Mid Staffordshire Foundation Trust Inquiry

Earl Howe Excerpts

Tuesday 26th March 2013 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I shall now repeat a Statement made earlier today in another place by my right honourable friend the Secretary of State for Health on the Government’s response to the Francis report. The Statement is as follows:

“With permission, Mr Speaker, I would like to make a Statement on the Government’s response to the Mid Staffordshire NHS Foundation Trust Public Inquiry. I congratulate my right honourable friend and predecessor on setting up the public inquiry, and on the many changes that he made foreseeing its likely recommendations. I would also like to pay tribute to Robert Francis QC for his work in producing a seminal report which I believe will mark a turning point in the history of the NHS.

Many terrible things happened at Mid Staffs in what has rightly been described as the NHS’s darkest hour. Both the current and former Prime Minister have apologised, but when people have suffered on this scale, and died unnecessarily, our greatest responsibility lies not in our words but in our actions—actions that must ensure the NHS is what every health professional and patient wants: a service that is true to the NHS values, that puts patients first and treats people with dignity, respect and compassion.

The Government accept the essence of the inquiry’s recommendations and we shall respond to them in full in due course. However, given the urgency of the need for change, I am today announcing the key elements of our response so that we can proceed to implementation as quickly as possible. I have divided our response into five areas: preventing problems arising by putting the needs of patients first; detecting problems early; taking action promptly; ensuring robust accountability; and leadership. Let me take each in turn.

To prevent problems arising in the first place, we need to embed a culture of zero harm and compassionate care throughout our NHS, a culture in which the needs of patients are central, whatever the pressures of a busy, modern health service. As Robert Francis said, ‘The system as a whole failed in its most essential duty: to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment that should never be tolerated in any hospital’.

At the heart of this problem, the current definitions of success for hospitals fail to prioritise the needs of patients. Too often, the focus has been on compliance with regulation rather than on what those regulations aim to achieve. Furthermore, the way that hospitals are inspected is fundamentally flawed, with the same generalist inspectors looking at slimming clinics, care homes and major teaching hospitals—sometimes in the same month. So we will set up a new regulatory model under a strong, independent chief inspector of hospitals, working for the CQC. Inspections will move to a new specialist model based on rigorous and challenging peer review. Assessments will include judgments about hospitals’ overall performance, including whether patients are listened to and treated with dignity and respect, the safety of services, responsiveness, clinical standards and governance.

The Nuffield Trust has reported on the feasibility of assessments and Ofsted-style ratings, and I am very grateful for its thorough work. I agree with its conclusion that there is a serious gap in the provision of clear, comprehensive and trusted information on the quality of care. So in order to expose failure, recognise excellence and incentivise improvement, the chief inspector will produce a single aggregated rating for every NHS trust. Because the patient experience will be central to the inspection, it will not be possible for hospitals to get a good inspection result without the highest standards of patient care.

However, the Nuffield rightly says that in organisations as large and complex as hospitals, a single rating on its own would be misleading, so the chief inspector will also assess hospital performance at speciality or department level. This will mean that cancer patients will be told of the quality of cancer services, and prospective mothers the quality of maternity services. We will also introduce a chief inspector of social care and look into the merits of a chief inspector of primary care in order to ensure that the same rigour is applied across the health and care system.

We must also build a culture of zero harm throughout the NHS. This does not mean that there will never be mistakes, just as a safety-first culture in the airline industry does not mean that there are no plane crashes, but it does mean an attitude to harm which treats it as totally unacceptable and takes enormous trouble to learn from mistakes. We await the report on how to achieve this in the NHS from Professor Don Berwick.

Zero harm means listening to and acting on complaints, so I will ask the chief inspector to assess hospital complaints procedures, drawing on the work being done by the Member for Cynon Valley and Professor Tricia Hart to look at best practice.

Given that one of the central complaints of nurses is that they are required to do too much paperwork and thus spend less time with patients, I have asked the NHS Confederation to review how we can reduce the bureaucratic burden on front-line staff and NHS providers by a third. I will also be requiring the new Health and Social Care Information Centre to use its statutory powers to eliminate duplication and reduce bureaucratic burdens.

Secondly, we must have a clear picture of what is happening within the NHS and social care system so that, where problems exist, they are detected more quickly. As Francis recognised, the disjointed system of regulation and inspection smothered the NHS, collecting too much information but producing too little intelligence. We will therefore introduce a new statutory duty of candour for providers to ensure that honesty and transparency are the norm in every organisation, and the new chief inspector of hospitals will be the nation’s whistleblower in chief.

To ensure that there is no conflict in that role, the CQC will no longer be responsible for putting right any problems identified in hospitals. Its enforcement powers will be delegated to Monitor and the NHS Trust Development Authority, which it will be able to ask to act when necessary.

We know that publishing survival results improves standards, as has been shown in heart surgery. So, I am very pleased that we will be doing the same for a further 10 disciplines: cardiology, vascular, upper gastro-intestinal, colorectal, orthopaedic, bariatric, urological, head and neck, thyroid and endocrine surgery.

The third part of our response is to ensure that any concerns are followed by swift action. The problem with Mid Staffs was not that the problems were unknown; it was that nothing was done. The Francis report sets out a timeline of around 50 warning signs between 2001 and 2009. Ministers and managers in the wider system failed to act on these warnings. Some were not aware of them; others dodged responsibility. This must change. No hospital will be rated as good or outstanding if fundamental standards are breached. Trusts will be given a strictly limited period of time to rectify any such breaches. If they fail to do this, they will be put into a failure regime which could ultimately lead to special administration and the automatic suspension of the board.

The fourth part of our response concerns accountability for wrongdoers. It is important to say that what went wrong at Mid Staffs was not typical of our NHS and that the vast majority of doctors and nurses give excellent care day in, day out. We must make sure that the system does not crush the innate sense of decency and compassion that drives people to give their lives to the NHS. Francis said that primary responsibility for what went wrong at Mid Staffs lies with the board. So, we will look at new legal sanctions at a corporate level for organisations that wilfully generate misleading information or withhold information that they are required to provide. We will also consult on a barring scheme to prevent managers found guilty of gross misconduct finding a job in another part of the system. In addition, we intend to change the practices around severance payments, which have caused great public disquiet. In addition, the General Medical Council, the Nursing and Midwifery Council and the other professional regulators have been asked to tighten their procedures for breaches of professional standards. I will wait to hear how they intend to do this, and for Don Berwick’s conclusions on zero harm before deciding whether it is necessary to take further action. The chief inspector will also ensure that hospitals are meeting their existing legal obligations to ensure that unsuitable healthcare support workers are barred.

The final part of our response will be to ensure that NHS staff are properly led and motivated. As Francis said:

“All who work in the system, regardless of their qualifications or role, must recognise that they are part of a very large team who all have but one objective, the proper care and treatment of their patients”.

Today I am announcing some important changes in training for nurses. I want NHS-funded student nurses to spend up to a year working on the front line as support workers or healthcare assistants, as a prerequisite for receiving funding for their degree. This will ensure that people who become nurses have the right values and understand their role. Healthcare support workers and adult social care workers will now have a code of conduct and minimum training standards, both of which are being published today. I will also ask the chief inspector to ensure that hospitals are properly recruiting, training and supporting healthcare assistants, drawing on the recommendations being produced by Camilla Cavendish. The Department of Health will learn from the criticisms of its own role by becoming the first department where every civil servant will have real and extensive experience of the front line.

The events at Stafford Hospital were a betrayal of the worst kind—a betrayal of the patients, the families, and of the vast majority of NHS staff who do everything in their power to give their patients the high-quality, compassionate care that they deserve. However, I want Mid Staffs to be not a byword for failure but a catalyst for change: to create an NHS where everyone can be confident of safe, high quality, compassionate care; where best practice becomes common practice; and where the way in which a person is made to feel as a human being is every bit as important as the treatment they receive. That must be our mission and I commend this Statement to the House”.

My Lords, that concludes the Statement.

--- Later in debate ---

[Earl Howe]

My Lords, I am grateful to the noble Lord, Lord Hunt, for his comments, and for the support that he was able to give to a number of the proposals that the Government have made. I will attempt to answer as many of his questions as possible. First, he asked why the Government’s response does not address all 290 of Francis’s recommendations. This report, which comes seven weeks on, is not and I think could not be a full response to each and every one of those recommendations. Francis himself notes in his report that:

“Some recommendations are of necessity high level and will require considerable further detailed work to enable them to be implemented”.

That work we will most certainly do. We accept most of the recommendations in Robert Francis’s report, either in principle or in their entirety, but I emphasise that there is much more to do. To rush ahead would mean that we would not give the full and collective consideration to the report that is clearly needed. It would also limit the clinical engagement and the patient and public involvement that is so important. Our response today is designed to be an overarching one, setting out our key early priorities.

The noble Lord asked me about the duty of candour. We recognise that attaching criminal sanctions to key areas of public service delivery can send an important message to the public about the expected standards of care and duty. That is why we will consider the introduction of additional legal sanctions at a corporate level where organisations wilfully generate misleading information, or withhold information that they are required to provide. I cannot be more specific about the extent and scope of that, but we do think there is an issue to be addressed there. I will take the noble Lord’s points on board as to how widely that should go.

However, we are concerned that the introduction of criminal sanctions on individual staff who provide NHS services could run counter to the creation of an open and transparent culture. It could instead create a culture of fear that could lead to the cover-up of mistakes, which is the very opposite of what we seek to achieve. That of course could in turn prevent lessons being learnt and could make services less safe. However, we agree that where staff are obstructively dishonest action will need to be taken to ensure that the quality of patient care is not jeopardised. We are asking the NMC and the GMC to look at how they might be able to strengthen professional standards and disciplinary measures to address those kinds of case. Registered clinical staff are, of course, already placed under a duty to be open through their professional regulators, but we will consider whether is a need to add to that duty in the light of the Berwick review on safety.

Turning to healthcare support workers, as I have frequently said in your Lordships’ House, the Government’s mind is not closed to statutory regulation, but regulation as such is no substitute for a culture of compassion and effective supervision. Putting people on a national register does not guarantee protection for patients, as was sadly seen at Mid Staffs. Instead, we have decided to tackle this issue at its root, focusing on making sure that healthcare support workers have the right training and values and, most importantly, support and leadership to provide high-quality care.

As I repeated in the Statement, we are today publishing minimum training standards and a code of conduct for healthcare and care assistants. In addition, all healthcare support workers work under registered professionals who are responsible for the care provided to their patients. Camilla Cavendish has been asked to conduct an independent study of healthcare and care assistants to ensure that they have not just the right training but the right support to provide services to the highest of standards. She is due to report in May. We will consider further action following that review. Health Education England is working with employers to improve the capability and training standards of the care assistant workforce. Its strategy will feed into the Camilla Cavendish review.

As regards nurse training and the idea that every prospective nurse should have bedside experience before undertaking formal training, we believe that that idea should be piloted. The charge that we have heard for so many years that some nurses are too posh to wash must be got rid of. We must ensure that we are training nurses who have an aptitude for the role and who know what it is like to have hands-on experience as a healthcare assistant before committing themselves to training. Starting with pilots, every student seeking NHS funding for nursing degrees should, we believe, first serve for up to a year as a healthcare assistant to promote front-line caring experience and values, as well as academic strength. The current first-year dropout rate for nurses alone is 25%. For that reason also, it is important to ensure that we have the right sort of man and woman as a nurse trainee. We recognise that the scheme will need to be tested and implemented carefully to ensure that it is cost-neutral. Of course that is a consideration and the noble Lord was right to raise it. We will explore whether there is merit in extending the principle to other NHS trainees.

The noble Lord asked me a number of questions about the chief inspector. We think that having a chief inspector as part of the senior team of the CQC will provide us all with an expert judgment on the part of those who have walked the wards, spoken to patients and staff, looked the board of directors in the eye and made a rounded judgment of an organisation’s health, and thereby give true quality assurance, as opposed to what I fear that we have seen all too frequently, which is a tick-box approach. It will be a powerful role and it is very important that the data on which the chief inspector relies are representative of quality. That is a job of work that needs to be done.

The noble Lord also asked me about the National Patient Safety Agency. We continue to believe that it is absolutely right to place the national reporting and learning service within the Commissioning Board if we are to learn from safety incidents and near misses and to enable that information to be fed directly into commissioning behaviour. It is obviously important that we do not lose the expertise that the NPSA has built up. I hope and believe that we will not and that this is the right model. Nevertheless, the noble Lord is right to flag up that we need to learn from experience and we will do that.

As regards the CQC’s responsibilities, the noble Lord may be aware that the Health Select Committee of another place recently reported on the role of Monitor. One of the key criticisms that it levelled against the current system was that it is, in many senses, ambiguous. Sometime the roles of Monitor and the CQC appear to overlap and sometimes there appears to be a gap as to exactly who is responsible for what. Having thought very carefully about this issue, our judgment is that it is important to be crystal clear about who is responsible for what. The CQC’s powers, in terms of warning notices and improvement notices, will remain, but should the CQC find that there is an intractable case of quality failure in a provider organisation, it should not be the CQC’s job to sort that out. There should be a single failure regime triggered by Monitor, which is the body currently responsible for triggering the financial failure regime. The details are yet to be worked out, but clarity of roles is vital in this area.

I am aware that there are one or two questions that I have not covered, but I undertake to write to the noble Lord on those.

[Baroness Jolly]

My Lords, I thank my noble friend the Minister for repeating the Statement. I am sure that many noble Lords will welcome, in due course, a full and spirited debate on this issue. Will my noble friend clarify which of the recommendations that are being adopted will require primary legislation, what the timescale might be and what the mechanism might be for that?

We welcome my noble friend’s remarks on the duty of candour but, as with all these things, the devil is in the detail. My question is about the chief inspector regime in general. We are going to have a chief inspector of hospitals so it would seem sensible to have a chief inspector of social care. Will we then need a chief inspector for public health and another one for mental health? Is that the way to have all the bases covered?

[Earl Howe]

My Lords, it is a little early to say what legislation we will need, but I can tell my noble friend that we can deal with the duty of candour by secondary legislation. It may be that many of the follow-up actions to Francis can be done without any legislation at all. However, primary legislation would appear to be the obvious route when statutory roles are to be changed.

With regard to the chief inspectors, the only firm decisions we have taken so far are to appoint a chief inspector of hospitals and a chief inspector of social care. We are looking at the merits of a chief inspector of primary care but we need to make sure that there is a genuine issue that needs to be addressed by way of a chief inspector role rather than leaving the CQC to perform its role in the normal way. Further details will be forthcoming at an appropriate time.

[Baroness Emerton]

My Lords, I would like to mention nurse education. The suggestion of having some front-line experience before entering university is, philosophically and practically, very good if it can be worked, but it raises all sorts of questions. I spoke to a healthcare support worker a few weeks ago who said that all the students who come on to her ward tell her, “I wish we had had this experience that you are getting before going into training”, so there is evidence that many of them would like to have that kind of experience. However, this raises the question of their supervision during that time. Will there be adequate numbers of trained staff to supervise the continuing support workers as well as those who are pre-nursing apprentices, or whatever?

The logistics of this are going to be important to work on. We need to know whether the Government will look at minimum staffing levels. Where there are enough registered nurses and the minimum is stated, there should be means whereby registered nurses will be available whenever demands on patient care escalate, such as during a time of winter problems, rather than abusing and misusing the support workers. There is a tremendous amount of work to be done on that.

There is also the role of the Nursing and Midwifery Council, which has responsibility for regulating the pre-nursing standards. I hope the Government will ensure that the council takes an active part in this pre-nursing experience, because that will be important. I urge Ministers to have this minimum staffing looked at, if that is possible. I am extremely disappointed that the Government are not prepared to take on the regulation of these support workers because I fear that we may find ourselves having similar problems as in the past, unless we have some regulatory system.

[Baroness Northover]

My Lords, I remind noble Lords that brief questions only are called for after Statements, and that the briefer they are, the more colleagues will be able to get in.

[Earl Howe]

I reassure the noble Baroness that all the concerns that she rightly raised are very much in our sights, not least the need for proper supervision of nurse trainees and the practical aspects of having the right level of support on the ward. This is why we believe that this idea should be piloted first, so that lessons can be learnt. Yes, we will involve the NMC, and indeed the Royal College of Nursing, in these plans. As regards ratios, having the right staffing in terms of numbers and skills is clearly vital for good care, but minimum staffing numbers and ratios, if laid down in a rigid way, risk leading to a lack of flexibility or organisations seeking to achieve staffing levels only at the minimum level. Neither of those is good for patients. However, I do not dismiss the general concept. It is ultimately up to local organisations to have the freedom to decide the skill mix of their workforce, based on the health needs of those on the wards.

[Baroness Pitkeathley]

My Lords, the principle of putting the needs of patients first will be welcomed by every Member of this House. However, does the Minister agree that this means looking at care in an integrated way, since the patient experience is very rarely one of either hospital or social care but a mixture—sometimes a very haphazard mixture—of the two? Can the Minister therefore give the House more detail about how the government proposals will facilitate the integration of care services across health and social care, particularly as there will be two separate inspectors and as the ability of the CQC to put the shortcomings right is apparently going to be passed to Monitor?

[Earl Howe]

My Lords, the main drivers and levers for increased integration will come from other directions, such as: the systems we are putting in place at local authority level and health and well-being board level; more sophisticated tariffs; better commissioning arrangements between the NHS and social care; and the financial imperative that all commissioners and providers now face. That will mean an imperative to ensure that resources are not wasted and are deployed to the best effect of patients.

We must also remember that the NHS outcomes framework will be the benchmark by which the success of the service is judged, just as the social care outcomes framework will act in that sphere in an equivalent way. The major domain in both areas is the patient experience. If we believe that integration is above all to be defined by reference to the patient’s experience, we can expect commissioners across the piece to address commissioning in a way that avoids disjointed care.

[Lord Cormack]

My Lords, is my noble friend aware that many people in Staffordshire will welcome this report but will wonder whether the present chief executive is the best person to oversee the implementation of the many recommendations to which my noble friend has referred?

[Earl Howe]

My Lords, it was a signal feature of the Francis report that he consciously avoided pointing the finger at individuals. The chief executive of the NHS did not have the finger of blame pointed at him. The House may be interested to know that I regard Sir David Nicholson as a truly outstanding public servant who has done an enormous amount of good for the NHS since becoming chief executive.

The benefit of hindsight is wonderful but we must remember that in the years in which these dreadful events took place the National Health Service was held to account by reference to two main indicators: access to care and waiting times, and finance. Above all, it was the arrival of the noble Lord, Lord Darzi, as a Minister and the Secretaries of State whom he served that saw the transformation of the NHS from an organisation that was concerned just about numbers into one that really appreciated that quality matters. Therefore, to accuse those with positions of responsibility with regard to Mid Staffs of overlooking the fact that quality was poor is to place a wholly unfair retrospective expectation on them.

[Lord Patel]

My Lords, a great deal of importance and emphasis is being placed on introducing zero harm with regard to patient safety. I am delighted that the Government have asked Don Berwick to advise them how to do this. Do the Government intend to have zero harm in the NHS as a concept or as a requirement? If it is the latter, what legal framework will make that happen?

[Earl Howe]

It is much more a question of culture than anything else. However, the noble Lord will be aware that Robert Francis recommended that we look at the concept of fundamental standards below which care should never fall. We are determined to do that. Defining a fundamental standard is something for wide discussion. However, we take this recommendation very seriously. Robert Francis was clear that if individuals or an organisation were found guilty of breaching fundamental standards, serious consequences should ensue.

On a more general level, it is impossible to expect human beings never to make a mistake or never to fall down on the job. The point here is to create an attitude of mind in all those who work for and with the NHS that puts the patient’s well-being at the centre of their daily lives and thinking. That is where we want to be.

[Lord Bilston]

The recent pronouncements of Monitor seem to ignore the vast majority of the people of Stafford, who, as my noble friend Lord Hunt indicated, require a range of safe, sustainable and comprehensive health services rather than the delegation of a range of services, including elective surgery, to other hospitals such as New Cross in Wolverhampton. That hospital is already under considerable pressure and has inadequate facilities in many areas, including a very restricted site with inadequate car parking. Will my noble friend comment on that, because there is great concern and anxiety in Wolverhampton that many thousands of people will be allocated to New Cross and that it will be unable to respond that heavy need? As always in these cases, the balloon will burst and we will quickly find that New Cross Hospital itself sinks into the abyss and then has difficulty responding to the health needs of the people of Wolverhampton.

[Earl Howe]

I understand the noble Lord’s concerns and those of the people of Stafford. Unfortunately, this trust is losing a substantial amount of money. That is not a situation that anybody can be relaxed about, which is why Monitor has taken the action that it has. One of the tests by which any trust administrator’s report will be judged will be whether the solution offered delivers high-quality care and the prospect of good health outcomes to the patients of the area. This is not just a pounds, shillings and pence exercise; it is an exercise that is necessarily looking at services across the piece to see how they can be better and more cost-effectively configured to ensure that high-quality care is maintained.

[Baroness Browning]

My noble friend will be aware that the Mental Capacity Act was not mentioned or used at Winterbourne View and that we have seen one too many reports from Mencap about the deaths on hospital wards of young people who have a learning disability or autism. In the next 12 months, this House will carry out post-legislative scrutiny of the Mental Capacity Act. Will my noble friend ensure that his department is not just a passive observer of that process but communicates with those on that committee to ensure that people on hospital wards who lack capacity, albeit a fluctuating or temporary lack of capacity, are not only spoken to but treated like any other patient?

[Earl Howe]

My noble friend is right to raise this issue, and I pay tribute to the work that she has so consistently done to improve the lot of those with autism. I undertake to write to her about this, but I can give her the general reassurance that the Department of Health will certainly be involved in the scrutiny of these measures, as will the NHS Commissioning Board. I want to ensure that we learn the right lessons from the actions already taken.

[Baroness Masham of Ilton]

My Lords, does the Minister not think that, with the duty of candour, those who make mistakes should take responsibility and be accountable for them? Otherwise people will not learn from those mistakes and they will continue. I also want to ask about the 10 disciplines. I was very surprised that respiratory conditions are not included as nearly all death certificates have pneumonia on them.

[Earl Howe]

I undertake to look at the latter point made by the noble Baroness. The 10 disciplines were selected as ones that could reasonably and readily be subject to the kind of assessment process that we are looking to achieve. I will come back to her on that.

As regards the duty of candour, individuals should certainly take responsibility for their actions and be encouraged to do so. We fear, however, that criminalising individuals’ behaviour within an NHS organisation could risk doing the opposite of what we all want to see: a much more open culture, one that has made the NPSA and its work so successful; a no-blame culture, where people take responsibility for when things go wrong but do not feel that the heavy hand of authority is going to descend upon them at the merest mistake. However, it is important that people are held to account if they are dishonest or deliberately withhold information, and that is a different set of issues.

[Lord Walton of Detchant]

The appalling failings highlighted in the Francis report clearly demonstrated that the managerial virus—an obsession with meeting targets—infected many of the medical and nursing staff in Mid Staffs and diverted them from their primary standards of providing a high quality of patient care. Many of the proposals set out in the Statement are essentially welcome.

I learnt only last week of the new assessment method, PLACE, and I would love to hear where that fits in to the programme. Having said that, will the Government take note of the fact that there is a danger in creating a superfluity of regulatory authorities that would divert doctors and nurses from their primary bedside responsibilities? Is it not better to make certain that regulatory authorities function much more efficiently and effectively in controlling standards?

[Earl Howe]

I wholeheartedly agree with the noble Lord. One of the concerns at the back of our minds as we have considered Robert Francis’s report is the need to ensure that we do not create oppressive additional regulation to cure the problems that Francis has identified. Indeed, we need to look at doing the opposite: how can we lift regulatory burdens and ensure that the culture Francis spoke about can thrive? The NHS Confederation is advising us on this. It is looking specifically at burdens placed on NHS providers and organisations, and we shall take its recommendations to heart.