Mid Staffordshire NHS Foundation Trust (Inquiry)

Wednesday 6th February 2013 Commons Chamber

12:33

[The Prime Minister (Mr David Cameron)]

Today, Robert Francis has published the report of the public inquiry into the Mid Staffordshire NHS Foundation Trust.

Mr Speaker, I have a deep affection for our national health service. I will never forget all the things that doctors and nurses have done for my family in times of pain and difficulty. I love our NHS. I think it is a fantastic institution and a great organisation that says a huge amount about our country and who we are, and I always want to think the best about it. I have huge admiration for the doctors, nurses and other health workers who dedicate their lives to caring for our loved ones. Nevertheless, we do them and the whole reputation of our NHS a grave disservice if we fail to speak out when things go wrong.

What happened at Mid Staffordshire NHS Foundation Trust between 2005 and 2009 was not just wrong; it was truly dreadful. Hundreds of people suffered from the most appalling neglect and mistreatment. There were patients so desperate for water that they were drinking from dirty flower vases. Many were given the wrong medication, treated roughly or left to wet themselves and then lie in urine for days, and relatives were ignored or even reproached when they pointed out even the most basic things that could have saved their loved ones from horrific pain or even death. We can only begin to imagine the suffering endured by those whose trust in our health system was betrayed at their most vulnerable moment. That is why it is right to make this statement today.

An investigation by the Healthcare Commission in 2009, a first independent inquiry by Robert Francis in February 2010 and, long before that, the testimony of bereaved relatives, such as Julie Bailey, and the Cure the NHS campaign all laid bare the most despicable catalogue of clinical and management failures at the trust. Even after those reports, however, important questions remained unanswered. How were these appalling events allowed to happen and to continue for so long? Why were so many bereaved families and whistleblowers who spoke out ignored for so long? Could something like this ever happen again? These are basic questions about wider failures in the system, not just at the hospital, but right across the NHS, including its regulators and the Department of Health.

That is why the families called for this public inquiry and why the Government granted one. I am sure the whole House will want to join me in expressing our thanks to Robert Francis and his entire team for their work over the past three years. The inquiry finds that the appalling suffering at the Mid Staffordshire hospital was primarily caused by a “serious failure” on the part of the trust board, which failed to listen to patients and staff and failed to tackle what Robert Francis calls

“an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities.”

The inquiry finds, however, that the failure went far wider. The primary care trust assumed others were taking responsibility and so made little attempt to collect proper information on the quality of care. The strategic health authority was

“far too remote from the patients it was there to serve, and it failed to be sufficiently sensitive to signs that patients might be at risk.”

Regulators, including Monitor and the then Healthcare Commission, failed to protect patients from substandard care. Too many doctors “kept their heads down” instead of speaking out when things were wrong. The Royal College of Nursing was

“ineffective both as a professional representative organisation and as a trade union”

and the Department of Health was too remote from the reality of the services that it oversees.

The way Robert Francis chronicles the evidence of systemic failure means that we cannot say with confidence that failings of care are limited to one hospital, but let us also be clear about what the report does not say. Francis does not blame any specific policy, he does not blame the last Secretary of State for Health and he says that we should not seek scapegoats.

Looking beyond the specific failures that Francis catalogues so clearly, we can identify in the report three fundamental problems with the culture of our NHS. The first is a focus on finance and figures at the expense of patient care—he says that explicitly—underpinned by a preoccupation with a narrow set of top-down targets pursued, in the case of Mid Staffordshire, to the exclusion of patient safety or listening to what patients, relatives, and indeed many staff members, were saying. Secondly, there was an attitude that patient care was always someone else’s problem. In short, no one was accountable. Thirdly, he talks about defensiveness and complacency. He finds that, instead of facing up to and acting on data that should have implied cause for concern, all too often there is a culture of only explaining the positives rather than any critical analysis. Put simply, managers were suppressing inconvenient facts in favour of looking for comfort in positive information. This is one of the most disturbing findings. It is bad enough that terrible things happened at that hospital, but what the inquiry is telling us is that there was a manifest failure to act on the data that were available, not just at the hospital but more widely. As Francis says:

“In the end, the truth was uncovered…mainly because of the persistent complaints made by a…determined group of patients and those close to them.”

The anger of the families is completely understandable. Every hon. Member in this House would be angry—they would be furious—if their mother, father or loved ones were treated in this way, and rightly so.

The previous Government commissioned the first report from Robert Francis. When he saw that report, the former Secretary of State—now the shadow Health Secretary, the right hon. Member for Leigh (Andy Burnham)—was right to apologise for what went wrong. This public inquiry not only repeats earlier findings, but shows wider systemic failings, so I would like to go further as Prime Minister and apologise to the families of all those who have suffered for the way the system allowed this horrific abuse to go unchecked and unchallenged for so long. On behalf of the Government—and, indeed, our country—I am truly sorry.

Since the problems at the Mid Staffordshire hospital first came to light, a number of important steps have been taken. The previous Government set up the National Quality Board and the quality accounts system. This Government have put compassion ahead of process-driven bureaucratic targets and put quality of care on a par with quality of treatment. We have set this out explicitly in the mandate to the NHS Commissioning Board, together with a new vision for compassionate nursing. We have introduced a tough new programme for tracking and eliminating falls, pressure sores and hospital infections, and we have demanded nursing rounds, every hour, in every ward of every hospital, but it is clear that we need to do more. We will study every one of the 290 recommendations in today’s report and we will respond in detail next month, but the recommendations include three core areas—patient care, accountability and defeating complacency—on which I believe we should make more immediate progress. Let me say a word about each.

First, let me address how we put patient care ahead of finances. Today, when a hospital fails financially, its chair can be dismissed and the board can be suspended, but failures in care rarely carry such consequences. That is not right, so we will create a single failure regime, where the suspension of the board can be triggered by failures in care as well as failures in finance, and we will put the voice of patients and staff at the heart of the way in which hospitals go about their work. In Mid Staffordshire, as far back as 2006, there was a staff survey in which only around a quarter of staff said they would actually want one of their own relatives to use the hospital that they worked in. Over the following two years, bereaved relatives and campaigners produced case after dreadful case and campaign after chilling campaign, but these voices and these horrific cases were ignored. Indeed, the hospital was upgraded to foundation trust status during this period. We need the words of patients and front-line staff to ring through the boardrooms of our hospitals and, frankly, right beyond, to the regulators and the Department of Health itself.

So from this year, every patient, every carer and every member of staff will be given the opportunity to say whether they would recommend treatment in their hospital to their friends or family. This will be published and the board will be held to account for its response. Put simply, where a significant proportion of patients or staff raise serious concerns about what is happening in a hospital, immediate inspection will result and suspension of the hospital board may well follow. Quality of care means not accepting that bed sores and hospital infections are somehow occupational hazards—that a little bit of these things is somehow okay. It is not okay; they are unacceptable—full stop, end of story. That is what zero harm—the jargon for this—means. I have therefore asked Don Berwick, who has advised President Obama on this issue, to make zero harm a reality in our NHS.

Francis makes other recommendations. Today it is possible to give hands-on care in a hospital with no training at all. Francis says this is wrong and I agree. There are some simple but quite profound things that need to happen in our NHS and in our hospitals. Nurses should be hired and promoted on the basis of having compassion as a vocation, not just academic qualifications. We need a style of leadership from senior nurses that means that poor practice is not tolerated and is driven off the wards. Another issue is whether pay should be linked to quality of care rather than just to time served at a hospital. I favour this approach.

Secondly, on accountability and transparency, the first Francis report set out very clearly what happened within Stafford hospital, and it should have led to those responsible being brought to book by the board, by the regulators, by the professional bodies and by the courts. But that did not happen. Most people will want to know why on earth not. We expect hospitals to take disciplinary action against staff who abuse their patients. We expect the professional bodies—the professional regulators—to strike off doctors and nurses who seriously breach their professional codes. And, yes, we expect the justice system to prosecute those suspected of criminal acts, whether they take place in a hospital or anywhere else. But in Stafford those expectations were badly let down. The system failed, and that is one of the main reasons we badly needed this public inquiry.

Now that the recommendations about systemic failure are public, the regulatory bodies in particular are going to have some difficult questions to answer. The Nursing and Midwifery Council and the General Medical Council need to explain why, so far, no one has been struck off. The Secretary of State for Health has today invited them to explain what steps they will take to strengthen their systems of accountability in the light of this report, and we are going to ask the Law Commission to advise on sweeping away the Nursing and Midwifery Council’s outdated and inflexible decision-making processes.

The Health and Safety Executive also needs to explain its decisions not to prosecute in specific cases. Indeed, Robert Francis makes a strong argument that the Health and Safety Executive is too distant from hospitals and not the right organisation to be focusing on health care and criminal prosecutions in such cases. So we will look closely at his recommendation to transfer the right to conduct criminal prosecutions away from the HSE to the Care Quality Commission.

Thirdly, we must purge the culture of complacency that is undermining the quality of care in our country. This requires a clear view about what is acceptable and what is not. In our schools, we have a clear system of deciding whether a school has the right culture and whether it is succeeding or failing. It is a system based on the judgment of independent experts who walk the corridors of the school and analyse more than just the statistics. The public therefore know which schools near them are outstanding and which are failing. They have a right to know exactly the same about our hospitals.

We need a hospital inspections regime that does not just look at numerical targets but examines the quality of care and makes an open, public and explicit judgment. So I have asked the Care Quality Commission to create a new post, a chief inspector of hospitals to take personal responsibility for that task. I want the new inspections regime to start this autumn, and we will look at the law to ensure that the inspector’s judgment is about whether a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking. In the meantime, I have asked the NHS medical director, Professor Sir Bruce Keogh, to conduct an immediate investigation into the care at hospitals with the highest mortality rates and to check that urgent remedial action is being taken.

Complacency in the system has meant that, all too often, patient complaints have been ignored. So I am today asking the right hon. Member for Cynon Valley (Ann Clwyd) and the chief executive of South Tees Hospitals NHS Foundation Trust, Tricia Hart, specifically to advise on how NHS hospitals can handle complaints better in the future.

I have talked today about some of the systemic failures, but at the heart of any system are the people who work in it and the values they hold. It is worth quoting in full what Francis says, early in his report:

“Healthcare is not an activity short of systems intended to maintain and improve standards, regulate the conduct of staff, and report and scrutinise performance. Continuous efforts have been made to refine and improve the way these work. Yet none of them, from local groups to the national regulators, from local councillors to the Secretary of State, appreciated the scale of the deficiencies at Stafford and, therefore, over a period of years did anything effective to stop them.”

What makes our national health service special is the simple principle that the moment you are injured or fall ill, or the moment something happens to someone you love, you know that whoever you are, wherever you are from, whatever is wrong, and however much you have got in the bank, there is a place you can go where people will look after you and do everything they can to make things right again. The shocking truth is that that precious principle of British life was broken in Mid Staffordshire.

We would not be here today without the tireless campaigning of the families who suffered so terribly, and I am sure that the whole House will join me in paying tribute to their incredible courage and determination over those long and painful years. When I met Julie Bailey and the families again on Monday, she said to me that she wanted the legacy of their loved ones to be an NHS safe for everyone. That is the legacy that together we must secure, and I commend this statement to the House.

12:49

[Edward Miliband (Doncaster North) (Lab)]

I thank the Prime Minister for his statement and for the tone in which he made it. The NHS represents the best values of this country, and what happened at Stafford was an appalling betrayal of those values. We all think that when our own loved ones—our mother or father, grandmother or grandfather—go into hospital, we are placing them in the trust of the NHS and we expect hospitals to be places of utmost compassion and the highest standards of care. At Stafford, patients became victims and their relatives who pleaded for assistance were ignored or even made to feel intimidated.

Let me join the Prime Minister in paying tribute to all those former patients, relatives and staff who came forward to speak out, including those who gave evidence to this and to previous inquiries. Let me also thank Robert Francis for his work on this and on the previous inquiry.

Let me also say, as was reflected in the Prime Minister’s remarks, that what happened at Stafford was not typical of the NHS. Day in, day out, the vast majority of those who go to work in our NHS deliver great care to patients up and down the country. They are as horrified as all of us by what happened in Stafford.

The previous Government were right to apologise on behalf of the Government and the NHS to the patients and families that suffered so badly at Stafford hospital. I reaffirm that today. We on the Labour side are truly sorry for what happened. What happened has no place in any NHS hospital. We must ensure that it does not and cannot happen again.

As the Prime Minister makes clear, today’s report says that the primary responsibility for what happened lay with the board of the hospital, but there are wider lessons that politicians on all sides must learn, including a lesson for all parties about the dangers of frequent reorganisations of the NHS, which Francis mentions.

The Prime Minister says it will take some time to digest the report in full, so let me ask some specific questions. First, on the patient voice, effective regulation is essential, but the reality is that regulators cannot be everywhere spotting every problem. Patients, their families and staff are everywhere in our NHS, so we must ensure that they are properly heard.

The challenge is to change the culture of the NHS and to support rather than shut out people who complain. The NHS constitution offers protections for whistleblowers, and we support moves to strengthen that. The Francis report, however, also highlights criticisms and concerns about both previous and current arrangements for patient bodies. Does the Prime Minister agree—from something he said earlier, I think he does—that whatever bodies we choose to represent patients, they need to be independent and have the powers to be an effective voice and challenge to the system.

Secondly, on staffing, the basic requirements of any NHS hospital are that there are sufficient staff to look after patients and that they act with compassion. In too many cases at Stafford, that just did not happen. Compassion should always be at the heart of nursing, and it needs to be at the heart of nurse training, so we support the moves that the Prime Minister announced.

As Robert Francis has said previously—I quote from the first report—in explaining what went wrong:

“the overwhelmingly prevalent factors were a lack of staff, both in terms of absolute numbers and appropriate skills”.

Does the Prime Minister accept the report’s point that we need to consider benchmarks on staff numbers and skills throughout our NHS?

Thirdly, on regulation, the problems at Stafford should have been picked up much earlier. Monitor and the Healthcare Commission should have worked together much more closely. We will look at the Prime Minister’s proposals around the chief inspector of nursing care, but does he support the move to a single regulator, which is in the Francis report? On health care assistants—the Prime Minister mentioned them—who do such important work in our hospital wards and communities, does he agree that we need training and registration for them to improve standards and safety?

Fourthly, on foundation trust status, the enthusiasm for foundation trusts has been shared on both sides of this House, and the journey to foundation trust status has clearly been a beneficial process for many trusts. In the case of Stafford, however, it clearly was not. For the future, has the Prime Minister made any reassessment of the current timetable for other trusts to achieve foundation status and of whether more flexibility is needed?

Fifthly, on waiting time targets, today’s report clearly states that

“it is not suggested that properly designed targets, appropriately monitored, cannot provide considerable benefit to patients”.

In other words, targets have their place, but they must be kept in their place. Does the Prime Minister accept that, as the Francis analysis suggests, the problem at Stafford was how the A and E target was managed by that hospital, and that many hospitals up and down the country have delivered excellent care while meeting the A and E target? Neither he nor I want to go back to the days when people were left waiting 12 hours on trolleys and 18 months for an operation.

Finally, let me turn to the issue of integration. I believe that there is a bigger overarching issue here, which applies not just in Stafford, but elsewhere in our NHS. It is something that my right hon. Friend the shadow Health Secretary has talked about recently. The ageing society is bringing a whole new set of demands on the NHS. A group of elderly and infirm patients require not just physical treatment for their immediate illness, but need much greater care and attention for their basic needs. As the Francis report says, we must address this new challenge that the NHS faces to make sure we avoid a repeat of what happened at Stafford.

Does the Prime Minister agree that in every hospital we need to put in place the right support for the whole of a person’s needs, including those of the elderly population? Does he further agree that that means breaking down the barriers that still exist in much of the country between health care provided by the NHS and social care provided by local authorities?

We cannot turn the clock back and undo the damage that happened at Stafford, but we owe it to those who suffered, to the people of Stafford and to the country as a whole to work together to act on this report and to prevent a scandal like this from happening elsewhere. We in the Opposition will play our part in making that happen.

[The Prime Minister]

I thank the right hon. Gentleman for his remarks and for the tone in which he made them. I apologise for not getting my response to the report to him a little earlier this morning. That was a technical mistake rather than anything more sinister. The right hon. Gentleman is right to thank the relatives and to thank Robert Francis for his work. Let me try to answer the right hon. Gentleman’s questions.

On the issue of reorganisations, Francis says:

“The extent of the failure of the system shown in this report suggests that a fundamental culture change is needed. This does not require root and branch reorganisation—the system has had many of those—but it requires changes which can largely be implemented within the system that has now been created by the new reforms.”

I hope we can agree that the best thing to do now is to learn the lessons and put in place what needs to be done.

The right hon. Gentleman is absolutely right to raise the issue of listening to patients. As he said, we have got to make sure that whatever organisation we have—we have established HealthWatch—is independent, credible and has power. It is interesting to note what Francis finds on page 46:

“It is now quite clear that what replaced”

community health councils, and there were

“two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite.”

We need to learn the lessons and try to make sure that HealthWatch becomes everything we all want it to be.

As for supporting complaints, what Francis and the right hon. Gentleman said is that when there are complaints, they have got to be given a bigger voice and be taken seriously. Here, Members of Parliament have a role to play. Somewhere, buried in the report, there is a passage that is mildly critical of MPs. Like others in the community, we love our local hospitals and we always want to stand up for them, but we have to be careful to look at the results in our local hospitals and work out whether we should not sometimes give voice to some of the concerns rather than go along with a culture that says everything is all right all of the time—sometimes it is not.

On the issue of staff numbers and benchmarks, we think it important that there should be some benchmarks. We believe that because of the funding commitment we have made, there is no excuse for understaffing or for staff shortages, but that obviously requires good management.

On having a single regulator, the right hon. Gentleman made a lot of points about Monitor and the Care Quality Commission and whether there was confusion between them. When he talks of strengthening the CQC and giving it greater powers, that is in principle, as I said in my statement, the right direction to go in.

The right hon. Gentleman asked about trusts, and both sides of the House have supported the idea of foundation trusts, making sure hospitals are more accountable, more responsible and able to take more decisions. The problem is not with creating foundation trusts, but arises if the move to create them means that other things that matter more than trust status—such as patient care—are pushed to one side. We must all learn the lesson and ensure that for the next round of trust creation, they must not be rushed and they must happen only when they are ready and on the basis that patient care comes first.

The point about targets is important. I believe that there is a place for targets in our NHS, but I think that under the last Government they became too tight and too obsessive. I also think that the last Government recognised that themselves, and started to change the approach.

The public have a right to know that waiting times in A and E will not be too long and that treatments will be carried out quickly, so there is an importance in targets. I think that what Francis is saying is that it was not the targets that were to blame, but a culture in the hospital—and perhaps in other hospitals, although he does not inquire into that—in which targets and their achievement were placed ahead of patient care. Again, the two should not be alternatives.

What the right hon. Gentleman said about the ageing population and the challenge facing our NHS was absolutely right. A key part of our dementia challenge is raising the standard of, in particular, the way in which we treat elderly people in our hospitals. I also agree with the right hon. Gentleman that we need to break down the barrier between health and social care.

I hope that the report will provide not an opportunity to try to find scapegoats or to fire up some phony political debate, but a moment when everyone in the House can agree. We all love our national health service, and this afternoon’s discussion shows that we have the same ideas about patient care, about quality, about bringing health and social care together, and about ensuring that a good, rational system has patients at its heart. I hope that this can be a moment when the country comes together over our NHS, rather than seeking divisions.

[Jeremy Lefroy (Stafford) (Con)]

Today is a day on which, first of all, we think of those who suffered in Stafford and of their loved ones. I thank the Prime Minister and the Leader of the Opposition for the tone that they have adopted. I also pay tribute to Julie Bailey and Cure the NHS, to Robert Francis, to my hon. Friend the Member for Stone (Mr Cash), to my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), to the Secretary of State and to the Prime Minister for the way in which they have championed the cause of this inquiry.

I know how passionate the Prime Minister is about the NHS and the work that goes on day in, day out, and I share that passion. Does he agree that the most important thing that we can do for the patients and their loved ones who have suffered is implement the recommendations that we are able to implement as quickly as possible, so that they can result in an NHS that is safe for all and is known for the highest standards of compassion and care?

[The Prime Minister]

I am sure that my hon. Friend, who has spoken up about this issue for many years, spoke for everyone in Stafford and throughout the country when he said that we should put the victims up front and centre. They are the people we should be holding in our thoughts today because of how they have suffered.

I agree with what my hon. Friend said about implementing the recommendations. There are 290 of them, so we must examine them carefully and see how we can best implement them, and the Department of Health will lead that work. Let me make two additional points. First, the recommendations are not simply for the Government or the Department; they are for every hospital, every nurse and every doctor to consider. I think it very important for that to happen. Secondly, as I tried to make clear in my statement, for all the changes in the system and all the corrections of regulatory failure that may be made, a system is only as good as the people who work in it. I think that at the heart of what Francis is saying is a cry from the heart that this is about quality, vocation and compassion, and that those are the values that we need to put back at the heart of the NHS.

[Joan Walley (Stoke-on-Trent North) (Lab)]

I welcome the fact that there has been a public inquiry, and I welcome the Prime Minister’s statement.

What has happened in Mid Staffordshire affects the whole of Staffordshire. In view of the emphasis that is now to be placed on compassion as well as on targets, and in view of what the Prime Minister has said about the role of social care, may I ask whether he will arrange for local Members of Parliament to have some form of oversight in Staffordshire so that the collaboration that will be needed to introduce this culture change can be put into practice on the ground, particularly in the light of closures that involve social care homes as well?

[The Prime Minister]

I think it very important for the voice of local Members of Parliament to be listened to. The Secretary of State has said that he will ensure that Staffordshire Members of Parliament, and Members of Parliament representing Stoke-on-Trent, can advise him on the issue. Let me refer again, however, to one of the things that may need to change in our political debate. If we are really going to put quality and patient care upfront, we must sometimes look at the facts concerning the level of service in some hospitals and some care homes, and not always—as we have all done, me included—reach for the button that says “Oppose the local change”. I know that that is what the hon. Lady was saying, but I think that this is a moment when we may be able to ensure that our political culture is more in line with what is required in our health culture.

[Mr Aidan Burley (Cannock Chase) (Con)]

Many of my constituents died unnecessarily at Stafford hospital between 2005 and 2009. Given Monitor’s continuing review of the future of Mid Staffordshire’s foundation trust, I remain astonished that it was given foundation trust status in 2009, when all these problems were going on.

Does the Prime Minister agree that the biggest lesson that can be learned is that when front-line professionals who love and care about the NHS are genuinely concerned about standards of care, we should have a system that allows them to speak out without fear of exposure or victimisation?

[The Prime Minister]

My hon. Friend is absolutely right to speak up for the victims from Cannock and their families, whom he represents properly in the House. He is right to say that we must listen to the voices of victims and patients, and he is also right to talk about the reform of regulatory bodies, although, as I said earlier, we should be careful about thinking that just reforming regulatory bodies will be enough.

My hon. Friend specifically mentioned the importance of whistleblowers. It should not be necessary to rely on whistleblowing to deal with problems of quality, but sometimes it will be. We have taken measures to fund a helpline to support them, to embed rights in their employment contracts, and to issue new guidance in partnership with trade unions and employers. So we are taking the issue of whistleblowers seriously.

[Frank Dobson (Holborn and St Pancras) (Lab)]

As Health Secretary, I changed the law to provide protection for whistleblowing and to make hospital boards responsible for the quality of care. I am sure the Prime Minister accepts my disappointment that those changes were clearly not sufficient to avoid the things that happened in Mid Staffordshire.

May I issue a warning? I greatly welcome the proposal to make openness, transparency and candour a legal requirement, but if we are to do that in a litigation-obsessed society, it will need to be matched by the introduction of a system of no-fault compensation. Otherwise, it is possible that in some hospitals the doctors will be outnumbered by ambulance-chasing lawyers.

[The Prime Minister]

I will consider carefully what the right hon. Gentleman has said about no-fault compensation. The cost of litigation in the NHS is clearly a rapidly rising part of the budget, and that is of concern.

The right hon. Gentleman’s point about the laws that he changed is important. What I think we have observed in Governments of all parties is the belief that changing the law to make it clear that quality is important as well as cost, and that patient care matters, does not necessarily lead to a change in the culture.

That returns me to the point made by my hon. Friend the Member for Cannock Chase (Mr Burley). The report makes it clear that when the issue of foundation trust status arose, those who were judging it did so on the basis of a whole series of metrics that were mainly financial, and on the basis of targets, rather than looking behind those for the quality. It is a culture change that will ensure that, when a hospital board meets, the first things that it considers are clinical standards, quality and patient care. That is the first stuff: that is actually what the organisation is meant to deliver. The board can think about the finances, the targets and all the rest of it afterwards. It is that culture change that needs to take place.

[Mr William Cash (Stone) (Con)]

On behalf of my constituents and the victims and relatives who have been so grievously traumatised by these tragic events and the lack of patient care, I congratulate my right hon. Friend on realistically listening, as Leader of the Opposition, to my repeated calls in Parliament for a real public inquiry, which he established under the Inquiries Act 2005, I also congratulate him on his statement, and on his praise for the inquiry itself and for Cure the NHS—in particular, Julie Bailey, my constituents Debra Hazeldine and Ken Lownds, and all the others who have campaigned so effectively and with such passion for patient care.

[The Prime Minister]

I thank my hon. Friend for what he has said. He did call repeatedly for a public inquiry, and he was right to make such a call. That is reflected in the report, and he can read it today. What was required was not an investigation of the failure in the hospital, but an investigation of the wider systemic failure. For instance, why was this not brought to light more quickly? What was the role of the regulator? What was the role of the Nursing and Midwifery Council? All that is laid out in the report.

However, I think that there was another very profound reason for holding a public inquiry, although I know that it will not satisfy some of the victims. They feel incredibly strongly, and rightly strongly. These terrible things happened to their loved ones, but where is the criminal prosecution? Where are the people who have been struck off? There has not been proper accountability, and there is not proper accountability in our system. A public inquiry can look to the future and say, “Here’s what needs to change,” so if this ever happens again—I hope to God it does not—there will be much better accountability than the people of Stafford have had.

[Paul Farrelly (Newcastle-under-Lyme) (Lab)]

The tragic events at Stafford are having a continuing impact on both management and care at the University hospital of North Staffordshire. A and E closures at Stafford have caused major strains, for example, and our new hospital was already struggling as a result of bed closures ordered a few years ago by Sir David Nicholson’s travelling troubleshooter, Antony Sumara. For reasons of patient safety, our hospital’s chief executive last year rightly reopened many of those beds to cope with the added A and E pressures. That has only added to the financial pressures, however. When rather distant bureaucrats at the Department of Health and the regional health authority play their part in responding to those pressures, will the Prime Minister ensure that they do so with sympathy and local understanding and put patient safety and care at the heart of the response?

[The Prime Minister]

I agree with the hon. Gentleman that when those above and beyond a hospital are making decisions on questions such as whether the hospital should become a foundation trust, they must look very closely at quality of patient care, not simply financial and other metrics. That is at the heart of what Francis is saying. The CQC believes that the hospital is currently providing an adequate standard of care. Only last week it carried out an unannounced inspection and it was content with what it found. Recent reports have been disturbing, however, and there is important work still to do in this hospital as in others, because “adequate” is never good enough; they have to strive to be better, and I know that that is what is going on.

[Nicholas Soames (Mid Sussex) (Con)]

Whatever the abject clinical and management failings, this was at heart a truly disgraceful failure of leadership at all levels. Indeed, too many inadequate and failing managers in leadership positions are repeatedly recycled through the NHS. Accordingly, will the Prime Minister consider establishing a national health service staff college to which senior managers may go, and ensure that no senior manager may take command of a hospital trust or any higher post unless he is a graduate of such a college?

[The Prime Minister]

I thank my right hon. Friend for his remarks. When he has a chance to look at the report in more detail, I think he will be pleased to see that Robert Francis suggests something along those lines: he suggests some form of leadership college. We think that has merit and will look at it carefully. I am nervous about committing instantly to creating more NHS organisations and institutions as there are a lot already, but the point my right hon. Friend makes is a good one.

The other point my right hon. Friend makes is vitally important in terms of the accountability issue: all too often when something has gone wrong in one of our hospitals, managers or overseers are recycled and reappear, as if by magic, in another part of the NHS. We need all those responsible for accountability—the CQC, Monitor, the Nursing and Midwifery Council, the General Medical Council—to take a clearer view about whether someone is up to the job or not.

[Alan Johnson (Kingston upon Hull West and Hessle) (Lab)]

I thank the Prime Minister for his statement and the manner in which he made it. Does he agree that our biggest challenge is to make quality of care the central organising principle of the NHS? That was recognised by Lord Ara Darzi, although I am not sure whether we were particularly successful at pursuing it. We can all say that that is the challenge, but addressing it creates a series of problems, including—as I was saying to my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson)—the problem of productivity. If nurses and GPs and other doctors are to spend more time with patients and focus on care, there will be ramifications for other ways in which we measure how the health service is working. Does the Prime Minister therefore agree that the challenge that Ara Darzi sets is about how to make care truly the central organising principle of the NHS?

[The Prime Minister]

The right hon. Gentleman speaks with great knowledge of, and affection for, the NHS, and I, too, am a fan of Ara Darzi and think he has a huge amount to offer. He had a big hand in giving priority to quality at the end of the last Government’s term. Francis is saying that there needs to be a culture change in respect of quality, but we must also look at what we are currently measuring. If hospital managers are measured on financial metrics and target metrics, rather than on quality of care—that is what we see flowing through the report—all the words we say and laws we pass on quality of care will not have sufficient impact. We need to look at that.

[Simon Hughes (Bermondsey and Old Southwark) (LD)]

I welcome the report and the Prime Minister’s response, including on the hospital inspectorate proposal. Will he ensure that the Government’s full response includes giving special consideration to trying to change the culture of calling for the lawyers, which is what often currently happens when there are complaints? Instead, everybody should know in advance who is responsible for the ward, who is responsible for the clinical care and who is responsible for the management, and that they will be held to account. We must also ensure that the best practice in clinical care—which we often see in our wards—is used to judge what works and we are very tough on those who have failed.

[The Prime Minister]

My right hon. Friend makes two points. First, I agree that we need clear lines of accountability so we can see who is responsible for standards of care on the ward and in the hospital, and they must be held to account for that. Secondly, I have a lot of sympathy with the point that sometimes people making a compliant are not seeking financial redress, and I think all constituency MPs would agree with that, too. They just want to be taken seriously. They want to be listened to; they want an acknowledgement. They will not go off and hire lawyers. They want an acknowledgement that their elderly relative was not treated properly, and they want it soon. I hope this report launches a debate in the NHS about how we can deliver that.

[Tristram Hunt (Stoke-on-Trent Central) (Lab)]

There remains real trauma and anguish in Stoke-on-Trent about the abuse, poor treatment and unnecessary deaths of relatives and friends in Stafford hospital. I welcome the focus on delivering a culture of care in the management of hospitals and on the accountability of boards, and I also welcome the questioning of nursing and medical bodies about the absence of accountability. I have two questions, however. What elements of the new NHS reforms make it less likely that a Mid Staffs will occur again, and are we absolutely sure that HealthWatch will be fit for purpose in April? On the north Staffordshire health care economy, the University hospital of North Staffordshire is taking a lot of slack from Mid Staffordshire. Can we ensure that the Department of Health supports North Staffordshire in addressing any problems?

[The Prime Minister]

Let me go directly to the important question about the reforms, the status quo once they are in place and how that will help deliver what Francis talks about. As I said in answer to the Leader of the Opposition, Francis says he is content this can be delivered:

“it requires changes which can largely be implemented within the system that has now been created by the new reforms.”

I hope the reforms will help in a number of ways. I hope HealthWatch can be created as a robust independent organisation that is taken seriously by those in the health service and more widely. I hope that having clinical leadership of the clinical commissioning groups, with local GPs and others in charge, will mean they will reach further into their hospital and perhaps ask better questions than the primary care trust put. As I said at Prime Minister’s questions, I also hope that the Department of Health sets a mandate for the national Commissioning Board and that we put quality and care for patients at the heart of it. While I accept that we need some process targets because things such as waits in A and E matter, I hope that the move towards judging outcomes rather than processes will reinforce the importance of quality, because if we do not get quality care, we will not get quality outcomes.

[Andrew Griffiths (Burton) (Con)]

The Prime Minister will be aware that since the closure of the A and E at Stafford, Queen’s hospital in Burton has been dealing with some of the patients that would have gone to Mid Staffs. Will he join me in thanking all the staff at Queen’s and the other hospitals across Staffordshire who have worked so hard to try to deal with the consequences of the Mid Staffs fallout? Given that he understands the genuine concern that is felt in my constituency and across Staffordshire about health care, will he assure my constituents that never again will ticking boxes be put ahead of caring and compassion in the NHS?

[The Prime Minister]

I can certainly give my hon. Friend that guarantee. The whole tenor of this report is that quality patient care must come before anything else, including targets, no matter how important they can sometimes be. I join him in praising those in his own local hospital who have been working hard and delivering accident and emergency services. If anyone wants to understand just how badly the target chasing and obsession got at Stafford hospital, they can see on page 108 in volume I some chilling evidence that staff just felt they could not complain about quality because they were being chased so hard on the targets that everything else was put to one side.

[Robert Flello (Stoke-on-Trent South) (Lab)]

The Prime Minister has said that the concerns of patients’ families were ignored, but in fact they and representatives were lied to. One consequence of what happened at Mid Staffordshire is that, despite nobody suggesting that there is a widespread problem throughout the NHS, people have a real fear: whenever there is a case of poor care in one of our hospitals, people immediately jump to conclusions and ask, “Is this a wider problem?” I look forward to hearing the Prime Minister’s comments in a moment, but I hope that this report will go some way to alleviating people’s very real fear that when they see one of their loved ones treated in a way that falls way below or slightly below the standard they were expecting, they can have the confidence to know that it is not Mid Staffs all over again.

[The Prime Minister]

I listened carefully to what the hon. Gentleman said, and I am sure he is right; I do not think we are looking at other problems across our NHS of a Stafford-style scale, where this went on for year after year and potentially hundreds of people lost their lives prematurely. However, we do know that there are problems in parts of our NHS and problems in individual hospitals. One of the things we have to learn from this report is that when that happens we must not say that everything is fine and we must not have a culture of complacency. Instead, let us have a proper way of dealing with the problems. That is the big change that needs to come out of this.

[Gavin Williamson (South Staffordshire) (Con)]

Many of my constituents both use and depend on Stafford hospital. Will my right hon. Friend assure them that future nurse training will all be focused on care and compassion, and not on an obsession with targets?

[The Prime Minister]

The Care Quality Commission has said that Stafford hospital is providing adequate care. There was a recent inspection to check up on it, and obviously more work needs to be done as it recovers from this. We need to be absolutely clear that nurses not only provide amazing care, but are also well trained and can carry out some quite complicated medical procedures, and they are proud of that. They are often—dare I say—better sometimes than the junior doctor at putting in the cannula or whatever. We should praise that and we should want to have professional nurses. The key thing that needs to change as we employ and train nurses is that we make sure that at the heart of their reason for wanting to do the job is not just access to the qualifications and the career, but a real belief in compassion and caring, and that it is a vocation.

[Ann Clwyd (Cynon Valley) (Lab)]

Apart from addressing the training of nurses, we need nurses who do not mind wiping people’s bottoms or holding the sick bowl under somebody’s face, but there are not enough of those any more. I am glad that the Prime Minister talked about compassion and care. I have received more than 1,000 letters and e-mails since I first spoke out from people who echo some of the points he has made today and which we all know about as constituency MPs. There must be an opportunity for whistleblowers to act without fear of reprisal. There must be freedom for people to make complaints, to speak out and to say when they see that something is going wrong. I only wish that I had spoken out and shouted, instead of thinking that I was leaving somebody in the hands of professionals, which, I am afraid, did not extend to the care and compassion we would all expect somebody to be treated with in hospital.

I just wish to pay a quick tribute to the campaigners, as the Prime Minister has done. I pay particular tribute to Julie Bailey, whom I have also met. I have met dozens of those people, and I think we would all applaud their tenacity in speaking out and sticking to their guns. I look forward to helping to make the system better because, as the Prime Minister has said, we all love the NHS, but we know that there are systemic faults in it at the moment.

[The Prime Minister]

I thank the right hon. Lady for what she says, and I am delighted that she is going to be helping us with this piece of work to really set out how complaints should be properly handled. I think she speaks for everyone when she says not only that she loves the NHS, but that when we see the best level of care handed out to loved ones, it is one of the most inspiring things in the world, and that is why it is so disturbing and so hurtful when we see poor standards of care and people let down. We have to get a balance right in this debate: we must continually and rightly praise nurses, health care assistants and doctors for the care and compassion they provide—for what they do every day—but we must marry that with a determination that where there is bad practice we should join them in pointing it out. There has been a culture of complacency that we have all been part of—MPs are to blame here, too—for too long.

[Christopher Pincher (Tamworth) (Con)]

I note that the Prime Minister shares the shock and incredulity of the people of Staffordshire, the county where I was born and which I represent, that such terrible things can happen in one of their local hospitals. I am pleased that he says he will make it easier for whistleblowers and for patients to put on record their experience of care. Will he say a little more about the speed with which he expects those data to be put in the public domain, so that patients, the public and hospital managers can make quick and informed decisions about what is going on in their hospitals?

[The Prime Minister]

I thank my hon. Friend for that. Like others, Staffordshire MPs have spoken with great passion about their care for their local health service and what it can provide.

On the timing, Robert Francis says that he wants all parts of the NHS to respond to him on what they are going to do right across the NHS, and that should be done over the next year. The Department of Health will be looking in the coming months at all the recommendations and responding. Specifically on the inspections, which are so important, as I said in my statement we are going to look at these changes to the CQC, but even before that Bruce Keogh is going to run this set of inspections into hospitals that have high rates of mortality and make sure that they are being dealt with properly.

[Mr Kevin Barron (Rother Valley) (Lab)]

It is quite clear that the Public Interest Disclosure Act 1998, which was supposed to encourage and protect whistleblowing, has failed in this case when faced with the culture of the NHS. On the lessons that could be learned, the Health Committee published a report in 2009 on patient safety and recommended that the Government should look at how whistleblowing was handled around the world, particularly in New Zealand. There, it is handled by an independent person, who carries out the inquiry, often anonymously from the complainant, and gets a far better reaction from institutions than we do here in the United Kingdom.

[The Prime Minister]

The right hon. Gentleman makes a powerful point about whistleblowers and how we handle them, and I am sure that Health Ministers will listen to that. I just make the point that supporting whistleblowers is one thing, but we also have to respond to what is being said. There were whistleblowers in the case of the Stafford hospital, but the problem was that the response to the complaints, the campaigns and the whistleblowing was completely inadequate.

[Dr Phillip Lee (Bracknell) (Con)]

I do not necessarily share the enthusiasm of others for hospitals to gain foundation trust status, particularly those serving less than half a million people. I note with interest that the chief executive of Heatherwood and Wexham Park Hospitals NHS Foundation Trust, who oversaw the foundation trust status being secured a few years ago, has now retired with a healthy pension and so on. That trust is now £80 million in debt and unsustainable. I also note with interest that the chief executive in this case cited the old chestnut of stress-related illness in order to avoid contributing to the report. When are we going to draw up contracts so that people get sacked for poor performance, be it financial or clinical? As far as I am concerned, the same should apply to hospital managers as applied to bankers.

[The Prime Minister]

My hon. Friend speaks with considerable knowledge of the NHS, and he is absolutely right to say that it is depressing to look down the list of those responsible for the Stafford hospital at the time and see what has happened. It reads “Left on compromise agreement”, “Left on compromise agreement”, “Stepped down” and “Now working somewhere else”. As I said, the accountability mechanisms in the NHS are not good enough, which is why this report is so important. I now want to see all the organisations—the trusts, the CQC, the Department of Health, the General Medical Council and so on—answering the question: why is bad practice not punished properly? That is one of the key things that has to come out of this report. That is not everything that those campaigners from Stafford want to hear; they want more accountability from the people involved in this problem. I can understand absolutely why they want that, but I think that what we can get out of the Francis report is a sense that there are going to be proper rules to deal with failure in the future.

[Several hon. Members]

rose—

[Mr Speaker]

Order. These are extremely serious matters being treated with great knowledge and sensitivity. I want to accommodate everybody who is interested in the subject, but we would now benefit from slightly shorter questions and I need therefore look no further than to a specialist in the genre, Gisela Stuart.

[Ms Gisela Stuart (Birmingham, Edgbaston) (Lab)]

Further to the Prime Minister’s previous answer, what precise steps will he take to force trusts not to accept early resignations or moving on? What will he do to stop that recycling, which has been going on for ever?

[The Prime Minister]

There are two answers. The first relates to the contracts that are signed in the first place; every trust board needs to read the report and think about how it will put in place those contracts. The second is to make sure that when there are failures, proper action is taken. That is what needs to happen.

[David Tredinnick (Bosworth) (Con)]

Will the Prime Minister ensure that the chief inspector of hospitals has access to all the information that he or she needs from the General Medical Council and all the other bodies? Does he agree that wards for the elderly in particular need regular inspections by nurses?

[The Prime Minister]

My hon. Friend makes an important point. My view—we can debate this over the coming weeks—is that quite a lot of transparent information is available in the NHS, but it is not properly acted on. What we need from the chief inspector of hospitals is a sense that, as in schools, you consider the data, walk the wards, look at the quality of care with a professional team and then reach a judgment. People do not necessarily need all the data; they need a judgment. They need to know whether the hospital is okay, whether it is clean and whether it cares for people. That is what is required.

[John Healey (Wentworth and Dearne) (Lab)]

The report is clear that at the heart of this dreadful series of deaths was a failure to pursue the concerns and complaints of patients and their families vigorously and properly. The Prime Minister mentioned the Nursing and Midwifery Council. Does he know that unlike other professional regulators that body does not have the power to review, reopen or revise disciplinary decisions, even when there is fresh information or when it thinks it has got it wrong? Will he fix that flaw without delay?

[The Prime Minister]

The right hon. Gentleman makes an important point. That is why we asked the Law Commission, as I said in my statement, to consider sweeping away the council’s current rules and putting proper rules in their place.

[Sir Tony Baldry (Banbury) (Con)]

Is there not always a role for concerned community oversight? Will my right hon. Friend confirm that members of local health and wellbeing boards, members of HealthWatch and constituency members of Parliament should always be welcome visitors at their local hospitals?

[The Prime Minister]

My hon. Friend makes an important point. Members of scrutiny councils or any of the other bodies he mentioned should be able to walk the wards and have a look around, and that is vital. It is worth looking in detail at the report’s findings on scrutiny committees and the rest of it. It has some pretty good recommendations on how they need on occasion to sharpen their act.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

The executive summary of the Francis report states on page 45:

“There was an unacceptable delay in addressing the issue of shortage of skilled nursing staff.”

The CQC tells us that 17 hospitals are operating with dangerously low levels of nursing staff, resulting in poor care. Does the Prime Minister agree that it is now time to do something about levels of nursing and those ratios rather than leaving it to hospital boards or individual trust boards to decide them?

[The Prime Minister]

What the hon. Lady says about the importance of having clear benchmarks for what is acceptable is right. Over the past few years, the ratio of nurses to acute beds has improved. The paragraph to which she refers is interesting, as it states:

“There can be little doubt that the reason for the slow progress”

in dealing with the shortage of nurses

“and the slowness of the Board to inject the necessary funds…was the priority given to ensuring that the Trust books were in order for the”

foundation trust application. This is absolutely what Francis is saying: finances and targets were put ahead of patient care, so that is the big change that needs to take place.

[Lorely Burt (Solihull) (LD)]

I have here the executive summary to the report; it alone is 100 pages long. The Prime Minister has acted swiftly in appointing an inspector of hospitals and exacting the help of a number of specialists in the industry. Does he agree that we also need political will and scrutiny, and will he ensure that all the findings can have full cross-party parliamentary scrutiny to drive the changes and ensure that this will never happen again?

[The Prime Minister]

I hope that we can have not just scrutiny but a proper debate. I am sure that the Leader of the House—who played a key role in ensuring that the inquiry happened, for which I pay tribute to him—will be able to make time for a debate at some stage to consider the report in detail. It is absolutely enormous, and I have the three volumes of it here, but helpfully volume 2 goes through the key areas—the strategic health authorities, the primary care trust and what the regulator did—so that we can see an outline of the concerns about the lack of focus on patient care that flow through it so clearly.

[Grahame M. Morris (Easington) (Lab)]

I compliment the Prime Minister on his statement and my right hon. Friend the Leader of the Opposition on his response. I have not had a chance to go through the recommendations, but the Prime Minister mentioned the failings at trust board level. Will he agree to consider a recommendation from the health service section of my union, Unite, that a national intelligence unit linked to a national telephone hotline, which could be answerable to the chief inspector of hospitals under the CQC, could analyse the information coming in and identify where the problems were so that the chief inspector could take corrective action?

[The Prime Minister]

I will consider carefully what the hon. Gentleman says and I am sure that colleagues in the Department of Health will, too. My sense is that there is quite a lot of transparent information about mortality and morbidity rates, through Dr Foster and the rest of it. In too many cases, there has been an unwillingness to act and to act with enough clarity. We should focus on that, too.

[Paul Uppal (Wolverhampton South West) (Con)]

Of the three main failings highlighted in the Francis report, may I point out particularly to my right hon. Friend the third—that of the defensive culture in the NHS? Historically, clinical negligence cases continually highlight the fact that it is the recognition by hospitals that something has gone wrong that often blocks the issue being addressed. My right hon. Friend was absolutely correct to say that often families are not looking for financial remuneration but for a clear apology. May I impress on him and the Secretary of State my request that any future inspection regime should put that at the heart and the centre of any inspection?

[The Prime Minister]

My hon. Friend is right. That was why I mentioned in my statement the importance of trying to have a transparent and frank inspection system, such as that in schools, because that challenges complacency. If a report is received that says that a school is not up to standard, the community knows and the teachers know. Yes, it can be depressing for a while as it is sorted out, but it is much better than leaving problems to fester.

[Valerie Vaz (Walsall South) (Lab)]

I thank the Prime Minister for his statement and I am sure that he will agree that care cannot and should not be measured as a chargeable unit. May I draw his attention to a report by the Health Committee, published in June 2011, on complaints and litigation? How will he ensure that it is not just the front-line overstretched staff who must listen to patient voices but, more important, the senior management?

[The Prime Minister]

The hon. Lady is right. What strikes me as I meet hospital managers is when they say that at their board meetings they take patient care, clinical standards and safety standards first. That is the right thing to do because if a hospital is not safe, if it is not clean and if it is not caring for people, it is not doing its job—never mind whether it is meeting its targets or whether the numbers add up. That is absolutely at the heart of this question and that is one of the things that needs to change.

[Andrew George (St Ives) (LD)]

Crucially, the report identified the problem of inadequate staffing levels, which often lies at the heart of care problems in the NHS. However, only recommendation 163 of the 290 recommendations mentions any action on that. Will the Prime Minister ensure that the Government bring forward stronger guidance to benchmark registered nurse to patient ratios on hospital wards to address that fundamental basic problem?

[The Prime Minister]

I have said that I think there is a role for benchmarking and considering those issues, but we would be missing something if we thought that this was all about systems and figures. Quality of patient care, vocation and compassion must be at the heart of all this.

[Mr Ronnie Campbell (Blyth Valley) (Lab)]

The Prime Minister mentioned that Members of Parliament should be involved and I think the report mentioned it, too. When I first came to this place more than 20 years ago, I was stuck on a Committee called the parliamentary Select Committee for the ombudsman, who has the power of a High Court judge. We used to look at health service cases very regularly and bring the board members and chief executive in front of us. Why was the ombudsman not involved in this case?

[The Prime Minister]

The hon. Gentleman makes a good point about how things have changed, and perhaps we should look at that. As Members of Parliament take an interest in this, let me read what the report says on page 47. It is not good news, I am afraid:

“Local MPs received feedback and concerns about the Trust. However, these were largely just passed on to others without follow up or analysis of their cumulative implications. MPs are accountable to their electorate, but they are not necessarily experts in healthcare and are certainly not regulators. They might wish to consider how to increase their sensitivity with regard to the detection of local problems in healthcare.”

I join others in pleading guilty: sometimes we can be too defensive of our local institutions, and sometimes we need to dig deeper into particular issues and complaints. It is important, as I have said, that everyone considers the report, and that is one for all of us.

[Julian Smith (Skipton and Ripon) (Con)]

As part of the Government’s response to the report, may I urge the Prime Minister to look at the use of compromise agreements and gagging clauses when NHS managers leave the organisation?

[The Prime Minister]

I certainly think Health Ministers should look at what my hon. Friend says. One of the outcomes should be a discussion about what sort of contracts are appropriate for board members, both for their service in the NHS and if anything goes wrong.

[Sarah Champion (Rotherham) (Lab)]

I would like to speak from my recent experience of being a chief exec of a children’s hospice. The CQC is a very good organisation, but in my own area, each officer is responsible for up to 40 organisations, so the attention they can give each one is not that much. I was pleased that the leaders of both parties have said that they would support more funding for the CQC and support strengthening it.

All nurses have to register with the Nursing and Midwifery Council, which is a disciplinary body, but it can take up to 18 months for the disciplinary process to go through. The NMC is the investigator, the judge and the jury. I am supportive of the Royal College of Nursing, which genuinely seems to be trying to help and support its nursing staff to give better care. It is prioritising care but, again, it is under-resourced.

To try to end on a positive, I urge the Prime Minister to look at examples of good practice. Rotherham Doncaster and South Humber NHS Foundation Trust has an exemplary service of putting patients first. It has 12,000 members who select a governing body, and the board is responsible to that governing body. It seems that one of the problems with Mid Staffordshire was that the public were not right at the heart of the organisation.

[The Prime Minister]

I am sure the hon. Lady is right, and I agree that there are many examples of excellent practice, not only in health care and patient care but in responding to complaints and involving the local public; I see that across the country.

I have just read out what the report says about MPs, and this is what it says about the Royal College of Nursing:

“At Stafford, the RCN was ineffective both as a professional representative organisation and as a trade union. Little was done to uphold professional standards among nursing staff or to address concerns and problems being faced by its members.”

That is uncomfortable for the RCN to read, just as it is uncomfortable for us to read what it says about MPs, but it must be acted on. Likewise, the Care Quality Commission is improving, but more work needs to be done. Francis is pretty excoriating, and says on page 931 of volume 2:

“The CQC has an unhealthy culture, in which senior managers are more concerned about public image than delivery, which is hostile to internal and external criticism, and in which staff feel under pressure and unsupported.”

There is real work to be done in all these organisations to get this right.

[Charlotte Leslie (Bristol North West) (Con)]

“Systems so perfect that no one will need to be good.” That is T. S. Eliot, but it is a slightly pithier version of many recommendations in the Francis report. Does the Prime Minister agree that it is a tragedy that it has taken a tragedy to produce the report? My dad, as president of the British Orthopaedic Association in 2006, gave a lecture entitled “A New Professionalism” to reflect the alarm of clinicians at the changing culture in the 2000s, with a burgeoning management system and management priorities, tick boxes and targets taking precedence over clinical priorities. The Prime Minister has acknowledged that systems cannot replace professionalism, but will he listen to current professionals, who say that professionalism, which is what keeps the NHS afloat, is being eroded by things such as the working time directive?

[The Prime Minister]

My hon. Friend packed a lot into her question, but I agree that we need greater clinical leadership across the system. When we look at Francis carefully, what he is saying is that things such as targets and better financial management were important. We cannot have an organisation such as a hospital, which is a multi-million-pound organisation with thousands of staff, without proper management, proper finances and the rest of it. We have to make sure that there is proper clinical leadership, and that the focus is on care and quality, as her father said.

[Helen Jones (Warrington North) (Lab)]

Does the Prime Minister agree that what happened at Mid Staffs was not just a failure of regulation but a failure of basic humanity? Apart from a few whistleblowers, ward sisters, nurses, doctors and consultants must have seen what was happening on those wards day after day, and did nothing, although their professional duty obliged them to speak up for their patients. Will he therefore look at any issues that need to be addressed in the regulatory bodies to enable such failures among staff to be tackled, because people who do that should not be working in the NHS?

[The Prime Minister]

The hon. Lady speaks for everyone in saying that, which is why all these organisations, including the Nursing and Midwifery Council, the Royal College of Nursing and the General Medical Council have to think about taking action when behaviour is not appropriate or professional codes are seriously breached. People should be struck off and should not be able to work again.

[Chris Skidmore (Kingswood) (Con)]

Page 1312 of volume 2 of the report describes a meeting that took place on 14 May 2008 between the chair of the Healthcare Commission investigation, Sir Ian Kennedy, and Sir David Nicolson before the investigation reported. In that meeting, the report states that Sir David Nicholson said that a local campaign group against Mid Staffordshire had been in existence for some time. He added:

“Clearly patients needed to express their views but he hoped the Healthcare Commission would remain alive to something which was simply lobbying or a campaign as”

opposed

“to widespread concern.”

I find those comments from the head of the NHS at the time utterly unacceptable. Does my right hon. Friend agree, and will he investigate Sir David Nicholson’s comments?

[The Prime Minister]

My hon. Friend is right to raise that issue. We should be clear, however, that David Nicholson has apologised publicly and repeatedly for the failure of the strategic health authority of which he was in charge for some important months during this whole approach.

The report makes it clear that we should not try to seek individual scapegoats, and I believe that Sir Robert Francis said this morning that too often that is what happens after a report is published: find someone to take responsibility, fire them out the barrel of the gun, then the job is done. That is not the case: in my view, David Nicholson has a deep affection for our national health service, does a good job on the NHS Commissioning Board, and he has thoroughly apologised and recognised his responsibilities for what went wrong in Stafford. The trust board was overwhelmingly responsible. Clearly all the other organisations, including the strategic health authority, need to learn the lessons, and I think that Sir David Nicholson has done so.

[Mr David Anderson (Blaydon) (Lab)]

Speaking as a former care worker and president of Unison, which is the biggest trade union representing people in health and social care, I am convinced that members of that union and other health workers will welcome the commitment today on developing a culture of zero harm and quality care as the priority, and they will not be frightened of a new inspections regime. However, unless we have a system alongside that which makes sure they have time to do the job and spend time with patients, as well as the resources, both physical and financial, to make that work properly, unfortunately we will have this debate again about another situation in a decade’s time?

[The Prime Minister]

The hon. Gentleman makes an important point. Clearly, a health service facing growing demands requires growing resources. We are growing those resources, but they are limited, so at the same time we must meet the challenge of increasing productivity and cutting waste in our NHS, which we are doing. I do not believe that that should impact on patient care. Every public sector body has to look at how it can become more productive and efficient, but that must not be at the expense of patient care, and that is important for the future.

[Dr Sarah Wollaston (Totnes) (Con)]

I join the Prime Minister in paying tribute to all those NHS staff who go to work with great care, compassion and vocation, but will he look in particular at one staff group—health care assistants, who deliver much of the day-to-day personal care in the NHS, yet have relatively poor access to training and development? They have no regulatory body, so if individuals are not acting with care and compassion, they can move on to another institution, and perhaps work unprofessionally there too.

[The Prime Minister]

My hon. Friend speaks with great knowledge about the NHS, with her long years of experience as a GP. On health care assistants, the Government have said that Robert Francis’s idea of proper training standards needs to be looked at. I tend to agree with that. The issue of registration is more complicated and potentially more bureaucratic. We will certainly look at it, but I think that needs some close examination.

[Nic Dakin (Scunthorpe) (Lab)]

Hospitals do not exist in isolation. Will Professor Sir Bruce Keogh’s immediate investigation into the care in hospitals with the highest mortality rates look at the role of primary, adult and community care in relation to those mortality rates, and the relationship between them?

[The Prime Minister]

Yes, I am sure he will do that. These things do not exist in isolation, but I hope we can do such investigations in a more frank way, because we do not want to fall into the culture of complacency or, as Francis says, into seeing the responsibility for quality as lying somewhere else.

[Henry Smith (Crawley) (Con)]

With increasing local clinician influence and with the increasing influence of local councillors and local patients over the commissioning of health services, what is my right hon. Friend’s assessment of how we can increase that culture of care in our local NHS settings?

[The Prime Minister]

There is everything that Francis says in his report about the importance of quality and a culture change. Under the new dispensation in the NHS and with GPs having a more leading role, I hope they will be very inquiring about the standards of care that their patients get when they go to hospital. In the past there was too much division between primary and secondary care. I hope that we are bringing them closer together.

[Steve McCabe (Birmingham, Selly Oak) (Lab)]

I thank the Prime Minister for his statement. Reports received by trust directors, governors and others are packed full of data, but in order for people to make sense of that information so that aggregate data in big organisations do not serve to mask problems, rather than shed light on them, do not trusts also have a duty to help people analyse those data?

[The Prime Minister]

Yes, the hon. Gentleman is entirely right. That is why the role of chief inspector of hospitals could be so important. There is no shortage of data, as the hon. Gentleman says. Francis says:

“There . . . are a plethora of agencies, scrutiny groups, commissioners, regulators and professional bodies, all of whom might have been expected by patients and the public to detect and do something effective”,

but it did not occur. We need to make sure that there is one single body that has the power, the ability and the judgment to say good practice/bad practice.

[Sarah Newton (Truro and Falmouth) (Con)]

Will the Prime Minister join me in praising the brave staff in the community and in the hospitals in Cornwall who have been speaking out about poor quality patient care, and reassure me and them that the Care Quality Commission will have the resources to make sure that quality care will be delivered in hospitals, in communities and in social care settings throughout the UK?

[The Prime Minister]

I certainly join my hon. Friend in paying tribute to health care professionals in Cornwall. I am particularly grateful to them, as they delivered my daughter two and a half years ago. I am ever grateful for the brilliant service that they performed for me, and it was a very caring environment too. The CQC has the resources it needs. It is a new organisation and has faced many challenges. A big reform of it is under way. Being asked to scrutinise everything from the dentist’s waiting room to the largest hospital in the land is challenging, and we need to work on the organisation and make sure that it can deliver what we need.

[Mark Durkan (Foyle) (SDLP)]

I commend the Prime Minister for his words and work on the issue. In the culture that he seeks, it is important that hospital chaplains and chaplaincy networks know what observer standing they might have and how and where they should channel any pastoral concerns or compliments that they have. On his important proposal for the chief inspector of hospitals, can the Prime Minister tell us whether that telling new faculty would be available to the devolved hospital services as well?

[The Prime Minister]

The hon. Gentleman makes an important point about the role of chaplains. If those who are closely involved with hospitals see anything going wrong, they should feel a duty to speak out. That could be groups of hospital friends or chaplains. With reference to the devolved Administrations, I expect there are similar issues in terms of culture, which Francis examines, and in terms of complacency and putting patient care above targets, and I am sure that they, too, will want to learn the lessons from the report.

[Jackie Doyle-Price (Thurrock) (Con)]

To tackle the culture of complacency that my right hon. Friend spoke about, will he take this opportunity to give a clear and unequivocal message to the board members of foundation trusts throughout the country that they are accountable for the performance of their hospitals and that if there is persistent poor care, the buck stops with them?

[The Prime Minister]

I am very happy to do that and to clarify that they are responsible for standards of care, clinical safety and the cleanliness of hospitals, as well as for meeting financial and other targets, and the buck does stop with them.

[Bob Blackman (Harrow East) (Con)]

Thousands of people outside the Chamber will be worried about what is going on in their own local hospital: could the same things be going on there? Part of that problem would be the willingness of NHS staff to make the best of a bad job. Does my right hon. Friend agree that as part of the cultural change, it is important that staff say, “We will not put up with poor standards,” and that as part and parcel of that, board management specifically must enforce the highest standards of patient care?

[The Prime Minister]

My hon. Friend makes an important point. There is lots of fantastic practice in our NHS right across the country, but there are problems. That is why I am so passionate about the friends and family test. I saw this in the hospital in Salford, where people are so proud of the fact that they ask the staff, the patients, everybody, “Would you have your friends and family treated in this hospital?” They put it up on the front of the door of the hospital and it is on every single ward. Of course there is no one magic bullet answer to the whole problem, but if there is a problem in a hospital or on a specific ward, it would be picked up quite quickly if there was that sort of very open and publicly available test.

[Mr Marcus Jones (Nuneaton) (Con)]

Can my right hon. Friend assure me that in implementing the recommendations of the report, he will seek to break down the culture of some in the NHS who close ranks to close down complaints, rather than dealing with them in a proper, open and transparent fashion, so that they and the rest of the NHS can learn from any failure that has taken place?

[The Prime Minister]

My hon. Friend is absolutely right. There has been a sense sometimes that when problems occur, there can be a closing of ranks. This clearly happened at Stafford. It is not acceptable and I am sure all hospital trusts will want to learn the lessons from that.

[Penny Mordaunt (Portsmouth North) (Con)]

I welcome the greater focus on care as well as finance in assessing performance that the Prime Minister has outlined. Does he agree that this will be welcomed by clinicians throughout the country, who have fantastic ideas about improving care and getting more from their budgets, but currently cannot get the management to listen to them?

[The Prime Minister]

My hon. Friend makes an important point. One of the aims of the reforms is to give greater clinical leadership. With greater clinical leadership, particularly in the commissioning groups, which are the ones tasking the hospitals, there is a much greater chance that what she talks about will happen.

[Andrew Bridgen (North West Leicestershire) (Con)]

A legal duty of candour would have ensured that the serious and systemic failures at Mid Staffordshire hospital came to light far earlier and ultimately would have saved many lives. On that topic, what reassurance can my right hon. Friend give to my constituents, Frank and Janet Robinson, who tragically and needlessly lost their only son, John Moore-Robinson, at that hospital?

[The Prime Minister]

It is right for my hon. Friend to speak out for the victims and to raise a specific case. The Health Ministers here with me today will look carefully at the issue of a duty of candour to see whether that would make a difference in the way that we want for this hospital and for others as well.

[John Pugh (Southport) (LD)]

One of the clear causes of the tragedy, according to Francis, is a

“failure to appreciate…the…disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.”

What lessons does the Prime Minister draw from this about NHS reorganisations?

[The Prime Minister]

The hon. Gentleman makes an important point. What Francis says is:

“A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.”

He also says, though, that he thinks the changes required

“can largely be implemented within the system that has now been created by the new reforms”,

so I hope we can allow the changes that Francis is talking about to be made within the proposed structure. Everyone—all parties, all Governments—should learn from this report. I hope we can then allow the structure to bed down and to deliver the changes that everybody wants.

[Andrew Jones (Harrogate and Knaresborough) (Con)]

My right hon. Friend’s statement was hard listening for those of us who care about the NHS and respect and value the work of the vast majority of those within it. Changing a culture of targets and a focus on process is an enormous task. Does he agree that one of the ways to improve care is to unlock the innate compassion of those who work in our NHS and our caring professions?

[The Prime Minister]

My hon. Friend is absolutely right. I remember going to the Royal College of Nursing conference at Harrogate in his constituency. Ministers are not saying this to nurses; nurses are saying to Ministers that, as they told me, they want to have this sense of compassion and vocation at the heart of their training. Nurses themselves think that some of the training systems have got too far into the classroom and too far away from the hospital ward, and they are the ones asking us to get that right. It is good to see Health Ministers nodding in agreement as I say that.

[Iain Stewart (Milton Keynes South) (Con)]

I welcome the proposals for the CQC to make public judgments about the quality of care, but those judgments must be in a form that is accessible and understandable to the public. Will my right hon. Friend take care to ensure that they are not too general, so that if a specific problem in our wards is rightly identified, it does not cloud the otherwise excellent care that the hospital might be providing?

[The Prime Minister]

Yes, my hon. Friend makes a very important point. If we are going to challenge complacency and have more frankness and openness about potential failure, we also need to have the more grown-up attitude that failure in one part of one hospital does not necessarily mean that the other parts are failing.

[Gavin Barwell (Croydon Central) (Con)]

Like the Prime Minister, I have a personal debt to the NHS: it saved my life when I had cancer as a child. As a constituency MP, I regularly deal with concerns about the quality of care at Croydon University hospital. With that in mind, I warmly welcome the Prime Minister’s statement, particularly his focus on the key measure of how well a hospital is serving its community—that is, the proportion of people working there who would be happy for a family member to be treated there.

[The Prime Minister]

I am grateful for what my hon. Friend says. I am not claiming that the friends and family test is the only change that needs to happen in the NHS, but if we are looking for something that will provide a pretty effective traffic light, then having that test, and having its results plastered over every ward in every hospital in the country, will be a pretty good start. The chilling statistic that only a quarter of staff members at Stafford would have been happy for their relatives to be treated in the hospital that they themselves worked in should have been the moment—publicised on every ward, in the local newspaper, and on the door of the hospital—when everyone said, “Hold on a minute: we’ve got to take some action here.”

[Andrew Percy (Brigg and Goole) (Con)]

My right hon. Friend compared the new inspection regime to that in schools. However, is not the challenge that whereas in schools service users—pupils and parents—are all too willing to speak up, in hospitals service users often feel that they are a burden to the service or are voiceless? Will he therefore ensure that any new inspection regime measures what protocols are in place specifically to monitor the care of patients who have nobody to speak for them?

[The Prime Minister]

My hon. Friend, who has great experience of being at the sharp end of inspections in schools, speaks with great knowledge and expertise. Because patients in hospitals often do not want to say anything bad about the hospital while they are in it, it is important for them that the friends and family test is carried out once they get home. I have listened carefully to his point about carers and others.

[Mr Speaker]

I am most grateful to the Prime Minister and to colleagues. I think that everything has now been said and, indeed, that it has been said by everybody.