The text of the speech made by Patricia Hewitt, the then Secretary of State for Health, on 28 November 2005.
Thank you Fergal for that warm introduction.
Good morning everybody. I’d like to welcome you all to the Patient Safety Summit, which we are holding as part of our 2005 Presidency of the European Union. I’m delighted to see so many people are here today. I welcome you all to London.
This week 15 years ago, construction workers finally drilled through the last wall of rock to join the two halves of the Channel Tunnel – linking Britain to mainland Europe for the first time since the Ice Age, 8,000 years earlier.
Today, the Tunnel has now come to be a “normal” part of our life for many of us, providing a seamless transport link between European cities. But it also reminds us that Europe is an increasingly connected community of countries – and that European cooperation can bring visible benefits to all of our lives.
Many of you will have used the Channel Tunnel to be here today. We have delegates from across the EU member states, from the European Commission, from other parts of Europe, and from the wider world (including international organisations the World Health Organization and OECD, and delegates from the USA, from Russia, Canada and Australia).
Most of you will be involved in making policy in some way. That is absolutely deliberate. This Summit is about solutions and action.
I’m also delighted to welcome a number of patients from around Europe and the world. Your participation is vital because as you’ve heard all of us need to keep in mind the individual and the family who are at the centre of our quest to improve the safety of patient care. They are the ones who suffer from any harm caused when things go wrong.
Once again, welcome to you all.
Patient Safety Internationally
Patient Safety is an international issue. No country – big or small – can claim to have solved the problem. That is why we have chosen it as a headline health theme to address in our 2005 Presidency of the European Union.
A stark figure which you will hear over and over throughout this Summit is that in approximately 1 in 10 of hospitalizations, something goes wrong. In the increasing number of developed countries where research has been carried out, over and over we find similar levels of health care errors.
Some of these errors are fortunately mild – for example a medication error which can simple mean a patient taking their medicine at the wrong time rather than the wrong medication – tragically others are not.
For Europe, this means that some form of unintended harm is almost certainly suffered by millions of patients every year.
We seem to have somehow forgotten the first law of medicine formulated by Hippocrates, almost over 2 and a half thousand years ago: ”first, do no harm.”
Of course the situation in developing countries is significantly worse. There you have dedicated staff working with desperately poor infrastructure and equipment, unreliable supply and quality of drugs, shortcomings in waste management and infection control all make the probability of adverse events much higher.
So wherever we are facing the challenge of patient safety isn’t easy. For patients, for those delivering health care, for policy makers, and for politicians, facing up to the fact that healthcare is an intrinsically risky – that in our complex healthcare systems, things do sometimes go wrong, and patients are sometimes harmed as a result – is not a comfortable or easy thing to do.
In seeking to be more open about patient safety, I think we find that cultures can be stubborn, old behaviours can be persistent and attitudes difficult to change.
The research and experience of other industries shows that an approach of blame and retribution – looking for a scapegoat – leads to a climate where individuals will be afraid to admit mistakes and no learning will ever take place.
I, for one, and I hope all of us would much prefer to be treated by a health care system that knows when it makes mistakes – and acts to reduce the risk of them being repeated – than one that did not.
The European response
Among the impressive programme of Summit sessions, speakers, experts – and patients – we have Fernand Sauer, the European Commission’s Director of Public Health and Risk Assessment, who will speak to us a little later on. I’m very much looking forward to that.
I am delighted that patient safety programmes are now emerging in many countries across Europe.
Patient safety has been a headline health priority theme of both the 2005 Luxembourg and UK Presidencies of the European Union. Activity at the European level builds on a programme established by the World Health Organization through the World Alliance for Patient Safety and the work of other key partners such as the Council of Europe.
We have representatives of the 2005 Luxembourg Presidency here: Health Minister Mars di Bartolomeo will speak tomorrow.
Our own Presidency aims to build on the excellent work of the Luxembourg Presidency to ensure that our deliberations on patient safety at the EU level are translated into clear goals, practical programmes of activity and strong partnerships. Our vision is simple – to leave a lasting legacy of safer health care for all Europeans.
I am pleased that the United Kingdom was one of the first countries in the world to give priority to tackling patient safety. We have tried in the past year to established safety as the first domain of the standards used to assess the quality of our healthcare service. We also have a national system for reporting – with learning from patient safety problems being translated into practical solutions for safer care.
Just four weeks ago, the National Audit Office (which scrutinises public spending on behalf of our Parliament) published its review of this country’s NHS Patient Safety programme. The report concluded that we have made progress; organisations and staff across the NHS feel that they are moving towards a more open and fair culture of safety – driven largely though our national focus on quality and safety. Although we know we have much more to do.
UK pledge of support
And of course our work in Europe is part of a much bigger international movement.
In May 2002 the World Health Assembly unanimously adopted a resolution urging all member states to take action on patient safety.
The Resolution requested WHO to take a lead in building global norms and standards and supporting country efforts in developing patient safety policies and practices. Since then, we have seen the establishment of the World Alliance for Patient Safety.
This was launched by the Director General of WHO, Dr LEE Jong-Wook in October 2004. I am delighted to say that Dr LEE is with us here today and will be addressing us shortly.
The UK has had a very close association with the patient safety programmes at the EU level and at the WHO through the chairmanship of Sir Liam Donaldson of the World Alliance. That partnership has been of great value both within the UK and internationally. It has allowed us to bring the best of learning and experience from the UK to the international stage as well as ensuring that we can learn from international experience.