Public Administration and Constitutional Affairs Committee — House of Commons, 2017-02-02
Topic: Health
Bernard Christison Jenkin (Conservative, Centre-right): I am grateful for the opportunity to present to the House the seventh report of PACAC this Session, "Will the NHS Never Learn?", a follow-up to the Parliamentary and Health Service Ombudsman report on the NHS in England, "Learning from Mistakes" Over the past decade, written complaints regarding NHS services have doubled, from just over 95,000 in 2005-06 to more than 198,000 in 2015-16. Investigations into such complaints have frequently failed to identify the root causes of any mistakes that occurred. Even more frustrating is that they have failed to prevent the same mistakes from being repeated over and over again, despite multiple reports highlighting that as a critical issue from both the Parliamentary and Health Service Ombudsman and the Public Administration and Constitutional Affairs Committee, which I chair In its report "Learning from Mistakes", which was published last year, the PHSO highlighted the fear of blame that is pervasive throughout the NHS. That fear drives defensive responses and inhibits open investigations, which in turn prevents NHS organisations from understanding what went wrong and why. That also undermines public trust and confidence, because the public can see that NHS organisations are failing to learn from mistakes—if they did, that would drive improvement. A combination of a reluctance on the part of citizens to express their concerns or to make complaints, and a defensiveness on the part of services to hear and address concerns, has been described by the PHSO herself, Dame Julie Mellor, as a "toxic cocktail" that is poisoning efforts to deliver excellent public services To further understand the issues and what more needs to be done to tackle them, PACAC recently undertook its inquiry, which followed up on the PHSO’s "Learning from Mistakes" report. In PACAC’s report, which was published earlier this week, we conclude that if the Department of Health is to achieve its policy of turning the NHS into a learning organisation, it must integrate its various initiatives to tackle the issue and come up with a long-term and co-ordinated strategy. That strategy must include a clear plan for building up local investigative capability, as the vast majority of investigations take place locally. We will hold the Secretary of State for Health accountable for delivering the plan. PACAC’s report also considered the potential impact of the new healthcare safety investigation branch, which is in the process of being set up. The creation of HSIB, as it is known, originates from our recommendations as the Public Administration Committee in 2015. The Government accepted our recommendation, and HSIB is due to be launched in April. It will conduct investigations into the most serious clinical incidents, and is intended to offer a safe space to allow those involved in such incidents to speak openly and frankly about what happened. In so doing, it is hoped that HSIB will play a crucial role in transforming the expectation and culture in the NHS from one that is focused on blame to one that emphasises learning. It should be a key part, albeit only a part, of the wider strategy that we want the Government to adopt Unfortunately, there is still a long way to go if the Department of Health’s aim of turning the NHS into a learning organisation is to be achieved. Most importantly, HSIB is being asked to begin operations without the legislation necessary to secure its independence and ensure that the safe space for its investigations is indeed safe. That undermines the whole purpose of HSIB. It is essential that the Government introduce the necessary legislation as soon as possible To ensure that the learning produced from HSIB’s investigations leads to an improvement in standards, PACAC also reiterates its previous recommendations, made in our 2016 report, "PHSO review: Quality of NHS complaints investigations", that the Government should stipulate in the HSIB legislation: first, that HSIB has the responsibility to set the national standards by which all clinical investigations are conducted; secondly, that local NHS providers are responsible for implementing those standards according to the serious incident framework; and, thirdly, that the Care Quality Commission should continue to be responsible, as the regulator, for assessing the quality of clinical investigations at local level according to those standards The purpose of complaints is not just the redress of grievances—which I must say is extremely unsatisfactory in the NHS anyway—although that is clearly important; complaints are a tool by which public services can learn and improve. When medical professionals are forced primarily to be concerned with avoiding liability and responsibility and are trapped in a culture of blame, there can be no learning. There is an acute need for the Government to follow through on their commitment to promote a culture in which staff feel able to speak out and in which the emphasis is placed on learning, not blame. I very much hope that they will implement PACAC’s recommendations as a step towards achieving that as soon as possible.