Good morning and welcome to my regular patient safety update. This week I look at the latest on COVID-19 and why - alas for our summer holidays - caution remains essential. I also examine what the Health and Care White Paper means for patient safety and the human rights scandal around the 2,000 people with autism/learning disabilities locked up because of a lack of community provision. We also have an interview with the Minister for Patient Safety Nadine Dorries.

MORE GOOD NEWS ON VAXXING We have now vaccinated more than 13 million people with a first dose or nearly 1 in 4 of all adults including 94% of all eligible care home residents. The NHS is now in a position to ask those over 70 who haven’t yet been vaccinated to call up and book an appointment, making it almost certain we will reach the first milestone of all in the first four priority groups being offered a dose by 15th February. At the same time daily new cases are down by two thirds (7-day average 18k down from nearly 60k in early Jan) and daily hospital admissions have halved (just over 2k from above 4k in January).

SO WHY THE CAUTION? Two linked issues concern me - and it is fair to say many in the scientific/NHS community. Firstly, because overall infection levels are still extremely high - 850,000 cases currently in England - there is still huge pressure on the NHS with more COVID patients in hospital than in either April or November. And secondly the more the virus is in circulation, the greater the chance of it mutating. Which leads me to the biggest worry of all – a vaccine immune variant.

MUTANT VS VACCINES That surely is the reasoning behind the new border controls including the rather extraordinary threat of a 10 year jail sentences for anyone who lies about where they have been. But if this is so serious, why are we not enforcing quarantine for the 20,000 new people a day who aren’t fully self-isolating? Lots of fake debate about whether or not we are seeking to eliminate the virus, largely from people keen to get the economy open. But the best way to do that is suppress new daily cases, as this powerful thread from Anthony Costello points out with a comparison to the Chinese province of Anhui which happens to have around the same population as the UK. In other words listening to public health experts is good for jobs and ignoring them destroys them. Getting new daily cases down also means enhanced contact tracing becomes possible for all new cases, including Japanese-style ‘backwards’ contact-tracing and genomic sequencing, something Matt Hancock all but confirmed to me in Parliament this week.

LEAKED WHITE PAPER The government is planning a new Health and Care Bill and we got a glimpse of what to expect from it with this leaked version of the accompanying White Paper. We’ll see the actual thing later today but the main change is abolishing CCGs and replacing them with ICSs on a statutory footing - in other words putting into law the workarounds to the 2012 Act that Simon Stevens and I/Matt Hancock have been trying to follow. The big frustration, which this should address, is that because ICSs are currently voluntary arrangements they go at the speed of their most reluctant members - this should speed up the delivery of integrated care, including joining up with the social care system. However there are risks: I remember well the criticism I got in 2013-14 for people job-shuffling often alongside large redundancy payouts. More generally there is always a danger when NHS managers have to think about their own jobs/futures rather than focusing on patients. Ian Birrell points out there are other, big issues this reorganisation will not solve in an analysis well-worth reading. But overall I think the changes will be worth it.

PATIENT SAFETY NOT FORGOTTEN either in the changes, which put the Healthcare Safety Investigation Branch (now inexplicably called HSSIB) on a statutory footing and other changes which are highlighted on our Facebook page including medical examiners. But the key change we need is to make sure the new ICSs are inspected for safety and quality so that there is pressure to continually raise standards, including by setting up properly-functioning safety collaboratives. If we don’t want ICSs to become cosy local monopolies they need the accountability of CQC Ofsted-style ratings which I think most would say have now proved their worth in improving the accountability of Trusts.

HEALTH AND CARE BILL WITHOUT THE CARE Apart from local authorities being on the board of ICSs, there was no detail regarding the much-needed long term reforms to the social care system in this paper. But it did say that “a broad range of options are being explored…and we have committed to bringing forward proposals this year.” As I’ve said before I think now is the perfect moment for some 1948 style major reforms and it is great that others also think the same.

HUMAN RIGHTS SCANDAL Earlier this week the select committee opened our inquiry into the treatment of autistic people and individuals with learning disabilities with a very powerful testimony from Alexis Quinn who told us about her truly appalling experiences of inpatient services. She described how she felt ‘othered’ by the system, had been transported in cages, handcuffed, and explained how the ‘assessment and treatment units’ often (but not always) run by the independent sector turn the challenges faced by people with autism and learning difficulties into sometimes permanent mental health scarring. We currently have around 2,000 people in 96 locked inpatient settings, many of whom would be far better off in more humane - and lower cost - community settings. Time to follow Italy and ban new admissions for all but forensic patients to force the system to set up proper community care, something that got strong support from Dan Scorer of Mencap and Julie Newcombe of Rightful Lives. We also talked about changing the law to make the use of restraint a last resort.  Hopefully this inquiry can provoke some fundamental changes which are long overdue.

MATERNITY UPDATE These weekly updates wouldn’t be complete without something on maternity safety so just to follow up on one of the issues we discussed at the select committee session last week it has been confirmed that the National Screening Committee will be considering the evidence on the late term scan that looks for potential breeched babies on 5th March. 

STAT OF THE WEEK on workplace bullying, harassment or abuse of NHS staff: those reporting it from managers is still at 12% (virtually unchanged from five years ago), from other colleagues it has actually increased to 19% and from patients it remains at a shocking 28%. Full stats here.

NADINE DORRIES INTERVIEW following her first select committee appearance last week as Patient Safety Minister we caught up with Nadine:

You spoke with a lot of passion on patient safety issues last week - is it personal for you? I was a proud nurse so always take patient safety seriously after some of the horrendous situations I saw. We had babies brought into the ward in plastic incubator boxes with DNRs. We weren’t allowed to feed them, only cuddle them until they passed away. It was heartbreaking and horrendous - although thankfully that wouldn’t happen now.

How easy was it for staff to speak out when you were a nurse? In my day on the wards if you spoke out about something you were not happy with people came down on you like a ton of bricks. I knew a nurse who became a whistleblower, was dismissed and had to go to court to clear her name. Her life became a cycle of letter-writing and court appearances and I remember feeling how unjust it was.

Are things better now? There is still much to do. I heard recently about a patient dying because a defibrillator had been borrowed by another ward and the proper checks had not been done to make sure it was working. I spoke to someone today who lost her 20 year old daughter - stories like this make my blood boil.

What are your priorities? I want the new Patient Safety Board I have set up to work properly as everything we do should be about patient safety. At the moment our approach is too messy and cluttered - for example on maternity safety. We have endless recommendations from reports which matter individually but we need to simplify the landscape.

Anything else? We are still not disseminating the lessons in HSIB reports widely enough and the no blame space is not working as well as it needs to [something addressed in the new Health Bill]. On my personal to do list is saving the 50 babies lives a year we could by screening for Group B Strep. More broadly we have to get the culture better, especially the way staff speak to each other which too often lacks dignity and kindness. I still see nurses being spoken to in a way that is authoritative but not kind. The way staff interact with each other has a key role in improving patient safety.

Jeremy Hunt