ORALSTATEMENT TO THE ASSEMBLY BY HEALTH MINISTER JIM WELLS MLA–27 JANUARY 2015– QUALITY OF CARE IN NORTHERN IRELAND
Mr Speaker, last year my predecessor as Minister commissioned an examination of governance arrangements for ensuring the quality of health and social care provision in Northern Ireland. That examination, led by Professor Sir Liam Donaldson, is now complete and the report is being published today.
I want to begin, and I am sure members will join me in this, by paying tribute to the commitment and efforts of all those working within our health and care services.
I want to thank Sir Liam and his team for completing this review in such a short time and I also want to thank all of those who met with his team which included clinicians, managers, patients and members of the public. All of them contributed evidence to inform the team's work and findings.
Sir Liam is a world renowned expert. The report is far reaching in its implications and I agree with the main conclusions Sir Liam has made. That said, I will need to take more time, as should others, to consider the specifics of some of the associated recommendations.
Mr Speaker, I want to highlight a quote from Sir Liam’s report. He concludes that our healthcare system “is likely to be no more or less safe than any other part of the United Kingdom, or indeed any comparable country globally”.
Although Sir Liam also acknowledges that we can do better, that statement, Mr Speaker, should be of some comfort and reassurance to those in our community who rely on our health service.
The report makes ten recommendations. While some focus on specialist areas of quality and safety improvement, such as maximising learning from incident reporting, other recommendations are broader and focus on our health system.
Members will be aware that I have already asked my Permanent Secretary to look at the administrative structures within the health and social care system and supporting it.
The purpose of that review is to ensure that the structures in place to support the delivery of health and social care are working – both individually and collectively – as efficiently and effectively as possible. This work will feed into future planning cycles, including 2015/16.
It is clear that in respect of a number of the recommendations that there is a need to hear the views of other stakeholders, many of whom will have contributed evidence to Sir Liam and his team but who will not have had sight of the actual recommendations before now. There are clearly recommendations which would need to be considered by the Executive and members will also understand that in respect of some of the recommendations we may need to take account of the findings of the Inquiry into Hyponatraemia-Related Deaths when it becomes available.
Despite this, there are also a number of recommendations which can and should be progressed and I am determined that this should happen as quickly as is possible where they point us towards opportunities for improving the quality and safety of our services.
Both I and my predecessor have highlighted issues in relation to commissioning and this is reflected in Sir Liam’s report. My officials have been asked to undertake a review of the existing commissioning arrangements to ensure they are effective. The review will also take account of the recommendations set out in Sir Liam Donaldson’s report.A copy of the terms of reference for that review is attached to my Statement.
A key point made by Sir Liam, both in the Northern Ireland and broader UK context, is that the health and social care system we have is not the one we need. However, while acknowledging Transforming Your Care as a strong forward thinking piece of work designed to address this issue, he notes that progress is slow. I wholeheartedly agree with his assessment. But we need to be clear that this does not reflect a lack of ambition or effort. In December 2011, the TYC Report set out a change vision which would take over 3-5 years to achieve, and require some £70m of transitional funding. Due to a change in the wider financial commitment, the Executive has been unable to provide this funding to my Department.
That said, TYC remains a priority. It directly addresses the challenges facing our hard-pressed health and social care system. By working to safely introduce services in primary and community care and supporting people to make good health decisions and manage their own conditions with appropriate assistance, we will be able to ensure that service users and patients are treated in the right place, at the right time and by the right people. We need to enthuse front line staff and empower them to make the changes that they can make in support of the aspiration for the highest quality health and social care service.
I am determined, even though we are working within a constrained financial context, that we must redouble our efforts to speed the implementation of TYC. The best change comes from the ground up and I want to facilitate those at the coal face to play a fuller role in delivering the transformation.
I note the review recognises the potential for pharmacists to expand their role in the provision of community services and I can confirm that I will shortly announce details of an implementation plan to guide the execution of the “Making it Better Through Pharmacy in the Community” strategy. This will set out the strategic direction and enhanced role of pharmacists in the community for the next 5 years. In addition I can advise that my Department will be issuing a Medicines Optimisation Quality Framework for consultation later this year. This framework complements existing policies and TYC and aims to support better health and wellbeing outcomes for our population by improving the appropriate, safe and effective use of medicines throughout the HSC.
Mr Speaker, I wish to confirm that a statutory duty of candour will be introduced in Northern Ireland. There should be no ambiguity in respect of my expectation regarding the crucial elements of patient safety which are openness and transparency. I recognise that, despite the best efforts of doctors, nurses, social workers, other staff and managers, mistakes can and do happen. Patients, service users and the public have a right to expect that when they do, they will be communicated with in an honest and respectful manner and that every effort will be made to correct errors or omissions and to learn from them to prevent a reoccurrence. I have asked my officials to begin the process to create a statutory duty of candour in Northern Ireland so that, supported by professional codes of conduct which already exist we might bring about the strongest possible form of openness and transparency in Northern Ireland.
The Serious Adverse Incident system has been the subject of a great deal of focus over the past 12 to 18 months. Sir Liam highlights that the SAI process needs to be strengthened. I agree with his assessment. However, I want to remind everyone that it is a system for learning, and that it should not be used as a source of information to attack the service and to sensationalise issues which affect people at a very difficult time in their lives. Such an approach can only serve to undermine the extent to which we are open about, and seek to learn from, mistakes that occur. The HSCB and PHA jointly manage the operation of the SAI system and I have instructed them to consider the recommendations made in this report and to prioritise changes that can be made now as well as setting out the direction of travel for the recommendations which will take a longer time to bring about.
Shortly, I will also publish the details of a look-back exercise into SAIs which was commissioned in 2014. The look-back report will confirm the desire of professionals to involve people but highlights how hard it can be to get this right because people want to receive information in a manner of their choosing which may be unique to them. It will show that reporting to the Coroner of deaths in hospitals is generally carried out appropriately. Sir Liam Donaldson and his team have however highlighted that improvements could be made. I want to reiterate today my commitment to progress to a conclusion, work previously announced by my predecessor to introduce a regional morbidity and mortality review system as well as the development of proposals, in conjunction with DFP and DOJ, to introduce a new independent system to review deaths in Northern Ireland complementing the role of and working with the Coroner.
Mr Speaker, a Never Events list will also be developed for Northern Ireland. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. They include incidents such as wrong site surgery, misidentification of patients and dosing errors. Some of these events are already dealt with in Northern Ireland in the context of existing SAI Learning Letters and other guidance issued. I have instructed my officials, as an interim measure, to urgently consider the list of never events for England and determine its applicability to Northern Ireland.
Sir Liam restates the need to use expertise and guidance from regulators in other countries. RQIA already uses, and will continue to use, experienced professionals from other UK countries in review work but will build on those existing arrangements proportionately in future review work.
Members will recall the announcement, made by my predecessor, that RQIA will begin a series of unannounced inspections of acute hospitals in April 2015. Members will agree with me that unannounced inspections are often of more value than announced. Best practice from other regulators is already being incorporated in that work and it will be shaped going forward on an analysis of key trends in the HSC in Northern Ireland on a rolling basis. I have asked my officials to investigate with RQIA the possibility of speeding up the roll out of this programme of unannounced inspections. My officials will also begin work on new policy proposals to review the 2003 Quality, Improvement and Regulation Order with a view to introducing a stronger system of regulation of acute health care providers.
These changes need to be taken forward alongside changes to the current system of regulation. My department will bring forward proposals to the Executive for changes to that system of regulation of non-acute services with the aim of issuing these proposals for consultation later this year.
I say again, openness and transparency are vital to ensuring a system that is focused on maintaining quality and continuous improvement. The system must learn to listen to the voices of people who use and who work in it and, to make sure that those voices are heard. It is often those voices which highlight poor standards. The effectiveness of Whistleblowingarrangements within the Health and Care system continues to be a cause for concern. As part of the 2015/18 RQIA Review Programme, I have directed that RQIA should undertake a review of the operation of whistle blowing in health and social care bodies and make recommendations on how we can improve its effectiveness.
I am conscious of the general conclusions within this report about how the health and care service is both reported and perceived. Focusing on reviews, complaints and never events is important. This focus can however skew everyone’s perceptions about these services. I want more work to be done to measure and report patient and client experience. With this express intention I have asked my officials to review the current arrangements for measuring patient/client experience to ensure we take the best available worldwide evidence and design a framework to strengthen the voice of patients at every level from the front line up to the Department. Monitoring patient and client experience, good and bad, is a much more effective way of driving improvements in the quality of our services. It is also an approach which will give a much more balanced view of the quality of the services being provided.
This is a time for those who are committed to the delivery of high quality health and social care services to engage in open, honest, intelligent debate about how we move forward.
This report should force us collectively to raise the standard of our debate with regard to health and care, to focus on the prize – a world class health and care service. We need to recognise the realities we face and arrive at the right decisions, beginning by ensuring that we are asking the right questions. Too often the discussion around the Health Service can be overly simplistic, and focused on a simple choice between closing or keeping open a particular facility. In this context, the reaction of the local community is understandable and instinctive – a “save our service” mentality. In reality, though it is not about “saving a service” but actually “saving a structure”. The real choice we face is an uncomfortable one for us all, including political representatives, “Do we want a world class service or a service on our doorstep which, while convenient, may be sub-optimal and compromise quality and safety?”
The discussion about the right structure for our services and hospitals has been going on for many years under different administrations and under the leadership of Ministers from different political parties.
The message from Sir Liam is clear, we now need a mature debate and we need to strive for political consensus to empower us to collectively make the right choice.
Borne out of a desire for that mature debate, I have chosen to place this report in the public domain and to address this Assembly at an early stage, in the interests of openness and transparency. I want to allow a wide range of stakeholders the earliest possible opportunity to reflect on the report and to begin to formulate the solutions to meet the challenges within it. Those solutions can only be informed by openness and honesty about where we are now and what needs to be done to deliver the changes needed. Whilst we are moving ahead with some of the recommendations as I have outlined here today, I am also asking for written comments on recommendations to be submitted to the Department by the end April 2015. This gives an opportunity for stakeholders to reflect and engage with each other, with political representatives, and with the Department.
I recognise that the analysis of this report will take some time and it will need to be given carefully measured consideration. Inevitably, some of the recommendations will have resource implications; some may require legislative change and Executive approval. Sir Liam, through his report, challenges us all on what is best for the people we serve.
The report highlights specific issues with regard to innovation, silo working and standardisation. As part of my approach to addressing these issues, I have specifically asked that the six Trusts work with each other, with their staff and other stakeholders to develop a combined response to the report and its recommendations. Their response should in particular reflect the views of front line staff and should also focus on their ideas for improving collaborative working, ending silos,increasing standardisation and promoting innovation. Front line staff must be empowered not only as a result of this work but they must also be empowered as a part of this work. In short, they hold the key to delivering on the change which is needed.
The Trusts along with other stakeholders will be asked to provide their views and comments back to the Department by the end of April 2015.
Mr Speaker, in light of the challenges posed in the report, we must all contemplate the tough choices to improve health and social care facing the Executive. I propose to ask Sir Liam to return next year to advise me on his view of progress made.
Mr Speaker, I want to conclude by highlighting another quote from Sir Liam’s report: “the leaders of the Northern Ireland Health and Social Care System should be clear in their ambition, which in our view is realistic, of making Northern Ireland a world leader in the quality and safety of its care. Northern Ireland is the right place for such a transformation, and now is the right time.”
In summary, Sir Liam has concluded that we have a real opportunity to transform our Health Service to be a world leader. That, Mr Speaker, is an ambition I cherish.
I look forward to the debate ahead.
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