Official Report 584KB pdf
09:15
The second item on our agenda is an oral evidence-taking session with the Patient Safety Commissioner for Scotland. The committee had lead responsibility for scrutinising the primary legislation that created the role of the Patient Safety Commissioner earlier this session, and this morning, members will have an opportunity to ask Scotland’s first Patient Safety Commissioner about her experience of the role and initial priorities since her appointment began last September. I welcome to the committee Karen Titchener, the Patient Safety Commissioner for Scotland. We will move straight to questions.
Good morning. During the whole process of establishing the Patient Safety Commissioner, it was stressed that public confidence in Scotland’s healthcare system was a core reason for establishing a commissioner who was independent. Therefore, I would be interested to hear how you can demonstrate independence from Government in order to pursue your Patient Safety Commissioner role.
Thank you for that question, and thank you for allowing me to be here today.
At every meeting and at every point, the first thing that I say is that I am independent of the national health service, and of Government. I try to emphasise that to anybody I meet. In order for this role to be successful, I have to collaborate with people, because I cannot do this work in silo, and the question, for me, is how I measure that collaboration while remaining fiercely independent. I have to ensure that when I meet Government, or an NHS board, I still have that independent voice.
Indeed, I am about the only independent on the latest maternity and neonatal task force. The Royal College for Nursing is represented on it, but most of the task force is made up of board members, representatives from Healthcare Improvement Scotland and so on. I said at a meeting of the group, “Just so you know, I am always going to bring it back to the fact that I’m independent and that we need to have independent voices at all of these meetings.” Independence is fiercely in my DNA with regard to this role, and I hope that I am able to be independent.
Do you think that the current statutory provisions give you enough independence, or are there any limitations?
I have it in my head that there might be, but I have been in position for only five months. I do not have my team in place yet, so I have not opened the floodgates to major investigations and inquiries.
I hope that there is enough in the Patient Safety Commissioner legislation that, if I find something very serious, I can act. Again, though, I have been discussing escalations in that respect. In the same way that Healthcare Improvement Scotland can escalate to Government, I am hoping that I can have that kind of tiered approach when I am concerned about something.
I think that we are almost at the two-year anniversary of the publication of a report by the Patient Safety Commissioner in England, and it was the fact that people such as mesh survivors felt that they were never listened to that led to the establishment of the Patient Safety Commissioner in England. We have also taken evidence on sodium valproate and Primodos and how they have affected people. How do you support and give confidence to people who have been failed previously and who feel they have not been listened to? How do we take that forward?
The legislation specifically says that I should not look at the past, but I have been very involved with sodium valproate in Scotland as well as with the mesh group. In fact, when I was down at the House of Commons last Thursday, I was invited to a patient safety forum, and the mesh advocate down there and Henrietta Hughes, the English Patient Safety Commissioner, were there. Indeed, Henrietta has brought out the Hughes report in order to get Westminster to move forward with redress.
In Scotland, the main concern for patients is twofold. There is the issue of redress, but people also need to understand the syndrome that is attached to the medication. When those affected go to social care and try to get help, people think, “What is sodium valproate syndrome?” I have been speaking to the health minister and asking whether there is anything that we can do while we are marking time and waiting for the Westminster decision, because patients’ lives are being affected now and today by the on-going situation. I did not really get anywhere with that, but I am still seeing whether we can we push Westminster on this; after all, we have a large patient group that is affected by this. Only yesterday, I heard that Henrietta Hughes is meeting Westminster to say, “This has been dragging on long enough. How are we doing this?”
I am very involved with the issue in both England and Scotland, because some of this involves Government decisions on issues that have not been devolved. I am trying to think how we can drive things forward to ensure that patients still feel heard and listened to, and that we do something about this.
Finally, has there been any movement on redress, or is it just not going anywhere? Is there a reluctance to address the issue of redress for sodium valproate?
There is reluctance, because of the amount of money that it is going to cost. I meet the Medicines and Healthcare products Regulatory Agency every month, and when I have asked about this issue, it has talked about the huge cost of redress. It has still not decided whether it is even going to provide redress, let alone how much it is going to provide.
That is why I have been saying that we have to do something about this. After all, the Cumberlege report came out five years ago, I think, so the question is: where are we with that? We have to keep pressing Westminster, so I am still talking to Henrietta Hughes about it and asking, “What can I do to help you move this forward?”
Thank you.
Good morning, commissioner. What mechanisms and processes will you establish to ensure that meaningful participation of individuals with lived experience shapes the work of your office?
We are doing two things—well, we are doing many things, but, first of all, I would highlight the advisory group that I am establishing, which will meet in March for the first time. I have not quite narrowed that down to a date yet, because I am waiting for my team to come, but the group has to have 50 per cent patient representation and 50 per cent clinical representation, so it will have the voice of the patients on it. I can probably get more voices in there as it grows; at the minute, there are only six people on it, but it has to have a 50:50 balance.
The reason why I am on, say, the maternity and neonatal task force is absolutely to represent the lived experience of all families, not just the mums who have serious concerns about maternity care in Scotland. Wherever I go and whatever I am invited to, lived experience is the biggest thing that I bring. For example, I have been out to Stranraer to meet people who have been affected by the reduction of maternity services there. I am talking to people in Wick and up that way, and they want me to go up and meet them. I have been out to patients’ homes. Members of the Scottish Parliament have said that they feel that the voice of the patient still needs to be heard, even though their operation was in 2007. If they have not felt heard almost 20 years later, we are doing something wrong.
I say to people that I do not come with a magic wand or a pot of money, but I come with a listening ear and I ask them what it is that they are asking for to find their peace, if you like, 20 years on. If they are still anxious and concerned about what happened, we have to look at how we address that.
Some of the Stranraer families still have post-traumatic stress disorder from the things that happened, so I am asking NHS Dumfries and Galloway: what is it doing about serving patients who feel that its care damaged them emotionally? I tell the health board that it should be supporting those patients through that. I am pushing back and challenging the status quo, because that is my role.
How do you ensure that disabled patients, ethnic minority groups and rural communities are captured meaningfully in what you are doing?
I have met many disabled people on Teams and said to them that, when I can balance the representation on the advisory group, they will come on to that. Someone whose care ended up making him disabled will bring a meaningful discussion to the table.
I have not got my website set up yet. I am in the process of doing so, but everything takes a long time. When I have it set up, I want it to be open access so that people can have a discussion with my office. I am also willing to travel out, because, for example, when the people in Wick were talking to me about maternity care, they said that they cannot travel to me, so I said, “That’s fine—I will come to meet you.” I want to meet the patients where they are at, but the act says that I cannot interfere or repeat processes. If it is an individual complaint, they have to go to the Scottish Public Services Ombudsman and do other things before that.
I try not to interfere with due process but, at the end of the day, I still want to support patients who feel that they are not being supported while they are going through something. I do not turn people away, but I do signpost them. The whole point is all about hearing the patients, and even now, I am hearing stories about how the patient’s voice is still being ignored. We have to do better in Scotland to amplify that voice and change healthcare practice because of it.
That is the big picture. The small picture is about how I do that on a daily basis. In whatever I do and the conversations that I have, I always bring a patient’s story to that to say that, although we might think that there is nothing to see here, the lived experience is saying something different.
I have no further questions, convener.
I make a declaration of interest as I am a practising NHS general practitioner.
I turn to the Queen Elizabeth university hospital scandal. Several families were lied to by NHS Greater Glasgow and Clyde over many years and the Scottish Government ignored their concern. On top of that, whistleblowers were sidelined, called troublemakers and put in danger of losing their jobs. What are you doing to ensure that the Government and health boards listen to the voices of patients like them and the whistleblowers?
That is still going on. Only yesterday, I had a conversation with a nurse who is afraid for her job, so she will not whistleblow, but she is talking to me. It is hard to not expose people who are living in fear while trying to implement change.
I agree with you and families are still being lied to and staff shut down rather than whistleblowing. When that comes to my attention and I hear about it, it is very important to me. At the minute, I am getting lots of candid reports. If I do not have a name and I do not hear about the issue directly, it is very hard to go with that. Yesterday, when I heard about that situation, I said that I would have to talk to the person, rather than it being a third-hand experience.
09:30
The role of Patient Safety Commissioner will grow, but it is still in its infancy—we have not even got our website up and running. In relation to the inquiry that you mentioned, rather than having lots of inquiries, we have to make sure that patients and staff are listened to on day 1 when they have concerns. If the processes that we have in place are not working, the issues will fall at my door. Rest assured that I am no wallflower and, if I hear from a patient about something that is endangering life, I will be going straight to the top—to the Cabinet Secretary for Health and Social Care. I have already promised him that, if I hear something, he will be the first person to hear it next.
If we are going to work collaboratively, we cannot have a shotgun approach. It has to be done so that the Government knows about it. At the same time, if I tell the health secretary something and nothing gets done, I will still make sure that that voice is heard, whether that means going to the press or to the health boards. We have to make sure that we are not bolting the door when the horse has already gone.
What I want for Scottish health is proactive, pre-emptive measures, rather than drama when something has happened. It is about looking for the little signs that are telling a story. I have already spoken to the ombudsman and said that, if they are seeing themes in a hospital and think, “Hang on a minute, this is the third time this has happened,” they must speak up and say, “Karen, I am a bit worried about this, because this is now the third patient who is reporting that.”
The problem is that we have no national reporting that brings all the facts together. Therefore, we are working in a very siloed area, where there are little reports—Datix reports and adverse events reports—and there is the ombudsman and Healthcare Improvement Scotland. I feel that we need to bring all the evidence together and, at the early stages, when we detect that something is going wrong, we need to do something about it there and then, rather than waiting for the 10th patient to tell their story.
I am glad to hear you speaking like this because—let us be frank and honest—this culture within health boards of secrecy, shutting down staff and gaslighting families is not new to the Queen Elizabeth university hospital scandal. This has been going on and on. I have been in the NHS for almost two decades, and that culture has been there the entire time that I have been there. That is because our management are working with complete impunity. Nothing affects them. At the end of the day, when scandals break, something happens, and we move on, but nothing happens to the management. What can you do to hold management to account?
I agree. I think that accountability is the biggest failing, because people hide behind the institution. Absolutely, accountability is one of my first things that I will be looking at. That is not about blame, but we cannot get change if there is no accountability and people are not speaking up and saying, “Yeah, we got that wrong.” That is what most of the patients want to hear. They just want somebody to say, “Karen, that care was terrible, and I’m really sorry. The next time, we’re going to do something else.” I have that lived experience with my mum, who died a horrible death in the hospital that I trained in as a nurse. When I made a complaint, all I wanted was that nobody else would die like she died. I said, “You wouldn’t allow a dog to die like that, but you allowed my mum to die like that.” All I wanted them to do was to say, “Karen, we’re going to bring in training for our staff on end-of-life care.” We know that that is something that hospitals are bad at in Scotland.
Obviously Pandora’s box is very big, and there are lots of areas where care could be better, but, for me, it is about holding people’s feet to the fire and saying that I will not let it go until accountability has been recognised and voiced, and change has happened. If we brush things under the carpet, nothing will change, and care will not be better. Scotland does a lot of things well, so let us make sure that our patient safety is recognised at a global level. I want Scotland to be the safest place in the world to have surgery and to go to accident and emergency. We must do that together. My office is very small, but it will be very influential and it will be a mighty division of the army of healthcare in Scotland.
I am glad to hear that. The big concern for me—you will know this, as a former nurse—is that nurses are really vulnerable when it comes to whistleblowing. Doctors have a bit more protection, especially at the more senior levels, but it is still very difficult, and nurses are very vulnerable.
I will ask my final question. After concerns were raised by the Women’s Rights Network, you called for health boards to consistently record or categorise all incidents of sexual assault and rape, which was not being done. The Cabinet Secretary for Health and Social Care says that it is now happening. Is it actually happening?
I had that conversation with the health secretary at our last meeting and was reassured, as you were, that that is happening. I am speaking with the Women’s Rights Network to see what it is hearing about that.
At the meeting about that issue that I went to, many points were raised, such as chaperone policies. This is about basic human rights and human needs. Even last week, I was hearing of staff who, because of their concern about losing their job, would not whistleblow about male patients identifying as female patients on acute mental health wards and female patients having to lock themselves in their rooms because they were concerned about that. We have not even got that right. Everybody has a right to care. I am not getting into the gender realignment discussion, but I am hearing too many times about concerns for patients. My remit is safety, and if patients are not feeling safe and are locking themselves in their rooms, who is looking after their mental health?
I hear stories of nurses having to share changing rooms—not just the case that is in the press. Whether it is in relation to healthcare or prisons, we have to decide what we are going to do about listening to that voice and keeping patients safe, because everybody has a right to care. This is not about a male who wants to identify as a female, because that is their right; we have a duty not just to give them the care that they need, but to protect the other patients. Why are we not doing single-sex wards—particularly for mental health patients? I am very concerned about that, because they are a very vulnerable group, as are older people in care. I really want to make sure that that recording is happening, and, over the next month or so, we will look at what has actually taken place after that report was given.
Going back to Stranraer, I remind everybody that I am still a nurse. I trained in NHS Dumfries and Galloway and worked in NHS Dumfries and Galloway, and Stranraer is the town that I was born in, so I have a particular interest in the maternity services there. I have been working with the Galloway community hospital action group, as have other colleagues at this table. We have been campaigning with that group and helping them to look at options for a long time now, since 2017, when babies stopped being born at the Galloway community hospital. I am interested to hear your current position on that. Is there a way forward? Some action has been taken in that there are overnight stays when early labour is presented, instead of women being sent back to Newton Stewart or Glenluce, but I would be interested in an update on the current situation.
I was going to have a meeting with NHS Dumfries and Galloway and the action group. We did not get the information that we asked for, so I had to cancel that meeting. Last Friday, I met with people from NHS Dumfries and Galloway—the director of nursing, the director of midwifery and the medical director—and they will get me the information that they did not give me for that meeting.
I understand the need to centralise things in order to get the expertise, but what I was trying to say to the board is that it has not demonstrated its risk mitigation. It has closed down the services but it has not reassured me about what it has done to ensure that somebody who is in labour in Stranraer is safe, or what it has done about response times for ambulances or about local responders. For example, is there somebody who has Entonox? I heard about a lady having to travel from Wick to Inverness in an ambulance that did not have gas and air, and I thought, “What ambulance doesn’t have gas and air? I don’t understand.”
We need to look at rural communities and, actually, we should not be doing that as a whole, because every rural community is distinct. Stranraer is distinct from the communities in the north. I want to see what Dumfries and Galloway can do. It is trying to reassure me, and it says that patient safety is paramount in what it is trying to do. I said to the board, “You’re failing to impart your risk mitigation to the locals, because they still feel that they’re not served well and are vulnerable and at risk when they are giving birth.”
We are in discussions on that. I am going to meet the head midwife, who will take me round Dumfries hospital, and I am also going to meet the midwives in Stranraer. I have to get both sides of the story and hear how everyone feels, but, as with the BBC story on the Edinburgh hospital, those midwives have to feel free and able to tell me their concerns. However, I agree that the issue has been going on for too long. That is why I have tried to force it by saying, “You need to tell me what mitigating actions you’re taking after you have retracted a service that was serving the local community.”
Do you mean mitigation measures such as making sure that accident and emergency teams have some SCOTTIE-ED—Scottish core obstetric teaching and training in emergencies for emergency departments—training for pregnancy emergencies, or something like that?
Exactly. That is what happens in the north. People are allowed to go to the emergency room. That is not the ideal place to have a baby, but at least it is a safe environment. However, the community in Stranraer are told that they cannot go to A and E.
I am also going to speak to the Scottish Ambulance Service. I am thinking, “Hang on—if I have a heart attack, you’ll medevac me to A and E, but, if I’m in labour with twins, as has happened in the north, you’ll put me in an ambulance, I’ll have a baby in one place and then move on and have a baby in another.” Why are we not thinking about maternity when we are looking at these issues?
We have to look to places such as Australia, which has communities that are more rural than the ones that we have, and think about what they do and therefore what we are doing. For me, it is about how we are going to do this. Part of the mitigation is about thinking differently. This is not just about brushing it under the carpet and saying, “We feel that everything is in place and these patients are safe.” I do not feel they are, which is why I am pushing back and saying, “What are you doing to mitigate the risk?” That is, for me, about more local intervention for those people.
09:45
I agree with you—quite why they were sending somebody back home when they were in labour, I do not know. Again, I asked for the figures of how many people they were offering accommodation to, and they said, “We don’t do that, because we can put them somewhere.” I said, “That’s not what I heard. I heard that you had no room at the inn and that you sent people all the way back home, even though they were 5cm dilated.” There is a gap between the lived experience and the perception of the lived experience.
Your discussion with Emma Harper was very helpful. I have spoken to people in that area and, right through pregnancy, there is some of that batting back and forth. As you say, it is about trying to help people to understand each other’s side and come to a conclusion. It is helpful to hear that you will be doing that work.
That leads on to the questions that I was going to ask you. You mentioned that there is such a big remit and that it is a Pandora’s box. I am interested to know how you are going to select your strategic priorities. Have you had a think about that? The committee’s report highlighted that it would be important to have a strategic plan. Is that starting to get put into place?
Again, I am waiting for my team to come on board, so that it is not my strategic plan. I am also waiting for the principles of the office and the charter of the office, because those have to be agreed by the advisory board and the Scottish Parliamentary Corporate Body.
In relation to a strategic plan, what is the thing that I need to focus on now? This is an eight-year tenure—clearly, Scotland realised that magic was not going to happen overnight and that it was going to take time. I really want to think about what we can impact within the first year and what we can impact moving forward and the long-term plan.
Obviously, maternity is a big focus and I am now on the task force for that. On women’s rights and how safe our hospitals are, I really want to make sure that we have dotted all the i’s and crossed all the t’s. Since that report, patients should be feeling safer, but they are not, because things have not been implemented, so I want to follow that through.
I have come from England, which has the Care Quality Commission, but you have HIS, which is not a regulator but an inspector that also does improvement. That is not critical, but it does blur the edges. How can you be a good cop and a bad cop? Some of the improvement that HIS does comes without a pot of money, which is restrictive. If you see bad practice and you are telling boards that they need to change but you do not have any authority to help them to make that change, it is quite difficult.
I am still trying to get my head around the regulatory field in Scotland, because it is about accountability and making sure that we are doing the right thing for the patient. Is that my first goal? No, but I am a little wary of the powers that other organisations have and whether those are enough to make sure that we are moving at speed.
I worry about inquiries and task groups, because, for me, maternity needs sorted now, not in five years, so, if it went to an inquiry, that would be a bad thing for maternity and for patients. The service needs to be redesigned. It needs people in a room with a whiteboard saying, “What we’re doing is not working for patients, so how can we move it forward?”
Having many years of big operational experience, I know that that is not my job, so I have to pull back and say, “I can’t sort everything.” However, let us consider not inquiries but service redesign and change.
As part of your plan, do you see yourself saying that people are telling us about issues now and that we need action to address them now?
Yes.
That is very helpful.
That is what I am trying to do at Stranraer. I am saying, “Look, guys—patients aren’t hearing what you’re telling them is going on. It’s not working.” Parents still feel vulnerable. Pregnant mums still feel vulnerable. We have to do something about that now; we cannot leave it for another five years.
My final question was going to be whether your plan will be dynamic enough to deal with issues as they emerge, but it definitely sounds as though, as well as doing what you are doing, you will aim to deal with issues that emerge if they can be dealt with quickly.
Yes.
Lovely. Thank you.
I was not going to come in here, but you have said a couple of times something that will concern some of the most vulnerable patients in Scotland: trans patients. A couple of times, you have almost implied that women need to be protected from trans patients, so I just want to give you the opportunity to make it clear that, as well as protecting women’s rights, we should be protecting trans people’s rights.
Exactly. I was saying that everybody has a right to care. There could be the perception of danger, but that does not mean that there is actual danger. However, what we are not doing is protecting both groups. Female patients might be feeling vulnerable, and there might be male nurses working. The situation with a trans patient should not be any different from a safety point of view. If there are two vulnerable people who both need exactly the same care, it is really important that they both perceive that they are getting the right care for them. We need to look at that issue, because I do not think that we are being very clear.
You said that you are speaking to the Women’s Rights Network, which takes a particular view in relation to excluding trans people. Are you also speaking to LGBTQ organisations, to ensure that you hear the lived experience of that very vulnerable group of people, particularly trans patients?
I have not spoken with them yet.
But you will.
Yes.
As we know, the Patient Safety Commissioner has no remit to deal with individual complaints from patients. How do you plan to communicate that clearly to the public and manage patient expectations about your role and the level of support that you can provide?
That work has started. Once my website is up and running—in, I hope, a month or a couple of months—I will put what we do and what we do not do on the front page, so that it is clear. I explain my role in my presentations to health boards and so on. If patients come to me, I say to them that I do not deal with individual complaints and direct them to the ombudsman, but I say that I am still here, because I do not want them to feel as though I am passing them off and their voice is not being heard. I say, “Please come back to me if you’re not satisfied with how you get on.”
Some individual patient complaints show that there is a systemic problem. There is a balance to be struck when considering whether it is a case of an individual patient having received bad or unsafe care or whether there is a system-wide problem. I always listen to the person’s story when considering whether the case is a one-off or whether a review is needed. However, we cannot blur the lines between what the ombudsman does, which involves dealing with individual complaints, and what my office should be doing.
That is great. To overcome perceptions of a cluttered landscape of scrutiny, do you plan to develop any protocols or memoranda of understanding with other scrutiny bodies?
Yes. In fact, I just got some through yesterday. I am trying to do that so that we can share information and so that our defined roles are very clear and we do not tread on each other’s toes. Even though we have HIS, the Nursing and Midwifery Council and the General Medical Council, some patients write to me thinking that I can get a doctor struck off a register and things like that, so it is very important not only that I understand but that patients understand that that is not my role. I am definitely starting to develop memoranda of understanding with other bodies, to make sure that we can work collaboratively, because that is really important, and that we do not overstep our reach in relation to what each of us is doing.
That is great. Thanks, convener.
Good morning, Karen. A couple of things have arisen out of the conversations so far. In response to Sandesh Gulhane, the issue around trans people was raised and my colleague Joe FitzPatrick quite rightly highlighted vulnerabilities and how we deliver healthcare across that. In terms of vulnerable patients generally, are we seeking informed consent? The issue with informed consent keeps rearing its head, so where are we with that?
I am concerned about that. It is not something that I have dived into yet but I am hearing about vulnerable patients getting care but not being chaperoned or not having given informed consent. It is definitely something that is happening, but I do not know how widespread it is, so I will be looking into it. Again, everybody is reassuring us that they have chaperone policies, but do they actually use them? GPs do it all the time—if they are going to do any sort of physical exam on a patient, they will bring somebody else into the room. Why are we not doing that in hospitals? There is a bit of a blasé approach to the issue. I am speaking to the board chairs at the end of the month and I will ask them how they can prove to me that informed consent is happening, and that chaperoning is happening with patients.
My concern is that there is potentially a breach of the law here, and we do not need any more of that within the health service.
I agree.
That leads me on to my next point, which is on whistleblowers. Again, the issue has been raised before and every board will tell you that it has a whistleblower champion—that it has somebody that people can go to. The reality is very different. How do you change that whole culture of trying to shut down whistleblowers? It is not peculiar to one area; it exists across the whole of Scotland at the moment.
Clearly, what we are doing is not working, so we need to look at it. People are saying, “I wouldn’t go to the whistleblower champion because I would have no confidence in doing that—I’d be concerned about my job,” so we have to look at how we are dealing with whistleblowing. Once or twice a week, I hear about people who are afraid to whistleblow. They are afraid of losing their jobs; they are being bullied and shut down. What we are doing is not working.
HIS has a whistleblowing route, but I could not persuade the people that I have been talking to to go down that route. If people are scared about whistleblowing, it means that what we are doing is not working and it is not keeping our patients safe.
Moving on from that, you have stipulated that part of your job is about “never again” events such as the Eljamel case—never again can that happen. However, somebody said that they are not convinced that some of the actions that should have been taken in the Eljamel case would be taken if there was a rogue surgeon right now in our health boards. Do you think that that is right? If it is not right, how do we change that confidence factor?
10:00
From what I am hearing, I am not confident that such a case could not happen again, because of the issue of people closing ranks and shutting things down.
Wow.
Obviously, there is an on-going inquiry in that regard, and I do not want to muddy the waters, but I would say that, even within the board where that happened, there are still concerns.
We have to start trying to open doors that have been closed and trying to prevent boards from closing ranks and stopping things, because there is nothing safe about that. Also, I could not work in an environment where I was continually shut down.
I am not quite sure what to say about that. I suppose that the question is, from your perspective, and given your role, what has to happen to make sure that such a case can never happen again?
We have to change what we do in relation to people speaking up. If a nurse or a patient is concerned about something and feels that it should not have happened in the way that it did, we should perhaps take that out of the internal processes. I think that there needs to be an independent voice. I am not saying that that person should be me, but the point is that what we are doing now is not working for staff or patients, and it is not keeping Scottish hospitals safe. If staff are worried about a trend that they see and they do not feel that they can express that, what can we do about that? We are in healthcare, and we should not be allowing nurses and doctors to feel like that.
I will put on my website a statement that says that, if someone is concerned about anything that is going on in their workplace, they should talk to me. Of course, that could open the floodgates, which might be a problem, as I have only four staff, but that is why I am saying that we have to stop the issues arising earlier: we have to stop something at the first whisper that it feels like another Eljamel case. I hope that there is not another case of that sort, of course; I am just saying that we have to try to stop such cases earlier, and I am not sure we are in a place where we can do that yet.
You mentioned that there is no real national reporting. One of my hobby horses is the issue of data analysis and intelligence gathering. I am not sure that we do not have enough evidence, data and so on; my concern is that we are just not properly exploring what we have. Where are we with that? Is there a need to have a real think about how data is delivered and how we engage in data gathering?
Obviously, data gathering takes very smart technology. When I asked for all the Datix information from Stranraer, I was told that someone would have to go into every individual Datix and read it before they could give me that data. We are not using a system that can be scanned. I told the person I was talking to—a senior midwife—that I did not want her to go into 100 patient notes just because I have asked for Datix information. Why is it not possible to simply generate a report? I should say that the NHS does not use Datix any more—I cannot remember what system is used now.
It is InPhase.
Yes—InPhase. However, I do not know whether anyone is particularly satisfied with it.
I am just saying that the data that we are gathering does not contain the emotional intelligence that would proactively give us themes that would enable us to take pre-emptive action. Nationally, we are getting information, but there is nothing that pulls all of that data together.
Am I going to address that in the first six months? Probably not. Is it something that I would like to target? Absolutely. The decision on that will be for Government—it is not a decision for a little Patient Safety Commissioner—but if we are going to make Scotland safe for patients, we have to look intelligently at the data that we are gathering. Currently, we are not doing anything with it, because we cannot merge it.
I urge you to keep talking about that.
I want to follow up on what has been said about the Eljamel situation. Obviously, the overwhelming majority of our surgeons and staff in the NHS are amazing and do a fantastic job. I acknowledge that the inquiry is on-going but I would raise two particular aspects that should be mentioned. First is the issue of the closing of ranks, which you have talked about, and which we probably all accept that we need to get better at dealing with. We need to ensure that the duty of candour that is in law now and the whistleblowing legislation are used to benefit patient safety.
The other aspect concerns the fact that Eljamel was performing outwith his competences. You say that you are not confident that the Eljamel situation could not happen again. Do you think that there could be a situation in which someone who is not qualified ends up doing surgery that they are not qualified to do?
What I do not understand is how that issue was not challenged at the time by the senior medical officer. I do not know what is within the capabilities of a neurosurgeon, but somebody must, and he was clearly going outside his scope, probably every day that he practised. Am I confident that that will not happen again? I do not know, because I do not know who should be watching somebody like him.
We have to look at our centres of excellence and almost define the roles better by setting out the things that, for example, a neurosurgeon should be doing. As a nurse practitioner, I did not do maternity work, because it was not my sphere of expertise. Similarly, a clinician should not be doing things that they are not qualified to do.
Eljamel started practising in Scotland in 1995, before this Parliament even existed, and a great many of the regulations around employment are still reserved. Once the Eljamel inquiry publishes its report, will you be liaising with your United Kingdom counterparts to ensure that those aspects are dealt with? We need to have confidence that the staff in Scotland and across the UK are competent to do the work that we put so much trust in them to do. Of course, we know that the overwhelming majority are competent, and that there is only a tiny number of cases in which they are not.
As I say, I need to wait for the output of the inquiry. However, I meet the GMC once a month, which means that I am meeting the right people to whom I can flag those issues. You are right to say that we do not want that situation happening again, so we need to think about what we are doing to ensure that people are keeping to what they should be doing.
Sandesh Gulhane has a supplementary question.
Thank you for allowing me to come back in on this important issue, convener.
When I was working in orthopaedics, I came across a surgeon who was not competent to be performing the operation that he was engaged in. That is a problem at consultant level: there is not really a competency that says that someone can or cannot do something, because a consultant is trained in the specialty that they are in.
One of my big concerns is that, in general practice, we have physician associates who are actively saying that they can do everything a GP can, so a lot of undifferentiated patients in general practice are being seen by people who are not GPs. To me, that is a patient safety issue, because I do not think that those people have the necessary qualifications to be dealing with those patients in that way. What are your thoughts on that?
As a nurse practitioner, I worked at a GP surgery and did all house calls. I know that you are not talking about nurse practitioners but about physician associates, and there is a big gap between those two professions, as a nurse practitioner has to have been a registered nurse before they can be a nurse practitioner, whereas physician associates can just come straight in from being a car mechanic to suddenly looking after people. I understand that, and they should definitely never tell people they can do everything a doctor can do. We should be making sure that, in terms of their competency and the framework that they are working under, they are always under the guidance of a GP. They should not be working independently of a GP.
When I worked in a GP surgery, if I was concerned about something, I would just knock on the door and say, “Hey, I am thinking this, but it might be this. Can you come and have a look?” We need to be careful with physician associates that, on top of their licence, their working practice keeps the patient safe. The problem is that registration is UK-wide, not Scotland only.
I have not looked into the issue so I do not know how many physician associates are working in GP surgeries, but I would be interested to know how GP groups are guiding the care that such people are giving.
I thank the commissioner for coming to give evidence today. I have a quick supplementary on prevention. We know that many in the NHS worry that cuts to facilities maintenance, for example, can create a culture of scarcity that is unhelpful for embedding a true focus on health and safety for staff. In the past few days, we have had a report about a lift at the Glasgow royal infirmary that has been broken for more than six months, leading to a significant number of lost appointments. There have been reports of sanitation issues in hospital wards, showers that have been broken for long periods of time and so on. That general pattern of poor facilities management can undermine confidence that the NHS is a prevention-focused organisation. How do we rebuild confidence? Do we use a combination of inquiry and lessons learned?
I agree that it is not a great picture if you walk into a hospital and see that the lift has been out of action for six months. No board has a bottomless pit of money, but functional facilities should be high on the list. If the showers or the lifts are not working, that is a patient care issue and it shows that what is happening with the patients is not being prioritised. We should be looking at enforcement and making sure that the building is safe, fully functional and operational. We should not be putting patients into buildings that are not fit for purpose. We need to be looking at that, for sure.
I assume that the nearby Marriott would not have the same problem, so why does the hospital have that problem? Perhaps there are benchmarking opportunities there.
Yes, that is worth thinking about.
I also want to look at your role in implementing recommendations. As a parliamentary office-holder, do you see any role for yourself in reviewing the implementation of public inquiries and reviews that are relevant to patient safety and making sure that their recommendations are being delivered?
Absolutely. That is very important. There is no point in spending public money on an inquiry, that inquiry making recommendations and those recommendations not being followed up. I do not know what HIS’s role is in that, so I would need to work with it. I would definitely be involved with anything that HIS needs to implement that I feel is to do with patient safety.
I think that boards should be given timelines. Rather than the soft approach and the hand holding that we sometimes see happening with boards, it should just be a case of, “No—these are the recommendations. You’ve got six months, and then we’ll come back in.” The UK Care Quality Commission gives boards six months and says, “We’re coming back in six months. If that’s not sorted, we’ll downgrade you.” If we really want to focus on patient safety, we need to get our big hobnail boots on, call people out and say, “You’ve got to do it in this timeframe,” although if it is something massive that a board has to do, it must be given a timeframe that is reasonable.
Again, I come back to accountability. The biggest safety gap that we have is the lack of accountability and the lack of people speaking up and saying, “We put our hands up—it’s our fault and we’re going to sort it.”
10:15
We have covered benchmarking opportunities and time-bound accountability for implementation. Are there any other metrics or processes that you envisage using to assess whether interventions are being properly implemented and are actively promoting patient safety?
I have not yet thought about that, but it is definitely something that we need to do, because there is no point in implementing change if we are not looking for improvement. That might involve saying, “A year ago, there were 800 deaths in our A and E departments that were avoidable. Next year, let’s get that down to 200.” We must look at what can be implemented to improve patient safety. I will look to ensure that, when our office recommends change, that change happens. I will provide timescales for that.
You mentioned the Care Quality Commission as a sort of template. Have you looked at anything similar to that?
Not really. Healthcare Improvement Scotland does the investigations and then helps with the improvement. That is a positive in relation to the CQC, which wades in, tells boards off and raps them on the knuckles, but it does not help them to implement the change. Therefore, HIS has an advantage over the CQC in that respect, but I am not sure that it has the same authority. It is a question of balance.
There are good things that are happening, and we must not let the bad muddy the good. We need to amplify the good and sort out the bad.
Thank you.
Good morning, commissioner. We have touched quite a lot on the issue of the cultural change that is required. It lies at the heart of why we are in the situation that we are in.
The committee’s stage 1 report on the Patient Safety Commissioner for Scotland Bill, which created the office of Patient Safety Commissioner, highlighted that, rather than being a result of gaps in policy, the systemic failures that we have seen have arisen because of deep-seated cultural and behavioural patterns in the healthcare system. You have already mentioned some of those, such as not listening to what patients say, the lack of accountability and the closing of ranks. Is the very hierarchical structure of our health boards a factor when it comes to tackling cultural barriers to change?
As someone who was new to Scotland and its health system, when I first came here I thought, “Oh my gosh—14 boards is a lot in a small country.” The fact that there are so many boards sets us up for finding it difficult to implement national change. I know that the boards are working to share learning and experiences. I certainly feel that the issue of having so many boards is something that I will have no say in, but I do think that the fragmentation makes it quite difficult to implement something at a national level.
How boards are set up creates silos and that sense of closing ranks, but I hope that I can build trust with them and that we can try to change the culture to ensure that it is not about blame, but about shared learning and our being all in this together for patients. At the minute, it does not really feel like that.
Boards are under immense pressure; their budgets are very tight; and their wards are imploding. I do understand the operational stretches and strains on the system, but that is no reason for not creating forums and environments where boards do not feel that they have to close ranks and shut things down. They should feel empowered—well, “empowered” is not the right word, because you do not empower people; they empower themselves—but we also need to ensure that our system helps people to implement change, to be open and honest and to have integrity and accountability the whole way along, from the smallest decision that they make to the biggest ones about, for example, shutting a unit or a ward. There must be openness, honesty and integrity, and it does not always feel as though we have those things.
Individual healthcare settings still have that very structured hierarchical system in place.
I agree.
How can we shift the culture so that anyone in that setting feels empowered to call out problems as they see them and that they have protection? At the heart of the issue are employees and workers—and, indeed, patients—feeling that they cannot speak out or that, if they do, they are not listened to. How do you foresee our driving the cultural shift that needs to happen?
Something as mammoth as that has to be done one step and one day at a time. When I get involved in something in, say, a hospital, I bring the voice that says, “This is safe. You need to learn to be able to speak up.”
I want to be able to implement such change through the lived experience of staff and patients. When I sit down and talk to nurses who are stressed, because they do not feel that they are being heard or because they are concerned about something, we try to knock that on the head there and then and say, “Right, let’s go and talk to your managers now and see why that culture is inherent.” You are not going to break down a national and systemic culture of hiding things and not being able to speak up simply by waving a magic wand; you have to do it by living those people’s experiences, and by helping them to move things forward.
I hope that that is what my office will be able to do. In every instance in which we are involved, we will make sure that everybody feels safe enough to speak out. As a result, cultural change will start to move forward.
But how are you going to measure and monitor that cultural change? As we know, and as you have said this morning, the lack of data is a big difficulty. How will you and your office monitor that?
I hope that, when it comes to the lived experience of people who fear for their jobs not speaking out, the volume of speaking out will increase. It would mean that the culture was changing if clinicians and patients felt, “Do you know what? Now is the time that our voice is going to be heard and things are going to change.” That is the only way in which we can measure it.
If nothing had changed two or three years down the line and people still felt unheard and unable to speak out because of the threat of losing their jobs, the system would not be working. Therefore, I hope that we are able to move the work forward.
How will you ensure that lasting organisational change comes about, and not just localised pockets of improvement? Which other organisations will you work with? We need to think outside the silos, so how will you drive lasting change?
We have to consider what training is lacking. In particular, what leadership training is lacking, and do we need more education around it? As you said, we cannot just say that staff have to be heard; people must know how to respond to that. There needs to be some process change and more education, and job descriptions need to change so that people recognise, “Actually, do you know what? Part of my role is that I have to hear the lived experience of patients and do something about it,” or, “I have to hear the lived experience of my staff and do something about it.”
It is about more than just listening; it is about looking at what can change systemically and what other education needs to happen. Do we need to change leadership structures? Do we need to change how patient complaints are dealt with in hospitals? We have to look at the whole system and consider whether what we do now is actually working. Change for change’s sake is not good; it has to lead to good outputs that result in better patient care and safety.
I will ask a final question, but first I want to put it on record that I hold a bank nurse contract with NHS Greater Glasgow and Clyde.
You have spoken quite a bit about maternity services this morning. Certainly, in the Parliament, we have heard some criticism about the delivery of neonatal services, and the best start report recommended moving to three neonatal intensive care sites for patient safety reasons. We have heard clear evidence from clinicians about why they feel that is necessary, and from the charity Bliss that it is the safest option for the sickest and most premature babies. You have spoken about the issue before. Can you set out your thoughts on the redesign of neonatal intensive care?
The care of neonates is not my forte, but I understand the need for centralisation and the importance of local expertise for those fragile perinatal children. I understand the decision that was made, but, as is the case with maternity services, you cannot just make decisions and then not back them up by not implementing other measures in the local area. For me, that is always the gap of change: people say, “This is a great idea, and we are going to do this,” and then they leave devastation behind. Even in the light of that realisation, there has not really been a full redesign and families are still expected to travel. We still have to look at risk mitigation and what we do in local areas so that those families feel supported if they then have to travel to a centre of excellence.
In the task force, I want to look at how we listen to the voices of families and ask, “How does this feel for you? Where is the service gap between suddenly losing your local neonatal unit and having to travel? Where is the local support to help families through all that?” That is the issue with service redesign: the focus is on the end product, not the tsunami that it leaves behind. I want to explore that.
There needs to be robust and honest communication and also probably less politicisation of some service redesigns, so that families get the correct information about what is changing and how it might or might not affect them, to alleviate some of the concern and worry. Is that fair to say?
I agree with that—it is one of the big gaps. To go back to an earlier example, people in Stranraer did not know what NHS Dumfries and Galloway had done to mitigate the risk of reducing services. It might have done some stuff, and the same applies in this context: families should consider holding a town hall meeting, so that services communicate what is being done in the local area.
My goal in this role is to go out into communities, hear people’s concerns and align health authorities’ decisions with the information that is provided to the local communities that they serve. There appears to be a gap in many such situations—there is either misinformation or a lack of information. It is very important, for the safety of everyone involved, that accurate information about service redesign is provided, rather than simply stating that changes are happening.
Thank you for your attendance this morning. I now suspend the meeting to allow for a changeover of witnesses.
10:31
Meeting suspended.
10:38
On resuming—
Air adhart
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