Jeremy Hunt MP is Secretary of State for Health. Follow Jeremy on Twitter.
failures at Mid-Staffs and Morecambe Bay hospitals show the terrible
consequences of lax safety and a culture of secrecy – two linked and mutually
reinforcing problems. In a speech today at University College London Hospital,
I am setting out how we break the cycle. Those of us who passionately believe
in the values of the NHS and the skill of its staff are often best-placed to
speak up where we know it can do better for its vulnerable patients.
The first duty of
every hospital should be to do the sick no harm. The NHS’ record on patient
safety is strong by international comparison but is it as good as it should be?
Julie Bailey, James Titcombe and other brave campaigners who have lost their
loved ones know the answer to that question is unequivocally "No."
In too many
corners of our NHS, we have become so numbed to the inevitability of patient
harm that we accept the unacceptable. Labour’s obsession with top-down targets
and process requirements fostered a culture which too often neglected the
individual and concealed failure. Only by ensuring that every person is treated
as though they were our own family member will be realise the ambition of zero
harm. And only by shining a light on poor performance will we confront
negligence and neglect.
Over time, grim
fatalism about statistics has blunted the anger we should feel about every
single person we let down. Figures show 0.4% of people treated suffered
unnecessary harm and 0.003% ended with a person’s death. This is a tiny
proportion, but still amounts to nearly half a million people harmed
unnecessarily every year, 3000 of whom lost their lives. That’s more than eight
patients dying needlessly every single day – deaths occurring not despite our
best efforts, but as a direct result of our failures.
Like the woman
who tragically died because her notes were mixed up with someone else, or the
woman who died shortly after being prescribed penicillin by a GP, even though
the GP had been told she was allergic to it. Or the 95 year old lady who starved
to death because her drip was not fitted properly and nobody checked to see if
it was working. All are stories I received in the last couple of months
in my postbag.
In all there were
326 so-called ‘never events’ reported in 2011/12. These are incidents of such
shocking negligence that they should never happen. And yet on this data, every
other day we leave a foreign object inside a patient, every week we operate on
the wrong part of someone’s body, and every fortnight we insert the wrong
This is the
silent scandal of our NHS. As James Titcombe, who lost his 9 day old son Joshua
at Furness General Hospital, said this week: "We need it to change. We
need that culture to change. Patient safety should be the number one
priority." World-renowned health safety expert, Professor Don Berwick,
will be reporting to government soon on how to drive cultural change across the
system. He understands, as I do, what it means for everyone from chair to
cleaner to be focused on where improvements can be made.
majority of medical staff already shares this belief. Exceptional leaders
within our NHS are tackling the problem head on, driving a culture of openness
and honesty that experts know to be vital. But a number of current initiatives
will drive this into every corner of the system.
Our new Duty of
Candour will make it a criminal offense to provide false data. Publishing
performance data will also have a huge impact and I welcome the support of the
Royal College of Surgeons on the publication of surgical outcomes data,
following the dramatic improvements resulting from publishing overall success
rates in heart surgery.
Also critical is
strengthening the doctor/patient relationship. We should return to having the
name of the responsible consultant and responsible nurse written above every
patient’s bed. We will be working with the professions, regulators and
employers to see how this can be taken forward across the NHS.
Finally, we need
to ensure a system of oversight that gives proper weight to patient safety
issues. That Morecambe Bay was registered ‘without conditions’ in April 2010 is
a disgrace. Our new Chief Inspector of Hospitals, Professor Sir Mike Richards,
will deliver deep dive inspections providing expert peer-review insight on
every hospital, with patient safety being one of the five key aspects he will
have asked Sir Mike to publish a six- monthly statement on the state of patient
safety in the NHS. As a culture of transparency takes hold, the reported number
of safety breaches is likely to increase rather than decrease. Sir Mike's
report will give us a vital independent perspective as to whether the actual
likelihood of a harm-free experience is increasing or declining.
will be underpinned by technological transformation to deliver a paperless NHS
by 2018. This transparency revolution will provide electronic medical records,
shared in an instant between GPs, hospitals and departments.
are huge and the system is rising to them. On broadly the same budget, we are
doing 400,000 more operations than at the time of the last election. But
we were also elected to make the NHS safer and more compassionate. That’s what
we promised in 2010. That’s what we’re delivering.