Candour in Health Care

Debate between Robert Syms and Liz Kendall

Wednesday 1st December 2010 Westminster Hall

[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Gray. Every 36 hours, NHS services are used by some 1 million people, the vast majority of whom receive safe and effective care. None the less, as in every other health care system in the world, not all care in the NHS is as safe as it could be, and too many patients are harmed by it, sometimes seriously and even fatally.

Modern health services are delivered in a highly complex, often pressurised, environment, and involve the care of many vulnerable and seriously ill patients. More than any other environment in which risks occur, health care is reliant on people taking difficult decisions that rely on judgments that are not always straightforward or clear cut. In such circumstances, things can and do go wrong. Sometimes, as I know from my own experience, the consequences can be very serious for the patient, their family and their carers.

Patients and their families have a right to know if something has gone wrong, to get an explanation of what has happened and to receive an apology and, if appropriate, compensation. As hon. Members have mentioned, it is also vital that professionals and NHS organisations learn lessons from mistakes to improve care for patients and, wherever possible, to save taxpayers’ money by reducing the cost to the NHS from clinical negligence claims.

During the past decade, important progress has been made on improving patient safety in the NHS. Last year, the Health Committee’s report on patient safety acknowledged that the previous Government became one of the first in the world to make it a priority to address patient safety across the whole health care system. A unified system for reporting incidents and learning from them was introduced, and it was centred on the national reporting and learning system and the National Patient Safety Agency. The creation of this system was, in a large part, down to the pioneering work of Sir Liam Donaldson, and I should like to pay tribute to him for his work on this vital issue.

Since the establishment of the data reporting system, the number of reported incidents has increased significantly, which is a good thing. At the last count, more than 3 million incidents had been reported, ranging from very minor incidents to the more serious ones. The NPSA has worked hard to improve patient safety, both nationally and within individual NHS trusts. I personally experienced such work when I was director of the Ambulance Service Network at the NHS Confederation. We set up a programme of work, with patient safety leads in ambulance service trusts, front-line paramedics, PCT commissioners of ambulance services and the NPSA to identify the particular areas of care where mistakes were being made—it is often in the handover period—and to share best practice to prevent such mistakes.

I question some of the comments that have been made this morning about managers wanting to cover up problems. In my experience, both managers and professionals have difficulties in blowing the whistle on their colleagues. I just want to put it on the record that the ones that I have worked with have wanted to be open and to learn the lessons.

My experience has shown me that the NHS needs to do more to improve patient safety. As identified by the Health Committee’s report and Ara Darzi’s next stage review, there is still huge under-reporting across the system, because, as hon. Members have said, there is too often a “blame culture” in the NHS.

I agree with the hon. Member for Carshalton and Wallington (Tom Brake) that this is not just an issue about hospitals. Primary care, which accounts for 95% of patient contacts with the NHS, accounts for only 0.25% of reported incidents. Although substantial progress has been made, patient safety is still not always a top priority for NHS boards. Most importantly, patients still too often feel that the NHS is not genuinely open and honest with them when a mistake is made.

In 2005, the National Audit Office’s 2005 report, “A safer place for patients” found that only 25% of NHS trusts routinely inform patients when an incident has taken place, and an astonishing 6% admit to never informing patients. Like other hon. Members, I have seen such practice in my own constituency. Patients feel that mistakes are not promptly or openly admitted to and they have to battle the system to—in the words of the hon. Member for Poole (Mr Syms)—“get at the truth”, which, so often, is the start of the healing process.

Last week, I went to a meeting at the University Hospitals Leicester NHS Trust with two of my constituents, Mr and Mrs Harkisan-Hall, who lost their son in the hospital’s neo-natal unit. It was only at the coroner’s inquiry that they found out that the two qualified nurses on the unit were both on a break at the same time, leaving a nursery nurse in charge of very vulnerable children. They felt that they had to battle to get that information, and they still have not seen the full reports of what the staff said. Like them, I believe that that is unacceptable.

[Mr Syms]

The hon. Lady makes a good point. One point that I meant to make was that if people do not hear what has happened, coroners can find it difficult to determine how someone has died. If people are not honest about what has happened to a particular individual, coroners do not have the full information.

[Liz Kendall]

In this particular case, interviews were conducted with the two qualified nurses. The trust did not read both transcripts together and did not see that both nurses were on a break at the same time. People are astonished that such simple things happen, and it is vital that we learn from this process.

Before I go on to talk about the duty of candour, I want to discuss two concerns about the Government’s policy in relation to patient safety. It is important that hon. Members do not look just at the duty of candour in isolation from what is going on in the rest of the NHS, including on patient safety. My first concern is the Department of Health’s decision to abolish the National Patient Safety Agency and to move responsibility for this issue to the new national NHS Commissioning Board. There are real concerns about whether the board will have the necessary skills, experience and time to focus on such a vital issue when it will also be responsible for setting NHS outcomes, assessing whether GP consortiums are delivering on those outcomes, commissioning a whole range of specialist services and managing contracts for all primary medical services. That is a huge agenda for any board, even without adding responsibility for patient safety.

Will the Minister tell us what resources and how many staff from the NPSA will be transferred to the NHS Commissioning Board? Which NPSA activities will the board take on? For example, will NPSA continue to publish patient safety alerts and bulletins and other guidance to identify key problems and help spread best practice? Will it also run workshops with leads for patient safety in individual providers, such as those I was involved with in the Ambulance Service Network? Will the national Patient Safety First Campaign, which was launched last year, and the annual patient safety week, which was held early this month, have the staff and resources to continue?

My second concern relates to the Government’s reorganisation of the NHS and fact that the service needs to make efficiency savings worth some £20 billion over the next three years, as the NHS chief executive said. The first report on adverse incidents in the NHS was drawn up by Sir Liam Donaldson in 2000. Its key recommendation was that the NHS must be open and honest and learn from its experiences. To do that, the NHS must become, as the report’s title suggests, “An organisation with a memory”. But the Government plan to abolish many of the very organisations that have worked hard to build this memory and understanding of how to improve patient safety.

If the NHS has to make efficiency savings worth some £20 billion, there will inevitably be job losses and posts frozen, some of which could include those staff who have worked hard to learn lessons from the mistakes that have been made in the NHS. How will the Minister ensure that the NHS retains its “memory” on patient safety when PCTs and strategic health authorities are being abolished, new GP consortiums are being established, community services are being transferred to different providers and staff posts are being frozen and reduced? In particular, what steps has she taken to ensure that managers and front-line staff who have knowledge and expertise in patient safety are retained in the NHS at a time when the Government want to cut management costs by 45% and make efficiency savings of £20 billion?

Finally, I want to talk about the duty of candour. As hon. Members have said, the introduction of a statutory duty of candour was first recommended by Sir Liam Donaldson in his 2003 report, “Making Amends”. I agree with hon. Members that there is a strong case to look again at this issue, as a Health Committee report recommended in 2009.

I think that it was the hon. Member for Carshalton and Wallington who said that too often the debate is split between those who want a statutory duty of candour and those who think the NHS should instead focus on creating a culture of candour. Of course, changing the practice of individual staff and organisations does not require legislation, but I think that we can see from existing laws, such as those that helped to reduce drink-driving, those that introduced the smoking ban and others, that legislation often plays a vital role in changing culture and behaviour.

Some professional bodies are concerned that a duty of candour would make it less likely that incidents would be reported. I am not convinced that that would be the case, particularly if the duty is combined with an

“exemption from disciplinary action for those reporting adverse events or medical errors—except where there is a criminal offence or where it would not be safe for the professional to continue to treat patients”.

That was the recommendation of Sir Liam Donaldson back in 2003.

Others question whether a statutory duty could be imposed when it might be difficult to specify or enforce sanctions. That concern has not prevented other parts of the world from introducing legal duties, including some US states, Sweden, France and Denmark. It is also worth noting that the Equality Act 2010, which was introduced by the last Government, imposes a number of legal duties on public bodies to consider the impact of their policies and decisions on different groups, without specifying what the sanctions will be if those duties are not complied with.

The final argument against a statutory duty of candour is that patients might end up trusting professionals less, because they have to report a mistake rather than because they want to. I think that the far greater risk for doctor-patient trust is the perception, and too often the reality, that professionals do not tell patients when things go wrong. I know that if a mistake was made in my own care, or in the care of one of my family or friends, I would want to know—and indeed I believe that I have the right to know.

To conclude, I think that the NHS has made important progress on improving patient safety and it has started to try to change its culture, to become more open and honest. However, the evidence shows and hon. Members have clearly demonstrated in this debate that the NHS is still not as open as it should be, not only with its own staff, but—crucially—with patients. The abolition of the NPSA, the huge reorganisation that the NHS is about to undergo and the future cuts in numbers of staff actually make a stronger case for having a duty of candour in place.

The White Paper, “Liberating the NHS”, says that the Government will

“require hospitals to be open about mistakes and always tell the patient when something has gone wrong”.

It also says that that requirement will be implemented by summer 2011. So I just want to ask the Minister to clarify whether the Government are therefore proposing a statutory duty of candour? Also, will she now agree to bring together patient groups, professional bodies, experts on the duty of candour in this country and abroad, as well as those who represent NHS trusts—such as the NHS Confederation—to discuss how we can all best move forward on this vital issue?