The Secretary of State for Health (Mr Jeremy Hunt)
With your permission, Mr Speaker, I would like to make a statement on the Government’s response to today’s report on NHS whistleblowing by Sir Robert Francis, and on progress to date in implementing previous recommendations from his public inquiry into the failures of care at Mid Staffordshire NHS Foundation Trust.
I asked Sir Robert to carry out a follow-up review because of my concerns that, despite good progress in implementing his original recommendations, the NHS was still not making fast enough progress in creating an open and transparent culture in which staff feel supported to speak out on worries about patient care. As a result, I was concerned that changes are still necessary if the NHS is to protect patients properly by adopting a transparent, no-blame, learning culture as is common in other sectors such as the nuclear, oil or airline industries.
Sir Robert has confirmed the need for further change in his report today. He said he heard again and again of horrific stories of people’s lives being destroyed—people losing their jobs, being financially ruined, being brought to the brink of suicide and with family lives shattered—because they had tried to do the right thing for patients. Eminent and respected clinicians had their reputations maligned. There are stories of fear, bullying, ostracisation and marginalisation, as well as psychological and physical harm. There are reports of a culture of “delay, defend and deny”, with “prolonged rants” directed at people branded “snitches, troublemakers and backstabbers”, who were then blacklisted from future employment in the NHS as the system closed ranks.
We of course recognise the high standards of care day in, day out in much of the NHS, and we know that many staff feel supported in raising concerns about patient care, with many dedicated managers going out of their way to address those concerns. However, the whole House will be profoundly shocked at the nature and extent of what has been revealed today. The only way we will build an NHS with the highest standards is if the doctors and nurses who have given their lives to patient care always feel listened to when they speak out about patient care. The message must go out today that we are calling time on bullying, intimidation and victimisation, which have no place in our NHS.
Before outlining the Government’s response to today’s report, I want to update the House on the progress made in implementing previous Francis recommendations. I have today laid in the House of Commons Library a report showing progress on all 290 recommendations originally made by Sir Robert, as well as the progress made in implementing other recommendations by Professor Don Berwick on safety, by the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart in their complaints review, by Camilla Cavendish in her work on health care assistants and by the NHS Confederation on reducing bureaucratic burdens. The progress was recognised this morning by Sir Robert, who said that the priority that must be given to safety, compassion and quality of care is now better recognised and acted on.
I want to highlight the impact of Professor Sir Bruce Keogh’s review of hospitals with high mortality rates. The special measures regime that followed introduced the toughest and most transparent hospital turnaround regime anywhere in the world, with 19 hospitals—more than 10% of NHS acute trusts—having been put into special measures so far. Among the vast array of improvements since the start of the process, those trusts have recruited 109 additional doctors and 1,805 additional nurses, and have made 129 board-level changes. The independent research company Dr Foster estimated this week that excess deaths in those trusts had fallen by 450 in less than a year. That means that between them, they may have saved as many lives as some estimated were tragically lost at Mid Staffs between 2005 and 2009.
We have moved from a system that tolerated or denied high mortality to one that, while it is by no means perfect, seeks out problems, shares them with the public, takes action and saves lives. Today I can announce that the Care Quality Commission, Monitor and the NHS Trust Development Authority have published a new memorandum of understanding to enshrine and further improve the special measures process.
The other measures that we have introduced include giving the CQC, under its new leadership, legal independence and the legal powers that it needs for its chief inspectors to root out failure and highlight excellence. The chief inspector of hospitals has inspected more than half of acute trusts and will have inspected them all by the end of the year.
We have introduced criminal sanctions for those who wilfully neglect patients and those who provide false or misleading information. The new duty of candour for institutions and professionals means that when mistakes are made, patients or their families must be told. Fundamental standards are now in place to ensure that all providers are required to treat people with dignity and respect. All acute hospitals are now asking patients if they would recommend the care that they receive to friends or members of their family. That is being rolled out to other parts of the NHS, including primary care. Two thirds of hospitals are now implementing the “name above the bed” initiative to ensure that hospital care is better joined up. More than 200 organisations have joined the “sign up to safety” campaign, which involves a commitment to halve avoidable harm and save 6,000 lives by 2017.
The entire NHS is now committed to patient-centred culture change as a key part of the “Five Year Forward View” plans that were put forward by NHS England last autumn. In that plan, we recognise the important point that safe care and efficient use of resources go hand in hand: doing the right things first time in health care saves lives and money.
In respect of whistleblowing, the Government have taken significant steps to protect NHS staff, such as enshrining the right to speak up in staff contracts, amending the NHS constitution, issuing joint guidance with employers and trade unions, extending the national helpline to social care staff, and changing the law to make employers responsible if whistleblowers are harassed or bullied by fellow employees.
Today, Sir Robert makes it clear that there is more to do, and I am extremely grateful to him and his team for their work. He sets out 20 principles and a programme of action. I confirm today that I accept all his recommendations in principle and will consult on a package of measures to implement them.
The recommendations include asking every NHS organisation to identify one member of staff to whom other members of staff can speak if they have concerns that they are not being listened to. Drawing on the inspirational work of Mid Staffs whistleblower Helene Donnelly, those “freedom to speak up” guardians will report directly to trust chief executives on the progress in stamping out the culture of bullying and intimidation that Sir Robert today says is still too common. We will consult on establishing a new independent national whistleblowing guardian as a full-time post within the CQC to review the processes that have been followed in the most serious cases where concerns have been raised about the treatment of whistleblowers.
Because too often the system has closed ranks against whistleblowers, making it impossible for them to find another job, I can announce today that the Government will legislate to protect whistleblowers who are applying for NHS jobs from discrimination by prospective employers. With Opposition support, those necessary regulation-making powers could be on the statute book in this Parliament.
We will provide practical help through Monitor, the NHS Trust Development Authority and NHS England to help whistleblowers find alternative employment. Those three bodies have agreed a compact for action on this issue, and will publish detailed arrangements later this year. We will ensure that every member of staff, NHS manager and NHS leader has proper training on how to raise concerns and how to treat people who raise concerns. As a vital last resort, the right of whistleblowers to contact the press with any concerns they have must always be safeguarded, although it should not have to come to that. Today I will write to every trust chair to underline the importance of a culture where front-line staff feel able to speak up about concerns without fear of repercussions. In addition, Monitor and the TDA will write to trust chief executives today to ask them to ensure that all managers discuss these issues as a matter of urgency with those who report to them.
There must be consequences for trusts that fail to develop a culture of openness, so today I am publishing consultation options to ensure that where hospitals are found to have knowingly withheld information from patients, the NHS Litigation Authority can impose financial sanctions such as reducing the indemnity it offers against litigation awards. The final decision on how we implement these recommendations will be made after proper consultation with NHS providers, whistleblowers and patient groups to ensure that we honour the spirit of what Sir Robert has recommended, and to avoid unnecessary layers of bureaucracy or financial burden. There is no reason for individual trusts not to get on with implementing Sir Robert’s recommendations right away, particularly in ensuring that staff have an independent person with whom they can raise concerns.
A further foundation of a safe and open culture is one where the NHS and the public have access to meaningful and comparable information about the performance of local NHS organisations. The new MyNHS website has already kick-started a transparency revolution by making the NHS in England the first health care system in the world to offer key, up-to-date safety information on every major hospital, including open and honest reporting, nurse staffing levels in every ward, and the number of falls and hospital-acquired infections. Some estimate that we have as many as 1,000 avoidable deaths in the NHS every month, so by the end of March 2016 the NHS will become the first health care system in the world to publish an annual estimate of avoidable deaths by hospital trust, based on case note reviews and the safety record of those trusts.
I will strengthen the accountability of trusts by asking the chair of every trust to write a letter to the Secretary of State by the end of May each year, outlining what measures they will be taking to reduce the number of avoidable deaths in their trust. In all cases we will make it clear that this is not a process of naming and shaming but one of learning and improving so that our NHS becomes the first health care system in the world to adopt system-wide the safety standards that would be considered normal in other industries. We must also better understand avoidable mortality outside hospital settings, and whether we can adapt the methodology to identify avoidable harm as well as avoidable death. I therefore announce today that the Department will fund a national study to establish the extent of avoidable death in community settings, and the feasibility of developing locally attributable death rates.
We will be taking steps to hard-wire transparency into the health and care system, and I am publishing a transparency architecture with plans for further information to be released on MyNHS. That will include comprehensive reporting on the friends and family test, data on residential care home admissions, and a new balanced scorecard on the work of CCGs and health and wellbeing boards. The Care Quality Commission and the National Information Board have confirmed to me that, starting this year, they will report annually and in public to the Secretary of State and the Health Select Committee on the progress of the transparency architecture, and on any recommendations about how we can improve it. The Secretary of State will report to Parliament annually on progress, and today I am publishing for consultation changes that will enshrine that right in the NHS constitution.
One of the biggest causes of poor care is when no one takes responsibility for a vulnerable patient and the buck is passed. That leads to greater costs and numerous personal tragedies as people are passed unnecessarily around the system. The “name above the bed” initiative has strengthened accountability in hospitals, as has bringing back named GPs outside hospitals, but there is still not enough clarity on the role of professionally accountable clinicians, particularly in community settings. Today I can therefore announce that the Academy of Medical Royal Colleges has agreed to develop guidelines for meaningful clinical accountability outside hospitals. It will publish its findings this spring, and before the end of the next financial year all CCGs will publish how many of their patients with long-term conditions are being looked after by clinically accountable community clinicians in the meaningful way the academy will define. Proper proactive care for our most vulnerable patients will not only reduce hospital costs but reduce avoidable harm and improve the quality of compassionate care.
We can fund the NHS with a strong economy, we can put in place new models of integrated care to support an ageing population and we can champion innovation, but if we do not get the culture in the NHS right, we shall never deliver the ambitions that everyone in this House has for our NHS. Today is about tackling that culture challenge head-on so that we build an NHS that supports staff to deliver the highest standards of safe and compassionate care and that avoids the mistakes that have led to both unacceptable waste and unspeakable tragedy. If we succeed, we will be the first country anywhere to put its entire health care system firmly on the path to eliminating avoidable harm and death. Our NHS deserves no lesser ambition, so I commend this statement to the House.
Andy Burnham (Leigh) (Lab)
I welcome the Secretary of State’s statement and his obvious commitment to improve the culture of tackling poor care in the NHS; there is plenty of common ground between us. We endorse the principles laid out in Sir Robert Francis’s new report and we will work with the Secretary of State to get new safeguards on the statute book in the remainder of this Parliament, as he requested.
It was the Labour Government who, in 1998, introduced the first legal protection for whistleblowers in the Public Interest Disclosure Act 1998, reinforced in the NHS constitution in 2008. Sir Robert’s new principles build on those foundations. We thank him and the review team for their work and praise every whistleblower who has had the courage to come forward.
Our shared aim must be to create a climate in which every NHS worker feels able to raise concerns and feels confident that they will be listened to, that appropriate action will be taken and that they will not face mistreatment as a result. Sir Robert’s report will help achieve that. We particularly welcome the call for whistleblowers worried about losing their jobs to be offered alternative employment and for training in whistleblowing for all staff. Those measures are overdue. Will the Secretary of State say more about how Sir Robert’s principles will be enforced across the NHS and about the timetable for implementation? Will he confirm that they will apply equally to all providers of NHS services, including voluntary and private providers?
That brings me to an issue of major substance not covered in Sir Robert’s report. As he points out, his remit did not apply to any form of social care. That is a major concern, given that it could be argued that some of the poorest care provided in England today is in social care settings or in people’s own homes. Only at the weekend, a BBC investigation found that one in five care homes for older people is failing to meet standards for safety. Should we not today, across this House, establish the firm principle that Sir Robert’s recommendations should apply equally to all places where people receive care?
Let me turn to the recommendation for an external organisation that staff can approach for advice and support. In response to the first Francis report in February 2010, I established an expert group to update whistleblowing guidance. It reported in June 2010, and the Secretary of State’s predecessor announced plans for a “safe and independent authority” to which staff could turn when their organisations were not acting on concerns. Will the Health Secretary say why that has not progressed since then and assure us that there will be no further delays now that Sir Robert has reinforced that recommendation?
Although I believe that the Secretary of State’s commitment to improve the culture in the NHS is genuine, he will no doubt be concerned by Sir Robert’s findings that it might have got worse in recent years. In his report, he said about the cases he examined:
“Many were relatively recent or current. This is not about a small number of historic high profile cases from a time when organisations might argue the culture was different. We had a significant number of contributions about cases in 2014.”
The report specifically references figures from the latest NHS staff survey, which shows that reports of bullying have increased from 14% of staff in 2011 to 22% in 2013. Over the same period, the percentage of staff who feel able to speak out about poor care or to report errors or near misses has fallen from 98% in 2011 to 94% in 2013. Those figures suggest that things are getting worse, not better. Will the Secretary of State explain why he thinks that is and whether he will investigate the reasons further? That underlines the importance of any moves to improve the culture being introduced in the right spirit and being supportive rather than punitive, so that they do not reinforce the wrong culture and have the opposite effect to that which the Secretary of State is obviously trying to achieve.
At the weekend, the Secretary of State proposed fines and jail sentences for failure to be open about poor care. Although we support his zero-tolerance approach, is he certain that how this is perceived on the ground will not create a climate of fear and have the opposite effect?
Those concerns also apply to the new inspection regime introduced since the Francis report. In advance of today, I was contacted by a whistleblower who works in a hospital about a Care Quality Commission inspection planned for later this month and about the growing practice of hospitals running mock inspection days in advance of the CQC’s arrival, as schools have come to do with Ofsted. The whistleblower’s letter states:
“I enclose a document that invites us for a mock inspection to show us what to do and say when the CQC comes. Is this the correct thing to do? I think not. I cannot reveal my name as I would be instantly dismissed. Can you help?”
I am sure that the Secretary of State will be as concerned as I am to hear that and I will forward the information to him this afternoon.
I turn now to the Secretary of State’s update on the Francis report on Mid Staffordshire. Both sides of this House supported Sir Robert’s original recommendations and we give credit to the Secretary of State for making significant progress with their introduction, but gaps remain where progress has not been made and that is a concern when standards overall in the NHS are recorded to be falling, not rising.
In particular, there is a long-standing need to reform the system of death certification which goes back to Dame Janet Smith’s inquiry into the Harold Shipman murders. I took a personal interest in that as a Minister on the back of concerns raised by my hon. Friend the Member for Denton and Reddish (Andrew Gwynne)and James Purnell, the former Member for Stalybridge and Hyde. I legislated for reforms of death certification in the Coroners and Justice Act 2009, which made provision for the independent scrutiny by a medical examiner of all deaths that are not referred to the coroner.
Following successful pilots, Sir Robert Francis reinforced Dame Janet Smith’s recommendation. Dr Suzy Lishman, the president of the Royal College of Pathologists, says that introducing these reforms will
“improve patient care whilst reducing harm and saving money”.
It will therefore be a cause of great concern to a great many people, not least the families of the victims of Harold Shipman, that those reforms appear to be stuck in the long grass. Chris Bird, whose mother Violet was one of those victims, recently told the “Today” programme that
“it is criminal that the Government is stalling on implementing something like this that could save lives.”
I have been informed by senior officials in the Secretary of State’s own Department that he personally is holding up this reform. Can he say whether that is true, and if so why? If it is not true, which I am prepared to accept, will he today set out a clear timetable for the introduction of this vital reform?
Alongside that, we need better arrangements in hospitals for reviewing case notes when patients have died, as the Secretary of State mentioned in his statement. Over the weekend, the Government announced plans to introduce an annual review from a sample of patients. Although that will help us to develop a more accurate measure of avoidable deaths than mortality rates, does the Secretary of State think it goes far enough? Should not the NHS learn from all serious failings? Will he give consideration to our suggestion that every death in hospital should be subject to an appropriate level of review?
We welcome the renewed focus on staff numbers since the Francis report, but we also remind the House that in the first three years of this Parliament almost 6,000 nurses were lost and, with record numbers of people in hospital, nurse-patient ratios have not kept pace with demand and there are fewer nurses per head of population now than in 2009-10. One of the problems with having made so many permanent staff redundant is that, post Francis, recruitment has been heavily reliant on agency staff. As Robert Francis warns today, that has made it even harder to get the culture right. We welcome the Secretary of State’s recent focus on nurse numbers, but will he concede that it was a mistake to cut staff so heavily? Will he back Labour’s plan to bring down the agency bill by recruiting 20,000 more nurses?
We welcome the progress made at some hospitals in special measures, but may I caution the Secretary of State on his use of statistics? Is he aware of the graph on page 8 of the Dr Foster report, which shows that mortality rates at the Keogh trusts fell faster between 2006 and 2010 than between 2010 and 2014? There was never a tolerance or denial of high mortality, as he seemed to suggest in his statement.
On openness and transparency more broadly, the Secretary of State will be aware that the King’s Fund delivered a damning verdict on the Government’s reorganisation, concluding that it had damaged patient care. That is consistent with a survey of NHS staff, which found that 69% said the reorganisation had harmed patient care, with only 3% saying it had improved. It is suggested that the Government’s own risk register on the reorganisation warned that reorganising the NHS at a time of financial stress would damage front-line care. So that any future Government can learn the lessons of the past few years, will the Secretary of State publish the risk register, as recommended by Sir Robert Francis?
In conclusion, as I have always said, the lessons from Mid Staffordshire need to continue to be learned if the NHS is to be what we all want it to be: the safest and best health care system in the world. The Secretary of State has today taken some important steps towards that goal, but I hope he will respond fully to the serious questions I have raised.
Mr Hunt
I welcome the broadly constructive tone that we have heard today. May I say, in that spirit, that I hope that that represents a change in substance from some of the other exchanges we have had on these topics? The right hon. Gentleman tried to vote down the legislation that set up the new chief inspectors and he opposed the holding of a public inquiry into Mid Staffs. If we are to have constructive agreement across the House, I do think we need to agree on substance as well as on tone. Let me just take the individual points he mentioned.
We are completely committed to death certification. That was recommended in the wake of the Shipman inquiry. The right hon. Gentleman’s Government took a very long time to do anything on this and we have been trying hard to do it. It is a complicated thing to get right. On the question of looking properly at avoidable deaths, I just want to say this. It is very difficult, when one looks at case notes, to work out whether a death was avoidable or not, but we think we have a methodology to do that. It is more difficult to relate that to individual trusts, but we want to try to achieve that as well. I was disappointed at the weekend that when we announced that, his response was that it was unambitious. Two weeks earlier, he had published Labour’s 10-year plan for the NHS, which did not actually mention reducing avoidable deaths at all. What we are proposing is the most ambitious thing that any health care system has proposed anywhere in the world, and I hope it will have his full support.
On the right hon. Gentleman’s comments about not generating a climate of fear, he is absolutely right; it is really important, in getting the culture right, to make sure that people are supported to speak out and that there is not, as an unintended consequence, the kind of bullying and intimidation that Sir Robert says is all too common today. I suggest to him that one of the reasons for that climate of fear has been over-dependence on top-down targets as a way of running the NHS. That is what has created the fear in managers that sometimes has led them to treat their staff in the wrong way. What would be very constructive would be a recognition from Labour that that top-down targets culture did go too far, and that we need to rely on transparency as a way of improving performance as a much better tool than endless new targets.
In anything we do—this is something else where I agree with the right hon. Gentleman—we must look very closely at making sure that we learn these lessons in the social care sector as well. That is particularly clear when we look at the scandal of what happened in Rotherham. That is why, when we introduced the new CQC inspection regime following the original Francis public inquiry, we did not just set up a chief inspector for hospitals but set up a chief inspector for general practice and for adult social care. We are now getting the same Ofsted-style transparent rankings of how good care is in care homes, and indeed in domiciliary care. I know that he, like me, is concerned about 15-minute care visits. I think those inspections will help to root out those problems.
With respect to nurse numbers, I really do think that is something on which, if the right hon. Gentleman wants to be constructive, he should commend the Government’s efforts. We have 8,000 more nurses in our hospital wards than we had four years ago. Of course, as a short-term response a lot of hospitals are employing nurses through agencies. That must only be a short-term response. We need proper long-term commitment to institutions, which we do not get with agency staff, but I commend hospitals that have said, “While we try and get enough staff in place for the long term we are not going to wait, because we need to make sure that patients are safe today.” They want to do what it takes to do that.
Finally, on the risk register, I simply remind the right hon. Gentleman that when he was Secretary of State he blocked the publication of the risk register. As a Minister, he said:
“This would inhibit the free and frank exchange of views about significant risks and…management, and inhibit the provision of advice to Ministers.”—[Official Report, 23 March 2007; Vol. 458, c. 1192W.]
More broadly, I just want to say this. There are many patients and whistleblowers looking at today’s exchanges and wanting to see constructive agreement on the way forward. I think we can get a measure of that. What they say they want is not just words, but actions.
As we put staff and patients first in England, will Labour do the same for patients in Wales and today commit to a Keogh review of high mortality hospitals, commit to a chief inspector of Welsh hospitals and commit to protect staff who speak out in Wales, as we want to do in England? Will he commit to putting right a top-down culture that prioritised the needs of the system over the needs of individuals? Will he, as we do, recognise that that is always the danger of treating the NHS as a political possession and not as a service for patients? Patients must always come first. Staff who want to do the right thing for patients should always be heard. Our NHS deserves nothing less.
Mrs Cheryl Gillan (Chesham and Amersham) (Con)
May I endorse the Secretary of State’s remarks on Wales, having seen it at first hand? Having seen at first hand a constituent who was a whistleblower, and how her career and her family life have been so badly affected after she did the right thing, I know that what the Secretary of State has done today will be widely welcomed.
On the Public Administration Committee, we took evidence from the CQC and others, and it became very obvious that there is still a major problem with complaints procedures for patients and their relations. Patients often tell me that they are afraid to complain about the way that they are being treated in whatever NHS establishment they are in. Is there some way in which the Secretary of State can ensure that there are clear instructions in all NHS establishments on how patients and their relations can raise their valid concerns without their worst fears being realised?
Mr Speaker
Order. The right hon. Lady, whom I know extremely well as a Buckinghamshire colleague, rather like Treebeard does not believe in unnecessary or undue haste, but if I could suggest to colleagues that questions could be pithy rather than too leisurely I think we would all profit from that. The same goes, of course, for the Secretary of State, from whom we expect characteristically pithy, succinct responses.
Mr Hunt
As indeed we learn from you, Mr Speaker.
I welcome the question from my right hon. Friend, who is a former Secretary of State for Wales. People will want to know that these lessons will be learned in Wales. In the original Francis response, we set out clear plans for the way in which hospitals should make it clear, in every ward of every hospital, how one can complain not just directly to the trust, but to independent external organisations, such as the ombudsman, if necessary.
Frank Dobson (Holborn and St Pancras) (Lab)
May I warn the Secretary of State not to think that because he has decided something and because a circular has been issued, something has happened? In 1998, against a lot of opposition, I insisted that the whistleblowing law should apply to the NHS. I also issued a circular banning the use of gagging clauses. As I said in my discussion with Sir Robert Francis on this whole issue, it clearly did not work.
Mr Hunt
I thank the right hon. Gentleman for what he did when he was Health Secretary. I am well aware that in the world’s fifth-largest organisation, nothing happens just because someone issues a circular, which is why some of what we have announced goes beyond what Sir Robert precisely recommended. For example, by publishing avoidable death rates by hospital trust, we want to make the energy for change come from inside trusts, not from their being told to do things by Ministers. However, I welcome what he did as Secretary of State, and I hope we can do some other positive things.
Sir William Cash (Stone) (Con)
May I commend my right hon. Friend for his nuts-and-bolts approach and Sir Robert Francis for what is clearly an extremely good report? My right hon. Friend will know that Helene Donnelly is a constituent of mine, and that I read out a letter from her in Westminster Hall when I called for an inquiry under the Inquiries Act 2005—an inquiry that this Government set up, despite its having been refused by the previous Government and successive Secretaries of State. Will he bear in mind the need to dismiss any chief executive who does not take account of lessons learned and the fact that anyone who puts a whistleblower at risk does not deserve to hold their job?
Mr Hunt
I thank my hon. Friend because without his work and that of some of his Staffordshire colleagues we would not have had a public inquiry into Mid Staffs in the first place. Helene Donnelly has been a great inspiration to everyone who has thought hard about this subject. She had the courage and guts to stand up for patients at Mid Staffs, and she experienced terrible bullying as a result, which is why I am delighted that she is helping us. In fact, I think she is the inspiration for Sir Robert’s recommendation on “freedom to speak up” guardians. My hon. Friend is absolutely right that managers and chief executives must be completely accountable for delivering on this agenda, but we also need to send a signal to them that success for a chief executive means more than meeting A and E or 18-week targets; it is about the quality and safety of patient care.
Barbara Keeley (Worsley and Eccles South) (Lab)
May I support the suggestion from my right hon. Friend the Member for Leigh (Andy Burnham) to extend to social care the measures recommended by Sir Robert Francis? I know from my own casework how hard it is for a whistleblower in social care working for a small organisation to reveal issues of bad care. In addition, the Health Select Committee pointed out that many whistleblowers suffer in their careers, including in social care, lose their job and find it hard to find a new post, and it recommended that whistleblowers who are vindicated receive an apology and practical redress. Does the Secretary of State agree?
Mr Hunt
I agree with the hon. Lady’s argument. Just as poor care has been identified in hospitals, so we have seen terrible examples of things happening in residential care and of inadequate domiciliary care. It is more complex, because the delivery of social care is more diffuse, but one way to deal with this is through the proper integration of health and social care and the proper assessment of quality based on the entire package of care that people receive, not just in individual institutions but across the board. We are doing a lot of work on that.
Andrew George (St Ives) (LD)
Like others, I welcome the report, but may I urge my right hon. Friend to reconsider the issue of safe staffing levels on acute hospital wards? I know that Robert Francis pointed to issues of culture and standards, but those are areas of interpretation and disputation. If we had the measuring stick of safe standards, particularly where a ward has less than one registered nurse to seven acutely ill patients—the level recommended by the Safe Staffing Alliance—whistleblowers would be able to point to a clear failing and service risk, which is especially important if the Secretary of State is worried about avoidable hospital deaths.
Mr Hunt
The hon. Gentleman makes an important point, but I hope I can reassure him, because NICE has published guidelines on safe staffing levels, although they are different for different parts of a hospital: in intensive care, it is 1:1; for less severe illnesses, it is one nurse to eight patients; and in other parts of a hospital, it is one nurse to four patients. Those are all published, and I hope they will help whistleblowers in Cornwall and elsewhere.
Valerie Vaz (Walsall South) (Lab)
What support will the Secretary of State give to trusts to ensure that safe staffing levels are implemented, given that they might need extra resources?
Mr Hunt
We have protected—indeed increased—the NHS budget in real terms at the time of the biggest financial crisis since the second world war, so I think the Government have done what they can to make resources available. However, improving care is not always about money, and some hospitals manage to staff their wards safely and achieve financial balance. In fact, hospitals that practise safe care tend to be in a better financial position than ones that do not, so safe care and good finances actually go together.
Mr Bernard Jenkin (Harwich and North Essex) (Con)
I commend my right hon. Friend for his statement and thank Sir Robert Francis for his excellent report, which, as the Secretary of State knows, goes to the heart of the Public Administration Committee’s inquiry into clinical incident investigation. It comes as no surprise that we still have severe problems in the NHS. Perhaps the “freedom to speak up” guardian role needs to provide complete legal protection for people speaking up, immunity from freedom of information requests so that the information and the names cannot be exposed maliciously, and the capacity to investigate what is reported to them on a completely independent basis. We look forward to his giving evidence to our Committee.
Mr Hunt
I thank my hon. Friend for his interest in the issue of culture change, including at his local hospital, which I visited last week and where I was pleased to see a change in culture happening, despite some very severe problems. It is excellent that PASC is doing this inquiry, and his suggestions sound very worth while. We will consider them as part of our consultation—in fact I would encourage his Committee to submit them formally, to ensure that we give meaning to these “freedom to speak up” guardians.
Grahame M. Morris (Easington) (Lab)
I welcome the report by Sir Robert Francis and the Secretary of State’s commitment to changing the culture around the protection of whistleblowers—the Health Committee recently published a report making specific recommendations about such protections. May I draw the Secretary of State’s attention to the actions of the General Medical Council, which wrote to the employer of a whistleblower who gave evidence to the Committee after he had expressly stated that he was acting in a personal capacity in raising questions and providing evidence of financial inducements being paid by private health care companies to secure referrals?
Mr Robertson
Thank you, Mr Speaker.
A good friend of mine, a consultant cardiologist, had his career ended and his life completely disrupted after he blew the whistle on the unnecessary deaths of patients at a hospital he worked at. It has taken him more than 12 years to win his case at a tribunal, and he still awaits compensation. These cases often manifest themselves in employment disputes, with trumped-up charges brought against the individual. What can the Secretary of State do to ensure that such things never happen again?
Mr Hunt
I add my congratulations to my hon. Friend, who makes an important point. The heart of the problem of whistleblowing is the confusion between employment law and patient safety. We need to divorce those two things and put in place a proper procedure to ensure that the right thing happens if someone raises a concern about patient care, and that it can be externally investigated to ensure that the trust did the right thing. Issues of employment law and someone’s professional behaviour should be pursued on a completely different track—those things are rightly and properly a matter for the courts. It is precisely because of the kind of issue he talks about that people are afraid to speak out. They worry that if they do, even if they win at an employment tribunal, they might never get a job again. For that reason, we welcome the shadow Secretary of State’s commitment to work with us and put on the statute regulation-making powers making it illegal for NHS organisations to discriminate against former whistleblowers.
John Woodcock (Barrow and Furness) (Lab/Co-op)
The Secretary of State and I spoke last week about the importance of the upcoming Kirkup report. Grieving families in my constituency want to be able to move on from the tragedies they have suffered and see proper change in the culture at Morecambe Bay. What happened was not right and is still under criminal investigation. Will the improvements the right hon. Gentleman has announced today be in place when the report is published, and does he agree that the response to it must be neither whitewash nor witch hunt? If he does, how can he help make it happen?
Mr Hunt
I thank the hon. Gentleman for the close interest he has shown in this issue and the constructive way in which he has engaged with families locally to try to get to the bottom of a really terrible tragedy. He puts it better than I could. We need to implement the recommendations in a tangible and real way so that something actually changes, but we do not want to do it in a way that has unintended consequences. That is why the focus of what Sir Robert is saying this time is not about new criminal sanctions. Although the law has a role—we changed the law on wilful neglect, for example—this is about creating a supportive culture through which people want to listen and learn when others speak out. Of course, if people do not, there should be sanctions, but that should not be the primary motivator.
Sir Bob Russell (Colchester) (LD)
I was pleased to be with the Secretary of State last Thursday when he visited Colchester general hospital—one of 19 in special measures—and I am sure he will want to join me in praising the hard-working medical and support staff for all they are doing. He referred in his statement to the “entire NHS” being “committed to patient-centred culture change”, and observed that no one takes responsibility for a vulnerable patient so that the buck gets passed. I suggest that Sir Robert Francis would do well to look at the silo mentality—the reality rather than the rhetoric—in the case of the Haven Project in Colchester, to which the hon. Member for Harwich and North Essex (Mr Jenkin) and I have drawn attention. That is a classic case where the reality does not match the rhetoric.
Mr Hunt
Yes, and I remember the conversation I had with the hon. Gentleman about that issue. I will look into the case carefully. I am not saying that the NHS culture is changing today, because I think it is a very long journey. That is why it is important to have cross-party agreement. This is something that will take decades to happen. If we look at the best hospitals in the world, in England or abroad, we find that they get their culture right over decades. We must understand that. Breaking down those silos, putting patients first and making sure that that is not compromised, whatever the external pressures—that is the heart of the matter.
Diana Johnson (Kingston upon Hull North) (Lab)
When Pauline Lewin, a whistleblower, came forward in Hull to raise concerns about the then chief executive, Phil Morley, she found herself subject to hostility and bullying and has not been able to return to work—despite corroboration from a damning Care Quality Commission report, an ACAS report that established bullying and an independent KPMG report on financial irregularities. Meanwhile, the chief executive has moved on to another such post, earning £170,000 a year. I listened carefully to what the Secretary of State said—that he was “calling time on bullying…and victimisation” in the NHS—so will he reassure me that that will apply to this case, which his Department is currently investigating?
Mr Hunt
I remember the good meeting I had with the hon. Lady and the former Secretary of State about that issue, which we are looking into. I hope she will understand that it would not be right for me to comment on that individual case, but let me say that it seems to exemplify exactly how things have gone wrong. That is why we need to look into it very carefully. We need to create a culture through which the management actually want to listen to their staff. I do not want managers to do so because of something I say; I want them to feel that they want it happen. It is as much about making sure that organisational priorities are correctly set from the centre, as it is about changing the law.
Charlotte Leslie (Bristol North West) (Con)
Culture change is a big tanker to turn, and senior managers under pressure from targets and headlines need significant sanctions and incentives to reveal rather than smother or downplay difficult truths. Doctors have the General Medical Council, although it needs improvement, but managers have no regulatory body to make them accountable. Will the Secretary of State consider doing something about that?
Mr Hunt
I thank my hon. Friend, whom I know has thought extremely hard about this issue. Indeed, we talked yesterday about getting the fit and proper persons test to work properly. It is still in the early stages, so it is difficult to assess whether it is having the impact we want. We certainly hope it will have some impact. There is an unfairness about the fact that a clinician as a chief executive of a hospital is accountable to the GMC as a doctor, whereas a chief executive who is not a doctor is not accountable. We actually want more doctors to become chief executives. On the whole, they do a really good job, and we should give further consideration to that.
Clive Efford (Eltham) (Lab)
It will take a great deal to change the culture. I have spoken to a senior hospital manager who would like to express his concern about the lack of qualified nurses, forcing him to advertise posts abroad. I have spoken to two A and E nurses who are concerned about the critical situations occurring at their unit every day. One of them has become an agency nurse so she can limit the number of hours she is forced to work. Then there is an ambulance worker who is concerned about the 12-hour shift and the lack of time he is given to clean his ambulance between dealing with patients. They would all like to come forward to express their concerns, but they do not feel that anyone above them would listen. What can the Secretary of State say today to reassure those people?
Mr Hunt
I can say that we are consulting on making a big change that would mean they would have someone independent in their organisations to whom they could talk and raise their concerns. They could say, “I want to say this, but no one is listening to me”. That is what Sir Robert Francis calls “freedom to speak up” guardians, whom he wants in every organisation. It is what Helene Donnelly is championing in her work. That is the way forward to address those concerns.
Andrew Stephenson (Pendle) (Con)
East Lancashire Hospitals NHS Trust was placed in special measures, following the Keogh review, in July 2013, and it successfully exited that regime in July 2014. The trust has employed an additional 201 nurses and nursing support staff and 26 more doctors since June 2013, taking the total increase since May 2010 to 391 additional nurses and 40 additional doctors. In January 2014, the Royal College of Midwives named the maternity services unit the maternity service of the year. Will my right hon. Friend join me in paying tribute to the dedicated staff at East Lancashire hospitals for working with the new tougher regime and turning my local hospital trust around?
Mr Hunt
I absolutely will. This is a great example, and I would like to thank my hon. Friend for the interest he has shown in this issue. For one hospital to have 390 more nurses over four years is remarkable. It may interest my hon. Friend to know that those numbers do not include agency staff, so if the hospitals have any such staff, they will be counted on top of those figures. This is a dramatic turnaround for the quality of patient care, which we all welcome. That just shows that if we get the incentives right from the centre, trusts do want to do the right thing. We did not instruct the trust to employ a single extra nurse; rather, we set up a new inspection regime and special measures regime, and what my hon. Friend said shows it has worked.
Steve Rotheram (Liverpool, Walton) (Lab)
I, too, welcome the report. In his statement, the Secretary of State committed to the view that the new measures are not about “naming and shaming”. Does he therefore agree with the Prime Minister, who said:
“Francis does not blame any specific policy. He does not blame the last Secretary of State for Health. And he says we should not seek scapegoats”?
Mr Hunt
I do not think we should seek scapegoats, but I do think we need to understand where policies have inadvertently led to the wrong outcomes. Sir Robert talks clearly about the dangers of an excessive focus on targets, which is one of the things that have driven the wrong culture. On that, I hope to get cross-party agreement.
Stephen Metcalfe (South Basildon and East Thurrock) (Con)
As my right hon. Friend will be aware, one reason why Basildon hospital came out of special measures so quickly is that under the new chief executive, openness and transparency are is encouraged at every level. Does he therefore agree that it should be incumbent on all of us to be open, transparent and honest? Why does he think the Opposition are tweeting that the numbers of doctors and nurses at Basildon hospital are down, when I have just checked with the chief executive and found that the reality is that the numbers are up?
Mr Hunt
It is very important that everyone uses the right figures. What has happened at Basildon hospital is an inspiration to other trusts in special measures. In just a few months, it moved from being in special measures to being rated “good” by the CQC. The trust has an inspiring new chief executive, Clare Panniker, who really does listen to staff. I have been there and been told by staff how they feel that they are being listened to. We all have an obligation to make sure that the right information goes out to local communities, so that they understand where things really are getting better.
Derek Twigg (Halton) (Lab)
Most, if not all, hospitals are very concerned about next year’s proposed 3.8% efficiency saving. They fear that it will have an impact on access to and quality of services, and hence on patient safety. In the spirit of the openness and transparency that we now want to see, may I ask whether the Secretary of State was aware of those concerns, and whether, if he was not, he will find out why?
Mr Hunt
I am glad to note that this is rapidly becoming one of the most open and transparent exchanges of questions and answers we have had in the Chamber. I am, of course, aware of trusts which say that they will find it difficult to meet stretching efficiency targets, but I would say to them that if they look at some of the safest hospitals in the world—such as Salford Royal in England and Virginia Mason in Seattle—they will find that they have the lowest costs. It is not a choice between cost and safety; better safety leads to lower cost.
Mr Marcus Jones (Nuneaton) (Con)
Will my right hon. Friend join me in welcoming the progress that has been made at George Eliot hospital since the Keogh review? The employment of 91 extra doctors and nurses has certainly helped, but does he agree that we cannot be complacent and must continue to root out bad practice wherever it exists, in a very open and transparent fashion?
Mr Hunt
Absolutely. I have visited George Eliot hospital, and observed a few beds in the A and E department. One of the most inspiring things about it is that it came out of special measures by developing a strong link with University Hospitals Birmingham NHS Foundation Trust—under the leadership of Dame Julie Moore—which enabled it to learn very quickly what changes were needed. The “buddying” of trusts in difficulty with high-performing trusts is one of the measures that have worked the best.
Liz McInnes (Heywood and Middleton) (Lab)
I am pleased that the report mentions support for the right of NHS workers to speak up. When I was a Unite workplace rep in the NHS, I spent much of my time giving support and advice to workers who asked about blowing the whistle on malpractice. Does the Secretary of State recognise the vital advisory and supportive role provided by trade unions in the NHS, and will the Government cease their attacks on trade union facility time?
Mr Hunt
I agree that unions have an important role, but this should not have to be about unions. Regardless of whether a hospital has unions, people should be able to contact someone independent if they feel that their concerns about poor care are not being listened to, and that person should be enthusiastic about listening to what they say.
Jackie Doyle-Price (Thurrock) (Con)
This morning I was contacted about a patient at Basildon hospital who was suffering from Parkinson’s disease and who, on asking for assistance to go to the toilet, was told by nurses that they were too busy, so he had to use his pad. He was left in some distress, and suffering from nappy rash. Does my right hon. Friend agree that, when we are developing a patient-centred culture in the NHS, such behaviour should not be tolerated?
Mr Hunt
I do agree, and I have had many discussions with my hon. Friend about how local health care services can be improved. It shows real courage to raise a concern about patient care at one’s own local hospital. Basildon is a fantastic hospital—it is very well run, and it has really turned a corner—but that does not mean it is perfect, as I am sure its chief executive would be the first to accept. It is possible to have a sensible debate about improving care while being honest about the problems. That is the big change we need to make, and my hon. Friend has given us an example.
Sarah Champion (Rotherham) (Lab)
I welcome the focus on whistleblowers and the support package, but the Francis report also said that patients’ complaints should be viewed as the canary for failing hospitals. What support is the Secretary of State giving to patients who make complaints, and can he reassure us that the hospitals and the Care Quality Commission will take the issue very seriously?
Mr Hunt
Yes. We have set out new guidelines. The right hon. Member for Cynon Valley (Ann Clwyd) helped us a great deal when we were looking into how to improve the NHS complaints procedure, in particular advising people about how to complain and ensuring they knew that they could talk to someone independent if they needed to. I try to look at a letter of complaint about something that has gone wrong in the NHS every day before I start my work, and I make sure that the trusts are aware of that.
Martin Horwood (Cheltenham) (LD)
Before Christmas, I alerted Ministers to attempts by Gloucestershire Hospitals NHS Trust to prevent a governor from expressing concern to the local media about the care of local people. Does the Secretary of State agree that gagging governors is also unacceptable, and that the new spirit of openness should apply to governors and board members as well as staff?
Mr Hunt
I do, and I think it important to bear in mind the role of the press as a last resort for whistleblowers. Many of the problems of which we are aware have come to light because people have spoken to the press, and that is to be welcomed, but I think we would all agree that it is a real shame if things have to reach that stage. We need a culture in which people are listened to straight away. That governor should have felt that he or she could talk to someone in the hospital who would do something about the problem, rather than having to go to the press.
Kate Green (Stretford and Urmston) (Lab)
The Secretary of State has said that trusts are becoming more transparent in relation to data, and of course that is welcome, but data alone may not provide full information for patients. In 2011, Trafford general hospital had very poor standardised mortality figures, but, thanks to the assiduity of my constituent Mr Dennis Wrigley, we now know that they were due to a recording error. How will the Secretary of State encourage trusts not just to provide raw data, but to contextualise the data and tell patients what they might mean?
Mr Hunt
I hope the hon. Lady will be pleased to know that we have now made it a criminal offence to supply false or misleading information, but let me respond to the broad point that she has made, because I think it is important.
The publication of data is indeed welcome, but we do not want it to cause the entire NHS to focus on gaming the system, or changing the way in which data are collected in order to make its organisation look better. The purpose of data is to identify issues. The CQC then makes rounded judgments on the performance of institutions, which are based not just on data but on visits and conversations with patients, doctors and nurses. I think that that system can provide us with the best understanding of how well those institutions are actually doing.
Chris Skidmore (Kingswood) (Con)
As the Secretary of State will know, my hon. Friend the Member for Bristol North West (Charlotte Leslie) and I wrote to him about Southmead hospital after a large number of our constituents had written to us about poor quality care there. Today the CQC published its report on North Bristol NHS Trust and Southmead, which states that the urgent and emergency services are inadequate and causing a
“serious risk to patients’ safety”,
and also states:
“Several staff told us they were ‘ashamed’ of the standard of care”
at Southmead.
I have just received a letter from the chief executive of North Bristol trust, which makes no mention whatsoever of the fact that Southmead A and E had been declared inadequate. Instead, she simply refers to
“some teething problems which are being dealt with”.
Does that letter not illustrate the overall culture problem in the NHS, namely that there is active denial among some chief executives who will not admit what is going wrong in their local hospitals?
Mr Hunt
I have not seen the letter, so I hope that my hon. Friend will understand if I do not comment on it, but I strongly agree with his broader point. Any chief executive or manager in the NHS needs to understand that the best way in which to reassure the public, and to reassure Members of Parliament who speak out for their constituents, is to be honest about the problems.
My local trust was the first in the country to be given an “outstanding” rating. When I last went to see its chief executive, I said that I had three constituency problems, and I raised all three of them with him. He said, “Yes—we were wrong on that one; we should not have done that; and we were wrong on that one.” One of the best trusts in the country was being totally honest about its problems, and wanted to do better. We need to make managers understand that that is the right thing to do, and that we will back them if they do it.
Robert Flello (Stoke-on-Trent South) (Lab)
Longton cottage hospital had to close because the local trust could not recruit enough nurses to ensure its safe operation, yet the Government slashed nurse training places. Now the Department refuses to release the secret KPMG report on “distressed” health economies. The people of Stoke-on-Trent deserve to know what is happening to their local hospitals and to local health care. The Secretary of State rightly says that we need to stop secrecy and have openness, but when will he whistleblow his Department’s own report? The Department is setting a very bad example when it comes to openness and transparency.
Mr Hunt
I will look into the issue that the hon. Gentleman raises, but let me deal now with the issue of nurse training places. The cuts began under the Labour Government, and we have been gradually reversing them. The main point, however, is that, in all parts of the House, there was a lack of understanding of the importance of safe staffing in wards before the Francis report, which is why successive Secretaries of State made mistakes in their projections of what was needed.
We have 8,000 more nurses in our hospital wards, including those at Stoke, and I hope the hon. Gentleman welcomes that.
Andrew Percy (Brigg and Goole) (Con)
The Secretary of State will want to congratulate North Lincolnshire and Goole NHS Foundation Trust on getting out of special measures and employing more nurses and doctors. On the issue of “freedom to speak up” guardians, will he ensure there is one in every hospital, because in my trust staff in the smaller hospital sometimes feel their voice is not heard by the two big district general hospitals, which are up to 60 miles away?
Mr Hunt
That is a very good point. I had a great visit to my hon. Friend’s local hospital and saw a knee operation which was quite gory but looked to me to be a very good example of safe care. He makes a good point and I will certainly feed into the consultation the idea that it should be easy to contact somebody who works in the same hospital or building, rather than someone who is a long way away.
Mr Ronnie Campbell (Blyth Valley) (Lab)
When I entered this House in 1987 I was put on a Select Committee for the parliamentary ombudsman, which dealt with the health service and complaints within it. In bad cases, we would bring chief executives, chief nurses and chairmen of the trust concerned before us. That was a good deterrent. Why not bring it back?
Mr Hunt
All these things should be looked at, but through the Select Committee on Health we do now get chief executives of trusts to be accountable to Parliament. The Public Administration Committee is looking at the role of the ombudsman to make sure that works as well as it can, and we should wait for its recommendations.
Eric Ollerenshaw (Lancaster and Fleetwood) (Con)
Following on from the question of the hon. Member for Barrow and Furness (John Woodcock) about Morecambe Bay trust, has the Secretary of State had a chance to look at yesterday’s “Better Care Together” future plans report by the trust, which finally puts to bed the wild allegations locally of hospital and A and E closures and also sets a road map for eliminating the pre-2010 deficit, provided we get some recognition of the difficult geography of our area?
Mr Hunt
I know geography is a big issue, and the driving distance between Morecambe bay and Lancaster is a big challenge for the trust. I will look closely at that report, and I think Members in all parts of this House would welcome a commitment to avoiding scaremongering about local hospital services in the run-up to the election.
Glyn Davies (Montgomeryshire) (Con)
I represent a constituency in Wales, and look with some envy at the commitment to openness and transparency on both sides of this Chamber, and indeed the commitment to transparency and openness throughout the NHS in England following the Francis report and the Keogh review. What discussions can my right hon. Friend initiate, perhaps with the Opposition, to introduce the same level of transparency and openness in Wales so that my constituents in Montgomeryshire can also benefit?
Mr Hunt
I think it is very simple—there is a lot of agreement between us about what needs to happen. I recognise that the shadow Secretary of State is not personally responsible for what happens in Wales, but his party is, and a Keogh review of high mortality hospitals, a chief inspector of hospitals for Wales and a commitment to the whistleblowing measures announced today would do a lot to allay the concerns of my hon. Friend’s constituents that the lessons about openness are not being learned across the border.
Charlie Elphicke (Dover) (Con)
Does the Secretary of State recall that the Care Quality Commission found that in East Kent hospitals senior management and the front line were disconnected, there were problems with bullying and harassment, and people would not say how things could be improved, including in terms of clinical risk? Does that not indicate that this is not just about whistleblowers, but that it is important that management sets a culture of openness, and listens and hears the staff voice?
Mr Hunt
My hon. Friend is absolutely right, and I thank him for his interest in his local hospitals and his campaign for them. In the end, culture comes from the top. When people start a job they look at the values of their direct line manager and they copy them, because they think that is what it takes to get on, and the line manager looks to the chief executive and the chief executive in the end looks up to the Secretary of State, so it is very important—[Interruption.] I grant that that may not be the best thing. It is important that right from the top we set the right example about these issues.
Robert Halfon (Harlow) (Con)
I thank my right hon. Friend for the work he has done on this and for his forthcoming visit to Princess Alexandra hospital in Harlow. Further to the question on trade unions, we have outstanding trade union representatives in the Princess Alexandra hospital and they do a huge amount of work on these issues. Can my right hon. Friend confirm that these guidelines will also include trade union workers, so that they are covered by his recommendations?
Mr Hunt
That is an interesting point and we should certainly reflect on it in the consultation. I am looking forward to visiting my hon. Friend’s trust in March. On many of the visits I have made to hospitals in special measures, which his hospital is not, I have met union representatives and they have an important contribution to make, because nine times out of 10 the real problem is that the people on the front line feel they are not being listened to, and when that is put right the other things start to be solved as well.
Steve Baker (Wycombe) (Con)
As a former airworthiness engineer, may I strongly endorse my right hon. Friend’s direction of travel? Will he confirm that Buckinghamshire Healthcare NHS Trust, having exited special measures after the Keogh review, has enjoyed a fantastic transformation, which I believe he saw when he visited Wycombe hospital?
Mr Hunt
I had a fantastic visit there. This was a hospital that, putting it bluntly, was one of the worst in the country, and it is now on its way to becoming one of the best. The motivation and excitement not just of the management team but also the staff there, were palpable, and I think a huge number of good things are happening. What has worked there is the sense that what we are asking of the hospital is the same thing that they want to deliver for their patients—safe, compassionate care—and that must remain the focus.