Norman Williams, former President of the Royal College of Surgeons, to conduct a rapid review into the application of gross negligence manslaughter in healthcare.

Absorbing the review’s recommendations into our healthcare system will be crucial to ensure that our healthcare professionals feel valued and secure, and that includes the GMC. The deadline for submitting evidence is April, and I encourage patients, families and professionals to contribute.

It is essential that infants have the best possible start in life, and the safety of mothers and their babies is a fundamental starting point for safer care. In November 2017, the Secretary of State announced his intention to bring forward the ambition to halve the rate of maternal deaths, neonatal deaths, birth-related brain injuries and stillbirths by 2025—a full five years ahead of our previous target. Pre-term birth is a major health inequality with mothers, and the Secretary of State has set an ambitious target to reduce the national rate of pre-term births from 8% to 6%.

Continuity of care is a key factor in a healthy pregnancy. Evidence shows that women who continue to receive care from the same midwives are 19% less likely to miscarry, and 16% less likely to lose their baby. That is why, yesterday, the Secretary of State announced important steps towards ensuring that the majority of women receive care from the same small team of midwives throughout their pregnancy, labour and birth by 2021. That announcement includes 650 new training places for midwives in 2019, which represents a 25% increase in the number of midwives in the UK.

We can never be complacent. Zero harm might sound impossible to achieve, but it should always be our aim. By learning lessons when things go wrong, listening to patients and their families, and working across the whole system to create a genuine culture of improvement, this Government are making a significant and lasting contribution to patient safety.

Question put and agreed to.