4 October 2022: Expert Group on Public Health and Administration - D

Core participant questions:

On the devolved nations following Westminster’s DH lead being due to a conscious decision or inertia; they said it varied but was mostly conscious.

On knowledge about Freedom to Speak Up Champions; they said if that role was given to the right person with sufficient seniority it could work, but basically did not know much about it. The Chair extended the question to ask about patients and their representative groups such as charities being involved in influencing health policy. They said there was an important useful role, for example, to collaborate for funding to carry out research. It is also a great way to access “patient expertise”. It was also noted how the Covid pandemic had highlighted the capacity of voluntary organisations to respond much more quickly than statutory agencies. The statutory sector does not value the voluntary sector as much as it should, not as “proper partners”. Too often local government see charities as “a cheap way of delivering services”. It should be a “pivotal moment” for the voluntary sector to be much more respected, valued, and involved. They should be referred to, at least, in service design but also in highlighting when things go wrong. There could be leadership options such as “co-chairing”, especially for patient groups with lifelong chronic conditions since there will be a valuable knowledge of the condition and the way the health providing service works or doesn’t work.

On extending the duty of candour to Government’s arms-length bodies; they said it might depend on whether the remit of the bodies allowed this in relation to openness and honesty, or should it do. So, in some cases it could be extended.

On learning and change still not being embedded in the NHS even after various Inquiries, and what might be done to facilitate this change towards learning to change; they said it is not always the best thing to just change the policy or law as the solution, but it is the culture and behaviour that needs to be embedded to effect real change. It needs a political and resourcing commitment, including for regulators. The main changes occur not through Inquiries and inspections but through the quality of leadership, meaning the leadership team. Nolan includes leadership and that is needed to set the right culture. Too often the message is not clear.

On the communication of a new risk to the public and if there should be a duty on Government to set the standard rather than rely on individual clinicians to advise patients about it; they said it can be difficult due to the lack of clear evidence for a Government to synthesise, especially at the start, but there is a key role. The rise of social media and misinformation makes it more important to provide leadership. If you don’t know at the start but are listening to the best possible advice, that should be stated. It is important to communicate the uncertainties and the unknowns. The way Norwegian, Danish, and Swedish Governments spoke about risks of Covid to children in their countries was very different to the UK and it could be said they achieved better outcomes. There is also the issue of preparedness so that the messaging had practical tools available. It also has a dimension of disproportionately affecting marginalised and vulnerable groups who may often be the very ones most likely to come to harm. The capacity to respond has been eroded over recent years, not improved. Government may no longer be the best communicator, since people are more likely believe charities and other bodies.

On the possibility of an adviser potentially misleading a Minister if there is a dissenting opinion among an expert group but a majority view is agreed; they said the information of there being dissent should normally be passed on to the Minister. Good Ministers should want to know about divergent views among experts. If a view is a consensus one, that should be explained.

On the situation of there being a change in a senior official and if the same rule applies about not seeing past papers the way it applies to new Ministers not to see them; they said the same rule does not apply.

On whether a Minister is entitled to seek advice from outside the civil service; they said absolutely yes.

On the possibility of a new independent and properly resourced advocacy service for patients across the UK; they said it might be possible and worth looking at if it was properly resourced so it could properly challenge, but not to see another organisation on top of other arrangements. It is about a “what do people want when things go wrong” model (i.e. explanations, apologies, professional accountability, and that what happened to that patient or family does not happen again); a “redress model”. It might be better not to focus on taking up individual cases but to have a “collective intelligence” which could be communicated quite forcefully. There are issues to ensure independence, and an example of a good model is the Health and Disability Commissioner in New Zealand. There was an alternative view about the dangers of taking the role of advocacy outside the NHS in case staff became less aware of their role in looking out for the needs of patients as a core part of their work. It might also need to be four national agencies and not a single UK one. If it is seen to be part of the NHS bureaucracy then people wouldn’t trust it.

On the convention of Ministers not seeing the papers of their predecessor on the occasion of it being someone of the same party; they said it is usually ok to pass these on in that case, but the answer would need to be checked to make sure. It was noted that even within a party in Government there could be partisan and rivalry problems. There is surely a role for the senior civil servant in assessing this issue and to provide a bridge between administrations. New Ministers do need to be as fully briefed as possible.

On inquests and coronial reports related to the role of coroners to make recommendation on the prevention of future death; they said some coroners were more active than others at following up on these issues. In Australia there is a statutory duty for any such findings of a coroner to be reported on within three months by the State Government.

On the Ministerial Code and if it should be made a statutory code; they said it should be, but that is not a universal view, suggesting the current Government are not enthusiastic about doing this but other parties appear to be.

On Ministers being drawn into defending the indefensible related to the Nolan Principles, does it mean Nolan is not working; they said it might show they are not working as well as they should. It is not just Ministers, but senior civil servants and senior managers can also be drawn in. It may be the relevant Nolan principles need to be “teased out” in this regard.

On standards in public life and whether things have improved since Nolan; they said it was a bit of a rollercoaster. Nolan has had an impact, maybe not so much due to sanctions but due to having a clear reference point. It is maybe time to look again at these and how they are defined.

The Chair asked for each witness to comment on the example of a nurse who was changing a dressing when another patient fell out of bed. The nurse rushed to the other patient without washing her hands. The other patient caught MRSA and the question is, where is the fault, blame, or accountability. One response was to look at the incident to make sure the situation of the person falling out of bed should have been better managed. If the nurse is blamed then that will discourage anyone else from taking the initiative to provide care where needed in case they get blamed for the outcome. There may be a difference between the matter of apportioning blame and the need to fix the system to stop something like that happening again. The need to intervene can result in it being better to ignore an otherwise correct infection-control instruction if the judgement is that the possible risk to the patient who fell out of bed of being in distress and hurt was greater than the risk of passing on a hospital acquired infection. Scenarios are used in training health professionals and there are tools such as “decision-trees”. The application of criminal law to such matters will tend to discourage learning. The Chair was asked if it was a real situation and he confirmed it was and the nurse was found to have taken the blame. Knowing this had actually happened produced a negative response from the Group.

The Chair then asked about Government messaging when there are divergent views on a particular risk. The Group recognised that having different expert views presents a challenge, especially if the solution to mitigate the risk is severe; such as stopping the public from eating beef products in case it caused lots of people to get CJD. There is also a role for Government to reject misinformation, such as that which occurs through social media channels.

The witnesses did not have anything to add.

The Chair thanked everyone who had contributed to the report and read out the names of those not able to attend the actual evidence session. He noted the significance of the subject to the Inquiry and how there could have been a much longer time given to hearing questions and answers on the matters allocated to this particular group of experts. He noted how they had not been frightened to disagree, and that was welcome.

On overall reflection, this writer was disappointed by the two days of evidence from this Expert Group. That may be down to a misunderstanding about what the Group was set up to do. It did seem to confirm how there had been and still are systemic failings in the governance of processes and structures related to health planning, resourcing, robustness, responsiveness, transparency, accountability, culture, efficacy, and much more. The way things have traditionally been done, the way procedures evolve in reactive and protectionist ways, the hierarchical empires, the lack of joined-up thinking and working, as so forth, do not put people-patients at the core of the business of providing healthcare. The reliance on the “gifted amateurs” who so often make up the civil service, combined with the very mixed bag of transient political masters and paternalistic scientists who dabble in doctoring so they can access subjects for reputational enhancement research means that the capacity to muddle through was simply not good enough. Add to all that the vast sums of money involved in making the service free (sometimes) at the point of delivery, alongside the colander of opportunities to sap money out for less than pure motives, and the end result was one big mash-up of incompetence, risk aversion (financial not human), knee-jerk bum covering, and self-serving career advancement.

The question remains open, when and how will the core material which exposes the multiple cover-ups at the heart of the Contaminated Blood Scandal be consolidated into a meaningful package of evidence which meets the expectations of those who have been so terribly and shamefully harmed?