On 29th October 2019 the House debated the second reading of the Health Service Safety Investigations Bill. The Bishop of London, Rt Revd Sarah Mullally, contributed:
The Lord Bishop of London: My Lords, I am grateful for the opportunity to speak at this Second Reading. I declare my interests as set out in the register. I too am grateful for briefings from the Library, the Royal College of Nursing, the Royal College of Surgeons and the Parliamentary and Health Service Ombudsman.
Like most noble Lords, I welcome the Bill’s proposal to create an independent body which will investigate serious patient safety incidents. The NHS is to be congratulated on the way in which it has sought over the years to develop as a learning organisation. Florence Nightingale said:
“Let us never consider ourselves finished nurses … We must be learning all of our lives”.
The Bill comes as part of the wider changes which we have seen undertaken over many years. I recognise those who work day by day in the NHS seeking to do their best and to provide safe, effective and compassionate care.
At the heart of my clinical practice when I was a nurse, a manager or even the Government’s Chief Nursing Officer, and latterly a non-executive director, was my desire to improve the quality of care that people receive. I believe that that is the intention of the majority of the people who work in our NHS, but things go wrong, and when they go wrong, it is often the result of a systems failure, at the root of which is culture. The 2013 Francis report into the Mid Staffordshire NHS Foundation Trust was mentioned by the Minister. It found that misaligned goals and behaviours in a plethora of agencies led to the tragic failure in patient safety. A system failed. It failed people and their families, and the report declared that regrettably it was a preventable tragedy.
The Francis report pointed to the need to develop a culture which was more open and transparent across the healthcare system. Professor Don Berwick, an international safety expert, called on us to embrace a culture of learning, particularly of learning from mistakes, but we have to recognise that when things go wrong, there is often a place deep within us where there is a tension between seeking to learn and wanting to apportion blame. So developing a culture in which we truly seek to learn must be a steel thread which runs through everything, including this legislation.
The stated intention of this legislation is to bring about a whole-system change to how the NHS investigates and learns from healthcare error. However, as the noble Lord, Lord Hunt, said, there is concern that the current drafting fails to do that and that there seems to be a disproportionate focus on the individual person or people involved in the incident. This could be overcome by any process of investigation, starting with reviewing the wide range of the system context, the factors and the conditions in which an incident occurred, well before any discussions with individuals involved take place.
Furthermore, to bring a whole-system change means having a collective understanding of dangerous activity across the board, with NHS and non-NHS patients. I join the noble Lords, Lord Hunt and Lord O’Shaughnessy, in saying that we ought to consider powers to investigate non-NHS patient issues in the independent sector. We should do this for the benefit of not just NHS patients but the non-NHS patients in our care.
I also welcome that the HSSIB must review the criteria, principles and processes of the investigation procedure within three years of their publication and subsequently within each five-year period, but I wonder whether the criteria, principles and processes ought to be co-produced with clinical and non-clinical health service leaders. I also wonder whether they should be reviewed in consultation with not just healthcare professionals but families and patients.
The opposite of a learning culture is a culture of fear. Again, I refer to Florence Nightingale, who said:
“How very little can be done under the spirit of fear”.
Therefore, I welcome the proposals for the development of safe spaces. The present draft of the Bill, I believe, has resolved some of the concerns of the nursing profession, particularly around the concept of safe spaces, but they will be safe only if the new organisation is able to build trust, as already mentioned. Trust is built only in part by legislation; it will need to be built by those recruited, as part of the HSSIB, to implement legislation. Therefore, I hope that the Minister can reassure the House that everything is being done to ensure that people of the right character are recruited to this new body.
I know that some have asked that the prohibition on the HSSIB disclosing information held within safe spaces to the Parliamentary and Health Service Ombudsman be removed. I would be very unhappy with that. Removing this prohibition will do little to create a culture where people working in the NHS feel safe to speak up when things go wrong. However, I think that further work is required to clarify how the HSSIB relates to and co-operates with the Parliamentary and Health Service Ombudsman and with other national bodies, such as the Care Quality Commission, which hold power and responsibility for reporting on patient safety incidents and the causal factors that impact patient care.
Finally, I know that the relationship between staffing levels and patient outcomes is contested, but it strikes me that an independent body such as the HSSIB may be best placed to begin to shed light on this. I hope that the Minister will ask the new body to consider this as part of its focus.
I support many of the intentions set out in the Bill and I look forward to working with other noble Lords as it progresses through the House. I thank officials and the Minister for bringing this Bill forward for our scrutiny.
Baroness Parminter (LD): [extract] …The final issue concerns the relationship of the new body to other bodies which not only focus on the causes of incidents but provide accountability for individual incidents and, if necessary, apportion blame. This issue has been touched on by the noble Lords, Lord Hunt and Lord O’Shaughnessy, and the right reverend Prelate the Bishop of London, although I think we will all come to different conclusions. …
Lord Patel (CB): [extract] …I agree with the noble Lord, Lord O’Shaughnessy, and others who mentioned that a culture change is required whenever a safety incident happens. It is important to work wherever it happened to bring about culture change, so that we grow an attitude and mindset about patient safety. We tried to do that when working with Don Berwick, who was mentioned earlier—I think by the right reverend prelate the Bishop of London. In Scotland, we employed his expertise for three years to bring about the culture change that was required. …
Baroness Jolly (LD): [extract] …Another theme running through the debate was picked up by the right reverend Prelate the Bishop of London, who talked about a culture of learning. …
Baroness Blackwood of North Oxford (Con): [extract] …The noble Baroness, Lady Finlay, and the right reverend Prelate the Bishop of London rightly said that the opposite of a learning culture is a culture of fear. …