Accountability and Transparency in the NHS
(11 years, 9 months ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
Charlotte Leslie (Bristol North West) (Con)
I beg to move,
That this House believes that in the wake of the Francis Report it is clear that accountability and transparency are of paramount importance to patient safety and trust in the NHS; and further believes that across the NHS individuals found to have breached those principles should face the appropriate consequences.
I would first like to thank the Backbench Business Committee for granting the debate; I realise that it did not have much time left to allocate in the Session and so am particularly grateful to its members for giving the House the opportunity to debate this timely and important issue. I would also like to thank all the Members who supported the motion, particularly my hon. Friends the Members for North East Cambridgeshire (Stephen Barclay), for Bracknell (Dr Lee), for Totnes (Dr Wollaston) and for Southport (John Pugh) and the hon. Member for Vauxhall (Kate Hoey). I must also thank all those who have contacted me, including the Patients First group. I am sorry if we are unable in the time available to do justice to all the information we have been given, but rest assured that this is the beginning of the scrutiny, not the end.
This debate is neither about playing party politics, nor about only the future of one man, David Nicholson; it is about transparency, and about a deadly cover-up in our NHS and how we can ensure that never happens again. As one concerned former nurse wrote to me:
“Please don’t let me read those meaningless words, Lessons Have Been Learned”.
It sometimes seems that politicians can dodge taking responsibility so long as they say quickly enough that “lessons have been learned”, but learning lessons is not the same as simply uttering a phrase. The truth must be revealed, and consequences faced, if accountability and transparency are to be anything more than just words.
Let me make it clear that refusing to play party politics is not the same as letting people evade responsibility and that statesmanship is not the same as letting people off the hook. We owe it to those outside this Chamber. We owe it first and foremost to those patients who were, in some instances, killed in our hospitals, and we owe it to their grieving families, for whom no amount of politicians saying that “lessons have been learned” can bring back their mum, dad, sister, brother, child or friend.
After patients and their families, we also owe it to those dedicated doctors and nurses who were struggling to raise the alarm against a system that systematically suppressed their concerns. Many of them retired early in protest at what they were being asked to do, and some of them tried whistleblowing and were met not with thanks from the authorities, but intimidation and gagging. We will hear about some of that later.
I must congratulate the Prime Minister and the Secretary of State for Health on their appointment of Don Berwick to ensure that the basic requirement of “Do no harm” is embedded in health care. Don Berwick, an adviser to President Obama, is an internationally renowned authority on health care. The Institute for Healthcare Improvement, which he co-founded and chaired for 21 years, is a world-leading centre of medical improvements based on proven success. I am delighted that the Prime Minister has put him right at the heart of improving our health care system.
The tragedy, however, is that Don Berwick’s wisdom and recommendations are not new; they have been delivered before. They were delivered to the previous Government in no uncertain terms back in 2008, when David Nicholson was chief executive of the NHS. Instead of implementing them urgently, the previous Government were uncomfortable with what they revealed about their NHS, so they decided to suppress those truths. They suppressed a report by Don Berwick and his institute along with two other damning reports by international experts—RAND and Joint Commission International—that contained burning recommendations to be implemented with all urgency.
Alan Johnson (Kingston upon Hull West and Hessle) (Lab)
If the hon. Lady turns to page 1,281 of volume 2 of the Francis report, she will see that, far from the reports being suppressed, every one of them was seen by Robert Francis. He states:
“As part of his work leading the working group, Sir Liam”—
Sir Liam Donaldson, the former chief medical officer—
“commissioned reports from three highly respected US-based organisations”.
Francis concludes that section by stating:
“Indeed it is clear that the NSR”—
the next stage review, the Darzi review—
“sought to address many of the concerns raised in these reports.”
Mr Deputy Speaker (Mr Lindsay Hoyle)
Order. Before the hon. Lady responds—[Interruption.] I am sorry, but does the Opposition Whip have something to say?
Mr Deputy Speaker
Thank goodness for that.
We need short and concise interventions, because many Members wish to speak and I do not want to have to reduce the time limit further, but that is what will happen if we are not careful.
Charlotte Leslie
I congratulate the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) on seeking to defend his Government’s record. I will address his point fully later in my speech.
Don Berwick’s report was commissioned by Ministers, led by Lord Darzi and with the support of David Nicholson, to celebrate the 60th anniversary of the NHS. It states:
“The NHS has developed a widespread culture more of fear and compliance… It’s not uncommon for managers and clinicians to hit the target and miss the point”.
It highlighted the inadequacy of quality-control mechanisms in the NHS, stating that the priorities that are emphasised by these assessments are
“seen as being motivated by political rather than health concerns”.
It also highlighted the anger felt by many conscientious medics at Government changes to their employment and at being pressurised to put targets ahead of patients:
“The GP and consultant contracts are de-professionalising... Far too many managers and policy leaders in the NHS are incompetent, unethical, or worse.”
The report warns that
“this… must be alleviated if improvement is to move forward more rapidly over the next five to ten years.”
But those warnings were ignored, and we know that the improvements never happened. The report’s conclusion on a decade of health care reform is that
“the sort of aim implied by Lord Darzi’s vision…is not likely to be realised by the 1998-2008 methods.”
Don Berwick’s report was not alone; let me reveal what the other two reports said. They referred to
“the pervasive culture of fear in the NHS and certain elements of the Department for Health”
and stated:
“The Department of Health’s current quality oversight mechanisms have certain significant flaws”.
Perhaps the most damning indictment of all is that the politicians are responsible:
“This culture appears to be embedded in and expanded upon by the new regulatory legislation now in the House of Commons.”
Instead of being acted on with urgency, this was all buried. We know of the existence of Don Berwick’s report and the other reports only because a medic was so concerned that Berwick’s warnings and solutions had been buried that he tipped off a think-tank, Policy Exchange, which had to use a freedom of information request to bring them to public light in 2010, two years later. They were not even available to the Health Committee.
Let us get one thing clear. The NHS is a huge, monolithic organisation with an exceptionally difficult and, some might say, almost impossible task. In reality, things will go wrong, sometimes very wrong. The crime is not so much that things were going wrong, bad as that is, but that instead of immediately focusing on tackling it, the priority was to cover up an awful truth that was uncomfortable for Ministers and chief executives. All too often, Dispatch Box appearance mattered more than the reality of patients’ lives, leaving whistleblowers and patient groups such as Julie Bailey’s, which was disgracefully dismissed by David Nicholson as a “lobby group”, screaming into a vacuum, often at great personal cost. The crime is the smothering of the truth which costs lives—the deadly silence.
What was the cost of suppressing Don Berwick’s urgent prescription for the NHS? The clinical director of NHS Scotland recently suggested that in following Don Berwick’s recommendations it has experienced an estimated 8,500 fewer deaths since January 2008. We may well ask what was the cost in lives for our NHS of the previous Government’s decision to bury the truth. Across the 14 trusts now being investigated as well as Mid Staffs, there were 2,800 excess deaths between the time that the reports by Don Berwick and others were presented to Ministers and their final revelation in 2010. If the previous Government had been urgently implementing Don Berwick’s recommendations for those five years, who knows how many of those lives might have been saved?
How was this allowed to happen? I have put in freedom of information requests asking what meetings took place to discuss the reports and who was present. Although David Nicholson was working closely with Lord Darzi on the next stage review, he said in front of the Health Committee that, incredibly, he
“knew nothing about the reports”.
That is the Select Committee, so we must take him at his word. The question that then remains is who did read and suppress these vital reports. Was it Ministers? Was it officials? If officials, how was this allowed to happen? If the Department of Health is to move away from a culture of cover-up, I expect a full and accurate response to my request to know who was responsible, and I ask the Secretary of State to assist me in that.
Former Labour Ministers will complacently say, as they already have, that these reports fed into Lord Darzi’s next stage review and informed the report, “High Quality Care For All”. I ask the House whether a document that starts with the then Secretary of State, the right hon. Member for Kingston upon Hull West and Hessle, beamingly saying
“On its 60th anniversary the NHS is in good health”
reflects the content of the reports that we have just heard about. It certainly does not. Indeed, while the Department of Health claims that it “drew heavily” on the three reports in putting together “High Quality Care For All”, a source close to the authorship of those reports said that they found that claim to be “disingenuous at best”. David Flory, the deputy chief executive of the NHS, later told the Francis inquiry that he at least had some responsibility for what happened to the reports, as he had read them, but insisted that they were “caricatures”. That would help to explain why they were not acted on, but it makes the Department of Health’s insistence that it “drew heavily on them” rather odd.
Further indication that the documents were not acted on is the fact that they raise issues almost identical to those highlighted five years later in the Francis report. If Don Berwick’s warnings had been acted on five years ago, there would be no need to ask him to come back now to step in to sort things out and implement his recommendations.
Alan Johnson
I wonder if the hon. Lady is coming to the point that Francis, a QC, in the course of a two-year public inquiry that produced two volumes, looked at all these documents and said that many of the issues within them had obviously been acted on. During a two-year review, Francis drew completely the opposite conclusions to those that the hon. Lady is drawing.
Charlotte Leslie
I find various elements of the Francis report rather strange, not least that the current chief executive, David Nicholson, is minuted as dismissing the activities of Julie Bailey as merely “lobbying” as opposed to expressing widespread concern about patients, and that this minute was dismissed in evidence, with David Nicholson saying that he could not recall ever having said something like that and thought that he could not possibly have done so. The fact that we are asking Don Berwick back five years after he initially gave his recommendations to Labour Members speaks far louder than a few sentences in the Francis inquiry with which people may beg to differ. However, I will not be distracted by the right hon. Gentleman but go back to my speech.
I will now reveal how crucial mortality data, which Harvard university says should have triggered an “aggressive investigation”, was ignored, and, when it became too prevalent to ignore, was, like so many whistleblowers, discredited. David Nicholson said in response to the Health Committee that he did not know that the Dr Foster mortality data existed until he became chief executive of the NHS in 2006. He also said he did not know there was a problem with the mortality rate at Mid Staffs until 2009. Again, that is the Select Committee, so we must take him at his word. It is odd, however, as we know that David Nicholson attended a presentation in Birmingham in 2004 at which the Dr Foster ethics team gave a presentation on the real-time monitoring tools that it was using to show mortality alerts and the hospital standardised mortality rates.
There are also records of Dr Foster telephoning chief executives of health authorities in 2005 to tell them about the mortality alerts. David Nicholson is named on that list of those getting calls, as chief executive of Birmingham and The Black Country strategic health authority. Between 2005 and 2009, there were 8,000 log- ons to the Dr Foster site from members of staff at West Midlands SHA. We even have a press release from Dr Foster from as early as 2005 congratulating Walsall hospital in, yes, West Midlands SHA, for its improvement in relation to this very same mortality data. The Dr Foster data were published in the “Good Hospital Guide” from 2000 onwards and in national newspapers from 2001 onwards. It is therefore incredible that that was not known about by someone such as David Nicholson, or indeed Ministers and others.
By May 2007, however, people were aware of the data. The then chief executive of West Midlands SHA, Cynthia Bower—Birmingham and West Midlands SHAs play a strangely prominent role in this story—received alerts that there were issues with high mortality rates in the health authority. But instead of taking urgent action to find out what was going wrong, she commissioned the university of, yes, Birmingham to write a report to discredit the data, at a cost of £120,000 to the taxpayer. Stunningly, the British Medical Journal—the journal of the union, the British Medical Association—is on record as allowing the author of the Birmingham report to publish his findings in the BMJ four months before official publication to coincide with the publication of the Healthcare Commission report, in order to discredit the data. A fact little publicised by Ministers and chief executives is that the Birmingham report was severely flawed. Harvard later did a study and found that the data were so watertight that on receiving the alerts,
“it would have been completely irresponsible not to aggressively investigate further.”
Yet again, the reaction to bad news was to bury it, or expensively discredit it, rather than act.
This went all the way to Government. I have seen an internal briefing for the right hon. Member for Exeter (Mr Bradshaw), then a Health Minister, in which officials brief him to stress that the mortality data were not known about until 2007. However, in that very same briefing it is revealed that they know this to be untrue, because they make specific reference to the data being published as far back as 2001 in the “Good Hospital Guide”.
This is only a drop in the ocean of a catalogue of attempts to cover up the awful truth. It is utterly wrong that no one should be held to account for such negligence in their duty to protect patients. The “Code of Conduct for NHS Managers” says that managers must
“make the care and safety of patients my first concern and act to protect them from risk”
and
“accept responsibility for my own work and the proper performance of the people I manage”.
If talk of accountability in this Chamber is to have any credibility at all, especially for those individuals who buried loved ones while Government, departmental and NHS individuals buried the truth, actions must have consequences. To scapegoat is not the same as ensuring that those responsible are held to fair account. Those who do not have a voice—the patients and their families—deserve accountability and more than just words.
Don Berwick is right. We must convert our anger over what has happened into action. That is what Julie Bailey did, without whom this debate and a push for a culture change in the NHS would probably not be happening. It is what my right hon. Friend the Secretary of State did this morning in banning gagging orders. Will he confirm whether that measure will be retrospective? I believe that this Government have secured a good base from which to put clinicians—not managers and politicians —at the heart of setting the priorities of our NHS.
Rosie Cooper (West Lancashire) (Lab)
Although I appreciate and endorse everything the hon. Lady has said about accountability and the managerial code of conduct, who does she think should enforce the code and ensure that it is being followed? Beyond the board and the chief executive, how will organisations be policed?
Charlotte Leslie
I believe that Francis is right: a regulatory organisation for managers is needed.
We must be brave. There must be a cultural clean-out and a new start, including a new head of the NHS Commissioning Board, who does not appoint a deputy who faces possible investigation for gagging whistleblowers —unless, of course, Dame Barbara Hakin deregisters from the General Medical Council beforehand—and who does not seem systematically to appoint those who had contact with West Midlands health authority or Birmingham, but has the trust and faith of doctors, nurses and patients, and epitomises this new era of transparency and accountability.
I believe that with Don Berwick’s help—albeit about five years later than it could have happened—we are now beginning to step in the right direction to ensure that never again can the NHS be too loved to be scrutinised or too holy to be questioned, and that this debate will go some way to breaking what has been, for more than a decade, a literally deadly silence.
Andy Burnham (Leigh) (Lab)
What happened at Stafford hospital was a betrayal of everything the NHS should stand for. We will face up to what went wrong and I will say more about that today. I repeat the apology to the families of people who suffered appalling abuse and neglect.
We must do more. People affected will be watching this debate and rightly wondering what it will achieve. They want to know what is going to change and when. The time has come for cross-party agreement on a way forward, and that is my hope for this debate. There must be more accountability and transparency, and that is why we support the motion.
We also support the Secretary of State’s ban on gagging clauses. It builds on statements made by the previous Government, which in turn were a response to previous scandals. That provides a crucial context for today’s debate.
In 1997 Labour inherited the job of responding to the Bristol heart scandal and the Harold Shipman murders. A series of major policy developments followed on patient safety, inspection and regulation. We passed the Public Interest Disclosure Act 1998, protecting whistleblowers. We published data that had never before seen the light of day on survival rates from heart and stroke care, and 1999 saw the first ever independent regulation of hospitals and care standards.
In 2001 we established the National Patient Safety Agency, which has sadly since been abolished and, in 2006, on the back of the public inquiry by Dame Janet Smith, the General Medical Council and the Nursing and Midwifery Council were reformed to end the professional closed shop. The truth is, however, that well-meaning as those steps were, there were places where the underlying culture of the NHS did not change and that is an important lesson for us all. When we make statements in this place and pass policies, we assume that everything changes on the ground, but it does not.
The previous Government made similar statements to that made by the Secretary of State today, yet the use of agreements persisted. Why was that? The answer is that there is a culture in the NHS—a tendency to pull down the shutters and push people and complaints away when things go wrong—that is more ingrained than we might think.
Stephen Barclay (North East Cambridgeshire) (Con)
On the subject of pulling down the shutters, will the right hon. Gentleman confirm that the world-leading expert, Professor Sir Brian Jarman, wrote to him in March 2010 listing concerns about 25 hospitals with high mortality rates, and that both the right hon. Gentleman and the Care Quality Commission took no action?
Andy Burnham
No, I will not. I was copied into an e-mail by Professor Brian Jarman in mid-March 2010 and, having asked the CQC to investigate what he had said, I wrote back to him on 31 March 2010. That was literally my last duty as Secretary of State for Health after the general election was called. I was not able to respond further to inquiries. It is important to provide some balance to the hon. Gentleman’s comments.
Changing the culture in the NHS requires vigilance and persistence. As Robert Francis says, we have all been too remote from the front line.
The foundation trust reform was a serious attempt to end the top-down culture in the NHS, bringing more accountability and transparency. If we look back, however, we will see that, when the centre stood back, there were places where an unhealthy local culture became even more firmly established. In some trusts a national top-down style was replaced with a local top-down, bullying style, which can be even worse. I can remember the shock I felt on reading the first Francis report’s finding that, on receiving FT status, one of the first things that the Mid Staffs board did was to resolve to hold more meetings in private. That was an audacious breach of the spirit of the legislation passed by this House.
Mr William Cash (Stone) (Con)
The shadow Secretary of State and I have been engaged on this issue for a very long time. Will he admit that it was totally unacceptable for him and his predecessor to refuse to have a public inquiry, which I demanded relentlessly, under the Inquiries Act 2005? Does he agree that it was wrong to give foundation trust status when it clearly should not have been given, and does he accept that I raised the issue of gagging orders and confidentiality in a health debate in 2009, not 2010?
Andy Burnham
Foundation trust status was not a matter for Ministers. It was a job for Monitor, so it has to answer that concern. The hon. Gentleman is right that we had many discussions about a public inquiry. He will remember that in July 2009, two months after I was appointed Secretary of State, I brought in Robert Francis QC to conduct an independent inquiry into what happened. I did not order a full public inquiry and I will explain the reason why later.
The difficult thing about the fact that the Mid Staffs board was holding more meetings in private was that we in this House had passed up our powers to intervene to stop it. That is another lesson we must learn: that the FT reform was naive in thinking that local autonomy would lead to improvement in all cases. In a national health service, there are areas where national direction is needed, and when things go wrong, there must be immediate powers of intervention, which, on my arrival in the Department in June 2009, I found I did not have. Foundation trust policy needs to be reviewed and adjusted to mitigate those dangers, including through a reconsideration of the power to de-authorise a failing foundation trust, which was recommended by the first Francis report, but repealed by the Health and Social Care Act 2012.
We also need to consider targets and how they are used. Targets helped to deliver the lowest waiting times in history and that must not be forgotten. However, in places, they reinforced negative management practices. In focusing on only part of the patient experience, there was not sufficient focus on the overall patient experience and the whole person—a particular problem when it comes to caring for very elderly people whose needs are a blur of the physical, mental and social.
Robert Francis is right to call for a fundamental rethink of the way in which we care for older people, and I have put his recommendations at the heart of Labour’s policy review. However, there are more immediate things that we can do and I will spend the rest of my time on five substantive points.
Mr Bernard Jenkin (Harwich and North Essex) (Con)
Will the right hon. Gentleman give way?
Andy Burnham
I will make some progress.
The first point is about implementation. I would like to take this opportunity to thank Robert Francis for his work on this inquiry and the previous inquiry, which I commissioned. Robert Francis has taken the best part of three years to consider these matters in detail and has made 290 measured and proportionate recommendations. The people affected by these events should reasonably be able to expect that they will be implemented without delay.
I make a genuine offer today to the Secretary of State. If he brings forward proposals, he will have our support in speeding up implementation. I say that because I am becoming concerned about the timetable for the Government’s response. On 6 February, the Prime Minister told this House:
“We will study every one of the 290 recommendations in today’s report and we will respond in detail next month”.—[Official Report, 6 February 2013; Vol. 558, c. 281.]
Since then, the Government have commissioned a review of the recommendations, which is due to report in July. Although, like the hon. Member for Bristol North West (Charlotte Leslie), I have great respect for Don Berwick, I am surprised that the response to a long public inquiry is to set up another review. Is it still the Government’s intention to respond in detail this month? Although I welcome this debate, it is narrow in focus, so will the Secretary of State consider having a full day’s debate in Government time? Instead of more delays and reviews, we need action and a timetable for implementation. I would be grateful if the Secretary of State would respond to my offer today.
Andy Burnham
No, I am making some progress.
The second area where more transparency and accountability is urgently needed is on staffing levels. If the Government are not yet able to commit to all the recommendations, I ask them to expedite their response to Robert Francis’s important recommendation on patient-staff ratios. The board of Mid Staffs embarked on a dangerous programme of staff cuts, and yet public and staff representatives had no outside guidance to challenge it. The chief nursing officer said yesterday that staffing should be a local decision. Surely the lesson of Mid Staffs is that there is a need for much clearer national standards and guidelines, as suggested by the Francis report?
This week, the Care Quality Commission reported that one in 10 hospitals in England and, worse, one in five learning disability and mental health services do not have adequate staffing levels. Surely that should ring alarm bells in the Department as it suggests that parts of the NHS are already forgetting the lessons of the recent past.
The third area on which we need a clear statement from the Government today is the accountability and transparency of all organisations providing NHS services. Under “any qualified provider”, the Government are persisting with their assumption that all NHS contracts should be open to full competitive tender. Despite a promise to rewrite the section 75 regulations that are being made under the 2012 Act, my reading of the rewritten regulations is that regulation 5 will not let doctors decide, but will in effect force clinical commissioning groups to open tender for contracts. That raises the prospect that there will be a significant increase in the coming years in the number of private and voluntary sector organisations providing NHS services.
If we believe in transparency and accountability, surely they have to apply across the board and on a level playing field. The problem is that private and voluntary sector organisations are not subject to the same strictures on freedom of information and whistleblowing. If action is not taken, we face the prospect of a serious reduction in transparency and accountability. Our attempts to find out new information under FOI requests on providers selected under AQP have hit the brick wall of “commercial confidentiality”. I say to the Secretary of State that that is not good enough. Accountability and transparency must always be paramount, as the motion says.
Will the Secretary of State require all providers of NHS services to adhere to FOI principles, and will he ensure that whistleblowers working in organisations that provide NHS services have the legal protections that he has announced today? I draw the attention of the Secretary of State to an early-day motion tabled by my hon. Friend the Member for Easington (Grahame M. Morris) on this subject, which has attracted the support of 109 Members.
The fourth area on which the people of Stafford need openness and transparency is the future of their hospital. They will understandably be worried about the recent recommendation from Monitor that the trust should be placed into administration. People will recall, as I said to the hon. Member for Stone (Mr Cash) a moment ago, that I commissioned Robert Francis in July 2009 to conduct an independent inquiry. I know that many people, including the hon. Gentleman, wanted me to go further and order a full public inquiry, but I stopped short because I was concerned about the effect that that would have on the hospital and its viability.
All of us in this House now have a responsibility to help this hospital heal. After all that they have been through, it would be highly unfair to the people of Stafford if, at the end of all this, they were to lose their hospital or their A and E. They deserve a safe and sustainable hospital and I hope that the Secretary of State’s response to Monitor’s recommendation will map out a way to achieve that.
Andy Burnham
I will give way one final time—to the hon. Member for Cannock Chase (Mr Burley).
Andy Burnham
No, that is not what I am saying. I commissioned a second-stage—[Interruption.] The hon. Member for Cannock Chase should listen to the answer. I commissioned a second-stage review before the general election after Robert Francis delivered his first-stage review to me. I simply said that I took that judgment because I was worried that if there was ongoing uncertainty about the hospital for a long period, it may affect its viability. I have seen the statements from Monitor that there is a concern about the future viability of the hospital. I am making an appeal, on a cross-party basis, to say that all of us owe the people of Stafford a safe and sustainable hospital. I hope that the hon. Gentleman would agree with that sentiment.
My fifth and final point concerns staff morale.
Andy Burnham
No, I will not.
This is a difficult time in the NHS. The chief executive of the NHS has described it as a period of “maximum risk” as it struggles with the simultaneous challenges of efficiency and reorganisation. Morale in the NHS is low and one thing is clear: patient care will not improve if it stays like that.
The Secretary of State is right to speak out for patients when the NHS falls short, and he should always do that. However, statements should be fair and should recognise the good that the vast majority of staff do, day in, day out, and the pressure that they are under, which is not of their own making. That balance has been missing from recent Government statements. I say to the Secretary of State that hospitals and NHS staff are not coasting—far from it. They are working flat out, with some coping better than others with the pressure that they are under.
Politicians need to do more than just point out the failings of hospitals and NHS staff. We all need to support them with proper staffing levels on the wards. We all need to support them to speak out, wherever they work. We all need to stop the reorganisations that distract them from patient care. Those are the lessons of Stafford. Today, let us all resolve to face up to them.
The Secretary of State for Health (Mr Jeremy Hunt)
I congratulate my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing this important and timely debate.
We should start by remembering why we are having this debate. Truly shameful things happened at Stafford hospital. Patients were left unwashed for days, sometimes in sheets soiled with urine and excrement. Relatives had to take bed sheets home to wash them because the hospital would not. Patients with dementia went hungry with their meals sitting right in front of them, because no one realised or cared that they were unable to feed themselves. If we are to prevent that from happening again, accountability for what happened is vital. I will talk plainly about that, including about the role of Sir David Nicholson.
At the outset, let me reiterate that the NHS is one of our most cherished institutions. We can be proud that for 65 years it has ensured that everyone is entitled to treatment, regardless of their background or income. We can be proud of the excellent treatment and care that is the hallmark of most parts of the NHS. Most of all, we can be proud of the front-line doctors, nurses and health care assistants who look after 3 million people every week, with dedication, commitment and compassion.
If we love the NHS, we must be prepared to be honest about its failures, and to criticise me for doing so suggests, I am afraid, dangerous complacency from the right hon. Member for Leigh (Andy Burnham). The tragedy of Mid Staffs shows how the desire to celebrate success got in the way of speaking out when things went wrong, and if we are to prevent such things from recurring, we must never allow our love of the NHS to stifle our determination to hold systems and individuals to account.
Where does that accountability lie? Sir David Nicholson has been the focus of much attention, and as a manager in the system that failed to spot and rectify the appalling cases at Mid Staffs, he bears some responsibility. As he said, the focus was lost, and he has apologised and been held to account by this House and many others. However, I do not believe that he bears total, or indeed personal, responsibility for what happened. He was at the strategic health authority for 10 months during the period in question, overseeing 50 hospitals at a time when his main responsibility was the merger of three SHAs into one. He consistently warned both Ministers and managers of the dangers of hitting the target and missing the point.
It is just not true that if there had been no David Nicholson at the SHA, there would have been no Mid Staffs; others bear far more direct responsibility and the Francis report tells us who. It makes it clear that the primary responsibility for what went wrong lies with the board of the trust. Astonishingly, members of that board seem to have melted into thin air, some moving to other jobs in the system, and others receiving generous payoffs.
Mr Cash
As my right hon. Friend knows, I do not agree with his assessment of Sir David Nicholson in this context. There was a systems failure that affected not only Staffordshire but the entire health service, and that lies very much at the heart of the problem. In my speech I will quote some statements made by Sir David at a conference a few months ago.
Nicholas Soames
I am grateful to the Secretary of State. May I follow up on one point that he raised? He said that a number of those managers have disappeared or melted away to other jobs in the service. Does he agree that whatever else happened, there was a monumental failure of leadership at many levels, and that it is a failing of public services in this country—and the national health service in particular—that failing managers are too often recycled through the service to the great and constant cost of patient care?
Mr Hunt
I will make some progress and then I will take more interventions.
My response will detail how we intend to restore accountability to the boards of hospitals, and today I have removed the ability of any hospital to insert gagging clauses on patient safety in compromise agreements made with senior staff. My hon. Friend the Member for Bristol North West asked whether that will be retrospective, and I have written to all trusts to remind them of their responsibilities towards whistleblowers in respect of contracts and compromise agreements already signed. If we are to protect patients, we need an atmosphere of openness and transparency in the NHS—something to which the motion rightly refers.
Mr Hunt
I will make some progress and then I will take interventions from both sides of the House.
Sir David Nicholson told the Health Committee last week that in the NHS as a whole, patients were not the centre of the way the system operated. Which party was in power when that culture was allowed to operate? If Sir David has been held to account, so too must the Labour party be held to account. The Francis report rightly states that Ministers were not personally responsible for what happened at Mid Staffs, and I have no doubt that no Labour Minister would have condoned, knowingly allowed or wanted the events at Mid Staffs to happen. We also know from the report that the pursuit of targets at any cost was a central driver of what went wrong. As the report set out, above all Mid Staffordshire NHS Foundation Trust failed to tackle an “insidious negative culture” involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. It went on:
“This failure was in part the consequence of allowing a focus on reaching national access targets,”.
Ministers, not civil servants, are ultimately responsible for the culture of the NHS, and it is clear that during that period a culture of neglect was allowed to take root in which the pursuit of targets at any cost compromised the quality of care that patients received, and made it harder for front-line staff to treat people with dignity and compassion.
Andy Burnham
I am listening carefully to the Secretary of State but it is not fair to people in the NHS for him to say that Stafford equals everywhere in the NHS, and that we can take one failing—a terrible failing, as I said in my speech—in a locality and apply it to the whole NHS. He must acknowledge that NHS staff did an incredible job to end the situation when people were spending months and years on waiting lists, and even dying on them.
Mr Hunt
I acknowledge the brilliant work done by NHS staff and, contrary to what the right hon. Gentleman says, I do that in every speech that I make on these matters. I will not, however, accept the complacency that says that problems at Stafford hospital were localised and happened only in one place. If we are to sort out those problems, we have a duty to root them out anywhere in the NHS that they occur.
The right hon. Gentleman talked about waiting times targets. Let us be clear: there is an important role for targets in a large organisation such as the NHS. Without the four-hour A and E target, or the 18-week elective waiting time target, access to NHS services would not have been transferred and I accept that the previous Government deserve credit for that. It was right to increase spending on the NHS, although it is curious that Labour now wants to cut the NHS budget. Labour did however—this is where Labour Members should listen rather than barrack—make three huge policy mistakes, and the right hon. Gentleman must accept that it is not simply a question of Government policy not being implemented in every corner of the NHS. Those three mistakes contributed to the culture of neglect that we are now dealing with.
The first mistake—a huge mistake—was that Labour failed to put in place safeguards to stop weak, inexperienced or bad managers pursuing not only bureaucratic targets but targets at any cost. That is exactly what happened at Mid Staffs, where patient safety and care were compromised in a blind rush to achieve foundation trust status. Secondly, Labour failed to set up proper, independent, peer-led inspections of hospital quality and safety that told the public how good and safe their local hospital was. Instead of a zero-harm attitude to patient safety, we have a culture of compliance and the bureaucratic morass that is the current Care Quality Commission. Thirdly, Labour failed to spot clear warnings when things went wrong. The Francis report lays out a timeline of 50 key warning signs between 2001 and 2009. Why did Ministers not act sooner? If those warnings were not being brought to the attention of Ministers, why did they not build a system in which they were? Instead, there was a climate in which NHS employees who spoke out about poor care were ignored, intimidated or bullied.
Alan Johnson
The Secretary of State is making an interesting speech and there is no way that the Labour party can escape criticism for what happened at Stafford. Does he accept, however, that before 2000 there was no independent regulation of the NHS and no standardised mortality ratios, complaints in hospitals stayed in the hospital and there was no recourse to any independent observance of those complaints, and A and E—a particular problem at Stafford—was a data-free zone?
Mr Hunt
I accept that progress was made in the collection of data and that the previous Government set up a star rating system. The problem, however, was what it measured. It did not measure the quality of patient care but basically focused on access targets. It was possible for a hospital to get a three-star rating by transforming its 18-week access targets, even at the expense of patient care.
Stephen Barclay
It is correct that improvements were made in the collation of data. In fact, the Dr Foster data were published in national newspapers from 2001, but what is remarkable is that they were not acted on. That is the central charge for Ministers. We were the world leader in the collation of mortality data. We had the data, but Ministers did nothing with them.
Mr Hunt
I will make some progress.
The question the right hon. Member for Leigh needs to answer is why he refused 81 separate requests to set up that public inquiry. He says that he did not want to distract the hospital from the essential task of making immediate improvements, but does he now accept that if he wants people to take his party seriously on NHS accountability he needs to apologise? That was a mistake. Until we have a proper apology—not just for what happened, but for the catastrophic policy mistakes made by his party—no one will believe that Labour would not make the same errors of judgment again. On the Government Benches, we are clear that accountability, dignity and respect for patients, particularly vulnerable, older people who are unable to speak out for themselves, must be embedded in every corner of the NHS.
We will announce measures to set up a proper, independent peer review inspection regime led by a new chief inspector of hospitals that will not simply look at targets, but make judgments on whether hospitals are putting patients first. We will set up a single failure regime, where the suspension of the board can be triggered by failures in care as well as failures in finance; a patient-centred culture, by making the friends and family test a key part of the hospital inspection regime; clinically led commissioning, so that key decisions are made by people who see patients in their own surgeries; and an overhaul of the hospital complaints procedures led by the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart. We will do that with the minimum of upheaval. It is worth emphasising that Robert Francis himself says that the changes he calls for can largely be implemented within the system that has now been created by the new reforms.
Mr Hunt
I am going to make some progress.
This debate is about accountability. I have been doing this job for six months, and in nearly every exchange on the Floor of the House, the Opposition have avoided engaging in substance, preferring instead to make baseless allegations about the Government’s motives in respect of the NHS. I put it to the House that we have shown our commitment to the NHS time and again through a protection of the budget; a willingness to face up to big challenges, whether in clinical commissioning, the funding of social care or the need to ensure that care is prioritised throughout the system—
Mr Hunt
No, the right hon. Gentleman needs to listen to my point. If Labour is truly committed to the NHS, it, too, has to show that it has learned. I did not hear that in his speech. Labour Members need to accept that they made some terrible policy mistakes that led to a culture of neglect. They must recognise that the party that claims to speak for the most vulnerable in society betrayed many vulnerable people, with tragic consequences. Only then will the public know that the lessons of Mid Staffs have been learnt—not just by the NHS, not just by civil servants, not just by Government, but by all sides of this House.
Mr Deputy Speaker (Mr Lindsay Hoyle)
Order. I remind Members that there is a seven-minute limit.
Rosie Cooper (West Lancashire) (Lab)
I welcome the opportunity to speak in this debate on our national health service. I resolutely believe that we should have an open and honest debate on how we can each contribute to restoring faith in the national health service, and that we should not play politics with the findings of the Francis report.
Increasingly, there is a deeply concerning creeping veil of secrecy across the public sector—local government, education or health. The application of greater accountability and transparency is the solution, ensuring that the interests of the public remain the singular and overriding No. 1 priority in public service delivery. As a society, we display a huge and deep faith that the NHS is intrinsically good, and we want unquestioningly to believe that at all times it is acting in our best interests. The findings of the Francis report, as they should, shake that faith and belief in the NHS to its very core. Francis should be commended for his report—an extensive and comprehensive forensic examination of Mid Staffs and the structure of the NHS.
I will be as brief as I can and focus on one tiny element: listening to patients, the people who pay for the NHS, and hearing what they are saying and acting on it. We do not need to keep on looking for a black cat in a dark room. Switch the light on! It is no good the Secretary of State simply repeating that we must listen to patients and their families. What assurance does he have that, until the next crisis, they are listening? In hearing after hearing of the Health Committee, senior people associated with the NHS trot out that the regulator is responsible and that the Care Quality Commission needs to deal with it. I never, ever thought I would feel sorry for the CQC, but, when everyone else ducks, it is supposed to catch the ball. We do not need to create another bureaucracy; we simply have to make work—really work—something we already have by giving it real teeth and enough resources to make it effective.
I agree with the comments of Dame Julie Mellor, the parliamentary and health service ombudsman, when she said that she hoped that the Francis report
“will trigger a debate that will support our view that good complaint handling should be at the heart of the NHS.”
From front-line experience, I believe that to be both true and essential. During my time as chair of Liverpool Women’s hospital, a standing agenda item at the public monthly board meetings was a summary of all complaints received that provided an overview—not in minute detail, but an overview—of each complaint and the outcome: upheld or not upheld. Most importantly, there was a column that stated what action was taken. Employing this system of regular review ensured that the board had oversight, asked questions, could spot trends, be assured that action was taken and demonstrate to patients and their families that they were being listened to.
Nick de Bois
Does the hon. Lady accept, notwithstanding the efforts made in the hospital she mentions, that when MPs take up complaints on behalf of constituents and try to get to the truth behind them, we are faced with tremendous bureaucracy and resistance?
Rosie Cooper
Yes, and if MPs have problems, God help members of the public and patients.
We had to demonstrate that we were really listening to patients. The medical and managerial staff had to take ownership and responsibility for complaints. They knew that at each board meeting they could be questioned and challenged. If we accept that there are large parts of the system that work well and focus our time and resources on areas that do not, we can raise standards and tackle deep-seated problems. As chair, I sought to build in assurance and be transparent about complaints; to solve them, not hide from them, and ensure that everyone was accountable right up through the management structure. I never believed in no blame; I believed in fair blame. Each time a problem was resolved properly, we became a better hospital. We were rightly proud that on the front page of the Liverpool Echo Liverpool Women’s hospital was called an NHS gem. Sadly, the main board’s complaints report stopped after I stepped down as chair.
We do not need to reinvent the wheel or have more reorganisation in the NHS, but we must make the complaints system work. From that important but simple action, culture changes happen and become embedded in the organisation. We then have real change, real transparency, real openness and real accountability—something we can all be proud of.
Barbara Keeley (Worsley and Eccles South) (Lab)
A complaints system sounds very useful. When staff knew that complaints were being assessed and reported on every month, what impact did it have on them?
Rosie Cooper
In essence, it encouraged a change of culture. They were not operating in a vacuum, where patients did not matter and where the complaint might not ever get resolved—where, if a manager said it was okay, it disappeared. The fact that the light was switched on and that people could ask questions was valued.
There is a huge disconnect between the rules and the enforcement of rules. When local resolution fails there must be another, proper avenue for patients to appeal that decision: just having the NHS investigate the NHS is not the way to improve the health service, or patients’ confidence in it. Currently, the message we send out is that unless people have the financial resources to fight the system in the courts it is easy for families and patients to be ignored.
Chief executives and boards know that the ombudsman investigates only a tiny proportion of the cases referred to it, and it is not as feared as it should be. I say to the Secretary of State that we need an ombudsman service that is properly resourced, has the necessary investigative powers and sanctions, and makes public in its reports its findings to everybody who pays for the NHS, not just to Ministers. Being able to name and shame in the spirit of openness and transparency will be a powerful tool, especially when, in these times of foundation trust hospitals competing to attract business, reputation is the key.
Given that all hospitals will eventually become foundation hospitals, is the Secretary of State willing to say that foundation hospitals will have to report all their statistics openly and that every board meeting should be a public meeting? There should be no hiding; there should be openness and transparency right across the NHS. The light needs to be switched on not just in individual rooms but in the NHS, full stop.
I have on the wall of my constituency office this quote from an editorial in the Liverpool Echo:
“Doing the right things does not automatically follow saying the right things”.
At present, everyone in the national health service is saying the right things. What assurance can the Secretary of State give us that the NHS will do the right things? Frankly, the public do not want any more politics from anybody. They do not want warm words or excuses; they want actions that will lead to real change. No more big reorganisations; we just need to make a difference. He must listen to the people’s complaints. Actually, in Mid Staffs the complaints could not have been any louder.
I said to the hon. Member for Bristol North West (Charlotte Leslie) earlier that we cannot keep on saying that it is somebody else’s fault, that somebody else should be held accountable and that somebody else is going to supervise. This goes to the core of the Department of Health. If we listen to the people and give the ombudsman—the right person for the job—the powers to deliver, we will see a culture change.
Mr Stephen Dorrell (Charnwood) (Con)
I want to follow the hon. Member for West Lancashire (Rosie Cooper) on to very similar territory. She and I both sit on the Health Select Committee, which I chair. I want to start where my right hon. Friend the Secretary of State and the right hon. Member for Leigh (Andy Burnham) started, with what happened in Mid Staffordshire. It was shameful, and we will be judged today by whether we show a serious willingness to learn and apply the lessons of the Francis inquiry.
Francis made 290 recommendations, but they amount to just one core recommendation, which is that there needs to be a fundamental culture change through the whole of the national health service. With respect to the shadow Secretary of State, that is the sense in which challenges are posed for the health service way beyond Staffordshire. We have to learn the lessons of Staffordshire and apply them beyond it, as well as demonstrating that we understand what we mean—in the modern jargon, we “get it”—when we talk about the need for a culture change.
My hon. Friend the Member for Bristol North West (Charlotte Leslie) encapsulated that when she used the words “accountability” and “transparency”. I will not follow her down the route that she took in her speech. I want to focus exclusively on what we mean by those two words. They seem to trip too easily off the tongue, without anyone understanding what they mean, and that must change if we are to sustain a culture change in the health service.
My first proposition is that accountability without transparency is entirely meaningless. The ability to see what is going on and how decisions are being made in the health service, and to see the effects of those decisions, is fundamental to the delivery of the objective of culture change. With respect to the right hon. Member for Leigh—and, indeed, to some of the points that my right hon. Friend the Secretary of State made—we have to acknowledge that a lack of transparency lies deep in the culture of the health service, and that it goes back to way before the previous Government were in office. It was present in my time as Secretary of State and well before that, too. I was regularly accused of supporting a gagging culture in the health service, although nothing could have been further from my intention. However, that charge was made against me, against the right hon. Members for Leigh and for Kingston upon Hull West and Hessle (Alan Johnson) and, in truth, against all our predecessors right back to 1948.
The instinct to protect, rather than the instinct to reveal, is deeply embedded in the health service. When something is said to be going wrong, there is an instinct for the wagons to gather round. That is why Francis’s recommendation for a duty of candour is key to the delivery of the objective of greater accountability and transparency.
Barbara Keeley
Was the right hon. Gentleman as disturbed as I was to hear that the £500,000 gag at the United Lincolnshire Hospitals NHS Trust was put in place without any sign-off whatever, on the basis that it had involved judicial mediation? The Secretary of State refused to answer my question about this. Does the right hon. Gentleman agree that the Secretary of State really has to stop that, because it involved a very large amount of money, which was used very ill-advisedly?
Mr Dorrell
The position I take is the one set out in the Francis report, which was explicitly endorsed by Sir David Nicholson in the Select Committee inquiry to which the hon. Lady has referred. I believe that it would also be endorsed by my right hon. Friend the Secretary of State, but he must speak for himself. That position is that it is hard to imagine circumstances in which the use of public money in the context of a compromise agreement should be governed by a confidentiality clause. In an age when a bill from Pizza Express has to be published on the internet, decision makers should be held publicly accountable for the use of large sums of money in the context of a compromise agreement.
Mr Jenkin
I accept my right hon. Friend’s challenge about openness and transparency in the way the health service reacts outwardly, but that is a means to an end. There is also a lack of honesty and openness between people working in the health service, and the mistrust between levels of management and institutions inhibits the proper flow of information and the ability of people to trust each other in the context of saying what is wrong and putting it right. People in the health service dare not tell their senior management what is wrong.
Mr Dorrell
I have a lot of sympathy with what my hon. Friend says. The successful delivery of a culture change that supports real transparency would build on the fact that it is not only a right but an obligation for a registered doctor or nurse who sees care being provided that falls below proper standards to raise their concerns and, if no action is taken, for those concerns to be raised with the regulator. Change will be required right through the health service if that professional obligation is to be made real.
John Pugh (Southport) (LD)
My right hon. Friend has mentioned the instinct to protect and to circle the wagons. Would he accept, however, that that is not exclusive to the NHS, and that it also exists in the police service, for example? It also existed in Parliament during the expenses scandal. It is an institutional feature of many kinds of organisation.
Mr Dorrell
I agree with my hon. Friend, but I hope he will forgive me if I do not follow him down the road to the police service in the three and a half minutes I have left.
My key objective is to enable Members to recognise that this is a deep-seated cultural issue, that we need to create a more open culture, and that a duty of candour is fundamental to that. I say to the right hon. Member for Leigh that we need to ask ourselves occasionally: accountable to whom? Surely in the first instance, the health service must be accountable to the patient. How can it ever be right for a failing in care provision that has been acknowledged and discussed not to be described to the patient? That duty of candour to the patient is fundamental to the culture change that I am describing. However, we have to remember that, within the tax-funded health care system, there is a duty not only to the patient but to the taxpayer. Although I do not want to go too far down this road, the challenge for the right hon. Member for Leigh when he speaks about competition and decisions about the use of public money is that commissioners and providers must be accountable for value as well as clinicians being accountable for quality.
In my remaining time, I want to pose this challenge for those elected to this House. The challenge of culture change has to apply right through the health service, but people looking into this debate from outside will, I suspect, conclude that thus far that challenge has not been fully responded to. There is a deep-seated culture here that pretends that the problems all started under this or that lot, or that every success is the result of achievements made by one particular side, but the truth is that this deep-seated requirement for culture change has been addressed by successive Governments over a protracted period.
We should not forget that waiting time targets were invented before I was Secretary of State for Health. Quality of care requires access to care as well as to high-quality clinical outcomes. We should not forget that deep in the pathology of what happened in Staffordshire, the health economy there was out of control. It was running sustained deficits and management was required to bring that health economy under control. There is no choice between quality on the one hand and management on the other. We need to develop a culture within the health service that allows managers to address questions of both quality and value, because unless we address both, we will deliver neither. That is the core challenge facing the health service over the period ahead.
Kate Hoey (Vauxhall) (Lab)
It is a pleasure to follow the right hon. Member for Charnwood (Mr Dorrell), who speaks with a breadth of experience and history in the national health service, and I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on securing this long debate, providing an opportunity to all of us to say a few words.
I agree wholeheartedly with everything my hon. Friend the Member for West Lancashire (Rosie Cooper) said, particularly about what seems to me, too, to be a growing public body desire for secrecy. This is happening not in the national health service alone, but in many other bodies. Indeed, as my hon. Friend well knows, it is happening in this House. I am concerned about a number of issues—how staff are treated, getting rid of the telephone exchange and a whole number of other decisions taken up there somewhere. We, as Members who work here, have very little say.
It is important for us to remember the Nolan principles of public life to which every public body is meant to sign up—accountability, openness, honesty and leadership. I do not want to say much specifically about what happened in Mid Staffordshire, but it was appalling. As someone who has had a good and well-led hospital in my constituency for many years, I find it almost unbelievable that all that could have happened in the Mid Staffordshire hospital with so few people seeming to know what happened or to speak out about it. Then, when it was pointed out, no one listened. That provides a terrible warning about what can happen. We all think that we know what is happening in our constituencies, but we do not always, as this episode has shown.
Let me talk about my local hospital Guy’s and St Thomas’, King’s College hospital and SLAM—the South London and Maudsley hospital. What has been called the “King’s Health Partners” has sought to bring together the research work at King’s College medical school with others, and the body is now growing to be almost an entity in itself, making decisions, sending out publicity and getting further and further away from the foundation trust.
Looking back to when my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson) was Secretary of State for Health, some of the decisions he made in the Health Act 1999 were more about accountability than anything that has been done since by any Government. For example, he instructed NHS chairmen to hold their board meetings in public, while non-executive directors were required to live in the area served by the trust—a crucial step that fundamentally changed St Thomas’ hospital when we had a local chairman who knew the area, was involved in the hospital and cared about it. She spent all her time as chairman wandering around the hospital trying to find out about everything that was going on: she was accountable to everyone. That was crucial to the public, too, as they knew that they had people on the board who knew what was happening in the locality.
I believe that one of the first responsibilities of non-executive directors—they are not part of the management —is to visit the wards, to talk to patients, to collate local concerns and to talk to MPs, local councillors and the local authority. That was always happening. We had a very good system. There were concerns about the treatment of the elderly at one stage in one of the wards for elderly people at St Thomas’, but they got dealt with very quickly because we had a responsive chairman and a responsive board. A lot of that happened when my right hon. Friend the Member for Holborn and St Pancras was the Secretary of State. The Health Act 1999 also gave the chief executive officer absolute personal responsibility for clinical governance standards—another important reform—in addition to the responsibility to be the accountable officer.
Later we had foundation trusts, although I have to say that I did not vote for them. I have had a well-led foundation trust up to now, but I did not feel that this was the right way ahead for the national health service at the time. We have got them, however, and some foundation trusts saw fit to erode the principles as financial considerations took precedence over clinical standards on many board agendas. The foundation trusts still remain the chief executive officer’s responsibility.
One thing the King’s Health Partners are doing in the name of foundation trusts is steamrolling ahead to bring about a merger of Guy’s and St Thomas’ hospital, which is a huge trust, King’s College hospital, which is another huge trust, and the South London and Maudsley trust. It is believed that the merger will somehow lead to a “world-class”—I do not know how many times Members have heard the term—hospital.
I am furious and angry—as are, I think, all five of the MPs representing the area at how this merger has been handled. The lack of openness has been appalling and there has been no public board meetings or disclosure of information about the proposed changes. The proposals have been either badly put forward or not put forward at all. The board at St Guy’s and St Thomas’ has an occasional surreal meeting as a showcase for public involvement, but it never discusses the real issues. It opens meetings for the public only when it suits the board.
Kate Hoey
That is precisely what the five Members of Parliament have asked for. Recently, on 28 February, we heard from the chairman of Guy’s and St Thomas’, who was previously a permanent secretary at the Department of Health. That takes me back to one of my earlier points about people moving around within the health service. It is always somebody who has been someone else in somebody else’s patch that gets a job with another NHS trust. This chairman wrote to say that the project is forging ahead with a full business case. William McKee, who brought together trusts in Northern Ireland, has been appointed and we are told that he is going to spend at least £5 million to bring about the business case to show why this will be such a wonderful idea. The right hon. Member for Bermondsey and Old Southwark (Simon Hughes) and I have written back asking who is actively responsible, how the money from the different bodies is being allocated, what the precise budget will be and how it will be spent by whom. The whole accountability thing is there in a nutshell. Who is actually accountable? Does the Secretary of State have any say whatsoever? No. Apparently he is only interested if the move will clearly not be good for patients in clinical terms.
I know that the establishment of such a large trust will be totally against the interests of people. Trusts cannot operate on such a large scale. One chief nurse cannot be responsible for all those hospitals.
Dr Phillip Lee (Bracknell) (Con)
As ever, it is an honour to follow the hon. Member for Vauxhall (Kate Hoey).
Let me begin by congratulating my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing a debate about this important subject. It is a subject that I think should be debated more often in the Chamber, and I find it surprising that fewer Members wish to speak about it than have wished to speak about some of the other issues that we have considered since Christmas. I think all Members should reflect on that.
I believe that the core of this problem is responsibility: responsibility in public life. The general public are fed up—not increasingly fed up, but completely fed up—with hearing about scandal after scandal involving the national health service, the BBC, the newspapers and so on, for which no one takes any responsibility. No one walks. No one looks at themselves in the mirror in the morning and says “I did not do as well as I should have; I am paid a decent wage; the honourable thing to do is resign”—not “be sacked”, but resign.
I do not want to make a speech about Sir David Nicholson. Sir David Nicholson should know that he ought to resign. I cannot comprehend how he can think that his position is sustainable from a moral standpoint, but if no morality is involved, what about competence? He may have been head of the strategic health authority for only a relatively short time, but he was aware of the mortality rates when he was in that job. What did he do about it? If he did nothing about it, why is he still in post? However, I do not want to make this a personal issue.
Having worked in the national health service for 13 or 14 years, I do not need to be told about the problems caused by the culture in that institution. I learnt how it was as a medical student, and I saw it at first hand as a junior doctor. I want to say something about that, and also about competence in general. We need competent individuals in charge of our hospitals and on hospital wards, but I am not sure that we have had them in recent years. I also want to say something about responsibility in the light of that.
The national health service is a huge institution—some might say too huge—and because of its size, the fact that it has grown over the past 60 or 70 years, and the fact that the people who work in it rarely leave, institutionalised behaviour is rife. It is rife in medicine and in management. In my view, former Secretaries of State on both sides of the House display such institutionalised behaviour themselves. They may wish to reflect on that at the end of the debate.
The first debate in the House in which I spoke, apart from the debate during which I made my maiden speech, was a Backbench Business Committee debate about compensation for haemophiliacs. I was struck then by the institutionalised response from the Department of Health. It seemed plain that the Department did not want to set a precedent by doing what was obviously the right thing, namely compensating about 4,000 people and their families for what the system had done to them.
I am therefore not surprised by the Francis report, which those who read it will discover to be a not particularly impressive document. Parts of it have the ring of a Nuremberg defence. It is remarkable that individuals cannot be held responsible for their actions within a system. That system is apparently so perfect that no one within it needs to be good. I think that we need a health service in which individuals, including Secretaries of State, take responsibility for their decisions at every stage.
Dr Lee
I am talking about those who were Secretaries of State in the last Administration. In response to an intervention during his speech, the right hon. Member for Leigh (Andy Burnham) said, “I passed it on to Monitor.” The attitude that leads people to push away the process of decision making and take no responsibility for the outcomes needs to end.
Andy Burnham
Surely, as a clinician, the hon. Gentleman would resent the idea of politicians’ interfering in the independent clinical regulation of hospitals. I did not do nothing. Within days I had asked the Care Quality Commission to investigate the outliers that Brian Jarman had given me. I will not sit here and accept the hon. Gentleman’s suggestion that I complacently did nothing. That is not true, and he should not repeat it in the House.
Dr Lee
Despite that, nothing changed, did it? The CQC has a terrible reputation in my profession, and to have handed the matter over to it—when it was run by someone who was implicated at Mid Staffordshire—is not a defence.
Let me broaden the discussion to something that I may know something about: practising medicine in organisations run by the Department of Health. I can tell the House that the prevailing atmosphere is one in which attention is not drawn to problems. There is a fear for jobs down the line. Let me give an example. When I was a junior doctor, I misused a photocopying machine in a hospital. Within hours, I received a phone call from a middle-grade doctor telling me that if I did that again, it would affect my reference. The phone call, I was told, had been authorised by the then consultant general surgeon at St Mary’s, Ara Darzi. I reflected on that at the time. It made me feel rather intimidated. [Interruption.] The prevailing mood in hospitals was that seeing or doing something wrong could adversely affect a person’s future career.
Charlotte Leslie
Does my hon. Friend share my regret that Opposition Members are groaning in that way? What he is describing has been very evident for very many years. One need only speak to a doctor to learn that there is a culture of fear. Nearly every doctor knows someone who has tried to speak out against something that has happened. People know that if they do that, there will be counter-allegations against them. The groaning and expressions of surprise from Opposition Members are very sad, because it reveals just how little they were actually talking to clinicians on the ground who have been complaining about this for a decade. I received an e-mail from the spouse of a clinician who said that over the past 15 years the management styles encouraged by the previous Government had made that clinician ill.
Dr Lee
I must get on, I am afraid. I do apologise.
The point I am trying to make is that a certain culture prevails, and into that culture, or environment, the last Administration introduced targets. I do not suggest for one second that the last Administration thought those targets would lead to the type of care that was provided at Mid Staffordshire, but I am not surprised that there were adverse consequences, and I think Opposition Members should reflect on that.
The final thing that I want to say about culture and competence concerns politicians. The right hon. Member for Leigh said that I would not want politicians to interfere in day-to-day care. Of course I would not, but I would like politicians to take responsibility for the service. Let me give an example. There are only about 250 acute trusts in the country, and not that many mortality figures have to be looked at in each trust. It could be done on a monthly basis. However, I am told that it was not done by Secretaries of State in the last Administration. Why? If I were the Secretary of State, the one thing I would want to look at would be clinical outcomes in hospitals. If that is beyond Secretaries of State, one is prompted to ask why they are in post. If those figures had been looked at earlier enough, we might not be having this debate.
Competence and the right culture are only possible with transparency. That is the most important aspect of this whole issue.
Alan Johnson (Kingston upon Hull West and Hessle) (Lab)
Well, there’s a man who knows all the answers!
It was four years ago on Monday when I apologised to this House on behalf of the Government and the national health service for what happened at Stafford. We had just received the report from the Healthcare Commission, and I think it is fair to say that no one with any experience of the NHS could quite believe what had gone on. The people in charge at a time when there were unprecedented resources and investment being put into the NHS had cut staffing on A and E to such an extent that a receptionist with no medical training was triage nursing in A and E.
We need a longer debate. There is nothing ostensibly wrong with the motion, and I agree with my right hon. Friend the Member for Leigh (Andy Burnham) that we should support it, but it is clear from the way it was moved and the last contribution that this is all about the blame game. If I can just quote Francis—[Interruption.] Yes, the hon. Member for Bracknell (Dr Lee) does not agree with Francis or with Ara Darzi and knows everything, and says that Francis was a Nuremberg—
Alan Johnson
No, I am not giving way—at least not to the hon. Gentleman. I have heard enough.
This is what Francis said in paragraph 108 of his report:
“To place too much emphasis on individual blame is to risk perpetuating the illusion that removal of particular individuals is all that is necessary. That is certainly not the case here. To focus, therefore, on blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified and further harm.”
So the man who knows most about what happened at Stafford hospital—and who was entrusted by this Government and their predecessors to conduct not one, but two, inquiries, and who in four volumes running to millions of words sets out what happened, why it happened and how it was allowed to happen—counsels against the very action that this motion appears to propose.
Francis identified who was accountable, and the Secretary of State was absolutely right: it was the chief executive, the chair and the board of the Mid Staffordshire trust. A number of clinicians are also held accountable for the appalling lapse in standards of care at Stafford. This accountability regime is set out in legislation approved by this House.
The Francis findings are consistent with those that emerged from the inquiry into the care of children receiving complex cardiac surgery at Bristol Royal infirmary between 1984 and 1995. In that case, five individuals at the hospital, including the chief executive, were the subject of adverse comments. In respect of both Bristol and Stafford, an argument was made to an inquiry that there was an extenuating failure of national policy. At Stafford, it was national targets; at Bristol, it was inadequate resources.
It is worth recalling the Bristol inquiry’s response. Sir Ian Kennedy said:
“The inadequacy in resources for PCS”—
paediatric cardiac surgery—
“at Bristol was typical of the NHS as a whole. From this, it follows that whatever went wrong at Bristol was not caused by lack of resources. Other centres laboured under the same or similar difficulties.”
We must remember that these were the days when one in every 25 patients on the cardiac waiting list died before they could be operated on, and when somebody with a serious heart condition could wait a year to see the cardiologist, three months to see the consultant and then 18 months to two years for the operation. That is why targets had to be introduced—to get a grip on this awful situation.
Mr Cash
I am astonished by the line on accountability that the right hon. Gentleman is taking. He was the Secretaryof State and I had a row with him at the time—and, indeed, with his successor—about the question of holding a proper full public inquiry under the Inquiries Act 2005. I wrote to him, too, and I did not get satisfactory answers under the guidelines laid down in the 2005 Act on the prime ministerial rules issued by the Cabinet Office.
Alan Johnson
On the question of a public inquiry, when Francis reported on his first inquiry, commissioned by my right hon. Friend the Member for Leigh, he made the point that it was about people affected being able to come and tell their story, and Francis said in his first report:
“I am confident that many of the witnesses who have assisted the inquiry in written or oral evidence would not have done so had the inquiry been conducted in public.”
It is very important that that first inquiry allowed people to come forward. The right hon. Member for South Cambridgeshire (Mr Lansley) may also well have been right to make the second stage of that a public inquiry, which was authorised because of one of the Francis recommendations, because we now have all the information, provided before a Queen’s counsel, about what happened there.
Francis is very clear about no blame being apportioned to any Minister. It is of course right for Ministers to be accountable if anyone knew what was going on and did nothing to stop it, or if something that was going on was a result of a Government edict or policy, but that was not the case at Stafford.
Targets had to be introduced to get a grip on this terrible situation of lack of access to health care. Targets did not cost lives; they helped to save lives. They were accompanied by the resources, the capacity and the political will that transformed waiting lists of 18 months to two years to a maximum of 18 weeks and an average of nine.
This is what Francis said about targets:
“It is important to make clear that it is not suggested that properly designed targets, appropriately monitored cannot provide considerable benefits and serve a useful purpose…indeed the inquiry accepts that they can be an important part of the health system in which the democratically elected Government of the day sets its expectations of providers who are funded by the taxpayer.”
The right hon. Member for Charnwood (Mr Dorrell) was absolutely right to say that long waiting lists have dogged the NHS since it was created in 1948. Rudolf Klein, the great historian of the NHS, says every Health Secretary shouted their orders from the bridge and the crew carried on regardless. Something had to be done to deal with that, and it was done.
Mr Jeremy Hunt
Does the right hon. Gentleman not accept that the issue was not targets, but the failure to put in place safeguards to stop managers twisting a targets culture into a culture of targets at any cost? That was the fundamental policy mistake. The lack of those safeguards meant Mid Staffs could happen.
Alan Johnson
The Secretary of State is right. Of course there need to be safeguards to ensure any system has a backstop to stop people misusing targets. The guidance from the Department of Health was very clear. In no way must the pursuance of targets interfere with the need for good patient care. The Stafford chief executive must have translated that into saying it was fine to put receptionists on triage nursing. With all due respect to the Secretary of State, I do not think that he or any of his successors or predecessors can make regulations to meet every eventuality, including for someone like that chief executive of the Mid Staffs trust.
Charlotte Leslie
In some ways I agree with the right hon. Gentleman, in that I think targets and ensuring that things are happening is not the main cause of what went wrong. Does he agree, however, that targets along with what many medical professionals criticise as the de-professionalising of the work force through the consultant contract, the working time directive and the new deal was a toxic combination?
Alan Johnson
The principal point about targets is that they reduced waiting list times. They changed a situation in which people were dying while on waiting lists, which was a disgrace in a civilised country like ours.
The Francis report also gives no comfort to those who expected him to offer up Sir David Nicholson’s head on a plate. The irony is that they choose to make this attack on an NHS that is learning the lessons of Stafford and an individual, Sir David Nicholson, who has done more than anyone to make quality of care the organising principle of the NHS. I, like my three successors as Health Secretary, consider Sir David to be part of the solution, rather than part of the problem He is not perfect—none of us is—but he is a good public servant who is committed to the NHS, its patients and staff. If he knew what was going on at Stafford, or colluded in the awful events there, or if any of his edicts, policies or pronouncements were in any way responsible for what happened, I would agree with his detractors. No one knew what was going on at Stafford; not even the press, who pride themselves on fearlessly exposing wrongdoing. Not a single question was raised by local MPs in this House about what was happening at Stafford, and Francis has something to say about the way they passed on complaints.
Alan Johnson
No, and I read the hon. Gentleman’s correspondence and it in no way drew attention to what was happening at Stafford.
Mr Deputy Speaker (Mr Nigel Evans)
Order. Please resume your seat, Mr Cash.
John Pugh (Southport) (LD)
I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on calling for this debate, which I want to widen and, I hope, put on a more consensual footing.
I have a constituent whose grown-up son tragically died of leukaemia some time ago. He went to the doctor many times and was diagnosed as a young, healthy man with glandular fever. A blood test was made far too late, and he died. After the funeral, the mortified doctor wrote to the parents and apologised frankly for her failure and her error. There was no litigation or talk of system failure; there was simply a frank admission of individual human error and a sincere apology, which was accepted.
In many cases of NHS failure, there is no one individual to blame, so people talk of systems and cultures, which we have talked about constantly today. No one individual can be held entirely to blame for the system, so it always seems that no one person is to blame or is prepared to take the blame—even those who manage and design the system, such as Sir David Nicholson.
When a hospital performs badly, and the one in Mid Staffs is simply the most telling example, some of the reasons lie in external factors: in the targets imposed on it, in the requirements made of it—becoming a foundation trust is one it could have done without—and in directions that impaired it. The NHS reorganisation certainly got in the way, according to Francis. When outcomes are poor, it can be hard to determine exactly how to apportion blame and responsibility. Do we blame those who witnessed what went on and did nothing; those who failed to notice worrying trends; those who did notice them but covered them up; or those who could have intervened from on high but did nothing? In one sense, they are all responsible—and some are more responsible than others. But we live in a very harsh and judgmental climate, as was said earlier, and we forget that people at every stage have mixed motives—good and bad—for not kicking up a fuss, for covering up, for not intervening. Some are good—usually, they are bad—but in most cases institutional or personal reasons outweigh the concern for patients. There are quite legitimate fears that the hospital or branch will be criticised or seen as underperforming, which will be bad for morale in hospital, or that one’s career will be in jeopardy—a legitimate concern—or that one is getting a colleague into trouble. Institutional or personal goals get separated from the avowed patient-centred mission of the NHS. Frankly, that is all too human an outcome, and it has always happened to some extent. The NHS is full of very good people, but it is not yet staffed by saints. All of us at some time cover up for colleagues.
However, we always try to find in an institution a way of correcting for this, which is why we have professional standards in the medical profession and an NHS constitution. It is why we need true accountability, good complaint-handling, protection for whistleblowers, duty of candour, the learning of lessons and, of course, proper redress. That is why we have had legislation on the NHS constitution and increased democratic scrutiny, introduced by both Governments, which I applaud. I am not entirely certain what has happened to the NHS redress Bill, but I applaud that too.
However, we build other sorts of incentives into the system, and it is as well to record them. They appeal to a different aspect of human nature, a more selfish side, perhaps out of realism, perhaps because of an ideological conviction that that is how people work. We model hospitals on profit-making institutions. We make survival dependent on competition with other profit-making institutions, which have gagging clauses in their contracts for good reasons—their competitors. We try to modify clinician behaviour not always by appealing to clinical judgment, but by appealing to the pocket. Therefore, we should not be surprised if the moral atmosphere, at times, becomes a little cloudy. We, as legislators, are partly responsible for that.
If we turn the NHS into a set of businesses united by a corporate brand, should we be surprised if occasionally, individual branches put their interests ahead of those of their patients, choosing to satisfy those who pay—the Government—rather than the patients they serve?
There are many good things that we can do and would wish to do. We can make the complaints process easier. We can assign accountability better, so that an individual’s job and survival in an organisation depends on serving the patient, not on always doing what the institution necessarily requires. We can ban gagging orders, and I applaud the Secretary of State’s move in that direction. We can improve inspection, not by making it more ferocious—we do not need to do that—but by linking it better to improvement. Above all, we need to start thinking about what we want the NHS to be. If we are unhappy with the culture, exactly what sort do we want to have? Do we want the moral enterprise that Bevan envisaged—a contract on behalf of the hale and hearty, to protect the sick and vulnerable—or a set of businesses that sink or swim depending on how good they are at getting state funding? We can either rediscover the moral purpose of the NHS, or regard it as an organisation that brings to book from time to time the businesses that work within it, independently of the Secretary of State.
Frankly, I know which I prefer, but I have to record that currently we exist in a strange kind of moral limbo. We are judging an institution that looks very different from the original NHS, according to the high standards and moral mission Bevan set. I have a lot of sympathy with the remarks of Harry Cayton of the Professional Standards Authority, who said in The Times only this week that the NHS must rediscover its “moral purpose”. We exist in a kind of moral fog, a state of limbo, and if we want to know who is accountable for that, it is us.
Jim Dowd (Lewisham West and Penge) (Lab)
It is a pleasure to follow the hon. Member for Southport (John Pugh), who always makes thoughtful contributions.
I congratulate those Members who tabled this motion, to which I was happy to add my name. I am grateful to the Backbench Business Committee for agreeing to this debate, but, like others, I feel that the issue is so important that it should be debated in Government time. However, I suspect that, in the light of developments, we have not heard the last of the issues raised by the Francis report. The Secretary of State outlined a few of the measures he is intending to bring before the House, so we will have opportunities for other such debates.
I will not refer in any great detail to the Mid Staffs fiasco, serious though that is, and the obvious implications for other areas across the country. I want to concentrate on transparency, and to avail the House of the experience in south-east London of the tender mercies of the first, and so far only, trust special administrator, who was appointed to the trust next door to Lewisham—the South London Healthcare NHS Trust. That trust comprises the Princess Royal University hospital, in Orpington; the Queen Elizabeth hospital, in Greenwich; Queen Mary’s hospital, in Sidcup; and the Orpington hospital—although that was actually subject to a separate consultation.
The then Secretary of State said in a statement on 12 July last year:
“I wish to inform the House that I have made an order to appoint a trust special administrator to South London Healthcare NHS Trust…The regime, included by the last Government in the Health Act 2009, offers a time-limited and transparent framework to provide a rapid resolution to the problems within a significantly challenged NHS trust”—
trust, singular. He continued:
“The trust special administrator’s regime is not a day-to-day performance management tool for the NHS or a back-door approach to reconfiguration.”—[Official Report, 12 July 2012; Vol. 548, c. 47-48 WS.]
On 13 July, he issued the order to give effect to those measures.
I raise this as a transparency issue because the trust special administrator brought forward proposals that damage, downgrade, devastate, destroy—whichever word one wants to use—Lewisham hospital, which is a completely separate trust. The right hon. Member for Charnwood (Mr Dorrell), who is the Chair of the Health Committee and has great knowledge and experience of these matters, said that accountability and transparency are interlinked: we cannot have one without the other. I agree with him wholeheartedly, but that has not been the experience of the people in Lewisham: the TSA is entirely unaccountable. The TSA stands at the head of a disgraceful, disreputable conspiracy—launched in the Department of Health, aided and abetted by NHS London and handled in the most autocratic manner—to downgrade Lewisham hospital.
The titles of both the orders issued by the Secretary of State, copies of which I have here, start with the words:
“The South London Healthcare National Health Service Trust”.
The order setting up the administrator states:
“That draft report to the Secretary of State must state the action which the trust special administrator recommends the Secretary of State should take in relation to the South London Healthcare National Health Service Trust.”
It contains no mention of anybody else, yet the Department now says, “Of course we needed to look at the whole of south London and the whole of the health economy of south-east London, because everything connects to everything else.” Well, that is true of everything in the whole wide world.
From day one, all the documents of the TSA included the phrase “Securing sustainable NHS services”. One such document was headed: “Securing sustainable NHS services—Consultation on the Trust Special Administrator’s draft report for South London Healthcare NHS Trust and the NHS in south east London”. This House did not give the administrator that authority—the law does not provide for the administrator to look at the situation across south-east London—and he has acted beyond his powers.
I come now to the most interesting thing, and I accept that the current Secretary of State has had this matter dropped in his lap. If this was always about the whole of south-east London, why when the former Secretary of State had a meeting in July to discuss this did he invite the Members who represented Bromley, Bexley and Greenwich—rightly, because they cover the South London Healthcare NHS Trust area—and the Members for Lewisham? One could say that it was because they were looking more widely. Of course that is so, but he did not invite the Members representing Lambeth or Southwark. However, when we met this Secretary of State in January, after the TSA’s final report had been published, the Members for Lambeth and Southwark were included; we were told that this was a south London-wide issue. The reason for the discrepancy is obvious: they knew what they wanted to do. They wanted to get an old plan that NHS London had fostered to try to get Lewisham hospital closed. That took place under a proper clinical review under “A picture of health” four years ago, which concluded that Lewisham hospital deserved to survive and that the services it provided for the people of Lewisham should continue.
Some 10,000 people marched in November to oppose the proposals. When the final report came out, 25,000 people marched because of the outrageous actions of this administrator and the activities he has undertaken. The manner in which he dealt with the consultations was dismissive, disdainful and high-handed. Whether the objections were from members of the public, GPs or other clinicians, he behaved in line with the instructions from his bosses, which were simply to close Lewisham hospital. The people of Lewisham will not stand for it.
Jeremy Lefroy (Stafford) (Con)
I wish to thank my hon. Friend the Member for Bristol North West (Charlotte Leslie) and the Backbench Business Committee for calling this debate. I particularly wish to remember all those in my constituency and elsewhere, and their loved ones, who suffered so grievously. I wish to pay tribute to those here today who campaigned to bring these things to light. I also thank the Prime Minister, the Secretary of State and all other hon. Members for their response to the report a month or so ago.
One of the main thrusts of the Francis report is to:
“Ensure openness, transparency and candour throughout the system about matters of concern”.
This is not the time to debate the Francis report fully—it was commissioned by the Government and it needs full and prompt consideration in Government time—but it is the time to say that the Francis report is of great importance. Mr Francis rightly dismisses the arguments of those who claimed at the time that the inquiry was unnecessary because Stafford hospital was a solitary exception—it was not. It may have been considerably worse than other places, but appalling standards of care have been revealed elsewhere.
The public inquiry has revealed complacency throughout the NHS and beyond; report after report detailed major concerns, which were either ignored or passed to others to deal with. What lay behind that? Perhaps it was a lack of willingness to shout and continue to shout for help when it was needed; or perhaps it was more often a fear of the consequences—the loss of one’s job or the removal of services from the local community.
Even just last week, when, as the shadow Secretary of State rightly said, a report to Monitor suggested removing most emergency, acute and maternity services from Stafford—something my constituents and I strongly oppose for reasons I set out in the House last week—there were those blaming Julie Bailey for the proposals. That comes on top of disgraceful threats—even death threats—that she has received over her work in revealing what Robert Francis, who should know if anyone does, calls the “disaster at Stafford Hospital”.
Let me make it clear that the proposals in the Monitor report are, in the main, a consequence of the financial and clinical pressures that all acute trusts, particularly the smaller ones, are facing. Stafford’s circumstances have done a little to hasten changes, but what happens at Stafford now will face all other such trusts in the coming years. That it is why it is so important that Monitor and the Secretary of State come to a good solution for Stafford, and indeed Cannock, and I will continue to work with them and with my hon. Friends on that. Nobody should take from the Monitor report the message that whistleblowing or more transparency will result in threats to their local services. Indeed, Monitor would be acting contrary to section 62 of the Health and Social Care Act 2012 if it acted in such a manner.
Let me raise another, perhaps more justified, fear of the unintended consequences of transparency. Only this week, I heard of a case where a patient could have a life-saving operation, but his chances of surviving it are only 50:50, yet without an operation he will die. Some surgeons are, even now, reluctant to take on the operation because if the patient dies, it will be counted against them in their personal mortality statistics. That is an unintended consequence of transparency, so transparency has to be balanced with understanding the context; otherwise, we will end up with a risk aversion that is so great that patients will suffer.
Transparency can also thrive only in a culture that is not led by blame. One of the doctors who gave evidence to Francis said:
“There was a blame-led culture, the culture being that problems had to be fixed or nursing jobs would be lost.”
How can we persuade the most suitable people to take up vital, often voluntary, roles on trust boards if their attempts to raise problems are met by blame or indifference? As my hon. Friend the Member for Southport (John Pugh) said, transparency must start right here in Parliament. He spoke movingly about moral purpose, and I agree with what he said.
Dr Thérèse Coffey (Suffolk Coastal) (Con)
I agree that we do not want to deter people from becoming board members, but surely my hon. Friend must agree that if things are still going wrong and the board is not holding the chief executive and the leadership to account, its members’ positions should be questioned.
Jeremy Lefroy
I would never disagree with that. I entirely agree with what my hon. Friend says, but there is a danger that there will be so much adverse scrutiny that people will be afraid to come forward. We must challenge that and say, “You have every right, as a board member, to raise whatever you want, whenever you want.”
As I was saying, we need a proper debate here in Parliament on health care in this country, one not constrained by party dogma or blind nostalgia. It is up to us to have that debate and, as a result, give clear direction, rather than simply to react to whatever is thrown at us. We need to debate, for instance, the nonsense of pretending that it is entirely the responsibility of local trusts to deliver. So much is out of their control, be it per-patient funding, which is still far too variable, clinical standards, which are set almost in a vacuum by the royal colleges, or the impact of the European working time directive on costs, rotas and training. We need to debate the impact of the large number of specialisations in the UK—we have 61 as against Norway’s 30—which is driving up costs and driving out vital general medical and surgical expertise. We need to debate emergency and acute tariffs, which have, for many years, meant that hospitals around the country are squeezed and face forced reconfigurations that may not be in the best interests of patients.
Robert Francis also says that one of the main principles is to:
“Make all those who provide care for patients—individuals and organisations—properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service.”
He also says:
“There must be a proper degree of accountability for senior managers and leaders.”
Accountability was sorely lacking at Mid Staffs. There were attempts to see that responsibility stopped with the board. As I have already said, that is based on the fiction that it is somehow entirely in control of its own destiny. It is not. That does not absolve the board or management, but the responsibility is shared by those who determine so much of the environment in which they operate, including us here. Professional organisations, for instance, have procedures that make it difficult to dismiss staff who are unsuitable. The Government signed up to the working time directive without preparing for the financial and manpower consequences. And for managers, and indeed politicians, targets became more important than care itself. Again, that is our responsibility.
I have already said how strongly I oppose the blame culture, and I am not going to start blaming, but accountability involves responsibility, and far too few people have taken sufficient responsibility in this case. We must reflect and they must reflect on the message that that sends.
Too many inquiries have been left to gather dust on Department shelves, and not just the Department of Health. I and my hon. Friends the Members for Cannock Chase (Mr Burley), for South Staffordshire (Gavin Williamson), Stone (Mr Cash) and Members further afield, all of whom are affected, will not allow this one to gather dust.
Valerie Vaz (Walsall South) (Lab)
It is a pleasure to follow the hon. Member for Stafford (Jeremy Lefroy) and to pay tribute to him for the dignified way in which he has represented his constituency during the Francis report.
I begin by thanking the Backbench Business Committee for securing this important debate. The NHS in England has a budget of £108 billion and employs 1.35 million people, with just under half of them clinically qualified, so it is right that accountability is at the centre of the NHS, for the people who work there, those who use it and those who fund it. I am sure that all my hon. Friends who have spoken and will be speaking in this debate do not see it as a chance to score political points or as background noise to denigrate an institution that was set up with the simple promise that is delivered every single day—that health care is free to everyone, irrespective of their ability to pay or of pre-existing conditions. It still operates as a service in which people are not judged on their illness but provided with a service.
I know that the debate is taking place against the background of the Francis report, but I wish to point hon. Members to a book that is about to come out—it is by Roger Taylor and called “God bless the NHS”. It was serialised in The Guardian last weekend. Roger Taylor says in the book:
“Paul Woodmansey was a senior doctor at Stafford throughout the period that things went wrong; He is mentioned by a number of patients for whom his department provided a haven of professional high quality care while standards in other wards collapsed.”
Let us not forget then that, even when a light is shone in a corner of the NHS where it is found to have failed the very people it was meant to help, there are areas of good practice.
Let us look at the background of this debate on accountability.
Jeremy Lefroy
I am sorry to interrupt the hon. Lady, but I would like to point out that the same Dr Woodmansey has been appointed as the new medical director of the Mid Staffs trust Stafford hospital. I welcome that, for the reasons that she has articulated.
Valerie Vaz
Let us look at what is going to happen in 18 days’ time when the Health And Social Care Act 2012 comes into force. I do not want to rerun the arguments about the Act, but let us look at what is to come. Let us look at the accountability of the structures under the Act. The NHS Commissioning Board becomes the conduit for everything, including the flow of money, and all the strategic decisions filter down. If anyone cares to look at the Department of Health website and the new structure, they will see a series of concentric circles. Parliament, the Department and the Secretary of State all appear to be in the outer circle, running round in circles. Where is the accountability in that?
I have to tell the Secretary of State—although I am pleased to see him here, this is a Back-Bench business debate—that section 75 regulations were signed off, under a negative resolution, by a Minister who is not accountable to the House. Section 75 says that everything has to be tendered except for technical reasons, or reasons of extreme urgency. That had to be changed to state that contracts can be tendered if the relevant body is satisfied that the services to which the contract related are capable of being provided only by that provider.
Regulation 10 previously said that commissioners may not engage in anti-competitive behaviour; otherwise, Monitor will be after them. Sorry, those are my words. That was changed to say that commissioners must not be anti-competitive unless it is in the interests of patients.
What of the future? I pay tribute to the right hon. Member for Charnwood (Mr Dorrell), who made an excellent speech. I want to draw attention to a report that our Select Committee produced on complaints and litigation in June 2011. I urge the Secretary of State, if he cares to listen, to read that report and consider all the recommendations. Even then, we called for all providers to have a duty of candour to patients. We also said that we found it striking that the Government did not mention complaints in the information revolution consultation and were surprised that they did not see how complaints information could help people see what is going on. My hon. Friend the Member for West Lancashire (Rosie Cooper), who is no longer in her place, was right to say that complaints can provide information about what needs to be put right.
Mr Deputy Speaker, I am not sure whether you are aware that the NHS litigation bill has now reached £1.3 billion. I urge the Secretary of State to look into the reasons why that is happening. We have to redress negligence, but there are other reasons why that bill is rising. There are remedies that do not involve money or changes in structures or reorganisations.
Valerie Vaz
I cannot answer that; I am not on the Front Bench.
We all agree that there is no place for gagging clauses if lessons are to be learned about patient care. I agree that the Government have made an important announcement today, but let me remind the Secretary of State that the NHS issued management directions in 1999 and 2004. I am concerned that the NHS still needs reminding about these gagging clauses. We must get away from a system in which whistleblowers are driven out of their jobs on spurious disciplinary issues. At Mid Staffs, doctors and nurses are under disciplinary reviews, but as yet I have not heard anything about whether managers will also be held to account.
Action plans that arise from complaints are a vital part of organisational learning, but they are only of value if they are followed through to implementation, and it was clear from evidence to us in the Select Committee that that did not happen at Mid Staffs.
Publication of complaints data must be obligatory for all care providers, including foundation trusts and private providers with NHS contracts. We must move away, as the hon. Member for Southport (John Pugh) said, from the blame and victim culture and reduce the emphasis on disciplinary procedures. We must put more emphasis on retraining and risk management.
We should enshrine accountability for patients at board level, making boards more diverse, not just comprising the usual suspects. Private providers, as my right hon. Friend the Member for Leigh (Andy Burnham) said, are not subject to FOI; they must be. The register of GPs’ interests must be open to clinical commissioning groups. It should not be up to the public to ask whether GPs have declared their interests. Every decision must be associated with a list of GPs’ interests.
I have spoken to the chief executive of the Royal Orthopaedic hospital, who said that he ensures that doctors, nurses and managers are all on an equal footing, which is an example of good practice. His phrase is that there should be “no gap between board and ward”. He puts his patient groups on the board, every ward gets rolling visits and board members even feed the patients.
In my own way, I have also been accountable and I have published on my website a table of all the complaints my constituents have come to me about so that they can see what sort of things are going on at the Manor hospital. The chief executive of the hospital is undertaking a patient survey and ensures that he looks at all the responses.
I hope that I have outlined some positive aspects as a way of moving forward and that we will continue to have an accountable, transparent and unique NHS that is the best in the world.
Mr William Cash (Stone) (Con)
I believe strongly that we must not only look back properly at what happened at Stafford hospital but look forward. We must learn the lessons and we must ensure that what happens in future does not lead to the trauma experienced by the victims and patients in my constituency and those of my hon. Friends the Members for Stafford (Jeremy Lefroy) and for Cannock Chase (Mr Burley).
This is a debate about accountability and transparency and, as others have said, we also need a debate in Government time on the Floor of the House on the Francis report. On the question of accountability and transparency, I want to start with an issue that has not yet been properly considered in the debate: the role of the Secretary of State under national health legislation. Section 1 of such legislation clearly states the duties of the Secretary of State, and always has done. I was astonished, as I made clear at the time, when the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) left out that part of the question of accountability.
I have been involved in the history of this case. As the Member of Parliament for Stafford from 1984 to 1997 and the Member of Parliament for Stone from 1997 to the present day, I have had many constituents, including Debra Hazeldine, a prominent member of Cure the NHS, who have played an important role in drawing attention to these matters. I have worked closely with them over the whole of this period.
Contrary to what the right hon. Member for Kingston upon Hull West and Hessle said—I imagine it must have been a serious slip of memory—I wrote letters to him. Ministerial guidelines from 2005, issued by the Cabinet Office, set out in great deal what must happen when a Member of Parliament writes to a Secretary of State. He must receive a personal reply. I do not need to go into the full details now, but only the other day I asked the Minister for the Cabinet Office and Paymaster General to reaffirm the contents of those guidelines, which are still applicable.
There are only 650 of us, and serious matters can arise from the complaints we make. I am talking not about the complaints procedure of the national health service but about a Member of Parliament going to the Secretary of State to raise a specific question, usually enclosing correspondence from a constituent, and asking for action. In my case, I said that the matters I raised were both serious and urgent and that they required the personal attention of the Secretary of State. I have not the time to go into the detail, but successive Secretaries of State simply did not take the kind of action that I would have expected following those letters.
Alan Johnson
This is a fascinating subject and I am willing to have a look at any correspondence between the hon. Gentleman and me when I was Health Secretary. I certainly tried very hard to correspond with all Members of Parliament. Does he accept what Francis said:
“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…They might wish to consider how to increase their sensitivity with regard to the detection of local problems in healthcare”?
We all have lessons to learn from the Francis report; does he accept that he has lessons to learn, too?
Mr Cash
We all have lessons to learn about all matters relating to these questions, but the guidelines also talk about the necessity of chasing and following up in the Department. It is probably a question of the correspondence unit in the Department and the private office. There was a failure and the Francis report made it absolutely clear that the guidelines were not complied with and were not operated effectively. I am sure that the right hon. Gentleman, on reflection, will recall that that was what the report said.
I referred to these matters in my witness statement, and Una O’Brien, the permanent secretary at the Department of Health, also made it clear in her evidence that if such letters were received now, they would receive an immediate response, irrespective of whether the hospital was a foundation trust or not. The bottom line is that there was a failure within the Department and by successive Secretaries of State. The shadow Secretary of State acknowledged in his evidence that he looked at these letters. I will not dispute that. However, not only were the matters not dealt with satisfactorily, but I cannot absolve the Secretaries of State from their failure to agree to the 2005 Act inquiry.
I do not need to rehearse the history of the case. I asked not once, not twice, but repeatedly, and I had to urge and persuade the shadow Secretary of State at the time and also—I am glad that, to his great credit, he decided to do so—the present Prime Minister who, as Leader of the Opposition, decided in the light of my representations and no doubt those of others to have the 2005 Act inquiry. Without that we would not be discussing the Francis inquiry—the present one, not the previous one, important though that was—and the others. They were Government inquiries, but they did not do the job in the way the present inquiry did.
Andy Burnham
I am listening carefully to what the hon. Gentleman is saying. It is not strictly true to say that that was a Government inquiry. I brought in Robert Francis—will he acknowledge that?—in July 2009 to conduct an independent inquiry. As my right hon. Friend the Member for Kingston upon Hull West and Hessle (Alan Johnson) said, in presenting his findings Robert Francis said that he felt that more people had come forward because of the nature of that inquiry.
Mr Cash
I will let the matter rest at that point for the present purpose.
I move on to the next question of accountability, with respect to Sir David Nicholson. I referred to Sir David in a number of debates way back as far as 2009. I also referred to him in my evidence to the Health Committee, in my witness statement and in correspondence with the Francis inquiry. In my judgment, for the reasons that I have already given, there was a systems failure with respect to this whole terrible tragedy, not only in relation to Mid Staffordshire, but more generally.
We need to turn a new page. I am not saying that Sir David should receive a P45 now. What I am saying is that, sooner rather than later, it is essential that he departs his post. I disagree with the Secretary of State and therefore also, I admit, with the Prime Minister on this matter, and so do many others. Accountability must mean what it says, and in this context it means carrying the can. The whole saga took place on Sir David’s watch, even though he was not at West Midlands for more than a certain time, and the problems that have arisen carry with them issues of accountability.
I acknowledge that Robert Francis referred to scapegoats. It is not, as has been said before and I repeat, a question of blaming scapegoats. It is a question of responsibility and where it lies at the time. In my judgment it did not lie only with the Secretaries of State of the time. In fairness, they have apologised.
I conclude with a statement made by David Nicholson at a conference that took place a few months ago. He made it clear in that statement that he took personal responsibility for what had happened. It is very important that we recognise that he has apologised and that he has made a statement that is clearly an admission that he lost the plot when, as he put it, ward 10 in Mid Staffs was under severe stress. That is the problem and I believe he has to go.
Ann Clwyd (Cynon Valley) (Lab)
I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on securing this debate. It is with great regret that I continue to speak about issues of abuse and neglect in our national health service. As of now, I have personally received more than 2,000 e-mails and letters. The letters continue to come every day; I want to mention just a few. All who have sent them want their stories to be heard.
The first letter says:
“My mother died in August this year”—
that is, last year.
“I still feel so angry about her treatment. She caught a hospital-acquired infection that certainly contributed to her untimely death. The lack of care and compassion that I saw horrified me. Oh yes, the boxes were all ticked. Water jug, food, medication. And all left out of reach. A nappy put on her because they couldn’t be bothered to answer her calls for assistance to the toilet. A proud and dignified mother left to sit in her own vomit. I haven’t put my complaints in writing to the hospital, as it’s not going to change anything. But maybe writing to you will help. I need my voice to be heard.”
The second letter says:
“Our Dad died in January last year. His death was quite unexpected by us as he was an active, cheerful pensioner, who went into hospital in October 2012 to have a knee operation. Unfortunately, whilst in there, his condition deteriorated, he also acquired hospital-acquired pneumonia and died. Throughout his stay in hospital his family visited him regularly and our experiences were very similar to yours. We found it very difficult to find any staff to talk to or to help him and our Dad told us about all kinds of mistreatment, neglect and mistakes that he was having to endure. Unfortunately, although normally a strong character, he also became afraid of some of the staff, who appeared to be bullying him, but he was absolutely adamant that he did not want us to mention any of his mistreatment to anyone as he was convinced that, once we left, these staff would then treat him even more badly. So we found ourselves in an impossible position, watching our Dad deteriorate before us—he had stopped eating—and hearing shocking accounts of his ‘care’ where he refused to give us any names, and yet feeling quite powerless and unable to speak to anyone about this.
Of course, at this stage, we did not know that he was going to die and we were just counting the days till we could get him out of there, but that never happened in the end.”
I have a third case:
“My memories of my father’s treatment in hospital are still so raw. He, like so many others who have suffered under the ‘care’ of NHS staff, was a man who had shown such bravery in the war (he was a veterinary officer in the Chindits in Burma, behind the Japanese lines) and in his life after, he was a true gentleman and would do anything for others, and he would not complain. He had faced death many times and through his bravery had survived against all odds, but in the end his death was to be hastened because of hospital-acquired infections, and from care bordering on neglect. Tragically he died sad and utterly disillusioned. He simply could not believe that medical staff, including consultants, could treat him and others as they did. He had placed utmost trust in them, and most of them could not care less. He looked at me one day, with utter anguish and despair in his face, and in great pain, and said, ‘Oh Annie, I would never have treated any of my animals in this way.’”
The next letter says:
“My husband of 84 underwent extensive tests to determine the reason for his illness, which didn’t manifest itself until the pancreatic cancer which had remained undiagnosed spread to his bladder. During all this time my main concern was the lack of nursing care.
He had been shunted into a side room on his own for being ‘difficult’ and as far as I could see was simply ignored. On one visit I found him lying in his own excrement while the staff were gathered gossiping round the nurses’ station. All my requests to see a doctor were fobbed off, until one doctor mentioned casually in passing that a lump had been found on my husband’s bladder. No attempt was ever made to discuss his diagnosis with me.”
I have some shorter examples:
“I went to the nursing station on one occasion to see the entire Team bidding at the end of an eBay auction. I was kept waiting, ignored, until it was ended!”;
“first time in hospital mother had 2 broken wrists. No one would feed her when meals were delivered, despite the fact that she had 2 arms strapped up in the air! My aunt had to travel over 2 hours by bus every day just to ensure she was fed”;
“When visiting my wife… after an operation to mend her broken hip, I asked a nurse for help as she was being very, very sick. She announced ‘I am a graduate, I don’t do sick’, and left me to deal with the situation”.
As I said, I have received many letters. I have tried to acknowledge each one and respond, although obviously I cannot do so in detail. They keep coming. It is not something that pertains only in England; the same is true in Scotland, Wales and Northern Ireland. I have received similar letters for all parts of the United Kingdom.
Mr Aidan Burley (Cannock Chase) (Con)
May I thank the right hon. Member for Cynon Valley (Ann Clwyd) and say how sobering it was to listen to those stories? I join my hon. Friend the Member for Stafford (Jeremy Lefroy) in paying tribute to the families and loved ones of patients from Stafford and Cannock who had such appalling care and praise them for their strength in telling their stories. My hon. Friend and I will fight against any serious downgrading of Stafford hospital and, more importantly, from my perspective, any possible closure of Cannock hospital, which is managed by the same trust. I note that the Staffordshire Newsletter today launched its “Support Stafford Hospital” campaign, which I am sure we will both be supporting.
Today’s motion calls for accountability and transparency in the NHS. In relation to Mid Staffordshire NHS Foundation Trust, there are three areas that most need accountability and transparency: the granting of foundation trust status in 2009; the opposition to the public inquiry into what went on; and the “targets at all costs” culture. I will deal with each in turn.
We have the indignity and embarrassment of Mid Staffordshire NHS Foundation Trust being abolished by Monitor only five years after being granted that status. I want Members to think about that for a second. Only five years ago it was considered so outstanding and such an exemplar of compassionate care and sound finances that the right hon. Member for Leigh (Andy Burnham) awarded it foundation trust status on 1 February 2008.
Andy Burnham
May I just correct the hon. Gentleman? I was not a Minister in the Department of Health on 1 February 2008. Furthermore, the awarding of foundation trust status was the responsibility of Monitor, not Ministers in the Department.
Mr Burley
I believe that the right hon. Gentleman’s second point is incorrect; as I understand it, the Secretary of State—I accept that that was the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson)—signs off the awarding of foundation trust status. We know that he admitted to the public inquiry that he looked at just four lines of civil service evidence about foundation trust status before signing it off. Is that good enough for a Secretary of State? Why did he not look at it in more detail? Was he not really bothered? I think that was a dereliction of his duty to ensure public health in Staffordshire and that he should have the decency to apologise to the people in the Public Gallery who have come here today from my constituency and that of my hon. Friend the Member for Stafford.
Alternatively, was the foundation trust status signed off because of the culture of targets at any cost under the previous Government? Was organisational form, whatever it means, more important than patient care? We know locally that they wanted to prove that their foundation trust policy was a success, and that took priority over what it really meant for patients and their care. Members do not have to listen only to me on that point. Here is what a Mid Staffordshire NHS Foundation Trust non-executive said just this week in a public meeting in Rugeley in my constituency:
“Our problems started when they made 200 nurses redundant in 2008 to achieve an acceptable financial footing for Foundation status, but care standards slipped thereafter and by 2009 they had a £2m deficit.”
Everyone knows that huge pressure was put on David Nicholson by his political masters to have a foundation trust in the west midlands, and poor little Mid Staffordshire was the one that was forced through. In the interests of the accountability and transparency that the motion calls for, I want to hear an apology from those who forced through foundation trust status at a time when people were dying from appalling care and the trust was going bankrupt.
This is not just about politicians. If anybody is in any doubt about how ingrained the targets culture had become, let me quote from an old press release from Mid Staffordshire trust that I found, dated 3 October 2002. It has been taken off its website but is still findable if one looks around on the internet. It says, under the heading, “Babies’ Service of Remembrance”:
“A short service of Remembrance for those whose babies have died in the past few years is being held in the Pilgrim Chapel at Stafford General Hospital.”
Just seven days later, under the heading, “Good News from Mid Staffordshire General Hospitals NHS Trust”, it said that David O’Neill, the chief executive, was
“delighted to announce that the Trust has been short-listed to the last three for the National Partnership Industry Award for our Bed Management System”.
This culture is absolutely astonishing, and it simply has to change.
We have now had the public inquiry and Robert Francis has laid out in full gory detail the horrendous failings at Stafford hospital. One might have thought, given what went wrong, that there would have been cross-party support for a public inquiry, but not so. I presume that Labour Members now support the findings of the Francis inquiry. There were certainly many Labour MPs at the all-party health group meeting with Robert Francis on Tuesday, but I want to know how many of them were among the 260 Labour MPs who voted against a Commons motion calling for a public inquiry on 18 May 2009. [Interruption.] These might be uncomfortable facts for the right hon. Member for Kingston upon Hull West and Hessle, but let me point out that Labour Members ignored 81 requests for a full public inquiry into Mid Staffs between January 2009 and May 2010. They received 20 letters from MPs, 36 letters from members of the public and 25 letters from organisations. They ignored the families who protested outside the Department of Health for a public inquiry, including people from Cure the NHS.
The right hon. Member for Leigh, as he has said today, rejected a full public inquiry on the grounds that it would “distract the management”. He is welcome to intervene to tell me whether he now accepts that that judgment was wrong.
Andy Burnham
Will the hon. Gentleman acknowledge that I asked Robert Francis to conduct two independent inquiries into what happened? It is not the case that I was not doing anything. I made that judgment because I wanted to get to the truth of what happened while not overburdening the hospital with the job of getting better. I tried to strike that balance, and that is why I reached the judgment that I did.
Mr Burley
I will accept, as will, I think, everyone in this House, that the right hon. Gentleman has refused to answer the question again. He will not say whether that judgment was a mistake, and until he does so we cannot take what he says seriously.
The then Health Secretary, the right hon. Member for Kingston upon Hull West and Hessle, joined in the refusal to have a full public inquiry. He said to The Birmingham Post on 19 March 2009,
“I really don’t think with the greatest respect that a public inquiry is going to take us any further forward”.
Will he intervene to tell me whether he will be writing to The Birmingham Post to tell people whether it has taken us any further forward? He can scowl across the Chamber, but I am afraid that that is no answer.
In the interests of accountability and transparency, we need to know why the Labour Government opposed a full public inquiry into Mid Staffordshire. Why were they so afraid of finding out the truth of what went on? Is it really so important to protect the reputation of the NHS as an institution rather than to protect the patients whom it serves and who ultimately pay for it?
There are now abounding claims and counter-claims about Stafford and Cannock hospitals as a result of the indignity of having our foundation trust abolished. One would have thought that having forced through foundation trust status and opposed a public inquiry, Labour locally would have some contrition, but sadly not. The Labour leader of my local council and Labour’s prospective parliamentary candidate for Cannock Chase are now teaming up to
“fight plans they feel are aimed at privatising Cannock hospital.”
The leader of the council said that he was launching a petition against being
“victims of Tory privatisation plans”.
There are no plans in the Monitor report to privatise Cannock hospital, so I want to know where the local Labour party is getting its information from. In fact, as a result of the FT status, private providers are already operating in Cannock hospital. I note that there were no protests from Labour councillors when private health facilities were introduced into Cannock hospital. Again in the interests of accountability and transparency in the NHS, I call on Labour Front Benchers to stop their parliamentary candidates and council leaders scaremongering among local people for political ends. They cannot fight privatisation if there are no plans to privatise anything. They cannot start a petition to save Cannock Chase hospital if the Monitor report suggests making it a centre of excellence for orthopaedic elective surgery in the west midlands. They cannot oppose a public inquiry and then welcome all of its findings. They cannot force through foundation trust status for its own sake rather than for what it will achieve for patients; and if someone does force it through and it has the reverse, perverse effect of causing appalling care, unnecessary deaths and the bankrupting of the trust and its abolishment just five years later, they should be man enough to apologise.
I agree that we need to be more accountable and transparent. That starts from the top with Secretaries of State and goes down to the bottom to the local council leaders and their parliamentary candidates.
Barbara Keeley (Worsley and Eccles South) (Lab)
I was appalled to read in the Francis report on the Mid Staffs inquiry the stories of the unnecessary suffering of hundreds of people and, indeed, to hear the examples given by my right hon. Friend the Member for Cynon Valley (Ann Clwyd) in this debate. Those Mid Staffs patients were let down and there was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed and fundamental rights to dignity were not respected.
Our Health Committee has taken evidence from Robert Francis, who has said that there was a failure of the NHS system
“at every level to detect and take the action patients and the public were entitled to expect.”
He has summarised his own recommendations as: fundamental and easily understood standards; openness, transparency and candour; accountability to patients and the public; enhanced training for nurses and leaders; and ever-improving measures of performance.
In the short time available, I want to focus on two areas: first, accountability or, indeed, the lack of it in our NHS structures, and secondly—this has already been touched on—the question of what is good practice on patient safety.
The Health Committee is increasingly seeing examples of a gap in accountability in the restructured NHS and I will touch on one small example that we heard this week. We had a session with senior Department of Health staff—the director of mental health, the national clinical director of mental health and the deputy director of secure mental health services—who are responsible for advising Ministers on mental health strategy, for devising mental health legislation and for clinical leadership on mental health. They did not know that patient groups were reporting cuts to community mental health services or that they lacked access to therapeutic services, with very long waits.
Alison McGovern (Wirral South) (Lab)
Does my hon. Friend agree that scrutiny to make sure that the dignity of mental health patients is protected is of utmost importance?
Barbara Keeley
Indeed. It is disturbing that the people responsible for advising Ministers on legislation are not aware of what is going on. In fact, they started by trying to tell me that they thought that community services were still expanding, as they had been up to 2010. They did not have a picture of the services. Indeed, they told us that there was no routine collection of waiting times for mental health services and they did not have data on readmissions. They did not even seem to understand the trends involved in those important issues.
The exchange left me feeling very concerned about accountability in our new NHS structures. If staff at the most senior levels of the Department of Health who are responsible for strategy and legislation have no idea what is going on in health services across the country, that is serious. The major restructuring of the NHS seems to us—this has been mentioned by fellow members of the Health Committee—to represent a decline in accountability.
We need to learn from good practice to improve patient safety, which has been touched on by my hon. Friends the Members for West Lancashire (Rosie Cooper) and for Walsall South (Valerie Vaz). A major review is taking place of the 14 hospitals with the worst mortality rates. In recent Health questions, I told the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) that good practice in hospitals with low mortality rates should be investigated alongside the review of high mortality rates and poor practice in the worst-performing 14 hospitals. He did not take that point on board, so I will try again today.
I want to talk about what has been achieved at my constituency’s local hospital trust, Salford Royal NHS Foundation Trust. I visited the hospital recently in the wake of the Francis report and was impressed to hear what it has achieved over the past five or six years. It already seemed to have in place many of Robert Francis’s recommended actions, which I touched on earlier. Salford Royal has taken action on nurse staffing ratios, which my right hon. Friend the Member for Leigh (Andy Burnham) touched on; reducing MRSA infection and pressure sores; the transparency of patient information; and involving clinical staff in quality improvement.
Mr Jeremy Hunt
I completely agree with the approach that the hon. Lady is taking. One of the jobs of the new chief inspector of hospitals will be to identify the outstanding hospitals, the safest hospitals and the hospitals with the best compassionate care, so that other hospitals can learn to do the same things.
Barbara Keeley
That is very good. I hope that the Secretary of State will make that point to the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich, because he did not seem to appreciate it when I made it to him in Health questions.
Let me touch on what other hospitals might find if they start looking at the excellent practices at Salford Royal. I do not underestimate the importance of the terrible examples that we have heard about, but at the same time, my trust has had a quality improvement strategy since 2008, with specific projects that are aimed at reducing falls, unexpected cardiac arrests, surgical site infections, sepsis and other harms. Because harm tends to be caused to patients much more over the weekend—we have seen many examples of that in the cases that we have looked at—the trust has moved back to seven-day working in an attempt to achieve the same standard of care on the weekend and overnight as people receive on a weekday during working hours.
I believe that having the right nurse staffing ratios is vital to patient safety, but that issue keeps being glossed over by NHS leaders and Ministers. I have asked questions about it repeatedly in this House. Salford Royal uses a safe staffing tool to ensure that it works to safe staffing levels. There are minimum staffing requirements throughout the hospital and incident reports are completed if the ratios are not met. Each division reviews its staffing establishment every day and escalates concerns if the numbers fall below the minimum safe level. Salford Royal is a mentor site for nurse rounding which, as we have heard, means that nurses go round their patients each hour to ensure that their needs are being met.
My right hon. Friend the Member for Cynon Valley gave examples that showed the impact of hospital-acquired infections. All the work that is done to reduce MRSA and other infections is crucial. As in the other examples of flattened hierarchies that we have heard about, anyone at Salford Royal can challenge others on issues related to infection control. There is also mandatory training in aseptic non-touch techniques.
Teams design their own quality improvement projects in a clinical quality academy. There has been a specific quality improvement project over the past two years that is aimed at reducing the number of pressure ulcers. Each pressure ulcer is declared, the root causes are analysed and the patients are involved in the investigations. Nurses can monitor the positioning of patients on their hourly rounds and help to turn them if required. Those examples of good patient care can help us to get over the kinds of awful care that have been described today.
My final point is about transparency. Patients and families can check the harm data, because they are shown on a whiteboard at the entrance to every ward. The board records not only how many days it is since the last MRSA infection or pressure ulcer, but provides assessment scores on 13 fundamental nursing standards. Such public reporting to patients and families is important because it aids accountability and helps staff to feel accountable for the standards on their ward. We need that now more than ever.
Unsurprisingly, Salford Royal has achieved the highest rating in the NHS staff satisfaction survey for acute trusts in the NHS. Staff are supported to challenge existing systems and test new ideas to improve standards. I am aware of how much of a contrast that is to what we have heard this afternoon. The NHS is a system in which one area has had a catastrophic failure at all levels of patient safety, while other areas have achieved the highest standards of safety and patient care. We must look at both if we want to understand why that is.
Dr Sarah Wollaston (Totnes) (Con)
I want to start by thanking the vast majority of staff in the NHS, who go to work every day motivated to serve their patients and deliver world-class care.
We should not think that we can just return to the halcyon, storm-free days of the 1970s, when NHS care was perfect. Before I started medical school, I worked as a nursing auxiliary, which would now be called a health care assistant, in what was then known as a geriatric hospital. I have no wish to return to the days of vast, mixed wards and a rather authoritarian approach to care. I would far rather the NHS of today than that of the 1970s.
However, the mantra that the NHS is the envy of the world sometimes gets in the way of providing decent feedback and criticism when things go wrong—and after listening to the words of the right hon. Member for Cynon Valley (Ann Clwyd), who could say that things do not go wrong? The failures at Mid Staffs, and the fact that more than 1,000 people died in a single hospital, are truly shocking. Robert Francis told the Health Committee that he had spent three years of his life “listening in horror”—how shocking! It is hard to imagine any other institution or organisation where death on that scale would not have led to prosecutions, yet too often in the NHS it is not prosecutions that follow but promotions, just as it was in this case.
It has, unfortunately, become something of a heresy to criticise the NHS, and my comments are not to be interpreted as criticising the vast majority of staff, but rather as a means of considering how we can help those staff and their patients. It is vital that NHS staff are free and feel safe to raise concerns. This week, at a meeting in the House that I was chairing, Robert Francis spoke about “complaints being a gift”, but that is not the experience of staff or patients within the NHS.
The Health Committee conducted an inquiry into complaints and litigation in the NHS that reported in June 2011, and I wish to read from the chilling evidence that we heard from Nicola Monte. She spoke of her experience of being barrier-nursed in Stafford, and said that a nurse came into her room and berated her saying, “I have been off sick because of you complaining about me. Do you realise the suffering you have caused me?” Too often, staff end up feeling that they are victims because—as they know—they are often scapegoated for what are system failures, often by management. That runs throughout the NHS; the response to complaints is defensive and dismissive and that must change if we are to implement what Robert Francis rightly recommends as a new culture change of openness, transparency and candour within the NHS.
I hope, however, that no one will think that introducing a statutory duty of candour can be a single approach. That will not work without a culture change that supports and welcomes complaints as a “gift” to identify problems and improve care. I hope the Government will implement in full the recommendations made by Robert Francis so that complainants are regarded not as the problem but as part of the solution.
I particularly welcome the Secretary of State’s announcement that gagging clauses are to be outlawed with immediate effect throughout the NHS but—I hope he will not mind my saying this—that must extend to the top of the system. Would the Secretary of State feel it appropriate for David Nicholson’s secretary to have the following clause in his or her contract:
“That they should avoid associating themselves with recommendations critical or embarrassing to the NHS commissioning board”?
I think we would find that wholly unacceptable, yet, if I may refer Members to the ministerial code of conduct, the Secretary of State’s Parliamentary Private Secretary, who is not a member of the Government, has exactly that clause within his contract. That is something we have to change because the culture of the NHS must extend from the Department of Health to the nursing auxiliary—or health care assistant—at the bedside, and to patients so that they and those around them feel safe and able to raise complaints.
Mr Cash
Is my hon. Friend aware that Public Concern at Work, to which I referred in my witness statement on Stafford hospital, has played a big role in highlighting whistleblowing and has set up a commission to look at that issue? The outlawing of gagging clauses should apply not only on severance, but also—emphatically—when people are in post so that they can be properly protected when acting in the public interest.
Dr Wollaston
I absolutely agree. This is about starting to identify the culture and values of the people we employ in the NHS, and making it clear that not only does everyone in the NHS have a duty to bring forward concerns, but that those concerns will be welcomed and acted on. I would like everyone in the NHS to have an individual to whom they can go and feel safe in raising their concerns. I thank my hon. Friend for raising that point.
My hon. Friend the Member for Reading East (Mr Wilson) has told me that he does not feel that he has been gagged, which is great, but there is still an important point of principle: as a PPS, he is not able to speak in this debate. We want everyone, from the very top of the NHS and the Department of Health, right through to the bottom of the system, to feel that they are fully free to raise any concerns they have, wherever they may be.
After the Bristol heart scandal, whistleblower Stephen Bolsin was asked how we could prevent this from ever happening again. He said:
“Never lose sight of the patient.”
His whistleblowing cost him his career. He first raised the alarm in 1989. His work over six years to raise his concerns remains one of the single most important improvements in clinical outcomes in the NHS—that is how important whistleblowers are to our system. Yet the scandals keep happening. Would it not be a tragedy if, five years from now, we were still saying, “We need to put patients at the heart of everything we do in the NHS”? It is time to make that happen.
Frank Dobson (Holborn and St Pancras) (Lab)
I congratulate the hon. Member for Stafford (Jeremy Lefroy) on his thoughtful contribution to the debate. We all owe it to the people of Stafford and those round about, all of whom depend on Mid Staffs, to ask the Secretary of State to guarantee that nothing and no one is allowed to use the horrors that occurred as an excuse to close the hospital or to run it down. That would punish the local people, the potential patients, and the good staff at the hospital. I hope he is willing to make whatever organisational changes—extra cash, or new ways of financing parts of the health service—are necessary to make that guarantee to the people in that area.
I started off as Health Secretary fully in favour of transparency. My last job before I became an MP was working for the local government ombudsman. It was my view, and it remains my view, that the best way to deal with anything that has gone wrong is to stand up and say, “Sorry, I got it wrong.” However, there is a problem. We are asking people in the NHS to operate in two different worlds. If something goes wrong in the hospital, the GP’s surgery or the clinic, we say: confess straight away. That is one world—the official world. People then get in their car, drive out of the car park to go home and bump into another car. What happens? Their insurer says, “Whatever you do, don’t accept any responsibility.” We need to recognise the clash of different worlds that people live in.
When the excellent hon. Member for Aldridge-Brownhills (Sir Richard Shepherd) introduced the Public Interest Disclosure Act 1998 to protect whistleblowers, I made sure that the Labour Government supported it, and that the provisions covered the national health service. There were those who did not want it to cover the NHS. I am delighted to say that I anticipated that some might want to have disappearance clauses in contracts—gagging clauses—and issued a circular that prohibited them. Any health body that has inserted such a clause is breaking the terms of the circular that was sent out in my name in 1999.
I also established the Commission for Health Improvement. It was intended to monitor and improve standards, and it was the first time in the history of the national health service that such a body had been set up. At that time, there was no machinery in the NHS for identifying good or bad practice, or for promoting good practice more widely and eliminating poor practice. I also required all health boards and chief executives to be responsible for the quality of treatment and care. No such obligation had been placed on them before, and that was a step in the right direction.
The hon. Member for Stafford rightly said that if transparency is to be based on experience and on data, those data have to be fair. We cannot have a situation in which someone who performs regular, straightforward surgery is compared favourably with someone who treats people in desperate circumstances and therefore has a greater chance of the operation or treatment going wrong. Everyone in the medical profession has got something wrong, and some have done so quite a few times.
If we are to have transparency in the provision of services to NHS patients that are paid for by public money, that transparency must apply not only to the NHS providers but to any other franchised provider of services. I know from experience that, when our lot were selling off a GP practice in my constituency, we were told that we could not find out the terms of the contract because it was commercially confidential. If we had been able to see the contract, we might have spotted that it enabled the contractor to leg it if things got difficult, which is what it duly did.
However keen Government Members might be on involving the private sector—I freely admit that I am not, but they are—they must ensure that patients and others are not denied information on the ground of commercial confidentiality. I strongly support the idea of making whistleblowing a duty, and that duty of candour must apply to any private sector provider. We cannot have them hiding away behind their private profit-making efforts. We must also ensure that, when anything goes wrong, the Secretary of State will answer to the House of Commons. We do not want anyone coming along and saying, “It wasn’t me, guv, it was the commissioning board wot got it wrong.” We must make it absolutely certain that our national health service is responsible to us here.
My final point is that I am sick to death of what is happening at the Whittington hospital. In order to qualify for trust status, it is being told to reduce the ratio of nurses to patients, yet it is already one of the five safest hospitals in the country.
Stephen Barclay (North East Cambridgeshire) (Con)
I join other Members in welcoming the Government’s announcement today of a ban on gagging clauses, but is it not surprising that we need such an announcement? The right hon. Member for Holborn and St Pancras (Frank Dobson) has just told the House that he issued guidance on this issue in 1999, and we also have the Public Interest Disclosure Act 1998 and the 2004 guidance. My right hon. Friend the Member for South Cambridgeshire (Mr Lansley) even put these conditions in the NHS constitution, and yet we find that we need an announcement on the matter today. My hon. Friend the Member for Stone (Mr Cash) has been repeatedly assured that there is no problem. I raised the issue in some detail with Sir David Nicholson in the Public Accounts Committee on a number of occasions, and I was constantly told that there was no need for change, so does Sir David agree with today’s announcement? Indeed, is a change being announced? Will the Secretary of State confirm that this announcement covers all payments, including those through judicial mediation, and will it apply retrospectively?
There seems to be a striking uniformity as between both Front-Bench teams when it comes to telling us that Sir David Nicholson is a wonderful manager, yet he did not know about the high mortality figures—even though they have been published in national newspapers since 2001; even though his own staff were logging in to the Dr Foster data; and even though the figures were high when he was the chief executive of the strategic health authority that was responsible for Mid Staffordshire. He did not know about gagging clauses when he was the accounting officer; he did not know about fixing mortality codes, yet they are now subject to police investigation. As he told the Health Select Committee, he did not know about judicial mediation—a flaw in the system, yet he is responsible for system and controls. He did not know about the Gary Walker case.
My hon. Friend the Member for Bristol North West (Charlotte Leslie) says that she has concerns about the US reports, but once again, Sir David seems not to know about them. He did not know about the Royal College of Surgeons 2007 report into Mid Staffs, which raised serious concerns, as my hon. Friend the Member for Stone is well aware, but in respect of which no action was taken. In other areas, too, we should remember that he was not just the accounting officer for the wonderfully successful NHS IT programme, but the senior responsible owner. We are told that he is a great manager, but it is difficult to see the evidence to sustain that claim.
Mr Cash
In a conference on 4 October 2012, I understand that Sir David Nicholson said that
“the senior leadership of the NHS and I was part of it in those circumstances”
but “lost the plot”. He continued:
“We lost the reason why we were there. We got so excited about…changes”,
but he went on to acknowledge that
“on ward 10 in Mid Staffordshire Hospital really bad things were happening”.
That is the sort of admission that he had to make in those circumstances. Does my hon. Friend agree that that amounts to admitting responsibility for the system’s failure?
Stephen Barclay
I do agree with my hon. Friend, and that does seem at odds with the Government’s welcome commitment to promoting individual accountability. In response to the Robert Francis report, the Prime Minister talked about three fundamental problems with the culture of the NHS. Of course that went beyond one individual.
I am concerned about the timing of the announcement of the appointment of Barbara Hakin, a close ally of Sir David Nicholson. It is important to note that she is innocent of any allegations being made against her, but I understand that she is under investigation at the moment. The timing of the appointment, then, seems strange. I invite my right hon. Friend the Secretary of State to intervene to clarify whether he was told of Barbara Hakin’s appointment prior to it being made. If he was not told, does not that say something about the power that Sir David wields within Richmond House?.
A further issue is whether Parliament knows the quantum or scale of the payments made to whistleblowers. I have repeatedly raised this matter over the last two years and was finally given a figure of £15 million paid over three years—silencing quite a lot of people. It now emerges, however, that that is not the whole story, as it does not cover payments such as the one for Gary Walker, which was paid through judicial mediation.
As seen in the NHS manual for accounts, each NHS body or trust is required to compile a register detailing all special payments made, including those through mediation. As I understand it, even the Department of Health does not know how many such payments have been made—and that applies to the Treasury, too. In a response to my parliamentary question this Tuesday, the Minister said:
“Approval has not hitherto been required by the Chancellor or the Secretary of State for Health for special severance payments made as a result of judicial mediation. However, as of 11 March”—
this Monday—
“approval will be required.”—[Official Report, 12 March 2013; Vol. 560, c. 182W.]
The position seems to be moving as of this week. Parliament does not know how much has been paid to whistleblowers, so will the Minister clarify when we will know?
In my Adjournment debate of a week last Monday, my hon. Friend the Member for Bracknell (Dr Lee) asked whether the chief executive of Mid Staffs was subject to a gagging clause. We received a welcome reassurance that we would be given an answer, but when we were on our way to the Chamber for this debate, my hon. Friend told me that he had received none. I hope that the Minister will clarify whether Mr Yeates was subject to a gagging clause.
Mr Burley
Is my hon. Friend aware that Mr Yeates left in 2009 with an £80,000 pay-off and a six-figure pension lump sum before moving to a job with a charity called IMPACT Alcohol and Addition Services, based in Shropshire, and that he refused to give oral evidence to the inquiry because of a unique form of post-traumatic stress disorder? Where is his accountability?
Stephen Barclay
My hon. Friend is right. Not only did Mr Yeates leave with, I understand, a significant payout, but he went to work for a charity that was in receipt of Department of Health funds. I think that as a matter of urgency we should clarify the terms on which Mr Yeates left the NHS, what Ministers knew, and what senior officials—in particular, David Flory—were aware of at the time of his departure.
I fear that we are in danger of sending a confused message to staff and families of patients in the NHS. On the one hand we say that the culture needs to change, but on the other we say that the people who are responsible for that culture—the people who are paid significant sums to lead it—should stay.
My hon. Friend the Member for Totnes (Dr Wollaston) is absolutely right: there is much in our NHS that we should celebrate and of which we should be proud. However, we do it a disservice if we are not prepared to identify where it is going wrong, and to be transparent about the areas with high mortality and about the existing culture which has a chilling effect on those who are brave enough to speak out. Is it not informative that the one person who spoke out at the Bristol inquiry, and who did so much good, is the one person who has never worked in the NHS again?
I think that the challenge for the House today, and in subsequent weeks, is to ensure that this time it learns the lessons that were clearly not learnt then.
Mr Virendra Sharma (Ealing, Southall) (Lab)
Thank you, Mr. Speaker, for allowing me to speak in this important debate. I congratulate all those who made it possible.
In the light of the tragedies at Mid Staffordshire and Winterbourne View, it is clear that some of the mechanisms for ensuring accountability and transparency in the NHS must be reviewed. Safeguards need to be put in place to make our NHS more accountable. That means listening to the concerns of patients, heeding the advice of NHS staff, and ensuring that whistleblowers are correctly protected.
Patients have always been, and always should be, at the centre of the NHS. It is true, of course, that the discoveries made at Mid Staffordshire do not represent the typical experiences of NHS patients, and that nurses and doctors deliver great care for patients every day, but it should not be possible for the failings of Mid Staffordshire to be replicated. If such failures are to be prevented in future, patients’ voices must be heard, and patients must receive clear assistance and information about their treatment.
Figures from the national cancer patient experience survey show that only 64% of patients felt they were able to discuss their concerns and fears with staff in the hospital, and that just over 50% were given information about the financial support to which they were entitled. While the survey goes a long way towards ensuring that there is more transparency, some of those figures are worrying. A large proportion of cancer patients still feel that they are not given sufficient information, or that they are unable to relay their concerns to those who are caring for them.
We welcome the creation of bodies designed to establish greater accountability to patients and the public by giving them a stronger voice in the Health and Social Care Act 2012. However, many councils across the country are still unsure whether they will have a running local HealthWatch in coming months, or have not even signed contracts with organisations to run it. These bodies are crucial in providing accountability for NHS patients; without them, the public does not have a voice.
One of the main reasons for the failings at Mid Staffs is the existence of a culture of covering up mistakes. Those who tried to speak out were bullied, hassled and silenced. It is crucial that NHS staff are allowed to voice their opinions without fear of unjust repercussions.
The previous Labour Government made huge inroads in helping NHS staff raise their concerns and in protecting their rights. These have, however, not been sufficient. I also have to commend the Secretary of State’s timely decision to ban gagging clauses in severance agreements. However, should not the Government be making it easier for NHS staff to voice their concerns while they are still in employment? We have seen many examples of consultants, doctors, nurses and other staff who spoke out about the failings of Mid Staffs and who were persecuted and struck off for doing so, and about NHS staff who felt unsupported and bullied by their supervisors to hide their concerns.
I must mention the case of Dr Narinder Kapur, one of Britain’s leading neuropsychologists and now campaigner for fairer treatment for whistleblowers. Out of his moral and ethical responsibility as a doctor, Dr Kapur alerted the NHS of certain failures he observed within his department, such as under-qualified, unsupervised staff treating patients and putting them at risk. His dismissal by the Cambridge University Hospitals NHS Foundation Trust was ruled unfair, but he still was not reinstated. This man, who was one of the best neuropsychologists in the country and was trying to help his patients and make his hospital a better place, was left penniless and lost his home.
The Government need to do more to ensure that NHS staff who blow the whistle on unethical practices do not receive the same treatment as Dr Kapur, and are protected from such persecution. Hard-working consultants, doctors, nurses and other staff who want to make the NHS a better place should not fear for their jobs and should not be bullied by their supervisors. Patients should be assured that they have recourse for complaints and that their voices will be heard. What will the Government do to protect patients and change this culture of covering up and bullying, to ensure that we do not have another Mid Staffs and to make the NHS more transparent?
Steve Baker (Wycombe) (Con)
My constituent Edward Maitland was a frail man who could not eat solid food following tongue surgery. He was admitted to Wycombe hospital from his warden-controlled accommodation suffering from dehydration, shortness of breath and weight loss, things from which he should have recovered. His son, a paramedic, clearly explained on his father’s admission that Mr Maitland could not eat solid food and he also provided liquids. About three weeks later Edward Maitland had died from aspiration pneumonia. At the post-mortem, Weetabix was found in his lungs.
Of course, the investigation was taken extremely seriously and the documentation is, up to a point, very professional. Under “root cause”, it states:
“The investigation found that there is no evidence to support robust communication between nursing and medical staff…No SBAR”—
situation, background, assessment and recommendations—
“documentation was used in EMC or in handover to Ward 6B this would have highlighted the patient’s nutritional needs.”
It proceeds to make some “recommendations”, but I want to highlight the “lessons learned”:
“To care for all patients with a holistic approach and the multi-disciplinary team must focus on all health concerns.
Better communications between all staff members, this should be ongoing and involve all the different professionals who may need to collaborate the care delivery plan. This collaboration and communication should involve the patient, family and the healthcare staff.”
Unfortunately, that is bread-and-butter, typical stuff—and managerial gibberish.
What I learned is that two words would have saved the life of Edward Maitland: “no solids”, written on the records at the end of his bed, on his wristband, and above his bed. The situation in his case is very simple. A man died who ought not to have died. He should not have died in these circumstances.
I have the hard task of saying, therefore, that I look to the courts, and the Francis report helps me. Recommendation 13 of the report, on fundamental standards, refers to:
“Fundamental standards of minimum quality and safety, where non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations.”
Elsewhere, the report discusses at some length—I do not have time to go into detail—a regulatory gap in relation to the Health and Safety Executive:
“It should be recognised that there are cases which are so serious that criminal sanction is required, even where the facts fall short of establishing a charge of individual or corporate manslaughter. The argument that the existence of a criminal sanction inhibits candour and cooperation is not persuasive. Such sanctions have not prevented improvements in other fields of activity.”
I took legal advice. I approached a retired circuit judge in my constituency, who in turn approached a firm of lawyers. I am most grateful for the guidance of Kate McMahon, of Edmonds Marshall McMahon, who has provided me with considerable free legal advice in relation to this case. The firm specialises in private criminal prosecutions. She has explained that, at least at the preliminary stage, there may be a corporate manslaughter case to answer, and liability for gross negligence manslaughter may well be attributable to one or more employees of the hospital.
I do not want people to be prosecuted unnecessarily, or to see taxpayers’ money wasted, but I do want accountability, and I believe that in the end the courts provide that crucial accountability. Edward Maitland’s son Gary now has this advice, and I have left it to him to decide whether to approach the police. I have briefed the police superintendent in Wycombe on the circumstances. I believe that the courts should be the ultimate way of sanctioning the NHS. Francis agrees, and I hope he will provide a policy in this area.
There should be more democratic control. I am delighted—
Frank Dobson
Does the hon. Gentleman not agree that one characteristic of involving lawyers is that there is a lot of money around, and it goes to them? Would it not be better spent trying to ensure that performance standards are enhanced, rather than employing lawyers to have a go at the people who got it wrong?
Steve Baker
Of course I would rather that the money was spent on standards and performance and not on prosecutions, because I would rather the problems did not occur. I do not wish to lecture the right hon. Gentleman, and I feel sure he did not quite mean it this way, but if we do not intend to apply the law of corporate and individual gross negligence manslaughter, let us repeal it, or amend it so that it does not apply to the NHS. I have to say to the right hon. Gentleman that it does apply to the NHS and that in certain cases, as Francis has said, things are so bad it should be applied.
I ask the Government to look at democratic control. I am delighted that the Secretary of State is reforming the Care Quality Commission, but how can we make sure that there is more direct accountability, perhaps to the health and well-being boards, and the overview and scrutiny committees? How can we give them the power to sanction or perhaps even, through due process, dismiss a board or a chief executive?
I think here of Paul Ryan, a man with vascular disease who had lost one leg already when he found himself sick. He had four days of GP visits and spent nine hours in accident and emergency on a Friday. He was then sent home, having had an MRI scan, after which he was expecting to lose his leg on the Monday. He was told to expect a phone call, but no phone call came. The Ryans eventually called 999 and were told that it was better to get a GP. The GP arrived and called an ambulance. It took two hours for that to arrive and Paul Ryan died in the ambulance with his wife on the way to hospital.
Mr Cash
Does my hon. Friend agree that accountability does reside also with the Secretary of State, as set out in the national health service legislation? That is essential in relation to our functions in this House and those of this Secretary of State and former Secretaries of State.
Steve Baker
I am grateful to my hon. Friend for his point, although it has been examined at length, so I do not want to go down that rabbit hole with him—I hope he will forgive me.
The post-mortem on Mr Ryan indicated that he probably would have suffered the same fate in any event, but the system let the Ryans down—Mrs Lyn Ryan made that point to me and to the local newspaper. Unfortunately, the case plays right into the fears of the public in Wycombe, because we lost our accident and emergency facility in 2005 and we recently lost our emergency medical centre. We have just had two similar repeat occurrences of the minor injuries unit failing to refer people across the car park into the excellent cardiology and stroke units. We have seen an enormous range of little problems, for example, an 85-year-old lady with dementia was sent home in a taxi at 2 am in just her hospital gown. This cannot go on, and the public’s concerns are justified. The trust is being investigated by Sir Bruce Keogh and although I have heard good reasons why its mortality levels are justified—they relate to running hospice care, in particular—this must be taken as an opportunity to improve things.
Finally, I wish to make a point on transparency. Yesterday, I spoke to Anne Eden, the chief executive of the trust. I am not going to put on the record the entire content of the conversation, but when I told her that I intended to raise this issue of corporate manslaughter on the radio this morning, I was told, in terms, “To protect the reputation of the Buckinghamshire trust, legal action would be sought.” This is a matter of public interest being raised by a Member of Parliament in good faith, but I have had to—[Interruption.] To be fair to her, she was talking about the radio. But I have had to rely on privilege to protect myself from being sued on this matter. It is not acceptable that such a matter should have to come to a Member of Parliament, simply to rely on privilege. The situation reinforces something I have experienced again and again since becoming an MP: second-hand rumours and half-truths about the state of health care in Buckinghamshire. I have encountered: people stymied; people thinking it is helpful to give half a rumour to a friend to repeat to me so that I can know how bad things are; and people’s frustration at not being able to do anything. I know that Buckinghamshire Healthcare NHS Trust is obviously close to your heart, Mr Speaker. I know that it expects to satisfy Sir Bruce Keogh, but it is really time for proper accountability and that must include the courts.
Mr Andy Slaughter (Hammersmith) (Lab)
Two NHS stories were leading the news this morning, both of which are relevant to the subject of this debate. The hon. Member for North East Cambridgeshire (Stephen Barclay) and my hon. Friend the Member for Ealing, Southall (Mr Sharma) have talked about the important issue of whistleblowers. I want to talk about the other subject, which is the conflicted interests of clinical commissioning group members.
All hon. Members should be grateful for the British Medical Journal report that was the basis of this morning’s new stories. In case anyone has not seen it, let me read the headline points. It states:
“More than a third of GPs on the boards of the new clinical commissioning groups (CCGs) in England have a conflict of interest resulting from directorships or shares held in private companies”.
It continues:
“conflicts of interest are rife on CCG governing bodies, with 426 (36%) of the 1179 GPs in executive positions having a financial interest in a for-profit private provider beyond their own general practice—a provider from which their CCG could potentially commission services.
The interests range from senior directorships in local for-profit firms set up to provide services such as diagnostics, minor surgery, out of hours GP services, and pharmacy to shareholdings in large private sector health firms that provide care in conjunction with local doctors, such as Harmoni and Circle Health.
In some cases most of the GPs on the CCG governing body have financial interests in the same private healthcare provider.”
Yet the cheerleader for the privatisation, Dr Michael Dixon of NHS Alliance says:
“The priority is to move services out of hospital and into primary care. The reason this hasn’t happened to date is because of blocks in the system. It’s more important to remove those blocks than be preoccupied with conflicts of interest.”
I say that the British Medical Journal has done a good job, but it has only just scratched the surface. I shall refer to my own experience of trying to get to the bottom of this matter in north-west London.
On 10 November an article by the social affairs editor of The Guardian began:
“Five family doctors have this week become millionaires from the sale of their NHS-funded firm to one of the country’s biggest private healthcare companies in a deal that reveals how physicians can potentially profit from government policy in the new NHS.”
It went through the individual shareholdings of those doctors who had sold out to Care UK and it continued:
“Another winner seems to be NHS reform champion Ian Goodman. The north-west London GP chairs the Hillingdon clinical commissioning group and was also a board director of Harmoni. He could make as much as £2.6 million.”
John McDonnell (Hayes and Harlington) (Lab)
This Dr Goodman chairs my local CCG and tried to force Hillingdon hospital to put £13 million of operations out to tender, which would have destabilised the whole hospital. I pay tribute to the Treasurer of Her Majesty’s Household, the right hon. Member for Uxbridge and South Ruislip (Mr Randall) and the Parliamentary Secretary, Cabinet Office, the hon. Member for Ruislip, Northwood and Pinner (Mr Hurd), who joined me in preventing that from happening. It would have meant Hillingdon hospital being financially destabilised in the long term.
Mr Slaughter
I am grateful for that. I did a company profile for Harmoni. It revealed that, although he might have sold his shares for that amount of money, Dr Goodman is still listed as head of clinical spine. A series of press articles deals with the failings of Harmoni—failures that have caused deaths through under-staffing or poor-quality staffing—and why it is under investigation.
Let me return in the time I have available to my attempts to get to the bottom of the matter. The same day as I read the article in The Guardian, I wrote a short letter to the chief executive of the NHS in north-west London. I said:
“I attach the front page article from today’s Guardian, which you may have seen, regarding the sale of out of hours GP service provider Harmoni to Care UK. The article states that a number of GPs will make substantial sums from the sale.
I note that four of the CCG chairs in NW London declare shareholding or directorship in Harmoni, as does your Medical Director. It would be helpful to know if they are beneficiaries of the sale and by what amount.”
I then asked for assurances as to the future.
A month later I received a non-reply reply, the most relevant sentence of which was:
“Any member who declares an interest in a meeting is expected to take no part in discussions and step out of the meeting.”
I wrote back a much longer reply, in which I pointed out that the chair of the Royal College of General Practitioners had said:
“it is not about excluding yourself from the room whenever there is a discussion; it is about how it will drive your decision-making overall”.
I pointed out that, as a consequence of hospital closures in north-west London, there had been a shift in funding from hospital to primary care, a greater involvement of private companies in the primary care sector, and an opportunity for those companies to increase their profits by cutting back on the level of service offered.
I principally raised the fact that the information that should be provided is not provided on declaration of interest forms, especially the scope and value of any interest. I listed doctor by doctor and CCG chair by CCG chair what those interests were and how they were not adequately declared. I dealt with seven out of the nine CCG chairs and the medical director. That was in a letter on 20 December.
I received a reply on 3 February which said:
“The Cluster does not hold this data.”
So three months on from my original inquiry, I am none the wiser in relation to these matters.
I advise any hon. Member to look at their CCG declarations of interest online—not Hillingdon, because it does not publish them online. I use Hammersmith and Fulham as an example here. The husband of one member is a partner of Drivers Jonas Deloitte. The first thing I found on the website of Drivers Jonas Deloitte was that it had been appointed to sell the Kent and Sussex hospital in Royal Tunbridge Wells when it closes in 2011. Another member is the owner of a provider of home care services. Another is the brother of the director of a design company that holds a number of contracts with NHS organisations. It might be that none of them has a direct financial pecuniary interest now or in the future, but it shows touching naivety, complacency or worse.
Before the 28 members of the joint PCT board made the decision to close the four A and Es in north-west London, I said at the public meeting that if any of them had or was likely to have interest of a pecuniary nature they should not take part in that decision. One of them rather touchingly volunteered the information that they had sold their shares. What world are we living in when a third of GPs on the new CCGs can hold financial interests in anything from land sales to an alternative provider?
I raised the question with the Prime Minister yesterday and mentioned Dr Goodman, although not by name, and his estimated minimum return of £2.6 million. Again, I got a non-reply in reply. Sooner or later the Government will have to address these matters.
There is another story in the Daily Mail today that states:
“In 1981 there were eight NHS press officers in Britain. Now there are 82 in London alone”.
It is not that there is a lack of spending on publicity in the NHS. Indeed, almost £1 million has been spent on a private consultancy firm simply to carry out the bogus and botched consultation on the closure of A and Es.
We are seeing the creation of a second-grade health service in north-west London.
Barbara Keeley
A number of months ago, I raised the case of a person who rejoices in the title “NHS head of brands”. There seem to be a whole set of units that keep cropping up.
Mr Slaughter
I am sure that all Members will have similar examples. It is an obscenity that millions of pounds are being spent on spin and disinformation while basic information is not being provided even to Members of Parliament after three months and persistent requests. Sooner or later, these issues will have to be addressed.
Of course, our main preoccupation is to maintain our first-rate health service—our blue light A and Es, our stroke centres and our major hospitals—rather than having it replaced by urgent care centres and minor primary care facilities. That is what we face in north-west London and, I am sure, around the rest of the country. It adds insult to injury if the individuals who are making the decisions to sell the land and to transfer services into the private sector are also the shareholders and owners or if they benefit in any other way. This is a corrupt act and it must be addressed by the Government. They cannot continue to turn a blind eye to it.
Mr Deputy Speaker (Mr Nigel Evans)
Order. Eight Members are trying to catch my eye and we will finish at 5 o’clock, with Charlotte Leslie having the last two minutes. In order to accommodate everybody, as well as interventions, the time limit is now five minutes.
Andrew Selous (South West Bedfordshire) (Con)
The NHS saved my life when I was 24 with an emergency operation in the middle of the night. It was there for me when I needed it, which is why I care so deeply for it.
We have heard some bad examples of what goes on in the NHS, but there are also many examples of excellent care in the NHS every day. NHS staff, especially nurses on busy wards, work extremely hard. They often rush around, have to miss their breaks and get home exhausted. We must all acknowledge that.
Today, we are debating what happened in Mid Staffordshire, but, as others have said, it was, sadly, not an isolated case. We know that 6,000 deaths in 14 other hospitals are being looked at. One area that no other Member has mentioned so far today is the training of our nurses and our doctors. Of course we want our nurses and doctors to be professionally well trained, but it is important that they do not just have academic skills. However good their biology, chemistry or maths, if they are not kind, if they are not compassionate and if they are not caring individuals, perhaps the people responsible for their training need to say to them that a career in the NHS might not be the right career for them and that research or something else might be more appropriate.
The most worrying thing that I have heard in the debate today is the comment that was allegedly made by a nurse to a patient and that was quoted by the right hon. Member for Cynon Valley (Ann Clwyd): “I am a graduate, I don’t do sick.” That is not acceptable. Other Members may also have read the article by Charles Moore in The Daily Telegraph a number of weeks ago, in which he looked in detail at whose job it is to make sure that patients are cleaned up if they need to go to the lavatory and do not get there in time. The faculty of health sciences at Southampton university made the point that ward sisters always have this responsibility, but went on to say that it is everyone’s job.
When I go round a school, I find that if a head teacher picks up the litter on the ground, surprise, surprise, there is not a lot of litter. When a doctor, however senior, sees a patient to give a diagnosis or a prescription, if that patient needs basic nursing care, no level of seniority in the NHS should be above that. That would send a powerful message that that was everyone’s job, as the faculty of health sciences at the university of Southampton said.
I am pleased that in Bedfordshire clinical commissioning group, the excellent Dr Paul Hassan has told me that there will be unannounced GP visits to the wards of the Luton and Dunstable hospital and other hospitals to which Bedfordshire sends its patients. There will be private TripAdvisor-style patient reports coming back—not report forms handed by a sister to a patient and filled in while the sister is leaning over them, but done genuinely in privacy so that GPs can get a proper report of what is happening. There will be real-time alert buttons on the keyboards of GPs and clinicians so that they can flag it up immediately if things are going wrong. That is excellent. That is the way to get an early indication of what is going wrong.
In addition to outstanding nursing care by caring, compassionate nurses, we need clinical leadership. We need the medical directors and the chief nurses of hospitals to step up to the plate. We need medical directors who are front-line clinicians—that is really important—and we need hospital boards to make sure that they have the proper data. Data on bedsores, for example, should be available at every trust board meeting. If the incidence of bedsores is increasing, that may be an indication that things are going wrong in the hospital. That information should be seized on and acted on urgently.
Above all, we need the medical director and the boards of hospitals to foster an esprit de corps and to create an understanding among all the staff that “we don’t do average” and that excellence is what they should aim for. We need a culture where peer review and challenge are normal, natural, accepted and of benefit to everyone. In that vein I commend the “Getting it Right First Time” report by Professor Tim Briggs, which is looking at a clinically-led hub and spoke peer review model in orthopaedics. That could usefully be extended across the whole of the NHS.
Mr Bernard Jenkin (Harwich and North Essex) (Con)
I am encouraged by the speech from my hon. Friend the Member for South West Bedfordshire (Andrew Selous) because it shows that accountability is not just about supervising organisations, regulators, targets, safeguards, mechanical things and statistics. Accountability is about creatively getting the intelligence into the system about what is happening and reacting to it positively, welcoming it and generating the complaints so that more intelligence comes into the system. That is the kind of accountability we want.
As Chairman of the Public Administration Committee, I feel I can add a new dimension to the debate because of what we are thinking about in our inquiry on the future of the civil service. We need to ask ourselves, “What does accountability feel like?” We think we know what accountability feels like, but my goodness, it goes up and down a bit. During the previous Parliament we felt very accountable in some periods, every single one of us. What do we want accountability to feel like in the health service? With the greatest respect to my hon. Friend the Member for Wycombe (Steve Baker), the lawyers must be the last resort. We do not want accountability to be about finger-pointing, blame and holding people to account. Indeed, that is part of the disease that afflicts the health service. We want accountability to be about nursing staff on the ward feeling accountable to each other for sharing information, accountable to the patients and welcoming the information they receive from them, and accountable to their managers and holding them accountable for what they do not feel is being done, in an atmosphere of trust and co-operation.
What is chilling about the Mid Staffordshire story is the question of what accountability felt like in that hospital at that time? To whom did people feel they were accountable. What did they feel they were accountable for? There must have been almost an atmosphere of “Apocalypse Now” in the hospital, in which nobody knew where to turn.
In the evidence we are receiving about the civil service, we have had powerful testimony from an adviser to our Committee, Professor Andrew Kakabadse of Cranfield university, who rather chillingly points out an obvious truth. Very few people who work in a failing organisation do not know that it is failing. Most people in a failing organisation know that it is failing. What is wrong? The answer is that they do not know how to talk about it. They do not know what to say, who to tell—or, if they try to tell people, it will be bad for them—or what to do. So people often just leave failing organisations, saying, “I can’t do anything about it.” I bet most of those on the board of the hospital trust knew it was going wrong and did not know what to do. There is this idea that this was just an isolated case, but it represents a systemic failure. There is absolutely no escaping that.
I remember the Paddington rail crash. One’s instant reaction was, “Well, the driver went through a red light; it must have been his fault,” but everybody knew that there must have been something much more fundamentally wrong. Something was wrong with rail safety. In aviation, when there is a plane crash, it is very rarely the pilot’s fault. Even if it is down to pilot error, that will be down to pilot training and that will be a system failure. We need to look at this issue in an holistic and sensible way.
The reaction of the NHS to the Francis report was immediately to reach for statistics and to start doing things. It immediately started a storm around our local hospital, the Colchester General, by latching on to one statistic and naming it as one of the hospitals being investigated, even though—I have written to Andrew Dilnot at the UK Statistics Authority and got a reply from him—a single statistic should never be used in such a fashion. In fact, the Colchester General is in the top quartile of its class of hospital, so that was entirely unnecessary. My wife has just had a knee replacement in that hospital. I was completely confident that she would get good nursing care and she indeed got very good nursing care.
There is now an uncomfortable atmosphere surrounding this issue. There is an atmosphere of denial, and this relates to Sir David Nicholson. Is he still in denial? Is the system still in denial? Can the system change dramatically enough unless people are seen to take responsibility for the culture? It is difficult to argue that he has not been individually responsible for the broad culture in the national health service that has led to this pass.
Mr Deputy Speaker (Mr Nigel Evans)
I am sure the House wishes Anne Jenkin a speedy recovery.
Jackie Doyle-Price (Thurrock) (Con)
It is a pleasure to follow my hon. Friend the Member for Harwich and North Essex (Mr Jenkin) and give a south Essex perspective on this issue by speaking about the Basildon and Thurrock Foundation Trust. It was found to have significant failings and high mortality rates in 2009, which led to regulatory intervention, on which the right hon. Member for Leigh (Andy Burnham) will recall delivering a statement to this House. At that time, the Care Quality Commission voiced its lack of confidence in the management at Basildon, but there was no change and no one was held to account.
As we all know—and as my hon. Friend has eloquently explained—institutions fail when they are poorly led. In the event of failure, senior management need to step up to the plate, either to take a grip of matters and force change or to take responsibility. The failure in accountability at that time has no doubt held Basildon back. Subsequent CQC inspections found Basildon failing in terms of care and welfare, safety of premises, safety and suitability of equipment, nutritional standards, dealing with serious incidents, record keeping and cleanliness. That is simply not good enough.
When I challenged the hospital management, the response was invariably, “We’re no worse than anyone else; we just get more scrutiny.” Indeed, in one letter the then chief executive criticised the sensational reporting of some unnecessary deaths at the trust and asked for my assistance in acquiring more positive media coverage, a clear example of the complacency to which the Prime Minister referred when he made his statement to the House on the Francis report. There simply has not been sufficient urgency in addressing weaknesses. That led me to conclude that the trust would not improve without a change in leadership—the same conclusion the CQC reached in 2009.
I also have some wider reflections on the systems of governance. At Basildon, the board clearly failed in its duty to provide effective challenge and to hold the management to account. I think that we need to give a clear indication to directors of foundation trusts that in the event of poor performance, the buck stops with the board. They are accountable and they need to accept that responsibility.
I must say that I found the CQC a very positive ally in seeking better performance at Basildon. I know that it has been criticised by some Members, but my feeling is that its powers were quite limited. It certainly had no power to hold senior management to account, a power that is reserved for Monitor. My right hon. Friend the Secretary of State has made his comments about the CQC, but I think that he really needs to look at Monitor. In my experience, the work of Monitor has been very disappointing. In Basildon it was not keen to take any enhanced action. Its view was that the trust was not doing as badly as it had been in 2009 and so the direction of travel was positive, even though it was failing to meet the basic standards of care that the public should be able to expect. I do not think that is good enough. It goes to the heart of what we are debating today: the collective failure of institutions in the NHS to hold people to account when things go wrong. I urge my right hon. Friend to look at whether Monitor is really fit for purpose.
Since I started challenging Basildon and Thurrock NHS Foundation Trust, I have been very heavily criticised, as if by holding the hospital to account for its performance I am attacking the NHS and its staff. The contrary is true. If we really believe in the NHS and in providing the best possible health services for our constituents, we must challenge it when things go wrong. We should have zero tolerance of failure. Do we not owe it to the staff who do their job well to ensure that those who do not are disciplined and held to account for poor conduct?
Thankfully, Basildon and Thurrock NHS Foundation Trust is now under new leadership. There are new non-executive directors who will provide a challenge. We have a new chairman, a new chief executive and a new medical director, and I am encouraged by the messages I have received from them. However, when senior management have been excusing poor practice for so long, there is a need for profound cultural change to get things fixed. An NHS with a stronger emphasis on accountability would have allowed us to start that process in Basildon so much sooner and to save many lives.
Christopher Pincher (Tamworth) (Con)
I would like to make two brief points. First, will my right hon. Friend the Secretary of State, when he comes to review the Francis report, heed the cause of Robert Francis, and indeed the passionate appeal of my hon. Friend the Member for Wycombe (Steve Baker), by extending the provisions on criminal liability so that in the final analysis charges of wilful obstruction of complaints and wilful neglect can be preferred? Had such sanctions been in place 10 years ago, we would have seen charges preferred at Mid Staffordshire, and then we might have seen the interesting spectacle of Ministers and former Ministers being called to the witness box to give evidence in defence of those public officials who were claiming that they were only obeying orders and pursuing the policies of their political masters. I think that sort of sanction would be enough to focus the minds of any Minister, past and present, even those who wriggle and twist to try to avoid their responsibilities.
Secondly, I wish to make a point about culture change. We have had the report and the debate, but it would be foolish to assume that there have been any great strides forward as part of a culture change in Staffordshire. I will give one example. After the Francis report was published on 6 February, South Staffordshire PCT issued a press release which said:
“Much has been learnt”—
that word again—
“since 2009 and the PCT now operates with quality at the centre of all that we do.”
My constituent Tom Berry might take issue with that statement. Tom is a gifted young man who is pursuing a degree at Wolverhampton university but suffers from spinal muscular atrophy, which means that he can barely move. He has round-the-clock care from a team of carers. When he needs to cough, those carers have to compress his torso—that is the kind of help that he needs. However, those at the Staffordshire NHS cluster seem to have forgotten his needs and want to change his care package, against his wishes, against the wishes of his family and carers, and against the advice of his GP. I have tried to help him, but the head of continuing care in Staffordshire refuses to answer my letters and hides behind lawyers in refusing to acknowledge my calls to heed the advice of Tom’s GP.
When I threatened to blow the whistle on that conduct in this House, I secured a conference call from the chief executive of the Staffordshire NHS cluster, Graham Irwin. He did not bring to that conference call the head of continuing care, or a clinician, or a carer—he brought his press officer, which suggests to me that, in Staffordshire, medical care runs second to media management. Although he was very insistent that Tom’s care package should still be changed, he said that he did not even know whether a proper impact assessment had been done on the effect of that change on Tom’s health. He said that he would go away and look into it, but three weeks later, after another phone call and another letter, we still do not know what is happening.
If Francis is right when he said that our
“comfortable set of assumptions about the NHS have been misplaced”,
he is certainly talking about what is going on in Staffordshire now. We still have a culture of complacency allied to determined obfuscation. I say to my right hon. Friend the Secretary of State that if we are to restore the battered credibility of care in my county, we need to ensure that we put patients, and not the godhead of targets, front and centre. We need to ensure that we recruit, recognise and reward the best people and sack the worst people. As my right hon. Friend the Member for Mid Sussex (Nicholas Soames) said, we cycle too many bad people through our public services. We need to make sure that when there is wrongdoing, people are punished not in the court of public opinion but in a court of law. If we do that, we can rebuild and restore confidence in our health service in Staffordshire, and we will have a system about which we are prepared to blow the trumpet, not blow the whistle.
Tracey Crouch (Chatham and Aylesford) (Con)
I congratulate my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing this very interesting debate, which has covered lots of issues to do with accountability and transparency, not only at Mid Staffordshire but throughout the entire country. It is clear from the speeches by the right hon. Member for Cynon Valley (Ann Clwyd) and my hon. Friend the Member for Wycombe (Steve Baker) that these concerns go beyond the appalling events at Mid Staffs. My own constituents need reassuring about their patient care, the quality of the information they are receiving and, unfortunately, the mortality rates at Medway Maritime hospital. Like other hospitals, it is now under investigation, and we await the outcome with interest.
It often takes a very long time for the truth about these matters to be completely uncovered. In the past, the quality of patient care has, in many respects, been secondary to the hospital meeting its targets. That is a shame, and it is part of the culture that we need to change. I do not want to believe that there is a culture of cover-up in the NHS. Like my hon. Friend the Member for Totnes (Dr Wollaston), I think that all those who work in the NHS—the nurses, the doctors and the consultants—do a brilliant job in delivering good quality care and the best patient outcomes. Unfortunately, that was not the case at Mid Staffs, and concerns about quality of care and mortality rates are spreading. As I have said, constituents are now concerned about the care they receive at the Medway Maritime hospital.
The trust is always incredibly good at responding to my questions, whether they be about what I consider to be the high use of the Liverpool care pathway at the hospital, constituent complaints, dementia care or specific patient services. However, I fundamentally believe that if a constituent has to involve an MP in a complaint, the system has failed. There is a growing perception that if someone complains, it is their fault and they are in the wrong, while the hospital paints itself as the victim of the complaint rather than the other way around. That is wrong.
The Medway Maritime hospital is under investigation for higher than expected hospital standardised mortality rates, and there is currently a specific outlier alert on septicaemia. Worryingly, this is not the first time this has happened. Discrepancies in coding were highlighted way back in 2008 with the discovery that 8% of deaths were being recorded as end-of-life care when the proportion should have been 37%. Adjusting the mortality index to exclude those deaths reduced the hospital’s score by more than a third. A clear manipulation and distortion of the information only served to damage the best outcomes and services for the patients. I hope that that will not happen again. However, as an outsider it appears to me that the complexity of coding is part of the problem with the lack of transparency.
A culture of bullying and its suppression within the NHS has been mentioned. The latest staff survey at the Medway Maritime hospital shows that there is still a perception that bullying is widespread. If we want to improve standards in patient care—which is a key aspiration for the newly restructured NHS—that has to be one of the most important issues to address. I welcome today’s announcement by the Secretary of State, but may I make a practical suggestion that was put to me by a GP this morning? One of the problems with the system for complaints is that they stay within the hospital—they go up to the management board and do not really go beyond it. Instead, complaints could be delivered on a quarterly basis to the new clinical commissioning groups, which would enable people outside the hospital structures to look at potential trends and patterns of poor quality, and at whether there are concerns about specific consultants. We could end up taking the responsibility from the hospital, having the outsider look in, and making more practical changes.
Greater transparency in the NHS is not just about honesty and accountability, but about better communication. As the most recent ombudsman report highlighted, the common pitfalls are also the result of equivocal language over care, the use of technical language and the failure of insincere apologies. We need to learn the lessons of the Francis report; patients from those families who use my local NHS services deserve nothing less.
Nick de Bois (Enfield North) (Con)
I will never forget the last time I saw my mother. It was three days before the general election in 2005. She had secondary cancer, but she was a fighter, though I make no comparison between her circumstances and the Francis report and the horrors that people went through at Stafford.
There are many reasons why someone might remember the last time they saw their mother, but my experience is overshadowed by a sense of guilt. During my mother’s long stay in hospital—she had been in and out—my brother, who lived abroad, had often been with me and he persistently picked up that the pervading culture on the ward was that he who shouted loudest got attention. My mother would describe how much pain and discomfort she was in—other Members have mentioned similar problems—and say, as elderly people do, “Don’t make a fuss.” To his credit, my brother dealt with it by shouting loud. On that last day, my brother was not with me because he had returned abroad. Unfortunately, I did not shout that day. I went back to the election and my mother sadly died. I am not drawing a comparison with what happened in Stafford, but many patients and relatives will recognise that one has to shout loudly to get heard. That points to a problem with the culture.
In 2005, to their credit, the last Government were increasing spending on the health service. However, that suggests to me that the answer to improving outcomes and care is not about money. We can pour a lot of money in, but it will not do the trick. It has its role, but it is not the final driver. I hope that one of the legacies of Francis will be that we can recognise that the debate needs to move on. It should not be a bidding war between different political parties and ideologies about money. It should be about the thing that matters most: will patients get better, will they receive quality care and will they be treated with respect and dignity, come what may? If we drive a mature debate in this country, we can achieve outcomes on that basis.
As Opposition Members have said, perhaps we can step aside from politics. I am not naive and I do not believe that that will happen. However, every time we debate these matters, let us remember that we have a far greater chance of achieving what we are here to do, which is to provide a health service that is the envy of the world, if we have a mature debate. I say cautiously and with respect that in the light of Francis, our health service cannot currently be the envy of the world, but its ideals are most definitely the envy of the world. We have a duty in this place to set the standards that will make it the envy of the world once more.
I am very conscious of the time, but I would like to make one quick point. We have heard a lot about the culture, but we cannot change it just like that. Culture is thoroughly and utterly inbred within any institution. It starts with the new people it trains—that includes the people who are there now—and it touches everything that it does. Everything that an institution does should reflect its culture, and changing the culture therefore takes time.
Where I disagree with some in this House is in my belief that leadership is where culture starts. This House, managers in hospitals and trainers all have a role to play. However, every time I consider the role of the current chief executive, Sir David Nicholson, I come back to the point that although he has voiced sentiments that I welcome in that he said that to achieve care we need an open, transparent and care-led culture, that it is vital for staff to be seen as an asset, and that it is vital for staff to be able to challenge their leaders, the reality is that he is a command-and-control manager. That is his legacy and others have paid a price for it. I believe that his departure, whenever it may happen, is absolutely necessary to change the culture because we need to start at the top and feed it throughout the business. I say that with a heavy heart, because I do not believe that we should be chasing scalps. However, as I said at the beginning, we should be chasing the ultimate outcome of serving our patients and that is one way of doing it.
Neil Carmichael (Stroud) (Con)
This debate has been thorough and, at times, moving. I congratulate my hon. Friend the Member for Bristol North West (Charlotte Leslie) on securing it. I was impressed by the moving speech of the right hon. Member for Cynon Valley (Ann Clwyd) because it demonstrated the tragedy that lies behind this debate.
The Francis report is a disturbing document in many ways. The Prime Minister and the Secretary of State for Health are right that we should not be looking for scapegoats. I do not want us to find any scapegoats and I am sure that you, Mr Deputy Speaker, do not want us to find any scapegoats. We must remind ourselves what a scapegoat is: it is somebody who gets the blame for somebody else’s behaviour. The question that we must ask is who is responsible. That is at the core of this debate. If we cannot find out, we must produce a system that has a mechanism for responsibility.
When someone accepts responsibility, it is refreshing and empowering. If a manager avoids that responsibility, they are effectively acknowledging that they are weak and insufficient at their job. If someone cannot answer those questions and does not feel able to say, “The buck stops with me”, they are not doing their job properly. We need to think about that system of responsibility and accountability.
Can gagging be consistent with effective, decent line management? Absolutely not. A person is effectively saying that someone beneath—or even above—them cannot say what they need to say. A show cannot be run with that kind of mechanism, and we should certainly not be content with the number of gagging clauses we have heard about today. I welcome the end of gagging clauses, and pose the same question that others have asked the Secretary of State: is the move retrospective?
Line management is also about culture because we must be able to trust people when we ask for something to be done, and know that the message is getting out and is clear and fair. That is what good management is. It is not just an issue in the health service; it is an issue in any organisation, and that brings us to the overall question of governance. Governance applies everywhere and must be accessible, transparent and something in which people have confidence. As hon. Members have pointed out, there is far too much buck-passing and evasion, and that will not help us arrive at a decent culture for patients, which is what we should be focusing on. Of course we are right to talk about “patients” rather than “targets”, but we also need patients to feel comfortable with the system in which they are operating.
My hon. Friend the Member for Enfield North (Nick de Bois) made a good point about speaking out. Many of us can speak out and do so nearly every day on a variety of subjects. Some patients cannot, however, and need additional advocacy that sometimes does not come easily to them or their friends and family. Just imagine them in a management system in which people cannot listen or talk to each other, let alone take into account the views of patients!
We must have a change of culture and, as the old saying goes, a fish rots from the head. This is about leadership and shaping a culture that effectively manages to spread out everywhere. That culture must be inclusive, transparent and open and effective at empowering people at every level, rather than shutting them down and isolating them in systems that are too complicated to feel comfortable in.
Finally, I welcome the appointment of a chief inspector for hospitals. That is a necessary appointment and will make a huge difference. They must, however, look at the leadership of what he, or she, is inspecting. Leadership is fundamental and matters, and we must ensure it is responsible and accountable.
Dr Thérèse Coffey (Suffolk Coastal) (Con)
It is a pleasure to contribute to this important debate, and I congratulate my hon. Friend the Member for Bristol North West (Charlotte Leslie), and other Members, on securing it. Transparency and accountability are the hallmark of good governance, but they can involve issues such as whether a patient is on the Liverpool care pathway, whether that is transparent and whether their families know, not solely about the running of a particular trust.
I welcome freedom of information requests, which are among the most useful tools available to a Member of Parliament trying to secure information on data held by hospitals, ambulance services and so on. It is extraordinary, however, that we must resort to those tools to try to get that information and help in holding the people running our services to account.
I accept that the NHS is a complex organisation—imagine a hospital that has issues with bed-blockers, social care, or people trying to find a place in a home, or where ambulances are exceeding their handover targets. Those are interlocking issues. I still think, however, that it is important to hold the chief executives and boards of these trusts to account.
I was late today because I was at a meeting with the chairman and chief executive of our ambulance trust. This is not the first time I have had to work with other MPs to highlight particular failures. In a Westminster Hall debate, I called for the chairman of James Paget hospital to step aside. I have not made that call today. I have asked the chairman of the board to consider carefully the potential issues arising from the CQC report that is due to come out at any moment. It is frustrating that in trying to hit the target people often miss the point. The point is to care for patients.
The Care Quality Commission and Monitor were mentioned earlier. I welcome the changes made by my right hon. Friend the Member for South Cambridgeshire (Mr Lansley) to introduce unannounced spot checks by CQC. A lot of issues were unveiled as a result of the changes and that is to be welcomed. I welcome the recommendation to merge the CQC and Monitor, as there is a risk of ambiguity over exactly which body is holding people to account. I welcome the move by the Secretary of State to have Ofsted-style inspections. I am sure he will learn lessons and ensure that they are focused on clear issues, and not just on myriad matters that get away from the key point of patient care.
MPs in the east of England came together and, by speaking to the CQC and providing evidence, we managed to stop the ambulance trust gaining foundation trust status, because of the issue of care. Politicians therefore can and should intervene when there is evidence of things going wrong, and not just accept the initial recommendation of Monitor.
I pay tribute to David Hill, chief executive of James Paget hospital. He had been chief executive of the hospital before and went elsewhere in the health care system. He came back and within a week I could see that he had made a difference in the attitude to care. A year on, I am delighted to report that all the warning notices have gone and that in the latest unannounced inspection it was given a clean bill of health. That is great news for the patients and great news for the staff. It is a reminder that being brave and being prepared to incur the wrath of people who assume one is attacking the NHS when one is actually trying to defend the NHS and patients, can be worth hile.
That leads me on to the matter of the difficult jobs we have to do. We have to remind all our governors and board members that they are there to represent the patients. They should not feel cowed. They should be tenacious in pursuing the outcomes that everybody wants in the NHS. These are not easy times—I appreciate that. Let us not have too much hand-wringing about how hard it is. We all know it is, but I believe that politicians of all parties are here to try to support the people. We will not do that by ducking the reality that we have to be accountable. That is true in this House if we let down our constituents, but it is also true for the members of boards who do not hold their chief executive to account and demand nothing but the best for their patients.
Charlotte Leslie (Bristol North West) (Con)
This has been an excellent debate. I thank the Secretary of State, who has been here for the duration of the debate—as indeed has the shadow Secretary of State. I think there can be general agreement that there has been a catastrophic failure of leadership. That was well and forensically expressed by my hon. Friend the hon. Member for North East Cambridgeshire (Stephen Barclay). It is worth nothing that although there may have been instances—there certainly have been—of clinical failures, it is only possible to hold to account those managers who have a medical qualification registered with the General Medical Council.
We had a blast of reality from the moving and extraordinarily memorable speech by the right hon. Member for Cynon Valley (Ann Clwyd). I thank her, and the people who wrote to her, for sharing their tragic stories. We had powerful and thoughtful speeches from Members involved in the Mid Staffs tragedy, including my hon. Friends the Members for Cannock Chase (Mr Burley), for Stafford (Jeremy Lefroy) and for Stone (Mr Cash). The debate benefited from the experience of Members who have worked directly in the NHS, including my hon. Friends the Members for Totnes (Dr Wollaston) and for Bracknell (Dr Lee), and from the political experience of those such as the right hon. Member for Holborn and St Pancras (Frank Dobson). I thank everybody for their contributions.
This has been an important debate, in that it has finally provided a voice for many people who have been kept silent for so long. Another lesson that we can draw from it is that it is not systems but people who care in our health service. We can take away from the debate the many mechanisms of accountability and transparency that have been suggested, as well as suggestions of how we can nurture the professionalism and the best instincts of those who work in our NHS. Let that be a mission for all of us. We must also really ensure—perhaps in contrast to what has been done before—that patients are at the very heart of what the NHS is all about.
The debate has been enormously important, and I hope that it marks the beginning of a consensus and of a cross-party drive to ensure that the scandals and tragedies that we have seen throughout our health system never occur again. I also hope that this marks the forming of a platform for the many people out there who do not have the benefit of parliamentary privilege. It is our duty to ensure that their silence—in many cases, a deadly silence—is ended by this debate and that a new era of transparency and accountability, which should be seen in by a new set of personnel in our NHS, begins here.
Question put and agreed to.
Resolved,
That this House believes that in the wake of the Francis Report it is clear that accountability and transparency are of paramount importance to patient safety and trust in the NHS; and further believes that across the NHS individuals found to have breached those principles should face the appropriate consequences.