Francis Report

Alun Cairns Excerpts

Wednesday 5th March 2014 Commons Chamber

[Andy Burnham]

My hon. Friend anticipates me, as I will come on to that subject. My point that the NHS has gone downhill is no better illustrated than by the crisis that is developing in mental health provision.

[Alun Cairns (Vale of Glamorgan) (Con)]

Will the right hon. Gentleman give way?

[Andy Burnham]

In a moment.

On all measures, this winter has been just as bad as the last, with some patients waiting hours on trolleys, or held at the door of A and E or in the back of ambulances. A and E is the barometer of the whole health and care system, and that barometer is warning of severe storms ahead.

--- Later in debate ---

[Ann Clwyd (Cynon Valley) (Lab)]

I congratulate the hon. Member for Stafford (Jeremy Lefroy) on his eloquent presentation. The Francis report carries lessons for everyone involved in health care—whether it be hospitals and their boards, regulators, professionals or Governments. However, those lessons need to be learned all over Britain. It is a matter not just for England, but for Scotland, Northern Ireland and Wales.

The letters keep coming. When I gave evidence to the Health Committee the other week, I was asked what had changed. I said that I did not know and could not honestly answer the question. Perhaps I will know when the letters stop coming. Every time I open my mouth, I am punished by yet more letters. I have had hundreds of letters from Wales; and hundreds too from England, Scotland and Northern Ireland. When I was carrying out my review, I received 3,000-plus letters and e-mails, and they still keep coming.

My concern today is for my constituents in the Cynon Valley and those elsewhere in Wales where health is a devolved function. I will not be popular for saying this, but when this House is asked to give yet more powers to Wales, I will ask many questions, because the main things for which the Welsh Assembly is responsible are health and education. I was a keen pro-devolutionist in two campaigns, but in future I will think very carefully before giving any more powers to the devolved Administrations.

Many people were to blame for what happened at Mid Staffs, just as there were many people to blame for the worrying situation that was revealed at several other English hospitals in subsequent investigations by Professor Sir Bruce Keogh. There is nothing to be gained by politicising such catastrophic situations and everything to be gained from being honest about the problem and seeking appropriate solutions. After all, we are talking here about sick and vulnerable people who are often afraid and in pain. Political bun fights here or in the Welsh Assembly are of little interest to them; they just want something to change for the better.

What was so shocking in Mid Staffs of course was that no one spoke out and the warning signs of a trust in meltdown were ignored. Robert Francis has listed some of those warning signs and they read directly across to many of my concerns about the NHS in Wales.

The first warning sign is an accumulation of patient stories that detail adverse incidents, bad practice or neglect. As I have said, I have had literally thousands of those, and they continue to arrive in my office every day from all over Wales and from England.

The second warning sign, said Francis, is the level of mortality statistics. In fact, they appear to be dangerously high in many hospitals in Wales. Confusion remains on how accurate the data are. The system by which they are collected is questionable, to say the least, and there is a backlog in the coding of cases for inclusion in the risk-adjusted mortality index—RAMI—so we are now seeing retrospective alterations in the figures in at least one hospital, thus making it difficult to compare hospitals in Wales, or to compare England and Wales.

[Alun Cairns]

I pay tribute to the right hon. Lady for her work in championing patients and in drawing attention to some very unpleasant outcomes in many hospitals across the whole United Kingdom. In relation to the higher mortality rates that she refers to, does she share my concern about the political rebuttal to an e-mail from one clinician in England to another clinician in Wales simply asking for further investigations?

[Ann Clwyd]

I am grateful to Professor Sir Bruce Keogh for offering to assist. Given his vast experience, the people whom he offered to assist would be sensible to take the offer very seriously indeed.

The Transparency and Mortality Taskforce, which was set up by the Welsh Assembly a year ago, has today announced recommendations on a measure of mortality for Wales. Although I welcome its finally releasing the recommendations, I will await details on their implementation, which is unlikely to start until the autumn of this year. On mortality statistics, the taskforce provides an interesting academic discussion of the pros and cons of using mortality statistics as a measure of service quality and a means to compare hospitals and countries. Of course, none of that is new, but neither approach is impossible.

After almost a year, it is disappointing that a taskforce of 31 members has failed to arrive at the benchmarks on mortality that are urgently needed, so that fair international comparisons can be made between Wales, England and other countries. That was the taskforce’s job. The promise of a further statement in September 2014 appears to put the resolution of this matter even further away; one can only speculate on the reasons for that. Some good intentions may be expressed, but that is not enough, given the high level of public concern.

We continue to have only the published RAMI figures to go on. Six Welsh hospitals have RAMI figures of between 105 and 115, with 100 showing cause for concern, as we all know by now. A figure of more than 100 was described as a smoke signal. If the figure is way over 100, there is a big fire. It is not surprising that people are worried about what is actually going on. This is horribly similar to the murkiness that surrounded the mortality statistics for Mid Staffs.

We now know for certain, however, the position as reported by the Royal College of Surgeons after visiting the University hospital of Wales at Cardiff in April 2013 to investigate poor standards of care. It describes certain parts of the hospital as dangerous. It was worried about people dying on hospital waiting lists while waiting for heart surgery. Even those who got their surgery had deteriorated on the waiting lists. When they got their surgery, they were much more ill than they would have been.

Last week, the Royal College of Surgeons wrote to Healthcare Inspectorate Wales to ask what action has been taken about concerns raised last July in a report about patients dying while waiting for heart surgery. Following its initial report, the Royal College of Surgeons wrote to Healthcare Inspectorate Wales in August to claim that 152 patients had died in the past five years while waiting for heart surgery at the University hospital of Wales and Swansea’s Morriston hospital. I put on record my alarm about the lengthy delay in the promised revisit of the Royal College of Surgeons to those hospitals. It was promised in September, but it still has not taken place.

Other warnings to be heeded, said Francis, should come from complaints made by patients. Well, what do we know about this in Wales? Complaints trebled last year, according to the Welsh ombudsman, but the system for dealing with complaints, let alone learning from them, is highly unsatisfactory, so much so that an inquiry is under way after several high-profile cases. Obviously, we look forward to seeing the outcome of that, mindful that the retiring Welsh ombudsman said in November last year that accountability in NHS Wales has “broken down” and that there is a “lack of challenge” in the system. He asked:

“Where is the voice of the patient in the NHS in Wales?”

The fourth warning sign that Francis mentioned was signals from staff and whistleblowers. Many of them have reached me, too. Some people have told me that they are no longer able to do their jobs properly. I have had several phone calls from consultants who will not even give their names and who say that, if they gave their names, they would be sacked from their jobs.

More people are speaking out openly, and this week a letter appeared in the Western Mail from a consultant paediatrician, who said:

“The intervention of Sir Bruce Keogh, Medical Director of NHS England, expressing concern regarding high mortality rates in several Welsh Hospitals may not be welcome… It deserves to be taken seriously.

Mortality rates are ‘risk adjusted’, which means that the mortality rate is ‘adjusted’ for hospitals that deal with a disproportionate number of seriously ill patients, some of whom, sadly, but inevitably may not survive their treatment. It’s therefore appropriate to review clinical practice in all hospitals whose mortality rates are above 100. The recent publicity relating to high death rates at the University of Wales following liver surgery, where an independent Royal College of Surgeons’ report identified 10 deaths that were deemed ‘avoidable’ highlights the sluggish response of the hospital’s own management to information that should have been spotted far earlier.

A ‘Wales-wide’ investigation...or indeed a ‘health board-wide’ investigation would be too general, and would probably fail to identify clinical practice where there is a need for improvement.

Any review needs to be ‘department-wide’. All health boards have sufficient information available to them that allows identification of individual departments, possibly individual practitioners, where clinical outcome falls below the norm”—

the outliers.

--- Later in debate ---

[Barbara Keeley]

I would prefer not to. That money could and should have been spent on improving staffing, particularly nursing staffing. Those patients and family members who have been let down by NHS failures, of which we have heard innumerable examples, deserve to know that everything possible is being done to avoid such failures in future.

Of all the things I have talked about, safe staffing is crucial, as is transparency and staffing ratios. We increasingly have to take on board the fact that there is a funding gap in both the NHS and social care. Indeed, the chair of the British Medical Association said in his new year statement that the funding gap in the NHS is so bad that if the NHS was a country, it would not have even have a credit rating. That is what we are facing.

[Alun Cairns]

Will the hon. Lady give way?

[Barbara Keeley]

No, I do not have time.

Given that situation, we have to learn that precious NHS resources cannot be wasted on reorganisation and redundancies any more, particularly where staff are being rehired. The NHS will reach its 70th birthday in 2018, so let us hope that all the measures we are talking about today, and the implementation of whole-person care under a Labour Government, will help it be in better shape.

[Alun Cairns (Vale of Glamorgan) (Con)]

Thank you for calling me to contribute to this debate, Mr Speaker. I am sorry that the shadow Health Secretary is not in his place. After repeatedly refusing to take any interventions from me during his lengthy speech, he said that I would have time to make my contribution later, and I wish he was here to hear it, because I will be referring to him and seeking his help and support.

I approach this debate with mixed emotions. I am extremely sorry about the need for the Francis report in the first instance and believe that there remain serious questions about why there was such a long delay before a thorough investigation took place into the lack of care and the misconduct at Mid Staffs. I pay particular tribute to my hon. Friend the Member for Stafford (Jeremy Lefroy) for his contribution earlier and for the role he has played in pursuing this matter right through to the end, and to my hon. Friend the Member for Stone (Mr Cash) for his contribution and for raising this matter from the outset. My heart goes out to those who suffered needlessly and to their families who campaigned for so long. It is also worth remembering that for every one person who went public and put their head above the parapet, there are probably tens who stayed quiet and are probably still silent on issues that will have affronted them.

On a positive note, I am pleased about the progress made over the past 12 months. I am also pleased about the strong action has been taken by the previous Health Secretary and by this one, and about the leadership and determination that the Prime Minister showed at the outset in 2010 in seeking to root out the issues. The present Health Secretary has taken direct action to ensure: that nursing numbers are published; that there is data transparency; that details on surgery outcomes by consultant will be available for inspection; and that named consultants will be available for older patients. Those positive interventions will make a significant difference and will go a long way to preventing any recurrence.

Ultimately, the staff involved deserve the credit for the change, but the Health Secretary has been key to being the patients’ champion. A culture has developed where we can rightly champion the NHS and can even question it. We have now come to a point where we can criticise the NHS without being seen as undermining it. All of the best organisations welcome feedback, particularly negative feedback, because it gives the best chance of putting problems right to prevent any recurrence.However, my mixed emotions are far more complex than that. As I see changes and improvements taking place in England, I remain concerned about what is happening to the national health service in Wales and the impact that that is having on my constituents. It is quite obvious from this debate that the concerns that have been raised are shared by Members on both sides of the House, which is something that we should view positively. However, I am not so sure that those concerns are shared in all quarters, especially by Members on the Labour Front Bench. Again, I must pay tribute to the right hon. Member for Cynon Valley (Ann Clwyd) for her determination and persistence in rooting out these issues wherever they occur—be it in Wales, Scotland, Northern Ireland or England.

It is fair to say that political points can be made about the cuts to the NHS budget in Wales, but I fear that the situation is even more serious and dangerous than that. Any criticism of the NHS in Wales is now dismissed as party political or politically motivated. It is the identical culture that existed at the time of the Mid Staffordshire crisis.

Only two weeks ago, my hon. Friend the Member for Bristol North West (Charlotte Leslie) discovered that Professor Sir Bruce Keogh, the NHS medical director in England, had last November written to his counterpart in Wales, Dr Chris Jones, raising concerns about the mortality rates at some Welsh hospitals—at six in particular. It has now come to light that that action was prompted by the right hon. Member for Cynon Valley. In the e-mail, Professor Keogh, who had investigated 14 hospitals in England for the same reason, offered his assistance. I have a copy of his letter here. It was not a criticism; it merely questioned the data and offered help should there be any need for further investigation.

There was no response from Dr Jones, which is worrying in itself. Most alarming, however, was the response from the Welsh Health Minister when the matter became public. Mark Drakeford rightly pointed out that simple comparisons cannot be made because of the different ways in which data are collected. However, in response to calls for an inquiry, he said that he was “coldly furious” and that it was

“a concerted political attempt by the Conservative Party to drag the Welsh NHS through the mud.”

He even had the audacity to accuse the NHS in England of being in crisis. He clearly felt that attack was the best form of defence. What worries me most is the blatant rebuttal without wider consideration. The politics appear to be more important than the patients. This was a letter from one clinician to another, yet it was a politician using every political tactic possible to undermine its contents.

A pragmatic approach would have been to point out the differences in the collection of the data and to have reassured patients. I suspect that the reality was that the Welsh Health Minister was responding in the full knowledge of all the other statistics on the NHS in Wales, such as those on waiting times and diagnostic delays, which could well contribute to higher mortality rates. Again, a pragmatic approach would have been to announce an investigation, or at least to seek out the root causes of the apparent high mortality rate according to the way in which the data were collected.

It is ironic that the Welsh Health Minister has today announced a change in the way the data are collected. Obviously, that is some shift, but I note that it has come out only after the political games had taken place. It is two weeks since my constituents were alarmed by the accusations that I had dragged the Welsh NHS through the mud.

In researching for this debate, I looked at recent cases that have become public in the NHS in Wales. There are troubling similarities with those that led to the Francis report. Lilian Hopkins received treatment from a local health board that treats patients from my constituency. For several days, a sign was left above her bed that said “Nil by mouth”. That left Mrs Hopkins too weak to lift a glass of water. Her prosthetic limb was not removed for two weeks, when she was left in bed for that time. Screams of pain at night were treated with sedation. At an earlier date, her family had asked for an investigation. It was promised, but not conducted. Three nurses have been arrested for falsifying records.

This is the same local health board where the police are investigating the circumstances surrounding a man who waited four hours in an ambulance outside the hospital, only to die at the same A and E department some hours later. The right hon. Member for Cynon Valley has listed several examples that I could refer to, but these are examples that I have picked up in the past couple of weeks.

The Royal College of Surgeons published a report last July that claimed that 152 patients have died over the past five years while waiting for cardiac surgery across two local health boards alone in Wales. The royal college also stated in its report that 2,000 cardiac operations were either cancelled or not scheduled between January and March last year. The report says that south Wales is the only part of the UK where patients are regularly dying on cardiac surgery waiting lists. It says that the provision of urgent and emergency surgery is simply inadequate.

I should like to be able to report that the situation has improved since the publication of that report last July, but it has not. Some patients are now being sent across the border to England to be treated in the independent sector, which strikes me as emergency action; instead, attempts should be made to identify the culture and issues that potentially parallel the Mid Staffordshire crisis.

I could point to lots of data, but I shall pick up just a few of the differences between Wales and England. Urgent cancer waiting times have not been met in Wales for the past five years. On average response times, in Wales 58% of patients are seen within eight minutes in category A calls. In England, the figure is 72%. One of the most worrying statistics, which Professor Sir Bruce Keogh particularly identified, relates to diagnostic services. In his e-mail, he pointed to the statistic that in Wales 26,000 patients are waiting more than eight weeks for diagnostic services. In England, 9,000 patients are waiting longer than six weeks. We need to bear in mind the difference between the populations: 3 million people in Wales and 50 million in England, yet 26,000 people are waiting for diagnostic services in Wales and 9,000 waiting in England. The statistics speak for themselves.

Peter Watkin Jones, a lawyer involved with the Mid Staffs inquiry, has said that a culture change is needed in the NHS in Wales. Having heard the shadow Health Secretary’s contribution, I do not think he recognises that. Again, I was sorry he felt that attack was the best form of defence. The right hon. Member for Cynon Valley has said that high mortality rates are a smoke signal indicating that something is wrong. The Royal College of Nursing has said that its members do not always have time for training and staff development in Welsh hospitals.

If the right hon. Member for Leigh (Andy Burnham) genuinely wants the lessons of Mid Staffs to be learned, if he wants to ensure that patients in Wales do not have to suffer the same indignity and if he wants to play a positive role in informing health care across the UK, I ask him to agree to make every effort to influence his colleagues in Wales to respond positively to the questions that are being asked, to put party politics aside and to introduce an effective inquiry for the sake of my constituents and those across the whole of Wales; otherwise, everything that he has said today will simply be hollow.

--- Later in debate ---

[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to speak in this important debate. Members on both sides of the House have shown that we are determined to learn the true lessons from the appalling failings at Mid Staffordshire and to understand what needs to change to prevent them from happening again.

We have heard many serious and thoughtful contributions, but I want to start by paying tribute to the hon. Member for Stafford (Jeremy Lefroy), whose calm, considered, thoughtful and dignified approach to the issue and the work he has done on behalf of his constituents is a lesson to us all. My right hon. Friend the Member for Cynon Valley (Ann Clwyd) hit the nail on the head when she said that there is nothing to be gained by politicising these issues, but everything to be gained by understanding the lessons and being open about the problems so that they can be tackled properly.

My hon. Friend the Member for Stalybridge and Hyde (Jonathan Reynolds) and my right hon. Friend the Member for Rother Valley (Kevin Barron), along with many other hon. Members, emphasises the importance of openness. As a constituency MP, I have seen how the NHS too often tries to sweep patient complaints and mistakes under the carpet, ignoring them and pushing patients away. Being open early on, admitting mistakes and learning the lessons is a much better way forward.

A number of hon. Members spoke specifically about the process that Mid Staffordshire hospital is currently going through. My hon. Friend the Member for Stoke-on-Trent North (Joan Walley) and the hon. Member for Stafford rightly said that there is a lack of clarity about the process and the timetable. I hope that the Minister, when he responds, will give those hon. Members and their constituents much greater clarity on what will happen.

My hon. Friends the Members for Rotherham (Sarah Champion) and for Wythenshawe and Sale East (Mike Kane) raised important points about making the system more accountable and how that is much harder since the NHS reorganisation, with all the different bodies—a point I will return to in a minute. My hon. Friends the Members for Worsley and Eccles South (Barbara Keeley), for Easington (Grahame M. Morris) and for Stockton North (Alex Cunningham) rightly talked about staff shortages and the serious impact they can have on patient care. If we are to get to the root of the problem, simply publishing data every month is not good enough. I was really pleased that the right hon. Member for Sutton and Cheam (Paul Burstow) talked about mental health. We have been talking mostly about physical health, but he was right to raise those concerns.

In the time available I cannot do justice to all the points raised today, or to the Francis report’s 290 recommendations, so I will focus my comments on the two most fundamental challenges we now face: first, ensuring that the views of patients, their families and the public are heard and acted on, at every level and at all times; and, secondly, ensuring that there is clear leadership to make the service changes we need to improve safety and quality at a time of unprecedented pressures on the NHS. Unless we do that, there is a risk of the failings in Mid Staffordshire happening again.

[Alun Cairns]

Will the hon. Lady give way?

[Liz Kendall]

I will give way to the hon. Gentleman this one time.

[Alun Cairns]

I am grateful to the hon. Lady for giving way, unlike her colleague earlier. In the spirit with which she has opened her contribution, and in relation to the comments made by the right hon. Member for Cynon Valley (Ann Clwyd), the comments of the Royal College of Surgeons and the example I highlighted of worrying cases in the NHS in Wales, will she make every effort to influence her colleagues in the Welsh Government, and indeed the Welsh Health Minister, to conduct a Keogh-type inquiry into the NHS in Wales?

[Liz Kendall]

Wherever there is evidence of poor care, it must be looked into. The hon. Gentleman did not mention that the Welsh Assembly has ordered a specific independent inquiry by experts outside Wales into aspects of care at the Princess of Wales and Neath Port Talbot hospitals, which I welcome.

Of all the lessons to be learned from Mid Staffordshire, the most important one is that the primary cause of the failures was the hospital and the trust board not listening to patients and their families, and not putting their needs and concerns first. Sir Robert Francis rightly says that there must be fundamental changes to ensure the real involvement of patients and the public in all that is done and to secure a common patient-centred culture throughout the NHS.

National Voices, a coalition of more than 130 patient, user and carer organisations, says that a concerted drive to listen to patients and carers must be a top priority for all trust boards and care organisations. It emphasises that over and above regulation, which it says has

“an important but limited role in ensuring quality and safety.”

Ministers have rightly spoken about the need for effective regulation and have taken some welcome steps, but the Care Quality Commission and the new chief inspectors will not be the main way of preventing the sort of failings we saw at Mid Staffordshire. Regulation identifies problems when they have begun, rather than preventing them from happening in the first place. Regulators cannot be everywhere all the time, but patients and their families are, which is why their views must be heard from the bedside to the boardroom, and at the heart of Whitehall.

The Labour Government made important progress. They published, for the first time, data on stroke and cardiac care. That helped to improve standards for patients and was a powerful incentive for staff to make changes. The next step is to provide systematic and comprehensive patient feedback. That must move from being the exception to being the norm.

The Government’s friend and families test is welcome as far as it goes but, as National Voices says,

“it is a crude measure on which the NHS would be unwise to place too much reliance.”

It asks only whether patients would recommend an NHS service to others, but not why, and it does not provide the detailed, real-time feedback that patients want and staff need to improve the quality of care. Developments such as the patient opinion and care opinion websites offer a powerful way forward. They enable people to tell the story of their NHS or care experience online, in writing or on the phone. That gives patients a voice, allows other people to see what is being said about a service, and in a simple and cost-effective way provides staff with a direct incentive to improve.

The Secretary of State said we must all be champions for change, and hon. Members may remember that I wrote to everyone saying that as a Member of Parliament they should sign up because it is a great way for us to understand what is really going on. I have asked my hospital trust and other services to do the same. That will be a powerful way of making change happen.

We must also look at how staff are trained to ensure that they always put patients first. Places such as Worcester university are leading the way: patients and families help to interview people who are applying to be nurses and health care assistants; they help to develop the content of courses so that they include what really matters to patients; and they take part in teaching students. Ministers should have spent the last three years championing such initiatives instead of reorganising the training structures as a result of the Health and Social Care Act 2012.

Individual patient voices are not the only ones that must be heard. We need a strong collective voice for users. The Francis report recommended investing in patient leaders to speak out on behalf of the public, to help to design services locally, and to hold them properly to account. Ministers claimed that that is what Healthwatch would do, but their rhetoric is simply not matched by the reality: national Healthwatch has nowhere near the same power, authority or levers to change services as NHS England, the Care Quality Commission or Monitor.

Local Healthwatch bodies are also weak. They were late out of the starting blocks and are woefully understaffed. Last week, we heard that £10 million of the £40 million budget that was promised for local Healthwatch has gone missing, despite the explicit recommendation in the Francis report that

“Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch”.

If Ministers are serious about giving patients a strong voice locally, they must look again at the support that Healthwatch is getting on the ground.

A strong patient voice is more essential than ever before because of the huge pressures on local services. Across the country, the NHS is struggling to cope with the increasing number of frail elderly people ending up in hospitals that were designed for a different age. Twenty per cent. of hospital beds have older people in them who need not be there if they had the right support in the community or at home. Half a million fewer people are receiving basic help to get up, washed, dressed and fed as council care budgets are cut to the bone. Mental health services, especially for children, are under intolerable strain as money for vital community services is being diverted to cope with pressures elsewhere in the system. This is not good for patients and families, it puts staff under pressure, and it ends up costing the taxpayer far more as people end up in more expensive hospital care or, in the case of mental health patients, being transported hundreds of miles around the country.

The NHS needs radical change, not to its back-room structures but to its front-line services and support. Improving safety and quality means that some services must be concentrated in specialist centres and others must be shifted out of hospitals into the community and towards prevention, fully integrated with social care. Under the previous Government, plans had been drawn up to reorganise services in every English region through Lord Darzi’s next stage review, but rather than pushing forward with those plans and making the changes that patients want and need, Ministers scrapped them simply because they were developed under the previous Labour Government. Instead, they embarked on a huge back-room NHS reorganisation, wasting precious time, effort and resources.

As several hon. Members have said, the new NHS structures are utterly confusing, with no clear lines of accountability or responsibility. There are now 211 clinical commissioning groups, 152 health and wellbeing boards, 27 NHS England local area teams, four NHS England regional teams—I am not sure what they are doing—23 commissioning support units, and 10 specialist commissioning units, alongside Monitor, the Care Quality Commission and NHS England. Can you make sense of that, Mr Deputy Speaker? Who is providing the leadership? Who is to be held to account? Across the country, people are doing their contract negotiations for next year, trying to make changes to services, and they say to me that there is no clear leadership in the system. That must change.

We have heard a lot about changing the culture in the NHS. That culture is about behaviour and the millions of personal interactions that happen every single day in the NHS. Getting those right will not happen through regulation alone but by giving patients and the public a powerful voice in every part of the system. This issue has had too little attention since the Francis report was published. Crucially, the culture is about leadership, and leadership comes from the top.

I warn Ministers not to be complacent about saying that the bullying culture has gone. On Friday, I met the chief executive of a trust who showed me an e-mail from the NHS Trust Development Authority, which is quite close to Ministers’ doors. I will not be able to say exactly what it said because it contained swear words, but it said, in effect: “Open the beep beds; just beep do it.” That was in an e-mail to a chief executive. The bullying culture is still going on. Ministers need to get a grip, particularly on what is happening at the NHS Trust Development Authority, which is causing real problems in the system.