Speeches

Address by Minister for Health, Mr. Leo Varadkar T.D., at the 4th National Patient Safety Conference, Croke Park, Friday 7 November 2014

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Introduction

There is something inspiring about being here today for the 4th National Patient Safety Conference – and seeing the passionate commitment of everyone involved in trying to protect patients during the process of health care – and I would like to thank you all for attending.

When I was a medical student in Trinity I was inspired by a number of people, including Dorothy Stopford Price – one of the first women to study medicine in Trinity almost one hundred years ago.  She was an active participant during the war of independence, and gave medical treatment to wounded volunteers at considerable risk to herself.  Later she became a key campaigner in the fight against tuberculosis, and was the person who introduced the BCG vaccination into Ireland.  Patient safety was at the centre of everything she did.  For example, she insisted that every doctor had to perform an intradermal injection on her own arm, before she would trust them with being sent out as vaccinators.  In the 1930s she campaigned for legislation to make milk safer, by ensuring that children were only given milk from cows that had been tested for tuberculin.  The minister of the day, Sean T. O’Kelly, refused to meet the delegation, but because Dorothy had served heroically during the war of independence she had no trouble arranging a meeting with him, and the legislation was passed.  She was as good a political operator as she was a medical doctor, and I have tried to learn from her example!

As I wandered around outside this morning – and looked at the wonderful poster presentations – I was reminded of Dorothy Stopford Price’s commitment to patient safety, and her insistence on precision and attention to detail.  There are 70 poster displays outside and they provide excellent examples of patient safety and quality initiatives across the health and social care system.  I congratulate everyone involved.

The Conference

This is the fourth year of the conference, and I am impressed with how it has grown since 2010.  This year over 450 people registered, and 107 abstract papers were submitted.  The efforts made by all you – health and social care workers from across the different services – is recognised and appreciated.  We support your work, as you strive to improve the safety and quality of our health service, always putting the safety of patients first.

I would like to extend a warm welcome to our two speakers from the UK – Dr. Helen Bevan and Professor Kieran Walshe.  Dr. Bevan is an expert on large-scale change approaches, and has led and supported initiatives that have created improvements for millions of patients.  Professor Walshe has extensive experience in health policy, health management and health services research, and has been particularly successful in putting ideas into practice.  I know that both speakers will challenge and inspire us.

I’m also delighted to welcome Ms. Ann Bridge, who will speak this afternoon, and offer a patient’s perspective of the health services.  Our National Standards for Safer Better Healthcare has as its first principle ‘placing patients at the heart of the care process.’  It is right that we don’t lose sight of that here today.

This conference showcases the work that is being done on the ground to improve patient safety and quality, and for that I am grateful to all the organisers.

Patient Safety

There have been significant developments in patient safety across many areas of the health system since the landmark 2008 report on ‘Building a Culture of Patient Safety’. We now recognise that ‘blame cultures’ only lead to further problems, as people are afraid of identifying the real causes of failure.  Instead we are working to create a ‘safety culture’, encouraging open reporting and balanced analysis, and embedding this culture in practice.  We are working to establish better reporting systems, so that sound, reliable information can provided a solid base for analysis and improvements.

However, as a major NHS report on Patient Safety correctly noted back in 2000, ‘Safety is a dynamic, not a static situation’.  Failures sometimes occur, through a combination of active failure and latent conditions, and it can be a mistake to focus only on the individuals involved and not the wider factors.  Our objective is have a unified mechanism for reporting and analysing when things go wrong, and not to be afraid of learning from failure.  This is the only way that the mistakes of the past can be avoided, and the lessons of past experience learned.

The findings of recent reports remind us that we still face many challenges in ensuring that our services are capable of identifying, reporting and learning from adverse events when they occur.  I’m thinking particularly of the HIQA Report into University Hospital Galway arising from the very tragic death of Ms Savita Halappanavar, and the recent Report of the Chief Medical Officer arising from Perinatal Deaths at the HSE Midland Regional Hospital Portlaoise.  But these tragic cases also inspire us to keep striving to ensure that our health and social care services are truly safe and of the highest quality.

My Department has put in place a regular reporting mechanism with the HSE to ensure that the recommendations of these and other reports are implemented.  Patient Safety has also been identified as an over-riding priority in the HSE National Service Plan and is one of the areas reviewed by my Department on a monthly basis with the HSE as part of the NSP monitoring process.

A significant challenge for the system is the gathering and use of information available that allows us to measure and track patient safety.  One of the recommendations of the CMO’s Report into Portlaoise was the development of a National Patient Safety Surveillance System.  Two further recommendations were the requirement for the HSE to develop a Quality and Patient Safety Accountability Framework and patient safety statements for all clinical services.  My Department is continuing to work with HIQA and the HSE to progress these recommendations.

Achievements to Date

A number of significant achievements have been made in the area of patient safety in recent years.

HIQA’s national Standards for Safer Better Healthcare were approved and published in June 2012. These Standards provide the blueprint for care which is safe, effective, person centred and which promotes better health for service users.  Implementation of the standards is a priority across all areas of the public health system and will be monitored by HIQA.

Within the HSE, the Directorate of Quality and Patient Safety has been established to strengthen the HSE’s internal quality and risk framework.

The Clinical Programmes have been established on a joint basis by the Royal College of Physicians in Ireland and the HSE and have greatly enhanced the strategic leadership of the system to develop and roll out models of best practice in clinical care nationally.

The National Clinical Effectiveness Committee was established in 2010 as part of the Patient Safety First Initiative, and three National Clinical Guidelines have been published so far.

In addition, work on the new National Clinical Guidelines commissioned by the NCEC in response to recommendations from the HIQA Report into Services at University Hospital Galway is at an advanced stage. I am aware that Dr. Kathleen MacLellan, Head of the Clinical Effectiveness Unit in my Department, will be speaking to you this afternoon and she will provide a more detailed progress report on the work of the NCEC to date.

A major development in the last year was the joint development by the HSE and State Claims Agency of the National Policy on Open Disclosure. The Policy is designed to ensure an open, consistent approach to communicating with patients and their families when things go wrong in healthcare.  Implementation of the policy across all health and social services has now commenced by the HSE.  Ms Angela Tysall, National Lead for Open Disclosure, HSE will be presenting later today and will provide more details on the policy and an update on the status of the roll out of the Open Disclosure policy.

In addition to these achievements, work on a number of other significant developments in patient safety is at an advanced stage.

In support of the commitments in the Programme for Government, my Department is progressing legislative proposals for the development of a licensing framework for healthcare facilities.  It is intended that licensing of healthcare facilities will extend across both public and private healthcare providers, with an initial focus on hospitals and high risk health services in settings other than hospitals. Heads of Bill are being drafted and finalised at present.

Work on the development of a Code of Conduct for Health Service Employees and Managers is underway in my Department and is expected to be finalised in the coming months. The Code will clearly set out employees’ and managers’ responsibilities in relation to achieving an optimal safety culture, as part of the governance and performance of health service organisations.

Conclusion

When Dorothy Stopford Price died in 1954 the ‘Irish Medical Journal’ lauded her as one of the giants of Irish medicine, part of ‘an international aristocracy of talent’.   This conference today is a gathering of a national and international aristocracy of talent, of inspiring men and women committed to showcasing the ongoing work for improving patient safety, and critically engaging with each other.

Sometimes, in the midst of much review and criticism, we can forget that we get a lot of things right.  One obituary noted that Stopford Price never cared about the criticisms, she was too focused on getting things right.  Today she reminds us that if we put the patient first, in a spirit of critical judgement, we won’t go far wrong.

It was also said about Stopford Price that ‘her honesty gave her the capacity to say “no” in a word, which some find refreshing and others disconcerting’.  And that’s something that has often been said about me, so I can sympathise!

Your presence here today in such great numbers reflects your strong commitment to patient safety, your refusal to accept the ordinary, but instead to constantly try and achieve something extraordinary.  This is an agenda of change and improvement and I wish you all the best of luck with your work.

Thank you.