Patient Safety Review
1/5Motion made, and Question proposed, That this House do now adjourn.—(Mark Ferguson.)
I am grateful for this opportunity to evaluate the Dash review of patient safety, and I thank the Minister for the meeting with her this afternoon. I hope that the House and Penny Dash will forgive me, but in the interests of brevity and clarity, I shall be direct. Whenever asked to justify the abolition of the Health Services Safety Investigations Body, Ministers refer to Dash, but Dash fails to make the case for what it recommends. This new clinical incident investigator was established less than three years ago. HSSIB is a new concept in healthcare, conceived to challenge the culture of denial and blame in the NHS. It is proving itself, even with its very limited budget. One early report on aortic dissection led to 300 more people receiving lifesaving treatment. The Minister now has a list of key recommendation impacts produced by HSSIB. A lot of them may seem small or piecemeal, but so far it is only a small body. After a boy suffered an avoidable death from cancer, HSSIB recommended to NHS England a new community language translation and interpreting services framework so that non-English speaking patients would get appointment letters for their children that they could read and understand. HSSIB recommended a protocol between prisons and ambulance services to avoid wasting ambulance time and new guidance for non-accidental injury of babies in emergency departments where no specific guidance had existed before. The Dash review shows no understanding of HSSIB’s purpose and no comprehension of coherent safety systems management. Dash gets facts wrong and misinterprets the law, either through a failure of understanding or because the recommendation to abolish HSSIB somehow reflected the desired outcome of the review, regardless of the facts. I will set out some specific questions, most of which the Minister has had in advance. If she does not have enough time to respond, I look forward to discussing them at a future meeting that we discussed having.
My hon. Friend is making a powerful case. Does he agree that one of the common themes in all the maternity scandals that we have been discussing in recent weeks, sadly, has been how a blame culture in the NHS makes it hard for NHS staff to speak openly about why tragedies have happened, and that that is why they welcome HSSIB, with its safe space protections? Is he worried that that could be undermined by putting HSSIB into the Care Quality Commission, which has a legal duty to act on information it receives, therefore creating the worry for people talking to HSSIB that the information that they give to it may no longer be protected in the same way?
I 100% agree with my right hon. Friend. He will note that I will pick up on those points during my remarks. I come back to the questions that I want to put to the Secretary of State. First, if HSSIB’s investigations are intended to continue unaffected by the transfer to the CQC, why bother with the expense of the transfer? Are Ministers simply using Dash as the pretext for what people in the Department or elsewhere in the NHS would like to have? HSSIB was deliberately started very small, but the intention was that over time it would take over more investigations in health and replace the need for wasteful, lengthy, inexpert ad hoc public inquiries. Over the years, inquiries have proved to be a chaotic means of investigation, assembling expertise from scratch, which is then lost after the inquiry, and failing to command public confidence or to fix the system. That is why, after the 1999 Paddington rail crash, the Ladbroke Grove inquiry in 2001 established the rail accident investigation branch. Since then, despite many fatal rail accidents, there has been no public inquiry into a rail crash—nor has the public felt the need to demand one—and rail safety has improved. Given that HSSIB is expert, full time, and can conduct much cheaper and quicker investigations than public inquiries, how can Ministers accept the Dash recommendation to abolish it? Why not consider expanding HSSIB to avoid the need for so many costly public inquiries? Dash complains about there being far too many recommendations—yes, there are—but, as Dash itself enumerates, it is the 30 public inquiries that, in its language, have “cluttered” the “landscape” with some 1,400 recommendations over recent years. HSSIB is therefore not the source of those recommendations. In HSSIB’s first 34 months of operation, it has produced only 56 recommendations. How can Ministers use that reason to justify HSSIB’s abolition? Dash refers more than once to “quality (including safety) of care”. That elides quality of care with safety. In any other safety-critical industry, safety is seen as a distinct, separate and overriding priority. It is telling that in the report, the words “including safety” are added merely in parentheses, as though safety is ancillary to quality, but that becomes justification for rationalisation while actually compromising safety. Safety system management is intrinsic to safety and public confidence in other safety-critical activities, such as aviation, but this is alien to NHS culture. I therefore ask the Minister again: without HSSIB, which independent body will promote a coherent understanding of safety system management in health, and who is to hold the NHS and Government to account for safety failures?
Will the hon. Member give way?
Very briefly—I have a lot to say.
In that case, carry on.
I thank the hon. Gentleman. Recommendation 1 in the Dash review says that the new National Quality Board should “avoid unfunded mandates being imposed on the system without due consideration”. Public inquiries have certainly made well meaning but unaffordable recommendations—I think of the Francis inquiry recommendation on blanket standards for minimum staffing—but it is wrong to see safety as a cost in opposition to other benefits. The cost of safety failures is astronomic, with NHS clinical negligence costing £3.6 billion a year, despite all the public inquiries. Effective safety management is about the cost-effective management of risk, not risk elimination at any cost. If the air accidents investigation branch did not balance costs with effective risk management, aeroplanes would not fly. Can the Minister therefore point out which of HSSIB’s recommendations have been too expensive to implement? If not, where is the justification for abolishing HSSIB? Neither the NQB nor the CQC should control investigations. The AAIB cannot be prevented from making independent recommendations by the Civil Aviation Authority, the Transport Secretary or airlines themselves. Why should the NQB, which will be subject to political direction, be allowed to decide what safety recommendations should be made and what should be investigated, as Dash recommends? On page 31, Dash incorrectly states: “HSSIB was not able to retain the maternity programme because the Health and Care Act 2022 does not make provision for maternity investigations under HSSIB.” Why have the Government accepted that assertion as true? It is wrong in fact and law. The new statutory HSSIB did not take on maternity and newborn safety investigations, because they were commenced without the safe space protections, so their evidence is available for legal proceedings. That is not how HSSIB operates. Since 2023, HSSIB has been conducting its own maternity investigations. Indeed, when the Amos review was established, it took on the relevant investigations from HSSIB and then relied on HSSIB for assistance with them. With sufficient resources, HSSIB could conduct all maternity investigations much more effectively than the maternity and newborn safety investigations programme. Amos reported that MNSI investigations are not trusted by families, as my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) was saying, and are not consistent or effective in identifying learning or providing accountability. Amos also says that families should have access to an independent investigation if they lose confidence in the local investigations. Without HSSIB, who will provide those independent investigations? Finding 6 accuses HSSIB of having “expanded” its “scope of work beyond the original remit…For example, HSSIB was originally established, along the lines of safety investigatory bodies in other industries, to look at specific cases or incidents of severe harm, but it has since broadened its work into making more systemic recommendations.” That is what Dash says. It is complete nonsense. HSSIB is exactly equivalent to the AAIB, the marine accident investigation branch and RAIB, and was, like them, set up to conduct systemic investigations. That is why they are such effective bodies. The Health and Care Act 2022 does not limit HSSIB investigations to individual incidents. There is no reference whatsoever to “severe harm”, as Dash puts it, in the 2022 Act. It was always intended by Parliament that HSSIB should make systemic recommendations arising from the investigation of specific incidents or groups of incidents. I can say that with authority because it was my Select Committee that recommended HSSIB in the first place, and I also chaired the pre-legislative scrutiny Committee on the draft legislation, so how can Ministers give any authority to the Dash review, which claimed that HSSIB has expanded its remit, when it has done no such thing? Recommendation 3 proposes: “Most investigations into safety incidents should continue to be managed within provider organisations”. This really is the fundamental flaw in Dash. Recent maternity investigations conducted by trusts have highlighted the deficiency of provider-led investigations, as Ockenden and Amos have pointed out. Do the Government accept that investigations by provider organisations are inherently conflicted? Just ask the clinicians, patients, families and patient safety organisations what they think about trusts marking their own homework. None of them has confidence, because providers are keen to protect themselves from litigation and reputational damage. How can Ministers accept the Dash recommendation that we should rely on investigations conducted by provider organisations?
I commend the hon. Gentleman for speaking so clearly about why having an independent HSSIB—independent of those providers—to investigate is so important. Time and again, we hear about devastating failings in the NHS. He alludes to maternity services, but we could add to the list infected blood and pelvic mesh. Does he agree that professionals and those working inside the NHS must be able to speak freely when things go wrong in order to learn lessons, and that that is only possible with an independent investigating organisation?
I thank the hon. Lady for that intervention. Only an independent investigator can find the causes of the incident that may be part of the culture or practice of that provider, or of the system as a whole. It is like suggesting that airlines or aircraft manufacturers can protect passenger safety without the independent accountability provided by the AAIB. Of course, providers should have the capacity and capability of conducting patient safety investigations, but they must know that HSSIB can and will look at that work and will hold them to account. Recommendation 3 also says that HSSIB should continue as what it calls “a centre of excellence for investigations” in the CQC, but I am afraid that this is just a sop. The CQC, as was pointed out by my right hon. Friend the Member for Godalming and Ash, is a regulator and compliance enforcer, not an investigator. How can the CQC also be an independent investigator? Dash also says that the CQC internal successor should collaborate through the NQB to agree the scope of any investigations it carries out and agree the recommendations. Dash is effectively saying that CQC investigations will be overseen by the NQB. That is a direct attack on the independence of investigations. Can the Minister explain who in future will conduct independent and unconflicted investigations into safety incidents in the NHS? For example, how would an investigation under the CQC be free to find that the CQC inspections themselves were causing unintended harm to patients, or is it back to the misery of litigation through the courts and more public inquiries? The recommendation also makes no reference to the statutory safe space raised by the hon. Member for Shipley (Anna Dixon) that provides for protected disclosure by patients and their families, clinicians and others in safety investigation bodies. It is a crucial safeguard, allowing people to speak. It allows for the duty of candour. I would just point out that the duty of candour does not work if it is just imposed on people. People cannot be forced to incriminate themselves. If placed under the CQC, confidence in the safe space investigations will collapse—and back we go to public inquiries. The Health Bill does attempt to address this by replicating the 2022 Act’s safe space provisions, but that Act also provided for disclosure in certain circumstances, which is allowed on the basis that the benefits for the safety of patients outweighs any impact on current and future investigations. But under this Bill, who will decide what protected information can be disclosed? How will the CQC give the same confidence that the safe space is not being compromised as HSSIB? Finally, Dash fails to look at the comparative cost of HSSIB investigations versus the cost of public inquiries. HSSIB at the moment only costs £6.3 million per year. To save money, the Secretary of State should request that HSSIB conducts far more investigations into matters which he thinks are important, provided that he also provides the funding for the necessary capacity. HSSIB, for example, has conducted eight investigations into mental health suicides since 2023. Each was completed in a few weeks or months, costing a total of £850,000. In comparison, the Lampard inquiry into the Essex partnership university trust in my constituency—investigating the same problem—is expected to cost more than £5 million. Ockenden cost £14 million. This is very far from the best use of resources for conducting investigations. So I ask the Minister, why have Dash and the Government ignored the whole question of HSSIB’s value for money? Even if HSSIB only saves a fraction of the £3.6 billion in costs of clinical negligence, it will pay for itself many fold. I do hope that Ministers will reconsider the whole issue, reflecting on the fact that none of the Royal colleges, nor any of the patient safety organisations, nor the all-party group on patient safety support this unjustifiable policy.
I thank the hon. Member for Harwich and North Essex (Sir Bernard Jenkin) for securing this important debate. He has long taken a serious interest in patient safety, including in the importance of independent investigation. I recognise the strength and sincerity of the points that he has raised and will try to answer all of his questions. At the heart of this debate is a simple question: when patients and families tell us something has gone wrong, does the system listen and learn, and, most importantly, does it change? Patients do not judge the system by the number of reports published, the number of organisations involved, or the number of recommendations written; they judge it by whether care becomes safer. For too long, across too many parts of the system, we have seen the same pattern: harm happens; a review follows; lessons are identified; but the change patients were promised does not always follow quickly enough. This Government are determined to change that. Dr Penny Dash’s review was commissioned to consider whether the current landscape of organisations provides effective leadership, listening and regulation on patient safety and wider quality of care, and whether a different approach could deliver better outcomes for patients.
I rise to intervene before the Minister goes down the HSSIB route, which I completely understand is the focus of the debate today. I want to put on record once more the concerns about Healthwatch and its abolition. I know there is a strong desire to see independent patient voice maintained outside the system; of course, Healthwatch was established due to issues within health structures, including, notably, the Mid Staffordshire scandal.
I thank my hon. Friend for putting that on the record. He will know that we are in Committee stage of the Health Bill and there will later be the opportunity to debate this issue on the Floor of the House.
I thank the Minister for outlining the case incredibly well. I have a request in relation to the vital lessons learned on data collection, streamlined complaints and patient safety culture. It is important for us all that those lessons are shared with the Northern Ireland Assembly Minister, Mike Nesbitt, as health is a devolved matter; we need to ensure that there is safety for all across this United Kingdom of Great Britain and Northern Ireland.
Absolutely. I am very privileged to have patient safety in my brief. I know everybody across this House really cares about it, and I will make sure that officials do as the hon. Gentleman requests.
I want to concur with all of the remarks by the hon. Member for Harwich and North Essex (Sir Bernard Jenkin), who has made a crucial point. But there is a wider issue, which the Health Bill completely misses and which I urge Ministers to look at, around the accountability systems within the NHS. The reforms are not going to deliver accountability. They are going to weaken it, and as a result we will see more requests for investigations into patient safety. I want the Minister to take that point away, because I am really worried that we are going to see a system that is more unsafe as a result of these reforms.
I thank my hon. Friend for her contribution—she is absolutely right. I take accountability very seriously and am going to talk about it in my remarks in this debate. Far too often, we see so many inquiries and so many recommendations but nobody taking responsibility for implementing the change. In the end, patients have to feel that things have changed, not that we are just having further reports and recommendations. The Penny Dash review examined six organisations that are overseen by the Department: the Care Quality Commission; the National Guardian’s Office; Healthwatch England and the local Healthwatch network; the Patient Safety Commissioner; the Health Services Safety Investigations Body; and the patient safety learning functions of NHS Resolution. The review’s conclusion was clear. The problem is not that people working in patient safety lack commitment—we all know that there are dedicated people across the system doing important work every day—but that the system around them has become too cluttered, complex and difficult for patients, staff and leaders to navigate. We inherited a landscape with more than 70 routes for patients and service users to raise concerns or provide feedback, and around 40 public bodies with a formal role in quality and safety. That complexity does not automatically make patients safer. It can make responsibility unclear, create duplication and make it harder to ensure that learning leads to improvement. A cluttered landscape, as we would all agree, is not an effective landscape. The hon. Member for Harwich and North Essex asked me about the expertise in HSSIB, the full-time job that it does and whether it could undertake investigations more cheaply and quickly than public inquiries. The investigation function within the CQC will be expert and full time, and it will be able to conduct investigations in the same cheap and quick way that HSSIB does now. In future, there will be the same opportunity to use the CQC investigation function instead of needing a public inquiry as there is currently with HSSIB. The review also found that too many recommendations are generated through reviews, inquiries and investigations, as the hon. Member said, without enough clarity on ownership, prioritisation, implementation and impact. This is the fundamental point: recommendations alone do not make patients safer; change does. That is why the Government have accepted all nine recommendations of the Dash review. The hon. Member asked how the CQC will provide the same confidence that the safe space is not being compromised. The criteria for disclosing protected information outside the investigative function are set out in the Bill. Those criteria set a high bar for any disclosure—as high as it is currently with HSSIB—and the CQC will publish further guidance setting out much more detail. As the Bill sets out, the CQC will appoint a responsible person who will decide whether the case matches the criteria and whether it warrants information sharing outside the safe space. That person is likely to be the CQC’s chief executive officer. The hon. Member asked why the Dash review and the Government have ignored the whole question of HSSIB’s value for money. Let me be clear: the Dash reforms are not about saving money; they are about strengthening patient safety and patient voice across the system. The abolition of HSSIB and the transfer of its functions to the CQC play an important part in making the system of patient safety much more effective. Safety is the issue, not money. Accepting recommendations is the beginning, not the end. Patients who have suffered harm, families who have campaigned for years and staff who have spoken up do not want another report sitting on a shelf. They want evidence that the system can listen, learn and prevent harm from happening again. I want to be absolutely clear: every organisation in the system has a responsibility to meet that challenge. Patient safety cannot be something we support in principle but resist when it requires us to change. No organisation, however established or well-intentioned, should believe that learning and improvement only apply elsewhere. That is why we are streamlining and strengthening the patient safety landscape. The hon. Member mentioned the National Quality Board. We have revitalised the board by giving it a stronger role in providing a single, authoritative view of quality across the system. That will help reduce duplication, bring greater clarity to recommendations and ensure that effort is focused where it has the greatest impact. All hon. Members recognise that we need fewer recommendations because we know that they disappear into the system. More recommendations are needed that are owned, tracked and delivered. I recognise the concerns raised by the hon. Member in respect of the Health Services Safety Investigations Body. We had a constructive conversation earlier today. On his point about the accusations that HSSIB had expanded the scope of its work beyond its remit, he explained to me in detail how HSSIB’s inception came about. The Government have accepted the Dash recommendation that HSSIB’s role as a centre of excellence for investigation should continue, and clarified the remit of any future investigations. I think that the investigation function with the CQC will perform the role of a centre of excellence for investigations. HSSIB has developed important expertise in understanding why things go wrong and identifying system-wide learning, and I acknowledge that work. The question before us is not whether investigations matter —of course they do—but how we ensure that investigations lead to action, because learning without implementation does not improve patient safety. The Dash review recommended transferring HSSIB’s functions to the Care Quality Commission, while maintaining a dedicated investigation capability. I understand why colleagues will want reassurance on that, because, as the hon. Member said, independence, transparency and trust are essential in patient safety investigations, but so is impact. The purpose of these reforms is not to weaken investigation, but to strengthen the link between investigation, learning and improvement. We need a clearer route from identifying problems to making recommendations and ensuring that someone owns delivery and that patients see change. The hon. Gentleman asked if I could explain who will conduct future investigations into safety in the NHS if the Dash review is implemented. The investigation function in the CQC will have autonomy to launch investigations into any part of the health system and will be able to make recommendations on any part of the system, just as HSSIB does now. There will be no barrier to an investigator finding out that CQC inspections are causing unintended harm. If they are, and if the investigator feels that a recommendation for change should be made, they will make it. There will be no need for litigation through the courts, and insights gained from investigations will continue to inform recommendations concerning the Care Quality Commission’s regulatory functions. The Bill also allows for the investigation function to make recommendations to the CQC in its report, and the CQC would be legally required to respond to such recommendations. I hope that the hon. Member is assured that we will work carefully with colleagues, patients, staff and system leaders as these reforms are implemented. The same principle applies to patient voice. Patients do not share their experiences simply for the system to record them; they do so because they want to see things change. Listening matters, but acting on what we hear is what makes patients safer. That is why we are ensuring that patient experience is closer to where decisions are made, with commissioners and providers responsible not only for delivering services, but for listening and responding. The Patient Safety Commissioner will continue to champion patient voice on medicines and medical devices and report directly to Parliament.
I am listening very carefully to what the Minister is saying. She has engaged positively with the questions I have asked, but she has actually made the case for keeping HSSIB separate. Will she reflect on that? If the only thing she wants is for the CQC to own the recommendations, she should amend HSSIB and say, “The CQC must ensure that the recommendations are implemented.” In fact, the recommendations are directed at Ministers and bits of the health service that are answerable to her and to the Secretary of State. We should keep HSSIB separate, but by all means let us discuss how to ensure that the recommendations are implemented properly.
I am grateful to the hon. Member for his comments. I did recognise the reason for keeping the functions separate, but just because they are part of the CQC does not mean to say that they do not have their independence. I have pretty much set out the powers that they current have and what they will be able to do, but they do not prioritise investigating the situations that we spoke about, such as “never events”. It is not simply about the investigation; it is about how we get those “never events” to lead to learning and change in the system. How do we hold the system to account to ensure that the very thing that the regulator recommends is implemented? What that journey looks like for patients will be far more significant, as opposed to those bodies simply doing investigations that lead to further recommendations.
House adjourned without Question put (Standing Order No. 9(7)).