Health: Patient Safety
Private Members’ Business
William Hay (DUP)
The Business Committee has agreed to allow up to one hour and 30 minutes for the debate. The proposer will have 10 minutes to propose and 10 minutes to make a winding-up speech. All other Members who wish to speak will have five minutes.
Paula Bradley (DUP)
I beg to move
That this Assembly calls on the Minister of Health, Social Services and Public Safety to put in place a robust strategy to promote patient safety across the health service.
As a former employee of our National Health Service, I am very proud of healthcare in Northern Ireland. I have seen at first hand the dedication and expertise of our staff as well as how hard they work to ensure that the people of Northern Ireland have access to the best healthcare they can provide. By tabling this motion, I do not mean to attack or demoralise our hard-working health service staff. Rather, I intend to support them by giving them additional tools to allow them to continue providing that important service.
When anyone needs to access our health service, they do so in the belief that they will get the right treatment as quickly as possible in a safe and controlled environment and that it will be free at the point of delivery. Of course, the NHS is not free: everyone in this country contributes in some form to the cost of the NHS, and therefore everyone has an interest in ensuring that it performs to the very best of its ability.
The European Union defines quality healthcare as healthcare that is effective, safe and responds to the needs and preferences of patients. In Northern Ireland, our 10-year quality strategy has safety as one of its three main headings. That shows how seriously we in Northern Ireland take our responsibility for patient safety. It is entirely correct that safety should be at the top of the healthcare agenda.
The role of safety is one of the cornerstone beliefs of anyone who enters our medical professions, with the instruction to first do no harm at the centre.
It is important that we understand what we mean by safe. Medicine is a practice that is driven by humans. Sadly, humans can and will make mistakes, which means that, in healthcare, there will always be some element of risk. Providing safe care involves placing an emphasis on providers to be proactive when identifying the risks and promoting strategies that will minimise those risks. That will, in turn, promote reliability, reduce variation in the care provided and minimise harm to service users.
When we talk of patient harm, we are covering a wide range of harm, from not enough attention by nursing staff to mistakes made over missed medicine, to unnecessary surgery and, finally, to the most serious, which results in death. Therefore, it is important to remember that safety incidences can involve a wide range of factors, from infrastructure, training, treatment protocols, procedure and communication to simple administrative errors. Safety is the responsibility of all staff — clinical and non-clinical. When adverse events occur, the service providers should ensure that the maximum lessons are learned and that procedures, where appropriate, are implemented to reduce the risk of the incident recurring.
It is not just in the United Kingdom that the role of safety in healthcare has received prominence. A number of international studies have examined the area of patient care. Those studies put the rate of adverse events in acute care at between 2·7% and 16·6%. Even at the lower end of the scale, this is an issue of deep concern. In the 1990s, it was increasingly noted that the majority of harm inflicted on patients was not done deliberately, negligently or through serious incompetence but through competent clinicians working in inadequate systems. That was the centre premise of landmark publications such as ‘To Err Is Human’. That publication argued that attempts to improve patient safety should not focus on punishing individuals when errors occur but rather on moving away from a blame culture, which encourages the covering up of incidents and fails to identify underlying causes and to learn lessons that could prevent the repetition of such incidents. Thus, it is my belief that we need to ensure that any robust strategy includes an open, no-blame reporting culture.
It is worth remembering that harm does not occur only when the patient is in a hospital setting; harm can be done when the patient is in the community attending many of the other services. The NHS is a multifaceted organisation, and there is always potential for harm to occur. Therefore, our approach to ensuring patient safety must also be multifaceted. As is highlighted in the ‘Safety First’ document, there are four main components of an informed safety culture: a reporting culture, a just culture, a flexible culture and a learning culture. Any safety strategy must endeavour to ensure that those cultures are promoted in the strategy and are communicated to the personnel involved.
We should also look to learn from examples of best practice elsewhere in the UK. Where an adverse incident has occurred or has been prevented from happening, systems need to be in place to assist individuals and organisations to learn from mistakes. In developing the safety strategy, we must also ensure that the voices of front line healthcare staff are listened to and actioned on. It is a sad fact that, often, the voices of those at the coalface are ignored in developing strategies, and yet that group of people has a rich insight into what needs to be done and what is actually happening. We ignore them at our peril.
Systems and procedures can go only so far, however, in reducing risk. We must encourage individual patients to feel confident enough to question medical professionals and challenge them over issues such as hand-washing. In Northern Ireland, we have a reverence for the medical profession that is long-instilled in us. People need to take personal responsibility and be proactive about their care and the care of their loved ones. That should complement our safety strategy and provide another important interface to prevent mistakes occurring.
The health service must also, as a whole, communicate to patients when a mistake or near miss occurs. By doing so, we can encourage the free flow of information from both sides, promote the learning aspect and turn the negative into a positive. The empowerment of patients is provided for in our ‘Quality 2020’ paper.
Aside from the massive human costs of mistakes, the majority of which are, thankfully, low-harm, we must be aware that such incidents have an economic cost to our NHS. That takes financial resources away from patient care. It is a drain that we can work together to ensure is kept to a minimum. No country has yet succeeded in completely eradicating any risk of harm. In a time of austerity, it is right and just that we look at ways that we can reduce unnecessary spending without affecting front line services. By developing a robust safety strategy, we have the opportunity to do that.
In conclusion, patient safety is a core domain of quality, and it demands a system-wide effort. It requires a range of actions and applies to all healthcare disciplines equally. We are not alone in trying to ensure patient safety. We must work to learn from other regions in the UK and other countries internationally about how best to develop a strategy that will be practical, workable and will have an impact. International studies suggest that 10% of all patients admitted to hospital will experience some form of harm associated with their admission. However, we should remember that not all that harm is preventable or serious. That notwithstanding, we must work tirelessly to endeavour to ensure that preventable harm is prevented, regardless of the level of harm.
Sue Ramsey (Sinn Féin)
Go raibh maith agat, a Cheann Comhairle. I welcome the opportunity to address the House as the Chair of the Committee for Health, Social Services and Public Safety. I commend the proposer of the motion for securing this important debate.
The Committee has been very concerned, particularly over the past three months, about issues of patient safety in our hospitals and about different aspects of our health service. Others will go into that, but the reality is that people go to hospital because they are already vulnerable, sick, unwell, suffering from chronic illness at times or have been in an accident of some sort. When people go to hospital, they have a right to expect that they are in a safe environment and will not come into harm’s way. However, as Paula outlined, that is, unfortunately, not always the case.
Recently, there have been incidents of people going to A&E and not receiving the care that they are entitled to. We are all aware of the tragic case of the man who died on a trolley in the Royal in early March. There have been other cases where people’s health has deteriorated because they had to endure a long wait in A&E and could not get a bed.
The Committee has taken a proactive approach to the situation in A&Es, because we know that it is an issue that our constituents are worried about. On 22 March, the Committee undertook an official visit to the A&E at the Royal Hospital. We were all hugely impressed by the dedication and professionalism of all the medical staff that we met. The nurses, doctors and support staff are all committed to sorting out this situation and have already put in place new measures to try to improve the flow of patients through A&E. However, we need a more joined-up approach across hospitals, particularly for discharge from wards, so that more beds are freed up for patients from A&E who need to be admitted.
The Minister announced the creation of an A&E improvement action group that will report to the health board. The Committee will take evidence from that group next month to see exactly what has been done to improve the situation. We have also commissioned a Research and Information Service paper on A&E waiting times and are holding an evidence session with the Department on the acute service budget for 2012-13.
The other issue of major concern with patient safety that the Committee has been dealing with is the pseudomonas outbreak at neonatal units. The Committee held a special meeting during recess and was briefed by Professor Troop on her interim report, which contained 15 recommendations. At our meeting tomorrow, we will consider a letter from the Minister detailing the update on those recommendations. We will all be very interested in that.
The final report from Professor Troop will be published towards the end of May. In advance of that report, the Committee will visit the neonatal unit at the Royal to see conditions for ourselves.
In conclusion, the Committee wishes to see patient safety as the number-one priority and calls on the Minister, the Health and Social Care Board, and the trusts to do all that they can to make that a reality. Go raibh míle maith agat.
John McCallister (UUP)
I congratulate Ms Bradley on securing today’s debate. In her opening remarks she set out the main themes of patient safety, people’s concerns, and how we identify the shortfalls when the system goes wrong. An important message to get out from the House is that, fortunately, most incidents are low or are not harmful at all.
As a general view, the fault in our hospitals is the fault of the systems; it is not the fault of the staff. Generally, when things go wrong the system is to blame; it is no reflection on the high quality of the staff that we have working across our health and social care system. Patients and families rightly expect a top-quality health service; that is what we all demand and want for our families and loved ones. We have to get the systems right because, ironically, people can be at more risk in hospital than at home.
Later, Ms Ramsey will speak about the tragic effects of the pseudomonas outbreak. We have also had issues with clostridium difficile across the hospital sector, particularly in Antrim Area Hospital. Therefore, it is about looking at where the systems let us down.
As Ms Bradley pointed out, it is about recording the issues and about identifying problems and learning from them, whether in primary or secondary care or in the community. When things go wrong, it is important that the health service says that mistakes have been made and that we identify those mistakes quickly and change the system to take account of that. It is important to deal with those mistakes and empower patients to feel that they have a voice in the system and that things will change if they highlight where problems are taking place.
I agree that there is an economic cost to the health service when things go wrong. Fortunately, as has been said earlier, most of the cases are lower risk, apart from the obvious awful example of pseudomonas, where the cost to families is immeasurable; none of us would ever want to be in that position. However, there is a cost to extended hospital stays, which is a major problem in the health service and a major strain on resources. That is why the risk has to be reduced.
I am under no illusion that we will ever eliminate risk totally. However, it is about managing and minimising risk, identifying problems quickly and dealing with them quickly and correctly, having a swift response and telling patients that there has been a mistake. Therefore, it is important to get the systems in place. Patients rightly expect the very highest standard of care, as we all do. If we get the systems right, the staff will respond, because it is the systems that have traditionally let us down in that area.
I join with colleagues in thanking Ms Bradley for bringing the motion today. Before addressing the substance of the motion, it is worth reflecting on the Assembly’s credibility to critique the health service and health managers when it is so deficient in its own functioning at times.
These are gravely serious issues, and I have huge sympathy for the Minister and the position he finds himself in as the political head of the health service here in Northern Ireland. We can come to the House with private Members’ business. The only business today is private Members’ business; in fact, since Easter, all the House has had has been private Members’ business. When you hold that against our ability to do what we were sent here to do by the people — to legislate — I think many in other positions of authority outside of the political sphere can, unfortunately, point the finger back at us.
Jim Wells (DUP)
There was a written response from the Minister yesterday about the potential legislation coming through from the Department. Can I guarantee the Member that, by the end of this calendar year, he will not be disappointed about the legislation that is coming forward?
The record stands for itself. We have had six Bills since we came back from the election. Three of them were Budget Bills, which were unavoidable; one was introduced by my colleague the Minister of the Environment; another was introduced by the Minister for Social Development. That is something that does not make us very credible when it comes to calling on others to up their game. I want to put on the record of the House my appeal to everyone who is in a position to influence these matters to up their game.
I move now to patient safety. It is undoubtedly the case that public incidents, such as the tragic death of an elderly man in the Royal Victoria A&E recently, undermine public confidence in the health service. They drill down into public fears and apprehensions about the state of our health service.
It is also worth noting that, in 2006, the Department of Health, Social Services and Public Safety produced a report, ‘Safety First: A Framework for Sustainable Improvement in the HPSS’. In that report, the Department talked about changing the health service’s culture in order to create a culture in which safety was able to be prioritised. It identified several key characteristics of a culture that puts safety first, which are:
“a reporting culture; a just culture; a flexible culture; and a learning culture.”
The report goes on to say:
“A just culture is one that is seen to be open and fair to staff. Creating such a culture encourages the reporting of incidents, which is essential to the success of data collection and subsequent improvement in activity, systems, and care.”
The report talks about an open and fair culture as one in which staff are not blamed, criticised or disciplined as a result of genuine slip-ups or mistakes that might have led to an incident. However, where serious misconduct or gross negligence has taken place and where there would be robust discipline, the report talks about determining the concept of blameworthiness and about making sure that the organisation as a whole is able to learn from mistakes, when they happen.
I would like to hold that report of 2006 up to recent experiences in the health service, because when there have been slip-ups and mistakes in the health service in recent times, what have followed have been witch-hunts. So, we need to ask ourselves whether the culture of the health service is undermining its own ability to promote a safety-first culture.
My appeal, from my seat today, is for people at every level in the health service to understand that a culture that is based on the principles outlined in that document would keep patients safer, promote active learning and not leave many health service professionals concerned about the consequences of reporting, internally or externally, which is their right and, many would argue, their duty.
I hope that from today’s debate we are able to promote a culture based on —
Kieran McCarthy (Alliance)
I also express my gratitude to the Members who tabled this very important motion. The Alliance Party fully supports the motion, which talks about patient safety across the health service. We would also include safety for everyone engaged in providing a first-class health service throughout Northern Ireland, be that patients, staff, ambulance or fire crew or whoever. We fully support the zero tolerance initiative, outside and inside a hospital setting.
Concern has to be expressed about patient safety, given the huge cuts imposed by the Tory-led Government at Westminster, which, undoubtedly, will have a significant impact on all services provided by the National Health Service here in Northern Ireland. Stern warnings have been issued. In September last year, it was reported that health chiefs admitted that:
“they will fail to meet a range of ... targets laid out to ensure patient safety and minimise suffering for ... the most vulnerable ... in society.”
The motion calls for:
“a robust strategy to promote patient safety”.
In November of last year, the Department issued a 10-year strategy to promote and improve quality in health and social care here at home. That comes under three headings: safety; effectiveness; and patient and client focus. We all acknowledge that providing health and social care is a complex, sophisticated and, indeed, increasingly technological service involving a diversity of people working together in multidisciplinary teams, providing this service day and night, all year round. They work through, in a compassionate and professional manner, an enormous volume of engagements each year, be it hospital admissions, patient appointments or consultations, and so on, with patients, families and carers at a time when they are in pain and suffering. For all those people, it is a fundamental expectation that the service they provide will be as safe as possible. The unfortunate fact is, of course, that, in such a highly complex and stressful environment, things can go wrong. Thankfully, it is in only a tiny proportion of cases that mistakes are made. However, a high-quality healthcare service needs to protect and improve by learning from all such happenings and so minimising the chances of them happening again. There can never be room for complacency. Safety must always be an aspect of quality that needs to be guarded. Equally, a high-quality service should mean that the services provided are the right ones, at the right time and in the right place. In other words, they must be effective in dealing with the clinical and social needs of patients. Just as importantly, services must have a clear patient and client focus. There is abundant evidence that such an approach delivers improved health and well-being outcomes. They, the patients, are entitled to be treated with dignity and respect, and must be fully involved in decisions affecting their treatment, care and support.
In conclusion, patient safety must be at the forefront of this and any strategy. I, on behalf of the Alliance Party, fully support the motion.
Gordon Dunne (DUP)
I welcome the opportunity to speak on what is a very important matter for everyone in Northern Ireland. Patient safety must be the central priority across our health service. I believe that now is the time to put in place a robust strategy to promote patient safety and ensure that it is the top priority.
Everyone in Northern Ireland quite rightly expects and deserves a high level of service, whether that is in a front line hospital setting, a community location or even their home. I welcome the work to date by the Health Minister, Edwin Poots, in prioritising the needs of patients. I trust that this important work will continue. I would add that the vast majority of complaints that we get from constituents are not about the standard of care in our health service, but about getting into the system, delays, waiting lists and trolley waits. Those are the real issues that need to be addressed.
I welcome progress on the Quality 2020 strategy, and I trust it will lead to real advantages in our health service. The three significant themes of any strategy aimed at improving patient safety are quite rightly set out as safety, effectiveness and a focus on patients. I welcome the ambitious and positive strategic vision set out for Northern Ireland, which is that it should be seen as a leader for excellence internationally and, most importantly, by the people of Northern Ireland, who quite rightly deserve the high level of patient safety for which we strive.
Patient responsibility is an important issue. Patients also have to act responsibly. The abuse and overload of our A&Es by those who do not need treatment at such a location needs to be addressed. Attacks on our staff within hospitals must stop, and so, too, must failure to turn up for appointments. All those issues have a negative effect on patient safety and the quality of care.
We have many positives and strengths within our health service, not least one of our best assets, our staff, who provide an excellent service to our population and go about their work in a professional and dedicated manner. I know of many staff who make many personal sacrifices on a daily basis to help improve patients’ lives and quality of care. In any strategy, staff have a key role to play in setting up and implementing changes and improvements. There is a need to ensure that staff are equipped with the necessary skills and knowledge to improve and implement changes in our health service. There is a feeling among staff that the system is too bureaucratic, with a top-heavy management structure in place. Staff need a sense of ownership and an improved sense of morale, and they need to become fully involved with any proposed changes. The provision and carrying out of health and social care is complex, and the reality is that it will never be fully error-free. However, there is always room for improvement, and we must ensure that any potential risk is kept to a minimum.
I welcome the commitment in the strategy to a person-centred approach, a fundamental approach that must be fully implemented. Quality is about patient satisfaction, and quality of care is about patient care, setting standards, working to ensure compliance through quality systems, monitoring performance, and ensuring non-recurrence of issues that arise. Those are the basics of quality improvement, and it is important that standards continue to rise. We must strive to ensure quality of care.
An effective partnership and communication between those who receive care and those providing services must be in place. Improving communication can often be one of the most cost-effective, practical and effective measures that can help to improve patient safety and the quality of their care. We need to ensure that trust and confidence between patients, their families and staff are maintained and improved. I support the motion.
Mickey Brady (Sinn Féin)
Go raibh maith agat, a LeasCheann Comhairle. I, too, welcome the important motion before the Assembly.
Paula Bradley talked about hospitals being “a safe and controlled environment”. I suppose that a simple approach in considering that would be to ensure that people come out of hospital in better condition than when they went in. Unfortunately, that has not always been the case in recent times.
Many years ago, when I was relatively young, when you went into hospital the first thing you smelt was disinfectant, so there was a perceived atmosphere of cleanliness and hygiene. At that time, obviously, there was a different regime, with matrons, etc. You had probably 10 people cleaning five wards, whereas now you have five people cleaning 10 wards. Presumably, that is because of reduced finances: we may be told different, but that seems generally to be the case.
As to what has been happening lately in relation to the implementation of the Compton review, we have been told that there will be streamlining and cutbacks in hospitals. Will that increase patient safety?
If it does not improve patient safety, will management be held accountable? The incidences of patient safety and people who suffered particular injuries in hospital were alluded to, although with MRSA that has been a huge problem. In the Northern Health and Social Care Trust within the past few years, with clostridium difficile, a number of elderly people died. That needs to be addressed.
Paula Bradley talked about the health service being multifaceted. I want to raise a concern with the Minister, which is the issue of patients’ safety within their own homes. Many of them are older people who have been discharged from hospital early and who need a very good support infrastructure in their homes. There are numerous safety risks for an elderly person, particularly one who has been ill and is in recovery.
One issue that needs to be addressed is malnutrition, because that affects more than one in three adults admitted to care homes and into hospital. For a lot of older people who live in their own homes, social isolation can result in disinterest in food, and immobility may lead to difficulties with shopping and preparing, cooking and eating food. Problems with incontinence may stop individuals from eating and drinking normally, and innocent medication can result in reduced appetites. These are all people who are suffering from particular illnesses and, at some time, may be admitted to hospital. However, obviously, the issue is to try and prevent that happening.
It has to be said that malnutrition is a significant burden on the health sector. The estimated expenditure on malnutrition-related disease in England, Scotland and Wales, and here in the North, in 2007 was thought to be in excess of £13 billion.
Many older people prefer to stay in their own homes within their communities, and meals on wheels are a positive measure to fulfil that ambition. Age NI recently highlighted that low-level services such as meals on wheels can enable older people to live independently and may prevent the development of significant health issues later in life.
Kieran McCarthy (Alliance)
I am very grateful to the Member for giving way. Does he agree that great concern must be expressed about the recent lifting of the bar in relation to eligibility for meals on wheels? As a result, there is a huge reduction in the number of people receiving meals on wheels.
Mickey Brady (Sinn Féin)
I thank the Member for his intervention. Certainly, he raises a very important point. Many on the Health Committee have been out with the service and have seen at first hand how important it is. Meals on wheels provides not only a nutritious diet for older people but also a safety and welfare check. In some instances, it is set up in conjunction with social services, and if the delivery person has concerns, people can be contacted immediately.
In four of the five health trusts, persons aged 85 and over were the largest cohort receiving meals on wheels at the end of March 2011. Those who carry out the service should be highly praised for the work they do, as should all staff in the health service. I do not think that what we are talking about in relation to patient safety is by any stretch of the imagination a criticism of the staff who do fantastic work in the conditions that they are sometimes forced to work in.
I commend the work being carried out to combat malnutrition, but not enough measures are being carried out to tackle the issue of patient safety in a community setting. I ask the Minister to treat patient safety as a priority, especially within the community setting, and to take a proactive approach in identifying and minimising such risks for patients.
George Robinson (DUP)
I congratulate my colleagues in bringing the motion to the House today. It would be unfair if I did not, first, thank and commend the dedicated staff of the health service for all the great work they do, day in and day out, and remind people that although errors sometimes occur, staff are never praised enough when things go right, as they do on a daily basis, 99.99% of the time. I also condemn anyone who abuses the valued staff in our hospitals and A&E departments.
This is a debate that I welcome as I was involved in some patient safety issues in the last mandate, which were protracted and difficult to solve; a situation that will not, I believe, occur under the present Minister.
I also believe that the tools required to achieve the patient safety on which the debate centres are already in place. They may need some adjustments, but they are there to be used. What we must have is strict enforcement. We can have handbooks and guidance notes up to our ears, but if their contents are not implemented, there is no point in having them.
We have already seen this Minister act decisively when action needed to be taken. When the tragic loss of babies to pseudomonas was discovered, he immediately ordered changes of equipment to prevent further loss of life. I believe that this Minister is the one to tackle the challenge head-on, and do so successfully. It should also be stated that money is not the only issue that can help us promote patient safety. It could well be that greater enforcement powers are needed and that trusts need to take a proactive stance when it comes to hand-washing or the use of hand-sanitising gels on wards by staff and visitors alike.
Patient safety is delivered on the wards of our hospitals, in people’s homes and in specialist accommodation. Therefore, those areas are the front line in protecting patient safety. I firmly believe that the key to ensuring that we further minimise the small risk to patient safety lies in enforcement and ask that the Minister look especially at that area during his discussions on a patient safety strategy.
Samuel Gardiner (UUP)
I join others in expressing gratitude to Ms Bradley for securing this very worthwhile debate. It is for the benefit of all our people. Patient safety is a key consideration for the health service. I understand that as many as one in 10 of all people admitted to hospital suffers an adverse incident of one sort or another, such as falling out of bed or a cleanliness-related incident. It could also be an element of a surgical or post-operative procedure.
It is my understanding that the previous Health Minister, Michael McGimpsey, had taken steps to put in place a patient safety strategy, and I would be interested to know how that has worked out in practice. I am aware of findings that one trolley round in a hospital had been interrupted over 100 times by others calling it. It was decided that, in future, that round would not be interrupted for any reason.
Any patient safety policy needs to incorporate what are called “never events”, which are things that should not happen. They include wrong site surgery; wrong implants; retained foreign objects after an operation; wrongly prepared high-risk injections and medication; maladministration of potassium-containing solutions, such as IV fluids; wrong route administration of oral treatment; maladministration of insulin; suicide using non-collapsible rails; the escape of a transferred prisoner; falls from unrestricted windows; entrapment in bed rails; misplaced nasal or gastric tubes; administration of the wrong gas; failure to monitor and respond to oxygen saturation; misidentification of patients; severe scalding of patients; and maternal deaths after caesarean surgery.
That list serves to show how complex such a patient safety policy can be. It must be based on anticipated events. I say to the Minister that all those precautions have already been identified by the Royal College of Nursing as being essential parts of patient safety policy. The list grows longer each year.
Michelle Gildernew (Sinn Féin)
Go raibh maith agat, a LeasCheann Comhairle. Like others, I support the motion and thank its proposer for bringing the debate to the House today.
Upon hearing Mr Gardiner’s list and the issues covered by colleagues in the House this morning, one could be forgiven for thinking that hospitals are not very safe places. So, from the outset, I want to commend the work of staff not just in our hospitals but in nursing homes and right across our healthcare system, because they do challenging and difficult work daily to protect people in hospitals. Notwithstanding that, we recognise that there are very many issues with patient safety and that certain things could be done much better. Ms Ramsey covered, for example, the whole issue of A&E and what the Health Committee is doing to try to ensure that the safety of patients in A&E is better than it has been of late. Obviously, that issue has received quite a bit of attention in the media over the past weeks and months.
Mr Brady talked about nursing homes and emphasised the important issue of malnutrition. I welcome his raising of that issue, which has been highlighted a number of times in the House over the past decade. The fact is that many elderly and vulnerable patients who go into hospital suffer from malnourishment, so it is much more difficult for them to benefit from the treatments in hospital because their bodies are already so weak and starved. We in the House have also laboured the point about the whole area of prevention and about how the Minister should be looking at areas such as transport, particularly rural transport schemes, to help people to keep well and enjoy a better quality and much happier life, which keeps them out of the healthcare system and does not put a burden on the system.
To that end, I would like to talk briefly about the issue of osteoporosis, which was raised on the Floor of the House towards the end of last year, and about how effective treatments are not widely available at the moment, so our elderly population is not getting the benefit of them. We heard the staggering fact that, if somebody over 70 breaks a hip, they have a one-in-10 chance of seeing the anniversary of that fall. Yet, if they are in a nursing home, their chances increase to four in 10. So, it goes up from 10% to 40% just by dint of the fact that they live in nursing home accommodation. That says something about the level of patient care and safety given to people in nursing homes. So, I think that we have to get a handle on the issues that show that people are not getting the proper level of care and support.
Another issue that has been highlighted in the media — I understand that there is an ongoing inquiry about this — is the amount of drugs given to patients, especially those going for an operation, and the appropriate amount of anaesthetic that someone can receive depending on their size and weight. There have been a number of cases recently where babies were not given the proper amount of drugs, with tragic and fatal consequences. Again, to bring the point back to the fact that healthcare workers work in a very difficult environment, a mistake can cost a life, and to that end, there has to be a robust patient safety strategy in place to protect the most vulnerable.
I recognise that staff support, peer support and proper supervision are important for people who work in our healthcare system. If somebody is in doubt, they should have the confidence to ask a colleague, be it in their own hospital or another hospital, and the ability to seek a second opinion and get reassurance that the decision they are taking and the pathway they have chosen is the correct one for a patient. It is hugely important that staff know that there is a team of people around them to help them to come to the right decision. Equally, we need to give people the confidence to say something if they see a colleague administering medicine in a bad way or making the wrong decisions for patients.
Go raibh maith agat, a LeasCheann Comhairle. What I had been about to say has largely been covered, but I will reiterate my party’s support for the motion. It is very important that we put patient safety to the forefront of the Health Department’s thoughts. Obviously, a lot of the direction and thoughts of the Department have of late been, and will be increasingly, focused on reducing expenditure because of the Budget that this Assembly passed last year. However, it is vital that, when these efficiencies are being sought, patient care is not compromised in any way.
I congratulate the proposers for the timeliness of the motion in the wake of some highly publicised and very tragic incidents over the past couple of months, many of which could have been avoided had there been greater emphasis on public safety. I also echo the sentiments that some of the contributors to the debate have expressed about health servants and the huge and important role that they play. The Assembly must do everything that it can to support them in their role.
Jim Allister (Traditional Unionist Voice)
It is good to have an opportunity to discuss something that is much more relevant to our constituents than some of the business that we discussed, for example, yesterday in this House, when, as time fillers, we ranged far and wide into excepted and foreign matters and all sorts of things, so it is good to return to an issue that is germane to the —
Jim Allister (Traditional Unionist Voice)
Yes, I am just setting the scene, Mr speaker is in charge of proceedings of the House of Commons in..." class="glossary">Deputy Speaker. It is good to have an opportunity to talk about something that is germane to our constituents.
Of course, by its very nature, when things go wrong in our health service we all hear about it. Equally however, when, on the vast bulk of occasions, things go as they should, we never think about it and we rarely hear about it. Therefore, it is right to record our appreciation and respect for the staff who keep our health service ticking over adequately and functioning, in the main, successfully.
Jim Wells (DUP)
The Member raises a valid point. Two weeks ago, the Southern Health and Social Care Trust won the award for the best telemedicine service in the United Kingdom, beating scores of trusts throughout England, Scotland and Wales. The Minister, quite rightly, held a reception in the Long Gallery to mark that tremendous performance, which got about one inch of media coverage. That was a good news story, but, sadly, the media were not interested in it. It is only interested, as the Member said, in the occasional event when things go wrong.
Jim Allister (Traditional Unionist Voice)
I am not entirely going to join in on media-bashing, because as politicians we all use the media in our own ways, but it is a legitimate point that, when the health service works as it should, very often none of us have anything to say. When things go wrong, of course, we all have lots to say. Nevertheless, the staff are there for the good times and the bad times, and we appreciate all that they do.
I wanted to focus, in the couple of minutes that I have, on an issue that has not yet been mentioned in the debate. When a patient has recourse to the health service, we are not just talking about their care when they get to hospital and in the hospital — we all know about rising waiting times and all that — but, very often, when patients avail themselves of the emergency services, about the time that elapses between the call to the ambulance and when it arrives and takes them to the hospital.
The Minister will be aware of a reply that he gave to me a few weeks ago about the downtime of ambulances and how we had, in some of our hospitals in the sample month of February, very unacceptable downtimes — the time that passes from when the patient arrives until he or she is handed over to the professional staff in the hospital. In one case, the downtime was five hours and 26 minutes — a staggering period — from when an ambulance arrived at the Ulster Hospital until it was free to leave again.
In a number of cases, it took two hours or three hours, which is utterly unacceptable. My purpose in making that point is my concern for the patient in such a situation. During that time, the patient has not been handed over to the nursing and healthcare staff in a hospital. What about the patient’s safety at that time? That, equally, has to be a radical concern for us all. Therefore, when the Minister responds to the debate, will he be able to tell us whether steps have been taken and guidelines are in place to expedite the handover period for patients? The answer that I was given covers all eventualities. It could cover the unlikely situation of an ambulance breaking down until it leaves a site again, but it is quite clear from the volume that, if 30% of ambulance downtimes at the Royal Victoria Hospital and the Ulster Hospital were taking more than 45 minutes, it has, patently, to involve lengthy delays for patients being held until they are handed over, whether in the corridor or elsewhere. I trust that, in responding to this debate on the concept of safety, the Minister might be able to reassure us that steps are being taken to address that issue.
This might be the first debate since the matter arose, so when the Minister responds, might he have the stature to apologise publicly to the Member for Strangford Mr McCarthy for the quite appalling and unparliamentary terms that were used to him in a previous debate?
Edwin Poots (DUP)
I have listened with considerable interest, and I welcome the opportunity to respond to this important motion and, indeed, to the important issues that Members raised. From my first day as Minister, I have made it clear that the underlying objective for me and, I believe, all the people who work in our health and social care system is to protect and improve the quality of those services. That means that services must be safe, effective and focused on patients and clients, who must, rightly, be at the heart of everything we do. For that reason, I launched my Department’s quality strategy, ‘Quality 2020’, in November last year, a copy of which can be accessed in the Assembly Library or on my Department’s website.
Mr McDevitt raised the issue of the business that we conduct in the House and the current lack of legislation in the early part of this Assembly mandate. If we were to compare our business in the first term with that of Scotland or Wales, we would find that they are not in a much different position with legislation. Legislation often takes around a year to come through, and Members should reflect on that. This year, we introduced strategies for mental health, nutrition, allied health, maternity, obesity, and investment, and this quality strategy, Quality 2020. The strategies are not just pieces of paper but important documents that set clear guidelines for people who work in our system. We expect those people to adhere to the guidelines, which should not be taken lightly or treated as some frivolous kind of business. They are serious elements of business, and we need to respect that. In the previous mandate, as Minister of the Environment, I think that I introduced eight pieces of legislation in the space of two years. That will not be happening in the Department of Health, Social Services and Public Safety, because it is not that type of Department. We will focus more strongly on strategies as a way forward.
Quality 2020 builds on the work of the past 10 years, and its purpose is to create a new strategic framework and a plan of action that will help to promote and improve quality in health and social care services.
Mr Gardiner said that the previous Minister had launched a number of initiatives on patient safety. One of those was the safety forum that was launched in 2007, and that has had a significant beneficial impact over time.
We want to present a clear vision for the future in which the health and social care system aspires to be recognised internationally, but especially by the people in Northern Ireland, as a leader for excellence in health and social care. That is a huge challenge, because we can see that we have more and more work to do. We have an older population, and we have many new medical devices and new drugs that will prolong people’s lives. That is a good thing, but it applies greater pressure to our system, and our budgets are largely flatlining. So, in all of that, we have huge challenges to meet to enable us to deliver on the demands that are expected of us. We have to be innovative and assertive in how we go about our business to achieve that.
We recognise that, over the next 10 years, we will have major challenges, but we also recognise that many opportunities lie ahead, and we should ensure that we are ready to deal effectively with the challenges and opportunities in order to protect and improve quality. This is the vehicle through which I plan to progress priority work to further promote high quality in health and social care in Northern Ireland.
It is important to note that Quality 2020 defines quality for health and social care by three key components: safety, effectiveness and patient focus. In particular, Quality 2020 builds on our achievements in assuring patient safety over recent years, including embedding robust clinical and social care governance practices and procedures through which health and social care bodies are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical and social care can flourish. That also includes creating an informed, open and fair safety culture across the health and social care system, raising awareness of risk, sharing learning, implementing change, ensuring compliance with recognised best practice, and involving and communicating with the public. It also includes establishing links with a number of external agencies as a source of expertise, such as the National Patient Safety Agency and the National Institute for Health and Clinical Excellence, and the establishment of local agencies to provide assurance and spread best practice, such as through the RQIA or the HSC Safety Forum.
It is recognised internationally that healthcare is not as safe as it should or, indeed, could be. Frankly, unintended harm and unnecessary deaths are too frequent an outcome in all healthcare systems, and Northern Ireland is not an exception in that regard. There are many factors that impact on the safety of care, including organisational leadership, governance systems, policies and processes, the work environment, team communication, task complexity and patient characteristics as well as the knowledge, skills and motivation of staff. Given the multiplicity of those factors, it is well established in research that most of the unintended harm and unnecessary deaths are due to a combination of circumstances within a system rather than the failings of a single individual.
It is essential to recognise that the vast majority of patients experience care that is safe and of a very high quality. Indeed, two million people are treated each year in Northern Ireland. Obviously, people are being treated more than once because that is a greater number than our population. However, the fact is that, on occasions, very often in very complex and stressful environments, things will go wrong for a variety of reasons. While that only applies in a tiny proportion of cases, for those patients involved, any harm is traumatic. So, for us to deliver a high-quality health and social care service, it is absolutely vital that we learn from those occasions and apply consistency, minimise risk and, where possible, eradicate that. There can never be room for complacency. Safety will always be the component of quality that needs to be guarded as foremost and continually improved.
Quality 2020 seeks to support existing patient safety arrangements established in HSC, which are already delivering quality improvements. The strategy aims to transform the culture. That means creating a new, dynamic culture that is ever more willing to embrace change, innovation and new thinking that can contribute to a safer and more effective service. It also aims to strengthen the workforce. We want to equip those who work in the health and social care system, including the volunteers and carers — they are very important people in the system — with the skills and knowledge they will need to deliver safe, effective services.
We want to measure the improvements. That means improving outcomes measures to ensure the delivery of continuous improvement. We want to raise the standards to produce a coherent framework of robust and meaningful standards against which performance can be assessed. Benchmarking is vital. We want to integrate the care, to build on Northern Ireland’s integrated health and social care system and develop integrated pathways of care for patients and clients to improve the quality of experience for them.
I have recently approved the implementation plan for Quality 2020 and am happy to share that with Members, particularly the Health Committee. Its implementation will lead to various initiatives, including those focused on patient safety, supporting the many initiatives of the health service organisations in the work that they undertake in seeking to fulfil the statutory duty of quality. My officials will now commence the establishment of the management structures and delivery mechanisms, which will be led by the Chief Medical Officer, with the first meeting of the steering group being scheduled within the coming weeks.
The implementation plan identified a number of projects that need to be initiated immediately and progressively over the first three years, with one, in particular, focused immediately on managing implementation and compliance with safety alerts. Thereafter, triennial reviews will reassess priorities in order to protect the integrity of the strategy and to continue protecting and improving quality, including safety of services.
I am heartened by the correspondence that I receive from members of the public, indicating that they are receiving good quality care. When they listen to some of the stuff that goes out in the media, a lot of them will put pen to paper and pass on the message about what really happens in our health and social care system. I want to pay tribute to the excellent staff that we have for the hard work that they engage in and for the fact that they deliver, day and daily, for tens of thousands of people across Northern Ireland. We need to give them the appropriate recognition for the work that they engage in in a safe way. We want to ensure that we support them in doing that.
Mr Allister raised the issue of ambulance downtimes. He referred to a particular circumstance in the Ulster Hospital, where the ambulance downtime was five hours and 26 minutes. I understand that, at that time, the norovirus was present in the Ulster Hospital for around two weeks and that the hospital was under exceptional pressure, which it dealt with and overcame in due course. That was a very difficult period that it had to deal with at that point. For individuals, remaining in the care of paramedics is remaining in the care of people who are skilled at a particular task. Should that person’s condition deteriorate, paramedics will avail themselves of other services and, indeed, other staff within the hospital to ensure that patient safety is upheld.
We need to develop and alter the system to ensure that there is a better flow of patients through our hospitals. Patients should not arrive at the accident and emergency department and be pushed through the system; rather, a flow should already exist, and accident and emergency departments should not have to wait as long to get people into the main-stay wards, where appropriate.
I am also of the view that our emergency departments should have the best staff with the best diagnostic equipment at the front door of the hospital, because I believe that that can substantially change the number of inappropriate admissions to hospital and ensure that we can move forward. To do that, we will need to have consultants on emergency departments at those critical times. Therefore, people who want a multiplicity of emergency departments manned by junior doctors across the country will not be able to achieve that.
In concluding, I am strongly committed to the principle of protecting and improving the quality of health and social care services, especially safety. As a key component of quality, patient safety has been and continues to be a priority for me and all those working in the health and social care system. I am convinced that Quality 2020 is a robust strategy that will play a major role in protecting and improving the quality, especially the safety, of health and social care services for the people of Northern Ireland over the next 10 years.
Finally, I thank those who tabled the motion, and I am grateful for the helpful comments that were made during the debate. I assure Members that all the points that were raised will be addressed as part of the implementation of Quality 2020. In that way, the people of Northern Ireland should know that no effort will be spared in ensuring that our health services will be of the highest possible quality, thus safe, effective and focused on patients and clients. I am convinced that, by that means, we can truly become a leader for excellence in health and social care.
Jim Wells (DUP)
Mr speaker is in charge of proceedings of the House of Commons in..." class="glossary">Deputy Speaker, 1 May 2012 will go down as “Health Day” in the Assembly. In addition to this debate, we have the debate on pseudomonas later and questions to the Department of Health. Indeed, three important health events are going on in this Building. We have a pain summit in Room 115, a multiple sclerosis reception and one of our leading consultants, Dr Morrow, is to receive a justified award at 5.00 pm. Given that today is just an insight into what is going on, it indicates the intensity of the workload in the Health Department.
I am disappointed that, with the exception of Mr Robinson and Mr Allister, to a large extent, this debate has been a case of the Health Committee talking to itself. Health is an important Department, and it is responsible for 40% of the expenditure of the Northern Ireland block grant and employs 70,000 people. So, it disappoints me that the only Members who showed interest in a debate about such an important Department are, with one or two exceptions, Health Committee members. As an Assembly, we need to address that issue. This was an opportunity for those without the insight of the Health Committee to express their concerns and make other comments about this issue, but that did not happen.
Kieran McCarthy (Alliance)
I am grateful to the Member for giving way. He will be delighted to know that not only are a number of MLAs here interested, but, above his head in the Public Gallery, a class from Drumlins Integrated Primary School in Ballynahinch is listening to his contribution.
Jim Wells (DUP)
Mr speaker is in charge of proceedings of the House of Commons in..." class="glossary">Deputy Speaker, of course I did not instigate that particular transgression.
I congratulate North Belfast Member Paula Bradley for raising this issue in the Assembly. She made the important point that most of what are called accidents arise from consultants, surgeons or other health professionals making genuinely honest mistakes. Given the huge numbers who pass through our hospitals and clinics in Northern Ireland, it is inevitable that mistakes are occasionally made or that proper action leads to unexpected outcomes. I was quite surprised by Mrs Bradley’s comment that 10% of all patients will suffer some form of harm, albeit that much of it will not be serious. There was also an indication that 2% of instances can be something about which to be very concerned.
The Chair of the Committee — I believe that she has been anointed permanent Chair, and I congratulate her on that — raised the issue of the Committee’s work on pseudomonas. The Committee took that extremely seriously and regards it as an absolute priority.
She pointed out, quite rightly, that the Committee responded immediately to the Minister’s request to return during the Easter recess to deal with an extremely serious issue in the health service.
John McCallister raised the point that systems and not people tend to be the problem. Indeed, systems and structures, rather than surgeons and staff, are the concern as far as health safety is concerned.
I thank Mr Wells for giving way. Of course, there is an issue with systems and structures, but there is also an underlying cultural issue. That issue was identified in 2006, and we need to keep it at the front of our minds when debating this issue. The culture in the health service needs to be open and allow self-critique, honest critique and, occasionally, whistle-blowing, without the fear of persecution or prejudice.
Jim Wells (DUP)
Yes; and Mr McCallister made that important point in his speech. He said that we require total openness and that, when the system, the structure or the culture goes wrong and something is amiss, there must be a willingness to come forward and honestly admit that a mistake has been made so that we can learn from it. I totally agree with him on that point.
Mr McDevitt spoke next, and I welcome him back to the Health Committee. He made a positive contribution in his previous sojourn on the Committee when I was Chairman, and I look forward to his future contributions. That is particularly so as he is a representative for South Belfast, where such a large and significant proportion of the health service estate is positioned.
Mr McDevitt said that he was disappointed with the lack of legislation. I hope that my interjection to him and the point the Minister made about the sheer mass of documents, strategies and consultation papers that come from the Department have eased his disappointment. I suspect that, if he recalls his previous time on the Committee, he will be looking forward to an extremely busy time during his new sojourn on the Committee. In my opinion, the Health Committee reflects the work of the busiest Department in the Executive, and I have never heard anyone on the Committee complaining about a lack of documents, strategies or written material coming before us. Indeed, I suspect that many of us complain that the workload is intense. However, having said that, Mr McDevitt made a positive contribution to the Health Committee previously and I welcome him back.
Mr McDevitt also asked for openness and fairness to staff, and I think that we all accept that. Having dealt with many of these issues over the past three years and with what are called serious adverse incidents, I very rarely found that staff members had gone in with the purpose or intention of doing something wrong, that they were lazy or did not pay attention to detail. Time and again it was genuine human error, and you have to accept that those things will happen. We cannot avoid risk, but we must manage it and stand up and find out where we went wrong and how we can improve things.
Kieran McCarthy was the next Member who spoke, and I have to be very careful about saying anything critical about him. However, as he often does, he lambasted the Department. I am sure that, in the village of Kircubbin, Mr McCarthy is a very pleasant and likeable man. Mr McCarthy blamed the cuts. Mr McCarthy, am I wrong in thinking that the Alliance Party is affiliated to the Liberal Democrats in GB? Is it not therefore in the coalition of the Conservative Party and the Liberal Democrat Party? Therefore, when you criticise the coalition Government, you are, to some extent, criticising your bedfellows in the Liberal Democrats, unless I am totally wrong about that relationship.
Like many other Members, Mr McCarthy raised the 10-year strategy and said that it is based on safety, effectiveness and a client focus. The Minister went further and explained exactly what he proposes to do with the outworkings of that strategy.
Gordon Dunne also raised the 10-year strategy and welcomed the progress that has been made. I think that he made a very interesting and novel point. He said that responsibility is on not only the health clinicians, the Minister, the trusts and the boards; it is also on the patients. I was alarmed at a recent question for written answer about the incidents of alcohol abuse in hospitals. Indeed, the Minister has statistics that reveal that 30% of the patients who report to Altnagelvin Hospital are under the influence of alcohol. That is placing an intolerable burden on staff, particularly those who work in A&E departments at night and at weekends. There is a responsibility on the general public — the 1·8 million of us who use the health service in Northern Ireland — to act responsibly and to not place intolerable burdens on those who are trying desperately to look after us from the cradle to the grave. Why, I wonder, are we having difficulty getting junior doctors to work in A&Es at night and at weekends, when one in every three patients they encounter — indeed, on a Saturday night, it is probably a lot more — is under the influence of drink and abusive?
Just yesterday, another written answer — I do read the copious written answers that the Minister provides — highlighted the sheer extent of resources being allocated for security staff in our hospitals, particularly the Belfast big three. Money is effectively being used to prevent patients from attacking or abusing hospital staff, and that is a waste. I found the statistics provided yesterday quite frightening.
Mickey Brady brought up the issue of looking at the whole health service, not just A&E. He was absolutely right to take us back to the fact that there is much more to consider than simply what happens under the surgeon’s knife, as it were. He raised the issues of cutbacks in meals on wheels and malnutrition in hospitals. He mentioned the shocking statistic that one in three people over a certain age is malnourished.
George Robinson, quite rightly, highlighted the swift action taken by the Minister in dealing with recent incidents affecting patient safety. We all remember, for instance, the Minister initiating the Troop review. Within three months it had reported back, and we will get the full report on 31 May. That is in stark contrast to other ongoing inquires that were initiated by previous Ministers, took years even to get going and could take a decade to report. Therefore, effective, quick action has been taken. Indeed, when there was clearly an issue of patient safety in the Belfast Trust, the Minister came in very quickly and enforced special measures on it.
Jim Wells (DUP)
I thank all Members who took part in this useful debate.
Question put and agreed to.
That this Assembly calls on the Minister of Health, Social Services and Public Safety to put in place a robust strategy to promote patient safety across the health service.