Date: 27 February 2013
Reference: NIA 102/11-15
Mandate Number: Thirteenth Report
Committee: Public Accounts
1. Health and social care services affect every member of society at some stage in their lives. Each year, there are in excess of 15 million key interactions between health and social care staff and healthcare patients and social care clients. The public expects, and deserves, that services are delivered safely. However, one guarantee that the health and social care services cannot give patients and clients is that they will not be harmed by the system meant to look after them. The challenge for the health and social care services is to ensure their patient safety systems minimise the risk of harm and to take steps to maximise the competence, knowledge and skills of health and social care professionals.
2. Two recent reports on unsafe care at Mid Staffordshire NHS Foundation Trust in England bring into particularly sharp relief just how crucial it is that the health and social care system treats patients as human beings and is open, transparent and accountable when things do go wrong. It is important that Trusts here learn from what happened in Mid-Staffordshire to ensure nothing like the events there could possibly happen here.
3. Adverse incidents are incidents that occur in a health or social care setting that could have resulted, or do result in the harm, or even death, of the patient or client. Around 83,000 incidents are reported by the Health and Social Care Trusts each year – around 250 of these are classified as serious adverse incidents. The Department told the Committee that of the 2,084 serious adverse incidents reported between July 2004 and March 2012, 813 individuals died in circumstances related to these incidents. The Committee acknowledges that deaths reported may not be a reflection of issues with the care delivered by health and social care services: for instance 488 of the fatalities reported relate to suicides, whether proven or suspected. However, while recognising such caveats, the Committee considers that the number of deaths still suggests that the standard of care being delivered by health and social care bodies requires continued close scrutiny.
4. Patient harm arising from adverse incidents is both a systemic and a human problem. While individual responsibility for adverse incidents should not be played down, systemic solutions to the problem are needed. Patient safety systems should include effective reporting and learning systems, effective remedial mechanisms and the active dissemination and implementation of evidence-based knowledge aimed at reducing adverse incidents.
5. Some, probably a very small proportion of, patients and clients who are dissatisfied with the care or treatment they receive, seek redress either by lodging a complaint or taking legal action against the provider. The latter can have significant financial implications — in the past five years, settling health and social care negligence cases has cost the Department of Health, Social Services and Public Safety (Department) £116 million. A significant proportion of this (around 35 per cent) related to legal and administrative costs.
6. The Committee’s overall conclusion is that, despite the introduction of a number of safety policies and initiatives, there is no reliable evidence to show that people receiving health and social care are any safer today than they were a decade ago. The Department still lacks a reliable means of tracking the progress of the health and social care services in improving the safety of those receiving care or in holding service providers accountable for minimising preventable harm.
7. The Committee was disappointed by the Department’s reluctance to undertake research to estimate the potential level of harm caused to patients and clients. In the absence of a robust measure of the level of patient and client harm, it will be difficult for the Department to demonstrate improvement over a period of time. The Committee considers that evidence of progress is a vital step in spurring Trusts to improve safety levels across both the health and social care sectors.
8. The Committee also considers that patients and clients must be provided with much more detail on the performance of individual Trusts. In practical terms, this will involve notifying those individuals involved in adverse incidents and routinely making sufficient information publicly available to enable comparisons of safety levels across Trusts and to create external pressure for improvement.
9. The Committee recognises that the year-on-year increases in the number of reported incidents indicate some progress in developing a more open and fair reporting culture. However, on the basis of evidence given by the Department, it considers that organisational culture does not always support reporting, while fear of the consequences in terms of job security and personal repercussions still exist. The Department told the Committee that under-reporting continues to be a widespread issue, particularly in the acute sector. On the basis of this, the Committee concludes that Trusts are not maximising the potential to learn when things go wrong. As a direct consequence of this, public trust in the extent to which Trusts are providing safe and effective care can be seriously undermined.
10. The Committee is extremely concerned that nurses within the health and social care sector have reservations about raising patient safety concerns. While the Department acknowledged that staff must feel empowered to speak up, challenge and share in the responsibility for patient safety, it confirmed that, to date, it has not actively engaged with nursing representative bodies to devise a methodology for reassuring nurses. The Committee considers that there is a strong link between the culture of an organisation and the willingness and capability of staff at all levels to report and learn from adverse incidents. The Department and Trusts must do more to embed a widespread culture of safety in which honest reporting is encouraged and genuine learning can take place.
11. The quality of treatment and care provided will, to an extent, depend on the competence of staff in post. Regularly appraising the performance of staff can identify gaps in knowledge or experience and identify potential training needs. The Committee is astounded that the lack of appraisal in some areas within the sector, which was identified in 2010, has yet to be addressed. While the Committee acknowledges that appraisal exists to help health and social care professional consolidate and improve on good performance, it is also its expectation that it will provide a formal system for identifying poor performance.
12. It is important that patients and clients with valid claims against the health and social care services understand their rights and have access to a range of timely remedies including an explanation, an apology, remedial treatment and, where justified, financial compensation. In the Committee’s view patients find the complaints and claims procedures confusing and difficult to navigate and can too easily and too quickly find themselves in a position where they have to seek legal remedies.
13. The Committee concluded that the absence of formal dispute resolution procedures which offer a viable alternative to litigation causes additional stress and expense for those dissatisfied with their care and treatment. Alternative dispute resolution, including mediation, can assist both Trusts and patients in reaching the non-financial remedies which patients often say they seek. The Committee urges the Department to consider how best to channel compensation to eligible patients and clients and has determined that the Northern Ireland Ombudsman is well-placed to offer advice in this area.
Summary of Recommendations
The Committee recommends that the Department undertakes research to produce robust estimates of the extent and cost of patient harm which includes both commissioning errors (where patients receive poor quality, unsafe care) and errors of omission, where the harm is attributable to a lack of access to care. The Committee also considers that the Department should develop a range of safety-related indicators to routinely evaluate the safety performance of Trusts and to use this information to set challenging safety targets. The Committee considers that, based on experiences in other high risk industries such as aviation, targeted improvements in the rate of adverse incidents can be achieved. The Committee expects the Department, in six months’ time, to provide it with: an action plan which sets out how it intends to establish a baseline measure of the incidence of harm caused to patients within the health and social care services; and how it intends to use this information for setting priorities for harm reduction efforts throughout the system.
All health and social care adverse incidents have the potential to generate learning across the sector. The Department should ensure that its data systems have the capability to identify the underlying causes of adverse incidents, with a view to preventing their repetition. In particular, it is important that the Department establishes an effective reporting and learning system for near misses (where the patient or client was unharmed) in an attempt to avoid more serious incidents in the future.
The Committee welcomes the Department’s commitment to improving its management information through the RAIL system but is concerned with the timescales involved. The Committee recommends that interim arrangements are put in place as a matter of urgency to ensure regional collection of relevant information and calls on the Department to provide it with a progress report in six months’ time.
The Committee notes the Department’s preference to develop a regional management information system rather than join with England and Wales in the NRLS. Given the obvious risks involved in such IT projects, the Committee recommends that the Department’s business case gives full consideration to all other options, particularly the NRLS option, and clearly explains why each of these is unacceptable.
The public has a right to sufficient information on individual Trusts in order to assess relative quality across service providers. The Committee recommends that the current reports produced by the HSC Board are enhanced by providing data on all adverse incidents, that they are made publicly available on a timely basis, and that they are sufficiently detailed to allow the public to get a regional and local picture of the safety of the treatment and care provided.
In the Committee’s view, the open and fair culture to which the Department aspires must extend to the increased participation of patients in their treatment. The Committee recommends that health and social care providers are advised of the need to inform those involved in any adverse incidents. Information provided should include the nature of the incident, the circumstances giving rise to the incident, the possible impact for the patient or client and details of learning arising from the incident.
The Committee sees considerable merit in learning lessons from health care experiences elsewhere. It therefore expects the Department to independently verify the extent of compliance with NRLS safety alerts across the health and social care sector. Further, the Committee considers that sanctions should be imposed where health and social care bodies fail to implement action on a timely basis.
In terms of learning lessons, the Committee welcomes the recommendations of the Francis Reports on Mid Staffordshire Hospitals NHS Trust, many of which have implications that could apply to any health and social care trust here. The Committee calls on the Department to work closely with the HSC Board and the Trusts to consider the full implications of the Francis Reports and recommends that it reports back to the Committee in six months’ time outlining what actions have been taken, or need to be taken, to address the concerns raised.
In the Committee’s view the reluctance of nurses to report safety concerns indicates there is a real need to challenge the existing culture in which errors are concealed. Failure to report incidents prevents learning. A positive culture would result in improvements in safety practices through better communication, teamwork and knowledge. The Committee recommends that the Department engages with all staff groups within the sector and takes urgent steps to ensure a more open and proactive reporting culture.
The recipients of health and social care services must be assured that their views on the safety and quality of the services they receive are important. The Committee recommends that Trusts become more proactive in obtaining feedback on the services they provide, encouraging patients and clients to identify areas for potential improvement or to highlight good practice. Improving links between data on complaints with other safety data, such as risk and incident reporting data, can lead to complaints being taken more seriously as a source of information and feedback on the standard of service or care being provided.
Ensuring the competence of staff is crucial in creating a safe environment for patients receiving treatment and care from the health and social care services. The Committee finds it unacceptable that so little regard has been given to assessing, maintaining and improving the competency of staff – particularly among medical staff in the Northern Trust. While the Department’s reminder to Trusts of their requirements in this area is encouraging, the Committee considers that action should have been taken as soon as weaknesses were identified. The Committee recommends that the Department follows up on its reminder to Trusts by carrying out annual verification checks on staff appraisal and development plans. The Committee also asks that the Department provides it with an update, in six months’ time, on the progress of Trusts in completing staff appraisals.
The Committee recommends that the Department continues to track the outcome of initiatives to speed up claims handling and that it provides the Committee with an update on the performance of long running cases up to September 2012.
The Committee considers that the current “fault-based” approach adopted across health and social care services can place additional, unnecessary stress and expense on those who suffer injury and on health and social care providers. The Committee recommends that the Department gives serious consideration to the feasibility of developing robust formal dispute resolution procedures which could offer a real alternative to litigation. The Committee considers that the Department should consult with the Northern Ireland Ombudsman in determining an appropriate way forward.
The Committee recommends that the Department assesses the relative merits of continuing to meet the compensation costs of clinical negligence settlements rather than requiring HSC bodies to assess their relative risks and contribute, on the basis of these risks, to a central pool from which compensation costs are met.
 The Mid Staffordshire NHS Foundation Trust Inquiry, Chaired by Robert Francis, 24 February 2010, HC 375, London: The Stationery Office; Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Chaired by Robert Francis QC, February 2013, HC 947, London: The Stationery Office