New Patient Safety Commissioner for Scotland should be given more power to ensure lessons are learned from health scandals – Alan Clamp

Something must change in the way governments respond to major healthcare failings

Following protests outside the Scottish Parliament, a public inquiry is to be held into claims the former NHS Tayside neurosurgeon Sam Eljamel may have harmed more than 200 patients during his time working there (Picture: Jeff J Mitchell/Getty Images)

The protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister.

As the Patient Safety Commissioner for Scotland Bill makes its way into law, what does this mean for Scotland and the safety of its patients? What does this mean for the Eljamel inquiry and others that will surely follow?

In the 20 years since the Professional Standards Authority for Health and Social Care (PSA) was formed, we have seen a pattern emerge surrounding major failings of care, with successive inquiries and reviews identifying similar problems and recommendations, and seeming to have no impact. As Bill Kirkup said in his review of East Kent Maternity services: “The answer cannot be to hope that individual reviews and recommendations prevent recurrences elsewhere. If that approach were the right one, it would have worked by now. It hasn’t.”

In our 2022 report, Safer Care for All, we discussed the risks to patient safety inherent in a fragmented and disjointed healthcare system which is difficult to navigate, and where concerns frequently fall between the gaps of organisational remits. It is a system that does not reliably identify harm or risk of harm and is not always capable of learning and improving when things go wrong. The burden of raising the alarm, in cases such as Eljamel, often falls to harmed patients, placing immense pressure on them to fight their way through an unnecessarily complicated system.

At the time, we called for a new commissioner role (or an equivalent function) to be introduced in each UK country with responsibility for checking that the framework intended to keep people safe in health and care was working as it should. We are therefore pleased that Scotland is going to have a commissioner that looks at the whole system to spot problems and recommend solutions.

This is a vital step forward in ensuring that the system is capable of learning from its failings, as well as identifying and acting on risks before they lead to harm. It comes in response to the Cumberlege review, which highlighted system-wide failures to identify and act on serious harm being caused by certain medicines and medical devices. The review was commissioned for England, but the Scottish Government committed to implementing all the recommendations within its remit.

With a broader remit than their English counterparts, who currently only cover medicines and medical devices, and an overarching role in improving patient safety, future patient safety commissioners in Scotland could play an integral part in making care safer. But is there anything we would change if we could?

Yes, there is. As health and social care have, rightly, become more integrated and will hopefully continue on this path, we would like to see the commissioner role extended to social care. The boundaries between the two parts of the care system are irrelevant to the person receiving the care, particularly when things go wrong. We would also want to be sure that the confidentiality clauses in the Bill were not an impediment to the free flow of information to regulators, where this is critical to patient safety.

Then we come back to the question of public inquiries. Our recommendation for a commissioner included a role in bringing consistency, coherence, and follow-through to the government response to major failings in care – something that is not envisaged for the commissioner for Scotland. We still believe this oversight is needed.

The impact of harms affecting particular groups should also not be ignored – in 2020, we saw reports on four major patient safety scandals involving women, including the Cumberlege review. Maternity failings are the frequent subject of inquiries while concerns continue to be raised about the variation in quality across maternity services and the inequalities in outcomes for patients. Black women are much more likely to die in childbirth than white women.

Clearly, something needs to change in the way that governments respond to major failings to make it more effective, more efficient, and more responsive. We’re not alone in saying this; our voice joins others including a House of Lords team that looked at how inquiries work, and the charity Inquest’s ‘No More Deaths’ campaign.

An Inquiries Office, or equivalent role, would help to ensure that failings receive the right kind of response, at the right time, and that lessons are learnt. The Cumberlege review is a prime example of where this is needed; with nine strategic recommendations and 50 actions for improvement, a joined-up approach surely makes the most sense.

And this makes sense not only for patients, but also for governments, who should be asking themselves whether the significant cost of successive inquiries and reviews is delivering real, long-term improvements. The Inquiries Office would ideally be one of the functions of the commissioner, because inquiries form such an integral part of how we identify and learn from failings – perhaps something for a future review of the role? Short of that, there would still be value in this office being developed and housed elsewhere.

We have watched with interest the passage of the Patient Safety Commissioner for Scotland Bill through the Scottish Parliament – and we welcome its many similarities to what we proposed in Safer Care for All, despite some lingering gaps in remit. We look forward to seeing how the role develops, and whether it can deliver on its promise.

In Edinburgh today, the protests outside Parliament are quiet – for now. But for how long?

Alan Clamp is the chief executive officer of the Professional Standards Authority for Health and Social Care