Good afternoon and welcome to my regular patient safety update. This week we look at safety related amendments to the Health and Care Bill, the Select Committee’s litigation reform evidence session, and what happens to the recommendations HSIB makes. As ever you can sign up to receive this update via our website here and please do pass it on to any friends you think might enjoy it.

LITIGATION REFORM SESSION The Select Committee held its first session into litigation reform on Tuesday hearing both from families who have had to cope when the health service has harmed a love one and legal experts on how we could change the system for the better. This is a genuinely difficult issue: few people think litigation is the best way to develop an open and just learning culture - but when hospitals put down the shutters often families have no one to turn to except a lawyer. We heard from some of the people I admire most: patient safety campaigners who relive their own tragedies to try and get the system to change. Scott Morrish, who lost his son Sam to sepsis, was one of the first I met and we also heard from Joanne Hughes who lost her daughter Jasmine. We also heard from my former special adviser Sue Beeby whose son Jasper was born disabled. She said she would not have found out the truth without her lawyers and rather than a blame culture there was such a relaxed acceptable of a mistake it was a more of a complacency culture. Sir Robert Francis explained how litigation is not designed to improve safety and learning. Dr Sonia MacLeod from Oxford said most errors are systemic rather than about personal incompetence but the system wants to punish people rather than learn. Sir Ian Kennedy made a radical suggestion to separate compensation from any regulatory or learning process. I’m attracted to what happens in Japan, Sweden, Virginia and Florida where earlier access to compensation seems to be one of the ways a system can move away from an adversarial approach and focus on the reduction of error.

HEALTH AND CARE BILL Ahead of the next House of Commons debate on this Bill I have tabled an amendment that would require the Secretary of State to publish independently verified workforce projections and needs for the next 5, 10, and 15 years. Amendment 10 is supported by 6 Select Committee chairs, the Labour, SNP and Lib Dem frontbenches plus 20 or so of other MPs. I’m hoping it will be debated, and if necessary voted on, next week but at the moment the vibes from the government are not good. Why on earth would they not want a measure that would address the biggest single issue facing the NHS and save money? For some reason we are willing to think outside the parliamentary timetable when it comes to HS2 or nuclear deterrents but not the number of doctors we train. I have also tabled an amendment to ensure that the CQC considers leadership, integration and the safety and quality of care in its inspections of the new ICSs.

LIAISON COMMITTEE I pressed the Prime Minister on this issue at the Liaison Committee meeting that has just finished. You can see our full exchange here but he didn’t really give an answer regarding the amendment itself. Perhaps not a surprise but still disappointing.

ARE HSIB SAFETY RECOMMENDATIONS ACTUALLY IMPLEMENTED? The short answer to this is that nobody seems to know. I asked the Department of Health and Social Care how many of the 1500 maternity safety recommendations and 39 national patient safety recommendations HSIB said it made last year had been implemented. No real answer was forthcoming. There is apparently a pilot going on to work out how to monitor this and responsibility lies with individual trusts. But if we have a national investigations body surely someone at a national level ought to know whether what it is recommending has in fact happened? My whole purpose in setting up independent reports for Each Baby Counts incidents was not the pleasures of another 1000 reports but to get learning spread much more effectively through the system…one for the capable Aidan Fowler, head of Patient Safety in NHS England, to sort out.

GP PRACTICE INQUIRY The Health and Social Care Select Committee has launched an inquiry into the future of General Practice. The sector is facing a real crisis with knackered and demoralized staff. But it is also the most important service in the NHS for many people and the heart of any effective prevention agenda. Do please submit evidence (and if you reference my failure to recruit 5000 GPs as promised in 2015 it will not the first time.…)

COVID LATEST Some welcome news on case numbers, for the first time in weeks the ONS infection survey finds that there were fewer people with the virus in the community. There were still over 900,000 representing 1 in 60 people but that is down from 1 in 50 for the previous week’s edition of the survey. Conversely the COVID dashboard has cases in the last 7 days going up by 15%. There are also now around 8,700 patients in hospital with the virus, slightly down on the 9,000 from last week. Perhaps the start of a gradual decline? Or simply a slight lull before the winter storm? Either way, we have to continue pressing on with the booster and young people’s vaccines programmes. It is good news that 12 million people have now had a booster and that those in their 40s are now eligible but we are slipping behind other major countries for overall rates of vaccination. The government has rightly decided to take a vaccination rather than restriction led approach to containing the virus but if this is to be effective we need to speed up the decision making around who can get the vaccines something I pressed the Health Secretary on in the House earlier this week.

Jeremy Hunt