I want to explore some of the detail of the clause, not least by means of the impact assessment. The clause will abolish the National Patient Safety Agency, which is tasked with promoting and ensuring patient safety, which clearly is of paramount importance. During our deliberations we have heard a lot from the Government about the need to protect patient safety and about what the Bill will not do on that, so it is worth having some debate on the NPSA and the implications of the Government’s proposals.
A number of people and organisations outside the House have raised concerns about the proposals. According to the Royal College of Nursing
“the agency has a critical role in collecting data on patient safety problems, and identifying trends and patterns of avoidable incidents as well as supporting ongoing education and learning.”
Given the numerous incidents in the lifetime of the NHS, collecting data and identifying trends and patterns of avoidable incidents are important. We need to be satisfied that patients are well looked after and that the Government’s changes provide such confidence. I will not go into specific patient safety incidents, but no doubt the hon. Member for Stafford could spend a long time talking about that in the context of the Mid Staffordshire trust and related areas.
The Royal College of Nursing cites the example of the national reporting and learning system, which since its inception has received more than 4 million incident reports from health care staff. We know that most, if not all, staff pay a lot of attention to patient safety and that it is given a great priority throughout the health service, but mistakes are made. Human beings make mistakes: there are mistakes in procedures, mistakes in the provision of treatment and mistakes in the various reporting systems of the various parts of the health service. We cannot overestimate the importance of patient safety. The Royal College of Nursing also believes that as a result of the NPSA’s abolition
“the patient safety function is likely to become considerably smaller”.
It would be useful if the Minister commented specifically on that.
The Royal College of Nursing goes on to state:
“This causes some concern regarding retention of expertise and… quality and safety in the NHS.”
The Royal College of Nursing has built up massive experience and knowledge about patient safety and about the health service. The Minister might want to say where we stand in terms of people leaving the service or staying, and how we safeguard the experience and knowledge that are critical to improving safety in the health service.
In its report, “Smaller Government: Shrinking the Quango State”, the Public Administration Committee concluded that the Government’s current approach to arm’s length bodies
“is not going to deliver significant cost savings or result in greater accountability.”
That is an important consideration, although patient safety is paramount in our present discussion. It goes back to the Government’s whole approach to quangos and arm’s length bodies and whether there are real savings to be made, or whether it is the product of an ideological drive to make changes. I do not want to muddy the waters, but concerns have been raised about that generally. The Royal College of Nursing is concerned that patient safety could be compromised by a much reduced service resulting from the NPSA’s abolition. As I have said, the Public Administration Committee has stated that the Government’s approach to abolishing quangos does not necessarily deliver all that they said it would. I would like to hear the Government’s views on that.
The patient safety division function will become part of the remit of the NHS commissioning board. There was some debate earlier about this, but this is our first chance to discuss it in some detail. The impact assessment states that
“Only the functions relating to the PSD will require primary legislation”.
I am not trying to make a political point, but I would like the Minister to say a bit more about that. The impact assessment goes on to state that
“The work of the PSD relating to reporting and learning from serious patient safety incidents will move to the NHS Commissioning Board as a Patient Safety sub-committee of the Board.”
I understand from the impact assessment that that is supposed to happen by September this year. The Minister may want to say some more about that, because the timing and the scale of the change are clearly important. Given that the new body would be a sub-committee of the board, what assurances can the Minister give us on the priority and focus that the NHS commissioning board will give it?
Again, the impact assessment states that
“The work of the PSD relating to reporting and learning from serious patient safety incidents will move to the NHS Commissioning Board...This is intended to happen by September 2011.”
I have just mentioned that, but it is useful to repeat it. The impact assessment continues:
“The functions for which the sub-committee would be responsible (for overseeing or arranging) would include: Coordinating system-wide patient safety activity in the health service; Improving the safety of NHS care by promoting a culture of reporting and learning from patient safety incidences including adverse events or near misses; Devising, implementing and managing patient safety systems, or arranging for these, including providing for the existing national reporting and learning system (NRLS) and central alerting system (CAS), with a view to informing and disseminating learning; Appraising and analysing information on reported adverse events and near misses, identifying patterns of practice or service provision that appear causally related to unexpected or serious adverse outcomes.”
Those are exceptionally important areas of responsibility. Is the Minister confident that that can all be simply transferred and taken on by the board? As I have stated, according to the impact assessment it is intended that the sub-committee should be up and running by September this year.
The priority that the sub-committee will be given by the NHS commissioning board is important, as is the make-up of the sub-committee. I suspect the Minister will probably say that that is up to the national commissioning board to decide, but I wonder whether in drawing up this legislation the Minister has had discussions with the other Departments or with the health service as a whole about the possible make-up of the sub-committee. Although he could say that that is up to the NHS commissioning board—he might not say that; I might be pre-empting him—it is important that we know the level, calibre and responsibilities of people who could be considered for that sub-committee, in order to give us confidence.
I note with interest paragraph E98 of the impact assessment, the second sentence of which states:
“If the NHS Commissioning Board is set up with outposts, the strategic thinking and leadership on safety could sit at Board level, while support for operational delivery could sit with the outposts.”
That is interesting for a couple of reasons. When we asked whether the national commissioning board would have regional or local offices, we were told that that was completely up to the board to decide, yet the impact assessment suggests that there could be outposts. What is the likely outcome? [Interruption.] The Minister can intervene if he wants.
In earlier sittings, Ministers refused to discuss whether the national commissioning board would have regional offices—I think you were here for that, Mr Hancock. Whether or not the word used is “if”, the matter is discussed in the impact assessment. It is interesting to see that a regional office is known as an outpost—that might be some indication of how important the regions will be. I am not sure where the terminology comes from. Has the Minister had any more thoughts on whether having regional offices would be a logical extension? I want to repeat the quote for him, because this is important:
“the strategic thinking and leadership on safety could sit at Board level, while support for operational delivery could sit with the outposts.”
Is the Minister able to confirm the costs? Paragraph E103 says that
“the Department anticipates that there will be”—
“indirect costs, such as a loss in output caused by the underperformance of a disenchanted workforce during the transition period.”
I accept that it is in the impact assessment as a possibility, but it will be useful to hear whether the Government are thinking along those lines. Is there more information on the staff and how they are reacting? What safeguards have been put in place? The paragraph also mentions
“a loss of NPSA stakeholder assurance”,
which is important. Interestingly, the following paragraph says:
“There is a possible risk that bringing the PSD into the NHS Commissioning Board will lead to reduced importance for patient safety”.
I accept what the Minister says about the mitigating measures in that regard.
These are important matters. We are not trying to score political points, but asking crucial questions about patient safety and the changes that the Government are making. Part of our argument, which is very real, is about fragmentation. The whole reorganisation process will take a long time and many people will be involved, and they could take their eyes off the ball—that is in the impact assessment. It is important to get answers to our questions and assurances about the crucial area of patient safety.
I have three very brief points, and with them three very brief questions.
My first point follows what the hon. Member for Halton said about the importance of patient safety. Clearly, after the Mid Staffordshire experience, patient safety is now taken extremely seriously throughout the NHS—I am sure that it always was in most cases, but it is now at the forefront of NHS services. There are two ways to regard the abolition of the NPSA. Either it indicates that there is less emphasis on patient safety; or—the alternative that I subscribe to and the explanatory notes endorse—it embeds patient safety in the heart of the NHS. In fact:
“The intention is to ensure that patient safety is embedded into the health service through commissioning consortia and the contracts they agree with providers.”
I welcome that.
The hon. Gentleman makes an important point. Does he accept that our concern is reasonable? I hear what he says about a lot of emphasis being put on patient safety, and of course there is, but the health service is about to go through the biggest reorganisation in its history. There is a massive amount of work to do, ranging from work on clinical care and commissioning to pricing, accommodation and other reorganisation issues, so there could be a danger that people will take their eye off the ball, because the reorganisation will pull them so much in one direction. That is the point I was trying to make.
I thank the hon. Gentleman and I would underline his point. I was about to say that it is vital that the ball is not dropped in the transition between the NPSA and the embedding of patient safety in the heart of the NHS and the national commissioning board. Patient safety is of the utmost importance. I would like to hear the Minister’s reaction to that and to get that on the record.
Secondly, I ask the Minister to comment on the likely outcome of the Francis inquiry. I am sure that there will be a lot on patient safety, and I ask him what his reaction will be to any suggestions that might be made. Patient safety has been an important part of that inquiry.
My third point concerns the national research ethics service. It may be a minor part of the NPSA’s remit, but I see the risk of something falling between the gaps when I read the explanatory notes. Research ethics are key if we want to be at the forefront of medical research internationally—indeed, we are at the fore at the moment, and we must not fall behind. How will the Government ensure that there is no hiatus between the present provision under the NPSA and that envisaged in the Bill?
At the end of his speech the hon. Gentleman the Member for Stafford asked a question I was going to ask. It is clear that the clause abolishes the National Patient Safety Agency and moves responsibility for the national reporting and learning service to the NHS commissioning board, but it does not say what will happen to the national research ethics service, which guarantees or attempts to guarantee the safety and rights of patients involved in research and to promote ethical research; nor is it clear what will happen to the national clinical assessment service, a part of the NPSA which helps practitioners and managers to prevent patient safety incidents from happening.
I have an example of what the National Patient Safety Agency does from my own experience of running the ambulance service network. The NPSA’s work is very important, and I am concerned about its responsibilities moving to the national board. We did a large piece of work with the NPSA where it provided from the ambulance services all the reports of patient incidents where there were real safety concerns. Those incidents often happened during the handover period, when ambulances turn up at hospital or people are leaving hospital. The NPSA gave its initial findings to the network and we met with all our members from the various ambulance services and talked about how to increase reporting rates where appropriate—there were big variations between different ambulance services which did not make sense. We explored the data, saw what was happening, what the impact on patients was and what was going wrong. We held a big event where people could, in a safe environment, say what had really happened and why they thought things had gone wrong. We learned from best practice and from what other people were doing to try to reduce those safety concerns.
That is one small area of patient safety, yet a very important one that had not been looked at before. My worry is that the national commissioning board has so much else on its plate that it will not be able to do that kind of work in detail across a range of different areas. With the big reorganisation that the Government want, I do not think that that sort of work will be at the top of the national commissioning board’s agenda.
It is right that safety is integral to the work of commissioners. However, we know staff have been worried in the past about reporting patient safety incidents, basically in case they got into trouble. Now they are being asked to report incidents not to an independent agency, but to the very board that is responsible for driving the commissioning of their services. Are they likely to say, “We have had some safety problems” to the people who will commission their service? They will not, because they will think, “The board might not commission us if they think we have problems with patient safety.”
I have a practical concern: will the board be able to do what is required of it, with everything else that it has on its plate? I am also worried about a point of principle. Is it likely that services will report such incidents to the body that determines whether their services are commissioned in future? That is why I am concerned that the clause and the abolition of the NPSA have not been thought through.
In that case, I will not repeat concerns that my hon. Friend has just raised, but I will add one further, important illustration. The National Patient Safety Agency is responsible for both funding and monitoring the national confidential inquiries. Three are undertaken every year; they examine patient outcome and death, maternal and child health care, and suicide and homicide. NCEPOD—the national confidential enquiry into patient outcome and death—is particularly important to the NHS. It is one of the key investigative tools that the NHS has to provide it with meaningful scrutiny of outcomes—the most important outcome, which is whether patients die as a result of NHS treatment.
By way of further illustration, the most recent NCEPOD report, which was about deaths of patients within 30 days of cancer treatment, has been hugely influential in shaping the latest iteration of the national cancer strategy. I cannot imagine that NCEPOD is being abolished, so will its funding and monitoring pass to the national commissioning board? Is the Minister confident that among the commissioning board’s many other priorities, many of which will be administrative, it will have the requisite time and expertise to conduct that work? Is there not a danger that some of the expertise of the NPSA will be lost?
My second point, as ever, relates to Wales. The NPSA is a prime example of a body that touches Wales and England. Its remit covers both countries, and in passing its responsibility wholly to the national commissioning board, there is, as far as I can see, no provision in the Bill for what will happen in Wales henceforth. Which body will be responsible for the activities undertaken hitherto by NPSA? If I am wrong, and the Minister can point me to the place in the Bill where it says what will happen in Wales, I shall be grateful.
My third and final point relates to the national clinical assessment service. The explanatory notes state that it will move to being self-funding, which raises a question in my mind, related to the one I asked on Tuesday about the abolition of the Office of the Health Professions Adjudicator. My concern is that that will lead to less independent scrutiny of clinicians’ fitness to practice. What reassurance can the Minister give that, in becoming somehow self-funding, the important work that the NPSA undertakes in that respect will not become less rigorous? In other words, will people not want to use the service if they have to pay for it in future, which seems an obvious risk? Ditto—will that apply to Wales and England, or will Wales have to fund the service itself in future?
I shall try to work my way through the various questions that I have been asked.
With the opening remarks of the hon. Member for Halton, we returned to a debate on which we spent some happy hours at the beginning of the Committee: whether the NHS commissioning board would have a local or regional presence. As I tried to intimate to the hon. Gentleman, the impact assessment is drafted to indicate that that is an if and remains so. All I would say is that we have indicated that we expect, not least because the NHS commissioning board will have membership of the local health and well-being boards, that it will have some form of local presence. We expect the NHS commissioning board to have the responsibility for defining precisely how that is delivered.
The hon. Member for Halton made a point about the RCN and its view about the important role that is currently discharged by the National Patient Safety Agency. There is no difference between either side of the Committee on the importance that the Government attach to patient safety. We see that as a key priority for all those working in the health service. We cannot allow patient safety to be an add-on, or an afterthought. For that reason, the Bill puts safety at the heart of the NHS and not at arm’s length, which is how it is currently arranged.
Currently, the NPSA’s core function is to improve the safety of the NHS by promoting a culture of reporting and learning from adverse events. It does that primarily through the patient safety division, which runs the national reporting and learning systems. Functions of the organisation, while necessary in the system to support wider quality and safety improvement, do not of themselves need to be reformed at arm’s length from the Department. Safety is a key domain of quality and will therefore be a central priority for the commissioning board. Patients rightly expect that any service provider within the NHS, and funded by the NHS, should be safe.
The hon. Gentleman’s suggestion that somehow this is an example of fragmentation, is really nonsense. Clause 19 inserts new section 13M in the National Health Service Act 2006 to make provision to give the NHS commissioning board responsibility for the functions currently carried out by the NPSA: the collection of information about patient safety incidents, the analysis of that information, and the sharing of the resulting learning with all providers of NHS services—those who contract with commissioning consortia, or directly with the NHS commissioning board. There is a notion that having those functions in a nominally arm’s length body somehow makes them more effective than bringing them right into the core of commissioning activity and leadership within the system, which we think is a far more powerful way of driving a safety agenda through the NHS.
Let me address the question from the hon. Member for Halton about what will happen to the NPSA. We now know of the power the national reporting and learning system has for driving improvements in the safety of services; the NPSA’s national reporting and learning system is the most comprehensive system of its kind in the world, and we will preserve and improve on it. There is no intention for that system to be jettisoned as part of the transition.
The hon. Gentleman also asked about staff at the NPSA. The NPSA is working with its board and the Department of Health to ensure that a robust transition plan is in place to help protect staff. The NPSA has offered various forms of support to its staff, and, in December, embarked on a consultation with staff on the detail of proposals for staff. Indeed, the hon. Gentleman referred to paragraph E104 of the impact assessment. If we read on, it notes:
“Furthermore the transfer of staff to the NHS Commissioning Board will ensure that expertise in patient safety is retained and the commitments outlined above”—
in that clause of the document—
“will ensure that the role of patient safety - and the importance that patients place on safety under the NHS care - are maintained.”
That is an important part of the impact assessment, which it is right to refer to in this part of our proceedings as well.
I was asked when the functions will be transferred. The NHS commissioning board is unlikely to take on NPSA functions until early 2012. Abolition of the NPSA is expected to take place on 31 March 2012. Therefore, the suggestion that it will take place in September 2011 is no longer the case. Following discussions with the shadow chief executive of the NHS commissioning board, it has been decided to make clear, to ensure—
Derek Twigg rose—
Let me finish. This is a change from what has been said before, which is why I want to make it absolutely clear. The reason for the change is to ensure continuity through all aspects of the transition, and to ensure that moves to the NHS commissioning board are done in an orderly fashion. Let me, therefore, move on to deal with some of the other specific ingredients of that transition, and where things end up.
Just to be clear, paragraph E97 states that the transition will happen by September. I accept that these things change. The Minister has just said that it will now happen in 2012. What led those who wrote the document, and the Ministers who approved it, to think that the transition could be made by September 2011?
The thinking was that it was a task that would need to be dealt with at an early stage in the preparations of the NHS commissioning board. We have now taken the view that to maintain continuity in service and to work through the issues of staff transfer, it makes more sense to work on the basis of 31 March 2012 as the point at which the National Patient Safety Agency is abolished.
I was asked some questions about the National Clinical Assessment Service, the patient safety division, the National Research Ethics Service and the national clinical audit and patient outcomes programme. The patient safety division, which both reports on and learns from serious patient instances, should move to the NHS commissioning board as a patient safety sub-committee of that board, covering the whole function from getting evidence to working up evidence-based services. That will provide an opportunity to preserve the synergy between the learning and operational practice that already exist in the system. We are engaging with the National Patient Safety Agency to discuss the transitional arrangements for the patient safety division.
In respect of the questions about the National Clinical Assessment Service that were asked by the hon. Member for Leicester West and my hon. Friend the Member for Stafford, I have to say that the service is widely valued by doctors, dentists and pharmacists. However, there is an expectation that revalidation of the medical profession and other incentives in the system will reduce the need for such a service in the future. The National Clinical Assessment Service will become self-funded, and the Department intends to agree a date with the service for achieving that self-sufficiency.
Reference was made to the National Research Ethics Service, which helps to protect the interests of patients and research participants in clinical trials and facilitates and promotes ethical research. It also recognises and authorises research ethics committees that approve individual research applications. We propose that the future of the National Research Ethics Service is considered as part of the wider Academy of Medical Sciences review of research regulation with a view to moving the function into a single research regulatory body in due course.
The hon. Member for Pontypridd asked about the National Patient Safety Agency’s work in respect of clinical audits and so on. Currently, there are three confidential inquiries to provide learning about what went wrong in adverse health care incidents. In future, the inquiries would sit with the national clinical audit and patient outcomes programme, which consists of 30 individual national clinical audits managed on behalf of the Department by the Healthcare Quality Improvement Partnership.
Finally, let me come back to the over-arching point about patient safety. We are developing outcome measures for patient safety so that everyone can see how the NHS is performing and organisations can be held to account by the people they serve. My hon. Friend the Member for Stafford asked about the inquiry and the Francis report. I reiterate the point that I made to him previously. We are listening to that inquiry.
The Minister said at one point that if someone is a whistleblower, it is at least probable that they will want to refer to a commissioning body rather than to an arm’s-length organisation. There is no either/or in this. I was slightly concerned by what he said. I am well aware of a specialist commission in which there are serious accusations of incompetence on the part of surgeons. I am also aware of allegations that these whistleblowers have been treated extraordinarily badly within the organisation.
It is obviously very important that a whistleblower with an honest concern should find it easy to blow the whistle when appropriate. The whistleblower can do one of two things. First, they can blow the whistle and get in trouble with their own provider, which is a tough choice to make, especially if they are not guaranteed anonymity or protection. I can cite a number of whistleblowers who have been offered anonymity but that anonymity has been betrayed by the provider.
Secondly, given the scenario laid out in the Bill, the whistleblower can report to an organisation that directly commissions the particular service. I am not certain whether that will make a whistleblower more or less confident to do the important job of whistleblowing. The Government have made appreciable progress and their rhetoric gives the impression that they genuinely wish to make it easier for whistleblowers to report errors.
I may be asking for too much, but I wonder whether there is sufficient evidence to suggest that people are more comfortable going to a body that provides the wherewithal—the funding or the cash—for their organisation, even if it is one of its sub-committees, or going to a completely independent body. The hon. Member for Leicester West made that point, but it was not quite answered by the Minister, who seemed to suggest that that might be an alternative. However, it need not be an either/or if the net effect is that fewer whistleblowers feel secure in what they endeavour to do.
I want to come back in, because the Minister did not answer my question about Wales. Other members of the Committee with Welsh interests may not be concerned about having an answer, but I absolutely am. I am very keen to hear who will be responsible for paying for services in Wales that were previously carried out by the National Patient Safety Agency.
I welcome some of the things that the Minister said, but we still have serious concerns. The fact that the Government got the date wrong—the change was intended to happen by September 2011—is a serious concern, as we are talking about national patient safety. It is worth repeating, so that we can understand this, that the Government stated:
“The work of the PSD relating to reporting and learning from serious patient safety incidents will move to the NHS Commissioning Board as a Patient Safety sub-committee of the Board. This is intended to happen by September 2011.”
We have now heard that that will not happen until September 2012, and I would not put money on even that being the date. If they can get that wrong in their impact assessment, that is a serious issue that raises more concerns about their going apace with the whole process.
We are told that that is what the Bill is all about, but we have to examine the fragmentation caused by the Bill, the pressure brought about by both the reorganisation and the monetary constraints on people, and the speed at which the Government are trying to take the changes forward. That is why we have had this debate. We have found out only one nugget of information on one or two other interesting issues. I am interested to hear what the Minister has to say on the points that have been made, as we have serious concerns. Unless he can convince us otherwise, we will vote against the clause.
I will be brief, not least because we are expecting one or two Divisions at 3 pm, and there are still 20 clauses and two groups of new clauses to be dealt with. As a result, we may not manage to get to them all.
Patient safety is an important issue, and hon. Members are right to want answers to their questions. The hon. Member for Pontypridd asked about Wales, and I confirm that we have agreed the provisions in the Bill with the Welsh Assembly Government and that we are working closely with colleagues in Wales to ensure that both the transition and future arrangements are adequately managed.
On reporting, health care professionals working in the NHS have not only the right to protection in law, but a fundamental professional duty to raise with their employer any concerns they may have about the quality of patient care. They should feel free to raise legitimate concerns within their organisation and be supported when they do so. The Government have made it clear to NHS organisations that they should have policies and procedures in place to support and encourage staff to raise legitimate concerns, which should be acted on. We want to see a culture in the NHS in which whistleblowers can come forward and raise legitimate concerns without fear of repercussions or reprisals.
Of course, we are not changing the system that people can use to report such concerns; we are merely moving the function back into the heart of the NHS, where it properly belongs. How people access that function and make their reports is not changing. In that sense, people should have no doubt about how they discharge their responsibilities to patients. If my hon. Friend the Member for Southport writes to me about the details of that case, I will be only too happy to follow those matters up with him subsequent to our deliberations.
My final point is on the question asked by the hon. Member for Halton about the change of date. We are in one of those “damned if you do, damned if you don’t” situations, where if we had more detail—
Derek Twigg rose—
Let me finish the point. If we had more detail, we would be condemned for having rushed it, having far too much detail and prejudging things. However, when we do not have a level of detail and we come to an initial interim timetable, we are condemned for not having enough detail. The Department of Health has received an early business plan from the NPSA—
Derek Twigg rose—
No, I will not give way until I have finished this point, if the hon. Gentleman will forgive me. The Department of Health has received an early business plan from the NPSA. The proposed transition will be in September 2011. When tested, it was clear that more time was required for the NHS commissioning board to determine how to deliver these functions. Early 2012 was a more appropriate date. In other words, we are ensuring continuity of service during transition. That is the right and proper thing to do with the reorganisation that we are going through.
On the hon. Gentleman’s suggestion about pace, all I would say is this. We published the White Paper last July and consulted extensively. There were 6,000 responses. We had a Command Paper in December and the Bill was published this year. That is not rapid. The hon. Gentleman may want to paint that picture, but it is not a true characterisation at all.
Derek Twigg rose—
I was not going to come back in, but now I feel that I must. If more time is needed and if what was done in the beginning in terms of the date will not work out as intended, of course we welcome the fact that the measure has been delayed. We are talking about the Government’s impact assessment, which is supposed to be well thought out. What is the point of an impact assessment, if the Government do not think of the issues that will result from what is being proposed?
The Minister talks about the time scale, but it was not until the details—the Bill and the explanatory notes, whatever they are worth—were produced that people realised what the Government’s changes were about. They wanted to rush the Bill into the House of Commons as soon as they could, but they will not rush it to Report.
Division number 96 - 12 yes, 10 no