Accountability and Transparency in the NHS

Alan Johnson Excerpts

Thursday 14th March 2013 Commons Chamber

[Charlotte Leslie (Bristol North West) (Con)]

I beg to move,

That this House believes that in the wake of the Francis Report it is clear that accountability and transparency are of paramount importance to patient safety and trust in the NHS; and further believes that across the NHS individuals found to have breached those principles should face the appropriate consequences.

I would first like to thank the Backbench Business Committee for granting the debate; I realise that it did not have much time left to allocate in the Session and so am particularly grateful to its members for giving the House the opportunity to debate this timely and important issue. I would also like to thank all the Members who supported the motion, particularly my hon. Friends the Members for North East Cambridgeshire (Stephen Barclay), for Bracknell (Dr Lee), for Totnes (Dr Wollaston) and for Southport (John Pugh) and the hon. Member for Vauxhall (Kate Hoey). I must also thank all those who have contacted me, including the Patients First group. I am sorry if we are unable in the time available to do justice to all the information we have been given, but rest assured that this is the beginning of the scrutiny, not the end.

This debate is neither about playing party politics, nor about only the future of one man, David Nicholson; it is about transparency, and about a deadly cover-up in our NHS and how we can ensure that never happens again. As one concerned former nurse wrote to me:

“Please don’t let me read those meaningless words, Lessons Have Been Learned”.

It sometimes seems that politicians can dodge taking responsibility so long as they say quickly enough that “lessons have been learned”, but learning lessons is not the same as simply uttering a phrase. The truth must be revealed, and consequences faced, if accountability and transparency are to be anything more than just words.

Let me make it clear that refusing to play party politics is not the same as letting people evade responsibility and that statesmanship is not the same as letting people off the hook. We owe it to those outside this Chamber. We owe it first and foremost to those patients who were, in some instances, killed in our hospitals, and we owe it to their grieving families, for whom no amount of politicians saying that “lessons have been learned” can bring back their mum, dad, sister, brother, child or friend.

After patients and their families, we also owe it to those dedicated doctors and nurses who were struggling to raise the alarm against a system that systematically suppressed their concerns. Many of them retired early in protest at what they were being asked to do, and some of them tried whistleblowing and were met not with thanks from the authorities, but intimidation and gagging. We will hear about some of that later.

I must congratulate the Prime Minister and the Secretary of State for Health on their appointment of Don Berwick to ensure that the basic requirement of “Do no harm” is embedded in health care. Don Berwick, an adviser to President Obama, is an internationally renowned authority on health care. The Institute for Healthcare Improvement, which he co-founded and chaired for 21 years, is a world-leading centre of medical improvements based on proven success. I am delighted that the Prime Minister has put him right at the heart of improving our health care system.

The tragedy, however, is that Don Berwick’s wisdom and recommendations are not new; they have been delivered before. They were delivered to the previous Government in no uncertain terms back in 2008, when David Nicholson was chief executive of the NHS. Instead of implementing them urgently, the previous Government were uncomfortable with what they revealed about their NHS, so they decided to suppress those truths. They suppressed a report by Don Berwick and his institute along with two other damning reports by international experts—RAND and Joint Commission International—that contained burning recommendations to be implemented with all urgency.

[Alan Johnson (Kingston upon Hull West and Hessle) (Lab)]

If the hon. Lady turns to page 1,281 of volume 2 of the Francis report, she will see that, far from the reports being suppressed, every one of them was seen by Robert Francis. He states:

“As part of his work leading the working group, Sir Liam”—

Sir Liam Donaldson, the former chief medical officer—

“commissioned reports from three highly respected US-based organisations”.

Francis concludes that section by stating:

“Indeed it is clear that the NSR”—

the next stage review, the Darzi review—

“sought to address many of the concerns raised in these reports.”

[Charlotte Leslie]

rose—

--- Later in debate ---

[Charlotte Leslie]

I congratulate the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) on seeking to defend his Government’s record. I will address his point fully later in my speech.

Don Berwick’s report was commissioned by Ministers, led by Lord Darzi and with the support of David Nicholson, to celebrate the 60th anniversary of the NHS. It states:

“The NHS has developed a widespread culture more of fear and compliance… It’s not uncommon for managers and clinicians to hit the target and miss the point”.

It highlighted the inadequacy of quality-control mechanisms in the NHS, stating that the priorities that are emphasised by these assessments are

“seen as being motivated by political rather than health concerns”.

It also highlighted the anger felt by many conscientious medics at Government changes to their employment and at being pressurised to put targets ahead of patients:

“The GP and consultant contracts are de-professionalising... Far too many managers and policy leaders in the NHS are incompetent, unethical, or worse.”

The report warns that

“this… must be alleviated if improvement is to move forward more rapidly over the next five to ten years.”

But those warnings were ignored, and we know that the improvements never happened. The report’s conclusion on a decade of health care reform is that

“the sort of aim implied by Lord Darzi’s vision…is not likely to be realised by the 1998-2008 methods.”

Don Berwick’s report was not alone; let me reveal what the other two reports said. They referred to

“the pervasive culture of fear in the NHS and certain elements of the Department for Health”

and stated:

“The Department of Health’s current quality oversight mechanisms have certain significant flaws”.

Perhaps the most damning indictment of all is that the politicians are responsible:

“This culture appears to be embedded in and expanded upon by the new regulatory legislation now in the House of Commons.”

Instead of being acted on with urgency, this was all buried. We know of the existence of Don Berwick’s report and the other reports only because a medic was so concerned that Berwick’s warnings and solutions had been buried that he tipped off a think-tank, Policy Exchange, which had to use a freedom of information request to bring them to public light in 2010, two years later. They were not even available to the Health Committee.

Let us get one thing clear. The NHS is a huge, monolithic organisation with an exceptionally difficult and, some might say, almost impossible task. In reality, things will go wrong, sometimes very wrong. The crime is not so much that things were going wrong, bad as that is, but that instead of immediately focusing on tackling it, the priority was to cover up an awful truth that was uncomfortable for Ministers and chief executives. All too often, Dispatch Box appearance mattered more than the reality of patients’ lives, leaving whistleblowers and patient groups such as Julie Bailey’s, which was disgracefully dismissed by David Nicholson as a “lobby group”, screaming into a vacuum, often at great personal cost. The crime is the smothering of the truth which costs lives—the deadly silence.

What was the cost of suppressing Don Berwick’s urgent prescription for the NHS? The clinical director of NHS Scotland recently suggested that in following Don Berwick’s recommendations it has experienced an estimated 8,500 fewer deaths since January 2008. We may well ask what was the cost in lives for our NHS of the previous Government’s decision to bury the truth. Across the 14 trusts now being investigated as well as Mid Staffs, there were 2,800 excess deaths between the time that the reports by Don Berwick and others were presented to Ministers and their final revelation in 2010. If the previous Government had been urgently implementing Don Berwick’s recommendations for those five years, who knows how many of those lives might have been saved?

How was this allowed to happen? I have put in freedom of information requests asking what meetings took place to discuss the reports and who was present. Although David Nicholson was working closely with Lord Darzi on the next stage review, he said in front of the Health Committee that, incredibly, he

“knew nothing about the reports”.

That is the Select Committee, so we must take him at his word. The question that then remains is who did read and suppress these vital reports. Was it Ministers? Was it officials? If officials, how was this allowed to happen? If the Department of Health is to move away from a culture of cover-up, I expect a full and accurate response to my request to know who was responsible, and I ask the Secretary of State to assist me in that.

Former Labour Ministers will complacently say, as they already have, that these reports fed into Lord Darzi’s next stage review and informed the report, “High Quality Care For All”. I ask the House whether a document that starts with the then Secretary of State, the right hon. Member for Kingston upon Hull West and Hessle, beamingly saying

“On its 60th anniversary the NHS is in good health”

reflects the content of the reports that we have just heard about. It certainly does not. Indeed, while the Department of Health claims that it “drew heavily” on the three reports in putting together “High Quality Care For All”, a source close to the authorship of those reports said that they found that claim to be “disingenuous at best”. David Flory, the deputy chief executive of the NHS, later told the Francis inquiry that he at least had some responsibility for what happened to the reports, as he had read them, but insisted that they were “caricatures”. That would help to explain why they were not acted on, but it makes the Department of Health’s insistence that it “drew heavily on them” rather odd.

Further indication that the documents were not acted on is the fact that they raise issues almost identical to those highlighted five years later in the Francis report. If Don Berwick’s warnings had been acted on five years ago, there would be no need to ask him to come back now to step in to sort things out and implement his recommendations.

[Alan Johnson]

I wonder if the hon. Lady is coming to the point that Francis, a QC, in the course of a two-year public inquiry that produced two volumes, looked at all these documents and said that many of the issues within them had obviously been acted on. During a two-year review, Francis drew completely the opposite conclusions to those that the hon. Lady is drawing.

[Charlotte Leslie]

I find various elements of the Francis report rather strange, not least that the current chief executive, David Nicholson, is minuted as dismissing the activities of Julie Bailey as merely “lobbying” as opposed to expressing widespread concern about patients, and that this minute was dismissed in evidence, with David Nicholson saying that he could not recall ever having said something like that and thought that he could not possibly have done so. The fact that we are asking Don Berwick back five years after he initially gave his recommendations to Labour Members speaks far louder than a few sentences in the Francis inquiry with which people may beg to differ. However, I will not be distracted by the right hon. Gentleman but go back to my speech.

I will now reveal how crucial mortality data, which Harvard university says should have triggered an “aggressive investigation”, was ignored, and, when it became too prevalent to ignore, was, like so many whistleblowers, discredited. David Nicholson said in response to the Health Committee that he did not know that the Dr Foster mortality data existed until he became chief executive of the NHS in 2006. He also said he did not know there was a problem with the mortality rate at Mid Staffs until 2009. Again, that is the Select Committee, so we must take him at his word. It is odd, however, as we know that David Nicholson attended a presentation in Birmingham in 2004 at which the Dr Foster ethics team gave a presentation on the real-time monitoring tools that it was using to show mortality alerts and the hospital standardised mortality rates.

There are also records of Dr Foster telephoning chief executives of health authorities in 2005 to tell them about the mortality alerts. David Nicholson is named on that list of those getting calls, as chief executive of Birmingham and The Black Country strategic health authority. Between 2005 and 2009, there were 8,000 log- ons to the Dr Foster site from members of staff at West Midlands SHA. We even have a press release from Dr Foster from as early as 2005 congratulating Walsall hospital in, yes, West Midlands SHA, for its improvement in relation to this very same mortality data. The Dr Foster data were published in the “Good Hospital Guide” from 2000 onwards and in national newspapers from 2001 onwards. It is therefore incredible that that was not known about by someone such as David Nicholson, or indeed Ministers and others.

By May 2007, however, people were aware of the data. The then chief executive of West Midlands SHA, Cynthia Bower—Birmingham and West Midlands SHAs play a strangely prominent role in this story—received alerts that there were issues with high mortality rates in the health authority. But instead of taking urgent action to find out what was going wrong, she commissioned the university of, yes, Birmingham to write a report to discredit the data, at a cost of £120,000 to the taxpayer. Stunningly, the British Medical Journal—the journal of the union, the British Medical Association—is on record as allowing the author of the Birmingham report to publish his findings in the BMJ four months before official publication to coincide with the publication of the Healthcare Commission report, in order to discredit the data. A fact little publicised by Ministers and chief executives is that the Birmingham report was severely flawed. Harvard later did a study and found that the data were so watertight that on receiving the alerts,

“it would have been completely irresponsible not to aggressively investigate further.”

Yet again, the reaction to bad news was to bury it, or expensively discredit it, rather than act.

This went all the way to Government. I have seen an internal briefing for the right hon. Member for Exeter (Mr Bradshaw), then a Health Minister, in which officials brief him to stress that the mortality data were not known about until 2007. However, in that very same briefing it is revealed that they know this to be untrue, because they make specific reference to the data being published as far back as 2001 in the “Good Hospital Guide”.

This is only a drop in the ocean of a catalogue of attempts to cover up the awful truth. It is utterly wrong that no one should be held to account for such negligence in their duty to protect patients. The “Code of Conduct for NHS Managers” says that managers must

“make the care and safety of patients my first concern and act to protect them from risk”

and

“accept responsibility for my own work and the proper performance of the people I manage”.

If talk of accountability in this Chamber is to have any credibility at all, especially for those individuals who buried loved ones while Government, departmental and NHS individuals buried the truth, actions must have consequences. To scapegoat is not the same as ensuring that those responsible are held to fair account. Those who do not have a voice—the patients and their families—deserve accountability and more than just words.

Don Berwick is right. We must convert our anger over what has happened into action. That is what Julie Bailey did, without whom this debate and a push for a culture change in the NHS would probably not be happening. It is what my right hon. Friend the Secretary of State did this morning in banning gagging orders. Will he confirm whether that measure will be retrospective? I believe that this Government have secured a good base from which to put clinicians—not managers and politicians —at the heart of setting the priorities of our NHS.

--- Later in debate ---

[Mr Hunt]

I acknowledge the brilliant work done by NHS staff and, contrary to what the right hon. Gentleman says, I do that in every speech that I make on these matters. I will not, however, accept the complacency that says that problems at Stafford hospital were localised and happened only in one place. If we are to sort out those problems, we have a duty to root them out anywhere in the NHS that they occur.

The right hon. Gentleman talked about waiting times targets. Let us be clear: there is an important role for targets in a large organisation such as the NHS. Without the four-hour A and E target, or the 18-week elective waiting time target, access to NHS services would not have been transferred and I accept that the previous Government deserve credit for that. It was right to increase spending on the NHS, although it is curious that Labour now wants to cut the NHS budget. Labour did however—this is where Labour Members should listen rather than barrack—make three huge policy mistakes, and the right hon. Gentleman must accept that it is not simply a question of Government policy not being implemented in every corner of the NHS. Those three mistakes contributed to the culture of neglect that we are now dealing with.

The first mistake—a huge mistake—was that Labour failed to put in place safeguards to stop weak, inexperienced or bad managers pursuing not only bureaucratic targets but targets at any cost. That is exactly what happened at Mid Staffs, where patient safety and care were compromised in a blind rush to achieve foundation trust status. Secondly, Labour failed to set up proper, independent, peer-led inspections of hospital quality and safety that told the public how good and safe their local hospital was. Instead of a zero-harm attitude to patient safety, we have a culture of compliance and the bureaucratic morass that is the current Care Quality Commission. Thirdly, Labour failed to spot clear warnings when things went wrong. The Francis report lays out a timeline of 50 key warning signs between 2001 and 2009. Why did Ministers not act sooner? If those warnings were not being brought to the attention of Ministers, why did they not build a system in which they were? Instead, there was a climate in which NHS employees who spoke out about poor care were ignored, intimidated or bullied.

[Alan Johnson]

The Secretary of State is making an interesting speech and there is no way that the Labour party can escape criticism for what happened at Stafford. Does he accept, however, that before 2000 there was no independent regulation of the NHS and no standardised mortality ratios, complaints in hospitals stayed in the hospital and there was no recourse to any independent observance of those complaints, and A and E—a particular problem at Stafford—was a data-free zone?

[Mr Hunt]

I accept that progress was made in the collection of data and that the previous Government set up a star rating system. The problem, however, was what it measured. It did not measure the quality of patient care but basically focused on access targets. It was possible for a hospital to get a three-star rating by transforming its 18-week access targets, even at the expense of patient care.

--- Later in debate ---

[Alan Johnson (Kingston upon Hull West and Hessle) (Lab)]

Well, there’s a man who knows all the answers!

It was four years ago on Monday when I apologised to this House on behalf of the Government and the national health service for what happened at Stafford. We had just received the report from the Healthcare Commission, and I think it is fair to say that no one with any experience of the NHS could quite believe what had gone on. The people in charge at a time when there were unprecedented resources and investment being put into the NHS had cut staffing on A and E to such an extent that a receptionist with no medical training was triage nursing in A and E.

We need a longer debate. There is nothing ostensibly wrong with the motion, and I agree with my right hon. Friend the Member for Leigh (Andy Burnham) that we should support it, but it is clear from the way it was moved and the last contribution that this is all about the blame game. If I can just quote Francis—[Interruption.] Yes, the hon. Member for Bracknell (Dr Lee) does not agree with Francis or with Ara Darzi and knows everything, and says that Francis was a Nuremberg—

[Dr Lee]

rose—

[Alan Johnson]

No, I am not giving way—at least not to the hon. Gentleman. I have heard enough.

This is what Francis said in paragraph 108 of his report:

“To place too much emphasis on individual blame is to risk perpetuating the illusion that removal of particular individuals is all that is necessary. That is certainly not the case here. To focus, therefore, on blame will perpetuate the cycle of defensiveness, concealment, lessons not being identified and further harm.”

So the man who knows most about what happened at Stafford hospital—and who was entrusted by this Government and their predecessors to conduct not one, but two, inquiries, and who in four volumes running to millions of words sets out what happened, why it happened and how it was allowed to happen—counsels against the very action that this motion appears to propose.

Francis identified who was accountable, and the Secretary of State was absolutely right: it was the chief executive, the chair and the board of the Mid Staffordshire trust. A number of clinicians are also held accountable for the appalling lapse in standards of care at Stafford. This accountability regime is set out in legislation approved by this House.

The Francis findings are consistent with those that emerged from the inquiry into the care of children receiving complex cardiac surgery at Bristol Royal infirmary between 1984 and 1995. In that case, five individuals at the hospital, including the chief executive, were the subject of adverse comments. In respect of both Bristol and Stafford, an argument was made to an inquiry that there was an extenuating failure of national policy. At Stafford, it was national targets; at Bristol, it was inadequate resources.

It is worth recalling the Bristol inquiry’s response. Sir Ian Kennedy said:

“The inadequacy in resources for PCS”—

paediatric cardiac surgery—

“at Bristol was typical of the NHS as a whole. From this, it follows that whatever went wrong at Bristol was not caused by lack of resources. Other centres laboured under the same or similar difficulties.”

We must remember that these were the days when one in every 25 patients on the cardiac waiting list died before they could be operated on, and when somebody with a serious heart condition could wait a year to see the cardiologist, three months to see the consultant and then 18 months to two years for the operation. That is why targets had to be introduced—to get a grip on this awful situation.

[Mr Cash]

I am astonished by the line on accountability that the right hon. Gentleman is taking. He was the Secretaryof State and I had a row with him at the time—and, indeed, with his successor—about the question of holding a proper full public inquiry under the Inquiries Act 2005. I wrote to him, too, and I did not get satisfactory answers under the guidelines laid down in the 2005 Act on the prime ministerial rules issued by the Cabinet Office.

[Alan Johnson]

On the question of a public inquiry, when Francis reported on his first inquiry, commissioned by my right hon. Friend the Member for Leigh, he made the point that it was about people affected being able to come and tell their story, and Francis said in his first report:

“I am confident that many of the witnesses who have assisted the inquiry in written or oral evidence would not have done so had the inquiry been conducted in public.”

It is very important that that first inquiry allowed people to come forward. The right hon. Member for South Cambridgeshire (Mr Lansley) may also well have been right to make the second stage of that a public inquiry, which was authorised because of one of the Francis recommendations, because we now have all the information, provided before a Queen’s counsel, about what happened there.

Francis is very clear about no blame being apportioned to any Minister. It is of course right for Ministers to be accountable if anyone knew what was going on and did nothing to stop it, or if something that was going on was a result of a Government edict or policy, but that was not the case at Stafford.

Targets had to be introduced to get a grip on this terrible situation of lack of access to health care. Targets did not cost lives; they helped to save lives. They were accompanied by the resources, the capacity and the political will that transformed waiting lists of 18 months to two years to a maximum of 18 weeks and an average of nine.

This is what Francis said about targets:

“It is important to make clear that it is not suggested that properly designed targets, appropriately monitored cannot provide considerable benefits and serve a useful purpose…indeed the inquiry accepts that they can be an important part of the health system in which the democratically elected Government of the day sets its expectations of providers who are funded by the taxpayer.”

The right hon. Member for Charnwood (Mr Dorrell) was absolutely right to say that long waiting lists have dogged the NHS since it was created in 1948. Rudolf Klein, the great historian of the NHS, says every Health Secretary shouted their orders from the bridge and the crew carried on regardless. Something had to be done to deal with that, and it was done.

[Mr Jeremy Hunt]

Does the right hon. Gentleman not accept that the issue was not targets, but the failure to put in place safeguards to stop managers twisting a targets culture into a culture of targets at any cost? That was the fundamental policy mistake. The lack of those safeguards meant Mid Staffs could happen.

[Alan Johnson]

The Secretary of State is right. Of course there need to be safeguards to ensure any system has a backstop to stop people misusing targets. The guidance from the Department of Health was very clear. In no way must the pursuance of targets interfere with the need for good patient care. The Stafford chief executive must have translated that into saying it was fine to put receptionists on triage nursing. With all due respect to the Secretary of State, I do not think that he or any of his successors or predecessors can make regulations to meet every eventuality, including for someone like that chief executive of the Mid Staffs trust.

[Charlotte Leslie]

In some ways I agree with the right hon. Gentleman, in that I think targets and ensuring that things are happening is not the main cause of what went wrong. Does he agree, however, that targets along with what many medical professionals criticise as the de-professionalising of the work force through the consultant contract, the working time directive and the new deal was a toxic combination?

[Alan Johnson]

The principal point about targets is that they reduced waiting list times. They changed a situation in which people were dying while on waiting lists, which was a disgrace in a civilised country like ours.

The Francis report also gives no comfort to those who expected him to offer up Sir David Nicholson’s head on a plate. The irony is that they choose to make this attack on an NHS that is learning the lessons of Stafford and an individual, Sir David Nicholson, who has done more than anyone to make quality of care the organising principle of the NHS. I, like my three successors as Health Secretary, consider Sir David to be part of the solution, rather than part of the problem He is not perfect—none of us is—but he is a good public servant who is committed to the NHS, its patients and staff. If he knew what was going on at Stafford, or colluded in the awful events there, or if any of his edicts, policies or pronouncements were in any way responsible for what happened, I would agree with his detractors. No one knew what was going on at Stafford; not even the press, who pride themselves on fearlessly exposing wrongdoing. Not a single question was raised by local MPs in this House about what was happening at Stafford, and Francis has something to say about the way they passed on complaints.

[Mr Cash]

Will the right hon. Gentleman give way?

[Alan Johnson]

No, and I read the hon. Gentleman’s correspondence and it in no way drew attention to what was happening at Stafford.

[Mr Cash]

rose—

--- Later in debate ---

[Mr William Cash (Stone) (Con)]

I believe strongly that we must not only look back properly at what happened at Stafford hospital but look forward. We must learn the lessons and we must ensure that what happens in future does not lead to the trauma experienced by the victims and patients in my constituency and those of my hon. Friends the Members for Stafford (Jeremy Lefroy) and for Cannock Chase (Mr Burley).

This is a debate about accountability and transparency and, as others have said, we also need a debate in Government time on the Floor of the House on the Francis report. On the question of accountability and transparency, I want to start with an issue that has not yet been properly considered in the debate: the role of the Secretary of State under national health legislation. Section 1 of such legislation clearly states the duties of the Secretary of State, and always has done. I was astonished, as I made clear at the time, when the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) left out that part of the question of accountability.

I have been involved in the history of this case. As the Member of Parliament for Stafford from 1984 to 1997 and the Member of Parliament for Stone from 1997 to the present day, I have had many constituents, including Debra Hazeldine, a prominent member of Cure the NHS, who have played an important role in drawing attention to these matters. I have worked closely with them over the whole of this period.

Contrary to what the right hon. Member for Kingston upon Hull West and Hessle said—I imagine it must have been a serious slip of memory—I wrote letters to him. Ministerial guidelines from 2005, issued by the Cabinet Office, set out in great deal what must happen when a Member of Parliament writes to a Secretary of State. He must receive a personal reply. I do not need to go into the full details now, but only the other day I asked the Minister for the Cabinet Office and Paymaster General to reaffirm the contents of those guidelines, which are still applicable.

There are only 650 of us, and serious matters can arise from the complaints we make. I am talking not about the complaints procedure of the national health service but about a Member of Parliament going to the Secretary of State to raise a specific question, usually enclosing correspondence from a constituent, and asking for action. In my case, I said that the matters I raised were both serious and urgent and that they required the personal attention of the Secretary of State. I have not the time to go into the detail, but successive Secretaries of State simply did not take the kind of action that I would have expected following those letters.

[Alan Johnson]

This is a fascinating subject and I am willing to have a look at any correspondence between the hon. Gentleman and me when I was Health Secretary. I certainly tried very hard to correspond with all Members of Parliament. Does he accept what Francis said:

“Local MPs received feedback and concerns about the Trust. However, these were largely just passed on to others without follow up or analysis of their cumulative implications…They might wish to consider how to increase their sensitivity with regard to the detection of local problems in healthcare”?

We all have lessons to learn from the Francis report; does he accept that he has lessons to learn, too?

[Mr Cash]

We all have lessons to learn about all matters relating to these questions, but the guidelines also talk about the necessity of chasing and following up in the Department. It is probably a question of the correspondence unit in the Department and the private office. There was a failure and the Francis report made it absolutely clear that the guidelines were not complied with and were not operated effectively. I am sure that the right hon. Gentleman, on reflection, will recall that that was what the report said.

I referred to these matters in my witness statement, and Una O’Brien, the permanent secretary at the Department of Health, also made it clear in her evidence that if such letters were received now, they would receive an immediate response, irrespective of whether the hospital was a foundation trust or not. The bottom line is that there was a failure within the Department and by successive Secretaries of State. The shadow Secretary of State acknowledged in his evidence that he looked at these letters. I will not dispute that. However, not only were the matters not dealt with satisfactorily, but I cannot absolve the Secretaries of State from their failure to agree to the 2005 Act inquiry.

I do not need to rehearse the history of the case. I asked not once, not twice, but repeatedly, and I had to urge and persuade the shadow Secretary of State at the time and also—I am glad that, to his great credit, he decided to do so—the present Prime Minister who, as Leader of the Opposition, decided in the light of my representations and no doubt those of others to have the 2005 Act inquiry. Without that we would not be discussing the Francis inquiry—the present one, not the previous one, important though that was—and the others. They were Government inquiries, but they did not do the job in the way the present inquiry did.