UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 151-ii

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

HEALTH COMMITTEE

PATIENT SAFETY

Thursday 22 January 2009

MR JOHN BLACK, REV DR PAULINE PEARSON and PROFESSOR DAVID WEBB

MS KATHRYN FAWKES, MS SARAH DHEANSA, DR SUSANNAH LONG and MR SIMON KRECKLER

Evidence heard in Public Questions 330 - 534

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 22 January 2009

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Mr Peter Bone

Sandra Gidley

Dr Doug Naysmith

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor

________________

Witnesses: Mr John Black, President, Royal College of Surgeons of England, Rev Dr Pauline Pearson, Deputy Director, CETL4HealthNE: Centre for Excellence in Healthcare Professional Education, Newcastle University, and Professor David Webb, Professor of Therapeutics and Clinical Pharmacology, gave evidence.

Q330 Chairman: Good morning. Could I welcome you to what is our fourth evidence session on our inquiry into patient safety? I wonder if I could ask you, for the record, to give us your name and the current position that you hold?

Rev Dr Pearson: Pauline Pearson. I am Deputy Director of CETL4HealthNE and senior lecturer at Newcastle University.

Mr Black: I am John Black, President of the Royal College of Surgeons.

Professor Webb: David Webb, Professor of Therapeutics in the University of Edinburgh.

Q331 Chairman: Once again, welcome. I have got a general question and then we will be asking some specifics to you as individuals. Mine is really just to open this session. Do you agree that patient safety is not sufficiently taken into account in clinical education and training?

Mr Black: No, I do not agree. I think there is an enormous emphasis on this element, certainly in the surgical specialities. Safety is what we are all about, and you cannot have any safe system unless training and education are done at the highest level. Do not forget, you must have clinical and technical skills, and the higher they are the safer the system will be.

Professor Webb: I would support what has been said. I think undergraduate medical training is all about patient safety and trying to educate doctors to be effective in their work. There have been some fairly radical changes in the way undergraduates are prepared to work as doctors, and I think mostly those have been very positive, but I think there are some areas where there is still room for improvement, and that is, perhaps, what we are going to talk about.

Rev Dr Pearson: I think I would say that it is taken seriously by people providing courses for all the health professions that we have looked at, but it is often implicit rather than explicit, so it is there in the curriculum but it is not always made clear or clearly assessed.

Q332 Chairman: David, John seemed pretty firm that it is sufficiently taken into account, but you said it could be improved. Would you like to enlarge on that?

Professor Webb: I think that comes back to my own specific area and perhaps other areas, where as you evolve an undergraduate curriculum some things improve, other things perhaps can get lost, and I think there are some areas where, for the benefit of safety, we could beef things up a little. I am going to talk about prescribing. I think that is an important area.

Mr Black: If I may come back, I cannot imply that it could not be made better and more emphasis could be put on it, but I do think there is emphasis on safety at the moment.

Chairman: Presumably a lot of this is about practice, and we are going to ask you individually about those areas, starting with Robert.

Q333 Mr Syms: The first question is to Dr Pearson. Your centre has been involved in the study on "Patient safety in health care professional educational curricula". Can you tell us more about the research and what has it shown?

Rev Dr Pearson: It has been a study that has been ongoing for 30 months that finished in the autumn last year. It was a two-stage study looking at four different health care profession's pre-registration education. We looked at doctors, nurses, physiotherapists and pharmacists and their pre-registration education. We looked initially at the curricula of 13 courses across England and Scotland and interviewed the course directors, course leaders, module leaders. We then looked at eight courses in more detail, so two for each of the professions involved. In those we looked at students' experience early in the curriculum and later in the curriculum through focus groups with students; we observed the delivery of the curriculum in areas that we imported from the curriculum documents; we also talked to newly qualified practitioners about how they felt they had been prepared. We then also talked to people responsible for patient safety in trusts and asked for documents about patient safety guidelines in those trusts, so we were understanding the organisational context. Finally, we undertook observation in those clinical settings, looking at particularly settings that were used as placements for students and observing the experience that students had, and also undertook focus groups with clinicians who were involved in supporting, teaching or guiding students in those practice settings. Out of that whole lot of obviously quite a big study and quite a lot of different findings, I think that one of the key things was the relationship for the student with the clinical educator. It is called different things in different professions but I will use that term for me to have one term. They are absolutely critical to student learning and environment. The role model that they offer, the relationship that is established with the students and the environment that they offer affects how confident students feel in challenging unsafe practice and how much they question and look at the evidence behind practice; so that was a really key area. The second area I think is really important was about exposure to patient stories, both in the clinical settings, where students told us of the importance of clinical exposure, and the stories that they saw, things that went well and things that went badly, but also talking with patients in the academic setting, if you like, in the university setting, and having the opportunity to explore the experience of things not working for them. I think those are probably two of the major things; there are a whole lot of others.

Q334 Mr Syms: Who should take the lead in making changes? Do the curriculum-setting bodies need to take steps to ensure that patient safety is fully integrated into all the clinical curricula?

Rev Dr Pearson: I think we feel that one of the major groups that really need to act on this are the regulators; that it is important for regulators to have professional bodies to make sure that they are setting standards that are clear for patient safety curricula, that are actually clear about what needs to be assessed and checked - for example, suitability of placements, the experience of those charged with education of students. Also, I think, we need commissioners to look at where patient safety fits into the courses that they are commissioning. We think that the educators need to have much clearer evidence about where patient safety is in the curricula - not to have it as a separate entity but to have it clear to all students and those who deliver courses - and we have suggested that it might be helped by patient safety champions within both trusts and in higher education who would promote curriculum change.

Q335 Dr Taylor: Dr Pearson, I am really following up on that, because you certainly separate the formal curriculum training from the training when they are out on the job getting work experience, and you do say patient safety in the curriculum is largely implicit rather than explicit. So your first suggestion for improving that is patient safety champions?

Rev Dr Pearson: Yes.

Q336 Dr Taylor: Can you go on and give us any other recommendations for improving the formal curriculum to help?

Rev Dr Pearson: Yes, I think one of the other key things is actually formally enabling students to question and challenge practice, to actually be critical of practice It is something that we do, but, again, it is often implicit, and we are not setting students up to actually think through: how do I deal with it if this practitioner does something in a particular way and I think it is wrong or I have been taught in university that it is wrong?

Q337 Dr Taylor: Do you think, these days, students have the courage to do that? In my day, which is quite a long time ago, if you were one of these questioning sort of students you got an awful reputation. Are students much more with it and able to do this now?

Rev Dr Pearson: No, I think that is why we need to actually do some work within courses to actually help students to do that more. We also have to educate the educators so that they promote that sort of behaviour. In the data that we gathered there were some examples where students had felt that they were put down when they had asked questions, but we had other examples where students were encouraged to asked questions, were encouraged to look at a range of options and to think through what the possibilities were. We also heard (another idea that I think would be worth pursuing) in physiotherapy, I think it was, but it may have relevance across different disciplines, about people keeping a reflective diary. Most courses, certainly in medicine, seem to have reflective portfolios now, but reflective diaries of incidents where safety was challenged or where they did or did not question practice and how they could have gone about it so that it is actually enabling them to go through the thought process as students before they get into practice as qualified practitioners.

Q338 Dr Taylor: How do we teach the consultants and the others doing the training to accept this questioning?

Rev Dr Pearson: I think we felt that that is partly about them being clear about the importance of not going with the status quo and the fact that because health care is continuously changing, and several of our people that we spoke to talked about the amount of change and the difficulty in the volume of knowledge that people might be expected to have, you are actually looking at trying to give people skills and principles to work from rather than necessarily a lot of factual knowledge. I think it is convincing those people of that really that is important.

Q339 Dr Taylor: Did you get the impression that the placement educators, the people out in the field, were instructed that patient safety was a prominent part of what they were trying to teach?

Rev Dr Pearson: Some of them were aware of it and others were not. It was not explicit. Again, very often they would flag. The practice environments had a lot of material, posters and guidance, so it was there in the environment, but it was not necessarily flagged, it was by some at some points. So it was not absolutely a black picture, but not for everybody.

Dr Taylor: You have given as a huge number of recommendations, for which thank you very much.

Q340 Sandra Gidley: I have got a formal question, but there is something that has been bugging me that I have to get of my system before we go on to it. We heard from John Black in his opening comments that it was knowledge that was important, but we have heard from previous witnesses that it is systems, attitudes and behaviours that are important. What would you say was the balance of the two? I can see how knowledge is included in the curriculum, but I am struggling to see how all of the things that we have heard over the last week or so are or can be included in the curriculum?

Rev Dr Pearson: I think there are people who argue that there is almost too much emphasis in modern curricula on behaviours and attitudes. It is something that we actually do pay a huge amount of attention to in medicine, in nursing, in pharmacy and physio (in each of those professions) very differently. I think, clearly, you need a secure knowledge base about core things, and I guess some of the debate is about what are the core things, but attitudes and behaviours and systems are about the structure that will enable people to adapt as knowledge changes and, certainly through CETL (Centre of Excellence for Teaching and Learning), we are very much trying to look, not just at producing practitioners for five years beyond when they qualify, but trying to look at how will things change in the next ten or 15 years and what different things should we be setting the ground work in place for? I think it is about a balance between different sorts of foundation. You need the foundations of behaviours and attitudes which can be built on and you also need core bits of knowledge from which people can build, and you cannot take those two apart: you need probably both to be significant.

Q341 Sandra Gidley: So attitudes and behaviours are looked at in the individual courses, but do the health professionals actually do enough training together, both during their pre-registration training and post registration training?

Rev Dr Pearson: In our study we found that there were moves, and it has been a sort of slow move towards more inter-professional learning, which is not necessarily the same as sitting in the same place hearing about anatomy or something, it is actually learning together. There were examples. There is an example, for example, of a role play initiative in one area where students from medicine, from nursing and from pharmacy were in a simulated environment of a busy shift in A&E, with a variety of demands on them, and seeking to work together to make decisions to give each other information and then to reflect on how they had done or not done, and that was an example in which students from at least two of the disciplines involved mentioned how valuable that was to them in realising how far they fell short of what was needed. These were interview focus groups with final year students in all of the disciplines, and it was among those final year students who participated in that that we heard how they valued that opportunity. The other examples that I can draw from, other than our specific study, would be examples where medical students and pharmacy students are working together looking at problems of discharge prescriptions, and then practising writing prescriptions and dealing with errors in prescriptions and understanding some of the processes together that are involved there. So those are the sort of examples, but at the moment I think there is not as much as there probably should be.

Q342 Sandra Gidley: Is it not logistically difficult in some places though? Southampton has a very good school of medicine and school of nursing, but the nearest school of pharmacy is in Portsmouth? I was a pharmacy student in Bath. The nearest school of medicine was in Bristol. It would mean a lot of extra expense to do some of this stuff, however worthy.

Rev Dr Pearson: Some of it could be done using either long-distance video conferencing opportunities or email - not email, but messaging, or that sort of technology, and, again, that is being explored so that students actually are in maybe peer and cross-professional groups on some sort of electronic network. You can do some things, but other things are difficult, like the simulation.

Q343 Sandra Gidley: We have heard a lot about teams. Is actually the answer concentrating on training the teams together and promoting the non-technical skills in that sort of environment? If that is not the answer, what is?

Rev Dr Pearson: I am very committed to inter-professional learning, but I do not think it is the absolute answer to everything. There are things that each profession has individually that they need to distinguish and develop skills in. Moving and handling is quite an important area where there is a lot of risks for physios, for nurses, it is not very significant for pharmacists, and maybe a bit for medics. You have to look at what individual professions are expected to do, but certainly emphasis on working together effectively. I think it can actually be done and it is important to emphasise.

Q344 Charlotte Atkins: Mr Black, let us follow up that discussion in respect of surgeons. We have already heard in this inquiry about the harm that can be caused by a lack of non-technical skills in surgical teams where deaths have actually occurred. Do you think there is a problem in the way that surgeons work in clinical teams, and, if so, what can be done about it?

Mr Black: Surgeons work in clinical teams all the time: obviously they have done it through their career from when they qualify. You work in a team in theatre, you work in a team on the ward and, particularly if you deal with cancer patients, you deal with a multi-disciplinary team. So, team working is implicit and you are used to it; you are doing it all the time. That does not mean to say that problems cannot arise within the team, which is where the human factors come in, and the College has been aware of this for a long time. I quote from a document of ten years ago: "The appreciation of the importance of factors other than purely clinical ones that can affect clinical judgment". We actually published a document in 2000, Consultant Surgeons, Team Working and Surgical Practice, so we are very well aware of the importance of teams, and we can only do everything we can to make it better.

Q345 Charlotte Atkins: Do you think over the ten years since you published that document that things have improved?

Mr Black: I think they probably have improved, but, of course, there is always room for improvement, whatever you do.

Q346 Charlotte Atkins: Sometimes a comparison is made between health care and aviation in terms of the use of human factors. Do you think it is a fair comparison, and do you think that health care lags behind aviation in terms of the way that they look at the issues that lead to near misses and actually appear to have much more of a reporting culture, so that, if there is a problem, then it is an absolute must that the professionals involved report it and own up to it?

Mr Black: Yes, we have learnt a lot from the aviation industry. The analogy can be taken a little far, but particularly with check lists. You have to remember that every aeroplane behaves more or less the same, every patient is completely different, but we have learnt a lot from check lists and the near miss reporting. The college, in association with one of the special associations, runs a thing called CORESS, which is exactly that, anonymous near miss reporting. This is very well publicised, very well read, and I think people are very well aware of it. The best analogy where the aircraft industry can actually help patient safety is when it comes to hospital care infections, where the most important factor is overcrowding. The Department of Health figures are that, if you go above 82%, the increase of infections goes up. When the pilot on your aeroplane takes off, the aeroplane is never overcrowded and it never takes on 20 more passengers without staff coming with them to look after them. So that is an analogy that could be made, but check lists, team working is different. Pilots learn mnemonics - what to do in an emergency - and there are an awful lot of those around in surgery as well, the classic one being ABC, which is the basic resuscitation: airway, breathing, circulation.

Q347 Charlotte Atkins: Surgeons are obviously working in different teams every day of their lives where they are not in established teams. Do you think that surgeons have the human skills which enable them to ensure that the whole of the team feels comfortable with raising any concerns, perhaps during an operation?

Mr Black: I hope they do. They should do. Again, our document from ten years ago said there are ways in which people concerned about patient safety can make their concerns known, and I hope the ethos is that everybody in the operating team should say so, and not just on the operating team. On the wards, or when assessing a patient, if something does not seem to be right, people should speak up, and I hope that we do encourage people to speak up. It is certainly part of our education and training that this should be encouraged.

Q348 Charlotte Atkins: I believe that non-technical skills are not yet mandatory in terms of being included in the curriculum for medical students in general.

Mr Black: Undergraduate students?

Q349 Charlotte Atkins: Yes.

Mr Black: I cannot comment on that, but it is certainly there in the curricula for surgical training. Our curricula for the nine surgical specialities are detailed online, and the service element is available to everybody and it is there both in the generic sections and in the specific sections.

Q350 Charlotte Atkins: I know that the Royal College itself runs a two-day course on safety and leadership for interventional procedures and surgery. Presumably that was developed because you felt that there was a gap in surgeons' training.

Mr Black: Yes, indeed, it was.

Q351 Charlotte Atkins: When was that set up?

Mr Black: The education department was set up in 1991 or 1992, after there were problems with the introduction of laparoscopic surgery. It got more momentum after the Bristol Inquiry, where this all came up, and the SLIPS course was started. We are about to open the latest phase of our education department in London, which has a mock operating theatre with screens on two sides, where team working can be studied with people looking in to see what is going on, and the people in the mock operating theatre are being watched from outside, rather like an aircraft simulator, to go back to your original question.

Charlotte Atkins: I think my colleague is going to follow up on that.

Q352 Dr Naysmith: You have answered the question, but should all members of surgical teams and other clinical teams do more training in a team setting? Do you think it should somehow or other be mandatory that teams train together?

Mr Black: I know what you mean, but you spend your life in the team, and the greatest menace to the team actually is the continuing change in team members due to working hours legislation, a subject no doubt we will be coming on to later. It is very nice if you can have a set team and stay with them all the time - it is much, much easier - and the check list, of course, aims to overcome that. That is something that we have learnt from the aircraft industry where the captain has never met the second pilot, so you overcome these problems with a check-list. In hospitals that is not quite so much of a problem, but it would be nice to have continuity of the team members. One of the things we have lost, not so much in operating theatres but on ward care of patients, is what used to be called "a firm", where there were two consultants, usually one a trainee and one a pre-registration person. That was a very good structure where team bonding was very, very strong indeed and there would be absolutely no worries about reporting safety fears in that environment.

Q353 Dr Naysmith: I think it probably depended on who was in charge of the team, because when I did my PhD with a very famous surgeon in Edinburgh he did not hold with any criticism at all.

Mr Black: I recognise the stereotype. The world has changed; we are not like that any more.

Q354 Sandra Gidley: We have heard mention of the check list a couple of times. Last week the NPSA issued a patient safety alert and mandated the use of the Safe Surgery Saves Lives check list. My big surprise here is that it was not being done anyway. If it is not being done, are you confident that all surgeons will now adopt this way of working?

Mr Black: It was being done. Lots and lots of hospitals have had safety check lists for a long, long time and when the original WHO 15-point one came up with the college council, most people said, "But we have got far more rigorous ones in use in our hospital at the moment." For example, in my own hospital in Worcester you would not have got through the theatre door on that check list; it is far more rigorous. Clearly, remember, this is designed for international use, but it is a good thing because you cannot be too careful on the real basics. Of course it will be accepted by surgeons, and it does not take much time to do, and we have given it our full support.

Q355 Sandra Gidley: That is good, but I was not aware that the NPSA were in the business of issuing patient safety alerts if there was not a good reason for it. So there must have been something that prompted them to do this?

Mr Black: I think they look at surgical safety in general. There was a publication in the New England Journal of Medicine following this WHO trial, so they know about it. They chose the opportunity of the production of this evidence that this did appear to reduce morbidity and mortality to launch this initiative, but, of course, the NPSA has no power to mandate its use, although it was implied in the media that they did, but it is a good thing because it has drawn everyone's attention to it and we fully support it.

Q356 Sandra Gidley: So this will not be a burden?

Mr Black: It is not a burden at all. The Royal College of Surgeons has given its full backing to the list.

Q357 Sandra Gidley: If we still have some old dinosaurs, I am told the world has changed, but if we still have some who refuse to go down this route, there will be a disciplinary procedure?

Mr Black: You do not need to go that far, because surgery is a team undertaking and the only sanction you need is, if you do not do it, the operation does not go ahead.

Q358 Sandra Gidley: But do not a lot of consultants think they are above that sort of thing?

Mr Black: No, of course they do not. You would not expect me to say yes to that.

Q359 Sandra Gidley: I am glad you did not. So you are telling me it would not happen.

Mr Black: I am absolutely certain it would not happen.

Sandra Gidley: Thank you.

Q360 Chairman: John, could the use of these lists be something that appraisal and revalidation would look at in terms of an individual?

Mr Black: They are the use of a check list. We are setting the standards for re-accreditation of specialists and the use of a check list will be part of this. It is also in all our web curricula.

Q361 Chairman: So a responsible officer might be somebody who would look at the individuals and make sure that they are taking these on board in their work?

Mr Black: That is right. It was very interesting. In this New England Journal of Medicine study something like 20% of all theatre professionals - not just the surgeons, the anaesthetists, the theatre nurses, everybody - were not sure of its value, but when they were asked if they were having an operation would they want to have it used, 5% said yes.

Q362 Sandra Gidley: It is the 5% I am worried about.

Mr Black: Yes, indeed.

Q363 Dr Taylor: In your written evidence you have given us a lot of examples of things that your college is doing. Do you think the medical royal colleges could play more of a role in the respect specifically of patient safety?

Mr Black: We hope we are, Richard. We hope it is absolutely something which we do. In the safety issues, we have talked about human factors, operating factors. That is a relatively small part of the whole patient journey. You have to have proper systems, proper training, proper knowledge. That is what we are all about. The surgical college actually was founded because of concerns about patient safety and surgery done by others, so it should, and I hope it does, pervade everything we do.

Q364 Dr Taylor: What did you think of Dr Pearson's suggestion of patient safety champions in each trust?

Mr Black: I think you are seeing this. There is always a slight danger that if you have a champion for safety people think it is not their problem, that this person will do it and part of us should each be our own individual patient safety champion; it should be absolutely second to none in what we do. Of course, everybody wants to be safe surgeons. It seems obvious that nobody actually ever wants anything to go wrong.

Q365 Dr Taylor: You tell us you have embarked on a major project: patient reported outcomes from ISTCs in a sample of NHS hospitals?

Mr Black: Yes.

Q366 Dr Taylor: This is of great interest to us following our ISTC inquiry. You said early results will be published at the end of 2008?

Mr Black: I have not seen them yet.

Q367 Dr Taylor: But we can expect something soon?

Mr Black: You can expect something, and it will be published.

Q368 Dr Taylor: You and I both remember the relative dread with which we expected the college to come and inspect us and go through accreditation of training?

Mr Black: We did.

Q369 Dr Taylor: And go through random selection of notes. Do you think we should think of bringing that back? Would that help with safety?

Mr Black: I think the highest standard of training is very implicit for the whole safety scene, and there is considerable concern in the royal colleges. Since the advent of PMETB we have not been able to visit hospitals. The data is collected in various ways - tick boxes. You cannot beat an experienced assessor talking to a trainee to find out what is actually going on.

Q370 Dr Taylor: In previous sessions when we have mentioned this, the arguments against it have been there are so many royal colleges we could not possibly do it, but that does not really hold water, does it, because it only needs the physicians and the surgeons, basically, to do it at houseman level?

Mr Black: Yes, it does. It is a five-yearly inspection. Trainees are assessed every year anyway, what is called an ARCP, used to be called a RITA, so concerns are picked up there, and that triggers the visit from the college. I think the argument against it was did it interfere with the service, but I think there are ways around that and, if properly organised, it does not. As I say, we have been very concerned about this. The other thing is, if we make a recommendation I think the medical professionals do have a lot of ownership of that. We are not seen as threatening in the way that a Department of Health agency doing the same thing would be. Not that we are not rigorous, I must emphasise.

Q371 Dr Naysmith: A few moments ago you answered a question about patient safety champions, which you very neatly deflected with a skill that most politicians around this table would appreciate. I am not sure whether you thought patient champions was or was not a good idea?

Mr Black: I think it is a very good idea for somebody to have overall responsibility for safety, to make sure the checks are done, to make sure the teams are together. Of course I am not against that, I am sorry, but I do retain the genuine concern that people might think it is someone else's problem. It is not someone else's problem. If you are a health professional, it is your problem.

Q372 Dr Naysmith: So both things are needed. The trusts need to instil that discipline and have someone to keep an eye on it?

Mr Black: Both are needed.

Q373 Mr Bone: Mr Black, last Sunday in one of our quality newspapers under the heading, "New EU working laws will be a disaster for NHS", you made some startling comments. You said the new European Union Working Time Directive rules are an impending disaster that will devastate medical training and lead to dangerous lapses in patient care. Given that the European Union is trying to look after doctors and clinicians, are you not being unfair to the European Union and is this not rather alarmist?

Mr Black: I am afraid I am not, and I wish I was being alarmist. This is, in our view, the biggest threat to patient safety and, not only that, to delivery of service for a long, long time. It has been coming for ten years. There has been a reduction in hours gradually, but the actual final cut to 48 hours with a legal thing that you cannot work more than that has reduced the level of cover. The level of cover in hospitals at the moment is groaning, it is under strain, but the number of people needed to supply 24-hour care, the number of handovers and just finding the sheer number of doctors to keep units open, is looking like it is going to be impossible with 48 hours. The people just are not there to do it, and those that are there will be spread so thin, unless something can be done about it, we anticipate significant service failures. I know it has been coming for a long time, but there have already been implications. Richard Taylor and I worked at adjacent hospital trusts. The problems with his actually first-rate small DGH started with a reduction in junior doctors' hours. That is what destabilised it originally. Next summer, if this is implemented, there are many hospitals and units that will not be able to provide a service and will be closing, and we would foresee many more Kidderminsters.

Q374 Mr Bone: Did you say, on that last point, hospitals will be closing?

Mr Black: I think units will be---

Q375 Mr Bone: Units of hospitals?

Mr Black: Units of hospitals will say, "We have not got the doctors to be on call to night", and what our patient groups are concerned about is this will lead to service reconfiguration that has not been planned.

Q376 Mr Bone: Would not the European Union say to you, "Look, you have known this has been coming for ten years. If you had a privately run health service you would be the first people jumping up and down and saying, 'Why have you not got all these extra doctors you need'"?

Mr Black: Yes.

Q377 Mr Bone: You have got a state run health service, that for ten years has known these rules are going to come in, that suddenly says, "Oh, by the way, we have not got enough doctors and clinicians." Is it not the fault of the state run health service not, in this case, the European Union, because you have known about it for ten years?

Mr Black: It is more complicated than that. We expressed our concerns at prime ministerial level in 2005. It is not just having more doctors, because if you have two or three times the number of doctors, they then have less work to do. How do they maintain their skills? What we want is the balance between the right number of doctors and the right amount of hours on duty; and the inflexibility of it. It is not so much hours worked, it is hours on duty. If you are driving heavy machinery or piloting an aeroplane, I guess 48 hours is enough, but the thing about the Health Service, the work load is very variable, so lots of the time when you are on call, quite a bit of the time, there is not a lot happening. Surgeons and other health professionals do not work absolutely continuously; there are always opportunities for breaks.

Q378 Mr Bone: I want to butt in there. We do all have all these media reports of junior doctors falling asleep. Is that just media hype: it is not the real situation?

Mr Black: The time you are most likely to be so tired that you fall asleep is on the third or fourth day if you are working a night shift. Night shifts have been brought in as a consequence of a reduction in hours. If junior surgeons, which I know about, were allowed to work on call rotas, that is less---. I am not making this up. Our own trainee associations have told us. They have produced a very detailed document, which we would be delighted to send to the Health Select Committee, explaining why apparently longer hours on call are less tiring and stressful than a system that makes them work shifts.

Q379 Sandra Gidley: It was that sort of point I wanted to pick up on actually. What assessment has the college made of the number of hours worked and the mistake levels as a consequence of tiredness? I think that is very important. If you had this information before, why could the profession not have made a case? If it stacks up scientifically, why could it not have made a case for a change or some sort of derogation?

Mr Black: We are making the change and we hoped that there would be a specialty opt-out. The evidence is there in the documents gathered together by our junior doctor associations, but it is absolutely right that a properly organised on-call rota, which apparently allows more hours, allows better cover; it also means you have fewer people so the intensity of training is better.

Q380 Sandra Gidley: Okay.

Mr Black: But implicit in this is a consultant-delivered service where the consultant and the trainee are there together in the team working together at all hours of the day and night.

Q381 Sandra Gidley: Can you remind me what the contract hours are now for consultants in the NHS?

Mr Black: Consultants in the NHS - it all depends on the contract, and it is not so much done in hours, it is done in PAs.

Q382 Sandra Gidley: How would that equate to hours of work?

Mr Black: It would equate to hours. It depends. Contracts are very variable. The basic ten PA contract is something like ten three and a half hour sessions. Interestingly enough, the European Working Time Directive exempts people with executive responsibility who make individual decisions.

Q383 Sandra Gidley: Does that mean consultants are exempt from the Working Time Directive?

Mr Black: I do not think it has been tested at all, but it seems strange that this health and safety is designed to protect the health of the workers, not the patients. So it says if you have got executive responsibility and you are allowed to make a decision, it does not matter how tired you are, which is crazy.

Q384 Sandra Gidley: Who is going to be adding up the NHS hours and the private practice hours?

Mr Black: I cannot answer that question, but the EWTD from next summer will apply to everybody. I do not think it applies to MPs. It does not apply to me because I am the head of an organisation, so the whole thing is bizarre. We talk a lot to our colleagues in Germany and particularly in Ireland. It was apparently not designed to apply to professional people with a very irregular work load, particularly out of hours. It was really intended to stop people who do repetitive jobs, hard work, being exploited. We are not being exploited.

Q385 Sandra Gidley: Surely is hard work though.

Mr Black: It is. Of course it is hard work. You do not go into surgery or medicine thinking it is going to be very easy, but our trainees are telling us that their lives would be better, they would be less tired and the patient care they provided would be safer if they apparently worked more hours.

Q386 Chairman: There was a vote in the European Parliament a while ago that said what they should do in relation to doctors is to look at when they are actually working at work as opposed to potentially resting at work. What did you think about that?

Mr Black: I thought it was very sensible, because of the variability of the things. I used to be on call for 400,000 patients in a large DGH in Worcester and about one night in four nothing would happen very much. The cases would be admitted; the consultant was freed up to do the emergencies with the trainees. At seven, eight in the evening everything finished, nothing much, a couple of patients admitted. One night in four, virtually all night, but all the hours, you see, the people who were sleeping in a bed, that counts as working hours, whereas when you are up all night you call other people in, and some of the time it was intermediate. So it is the inflexibility of the system. I am sure it is very worthy legislation, but it is not designed for professional people providing a surgical service, and the anomaly is, if it is implemented, we predict, and I am certainly not being alarmist, I am absolutely convinced that it will be disastrous. We have had enormous support by saying this, and there is still time. We have done everything we can as well. We did a report with the College of Anaesthetists to see if there was a way round working 48 hours. We did produce some solutions which probably would work, but the NHS cannot deliver them because they are so radical. If we had twice the number of consultants and closed half the hospitals, we could possibly do it, but we think the present set-up of hospitals is pretty good and provides a local service and we do not want any more small DGHs closing.

Q387 Mr Bone: Finally, why is it that we cannot do it and our European Union colleagues can?

Mr Black: In Germany they have got a specialty opt-out which they have managed to achieve, and we are talking to them. Interestingly enough, the Irish have the usual Irish system of optimism, half truths and fudges and they have decided that they cannot go on like this, and they have been very interested in our initiative and the 65-hour ideal on-call week as defined by---. Our training organisations are pan-British Isles groups and we are talking to the Irish about it shortly.

Q388 Mr Bone: I am getting the view from what you are saying there that we are going to abide by the laws very strictly in this country, which is our concern, whereas I think you are indicating that some our European colleagues might be more flexible with the interpretation.

Mr Black: I think they are. Of course there is a legal way out; it is actually political will. I am told that lots of the measures that have been done with the economy recently break all sorts of European laws.

Q389 Mr Bone: They do.

Mr Black: We would like to see some of the European laws dealt with to, in our view, make the NHS safer.

Q390 Chairman: Is not taking resting time as not work time just a way round it?

Mr Black: Maybe, maybe not, but it is complicated and it is how it is interpreted in local trusts and whether you are resident or whether you are not resident. The simple way, the neat way, is to fix it for good, and that is to produce a reasonable working hours maximum for which you may be on call. Once that is done, we are confident that it would fix the situation in terms of providing safe cover for hospitals and also the training side, in that fewer people would be needed, they would have more time available to attend the wards, the out-patient clinics, the ward rounds and the training sessions.

Q391 Chairman: Would that include people resting as well, if there was no---

Mr Black: Yes, I think so. The 65 hours is the optimum. As I say, that was not produced by the senior members of the profession like myself, this was produced by those actively training at this moment who are concerned about the lowered intensity of their training and, of course, that means they would have to stay in training longer, which they do not want, and if people stay in training longer there could be a shortage of consultancy. We really do think that this derogation - it is not a derogation, it is an opt-out - is vitally important.

Chairman: We are going to move on to clinical education safety now, you will be pleased to know, David.

Q392 Dr Stoate: I do not know what the world is coming to. When I was a junior doctor we had units of medical time and they were four hours each, and I had to do 30 of them a week in many of my jobs - 120 hours a week - and look where it got me! Anyway, we shall move on. We have moved from surgery on to therapeutics. Again, when I was a young doctor we took therapeutics as an extremely important part of the curriculum and we spent a long, long time looking at therapeutics and pharmakinetics and clinical pharmacology. That is, I gather, considered such an important part of the curriculum. Professor Webb, you are quoted as saying that many patients are being made ill and even killed by prescribing errors as a result of inadequate pharmacology education. What is going on?

Professor Webb: If I can start by going backwards slightly, prescribing is an important, complex, high-level skill. It involves making a diagnosis through taking a history, doing an examination and arranging investigations and then creating a therapeutic plan. All doctors prescribe - surgeons and physicians. It is one of the things you do the first day you get qualified and you do it mostly for the rest of your working life, and you do it largely unsupervised. I think all the evidence suggests that junior doctors are on their own from day one in hospital. Clearly, medicines have fantastic benefits for patients, but they come with a risk as well, and it is making sure that patients get the benefits and, wherever possible, not the risks. We have an ageing population who often have more than one illness, and so need more tablets than perhaps there would in the past, and we have more tablets anyway - we have lots more medicines available to us - and some of them are rather more powerful than the ones that existed 30 years ago. When I qualified we had two drugs we would use for people who had had heart attacks; now we might use 22 - so it is a lot more complicated. You would think that probably students would get more therapeutics teaching on that basis, but actually they got a lot less, and the reason they got a lot less is a document called Tomorrow's Doctors that was produced by the GMC in 1993, which was a very important, a very positive step for medicine. It radically reorganised their education with integration, which we have heard about already, and around organ bases. The problem with it being organ based - our hearts, kidneys, lungs - is that the things that did not happen organ based, like therapeutics, disappeared and, very slowly, pharmacology departments closed, clinical pharmacologists were not reappointed and the teaching around how medicines work and how to prescribe them disappeared from the curriculum. The other issue that occurred was that when you and I were students we would have prescribed under supervision. That was also removed. So often, in fact most, medical students do not get any experience of prescribing until the day that they qualify.

Q393 Dr Stoate: Not only is that extremely alarming, why has it not been picked up and dealt with?

Professor Webb: A number of us have raised concerns about this. I think the first was Ken Woods, Chief Executive of the MHRA, who raised this in 2001. A number of us from the British Pharmacological Society raised this again in 2005 and there are two really important pieces of research that have been published since that time. The first was a study from Simon Maxwell in Edinburgh that showed that the 2,500 medical students cross the UK, their perception, a large amount of them, the vast majority, about 80%, thought they were either poorly or very poorly prepared for prescribing at qualification, and the majority thought they would not meet the then GMC competencies in prescribing. So that is a concern.

Q394 Dr Stoate: But even more alarming, if this is all well-known and well documented and all out in the open, why has not PMETB, the colleges, the GMC jumped on it?

Professor Webb: To quote the GMC, this is Peter Rubin in 2007, "There is no evidence that supports recent claims that trainee doctors are insufficiently prepared for prescribing." He said that in 2007. The GMC now publish their own findings from a report on three medical students about how prepared medical graduates are to begin practice, and it is very clear from this document that of all the things they do there is one that stands out head and shoulders above the others as one that they are not prepared for.

Q395 Dr Stoate: You have not answered my question. It answers my question as to what is happening; it does not answer my question as to how it happened and why it has not been sorted.

Professor Webb: I have not idea why it has not been sorted, but I think it will be sorted. There are ways forward. I am an outsider, a clinical pharmacologist concerned that doctors are not getting trained in the right way. I cannot implement that change; it is up to the GMC to implement that change. We have made it very clear to the GMC that we think there is a problem; they have now identified it themselves. The good news is that the document in 1993, which was renewed in 2003, was much the same as the original document. The 2009 version now enshrines a series of competences in prescribing that were generated by a Medical Schools Council Safe Prescribing Working Group, chaired by Professor Robert Lechler, and was multi-professional - it involved medical students, it involved doctors in hospitals and in general practice, it involved pharmacists and it involved clinical pharmacologists - and those prescribing competences will be there, I hope. They are there in the draft; I hope they will be there very fully in the full document. The key thing then is that you know in every discipline that, if you do not assess competences, students do not think they are a high priority. The other thing that has been lost is therapeutics exams, or competences in prescribing, and what we need is some very clear assessment that doctors are actually competent to prescribe.

Q396 Dr Stoate: I certainly agree with you there. One of the things we have learnt on this inquiry is that there is a massive lack of evidence for most of this stuff. The National Patient Safety Agency admitted that only a very small number of adverse incidents ever actually get reported compared to the number that there are, and certainly in primary care there is almost no evidence whatsoever. Obviously, you would say that would you not. The question I put to you is, how do you know things are as bad as they are given the lack of evidence for real harm caused by prescribing errors?

Professor Webb: It is not easy, so I will start with what we do know. We do know from our report in Edinburgh and the report from the GMC that there is evidence of unpreparedness, a perception of that from the point of view of the medical students, but this was a triangulated report and it was very clear that those colleagues, doctors with whom they were working and the pharmacists with whom they were working, shared not only the perception but the pharmacists were very concerned about the error rates that were occurring. So we have evidence that there are errors occurring, we have evidence that goes back to a report from a London hospital in 2002 which showed that about 0.4% of prescriptions have potentially serious errors; so errors are occurring.

Q397 Dr Stoate: Do we have any evidence that they are really harming patients? If there is a real lack of evidence for patient harm, we have not been able to get this evidence. Do you have any evidence that these medication errors are directly causing patient harm?

Professor Webb: I think that is really difficult. How would you do that? You would have to divide medical schools, train students differently and look at the mortality and morbidity rates from the people they treated. It is an extremely hard piece of work to do, to show that the teaching makes a difference. I think if we know, and we do know, that teaching can make a difference to error rates - it reduces error rates - and we know there are error rates, it stands to reason to me that teaching would be of value in preventing potential harm to patients?

Q398 Dr Stoate: Can you, in that case, outline very simply for the committee exactly what changes you would propose to put things right to ensure that the next generation of medical students are up to speed and, hopefully, the current generation of young doctors are quickly brought up to the speed they should have been at some years ago?

Professor Webb: First of all, Tomorrow's Doctors in 2009 is a crucial document. It needs to be very explicit about the prescribing competences required, and these are not particularly high level, they are what you would expect, and that they ought to be assessed in an effective way by the medical schools. The second thing is (and I think this came out of the Safe Prescribing Working Group at the Medical Schools Council) the Department of Health is putting money into an e-learning for healthcare initiative in prescribing which will produce a range of materials online that students and doctors can use to support their prescribing skills. I think that is going to be a tremendous help; so I think that is important. My own personal concern is that because this is a high-level and complex task (and I know the GMC focuses on the fact that it is the prescribing skills, the writing of the prescription, that they need to learn), I actually think medical students still need to understand how drugs work, how they might not work well together in certain cases and know a basic maybe 50 or 100 drugs that they might use on a regular basis, and I think a little bit of knowledge is absolutely crucial around pharmacology and clinical pharmacology as well as prescribing.

Q399 Dr Stoate: Personally, I am horrified that is not happening, because it certainly happened in my day and I still remember most of it now. I could probably even write the Creb Cycle up if I had to. Can you give examples of any good practice in UK medical schools, either here or elsewhere, that we could perhaps flag up?

Professor Webb: I am going to start with my university, because Edinburgh has produced, in fact, Simon Maxwell has produced a thing called e-drug, which is to help students to create their own formulae, which will be part of the Department of Health project which he is helping, so I think that e-drug programme is useful. Safety in practice in prescribing comes right at the end of the training period for medical students. That is something that Edinburgh has led on. Both of those initiatives were commended by the GMC in a recent visit. St George's Hospital in London has a very good booklet about clinical pharmacology and therapeutics; it also gives a limited formulae list of 100 drugs that students need to know about. That, I think, is impressive. UCL, again, has a very in-depth programme of training from pharmacology through to therapeutics which I think is very impressive. All of those are led by clinical pharmacologists, and, if I can have my plug, it is worth remembering that if we lost our clinical pharmacologists (and we certainly are losing them at the moment), then people like Sir Alistair Breckenridge, who runs the MHRA, Sir Michael Rawlins who runs NICE - they are all clinical pharmacologists - we will not have that cadre of people if we lose that specialty.

Q400 Dr Stoate: Let us hope things do improve. Just a last point: do you think there will be any benefits in medical students and pharmacy students being taught the same curriculum at the same time, or is that not likely to work?

Professor Webb: Sandra raised some practical issues. We bussed students down from Aberdeen from pharmacy school to learn with our students in an inter-professional way, and it is really interesting. I think there are two areas where it is good. Certainly in terms of the pharmacology there are obviously some overlaps, but pharmacy students tend to learn their pharmacology in much more depth than medical students do, and then, at the point of prescribing, learning about prescribing, I think there is fantastic benefit from putting the two together because pharmacists are the guardians of safe prescribing and I think they could help medical students learn what an important professional responsibility it is and a little more about how to do it properly. Those are the areas. In the middle, doctors are about diagnosis and treatment. It is a slightly different process.

Q401 Dr Stoate: A final supplementary, and that is the use of expert systems to help prescribing physicians. Do you think they are a help or hindrance, particularly on GP's desks?

Professor Webb: You will know that you can by-pass all those safety flags that come up. You do not want too many flags, otherwise people do not use the system, but I think they have some benefits and I think nothing would be better than being able to know, when a patient is coming to the hospital, what medicines they are actually receiving from their general practitioner at the time they arrive.

Q402 Chairman: Given what you have said about the deficiencies in medical students' training, do you think that the non-clinical prescribers - pharmacists and nurses - are likely to prescribe safer and probably better than you or your doctors?

Professor Webb: I think the situations are different, in that, in general, nurses and pharmacists do not undertake history examination and diagnostic activity; what they do is take patients who have a diagnosis and treat to very carefully defined protocols, which many doctors do as well, so that there are conditions where it is driven by protocol, the treatment one uses. Hypertension is an important area. What we would use first, second and third line is pretty well described and, I think, could be done by a different range of professionals. Within a certain context I am sure they do it just as well, and I think pharmacists really understand the importance safe prescribing.

Q403 Chairman: You used the phrase yourself that students should be taught how drugs work. That is pretty fundamental in terms of prescribing, is it not?

Professor Webb: I am afraid it has largely disappeared in many medical schools.

Q404 Dr Naysmith: A couple of tidying up points, Professor Webb. I think you and Howard kind of agreed that the evidence base about adverse drug events was not very good. Is that right?

Professor Webb: Yes.

Q405 Dr Naysmith: How could it be improved? How do you think you could improve the recording and the incidence of adverse drug events?

Professor Webb: I think a lot of this goes back to the champions thing. I think we need local champions for clinical governance and patient safety who are interested in medicines; I think we need open reporting systems that do not carry guilt. That is perhaps an analogy with the aircraft industry. What we want is reporting, lots of reporting, because a lot of problems that occur are systems problems and need systems solutions, so I think we need as much open reporting as possible. I am involved with a regional monitoring centre for the yellow card system, which is a system for reporting adverse drug effects. We have a very good centre in Edinburgh which runs for the whole of Scotland. Eight years ago we received from MHRA all the local data for Scotland so that we could tell our colleagues how well they were doing, and that really geed up their reporting. We had a region that was reporting very few adverse effects but it soon went back to their locality that they needed to work a bit harder. We do not get that local reporting now, and I think it is really important that it comes from the locality, not from the centre.

Q406 Dr Naysmith: This is self-reporting we are talking about?

Professor Webb: We are talking about doctors and patients.

Q407 Dr Naysmith: Both.

Professor Webb: I think it should come from the local region. It is much more likely to be successful if it is being driven from the local region.

Q408 Dr Naysmith: One final point, I think, related to what you said earlier. I am not quite sure I got it right. You said you bussed down pharmacy students from Aberdeen to Edinburgh. Is there not a medical school in Aberdeen?

Professor Webb: There is, but we thought the initiative was an interesting one to bring them together. It was a project.

Dr Naysmith: Thank you.

Chairman: Can I thank you very much indeed for coming along this morning and helping us with this is inquiry. Thank you.

Witnesses: Ms Kathryn Fawkes, Senior Theatre Nurse, Great Ormond Street Hospital, London, Dr Susannah Long, Clinical Research Fellow, Clinical Safety Research Unit, Imperial College London, Mr Simon Kreckler, Clinical Research Fellow, Nuffield Department of Surgery, and Ms Sarah Dheansa, Matron for Surgical Care, Queen Victoria Hospital, East Grinstead, gave evidence.

Q409 Chairman: Good morning. Welcome to our fourth session on our inquiry into patient safety. For the record, could I ask you to give your name and the current position you hold, please.

Dr Long: My name is Susannah Long. I am a care of the elderly medicine specialist registrar. At the moment I am undertaking a PhD looking at safety in the elderly with Professor Vincent at Imperial College.

Ms Dheansa: I am Sarah Dheansa, Matron for Surgery at Queen Victoria Hospital.

Ms Fawkes: I am Kathryn Fawkes, I am a sister in theatres at Great Ormond Street Hospital.

Dr Kreckler: I am Simon Kreckler. I am a surgical registrar in the Oxford Deanery and I have just completed an MD in quality improvement in patient safety.

Q410 Chairman: Thank you very much. I think all of you have been in at the last session, so you will have heard some of the interaction and questions that we have asked. My question is: Do you think that patient safety has been adequately covered in education or training?

Dr Long: I can only talk for my training, obviously. I qualified in 2002, so I started my training in 1994, in the old-style system, I think. Although I knew safety was of crucial importance, that everything I was learning was so that I could treat my patients safely, it was never really made explicit. I never really heard the expression "patient safety". The only thing I can vaguely remember is a talk given to us as undergraduates by one of the defence unions about prescribing safely and trying to avoid complaints. When I qualified, I was always very worried about making mistakes, but I never really stepped back and thought about why mistakes might occur or what the consequences might be or anything like that. It was not until I joined Professor Vincent's group that I realised that there was so much science underlying patient safety of which I was just completely unaware. I have thought, ever since joining the group, that I would have loved to have known about these things earlier on.

Dr Kreckler: I can certainly echo those views. In the first session it was said that it was very much implicit rather than explicit and that has certainly been my experience. There is a lot of activity going on now, particularly in the last couple of years, trying to bring patient safety to the undergraduate curriculum. I have been personally involved in training not only undergraduates but foundation year doctors, and when you start teaching about patient safety, they are completely unaware of safety as a concept in its own right. Perhaps to echo some of the things that were said by Mr Black earlier, surgery specifically does focus a lot on technical ability, technical safety. Everyone wants to be a good surgeon and a safe surgeon but I still do not think there is sufficient emphasis on the non-technical aspect of safe practice.

Ms Fawkes: From a personal perspective, my educational background is a bit different from that of some of those whom I work with. One of the things that has been brought to my attention when I work with paediatric nurses is that there is a lot more social factor in their education programme, less science factor, and there is not a lot about patient safety. Without the science factor you miss a lot of it.

Ms Dheansa: The one thing in relation to patient safety that is not mandatory anywhere is the leadership side, the communication that very much links with patient safety. When consultants become consultants, there is no mandatory requirement for them to do any leadership. I think a lot of things around patient safety, because of complex communication channels, links back in with leadership. I would say that I do think they need to be looking at some leadership.

Q411 Chairman: The issue that came up in our earlier session was the issue of clinical teams and the need to train together and presumably to get to know one another. Communication would be important there. Also, there was the concept not just of training together but retraining. What are your views about that?

Ms Dheansa: As nurses, when you are doing your Advanced Life Support you are trained in a multidisciplinary team with doctors. I think it is paramount to making sure that people understand each other's roles and that you are all on a par, as an equal, and that especially nurses feel able to voice concerns that they have and do not look at the surgeon and become very, very frightened to speak up when things are going wrong.

Dr Long: I would agree with that. I work in a specialty where multidisciplinary team working is basically what we are doing all the time, but it was not until I worked as a junior doctor in those teams that I understood what the different people's roles were and what my role was and how to interact with the other team members and how to make sure that things ran smoothly.

Q412 Chairman: Was none of that in your basic education?

Dr Long: Not as an undergraduate.

Dr Kreckler: Coming from a surgical background, I think there is a lot to be said for teams of scrub nurses, anaesthetists, surgeons training together. In a practical sense, though, it would be very difficult to achieve. There is a very high turnover. As a junior, I am with one team one minute and another team the next minute. When you are doing emergency work, the people turning up to work with you may never have met before. The training needs to be more directed at training an individual to fulfil a role so that they can then slot into a team within that specific environment.

Q413 Chairman: Teams differ. In most circumstances they would be led by the senior surgeon. Do they differ in terms of how they interact with one another?

Dr Kreckler: There are certainly different team dynamics. If you do not know the people you are working with, if you turn up to do a case and the anaesthetist you have never met before and the scrub nurse you have never met before, it is very difficult to have that interactional need, especially when things need to move more quickly perhaps

Q414 Chairman: Your slot in the team would be something that you could do, and you would just fit into a team because you were trained to do that.

Dr Kreckler: I think that is probably where the training needs to head, yes.

Q415 Chairman: Are there any changes you would like to see in clinical education and training? Clearly this is with patient safety in mind, being the subject of our inquiry.

Dr Long: From my point of view just the general awareness. As I said before, I was not aware of safety as a concept and had not thought about it, so I think that is the most important thing.

Ms Dheansa: I think leadership training should be as mandatory as the teaching qualification. Everyone post-registration within nursing and doctors must have a teaching qualification and I think leadership needs to be made mandatory.

Ms Fawkes: I think you also need a basic understanding of science as a foundation and then build upon it and have it reinforced throughout the programmes; for example, anatomy and physiology. I am told by a lot of the neuro-nurses that they are not being taught that, that until they go through the surgical course they have had very little anatomy and physiology. I think you should teach that at the beginning level and incorporate it throughout your programme into your different body systems as you study them. With that you can then add patient safety, depending on what the subject is you are talking about, whether it is moving and handling, whether it is wearing protective equipment, or what is a high risk area, and also adding in risk assessment. I do not think they are taught a lot about risk assessment and how to think critically in given situations.

Dr Kreckler: I would add that change in the NHS is incredibly difficult at all levels and in all aspects. The hardest thing to overcome is the cultural barrier. If we integrate patient safety from day one in medical school and continue enforcing it right the way through to consultants at revalidation level. Once that culture has dissipated through the whole system, you will find making new initiatives with regard to patient safety aspects much more easy to facilitate, I would have thought.

Chairman: Thank you.

Q416 Charlotte Atkins: It would be really helpful if you could describe any patient safety challenges you have met in your own practice and maybe outline some of the reasons why they happened.

Dr Long: I am an elderly care physician, so if you imagine an elderly patient coming into hospital with an acute medical problem, perhaps they have cognitive impairment and they are quite frail, there are so many things that I have seen go wrong form the moment they come into the hospital until the moment they leave. The first problems on admission might be, for example, that we are not always aware of what medication somebody is taking and whether they have been compliant with them at home. Often we do not know what their usual functional state is, and that can lead to unnecessary admissions and things like that. They go through the admission process, they are moved around the hospital, forms are handed over between different teams on different shifts, and I have seen several instances where messages have not gone through, things have not been followed up, or things have been missed initially. When they then get to their final ward, there are so many problems on the ward for an elderly person. There are the obvious things like wandering and falls, et cetera, or becoming acutely confused, and people not picking up when new problems are occurring. There are so many things that I do not really know when to stop. When the patients are discharged, there are then problems with communicating with primary care, making sure follow-up is adequate, making sure that the patients understand what their treatment should be. I saw a patient a while ago who had been discharged on a whole new range of medications for heart failure, but she went home and returned to what she was taking before and was readmitted three days later with the same problem and had to go through the whole process all over again from the beginning. I have heard of or been involved in incident safety issues, but I think it is meaningful to concentrate on the common things that you would see if you went on to a ward now.

Ms Dheansa: I would agree with what Susannah has just explained about complex communication channels.

Ms Fawkes: I would like to add to that the cultural issues. For example, I had a situation where in one of the operating theatres they were using laser and the person that set it up set it up incorrectly. Part of the procedure for this laser is that you should test fire, but the control tech did not want to test fire. The nurse involved did not stand up and say, "You need to test fire." He used it on the patient, it was put together wrong, and it gave the patient more of a burn than they should have been given. Because of cultural issues - the nurse who was involved was Filipino - she does not feel that it is her place to stand up and say, "You need to test fire." So you have those kinds of issues.

Q417 Charlotte Atkins: Why did the surgeon not want to test fire?

Ms Fawkes: He just did not think it was necessary.

Q418 Charlotte Atkins: It was a waste of time.

Ms Fawkes: Yes - wanted to get things done.

Q419 Charlotte Atkins: What happened in that situation? Was there disciplinary action? What occurred as a result of that incident?

Ms Fawkes: There was an incident report written. There were different pictorial aids made to help with setting up the laser properly. There was also more education on the use of the laser for the people involved.

Dr Kreckler: One of the problems we all face, which again was referred to on the previous session, is that there really is very little redundancy in the system. Mention was made of overcrowding and the impact that has on infection rates, but it is not just on infection rates. You have patients being transferred to inappropriate areas. Because there is no space on the surgical ward, they end up on the medical ward, or people stay in CDU longer than is appropriate, or we cannot get the diagnostics through quickly enough and people end up in hospital longer, or they do not get their therapy in a timely fashion and they encounter complications, a protracted hospital stay, and further problems. In a situation that came up in a hospital I previously worked at, a patient was admitted and placed in a clinical decision unit where a naso-gastric tube was placed to drain their stomach - they were obstructed at the time. That tube was placed by a member of staff who was not adequately trained in placement - that is perhaps a reflection of the fact that they were on a non-surgical ward - and they were later transferred to a surgical ward where it was assumed that the correct checks had been put in place. The following morning a contrast swallow was requested. The contrast was put down into the NG tube and, as it turned out, the tube had been placed in the bronchus and the patient ended up on ITU for six weeks and very nearly died. With all of those problems it is not really that any particular individual is at fault there, it is just that the whole system is set up in such a way that if the right things all line up in the right order you are going to have an error occur, as it did in this case. That is really the tip of the iceberg. The serious untoward incidents are the ones we hear about and get very upset about but, beneath that, the number of times that patients go, for example, to an inappropriate clinical setting is so frequent that it is almost a miracle it does not happen more often. We need to deal with those very minor problems and those minor issues in the system rather than concentrating on the specific serious incidents when they occur, because by dealing with minor issues we will hopefully intervene in that error chain and prevent these serious events from occurring.

Q420 Charlotte Atkins: What happened after that particular unfortunate incident? Were there any changes introduced which would prevent that happening in the future or did it just carry on happening?

Dr Kreckler: I looked into it at the time. At the time there had been about 16 incidents reported nationwide of misplaced naso-gastric tubes. It is estimated that over so many x million are placed per year, so again it is a very, very small percentage. There are hospital protocols in place for specifics: if a tube is to be used for drainage versus feeding, then chest X-rays must be conducted. At the time, however, that had only just come in as a protocol and was only about to come in, and things like Ph testing were still being used, listening for bubbling when you blow air down the tube. These have all now been discredited but at the time it was certainly not clear in the hospital protocol - but it was addressed.

Ms Dheansa: Those examples of system failures, where the pressure of all the targets lines up - the four-hour wait, the infection control target, privacy and dignity mixed-sex targets - that is when the patient gets placed in the wrong environment. That is the root cause, where you have a medical nurse who is not used to putting down NG tubes. That is where the Swiss cheese layers all line up. It is sometimes that working with all of the targets - which in isolation are very, very good - when you are trying to pull them altogether makes it extremely hard on the coal face to deliver all of them.

Q421 Charlotte Atkins: What change would you introduce to improve patient care in that respect?

Ms Dheansa: It is making sure that first and foremost patient safety is deemed the most important and then all the other targets come in after that. Aspects of four-hour waits are: "Okay, if we don't place this surgical patient in, say, a geriatric ward, they're going to fail the four-hour wait." There should be some clause for not so much pressure on the ground floor, with sometimes shoving patients through a funnel.

Dr Kreckler: There is a lot of opportunity for more integration between clinical and managerial aspects of health care. Clinicians are very good at looking after their patients and, to some extent, to hell with the targets. Vice versa, the managers are very interested in hitting their targets and often at the expense of clinical judgment. As a very quick and simple example, I remember seeing a patient with open MRSA wounds in A&E when I was an officer there. She was going to breach and I was waiting for an investigation to come back. I said, "Please don't move the patient. I am afraid we are going to have to accept this breach, but why transfer to CDU and spread MRSA around the hospital now and have to deep-clean other areas?" I came back and of course she had gone. There is this conflict. If we can get better integration between clinical and managerial aspects of the healthcare process I think we can certainly address a lot of these issues.

Q422 Charlotte Atkins: You think that is the most important change to help ensure that we have better patient safety.

Dr Kreckler: That certainly would be a large step forward. Something that I think the inquiry has established already is that there is a huge lack of evidence at the moment for what does work. I have been involved in research myself for the last two years. We find it very difficult to secure funding. What is quite interesting about safety research is that a safe system is inevitably a more efficient system which is inevitably a cheaper system. To give you an example, we found that when we looked at the improvements we had made over the six-month process, for every approximate pound that we had invested in the research programme we saved £4 in terms of missed patient events, if you like - complications. The problem is that it is very difficult to attribute that to a specific budget when it comes to liaising with hospital management.

Q423 Charlotte Atkins: Kathryn, what change would you see as being the most important to improve patient safety?

Ms Fawkes: I think you have to put that as the number one priority. An example that I have is that one day we were doing the list and we were trying to get the list done to meet the targets. We had one patient who had had two procedures and they needed a third, but it did not necessarily have to be done in the theatre - so it could be done in the induction room. It is hearing testing. They wanted to anaesthetise the next patient and get on with the next procedure. The first patient is asleep in theatre and they put the second patient asleep in the anaesthetic room and they switch them. They switch them through the doorway. Essentially, at one point in time, we had two patients in the theatre. These are not bad people who did this but they are trying to meet their targets and get the list done by the end of the day. Then they finished this hearing test, which takes about 45 minutes to do, in the anaesthetic room. But we had two patients in, and I have a problem with that. It is not safe to do that. You can mix records up and just a multitude of things.

Q424 Charlotte Atkins: Susannah, would you like to add what you think is the most important change that could be introduced which would improve patient safety from your point of view?

Dr Long: There are several, as you can imagine. There are some elderly-specific things, like making the hospital more elderly friendly from start to finish, making sure we communicate better with primary care before and after an admission, but there are some general things, as I said before, just making everybody aware through training of patient safety and of the theories behind it, and of what we can do as individuals to stop problems occurring. Also I do think the team working aspect of it needs to be encouraged more. Junior doctors have to do audits as part of their training - it is one of those things that you have to have on your CV when you go for job interviews - but I think often people get disillusioned or they do not really see that things are improving as a result of what they are doing. I would say instilling in people the fact that they can change things and make things better - very simple things, just giving them the encouragement and role models to show that we can change things.

Charlotte Atkins: Thank you very much.

Q425 Chairman: Susannah, when you did your undergraduate training, did you look at issues about discharge policy from the acute sector? Earlier you gave us a frightening picture of somebody going back home and going back on to old pharmaceuticals, that had been provided for an issue that was not around when they were discharged. Were there fundamental things like that about discharge policy?

Dr Long: No, that was the sort of thing I learned on the job, after I qualified, by experiencing things going wrong and by talking to other people. You sort of develop a way of continually thinking what can go wrong and what should I be doing to stop it, but you cannot always predict everything. But there was not any training on practical things like that.

Q426 Sandra Gidley: We hear a lot about the NHS trying to move towards a "no blame" or "fair blame" culture. Are we there yet or do we have a way to go?

Dr Long: It is very difficult, because, when something serious happens and a patient dies as a result of a safety incident, I think there is still an automatic reaction: people look around and try to work out who is to blame, but if there is blame, it tends to be interdisciplinary. That might be a reflection of us not understanding the difficulties faced by other disciplines. The nurses might say, "It's the doctors' fault" or the doctors might say, "It is the nurses' fault". I have been very lucky - the people I have worked for have been very encouraging and supportive in trying to take these things as a learning exercise and not blame and try to develop people so that it will not happen again - but within the hospital culture there is always going to be a bit of that.

Ms Dheansa: I think it is getting considerably better. With anonymous adverse incident reporting it is getting better.

Q427 Sandra Gidley: But we are not there yet.

Ms Dheansa: No.

Q428 Sandra Gidley: What needs to happen to get there?

Ms Dheansa: I do not know whether we will ever get there. We do not know whether we will ever get to a no blame culture.

Q429 Sandra Gidley: Is that human nature?

Ms Dheansa: Yes.

Ms Fawkes: I do not think we are there yet but, also, you need to look at the instances and discuss them and talk about what can be changed in a given situation or whatever and not have incident reports just put in the files. I think they need to be brought out for educational purposes.

Q430 Sandra Gidley: Is it better when it comes to a near miss? Are we there with "near miss" reporting? Do people feel happy and comfortable because patients have not suffered but they could have done?

Ms Dheansa: I feel that the cycle is not there within the incident reporting yet. Incidents will get reported and I am still not convinced that the feedback comes full circle.

Q431 Sandra Gidley: So you do not learn from the mistakes, basically.

Ms Dheansa: Not the near misses. A lot will be learned from the serious untoward incidents, but I do not think with those near misses -----

Q432 Sandra Gidley: They could be used more proactively.

Ms Dheansa: Yes.

Q433 Sandra Gidley: That is interesting.

Dr Kreckler: I would add to that that near misses, on the whole, are not reported as much as the incidents themselves. It is: "We've got away with it this time" or "No harm came, so why bother reporting it." Then I must also echo what my colleague just said, that really there is very limited feedback that comes back down the frontline which also further reinforces to some extent the pointlessness of incident reporting.

Q434 Sandra Gidley: Would that be everybody's experience? I would have thought that a lot could be learned potentially from near misses.

Dr Long: In my general experience of reporting, say, incidents I have reported, I have always been aware that somebody is taking it seriously somewhere but I have never been told what is being done. Unless it is something immediate that I have seen put in front of me, you never get feedback.

Dr Kreckler: Also, for people to report, they need to recognise that a near miss has occurred. One of the most commonly reported incidents is falls. The knee-jerk reaction to a fall is to fill out an incident form, but where there is something less obvious, where maybe a patient was not cross-matched for theatre, and blood was not required but the patient should have been cross-matched, who is likely to spot that, or, if so, who is going to act on it? There are some issues that are not necessarily spotted because they are near misses. It is not until harm occurs.

Q435 Sandra Gidley: It is unrealistic to expect you to go looking for things, but, obviously, if somebody is aware of it. Let us have a slightly different question: if a mistake happens, how easy is it to talk to the patient and be open and honest about what has happened? Do you feel confident? Is there any training on this? Is it something you pick up on the job? Is it something you hope somebody else will do?

Dr Long: I personally have no problem with doing that. It tends to start putting things right when something has gone wrong if you can be very clear and explain, "We didn't mean this to happen, but it has, and this is what we are going to do about it for you." Again I think I have been lucky, in that the people I have learned from on the job have been very good at that generally and I have never seen anybody shy away from that. That is my experience.

Ms Dheansa: I would echo that it is a lot more open. There is much fear of litigation and the reputation to the hospital, et cetera, but from a clinical point of view I would say that we are now able to be very, very open.

Q436 Sandra Gidley: Is everybody confident? Are people trained in that or do they learn by observation? It is quite a difficult thing to do.

Dr Long: I think I learned by observation, not explicit training.

Ms Dheansa: Now we have the support of, say, the PALS co‑ordinator, and the complaints person we would involve. Where I work we have a psychotherapy team which is there to offer a lot of support to the patient and the staff involved. In the organisation where I am at the moment, it is set up quite well.

Q437 Sandra Gidley: I take it that is not the norm.

Ms Dheansa: No.

Q438 Sandra Gidley: Kathryn?

Ms Fawkes: I cannot really comment on that because, being in theatres, I very infrequently have direct contact with the families.

Q439 Sandra Gidley: Okay. Fair point. Simon?

Dr Kreckler: In surgery, complications of surgery are an occurrence that happen all the time, and communication with families and support is usually excellent in my experience. We should flag up here that in medical education we have been talking about moving away from some of the more specific education in pharmacokinetics and the other aspects of anatomy, and there has been a big drive towards training in communication skills. When I was a student, this was coming in, and I certainly think that the doctors coming through now are better equipped to deal with this sort of situation than they once were.

Q440 Chairman: Sarah, you mentioned litigation, and earlier on you said that you did not think this blame culture would change because it is embedded, in a sense. Litigation is obviously one, and your own professional regulatory body could be another if you made the mistake yourself. Are there others that spring to your mind?

Ms Dheansa: Reputation to the hospital itself.

Q441 Chairman: That would go along with not being professional, as your regulatory body says you should be. Are there others?

Ms Dheansa: Not that I can think of.

Q442 Chairman: What about the media?

Ms Dheansa: Media, yes, definitely. The Daily Mail is just -----

Q443 Chairman: You do not have to name individuals. I am interested in the concept that to get an open and honest way of looking at things is to be able to say that we have had near misses which could have been serious. Admitting that and changing the culture where something is not admitted because it has not been serious - it could have been serious but has not been - what stops you doing that? What stops the culture change inside our health system? You have litigation, you have your own regulatory body, your professional standards that you could be referred to that for, you have the local press. Which is number one that keeps the culture as it is now? Which is number one of those three? Which are numbers two and three? What do you fear most?

Ms Dheansa: Litigation, the local press - and what was the third one again? Sorry.

Q444 Chairman: Your own professional body. If you have done something wrong you could go in front of a regulator. I am an ex member of the General Medical Council - as of this month - so I have had experience.

Ms Dheansa: My professional regulatory body.

Q445 Chairman: That would be number one.

Ms Dheansa: Yes.

Q446 Chairman: Because that is your livelihood, basically.

Ms Dheansa: That is it.

Q447 Chairman: Where do the other two fall: litigation and the media?

Ms Dheansa: The media can very much destroy morale on the ground floor. Very much.

Q448 Chairman: Is that collective morale or is that ----

Ms Dheansa: Collective morale, yes - when you are working extremely hard in the interests of the patient and when it is spun round. I would say that first and foremost would be professional, and then litigation and media together really.

Q449 Mr Syms: Kathryn, with the accent, presumably your experience is NHS and somewhere else.

Ms Fawkes: And somewhere else.

Q450 Mr Syms: Do you feel more confident within the NHS or is your experience somewhere else better or worse? Has your experience been in the United States or Canada?

Ms Fawkes: The United States. Out of 250 paediatric hospitals in the United States, the hospital I worked in is ranked eleventh. The experience there was a little different. I have always worked in theatres. In this particular institution, they used the Association of Operating Room Nurses Standards as their standards to work by. Everyone tried to practise within those recommended guidelines.

Q451 Mr Syms: Because people are rather more litigious in the United States, was the system open there? Would you be more confident that your team would report things here, as opposed to your experience across the Atlantic, or not?

Ms Fawkes: Across the Atlantic, we had no problem going to a manager. If something happened, we would go to report to our manager that there was an occurrence because we felt that she needed to know. Recently where I work, there was an occurrence of something they told the senior sister but the manager was told by the physicians. The nurses did not go to the manager. I think it is not understanding that this sort of communication is important. The communication is in its box.

Q452 Dr Taylor: I am going to ask you some questions about senior colleagues. You have all had lots of senior colleagues, so I do not want you to be inhibited by people thinking that you are talking about a specific individual or somebody you are working for at the moment. How do senior colleagues react if you make a mistake or a near miss?

Dr Long: As I said before, I think in the majority of cases they have been great. They have been supportive, they have tried to help me or use it as a learning experience for the whole team. There has only been a very small number of instances where I have felt I have been unduly criticised or unduly blamed or made to feel bad about it.

Q453 Dr Taylor: Are you really saying that the day of the godlike consultant is fading away?

Dr Long: I do not know if it is specialty specific.

Q454 Dr Taylor: What about in surgery? - because they used to be some of the worst.

Dr Kreckler: I think it is very, very important. You could argue that there is a real dinosaur around who will still be very unsympathetic to error, if you want to use that word, or natural mistakes, if you like - but, on the whole, I think that is changing. On the whole, there is a lot more senior support than perhaps there once was.

Q455 Dr Taylor: What about from the theatre point of view?

Ms Fawkes: I think it varies upon the manager and what their background and experience is. If they are open to change, understand evidence-based practice, then I think they are more open to discussing something that happens and trying to look for solutions.

Q456 Dr Taylor: In the States you were able to go direct to the manager.

Ms Fawkes: Yes. We always went to our manager if something occurred.

Q457 Dr Taylor: The difference here is that you would go to your senior nurse.

Ms Fawkes: A lot of people will go to the senior nurse and discuss it with them, versus going to the person above her who is the manager of the whole perioperative area.

Q458 Dr Taylor: With your experience in the States, does that mean you would go one higher?

Ms Fawkes: Yes. I would go one higher.

Q459 Dr Taylor: Would that be a recommendation, that you should go to the highest level you can?

Ms Fawkes: In your given area I think you should. I think you should because they are ultimately responsible.

Q460 Dr Taylor: You gave this awful example of the laser equipment being used incorrectly. I think you said it was a Filipino nurse who did not feel she could complain.

Ms Fawkes: She did not confront the doctor and say, "You need to do it this way. This is our approach, standard."

Q461 Dr Taylor: I understand that she did not want to confront the doctor. Who should have been available to help her? Was there a more senior nurse there or was she very much on her own?

Ms Fawkes: She is the senior in that particular theatre.

Q462 Dr Taylor: She was a senior?

Ms Fawkes: Yes.

Q463 Dr Taylor: Going on on this, have you worked with senior colleagues who have discussed their own errors with you?

Dr Kreckler: It does happen but it happens rarely. In surgery, there is a forum for reviewing particularly surgical complications, the morbidity and mortality meeting. It has been in place for centuries. That is a forum where surgical decisions are reviewed and discussed, but it tends very much on the technical side of things.

Q464 Dr Taylor: You were in for the first bit and would have heard somebody saying that medical students should be taught to challenge everything. Is that feasible, do you think?

Ms Dheansa: I think the promotion of critical thinking should be - then it will embed within the culture of the organisation and the way they are working so that they do feel able to. I think it is very important, actually, and the same within nursing. I very much encourage nursing students to question everything.

Q465 Dr Taylor: All of you would teach people to question.

Ms Dheansa: Yes.

Q466 Dr Taylor: And you would all feel able to question those above you.

Dr Long: Yes.

Ms Dheansa: The majority of people above me I would feel happy to question. There will be some personalities where you know that it is probably not even worth it because they will just ----

Q467 Dr Taylor: They will not take notice.

Ms Dheansa: Yes.

Dr Taylor: Thank you.

Q468 Dr Stoate: Do you all feel that patient safety incidents are adequately reported and learned from in the NHS?

Dr Long: I do not think so. A lot of things go unreported, as we have said. I know that a vast majority of reports are about things like falls, where something really obvious has happened. That seems to be what the management plan put forward is. Someone falls, a nurse calls a junior doctor, a form is filled in, and that is part of the management plan. I think people only ever report other things if something serious has gone wrong and they think that it is worthy of it. We are not encouraged to be generally open about things so much.

Q469 Dr Stoate: Does anyone have a different view, or do you all feel the same?

Dr Kreckler: There is a whole culture behind incident reporting. We know for a fact that nurses fill out 90% of incident reports whereas clinicians will only fill out 10%. I think that part of the problem behind incident reporting is that people do not necessarily see the benefit from it because there is that lack of feedback. If there was a regular loop set up, people might see the impact and be encouraged to report more liberally, and the whole thing would positively build on itself. At the moment, the incident report disappears into a black hole, never to be heard of again.

Q470 Dr Stoate: Are you saying that incidents are reported but they are not being adequately dealt with.

Dr Kreckler: They are being dealt with. This is as a frontline staff member rather than a patient safety researcher now: I have very rarely seen anything come back. Unless a serious incident has been investigated more from a litigation point of view, it very rarely comes back.

Q471 Dr Stoate: Until some manager is worried about being sued, not much happens.

Dr Kreckler: That is one way to put it, yes.

Q472 Dr Stoate: Is that a view shared by you or is that the culture?

Ms Dheansa: I have the responsibility within my job of having to sign off a lot of these. Before they go up the ladder, the investigation is carried out and then I end up as the handler. I do try to make sure that, where there are incidents, we try to institute feedback at ward meetings. It is engaging people right on the ground floor in it, so they are educated. But that is not everywhere. It is only because I so believe that we can learn from them.

Q473 Dr Stoate: At the very best, there are some pretty big gaps in the system.

Ms Dheansa: Yes.

Q474 Dr Stoate: Assuming that, can any of you think of examples where a patient safety incident has really led to proper learning and actual culture change? Can any of you give any examples that you see?

Dr Kreckler: At the local level, in terms of individual incidents we may have been involved in ourselves, the answer personally is no. But, for example, at a national level there is now re-standardisation of the crash call number to 2222 for every hospital in the country as a result of incidents that were collated and put together. I think the NPSA's national reporting service can play an important role in picking up these rare occurrences, announcing where something can be sent out on a national level and be effective - something simple such as that.

Q475 Dr Stoate: You have come up with one simple answer. Have any of you seen a real culture change, within your unit or wider, resulting from an incident that you have all managed to learn from? Or has it been a bit woolly?

Dr Long: I think that sometimes you have a brief culture change and it sort of wears off as new staff come in. People move on and people forget about it and new problems occur. I have seen a lot of trust-wide policies and protocols, things like antibiotic prescribing guidelines after C.diff outbreaks and so on, and lots of things specific to the elderly, where all nursing staff particularly are asked to fill in lots of risk assessment tools for people on the ward for nutrition and falls and what-have-you. The one thing I would say about that is that it tends to be a knee-jerk reaction to these incidents. People think, "We have to fill out these forms and make risk assessments more" but I know that some of the nurses I work with feel that that takes a lot of their time and they do not act on it because they do not really understand what the underlying problems are.

Q476 Dr Stoate: Are you saying that you get a flurry of activity after an incident.

Dr Long: Yes.

Q477 Dr Stoate: But that very quickly disappears again.

Dr Long: In my experience.

Q478 Dr Stoate: That is pretty alarming, is it not? Do you not feel fairly alarmed by all that? It is pretty frightening stuff, is it not? You get the incident, it gets reported, you do see some change, and then a few weeks later things have gone back to business as usual.

Ms Dheansa: We had an incident where all the junior doctors were not prescribing properly and there were big prescribing errors. The trust realised this was an issue and sorted out competency training which all the junior doctors have to undertake and have to pass. That improved things. It has not eradicated the prescribing errors, but it has highlighted the staff who really have a low knowledge, junior doctors who are not up to it, and they are not allowed to prescribe.

Q479 Dr Stoate: Do you think that is a permanent change or do you think that when the next round of junior doctors comes in it will just go back to the old style again?

Ms Dheansa: No, it is permanent. They have recently ended somebody's contract who failed that prescribing error three times.

Q480 Dr Stoate: That is encouraging. Does anyone else have any good news for us? I am feeling fairly depressed at the moment.

Dr Long: The thing that sticks are the trust-wide things, the things everybody knows they have to do for every patient. They stick. Certainly since I have qualified there have been lots of things that have changed that have stuck.

Q481 Dr Stoate: If nurses are making these nutrition assessments but they think it is all a bit of a bore and not doing it, then not much has moved on, has it?

Dr Long: No.

Dr Stoate: Thank you.

Q482 Dr Naysmith: Could we move to another aspect of all this, to do with the aftermath of some incidents taking place - and we are probably talking about serious incidents, where harm results to a patient or maybe even more serious than that. What kind of support is given to patients and their relatives and carers when there has been an incident and it is recognised, either because it has been reported or because something goes wrong afterwards? We have heard stories here already of people having to fight to prove that something did go wrong before anybody admitted that it had gone wrong. Is that your experience?

Dr Long: As I said earlier, I have been lucky to work with seniors who have always been very open and clear with patients and their families as soon as something has gone wrong. I am not sure what formal support there is. I know that the patient liaison services have developed a lot in the years since I have qualified, but I do not think I have ever come across a case where I have felt we have not done everything we can to support people after an incident.

Q483 Dr Naysmith: What about the staff who are involved, particularly if they are relatively junior staff.

Dr Long: I think that is an area where more work should be done. We tend to support ourselves informally. We talk to each other. Again, it is very much within your own discipline usually, unless you have worked in a place for a long time and you know the other people very well. There has only been one occasion, where something really bad happened, that we all had a meeting. We were debriefed and offered counselling for something really horrible that happened. That is my experience.

Q484 Dr Naysmith: What about you, Sarah?

Ms Dheansa: I would say that patient advocacy in the PAL service is a great improvement. On any issues that we have, they are always brought in. As I have said before, we have a very good psychotherapy team that the trust, I know, has fought to keep and they are involved with the patients. We are a small specialist trust and we are quite lucky in that respect, having worked in a larger organisation where the psychotherapy team is not given the resources that are needed.

Q485 Dr Naysmith: Have you come across any incidents of trying to cover something up rather than be open with patients?

Ms Dheansa: Most of the time I have found that they are very happy to be open. Years ago I can think of an incident where a surgeon operated on the wrong eye. It turned out that the patient needed to be operated on both eyes anyway -----

Q486 Dr Naysmith: That must have been a relief for everybody.

Ms Dheansa: -- but still wrong-side surgery took place. Most of the time, I would say in the last five years, things are getting a lot more transparent.

Q487 Dr Naysmith: Does that apply to staff as well?

Ms Dheansa: I think so. With junior doctors, if they ask for help they will get more support. It sometimes happens with the culture, if you have a consultant who will say things to them like "Please do not hesitate not to call me because I am on the golf course" or wherever, and they have a very old, fiery attitude, that the SHO, the more junior doctor, will not ask for help when needed. That is when you start running into problems. Doctors are a lot more junior now, and at the consultant level they need to be prepared that they are going to be disturbed when they are on call and have to come in.

Q488 Dr Naysmith: Do you think that is part of the new contract?

Ms Dheansa: Yes, but it is whether .....

Q489 Dr Naysmith: Kathryn?

Ms Fawkes: I cannot be sure about directly with families.

Q490 Dr Naysmith: You have said you do not see patients.

Ms Fawkes: Yes.

Q491 Dr Naysmith: Do you have the support of the general staff? Probably in theatre is where most of the serious incidents take place anyway, apart from giving the wrong drug, I suppose.

Ms Fawkes: I think there is still some of a culture where some things may be ....

Q492 Dr Naysmith: From some of the earlier answers it sounds as if people may be reluctant to report things in theatre.

Ms Fawkes: I think they report things, but I think sometimes it takes a while to get change in. For example, the laser incident: it has taken two years for us to have everyone to have laser training. I think it takes a while. Part of it is financial, but it is part of patient safety.

Q493 Dr Naysmith: Simon, you are the sweeper-up on this one.

Dr Kreckler: I have personally not had a huge amount of experience of this but, anecdotally, I understand that there is a lot of support initially for patients, up until the point that litigation is mentioned. If there is any litigation whatsoever then there seem to be big brick walls that go up, and the patients then get a pretty rough ride of things. In terms of staff, again I know of colleagues who have been in coroners' inquests and the support they have received has been almost non-existent.

Q494 Dr Naysmith: Non-existent?

Dr Kreckler: From their trusts that they work for.

Q495 Dr Naysmith: Do you think that is something which should be improved?

Dr Kreckler: Absolutely. Of course.

Dr Naysmith: Thank you.

Q496 Chairman: Sarah and Susannah, litigation was mentioned there. What is your experience if litigation is mentioned? Does it affect the way that PALS works, or not?

Ms Dheansa: How PALS works, did you say?

Q497 Chairman: Patient liaison is good at talking to patients' families about incidents, et cetera. Simon has just said - and correct me if I am wrong on this - that everything is going fine until litigation is mentioned and then the drawbridges are pulled up a little bit. There is an issue here, if we are talking about changing culture. I just wonder if, in your experience, this word "litigation" does affect the interaction, if a patient has been involved in an incident, with their family.

Ms Dheansa: I can think of a recent incident where dirty instruments were used on a patient. It came to light and the trust was very open. As soon as it came to light, they brought the family in and went through it all. Obviously the family and the patient were extremely distressed by it. Our PALS team got involved and remained extremely independent.

Q498 Chairman: Would they have been conscious or did they change in any way if litigation ----

Ms Dheansa: Yes, definitely. There was this feeling of the first thing that senior management were worried about was the press and litigation. But I would say in that case that it was more the press that they were worried about. It is very much reputation.

Q499 Chairman: But they stuck to their guns in that particular incident.

Ms Dheansa: Who?

Q500 Chairman: PALS.

Ms Dheansa: Yes. PALS remained completely independent.

Q501 Chairman: Susannah, do you have any experience of this, where PALS have reacted to litigation or threat of litigation?

Dr Long: I have only had experience of one case where litigation was threatened. I do not know that it made much difference. I think they were very anxious to try to resolve things, regardless of litigation or not.

Chairman: That is fine.

Q502 Sandra Gidley: I asked Mr Black earlier about the NPSA and the patient safety alerts with regards to the Safe Surgery Saves Life check list. He seemed to think that this was already something that was widely done. Will this be complied with by all surgical teams?

Dr Kreckler: I do not think there is any question that everyone involved in any healthcare delivery wants to do anything but the best for their patients. Check lists seem on the face of it to make complete sense. Certainly to myself - and I have been involved a lot in patient safety research - they make absolute sense.

Q503 Sandra Gidley: In your experience are they always used?

Dr Kreckler: That is what I am coming on to. The short answer to that is no. The reason for that really depends on the way in which this initiative is implemented locally. It depends on those who require to use it to understand the purpose of it, if they are adequately trained and educated and the fact that we have evidence behind this - and the recent New England Journal article will help a great deal with this latest initiative. Where they do not necessarily understand the purpose of it, they just see it as another box-ticking exercise to interfere with their attempt to deliver care to their patient. We have been using Saves Lives surgery checklists for the last couple of years. They were required by the NPSA towards the end of 2005. This requires that you sign a box when the patient is first consented, when they leave the ward, when they arrive in the anaesthetic room, and just before the operation starts, to confirm that you have the right patient, the right operation, and that it is the right side. I certainly know of situations where I have seen the scrub nurse bring a form down to the coffee room, to be signed by a surgeon in the coffee room rather than the surgeon going to check the patient in the room. These are not bad surgeons, these are not people who are flippantly ignoring safety protocols, they simply do not appreciate the purpose of the form because they have not been adequately trained.

Q504 Sandra Gidley: Surely they are not stupid. This is not rocket science. All the thousands of pounds of training we spend on a surgeon and they do not understand the purpose behind something simple. Does it not come down to not being told what to do rather than not understanding?

Dr Kreckler: I think possibly the problem is that all that happens is they are simply told what to do without being given the necessary information to go with it.

Q505 Sandra Gidley: But I am saying that this is not rocket science. I should have thought it was blindingly obvious.

Dr Kreckler: Yes. I could not agree more, but, unfortunately, it is the way these things are implemented. Perhaps a simple analogy is to think back to the 1980s when the seatbelt law was brought in. At the time people were up in arms about wearing seatbelts: "I've never worn a seatbelt, I am a safe driver." "I never crash my car." You would not dream of getting into a car now without putting a seatbelt on because a culture change has come about. That culture change has to happen. It is not going to happen with a big stick and a diktat because you automatically get resistance to that. Certainly, the way the Saves Lives surgery was implemented in my experience, was that it was done one day: "This is what you're going to do from tomorrow" and everyone was, "Oh, another box-ticking exercise." There was no explanation, nothing to back it up. If it is done properly, I think everyone will do it and will embrace it. I think that, with time, it will become part of the culture and will be done anyway.

Q506 Sandra Gidley: Kathryn?

Ms Fawkes: We started implementing that at Great Ormond Street in the cardiac theatres about a year ago. Most everybody is on board with doing it. It has to be a team effort. It is not just the surgeon who can be non compliant. You can also have an anaesthetist who chooses not to be compliant within the process. The nurses have found it very beneficial because they are all introduced, everyone is acknowledged, they are made part of a team, the patient is discussed. They are empowered to ask questions and to say, "We don't have this particular item today but we have this." They are empowered to communicate. It is a very good thing.

Q507 Sandra Gidley: So there have been other benefits as well from that perspective.

Ms Fawkes: Yes. They did not say we had to do it, they worked on it through education and then they are starting to work through the process in the different theatres.

Q508 Sandra Gidley: What shall we do with those who do not comply with this? Should it be a matter for regulation or the employers?

Ms Fawkes: One hospital I worked with in the States had a computerised programme. Their surgery record and all the patient care, the nursing care plan, et cetera, was all computerised. The only way you can get to complete and close your patient after they leave the theatres is that you have to tick the box one way or another whether this checklist was done, so they have an audit trail of who is doing it and who is not.

Q509 Sandra Gidley: That is good. Simon.

Dr Kreckler: I have to say I feel slightly uncomfortable with that question. Earlier on in the inquiry we asked: Is there now a no blame culture in the NHS? and here we are trying to work out who to blame when something has not been done.

Sandra Gidley: I am just asking. I asked what should be done about those and the answer may be nothing.

Q510 Chairman: We are not coming to conclusions here.

Dr Kreckler: To build on what I said earlier, I think that if it is not being complied with we need to look at how it has been implemented and we need to address at the core level some way that initiatives are being started in trusts and the way that people are educated and trained. If it is not being followed, then clearly that has failed and it needs to be reviewed, with further training and education as necessary.

Q511 Sandra Gidley: What if you have educated somebody to death and they say, "I don't care, I'm still not doing it. I've always done it like this and it has never done me or anybody any harm"?

Dr Kreckler: Everyone wears their seatbelts now.

Q512 Sandra Gidley: But what do you do to that person?

Dr Kreckler: It will change in time with culture.

Ms Dheansa: You have to take a transformational approach to it, I think.

Dr Naysmith: Simon, there is a significant proportion of people in this country who do not wear seatbelts. It is going on for 10%. There may be 10% of surgeons.

Q513 Sandra Gidley: We are talking about the 5% to which Mr Black was alluding earlier - in a slightly different context, I will admit.

Dr Kreckler: I think they will end up retiring soon.

Ms Dheansa: But there are lots of other people in that operating theatre who should be empowered to if the surgeon is not doing it.

Q514 Sandra Gidley: That is a very interesting point. I do not know when this incident with the Filipino sister occurred, but it might have been that if the right checklist was in place - and I am not saying the NPSA is the right one - she would have been able to say something because the culture would have been different.

Ms Fawkes: I will say that we have not started the actual checklist but we have done what we call the time out, where we identify the patient, decide where we are operating, the correct side surgery, allergies and a couple of other pertinent things. We do not have co­‑operation, with everyone doing it, but the nurses have decided that they are going to do this as our minimal before we are incorporated into the whole checklist programme. We have decided we are doing this anyway, and we do make them stop so we can identify we are doing the right patient.

Q515 Stephen Hesford: Can I apologise for not being here at the beginning of this session. You interest me, Simon, by what you have just been saying to Sandra. If you have your checklist and if you have your recalcitrant surgeon who still will not use the checklist, even though they have had the training and all the rest of it, and then they have made one of these mistakes that would have been prevented by the checklist - wrong side, or something like that - given your analogy with the seatbelt thing, that the reason the culture change comes about is that people realise it prevents them getting hurt or that they will lose their licence or they get endorsements or some things will get whacked, what should happen to the surgeon who does not do the checklist and then makes the mistake that would have been prevented by the checklist in the no blame culture?

Dr Kreckler: What you have just described there is evidence-based medicine. In patient safety in general, we are just building up our evidence base at the moment. A lot of the checklists that have initially been instigated, whilst they seem to make perfect sense, do not have that evidence to back them up. We do now have that evidence coming from a recent study. I think that what we probably need to do is to collect data on how many surgeons there are who are blatantly refusing to do this in three years time. I suspect it will not be as high as 5% or as has been suggested. I think we need to wait until we have evidence before we start concerning ourselves with that question.

Q516 Stephen Hesford: You are an extremely polite young man. In the situation I have just described, would that not be quite serious professional misconduct? Should we not look at it like that?

Dr Kreckler: Once the evidence is in place, once the protocols are in place, then it should be dealt with as any other breach of hospital protocol where that has proven to be the case.

Q517 Stephen Hesford: But you will not adopt my suggestion that it is professional misconduct?

Dr Kreckler: It is the same thing.

Q518 Stephen Hesford: Or prima facie negligence.

Dr Kreckler: A breach of standard protocol could be construed as such anyway.

Q519 Chairman: I think that would be a matter for the regulator of the profession whether it was serious professional misconduct of not. In the earlier session I asked John Black about revalidation. I asked a very specific question about whether, if these guidelines on safer surgery were not adhered to, that should affect revalidation or appraisal. He seemed to be very firm in saying that, yes, it should. When revalidation is brought into your profession particularly, or into Susannah's, there may be an issue about going to a regulatory body for a failure if it is the case that you do not stick to the guidelines as outlined just recently. Or do you think the culture will take a lot further getting there? Is that too simplistic an analysis? What do you think?

Dr Kreckler: Ultimately there will be a role for a big stick, but I think initially we need to approach this with a big carrot. There is an awful lot that can be done in a positive way before we have to go down a negative route.

Q520 Chairman: The concept of revalidation of course is that anybody who becomes a doctor or a surgeon will not necessarily remain in that mould of professionalism for the next 30 years and, providing they do nothing wrong, nobody is going to question them. It is actually to say that you will skill or reskill and get used to the different methods of working. Sandra was alluding to what do you do if they do not. Revalidation would immediately catch people who did not keep up-to-date with their skills and with changes in clinical practice.

Dr Kreckler: It is certainly another opportunity to build redundancy into the training and education system to ensure that the new policies are implemented.

Chairman: Thank you.

Q521 Dr Taylor: Susannah and Simon, I want to try to clarify what happens to emergency admissions at night and at weekends and to see how safe the procedure is. Obviously going back a few years, with medical admissions there was always in my day an RMO who knew what was coming in and they delegated to the most junior to do the admission procedure but knew what was there and so would be available for help if necessary. Is that still the case, or is it left entirely to the most junior to cope at night and at weekends?

Dr Long: It is still the case. I think that is the role of the medical registrar. I do think it is slightly personality dependent: some people are more hands-on than others. I try to know exactly what is going on with the take, who is expected, who is in, who the juniors are worried about and who I need to be worried about, where people are and what jobs need to be done. I think that is very much the role of the medical registrar.

Q522 Dr Taylor: So there is still a middle grade on.

Dr Long: Yes.

Q523 Dr Taylor: Does that go for surgery as well?

Dr Kreckler: All admissions will come through SHO/registrar level, yes.

Q524 Dr Taylor: How does the shift system affect continuity of care and the post-take ward round? Does that take place regularly? Does it take place with the same juniors to have admitted, or will they have changed by then?

Dr Long: I think it has changed with the introduction of the shift systems. I think the continuity has decreased a bit. It seems to be up to the individuals to ensure that there is a really good handover. In some hospitals I have worked in, the hospitals themselves have taken the decision to make sure there is a really good handover; in others, it is less good. For example, in one hospital that I work in, every day at nine o'clock the whole medical team meets in the room, the whole medical department from consultants to house officers, and the names of all patients who were admitted the day before are read out and handed to whichever teams need to look after them. Interesting things or difficult things are discussed, and that is very good. On Friday afternoon, the same group gathers, and all the jobs for the weekend from all the different teams are passed on to the on-call team. There is usually a consultant there supervising it, to make sure that jobs are appropriate for whichever member of the team they are being delegated to.

Q525 Dr Taylor: Is there time for that to take place?

Dr Long: Yes. I have seen it in that hospital. It works very well. But you have to have the individuals there to push it and keep it going and make sure it continues and make sure it is effective. I have not seen that everywhere I have worked.

Q526 Dr Taylor: Have you seen that sort of thing happen?

Dr Kreckler: In my personal experience, not particularly. I think it happens probably more in medicine than surgery. Personally I think handovers are a real opportunity for problems to be missed and things to be overlooked. We still operate a 24-hour on-call system/take system where I currently work for the more senior level doctors. We get through three shifts of house officers in 24 hours and two middle grades. The more senor registrars do a 24-hour shift. That is going to be stopped fairly soon. You have to trade off tiredness with continuity of care.

Q527 Dr Taylor: There must be a terrible temptation when they are just finishing to dash off.

Dr Kreckler: Yes.

Q528 Dr Taylor: Without adequate handover. The answer there is for somebody more senior who is on for a longer shift.

Dr Kreckler: That is the current system that I work in.

Q529 Dr Taylor: Is that going to become impossible?

Dr Kreckler: If not already, it will be soon be illegal.

Q530 Dr Taylor: Because of the European Working Time Directive.

Dr Kreckler: Because of the working time rules, yes. I think the way we currently get around it is that theoretically they are on-call off site. The senior can go home when things quieten down at midnight or whatever.

Q531 Dr Taylor: You probably heard a previous witness - I forget who - say that a 65-hour week was something that should be possibly aimed at, to allow for time on-call and to allow for training. Would you agree with that or is that too much?

Dr Long: I think that is roughly what I worked as a house officer. I am not sure exactly what I worked, but I worked a system where I would come in on a Friday morning and not leave until Monday afternoon. I was supposed to have protected sleep at night, but I would never really get the protected sleep: I would always be still trying to do all the jobs on the ward. I worry that a lot of the F1s that I see now do not do nights at all. That does worry me because I know that that is when I learned a lot of important skills - the skills we were talking about before: the team working, the handover, and how things work in the hospital, that I did not know until I started working.

Q532 Dr Taylor: You would agree that 48 hours is going too low?

Dr Long: I am not quite sure of the exact figures but I am concerned that people do not work in those antisocial hours, at nights and weekends, when they really get to see how the hospital works.

Q533 Dr Taylor: Is that general that a lot of F1s do not do any nights?

Dr Long: I can only speak for where I have worked recently, but in recent years I have come across quite a few cases where that is true.

Dr Kreckler: It varies. We have some that do and some that do not. I could not tell you the proportion that do and the proportion that do not.

Q534 Dr Taylor: Would you go as far as Mr Black went, to say that it is an "impending disaster" when we go down to 48 hours.

Dr Long: I am not sure. I think it depends if we are aware of the dangers and if we put other systems in place to combat them, if we make sure our handovers are good between shifts. Another problem with the shift system is that people tend to defer decisions. They think, "There's only a few hours left. I'll leave it to the person who comes on at eight" or whatever "to make that decision." I think we need to be very wary of that and make sure that people are encouraged to make sure the job is done before they leave. When I was a house officer, we would not leave at five o'clock if our jobs were not done: we would stay until seven or eight o'clock or whenever to make sure that everything was done. I am not sure the same attitudes are always present now.

Dr Taylor: Thank you. So communication, as you have all said many times, is absolutely vital.

Chairman: Could I thank all four of you very much indeed for coming along and sharing your individual experience with us. It is enormously useful to hear from people at the coal face, as it were. Thank you very much indeed for helping us with this inquiry today.