My Lords, I am last and probably least. I have a problem: how much do I say? I have been here and I have done this.
It has been mentioned that this will be the first time that a world-class patient safety organisation is developed. That is wrong; it is not the first. We had one. It was called the National Patient Safety Agency, which was established by another Secretary of State. It was internationally respected for the work it did, but another Secretary of State decided that it was a quango and got rid of it. I remember the conversation that I had. He asked, “What has it achieved?” I can tell your Lordships, it achieved a lot and I can give loads of examples. However, it had also failed to achieve a lot, partly because of the volume and the methodology; it was only a drop in the ocean. It was disbanded, and I tried to persuade that Secretary of State that he should give it more statutory powers that it did not have, particularly of investigation.
Of course I welcome this Bill, because it gives the HSSIB statutory powers to investigate incidents that occur within the health service, which is not easy to do. I agree that the experiences of the aircraft industry are not always transferable to healthcare. Healthcare is complex, and many other types of issues can arise.
I should declare an interest. For 37 years I have been a maternity care clinician. I have had other positions in my life connected with patient safety, not only as a chairman of the National Patient Safety Agency but also in Scotland, implementing patient safety across the health service in all its aspects.
The noble Lord, Lord Turnberg, mentioned a case involving medicine being given through the wrong route. There were lots of examples, which have been investigated, of medicine being wrongly given through the spinal route or in long doses intravenously. We also found three cases of wrong-site surgery—but then we found that actually, there were 179 cases over three years. The agency established what is now universally regarded as an excellent idea: the surgical checklist. The Royal College of Surgeons gave it the credit—it does not deserve much credit otherwise—and it took it on board. Usually it is gung-ho, but it has taken on the responsibility of implementing what we developed as a safe surgical checklist. It is now universally accepted. By the way, the learning that we produced was also accepted in Canada, Australia and parts of the United States. Canada and Australia adopted our system in totality. So yes, it is possible to do this, but it is not easy to realise an ambition to stop however many hundreds of thousands of incidents. Neither is it necessary to chase that. It takes a long time to analyse where the system failure is. The safe space is a novel way to deal with it, but whether it is successful will depend totally on the respect that it gains of the profession, the patients and the public. If it does not gain their respect, it will be dead in the water.
There will be lots of challenges. We have already seen reports in the media—in one of the health journals, I think—about the dysfunctionality of the organisation. That will continue. We must also ensure that in its reporting it is fair and proportionate. Where it finds that there is a resource or staffing issue, as the noble Baroness, Lady Hollins, and others, mentioned, then it must say so, even though the Secretary of State and the NHS leadership might not like it. If it gives guidance that is directed to the leadership of the NHS, it must say so. That includes NHS England, the commissioners and anybody else. If it only targets the health professionals, it will fail, because system failures are not necessarily always the fault of the health professional, as we have found in many other areas. For instance, a drug was packaged in a 50-millilitre vial, even though it was always given as 5 millilitre infusion or less. The error occurred because somebody thought that 50 millilitres was the dosage and put that in an infusion, and the patient died. That had happened a couple of times in other hospitals, so we had to persuade the industry to change the packaging. It objected because of the cost, but in the end it was persuaded.
Incidents also occur in intensive care—for example, pneumonia-related incidents. By examining the system, the death rate from pneumonia caused by using a humidifier in intensive care was reduced to less than 30%. I could keep giving lots of examples but the point I am trying to make is that the systems must be examined. The organisation must also make sure that it gets the respect of the profession.
The key thing is learning; where we failed was in implementing the learning. Here, the organisation must address the issue of who will implement the learning. If that is not done, three years later we will be having the same problems and the organisation will be blamed for not doing much, rather than the people who should be blamed for the implementation. In that respect, you need all the other people: not just the leadership of the NHS but professional organisations and others. I will give the example of an airline pilot’s wife who died because of failed intubation during minor surgery, in the presence of an ENT surgeon. They were all concentrating on getting the tube down to intubate while the surgeon, who was completely scrubbed, was standing there and could have done the tracheostomy in 30 seconds. But that patient died, and the Royal College of Anaesthetists took on board how to find a safe system so that that might not happen again. It implemented that through its training procedures; anaesthetists in training practised this on models. I pay great credit to it but there are lots of other examples.
I agree with the noble Lord, Lord O’Shaughnessy, and others who mentioned that a culture change is required whenever a safety incident happens. It is important to work wherever it happened to bring about culture change, so that we grow an attitude and mindset about patient safety. We tried to do that when working with Don Berwick, who was mentioned earlier—I think by the right reverend prelate the Bishop of London. In Scotland, we employed his expertise for three years to bring about the culture change that was required.
Governance was mentioned—I think by the noble Lord, Lord Hunt of Kings Heath—and it is an important issue. When I took over, I faced the problem of poor governance that was making the organisation dysfunctional. I spent nine months trying to get rid of everybody in the leadership of that organisation. I was the bad guy, but it was not respected because of its poor governance issues. In that respect, it would help a great deal to have a chair with experience of patient safety. I am sure that we could find one.
I also agree about the private sector. I know that I commented yesterday to the noble Baroness, Lady Finlay, that maybe the private sector ought not to be involved. However, there should be an all-systems approach. I note that a briefing I got from the private sector says that it would like to be involved.
Maternity care and childbirth injuries are an area crying out for urgent attention. Litigation is to a large degree about money. Any practice that may cause damage to the new-born is horrendous—it should not happen. There should be zero tolerance of a baby that has grown normally having hypoxaemia at birth and brain damage for the rest of its life. It must not happen. We must not talk any more about who should do it and in what way; just have a strategy so that it does not happen. I assure your Lordships that it can be done. I would not like to blow my colleagues’ trumpets, but it is possible to do it. I know that the current medical director of the HSSIB is capable of undertaking this exercise—a preliminary study on how to investigate and bring about the change that is needed in order to have zero tolerance of childbirth injury to the baby. It is possible to do that.
I look forward to Committee—whenever we get it—and I hope I can be fully involved then.