NHS: Learning from Mistakes — House of Commons, 2016-03-09
Topic: Health
Jeremy Richard Streynsham Hunt (Conservative, Centre-right): With permission, Madam Deputy Speaker, I would like to update the House on the steps that the Government are taking to build a safer, seven-day NHS. We are proud of the NHS and what it stands for and proud of the record numbers of doctors and nurses working for the NHS under this Government, but with that pride comes a simple ambition: our NHS should offer the safest, highest-quality care anywhere in the world. Today, we are taking some important steps to make that possible In December, following the problems at Southern Health NHS Foundation Trust, I updated the House about the improvements that we need to make in reporting and learning from mistakes. NHS professionals deliver excellent care to 650,000 patients every day, but we are determined to support them to improve still further the quality of that care, so this Government have introduced a tough and transparent new inspection regime for hospitals, a new legal duty of candour to patients and families who suffer harm, and a major initiative to prevent lives from being lost through sepsis. According to the Health Foundation, the proportion of people suffering from the major causes of preventable harm has dropped by a third in the last three years, so we are making progress, but we still make too many mistakes. Twice a week in the NHS we operate on the wrong part of someone’s body and twice a week we wrongly leave a foreign object in someone’s body. The pioneering work of Helen Hogan, Nick Black and Ara Darzi has estimated that 3.6% of hospital deaths have a 50% or more chance of being avoidable, equating to over 150 deaths every week Despite that, we should remember that our standards of safety still compare well with those in many other countries. However, I want England to lead the world in offering the highest possible standards of safety in healthcare. Therefore, today I am welcoming Health Ministers and healthcare safety experts from around the world to London for the first ever ministerial-level summit on patient safety. I am co-hosting the summit with the German Health Minister, Hermann Gröhe, who will host a follow-up summit in Berlin next year. Other guests will include Dr Margaret Chan, director general of the World Health Organisation, Dr Gary Kaplan, chief executive of the renowned Virginia Mason hospital in Seattle, Professor Don Berwick, and Sir Robert Francis QC We will discuss many things, but in the end all the experts agree that no change is permanent without culture change. That change needs to be about two things: openness and transparency about where problems exist; and a proper learning culture to put them right. With the new inspection regime for hospitals, GP surgeries and care homes, as well as a raft of new information now published on My NHS, we have made much progress on transparency, but as Sir Robert Francis’s "Freedom to speak up" report told us, it is still too hard for doctors, nurses and other front-line staff to raise concerns in a supportive environment Other industries, in particular the airline and nuclear industries, have learned the importance of developing a learning culture, not a blame culture, if safety is to be improved. Too often, the fear of litigation or professional consequences inhibits the openness and transparency we need if we are to learn from mistakes Following the commitment I made to Parliament at the time of the Morecambe Bay investigation, we will from 1 April set up our first ever independent healthcare safety investigation branch. Modelled on the air accidents investigation branch that has been so successful in reducing fatalities in the airline industry, it will undertake timely, no-blame investigations. As with the air accidents investigation branch, I can today announce that we will bring forward measures to give legal protection to those who speak honestly to investigators. The results of such investigations will be shared with patients and families, who will therefore get to the truth of what happened much more quickly. Unlike at present, however, those investigations will not normally be able to be used in litigation or disciplinary proceedings, for which the normal rules and processes will apply. The safe space that they will therefore create will reduce the defensive culture too often experienced by patients and families, meaning that the NHS can learn and disseminate lessons more quickly, so that we avoid repeating mistakes My intention is to use the reform to encourage much more openness in how the NHS responds to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything else is a guarantee that no one else will have to re-live their agony. The new legal protection will help us to promise them, "Never again." Fundamental to the change is getting a strong reporting culture in hospitals under which mistakes are acknowledged, not swept under the carpet Today, NHS Improvement has also published a "learning from mistakes" ranking of NHS trusts, drawing on data from the staff survey and safety incident reporting to show which trusts have the best reporting culture and which need to be better at supporting staff who want to raise concerns. It will be updated every year in a new Care Quality Commission state of hospital quality report, which will also contain trusts’ own annual estimates of their avoidable mortality rates and have a strong focus on learning and improvement. Furthermore, the General Medical Council and the Nursing & Midwifery Council guidance is now clear: where doctors, nurses or midwives admit what has gone wrong and apologise, the professional tribunal should give them credit for that, just as failing to do so is likely to incur a serious sanction The Government remain committed to further reform to allow professional regulators more flexibility to resolve cases without stressful tribunals. The culture change must also extend to trust disciplinary procedures, so NHS Improvement will ask for a commitment to openness and learning to be reflected in all trust disciplinary procedures and ask all trusts to publish a charter for openness and transparency, so that staff can have clear expectations of how they will be treated if they report clinical errors Finally, from April 2018, the Government will introduce the system of medical examiners that was recommended in the Francis report, which will make a profound change to our ability to learn from unexpected or avoidable deaths, with every death either investigated by a coroner or scrutinised by a second independent doctor. Grieving relatives will be at the heart of the process and will have the chance to flag any concerns about the quality of care and cause of death with an independent clinician, meaning that we get to the bottom of any systemic failings much more quickly. The NHS is one of the largest organisations in the world and learning from mistakes and becoming the world’s largest learning organisation is how we will offer the safest, highest-quality standards of care. I commend the statement to the House.