Sir Nigel Crisp: No, I do not. As a patient, this is something I want to know that we take extremely seriously.

Q23 Mr Khan: What are the experiences of other countries?

Sir Nigel Crisp: Broadly similar. I think it is worth drawing out, as it does in this report, that two-thirds of that 10% do not experience any harm, so we are lumping everything together in that. Again, Sir Liam is the international expert on this and he could talk more about that.

Q24 Mr Khan: What I am interested in is 10% is not realistic and it should be lower - the obvious thing is to say it should be zero of course - if you were to come back here in a year's time or 24 months' time, what would that figure be?

Sir Nigel Crisp: I doubt in that sort of period that it would shift, but I do not like using an argument that we are just as bad as everyone else.

Q25 Mr Khan: How long do patients have to wait before they see an improvement that is noticeable?

Sir Nigel Crisp: You will see certain categories where we have got improvements. I could have said in response to an earlier comment that the National Patient Safety Agency has sent out 15 safety alerts in the last three years about specific devices or use of drugs or whatever; and that compares with ten in America over the same period, for example. We are actively trying to focus down on individual issues and make sure that those particular sorts of incidents never reoccur. We have got the IT system. A lot of these incidents were about slightly wrong levels of medication and when we are not relying on people's handwriting we will get better at that as well, so you will see some changes.

Q26 Mr Khan: How soon before we see changes on the ground?

Professor Sir Liam Donaldson: Could I add a comment? I think in most developed countries the ballpark figure is similar. The comparison should be with other high risk industries, like the airline industry who have systematically improved safety. It has taken them a decade or more to get to where they are, in fact even longer than that in some industries, but we have some of the key ingredients in place that have been shown from evidence from other industries to work. We are seeing cultural change which is probably the most important thing, more safety awareness in local services, and that is acknowledged in the report. We are seeing more reporting and analysis of reports, which was also a way in which the airline industry changed. We are seeing specific solutions coming through to reduce risk. Those are not working as well as they could be yet but, as Sir Nigel said, there are more of them coming through and certainly the advent of the electronic patient record will benefit safety of medication which accounts for 25% of the harm worldwide, medication errors, and it will also reduce some of the problems that result from poor communication and fragmented clinical information.

Q27 Mr Khan: So a noticeable change a decade from now?

Professor Sir Liam Donaldson: Absolutely, yes, but with incremental change over that period.

Q28 Mr Khan: One of the things you referred to was the culture. In the context of enhancing the safety culture within NHS trusts, there are comments made in the report about having an open and fair employer so that staff feel confident coming forward. Can I ask you what further actions you expect the NPSA to take to improve the culture in the NHS so that staff feel they have an open and fair employer?

Professor Sir Liam Donaldson: I think they have already put out guidance to good practice that staff should not be suspended unless there is evidence of negligence or careless conduct. On the majority of occasions when something goes wrong there is an error but it is a failure provoked by weak systems supporting the practitioner concerned, so just by careful monitoring. We do live in a blame culture society, as is the case in many Western countries, where scapegoats are looked for and individuals are blamed for mistakes but as we have seen in other industries, like the airline industry, that blame culture can be rolled back but it requires effort not just within the service concerned but by society as a whole and in particular the media.

Q29 Mr Khan: In particular, in your answer a knock-on effect that will have on clinical negligence cases is if you are admitting your mistakes that may have an impact on the number of cases that are settled.

Ms Williams: The programme we have to support a culture of change is we have trained 8,000 staff in contributory analysis, which is a particular technique which seeks to look at the contributory factors that lie behind an incident which starts to move people away from individual blame. At our conference next week we are launching a cultural assessment tool so that trusts themselves, whether at unit team level or strategic health authority level, can assess the level of maturity against a well recognised and used tool in other industries. We have trained and worked with 113 boards to talk through the issues of open and fair culture. We have issued a chief exec checklist so that chief execs themselves know the role that they can play to promote safety. Also, we have run leadership courses through the lens of patient safety to introduce them to some of these concepts. In terms of your last question, I am sorry I lost the ----

Q30 Mr Khan: The impact on settlements in cases.

Ms Williams: Just recently we issued a being open policy and teaching materials. This involves apologising and giving a full explanation involving the patient and their relatives in working through what actions might prevent harm in the future. We built that policy from experience both in Australia but particularly in veterans' health services in the USA where they have run this policy for a number of years and their negligence bill has not increased during this time.

Q31 Mr Khan: At the beginning of your answer you referred to your 8,000 staff who have been trained on the forms. How will the NPSA be able to identify learning when it says in paragraph 2.38 that trusts "are not required to provide information on contributory factors"?

Ms Williams: A number of trusts are using the form that ----

Q32 Mr Khan: They are not required to, are they?

Ms Williams: Not at the moment because we are reliant on seven or eight commercial vendors and not all of those systems collect contributory factors. The numbers where we are getting this information is increasing. What we would like to see over time as people become familiar with these terms - these are very new ways of looking at incidents - as trusts become more familiar is their internal forms changing.

Q33 Mr Khan: Do you envisage it being a requirement to provide those?

Ms Williams: I think in time, yes, it will be.

Q34 Mr Khan: This is probably a question for Sir Liam. Most countries favour a confidential rather than anonymous service for reporting because it means that you can learn from the information you are given. Why is the National Reporting and Learning System that we have anonymous?