Accountability and Transparency in the NHS
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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.
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.
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.