Patient Safety Commissioner

Listening to Patients

Meeting Notes

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2nd Meeting – Thursday 22 June 2023 held at 18 Smith Square

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England)
Rabbi Dr Harvey Belovski
Helen Buckingham (Nuffield Trust / National Voices)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London) – joined remotely
Ian Green (Chair of Salisbury NHS Foundation Trust) – joined remotely
Dr Habib Naqvi (NHS Race and Health Observatory)
Rachel Power (Patients Association)
Rachel Downey (Secretariat)
Mel Peffer (Secretariat)
Apologies
Saffron Cordery (NHS Providers)

Meeting Notes

1. Welcome, introductions and apologies
1.1 The Chair welcomed everyone to the meeting and invited Louise Ansari and Harvey Belovski to introduce themselves.
1.2 Apologies had been received from Saffron Cordery (NHS Providers)
2. Note of the previous meeting
• agree meeting note
• actions and matters arising
2.1 There were no corrections to the notes of the last meeting (23 March 2023), which were agreed and would be added to the PSC website.
2.2 Actions from the previous meeting were reviewed and matters arising included:
• It was agreed that the current membership provided a wide range of views and would remain at 10 (including the Chair) for the time being. Going forward members could flag any substantial gaps in response to issues arising.
• The Chair reminded members of the importance of completing and returning the register of interests form as soon as possible, if not already done so, for adding to the website (Action)
• The Chair confirmed that the list of parliamentarians that Julia Cumberlege had suggested for inviting to a meeting aligned well with the list the Commissioner’s Office had identified.
• Ian Green will follow-up to help facilitate the Commissioner attending a meeting of NHS Chairs/Chief Executives.
3. Terms of Reference sign-off
3.1 There was some further discussion on the Terms of Reference. The Chair confirmed the accountability routes of her Office. Members were not accountable for the policies, financial or other management aspects of the OPSC and had no assurance role. The Commissioner’s financial accountability is through DHSC; operational accountability is to the Chair of the Health and Social Care Committee.
3.2 Final changes agreed to the Terms of Reference:
• Indicate that any technical expertise regarding medicines or devices would be sought externally on an ad-hoc basis if required.
• Add ‘England’ to clarify the scope applies to England only.
• Add ‘where required’ to paragraph 4 in the role section.
3.3 The amended Terms of Reference would be circulated for final sign-off via email and published on the website before the next meeting (Action).
4. Chair’s update
4.1 The Chair provided an update, including:

• The team now had desk space within the NHS Confederation and it felt that the office had moved out of the initial ‘set-up phase’.
• The Chair thanked Julia Cumberlege for asking the recent questions in the House of Lords on sodium valproate.
• Launch of PSC website.
• The Commissioner had published a new resource for patients with complications from pelvic mesh which was co-produced with campaign groups and was available on the PSC website. Rachel Power offered to include a link on the Patients Association website (Action).
• The Commissioner had been invited to join the MedTech Strategy Programme Board, and had also been working to support patient involvement in the Outcomes and Registries Programme.
• Two staff had joined the team to work on the redress project, and the Chair said she was keen to understand redress in its totality, including restorative practice. An expert would input to the project.
• The Chair had attended the recent Patient Safety Movement Foundation summit which had included inspirational patient speakers, the sharing of excellent examples of good practice, and there had been much interest in the PSC role and several offers of help.
• There had been no further update from DHSC on confirmation of budget allocation or resourcing, which put at risk the Commissioner being able to fulfil all her statutory obligations, including the consultation on principles.
5. Website
5.1 Rachel Downey (Head of Communications and Engagement) explained that the website had gone live in the last couple of weeks and was still very much in development mode and would incorporate feedback from the focus groups that the Patients Association had facilitated.
5.2 Rachel gave a demonstration of the website and feedback from members and other points of discussion included:

• The suggestion that signposting links should direct users to the relevant page of external websites, rather than the default homepage.
• Add captions to photos
• Move the section on the Advisory Group from ‘our work’ to ‘about us’
• Add an explanation about pelvic mesh to the webpage text introducing the resource
• Rachel will commission blogs from all members to include their voices on the website (Action).
• Part of the development plan will consider the naming of sections, and sub-sections (e.g ‘Resources – innovations’).
• There was a discussion around not promoting or endorsing initiatives/innovation (e.g that have a commercial element).
• Positive comments were received on the visual approach and identity.
• A continuous programme of user testing and having relevant, fresh and reliable content would be important.
5.3 Rachel said the driver to get the website up quickly was the pressing need to have a platform to publish. A development plan could now be implemented that would include sections on patient stories and patient resources, including where people can go for help. Video and audio content would be included recognising different mediums can appeal to different audiences and help support literacy. Mike Durkin suggested the Patient Safety Movement Foundation would be able to provide support on video content.
5.4 Rachel welcomed any future feedback and views on the website as it continued to develop and grow.
6. Engagement
6.1 Rachel Downey introduced the next agenda item to generate a discussion about how to best achieve engagement with very limited resources yet maximise opportunities for the Commissioner to hear directly from patients.
6.2 Louise Ansari offered use of the Healthwatch networks to facilitate meetings and Habib Naqvi said NHSRHO had a number of forthcoming report launches that would include engagement opportunities. Rachel Power offered support and the Chair said she was keen to take part in similar events to the Patient Association’s ‘Patient Partnership Week’ and ask what matters to patients, hear examples of both good and bad experience and pull out what it was that made a difference. Rachel Power had attended an event organised by the Healthcare Partnership Network (HPN) and would follow-up with Rachel afterwards. It was agreed to make the Commissioner aware of opportunities in members own organisations and elsewhere for engagement.
7. Forward look
7.1 Items covered included:
• World Patient Safety Day was being held on 17 September this year with the theme ‘Engaging Patients for Patient Safety’, and the Chair asked Members to help promote it.
• Members would be asked to engage with Rachel regarding contributing a guest blog for the website.
• An update on the redress project would be provided at the next meeting.
• The Annual Report would be laid in Parliament in July before summer recess.
8. AOB
8.1 Julia Cumberlege shared a report on progress with the IMMDS recommendations, which would be circulated to Members afterwards (Action).
9. Next meeting
9.1 Thursday 12 October 2023

Actions

  Action Who
1 Reminder to complete and return register of interests form if not already done so All members
2 Help facilitate the Commissioner attending a meeting of NHS Chairs/Chief Executives Ian Green
3 Circulate amended Terms of Reference for final sign-off via email Secretariat
4 Add link to new resource for patients with pelvic mesh to the Patients Association website Rachel Power
5 Members to engage with Rachel Downey on contributing a guest blog for the website Rachel Downey, All members
6 Circulate the report on IMMDS recommendations that Julia Cumberlege shared at the meeting Secretariat

1st Meeting – Thursday 23 March 2023 held at 18 Smith Square

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Helen Buckingham (Nuffield Trust / National Voices)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London)
Ian Green (Chair of Salisbury NHS Foundation Trust)
Rachel Power (Patients Association)
Gary Duncan (Secretariat)
Mel Peffer (Secretariat)
Apologies
Louise Ansari (Healthwatch England)
Rabbi Dr Harvey Belovski
Saffron Cordery (NHS Providers)
Dr Habib Naqvi (NHS Race and Health Observatory)

Meeting Notes

1. Welcome
1.1 The Chair warmly welcomed everyone to the first meeting of the Advisory Group and thanked everyone for agreeing to join the group.
1.2 Apologies had been received from Saffron Cordery (NHS Providers), Louise Ansari (Healthwatch England), Rabbi Dr Harvey Belovski, Dr Habib Naqvi (NHS Race and Health Observatory).
2. Round table introductions
2.1 The Chair invited round table introductions. Members’ biographies would be circulated after the meeting and made available on the Commissioner’s website (once live) (Action).
2.2 The Chair said there was one vacancy on the Group remaining and asked members to consider and provide suggestions after the meeting, perhaps someone with a background in research/science or other areas not represented on the group. (Action).
2.3 The Chair asked members to complete and return the register of interest form (Action).
3. Purpose & role of the Advisory Group
3.1 The Chair introduced the Terms of Reference which had been circulated before the meeting, indicating that the group was a statutory requirement to provide her with advice and assistance and to encourage good practice in involvement with patients.
3.2 Scope of the Patient Safety Commissioner

  • The Group discussed the scope of the Commissioner’s role, and it was acknowledged that many other issues had already been brought to the Commissioner’s attention outside the scope of First Do No Harm.

 Role of the Advisory Group

  • There was agreement that the wording in the terms of reference facilitated the statutory requirement of the group to advise and assist.
  • There was a suggestion that temporary sub-groups possibly focussing on research and communications could be considered.
  • The Group’s membership, biographies, terms of reference, meeting notes and other documentation will be published on the website (once live) to ensure openness and transparency.
  • Offers of help were received from the Patients Association and National Voices to host on their website and include updates in their communications.
3.3 The Chair suggested additional comments on the Terms of Reference could be emailed after the meeting with a final version of the Terms of Reference signed off at the next meeting in June, and thereafter to be reviewed at the end of the first year. (Action).
4. Scene setting – the first 100 days
4.1 The Chair reflected on some of the challenges faced during the initial set-up period including negotiating practicalities such as securing office space, staff resources, procuring a website, and in doing so having to work through government department processes and the inherent complexity and time-consuming nature of the various approvals required.
4.2 Resourcing was discussed; the original set-up budget/resourcing was considered insufficient going forward and a headcount of only four staff was very modest compared with some commissioner offices.  The budget for 2023/24 had not yet been confirmed by the sponsoring department (Department of Health and Social Care) and this was cause for concern. The Chair said she intended to write to the Department after the Advisory Group meeting and would raise resourcing again (Action).
4.3 The Chair described some of the work that had been done and was ongoing including:

  • Work to avoid sodium valproate being dispensed in white boxes, including raising concerns to the General Pharmaceutical Council who then wrote to all community pharmacists.  Engaging with NHS England and keeping visible the pressing need for this to be resolved, including raising delays with the white box consultation with the responsible DHSC Minister.
  • Redress – the Commissioner had been asked by Minister Caulfield to look at redress for those harmed by pelvic mesh and sodium valproate, and since December there had been a process of negotiation with DHSC to agree the precise scope of the work to ensure that it is patient focussed, and to secure additional resource, including expertise in the area of redress. The work would start once resource was in place.
4.4 There was a general discussion around engaging stakeholders and the need for the Commissioner role to influence in a really strong way.  The Chair had met with patient groups, visited clinics and spoken at numerous types of events which had been well received. The Chair had met regularly with various leaders in the healthcare system to help amplify patient voice including different directorates in NHSE, MHRA, professional regulators, parliamentarians, officials, and trade bodies. Building networks of allies was seen as important, including the informal network of patient safety leaders. It was noted that extending reach and awareness of the role needed to be at a manageable pace given existing resources.
4.5 There was a suggestion that engaging parliamentarians from both houses was useful, and Baroness Cumberlege offered to convene a small group, starting with the Lords to meet with the Commissioner and help apply pressure where action was needed (Action).
5. Priorities: pelvic mesh, sodium valproate, culture change
5.1 The Chair ran through some slides, introducing her current three priorities: culture change, pelvic mesh and sodium valproate. The slides would be circulated after the meeting (Action).
5.2 The Chair described her three focused elements of culture change as: a psychologically safe environment where people can ‘speak up, listen up, follow up’, consent, and conflicts of interest.
5.3 The journey of consent and supported decision making were mentioned, and the need for all healthcare professionals to be aware of and follow current legislation.
5.4 The Chair said she was in touch with the policy team at DHSC leading on the conflict of interest pilot, but there was some concern raised at the meeting about progress of the pilot.
5.5 From the slides, the Chair gave some examples of actions against each of the three priorities, including:

  • Campaigning to improve the use of yellow card reporting, including design of the patient information leaflet and packaging, and raising awareness.
  • Seeking to understand how organisations listen to patient voices, for example with a patient director at board level and through having patient stories at the top of their meeting agendas.
  • Working with NHS England to ensure patients are aware they have a choice of specialist mesh removal centres.
  • Helping the NHS England team leading on the registries work to have input from patients by connecting them with patient groups.
  • Co-producing resources for patients and GPs on pelvic mesh complications.
  • Working with health leaders to ensure that all relevant patients are on a Pregnancy Prevention Plan (PPP) and given the necessary information.
5.6 It was thought important that identifying a patient director at board level did not end up as just a tick box exercise. It was queried whether complaints learning was brought to Boards and also if measuring patient experience was taken to Board level.  One member indicated he had commissioned work to review how their Board was working and Ian Green offered to help facilitate the Commissioner speaking at a future NHS Chairs & Chief Executive meeting (Action).
5.7 The Chair explained that achieving the ambitions outlined in the slides would take leadership, listening and partnership, and that she was keen to understand and map out the powers held by different organisations across the health system.  The group thought it sensible to focus on a few areas until more resources were made available.
6. Statutory requirements
6.1 The Chair’s Chief of Staff briefly described the Commissioner’s statutory requirements, all of which would benefit from some level of input and review by Advisory Group members.

  • Consultation on principles of better patient safety
  • Publication of a business plan, currently with DHSC
  • Annual report (to be laid in Parliament – before summer recess)
7. Next steps & actions – discussion
7.1 There followed a final short discussion; points raised included:

  • The benefit of learning from other countries and systems, including fragile, vulnerable and conflict states, and recognising that within our own systems and services there are vulnerabilities – where can we make the most impact in these areas. How can we best learn across our own system and elsewhere.
  • Engaging with integrated care system leaders would be beneficial to learn about good practice.
7.2 The Chair thanked the offers received to host communications until such times as the Commissioner’s website was live, and in the meantime twitter would be used to announce the group had been established and met for the first time.
8. AOB
8.1 None.  For future meetings the Chair asked that she is made aware of any other business before the meeting starts.
9. Next meeting
9.1 The next meeting was scheduled on Thursday 22 June, but depending on availability, particularly those not in attendance at today’s meeting, an alternative date may need to be found.

Actions

  Action Who
1 Circulate Members’ biographies and the slides to the Advisory Group. Secretariat
2 Provide suggestions for the remaining vacancy on the Advisory Group. All members
3 Complete and return register of interests form All members
4 Provide any further comments on the Terms of Reference by email – by end of April All members
5 Write to DHSC after the Advisory Group meeting to raise budget/resourcing for 2023/24 Henrietta Hughes
6 Convene a small group of parliamentarians to meet with the Commissioner Baroness Cumberlege
7 Facilitate the Commissioner attending a meeting of NHS Chair/Chief Executives. Ian Green