Dr Caroline Johnson
MP for Sleaford and North Hykeham · Conservative · United Kingdom
“So someone was watching to make sure he was safe, and I am so glad that was the case, but it is so very rapid, as others hon. Members have testified. There is no single test. There is no single thing we can monitor or measure that helps.”
“I want to mention group B streptococcal infection, which I have seen in paediatric practice, particularly in babies. It is a common bacteria that lives harmlessly in the gut or lower reproductive tract, but there is a risk that it can enter the bloodstream, causing neonatal sepsis when passed to newborns.”
“The Joint Committee on Vaccination and Immunisation met in July 2026 and suggested an increase in the vaccination schedule for those young people.”
“I remember sitting in this Chamber a little over two years ago—I am sure you were there too, Madam Deputy Speaker—when the then Member for South Thanet, now Lord Mackinlay, received a rare standing ovation from the House and from the Gallery as he returned to Parliament following his remarkable recovery from sepsis.”
“That was a good start, but of course, as always with medicine, there is more to do, and it was pleasing to see the previous Starmer Government build on this work by introducing the modern service framework for sepsis. We have modern service frameworks for other diseases, and it seems good to have one for sepsis specifically.”
“I remember seeing a patient whose mum had got up in the middle of the night to use the bathroom—not something she did normally, and she was not quite sure why she had on that particular night—and when she was walking back along the landing, she thought, “It’s a bit cold—I’ll just check.” She checked her son had his blankets on and was war…”
The complete record
Every one of 604 lines we hold for Dr Caroline Johnson, in date order, each linked to its source. Free to read, in full, without an account. Page 4 of 13.
“(5) In consequence of the revocation made by subsection (3), the following 15 provisions of the Special Educational Needs and Disability Regulations 2014 are also revoked— (a) regulation 10(3)(e); (b) regulation 14(2)(e); (c) regulation 201(11)(e); (d) regulation 21(10)(e); (e) regulation 22(5)(e); (f) regulation 25(2)(e); and (g) regulation 31(3)(e).”— (Dr Chambers.) This new clause extends the powers of the First-tier Tribunal so that when it is determining an appeal it may order that Education, Health and Care plans must include health and social care needs and provision, rather than just making recommendations on these matters. Brought up, and read the First time.”
“(14) The time limit specified in paragraph (13) does not apply where the First-tier Tribunal directs that a different time limit is to apply. (15) The local authority must send a copy of the amended EHC plan under paragraph (13) to the Secretary of State within 1 week beginning with the date on which this is issued to the child's parent or the young person.’ (4) The Special Educational Needs and Disability (First-tier Tribunal Recommendations Power) Regulations 2017 (S.I. 2017/1306) are revoked.”
“(11) A response under paragraph (9) must— (a) be in writing, (b) state what steps, if any, the responsible commissioning body has decided to take following its consideration of the order, and (c) give reasons for any decision not to follow the order, or any part of it. (12) The local authority must send a copy of the response received from the responsible commissioning body under paragraph (9)(b) to the Secretary of State within 1 week beginning with the date it was received. (13) When the First-tier Tribunal makes an order in respect of social care needs or social care provision, the local authority must issue the amended EHC plan to the child's parent or the young person within 5 weeks beginning with the date of the order.”
“(7) When the First-tier Tribunal makes an order in respect of health care needs or health care provision, it must send a copy of the order to the responsible commissioning body. (8) When sending a copy of an order, the First-tier Tribunal may also send a copy of the decision which disposes of any appeal brought under section 51(1) of the Act or under regulation 42A to the responsible commissioning body. (9) The responsible commissioning body must respond within 5 weeks beginning with the date of the order to— (a) the child's parent or the young person, and (b) the local authority that maintains the EHC plan. (10) The time limit specified in paragraph (9) does not apply where the First-tier Tribunal directs that a different time limit is to apply for the responsible commissioning body's response.”
“(6) When determining an appeal on the matters set out in regulation 42A(2)(b), the First-tier Tribunal has the power to order that— (a) the health care provision specified in the EHC plan in accordance with regulation 12(1)(g) is amended; (b) the social care provision specified in the EHC plan in accordance with regulation 12(1)(h) is amended; (c) health care provision, or health care provision of a particular kind, is specified in the EHC plan in accordance with regulation 12(1)(g) where that provision has not been specified in the EHC plan; and (d) social care provision, or social care provision of a particular kind, is specified in the EHC plan in accordance with regulation 12(1)(h) where that provision has not been specified in the EHC plan.”
“(5) When determining an appeal on the matters set out in regulation 42A(2)(a), the First-tier Tribunal has the power to order that— (a) health care provision, or health care provision of a particular kind, is specified in the EHC plan in accordance with regulation 12(1)(g); (b) social care provision, or social care provision of a particular kind, is specified in the EHC plan in accordance with regulation 12(1)(h).”
“(4) When determining an appeal on the matters set out in regulation 42A(2)(b), the First-tier Tribunal has the power to order that— (a) the health care needs specified in the EHC plan in accordance with regulation 12(1)(c) are amended; (b) the social care needs specified in the EHC plan in accordance with regulation 12(1)(d) are amended; (c) health care needs, or health care needs of a particular kind, which relate to the child or young person's special educational needs are specified in the EHC plan in accordance with regulation 12(1)(c) where those needs have not been specified in the plan; and (d) social care needs, or social care needs of a particular kind, which relate to the child or young person's special educational needs or to a disability are specified in the EHC plan in accordance with regulation 12(1)(d) where those needs have not been specified in the plan.”
“The matters are— (a) a decision of a local authority, following an EHC needs assessment, that it is not necessary for health care provision or social care provision to be made for the child or young person in accordance with an EHC plan; (b) where an EHC plan is maintained for the child or young person— (i) the child’s or young person’s health care or social care needs as specified in the plan; (ii) the health care provision or social care provision specified in the plan.’ (3) In regulation 43 (appeals), after paragraph (2) insert— ‘(3) When determining an appeal on the matters set out in regulation 42A(2)(a), the First-tier Tribunal has the power to order that— (a) health care needs, or health care needs of a particular kind, which relate to the child or young person's special educational needs are specified in the EHC plan in accordance with regulation 12(1)(c); (b) social care needs, or social care needs of a particular kind, which relate to the child or young person's special educational needs or to a disability are specified in the EHC plan in accordance with regulation 12(1)(d).”
“I beg to ask leave to withdraw the motion. Clause , by leave, withdrawn. New Clause 28 Appeals against health and social care provision in EHC plans “(1) The Special Educational Needs and Disability Regulations 2014 (S.I. 2014/1530) are amended in accordance with subsections (2) and (3). (2) After regulation 42, insert— ‘42A Other matters relating to EHC plans against which appeals may be brought (1) In addition to the matters set out in section 51(2) of the Act, a child’s parent or a young person may appeal to the First-tier Tribunal against the matters set out in paragraph (2), subject to section 55 of the Act (mediation).”
“I would be grateful for the Minister’s comments on how she thinks this could work in practice and whether it is legislation or a more widespread plan that is required.”
“I should say that I am a member of the Education Committee. As the hon. Member for Winchester says, new clause 28 would extend the powers of the first-tier tribunal so that, when determining an appeal, it may order that EHCPs must include health and social care needs and provision, rather than just making recommendations on those matters. It is clearly important that children with special educational needs get the support they need. We are all very aware, from our inboxes, that that does not always happen. I do not know whether putting this into legislation would make it happen, or whether it would need much more work than one clause, but clearly it is a very important aim and I support the principle of it.”
“In restricting access to jury trials, the Government have leant quite heavily on the Leveson report, but the Government go much further than the report recommends. Will the Solicitor General explain why?”
“We should start with prevention, care at home and virtual wards. We need to think about delivery in rural areas. The hon. Member for Bury St Edmunds and Stowmarket (Dr Prinsley) talked about care and treatment in the community, and others have talked about improved social care. I hope the Minister will tell us whether, when we debate the Health Bill in Committee, she will accept new clauses 105 and 106, which relate to how people can care for themselves, to education and to the safety and classification of prescription-only medicines, so that the more simple conditions can be managed closer to home by pharmacists.”
“Last year, the Government produced their urgent and emergency care plan, in which they set their targets, including the target for an absolute minimum of 78% of patients to be admitted, transferred or discharged within four hours. That target is well below the NHS constitutional standard, but, furthermore, the latest NHS data shows that the Government have missed it, with 25.7% of patients seen within four hours in May 2026, down from 76.9% in the previous month. Things are actually going in the wrong direction. We need to consider why patients are being cared for in corridors. Essentially, it is a reflection of the lack of appropriate spaces, often spaces in an in-patient ward. We therefore need a structured plan. The hon. Members for Shipley (Anna Dixon) and for Worthing West (Dr Cooper) spoke about where we should start.”
“We have heard upsetting stories this afternoon, and I have heard some myself in my constituency, including that of a gentleman who sat for more than 60 hours in a plastic chair while receiving intravenous antibiotics for sepsis. These are all examples of a much broader and more serious problem. Every day, patients, often frail and elderly, are kept for hours on trolleys in corridors or on chairs in waiting rooms. As we heard from the hon. Member for Stroud (Dr Opher), we have an ageing population, so this problem is applying more pressure. A&E attendances increased by 2.5% last year. The latest figures show that in May this year alone, 50,212 patients waited in A&E for more than 12 hours after a decision to admit them to hospital. That represents a 17.1% increase since last May.”
“That is not good enough. Corridors are no place to provide clinical and nursing care. There is no privacy and dignity for people getting changed or being examined, and others may overhear what is said about their medical conditions. It is not safe. The hon. Member for Mid Sussex (Alison Bennett) pointed out the infection control risks. Availability of oxygen has also been mentioned. If someone has a cardiac arrest and collapses, where is the space for them to be looked after? I wonder if the Minister can tell us whether the Government intend to support new clause 84 of the Health Bill when we discuss it in Committee, probably next week. The new clause requires the number of patients who have died when 12-hour waits in A&E departments were a contributory factor to be recorded.”
“I should begin by declaring my interests as a member of the British Medical Association, a member of the Royal College of Paediatrics and Child Health, and an NHS paediatric consultant. I thank the hon. Member for Tooting (Dr Allin-Khan) for initiating the debate. I know that, as a practising doctor like me, and, in particular, as someone who works in an emergency department, she understands the importance of this subject. Let me also pay tribute to the staff who work throughout our health service, some of them in quite difficult circumstances. I am glad to respond to this debate on what is a very important but very difficult issue. Every day in May, nearly 3,000 patients spent time in so-called clinically inappropriate spaces. These may be corridors, but as we have heard, they may also be cupboards or waiting areas.”
“What will be the effect of reducing the capital budget, as announced in the defence investment plan? What does she think will be the effect of removing the social care voice from ICBs? Importantly, as we look forward to winter, what planning is being done now to make sure that patients are kept safe in the autumn and winter?”
“We often hear of targets and aims, which are easy to set but hard to reach. What have we seen so far? Long A&E waits are up, and we have seen overall waiting lists increase by 112,000 on the previous months. The number of people waiting for operations and procedures is up on last year and last month. The Government have ditched their promise to deliver a doubling of medical school places, and delayed the workplace plan. The promise to roll out fracture liaison services is running behind schedule, and there is still no response to the Hughes report. I could go on, but the basic issue is that the Government seem keen to set targets—worthy and important goals—without knowing how to deliver them, leading inevitably to disappointment. Can the Minister say how she will meet the target of abolishing corridor care?”
“It has now been “imminent” for quite some time, but how soon is imminent? As many Members have said, we need to tackle corridor care, but we also need to tackle the back door: social care. Two years ago, this Government promised cross-party talks. As has been mentioned already, they took nine months to have the first meeting and have only recently had the second meeting. That is not tackling the problem with the urgency that it needs. The Casey report is not due till 2028, and this is being kicked into the long grass. We can only hope that the new Prime Minister will make a difference. As my hon. Friend the Member for Reigate (Rebecca Paul) said, the Government need a plan. I hope the Minister will explain in detail how they intend to deliver on their plan, because delivery is key.”
“The number of beds has reduced over time, partly because we do clinical care differently—for example, people now stay in hospital for a much shorter period after having a baby, and that is true of other operations too. However, my understanding is that the total number of beds has dropped further since Labour came into office. Can the Minister explain why that is? It is fair to say that we did not get everything right when we were in office, but we did increase the number of emergency department doctors by 100% between 2010 and 2024, and we met our manifesto commitment to hire 50,000 new nurses. We developed a long-term workforce plan, but this Government did not want our plan; they wanted their own. They said that they would deliver it by the autumn, and then by the spring.”
“I absolutely agree. The NHS is devolved in Scotland, but that sounds like a very unwise decision that it should certainly reconsider. I am sure my hon. Friend will be a doughty campaigner in ensuring that it does so. That brings me to the next part of my speech, which is about the extra space in emergency departments and the importance of caring well for people in A&E. I ask the Minister for an update on the work that Dr Acheson and the Royal College of Emergency Medicine have been doing on on-time medication, as we need to make sure that patients do not suffer detriment in A&E because they are not given medication on time. An hon. Gentleman on the Labour Benches talked about the extra space on wards and the number of beds.”
“The life sciences industry talks about how it wants products to be rolled out. When it is investing and doing research in this country, it wants to see new products rolled out as quickly as possible once they have been approved, and the clause is a sign that roll-out might be delayed. I understand that the Government might want to be able to vary on certain products, but they already can; why do they want to vary on a more general basis? It is presumably to slow down roll-outs, but by how much?”
“The patient’s right to treatment with a NICE-approved product within 90 days will become a right to getting the product when the Secretary of State says so. That is not really a right at all, because it does not give patients any comfort and may mean that products are received later. The Government have put this power into the Bill, so they clearly intend to use it. Given that they have the power to vary on an individual basis, why do they need the power to vary on a blanket basis? Do they intend to extend the 90-day limit across the board? If so, by how much? There is no ceiling. The Committee received written evidence from Henry Burkitt from Oxygen Strategy, who made the point that there is no ceiling, no maximum time, no duty to consult and no necessity for the Secretary of State or NICE to give reasons why a delay has occurred.”
“I understand why there could be variation and why the Government may want to consider varying the period, but it is not clear why they need to do so in legislation, because it is possible now to vary the period on an individual basis. For example, the Government imposed a five-year limit rather than a 90-day limit for the introduction of hybrid closed loop systems for diabetes, because that is a technology that requires proper training and they were never going to be rolled out in such a short period. The other product that notably has a longer time is tirzepatide, which is more commonly known as Mounjaro. I suspect that that is down to cost, but I am not certain. Why do the Government want to change the 90 days?”
“Clause 58 amends the Health and Social Care Act 2012 by inserting a new section 237(8A), which states: “Provision made under subsection (8)(b) may include provision about the period within which a recommendation is to be complied with (including provision for the period to be determined by NICE or the Secretary of State).” At the moment, NICE technology appraisals check the value of a product, whether a drug or a technology, then NICE makes a recommendation. It is then supposed to be the case that within 90 days or three months, ICBs ensure that those technologies are available, but we know that in the real world it can take longer—sometimes 12 to 24 months—for some things to become available. That could be because technology needs to be bought or training needs to take place.”
“A patient may have a particular set of symptoms or conditions or be on a particular set of medications that mean that the doctor or clinician looking after them needs to vary from the guidance. NICE intends the guidance to be just that, guidance, not law, but if guidance becomes law, the doctor or clinician will not be able to vary from it. My concern is that the amendment would be overly restrictive. Although it is well-intentioned, and it is a good idea to ensure that guidance is followed where possible, it would be too rigid. I therefore do not support the amendment, while continuing to support the aim of better treatment.”
“The Government also committed in the ME/CFS action plan to develop and run a public awareness initiative, with implementation expected by May this year. Has the Department developed that initiative yet? If not, what is responsible for the delay? It is not marked as complete on the Government website. The amendment would put guidance for medical professionals into legislation, though, and my concerns about that are twofold. First, it may slow down improvements in the future. If individuals have to legally follow that guidance, how can they innovate and improve treatment without having to come back to Parliament for more primary legislation? That will take time and may mean that people with ME get worse rather than better care in the short term. The requirement would also limit clinical judgment.”
“I have sympathy with the principle behind amendment 58, in the name of the hon. Member for Wells and Mendip Hills. The hon. Member for North Shropshire is right to say that individuals with ME have not always received the best quality care. In many cases, ME is a debilitating and incredibly frustrating condition, and around 10% to 25% of sufferers have severe ME, meaning that they are housebound or bedbound. We know that some patients are sadly not believed by medical professionals. In 2021, NICE said that most medical students have little or no training on the condition. The Government have previously committed to increasing the uptake of ME modules among NHS professionals. What progress has been made on that in the last couple of years?”
“For example, the Health Foundation wrote in its submission that “the government needs to do more to explain how the abolition of HSSIB and transfer of its functions to CQC will meet its aim of reducing complexity and, most importantly, maintain the essential focus on improving patient safety.””
““The Dash review says so,” they argue, “so that’s what we’re going to do.” I have huge respect for people who say, “I’ve asked for some experts’ advice, and they have given it, and therefore I should follow it.” However, Ministers also commissioned the report by Lord Darzi, which said that “a top-down reorganisation of NHS England and integrated care boards is neither necessary nor desirable”, and yet here we are, doing exactly that. It is perfectly possible for Ministers to take one report as gospel and another as guidance. I would be grateful if the Minister could explain that. The other reason given for this measure is that it will declutter the landscape, yet few people outside Government seem to think that HSSIB is responsible for cluttering the landscape.”
“564-565.] I think that I have demonstrated that the creation of HSSIB was a matter of consensus and it was confirmed that it was the right thing to do. In order to work, HSSIB needed to be independent and without conflict of interest. NHS staff backed it, the providers backed it, the patients backed it and even the Minister backed it. That is what makes the Government’s plans for HSSIB so perplexing. I am not aware of a single royal college or union that supports folding it into the CQC. Essentially, Ministers have said that this is being done because of the Dash review.”
“Only then can true improvements to patient safety be made.” Similarly, NHS Providers told Parliament: “NHS Providers welcomes the creation of the HSSIB as an opportunity to develop a just culture in the NHS and a focus on learning…For the HSSIB to succeed in contributing to improved patient safety, any investigations associated with it must be carried out independently and without conflict of interest, and be perceived as such.” Indeed, the Minister for Secondary Care herself is on the record as having said: “HSSIB is a really important new body…It must absolutely be built on the highest standards of trust when it comes to the wider system and the general public.” –– [ Official Report, Health and Care Public Bill Committee, 19 October 2021; c.”
“This is consistent with our guidance to doctors about their responsibilities to learn from mistakes and reflect on their practice, and their duty to take part in systems of quality assurance and quality improvement to promote patient safety.” The British Medical Association told Parliament: “We welcome the establishment of the HSSIB…Doctors must feel able to report errors and reflect on their own mistakes openly, without the fear of these reflections being used against them at a later stage.”
“It can lead to a culture of cover-up, whereby people try to avoid getting either themselves or their colleagues into trouble. That is where HSSIB comes in because, like the air accidents investigation branch and the similar bodies for rail and shipping, it provides a safe space. That safe space is important in ensuring that people can speak up freely without fear, and know that we can get to the bottom of a problem and understand why and how something went wrong, because that is how we fix it. At the time that HSSIB was established, there was consensus about it. The General Medical Council said: “We support the creation of a ‘safe space’ approach to investigation.”
“One of the key factors in that work is accepting that where there is human decision making, mistakes can happen, and that we need to identify and learn from those mistakes. One of the main ways of doing that is striking a balance between accountability and blame. If there is insufficient accountability, there can be an unclear escalation process, such that people do not know who to go to when they identify a problem. There can be a careless culture, which can develop in places where there is not enough accountability. However, if there is too much focus on fault and determining whose fault something is, we can get a blame culture. That can lead to a failure for people to come forward and therefore to a failure to learn from mistakes.”
“Broadly, yes, I think we would say they are safe, but they have not been without incident or safety issues. Healthcare is similar. It involves millions of people, clinical judgment, human decision making and huge variability in the way that patients can present with different symptoms for different problems at different times. Is healthcare safe? Yes, it is safe. Again, however, we know from the many reports we have read that there is a long way to go to make it better and we need to prepare for that. We need to make sure that we design out room for error—that we design processes that limit the opportunities for error—use technology to limit the risk of error, and train people in a way that reduces the risk of error.”
“These clauses are about patient safety. As has been pointed out this morning, patient safety is the absolute key here: that is well recognised across the House, among the public and across the national health service. Before going any further, I declare an interest as a patient of the NHS, a member of the British Medical Association, a member of the Royal College of Paediatrics and Child Health and a consultant paediatrician. When I was interviewed in 2012 for my current consultant role, I was asked to deliver a presentation about how I could demonstrate to the trust board that the paediatric services in the hospital were safe. The first question I posed—Members will be pleased to know that I will not go through the whole presentation—was: “What is safe?” Are football stadiums safe? Is the London underground safe? Are aeroplanes safe?”
“24, Q40.] and that makes it difficult for people to come forward. People come forward now because they know that HSSIB is independent, but they will be less likely to come forward when HSSIB is an office in the CQC that is independent in name only. The Chair of the Health and Social Care Committee, the hon. Member for Oxford West and Abingdon (Layla Moran), said that “people cannot sit at desks near other people who are making decisions and at the same time be perceived as entirely independent. The perception of independence cannot be legislated for—the perception is everything”. —[ Official Report , 1 June 2026; Vol. 786, c. 915.]”
“The hon. Gentleman is right. When someone comes forward, they need to have trust in the system. If they think that coming forward will harm their job or career, or perhaps their colleagues’, they may be more reluctant to do so. There is a difference between a mistake and a reckless act. If people behave recklessly and badly, that needs to be dealt with for the sake of accountability, but if an individual is aware of a mistake, or aware of a loophole through which a mistake could have been made if only something else had not happened at that moment, they need to come forward and say so. It would be much more difficult for them to do so if there was a culture of fear. Dr Benneyworth made it clear to the Committee that “we are still working in a culture of fear” –– [ Official Report, Health Public Bill Committee, 16 June 2026; c.”
“Do the Government want HSSIB to lose its international standing, or do they want British taxpayers to subsidise training for foreign health services? It is not clear. I would be grateful if the Minister explained that. We need to come back to what the hon. Member for Bury St Edmunds and Stowmarket said at the beginning: what is the purpose? The purpose is patient safety.”
“Very occasionally, health events have national security connotations—the Salisbury chemical weapons attack, for example. In such circumstances, restrictions on investigatory capabilities could be necessary. I do not know—I was just interested in why the Government have chosen deliberately to remove that particular clause. Amendment 56 would allow “the Commission to recoup charges in excess of the costs incurred in providing assistance.” The HSSIB programme is world-leading. People look at it from across the globe, and some have asked for training or information on it, for which we have been able not just to recoup costs but actually charge. I do not understand why the Government have removed that provision, because it is an opportunity for them to get extra money without taking it off people in taxes.”
“Member for North Shropshire is trying to help by creating something better than what the Government have produced, but I do not think it is enough. We have also tabled some amendments, including new clause 42, which would ensure that there is some operational independence in the choice of investigation by requiring the Secretary of State to adequately fund and resource patient safety investigations, including some of those initiated by this unit within the CQC. Amendment 55 is a probing amendment. We noticed that much of the legislation has been lifted and shifted from the previous Act, but some things are missing, including national security grounds. We want to understand why that ground has not been included in the Bill.”
“Under the Bill as drafted, the Government are planning to direct the “vast majority”—according to the impact assessment—of the investigations, and the quality board is going to have some influence over the recommendations, again under the direction of the Secretary of State. The Liberal Democrats have tabled amendment 5, which would require the appointment of a committee. That idea is well intentioned, and we recognise the same problems and the same flaws in the Government’s approach, but I do not think it is enough to solve the problem. Even if the law says that the oversight of the investigative units will remain operationally independent, I just do not see how that is possible. I can see that the hon.”
“My hon. Friend is absolutely right. That answer was quite shocking, really. The pause before it and the reaction was remarkable. The purpose of HSSIB is to investigate without fear or favour, and to enable people to come forward in a safe way, but if it was folded into the CQC, as the regulator, and the problem was the regulator, how would it investigate itself? How would it make recommendations to itself? What if it thinks the board that it works for is incompetent? Is it going to tell its boss that it is incompetent? How does that work? No one seemed to know the answer. It also seems that Ministers have not thought about how the HSSIB unit will be vulnerable to political pressure.”
“Fundamentally, I do not think I have heard anything from any of the Ministers, and I do not think it is in the Dash report either, to explain why the Government believe that rolling HSSIB into the CQC with all the problems that it might cause—the risk of it suing itself over whether the safe space is available or not—makes patients any safer.”
“The assurances that can be provided are that the staff and equipment are available, that training is available for people to do the job, and that processes are in place to identify shortcomings and learn from them, so that they are not repeated. That is key: to find the learning and spread it more widely. As the hon. Gentleman said, implementation is a challenge. It is possible to implement this on an individual basis or to implement a lesson in a unit that has had an error or mistake. Spreading it more widely, so that this is heard in every unit across the country, is more challenging.”
“If a mistake or an event happens, it is investigated by HSSIB—HSSIB produces a set of investigations based on understanding how and why it happened, because of the safe space—and then those recommendations are put forward to the Government. The Government then, ideally, implement those changes. The Minister is there to ensure that those are implemented. It will be her job to ensure, having decided which recommendations are to be implemented, that that is done fully and properly. It is a separate function. The CQC is a regulator, HSSIB is an investigator, and the Minister is there to ensure that things are delivered properly. Going back to patient safety, at the end of my interview, I essentially told the panel, “I cannot tell you that anything is 100% safe”.”
“I thank the hon. Gentleman for that intervention, but I think this comes to part of the problem. When producing a list of faults—of things that are wrong with the service—and saying, “We need to improve the culture; it needs to be better”, we need to ask, “Okay, but how? What will be the deliverable, measurable way of doing that? How will we go about improving things?” For example, let us say that there is a problem with patients with aortic dissection, so how will we prevent that? The benefit of HSSIB is that it produces a plan, the plan is implemented and patients are safer. Part of this is about the delivery plan. As for the other part, the hon. Member talked about monitoring progress, but that is not the job of HSSIB.”
“My right hon. Friend will be aware that it is not the only thing that the CQC is being asked to take on. It is also being asked to take on the regulation of event healthcare, which is another new function for the CQC, all at a time when, as he says, it has its own difficulties to manage.”