Mid Staffordshire Foundation Trust Inquiry

Lord Hill of Oareford Excerpts

Wednesday 6th February 2013 Lords Chamber

[The Chancellor of the Duchy of Lancaster (Lord Hill of Oareford)]

My Lords—

[Lord Campbell-Savours]

My Lords, will the Minister make it clear that brief interventions are required? Otherwise not everyone will be heard.

[Earl Attlee]

The noble Lord has taken the words out of my mouth.

[Lord Hill of Oareford]

My Lords, with the leave of the House I will now repeat a Statement made earlier in another place by my right honourable friend the Prime Minister. The Statement is as follows:

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

Mr Speaker, I have a deep affection for our National Health Service. I will never forget all of the things doctors and nurses have done for my family in times of pain and difficulty. I love our NHS. I think it is a fantastic institution and a great organisation that says a huge amount about our country and who we are. I always want to think the best about it. I have huge admiration for the doctors, nurses and other health workers who dedicate their lives to caring for our loved ones.

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

There was a healthcare commission investigation in 2000; a first independent inquiry from Robert Francis in February 2010; and, long before that, the testimony of bereaved relatives such as Julie Bailey and the Cure the NHS campaign. They all laid bare the most despicable catalogue of clinical and managerial failures at the trust. But even after these reports, some really important questions remained unanswered. How were these appalling events allowed to happen and how were they allowed to continue for so long? Why were so many bereaved families and whistleblowers who spoke out ignored for so long? Could something like this ever happen again? These were basic questions about wider failures in the system—not just at the hospital but right across the NHS, including its regulators and the Department of Health. That is why the families called for this public inquiry and that is why this Government granted one. I am sure that the whole House will want to join with me in expressing our thanks to Robert Francis and his entire team for all their work over the past three years.

The inquiry finds that the appalling suffering at Mid-Staffordshire hospital was primarily caused by a “serious failure” on the part of the trust board, which failed to listen to patients and staff and failed to tackle what Robert Francis calls “an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities”. But the inquiry finds that the failure went far wider. The primary care trust assumed that others were taking responsibility and so made little attempt to collect proper information on the quality of care.

The strategic health authority was “far too remote from the patients it was there to serve, and it failed to be sufficiently sensitive to signs that patients might be at risk”. Regulators, including Monitor and the then Healthcare Commission, failed to protect patients from substandard care. Too many doctors “kept their heads down” instead of speaking out when things went wrong. The Royal College of Nursing was “ineffective both as a professional representative organisation and as a trade union”, and the Department of Health too remote from the reality of the services that they oversee.

The way Robert Francis chronicles the evidence of systemic failure means we cannot say with confidence that failings of care are limited to one hospital. But let us also be clear about what the report does not say. Francis does not blame any specific policy; he does not blame the previous Secretary of State for Health; and he says we should not seek scapegoats. Looking beyond the specific failures that he catalogues so clearly, I believe we can identify in the report three fundamental problems with the culture of our National Health Service.

The first is a focus on finance and figures at the expense of patient care; Francis says that explicitly. This was underpinned by a preoccupation with a narrow set of top-down targets pursued in the case of Mid Staffordshire to the exclusion of patient safety or listening to what patients, relatives—and indeed many staff—were saying.

Secondly, there was an attitude that patient care was always someone else’s problem. In short, no one was accountable. Thirdly, he talks about defensiveness and complacency. Instead of facing up to and acting on data which should have implied a real cause for concern, Francis finds, all too often, a culture of explaining only the positives rather than any critical analysis. Put simply, managers were suppressing inconvenient facts in favour of looking for comfort in positive information.

That is one of the most disturbing findings. It is bad enough that terrible things happened at that hospital, but this inquiry is telling us is that there was a manifest failure to act on the data available not just at the hospital but more widely. As Francis says:

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

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

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

Since the problems at Mid Staffordshire Hospital first came to light, a number of important steps have been taken. The previous Government set up the National Quality Board and the quality accounts system. This Government have put compassion ahead of process-driven bureaucratic targets and put quality of care on a par with quality of treatment. We have set that out explicitly in the mandate of the NHS Commissioning Board, together with a new vision for compassionate nursing. We have introduced a tough new programme for tracking and eliminating falls, pressure sores and hospital infections, and we have demanded nursing rounds every hour, in every ward of every hospital.

However, it is clear that we need to do more. We will study every one of the 290 recommendations in today’s report and respond in detail next month, but the recommendations include the three core areas—patient care, accountability and defeating complacency—on which I believe we should make more immediate progress. Let me say a word about each.

The first is how we put patient care ahead of finances. Today, when a hospital fails financially, its chair can be dismissed and the board suspended, but failures in care rarely carry such consequences. That is not right. We will create a single failure regime where the suspension of the board can be triggered by failures in care as well as failures in finance, and we will put the voice of patients and staff at the heart of the way that hospitals go about their work.

In Mid Staffordshire, as far back as 2006, there was a survey in which only about a quarter of staff said that they would actually want one of their own relatives to use the hospital they worked in. During the following two years, bereaved relatives produced case after dreadful case and campaign after chilling campaign, but those voices and horrific cases were ignored. Indeed, the hospital was upgraded to foundation trust status during that period. We need the words of patients and front-line staff to ring through the boardrooms of hospitals and beyond to the regulators and the Department of Health itself.

From this year every patient, every carer, every member of staff will be given the opportunity to say whether they would recommend their hospital to their friends or family. This will be published and the board will be held to account for its response. Put simply, where a significant proportion of patients or staff raise serious concerns about what is happening in a hospital, immediate inspection will result and suspension of the hospital board may well follow.

Quality of care means not accepting that bed sores and hospital infections are somehow occupational hazards and that a little of them is somehow okay. They are not okay. They are unacceptable—full stop, end of story. That is what zero harm means. I have asked Don Berwick—who has advised President Obama on this issue—to make zero harm a reality in our NHS.

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

Secondly, there is accountability and transparency. The first Francis report set out clearly what happened within Stafford hospital. It should have led to those responsible being brought to book by the board, the regulators, the professional bodies—and, yes, even by the courts. But this did not happen.

Most people will want to know why on earth not. We expect hospitals to take disciplinary action against staff who abuse their patients. We expect professional regulators to strike off doctors and nurses who seriously breach their professional codes, and, yes, we expect the justice system to prosecute those suspected of criminal acts, whether they take place in a hospital or anywhere else. In Stafford, these expectations were badly let down. The system failed. That is one of the main reasons we needed this inquiry.

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

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

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

So I have asked the Care Quality Commission to create a new post—a Chief Inspector of Hospitals—to take personal responsibility for this task. I want the new inspections regime to start this autumn. We will look at the law to make sure that the inspector’s judgment is about whether a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking. In the mean time, I have asked the NHS Medical Director—Professor Sir Bruce Keogh—to conduct an immediate investigation into care at hospitals with the highest mortality rates and to check that urgent remedial action is being taken.

Complacency in the system has meant that all too often, patient complaints have been ignored. I am today asking the honourable Member for Cynon Valley and the Chief Executive of South Tees Hospitals NHS Foundation Trust, Tricia Hart, specifically to advise how hospitals in the NHS should handle complaints better in future.

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

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

What makes our National Health Service special is the very simple principle that the moment you are injured or fall ill, the moment something happens to someone you love, you know that whoever you are, wherever you are from, whatever is wrong, however much you have in the bank, there is a place you can go where people will look after you and do everything they can to make things right again. The shocking truth is that this precious principle of British life was broken in Mid Staffordshire. We would not be here today without the tireless campaigning of the families who suffered so terribly, and I am sure that the whole House will join with me in paying tribute to their incredible courage and determination over these long and painful years.

When I met Julie Bailey and the families again on Monday, she said to me that she wanted the legacy of their loved ones to be an NHS safe for everyone. That is the legacy that together we must secure. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Lord Hill of Oareford]

My Lords, I am grateful for the way in which the noble Lord, Lord Hunt of Kings Heath, put his questions and responded. I agree with what he said at the outset about the NHS representing the best values of our country, his important point that these awful things are not typical of everything that goes on, and that there are many hundreds of thousands of people delivering great care. He is right to remind us of that but also right to be clear, as he was, that together we need to face up to the problems that this extremely important report from Mr Francis has uncovered. I also take the noble Lord’s point, which the Francis report mentions, about the dangers of over-frequent reorganisation. All parties need to be conscious of that, and I think that all politicians are sometimes guilty of it. One of the great lessons of all systems is that the simpler and more stable one can keep them, the better the framework in which people have to operate.

I agree with the noble Lord about the importance of patients having a strong and independent voice. I think that is the way he put it. I certainly know from the world of education that it is hugely important to find ways to ensure that parents and those who care and have to use the services can plug into the system and can help to hold those services to account, and the findings in the Francis report underline the effort that we need to make to ensure that that happens.

On the noble Lord’s specific question about Healthwatch, I know that my noble friend Lord Howe spoke yesterday evening about some of the ways in which we are trying to strengthen the role and voice of patients and the public through local Healthwatch. We are determined to ensure that local Healthwatch can act as an independent and powerful voice for patients in local areas, and we are creating Healthwatch England so that there is a national voice for patients as well. I agree with him about the importance of that.

I also agree with the noble Lord’s emphasis on having compassion at the heart of medicine. Again, that point came out of the Francis report.

On the question of skills, numbers and finances, the noble Lord is right to say that that question was put to my right honourable friend the Prime Minister by the Leader of the Opposition earlier on. My right honourable friend said that he believes that the resources that are going into the health service, which are increasing, are in place. I agree that we have to ensure that every ward has the right mix and number of doctors, nurses and healthcare assistants so that staff have the time and the skills to ensure that they are providing safe and effective care. I believe that the recent nursing vision, Compassion in Practice, set out new measures to help to ensure that locally, but I know that my right honourable friend the Health Secretary will study the report to see whether there are other steps that may need to be taken.

On the subject of the chief inspector, again there is an analogy with schools. Having a figure that we can identify as a champion of standards is going to be a good step forward. He or she will be part of the CQC. The precise process by which they operate will need to be sorted out in detail over the days and weeks to come, but obviously we will share that with the noble Lord and other interested Peers.

On the noble Lord’s question about the National Patient Safety Agency, I understand that that was merged into the Commissioning Board to try to make safety integral to the commissioning of care. We need to ensure that happens.

On the merging of Monitor and the CQC, another important question, the noble Lord asked for reassurance that a decision on that has not already been taken. I can say to him that it has not. We have already made clear that we aim to create more generally a single failure regime under which organisations can be held accountable for failures in care, as well as with their finances. Francis’s recommendation to merge those two organisations is one that we will consider. There are clearly questions about the balance between making sure that quality is high and money.

On the noble Lord’s important question about the registration and training of healthcare assistants, we are certainly committed to supporting healthcare assistants and support workers to provide proper, compassionate and safe care. We will take Francis’s recommendations seriously, but the report in another place also points out, rightly, that compulsory statutory regulation does not necessarily prevent poor care, and that cultural issues—one of the recurring themes of the report—are indeed central.

The noble Lord asked about the effect on the quality of care of the process of moving to foundation trust status. Like the previous Government, we believe that foundation trusts can make our hospitals more accountable and responsible and better able to take decisions. However, the move to trust status for Mid Staffs was at the expense of patient care, and that was clearly wrong. I agree with the noble Lord that it is a move that must not be rushed and that patient care must come first. In answer to his question: yes, there will be no pressure. The essential requirement is that they be ready.

In response to the noble Lord’s question about targets, I accept—and this is clearly the case in all sorts of areas—that there is a place for sensible targets. We also know and accept that if we have the wrong targets, or too many of them, there is sometimes the danger of perverse incentives and confusion as well. As the noble Lord said, getting that balance right is extremely important.

On integrated services, it is important to make sure that we are able to look across the piece, and that there are not the barriers that he described. Of course I recognise the amount of interest in the subject. I know how much expertise there is here, and I am very happy to see whether we can find an opportunity for a fuller debate through the usual channels, which I think would be well received by noble Lords.

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[Baroness Jolly]

My Lords, we, too, welcome the Francis report, and the many recommendations that we believe will strengthen the whole NHS. In particular, we welcome Francis’s recommendation of a statutory duty of candour: the duty of a clinician to explain and apologise when things go wrong. When and how does my noble friend see this being implemented?

[Lord Hill of Oareford]

As my noble friend said, Robert Francis certainly recommended a statutory duty of candour, and my right honourable friend the Secretary of State will give full consideration to that. So far, he has said that he will work through all 290 recommendations in the report, and that the Government aim to give an initial response within a month. Precisely what the timeframe will be on all these elements, I cannot say. As my noble friend will know, in the interim we created legally binding rules that require the NHS Commissioning Board to insert a contractual duty of candour into the NHS standard contract in 2013-14. That means that NHS hospitals will be required contractually to tell patients when they have been significantly harmed by a patient-safety incident during their care. Otherwise, I take my noble friend’s point on board.

[Lord Campbell-Savours]

My Lords, the Statement says:

“every carer, every member of staff will be given the opportunity to say whether they would recommend their hospital to their friends or family. This will be published … where a significant proportion of patients or staff raise serious concerns about what is happening in a hospital immediate inspection will result and suspension of the hospital board may well follow”.

That is a very radical proposal. My question is very simple: will a member of staff making such a report have their name published, or will their contribution be anonymous? If it is not anonymous, this system will not work.

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[Lord Hill of Oareford]

I understand the noble Lord’s point. Like many things in this report, we will need to consider exactly how the details of the system will work. Generally, on whistleblowing and giving people the opportunity to make their views known, we have already taken steps to try to protect and support whistleblowers. We are funding a helpline to support them, we are embedding rights in their employment contracts, and we are issuing new guidance. We will be studying the report to see whether there are any further procedural or legal measures, and I hope that we will be able to provide more information to the noble Lord in due course.

[Baroness Knight of Collingtree]

My Lords, would that it were only the Mid Staffordshire hospital that was guilty of the kind of wrongdoing that we have been talking about tonight. My noble friend has made a wonderful, genuinely caring, speech about what has been happening and his determination to stop it. However, I feel very strongly about this, because I have tried for years and years, from 2002 onwards, to bring cases to this House. We should sometimes listen to people, here and in the other House, who bring cases before their House to be considered.

As many Members know, I produced a long document of 26 cases of the various bad treatment of patients. I went to endless trouble to make absolutely certain that every fact I put forward was correct, and that each patient for whom I pleaded had given me full permission to raise his or her case. The noble Lord, Lord Hunt, might remember the occasion when I went to him with a long and detailed dossier of these cases. It was certainly not his fault, but a number of those 26 cases were never investigated at all, and I never got an answer. I even tried to get through this House a parents’ protection Bill, which was quietly squashed at the time. My plea to my noble friend is that he also lets Members of Parliament, in one House or the other, be heard. They do not raise cases for fun but because of their feeling for the patients or relatives who have contacted them. I ask him please to listen in future, because what they say is of crucial importance.

[Lord Hill of Oareford]

I very much agree with the broad point that my noble friend is making. One of the recurring themes of the report is that whomever complaints came from—family or whoever—they were not being listened to. I am sure that my noble friend will have noted the part of my right honourable friend the Prime Minister’s Statement that announced that there will be a complaints review, which will be jointly led by Ann Clwyd MP—that makes the point about Parliament being involved in this process—and Professor Tricia Hart, chief executive of South Tees Hospitals NHS Foundation Trust. We need to make sure that we have these proper mechanisms and that where there are concerns, they are raised and listened to.

[Baroness Emerton]

The report calls for NICE to devise tools to calculate safe staffing levels, which have already been mentioned this evening. The evidence is growing. A group of senior nurses has come together to collect the evidence. The evidence base determines that safe and cost-effective care is determined by the safe levels of trained staff—registered nurses—to support workers. Will the noble Lord the Leader of the House be taking from this report that NICE will be devising tools to determine safe staffing levels as an urgent requirement because until we get them right, we are not going to see safe care delivery?

On the registration of support workers, one reads in the report that patients were suffering appalling neglect and mistreatment. Hundreds of people suffered from being given the wrong drugs because support workers were not trained. Please will the noble Lord take away the recommendation on the registration of support workers as a matter of urgency?

[Lord Hill of Oareford]

As I think I said in my earlier response to the noble Lord, Lord Hunt of Kings Heath, the registration of support workers is something that the Government will consider as part of their response to the Francis recommendations. We need to have well trained staff at all levels.

On the noble Baroness’s other point about ratios, I am sure that my colleagues in the Department of Health will reflect on what she said. Ultimately, decisions about staffing levels and so on need to be made locally, but I know that as part of this whole debate the department will be thinking in every way it can to try to make sure that all these sensible points are acted upon.

[Baroness Williams of Crosby]

My Lords—

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[Lord Harris of Haringey]

The noble Lord the Leader of the House has referred to the fact that there is now to be a contractual obligation of candour on healthcare organisations. Presumably Robert Francis was aware of that in framing his recommendations, feels that it is inadequate and is advocating a statutory duty of candour, which, so far, the Government have resisted. I hope that policy will change. The noble Lord the Leader of the House also talked about the importance of an independent voice for patients. Given the suggestion that has been made about merging Monitor and the CQC, will he accept that it is therefore inappropriate that Healthwatch England, the national voice of patients, should be subordinate to that monster new body? Secondly, does he also accept that it is inappropriate, if you are to have an independent voice, that local Healthwatch is subordinate to local authorities, some of the organisations that they are supposed to monitor?

[Lord Hill of Oareford]

On the duty of candour, I said in my response to the noble Lord’s noble friend that the suggestion about a statutory duty of candour is something that the Government will consider in their response to Francis. I pointed out that there is already a contractual duty in place, but I understand the point that he makes.

So far as Healthwatch England is concerned, I understand that that was debated at length. My noble friend Lord Howe is sitting here, and I am sure he will have heard the points that the noble Lord has made.

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Baroness Williams of Crosby: I have much to comment about on this front, and I am going to finish my sentence. We all need to be responsible and accountable for making sure that no Mid Staffs ever happens again. That means that we may not pass the burden of responsibility to and fro. We all have to accept our common responsibility, and if that means abandoning party statements, so much the better.

[Lord Hill of Oareford]

I agree about the theme, which I think we have all accepted, that there is a common responsibility. One of the themes of the report is that we should not seek to single out individuals or particular organisations for risk of not seeing the bigger picture which, as my noble friend said, is that there is a common responsibility.

[Lord Cormack]

My Lords, for some 35 years, my constituents in South Staffordshire had good healthcare from Stafford hospitals. It was only in this very bad period that we had these appalling stories, and we all feel ashamed. It is important to recognise that there was good healthcare before, and there must be after. In that context, will my noble friend assure me that all those appointed to boards of hospitals will receive adequate training about what their true responsibilities and powers are?

[Lord Hill of Oareford]

That is an extremely important point, and it is part of what the Government need to do in their response in ensuring that boards accept their responsibility and understand what it is. It is not just to do with running hospitals economically and efficiently; above all, it is to do with patient care.

[Lord Patel]

My Lords, I have questions relating to two areas in the Statement on which a decision has already been made. The first relates to the Prime Minister asking Sir Don Berwick to advise on zero harm. The noble Lord the Leader of the House did not answer the question asked by the noble Lord, Lord Hunt, about whether it is now the Government’s intention to re-establish the National Patient Safety Agency. I declare an interest as I was chairman of the National Patient Safety Agency for four years. I have worked with Sir Don Berwick in my hospital. The implementation of zero harm is possible in patient care in certain areas, but to implement it requires an organisation in every hospital and a national organisation to monitor it. How is it intended that that will happen? The second decision was to ask Sir Bruce Keogh, the medical director, immediately to investigate hospitals that have high mortality rates. That implies that we know which hospitals they are. Will the noble Lord the Leader comment on that? I hope that investigation will also include all higher mortality rates including still births, neonatal deaths and infant deaths.

[Lord Hill of Oareford]

My Lords, perhaps I responded elliptically to the noble Lord’s first point about whether we had plans to reintroduce the agency by saying that it had been merged. We do not have plans to reintroduce it. On his second question about Sir Don Berwick, it is for him now to work out how he will carry out his review and come back to us with his recommendations. On his third question about the immediate inquiry being carried out by Sir Bruce, mortality rates are the factor he will take into account in identifying the cases that would most benefit from his urgent attention.

[Lord Willis of Knaresborough]

My Lords—

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[Lord Wills]

My Lords, I welcome the Minister’s emphasis on the importance of involving patients and their relatives more centrally in decisions about their own care. Does the Minister think that principle should be extended throughout the NHS, including the new policy on value-based pricing for new medicines?

[Lord Hill of Oareford]

I certainly take the point that that principle is one we need to apply in our response. As regards the specific question, my noble friend Lord Howe will follow up with the noble Lord.

[Lord Willis of Knaresborough]

My Lords, Francis quite rightly recognises the contribution made by healthcare support workers. He makes seven recommendations about how they should be included within a reinvigorated National Health Service. The report makes the claim that healthcare support workers have to be properly trained to appropriate standards. I want to ask the Leader of the House two questions. First, will those standards be set independently, by the NMC or another body, and not the department? Secondly, will he guarantee to the House tonight that, whatever those standards are, the training will be mandatory, not an optional extra?

[Lord Hill of Oareford]

My Lords, at the moment I cannot give the specific assurance my noble friend would like because the Secretary of State for Health has to look at all the recommendations, working out how to respond to them and the most sensible way forward. However, it is clear that the standards would need to carry weight and be recognised as doing so. I know my right honourable friend the Secretary of State will reflect on that and that my noble friend Lord Howe will have heard the points the noble Lord has made.

[Baroness Masham of Ilton]

My Lords, can the Leader assure me that there will not be bullying and that there will be kindness? Kindness does not cost money. Nurses should be kind and treat patients with dignity.

[Lord Hill of Oareford]

My Lords, I could not agree more. One of the things that are most distressing when one strips away everything to do with structures is the lack of common humanity. That is the most extraordinary thing. I agree very much with the noble Baroness about the importance of compassion.