Acute Hospital Wards (Staffing)

Andrew George Excerpts

Wednesday 15th January 2014 Commons Chamber

[Andrew George (St Ives) (LD)]

I am delighted to have secured this important debate on the staffing of acute hospital wards, on which I know the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter)—I am pleased to see him in his place—is aware I have been campaigning for a number of years.

The pressures on acute hospitals have, without question, intensified over the past couple of decades. There are now a third fewer general and acute hospital beds than there were 25 years ago. The past decade alone has seen a 37% increase in emergency admissions. An increasing number of older patients are being admitted to hospital: 65% of admissions are of people over the age of the 65. These patients are more likely to present more complex and multiple comorbidities, and the increased demand on acute care and the increased complexity of patients’ needs will have a knock-on effect, including placing greater demand on hospital resources and increasing pressure on registered nurses, doctors and other health care professionals. It will also, of course, have an effect on patient care itself.

I intend to concentrate on the staffing levels of registered nurses. Although much of the health debate has become obsessed with changing and tweaking management tools for commissioners—for example, by incentivising health systems with payment by results and more sophisticated tariffs, creating new pathways of care and, as far as the previous Government were concerned, wasting billions on fancy information technology systems—front-line nurses are often run ragged and overstretched on hospital wards.

The background or history to this debate goes back to the case of Graham Pink, who was sacked by Stepping Hill hospital in Stockport in 1990 for speaking out about poor staffing. I raised the matter as long ago as 2001 with John Hutton, now Lord Hutton, who wrote in response to a question from me:

“The work force commitments to recruit additional nurses, doctors and therapists in the NHS Plan take account of the need to increase the number of staff necessary to deliver diagnosis and treatment within the agreed clinical standards set out in the National Service”.—[Official Report, 17 July 2001; Vol. 372, c. 114W.]

There was therefore recognition in 2001 about the need to increase the complement of staff within NHS hospitals.

Since that time, there has been an acceleration of activity. To a certain extent, that activity was stimulated by the publication on 6 February 2013 of the Francis report on Mid Staffordshire NHS Foundation Trust, which has been debated a great deal in the House and elsewhere. As a member, as the Minister once was, of the Select Committee on Health, I know that it has exercised our consideration on many occasions.

To respond to the concerns about the arguably inadequate registered nurse staffing levels in many acute hospitals, the Safe Staffing Alliance has been formed with members from the Royal College of Nursing, the Patients Association, the Florence Nightingale Foundation and many other bodies. In an important launch on 12 May, it released a statement on the risk of excess deaths, indicating that the risk was significantly increased by lower registered nurse to patient ratios. I met the Minister on 14 May, after which I submitted a substantial file of evidence to back up the argument in favour of improving those ratios.

On 16 July, Professor Bruce Keogh published his study on 14 hospitals. Certainly one of its key themes was the inadequate registered nurse to patient ratios on wards, which caused concern within those hospitals, and that has been debated on many occasions. On 16 August, Professor Don Berwick published a very significant report on patient safety, from which the same theme arose that we cannot achieve safe patient outcomes if we do not have adequate safe staffing levels.

On 9 October, the Safe Staffing Alliance held a reception, which I was pleased to host, and I tabled early-day motion 643 on safe staffing on 29 October. The Government have since responded, with the National Quality Board—headed by the chief nursing officer, Jane Cummings—publishing a “How to” guide on using the right tools to establish safe staffing levels on hospital wards. On 19 November, the Government responded to the Francis report, as did the Health Committee on the same date, and announced further initiatives to address the issues, which I will come on to in a moment.

The question is how bad the problem is now, when there is so much attention on it. Interestingly, a report in the Nursing Times this week stated:

“Serious concerns over staffing levels and patient safety were raised last week at four hospitals in different parts of the country”

as a result of Care Quality Commission reports. A number of CQC reports in recent years have highlighted inadequate staffing levels.

[Dr Phillip Lee (Bracknell) (Con)]

One of those CQC reports was on Wexham Park hospital, which serves part of my constituency. There have been reports of pretty woeful nursing standards, particularly on acute medical wards. Does the hon. Gentleman agree that part of the challenge is that we have too many acute hospitals in the 21st century to deliver the appropriate care that we would all want our constituents to receive? A reconfiguration of hospital services, with fewer acute sites, would allow proper staffing of acute medical wards.

[Andrew George]

The hon. Gentleman speaks with great knowledge on this subject. Of course, we have fewer acute hospitals than we used to have, but we still have serious staffing problems. On its own, that idea is not the answer, but it does need to be considered if we are to address the issue of patient safety.

As the hon. Gentleman rightly says, the report on Wexham Park hospital stated that CQC inspectors found evidence of regular short staffing on “almost all wards” and a culture in which

“staff did not always feel they could raise concerns”.

The inspectors concluded that the trust was more focused on “responding to…targets” than on

“ensuring that overall patient experiences were positive”.

The article in the Nursing Times states:

“Despite a previous CQC warning in May, almost all the wards inspected were found to be regularly short staffed. Staff did not always feel they could raise concerns, with a number expressing concerns about bullying and harassment, the CQC said.”

The article states that there were similar problems at Bradford Teaching Hospitals NHS Foundation Trust and that, last Wednesday,

“Belfast Health and Social Care Trust declared a ‘major incident’ at its Royal Victoria Hospital due to a backlog of A & E patients. At one stage, 42 people were waiting on trolleys.”

A hospital porter, Pat Neeson, is quoted by the BBC as saying that he was

“fed up watching our nurses cry”

as a result of long-standing A and E pressures. There are significant pressures in many hospitals. Although those examples have been in the press this week, we all know that the problem is not exclusive to those hospitals.

This is also a political issue. The question is whether the reports implicate uncaring nurses or whether the problem is that there are not enough nurses on hospital wards. The Prime Minister has become involved in this issue through his presentation of the Francis report to the House last year and what he has said elsewhere. On 6 January 2012, he said:

“If we want dignity and respect, we need to focus on nurses and the care they deliver. Somewhere in the last decade the health system has conspired to undermine one of this country’s greatest professions.”

Last year, in the light of the Francis report, the Government proposed that all trainee nurses should have one year’s experience as a health care assistant before they become fully qualified. The Prime Minister said:

“We have said in the light of that report that nurses should spend some time when they are training as healthcare assistants in the hospital really making sure that they are focused on the caring and the quality and some of the quite mundane tasks that are absolutely vital to get right in hospital”.

The question is whether the problem is the attitude of nurses or nursing numbers.

The Safe Staffing Alliance suggests that there are excess deaths as a result of there being insufficient nurses. Some people ask how many excess deaths there are. Given the statistics and methodologies that are available, academic statisticians would blanch at suggesting what the figure might be. I have been cautioned by House of Commons statisticians and the academics who back up the Safe Staffing Alliance about ever doing so. It is suggested that there were at least 20 excess deaths per annum in hospitals with unsafe average staffing. The RN4CAST survey of 32 English hospitals, including more than 400 wards, showed that 43% had registered a nurse staffing ratio of more than 1:8.

There are about 240 acute hospitals. I have been heavily cautioned by the House of Commons Library and other statisticians not to extrapolate a figure, and I appreciate that I am doing what academic statisticians would never do, but I am going to step off the tightrope of academic equivocation and be a brazen politician and suggest only an indicative figure. While surrounded by so much caution and so many caveats—I do not have time to list them all—the number of excess deaths will be higher than zero and much lower than the approximately 248,000 patients who die each year in acute and community hospitals. Taking those statistics together, the indicative figure would be 4,000 excess deaths in acute hospitals in England. Clearly, this issue needs to be seriously addressed.

All the review reports last year showed that nurse staffing was a critical issue to prevent poor care, and they absolutely corroborate the research findings of the link between registered nurse staffing and quality of patient outcomes. The National Institute for Health and Clinical Excellence has been commissioned to give guidance on acute ward nurse staffing by July and it will look at validating methodologies. I have spoken to Professor Gill Leng of NICE and it is clear that it will be conducted on a robust evidential basis.

The Berwick report, the Nursing and Care Quality Forum and the Council of Deans have all publicly endorsed never having more than eight patients per registered nurse on acute wards, based on current known evidence. A number of trusts are now displaying nurse staffing on boards at ward level, with some trying to ensure that they take account of the “never more than eight” standard. A lot of action is being taken to address this issue.

As well as avoiding excess deaths, the issue needs to be addressed by health care economists, too. Recent evaluations in Perth, Australia, which has mandated levels of safe staffing, show that investment has more than paid for itself in reductions in patient harm, fewer bedsores, less complications and infections, and fewer falls. California, which has the same arrangement, has shown a 25% reduction in readmissions. These are important benefits, which health economists need to look at when they address this issue.

Jane Cummings, the chief nursing officer, has looked at the issue and I will read a key quote from her in the National Quality Board report:

“There has been much debate as to whether there should be defined staffing ratios in the NHS. My view is that this misses the point—we want the right staff, with the right skills, in the right place at the right time. There is no single ratio or formula that can calculate the answers to such complex questions. The right answer will differ across and within organisations, and reaching it requires the use of evidence, evidence based tools, the exercise of professional judgement and a truly multi-professional approach. Above all, it requires openness and transparency, within organisations and with patients and the public.”

My concern about this kind of management babble, and those who possess the presentational skills to get away with it, is that it throws a warm comfort blanket around the issue and creates a cloud of obfuscation. We need some of the hard lines proposed by the Safe Staffing Alliance, and we need fundamental standards below which no service should fall.

I have given the Minister advance notice of my questions. Does he accept that there are still a significant number of hospital settings where the number of registered nurses on duty is insufficient to ensure patient safety, professional standards and morale among many in the nursing profession? Does he agree that the Safe Staffing Alliance proposal for a fundamental standard of never less than one registered nurse to eight patients would be a useful tool for inspections and act as a benchmark for management to use, alongside other safe staffing tools? Does he agree that the CQC should in future concentrate more on using safe staffing tools and clear measurements of how many registered nurses are on a ward? Does he agree that as part of future work force planning, hospital managers should not conflate or blur the distinction between registered nurses and advanced care practitioners? Finally, without pre-empting NICE’s conclusions this summer, what can Ministers do to guarantee that hospital boards follow, or at least apply, its proposed guidance? I look forward to his response.

--- Later in debate ---

[Dr Poulter]

As I will come on to say, if my hon. Friend will bear with me, it is now a matter for the CQC to inspect trusts on issues such as quality of patient care and safety. I will outline those measures later in response to my hon. Friend the Member for St Ives.

It is important that we support staff as much as possible when they raise concerns, whether about minimum staffing levels or other quality-of-care issues—this was the point just raised by my hon. Friend the Member for Stafford (Jeremy Lefroy)—and to do that we are facilitating and enhancing a duty of candour on trusts to ensure a more candid and open approach and to ensure that staff who have concerns are better supported and are better able to raise them.

Turning specifically to the matters at hand, superficially the principle of minimum staffing ratios sounds seductive, but when it comes down to it, we will see that they do not guarantee safe staffing or care. For those reasons, the Government do not support them. The principle of good care is about having the right staff in the right place at the right time. As we will all be aware, the needs of patients can change not just daily, but hourly—a patient can rapidly deteriorate—and just having ticked a minimum-staffing box does not mean that the right care is necessarily being applied. The lesson to learn from Mid Staffs is that we followed the bureaucratic tick-box approach and that led to failings in care, and that just ticking boxes saying we have done something, however seductive or good it might sound, does not necessarily mean that patients are being treated right. That is a matter of clinical circumstances and the clinical judgment of staff.

[Andrew George]

I am well aware of the Minister’s line, but if we followed its logic to its conclusion, we would withdraw minimum staffing levels from paediatric wards, intensive care and, in other sectors, child care, which is a topic that has been hotly debated politically as well.

[Dr Poulter]

As my hon. Friend will be aware, the CQC inspection regime inspects all parts of hospitals. Good care in a cardiac or intensive care unit is not necessarily about having one-on-one nursing; it is also about ensuring that all the other additional supports and other parts of the multidisciplinary team are in place to deliver high-quality care. That is at the heart of what the Government are trying to do. I believe that the CQC, looking not just at staffing levels but at wider determinants—for example, using the NHS safety thermometer, which looks at the issues my hon. Friend raised about bedsores—and putting together a whole picture of what the care at a trust is like, is well placed to make judgments. Part of the CQC’s inspection regime entails full clinical involvement, so it has become more of a peer-review process about what “good” looks like from one hospital to another—an important improvement in the quality of the inspection regime, which enables it to weigh up staffing issues.

My hon. Friend will be aware that we are going to support the CQC and provide greater transparency throughout the health system—in regard to staffing levels, by ensuring that they are published in future. Trust boards will have a requirement specifically to look at their staffing levels and to address problems. We shall not simply wait for the CQC to react to staffing issues as part of its wider inspection regime; there will be a requirement on trust boards to look at them. On Christmas day, I visited my local trust and found that staffing levels were discussed on a daily basis, in direct response to improvements following the Francis inquiry. I believe the same thing is taking place in a number of hospital trusts throughout the country.

Let me deal with my hon. Friend’s specific questions. He asked whether there were a significant number of hospital settings in which the number of registered nurses on duty was insufficient to ensure patient safety, professional standards and morale among many in the nursing profession. Our patients, their families and the public need to be assured that, wherever they are cared for and treated, there is a strong and positive patient safety culture, led from the top and embedded in every organisation.

There can be cases where hospitals are under-staffed and there is an impact on the quality of care provided, but these cases need to be addressed from a whole-care perspective, in which staffing numbers form just one element of a broader safety assessment. It is right that clinicians and trust boards have the freedom to agree their own staff profiles, which should not be dictated from Whitehall or by some blanket tick-box approach saying “You have met the minimum staffing number; you are therefore delivering good care”. We know from what happened at Mid Staffs that that is not the case. We must do everything we can to support good decisions made in the best interest of patients on the ground. This approach will give trusts the flexibility to respond swiftly to changes in patient demand or to meet the urgent needs of patients who have deteriorated, ensuring that safety and quality care is available.

We need to make sure that patient safety is a constant concern to each and every NHS trust and NHS employee, ensuring that risks to patient safety are always acted on as soon as they are identified, whether it relates to a “never event” or to the number of staff on a ward at any time of the day or night. We expect trust boards to sign off and publish information on staffing levels at least every six months to demonstrate that they are using evidence-based tools to calculate their staffing levels and provide assurance on the impact on quality of care and patient experience.

My hon. Friend asked whether the Safe Staffing Alliance proposal for a fundamental standard of no less than one registered nurse to eight patients would be a useful tool for inspection, surveillance and as a benchmark for management to use alongside other safe staffing tools. I hope he will understand that no single dimension and no single tool can ensure patient safety and that setting minimum staffing levels does not necessarily ensure that patients get the best possible care. Patient safety is not just about safe staffing; it is about listening to patients, assessing their needs and staff taking action where there are concerns. The number of staff—not just nurses, but doctors, physiotherapists, health care assistants and all other important members of a multidisciplinary team—needed to look after patients in a cardiac intensive care unit will differ from the numbers and skill mix required in a rehabilitation setting or another care setting—and it will differ from day to day, ward by ward and sometimes even from hour to hour, depending on the care needs of patients.

Ticking boxes on minimum staffing levels does not equate to good care. As the Berwick review made clear, ticking boxes in relation to minimum staffing levels does not equate to good care. Patients must be assessed individually, and the level of care required to ensure their safety must be determined by front-line staff locally, supported in their decision making by a range of factors that determine safe care. That should include staffing levels, but they are not the only issue: the Berwick review made that clear as well.

The Care Quality Commission also considers staffing levels in its inspections of registered providers, including acute hospitals. All providers registered with the CQC must ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced staff. In time, the guidance that we are developing on safe staffing will help providers to understand how to calculate reference staffing levels. It will also be used by the CQC when it assesses whether the right number of staff are employed to provide safe patient care.

My hon. Friend asked whether I agreed that in future the CQC should concentrate more on using safe staffing tools and clear measurements, and on how many registered nurses were on a ward. I do not want to dictate from Whitehall—indeed, I am sure that none of us do—the details of what the CQC will look for; it is important for the CQC to take a flexible approach to its inspections, and to be prepared to pursue different avenues depending on what it finds. What we can all agree on is that the provision of enough trained and skilled staff is vital to the delivery of acceptable care, and that CQC inspections should continue to consider staffing levels.

I must end my speech shortly, so I will write to my hon. Friend about the other points that he raised. I know that we are approaching this issue from the same position, and that all of us care about supporting staff and delivering high-quality care. However, I hope my hon. Friend will agree that safe staffing levels could have perverse consequences, that they are only a part of the picture when it comes to delivering good care, and that it is for the CQC to ensure that it takes an accurate and holistic view when carrying out its inspections to ensure that high-quality patient care is provided in the future.

Question put and agreed to.

Accident and Emergency

Andrew George Excerpts

Wednesday 18th December 2013 Commons Chamber

[Paul Burstow (Sutton and Cheam) (LD)]

I want to pick up on a couple of points that were made by the hon. Members for Mitcham and Morden (Siobhain McDonagh) and for Bracknell (Dr Lee) about reconfiguration. The hon. Gentleman said that all too often the experience of hon. Members is that reconfiguration feels as if it is being done on the hoof. I agree with the hon. Lady about the proposed reconfiguration in south-west London and about St Helier hospital. Whether that will ever happen is still up in the air—let us hope that it does not. A leap of faith was demanded of constituents across south-west London, not least because the plans did not contain any measures to improve out-of-hospital care, without which it would not be possible to achieve the changes to emergency services that were being proposed. Those points are part of this debate, which is primarily about whether there is a crisis and, if there is, what the nature and causes of it might be. Although the Labour motion acknowledges that there are many causes of the problem, it has a very simplistic solution.

The evidence shows that there is a mixed picture across the country. That is reflected in the allocation of the first wave of additional funding for the NHS to meet winter pressures. That funding went to the health economies that were the most challenged. Some are coping well with the seasonal change from the higher volume, but less complex A and E attendance pattern of the spring and summer to the winter pattern of fewer, but much more complex cases, which often involves more frail and older people, and leads to more admissions. That pattern is repeated year on year and the demographic changes continue year on year. The pattern is well documented and it is very sensitive to the weather. That is why I welcome the Government’s cold weather plans and their support for local government and other agencies to put in place the extra social support that is necessary to avoid admissions in the first place.

Where there are problems, the causes vary. Some of the pressure stems from changes in behaviour. People now see A and E as the easiest point of entry into the system for any ailment. Often, there is confusion about the access arrangements for out-of-hours care. Those behavioural changes are cumulative. They are a consequence of changes that were made some years ago, not least through the changes to the responsibility for out-of-hours care in the GP contract. The implementation of those changes undoubtedly sowed much of the confusion over how to access emergency care.

[Andrew George (St Ives) (LD)]

Does my right hon. Friend agree that a lot of potential patients are confused about what out-of-hours unscheduled care is available? There are A and Es, minor injuries units, out-of-hours GP services, GP walk-in centres, NHS 111 and so on. Many people cannot discriminate between those services and do not know what they are supposed to provide. They therefore need to be further integrated.

--- Later in debate ---

[Andrew George (St Ives) (LD)]

My expectations for this debate were low, having previously endured shouting matches between the former Labour Secretary of State, the right hon. Member for Leigh (Andy Burnham), and the current Secretary of State, with the usual antics of carefully selected and spun statistics thrown at each other. Those expectations were not disappointed. This issue is not helped by being dragged into the gutter of partisan politics. The fact is that the A and E crisis—if there is indeed an A and E crisis—has existed and has been endemic in the NHS before and after 2010. This is largely the result of A and E being seen as an issue that somehow needs to be treated separately and not part of an integrated NHS. Before 2010, there were ambulances queuing outside the A and E in my constituency and in the Royal Cornwall Hospitals Trust in Truro. The problem exists. From time to time, there will be those kinds of pressures, which are created by a whole set of things that are not entirely the fault of a failing A and E service.

One aspect of unscheduled care in Cornwall that I raised with the former Secretary of State is the out-of-hours GP service. The previous Labour Government were perfectly happy to see that service put out to tender and privatised, and we saw a fragmented unscheduled care service. I reported the Serco out-of-hours GP service to the CQC, because it was simply putting profit before patients by manipulating statistics to make the outcomes appear better than they were. It was announced last week that Serco will be handing that contract back early. I hope that that will result in an integration of unscheduled out-of-hours care, as that is the kind of thing we need to do. This is not an issue that should be subject to party political point scoring, because that completely misses the target.

[Valerie Vaz (Walsall South) (Lab)]

The hon. Gentleman sat on the Select Committee with me. He must surely accept that there was a top-down reorganisation that nobody wanted and that cost the NHS £3 billion.

[Andrew George]

Yes, and the previous Labour Government were involved in multiple top-down reorganisations of the NHS. The hon. Lady knows that I opposed that top-down reorganisation; I voted against the Health and Social Care Bill.

We could just bemoan the things that are going wrong, but I want, in two minutes, at least to lay on the table my prescription for what needs to be put right. The two themes have to be integration and prevention. My intervention on my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) spelled out the theme of integration. Unscheduled care includes not only A and E, but minor injuries units, urgent care services, the 111 service, the ambulance service, the out-of-hours GP service, GP surgeries themselves, and, indeed, GP walk-in centres, which the previous Government created. Significant confusion is created about where the general public are supposed to take themselves if they have an urgent need for medical attention. We really need to find ways to integrate those unscheduled services in a way that does not result in the fragmentation that bedevils the service at present.

On prevention, often in acute hospitals planned work cannot go ahead because patients cannot be discharged from hospital and other patients cannot be admitted because there are insufficient beds. The health service is not integrated, because there are insufficient community beds and the primary care service is struggling and stretched to the limit, unable to provide the kind of care for people in their homes and community hospitals that would avoid them ending up in hospital as emergency cases. Those are the two themes: further integration of the service, which is not helped by the Health and Social Care Act 2012, and significant investment in preventive care and primary care.

Care Bill [Lords]

Andrew George Excerpts

Monday 16th December 2013 Commons Chamber

[Kate Green (Stretford and Urmston) (Lab)]

rose—

[Andrew George (St Ives) (LD)]

rose—

[Mr Hunt]

I will give way to my hon. Friend.

--- Later in debate ---

[Andrew George]

I am very grateful to my right hon. Friend for giving way. He says that everyone will be protected, but of course the cap on care costs is not a cap on “daily living costs”, as the Bill puts it. Will he therefore confirm that the £70,000—or whatever figure the cost ends up at—will not be the end of the costs for many people going into residential care?

[Mr Hunt]

My hon. Friend is right. We followed the recommendations of Andrew Dilnot, who did not think that the cap should apply to hotel costs, and, indeed, the policy that the Opposition followed in their national care service White Paper. We think that it is reasonable to cap the care costs. There is a cost issue—we would like to be more generous, but by the end of the next Parliament this proposal will cost nearly £2 billion. People who would like a more generous system must be obliged to tell us where they will get the extra funding.

--- Later in debate ---

[Andy Burnham]

I would have thought that the hon. Gentleman had been here long enough to know the difference by now. We will not oppose the Bill, in the sense that we will not vote against it on Second Reading, but it contains measures to which we simply cannot give a clear endorsement, as I will go on to explain. That is the purpose of our reasoned amendment. We will not oppose the Bill’s passage on Second Reading, which is why I objected to the Secretary of State misrepresenting my position.

[Andrew George]

I was going to make a similar point. Is it wise to bring forward an amendment of the type the right hon. Gentleman has tabled, bearing in mind the rather partisan nature of the debate we have had so far? What we really wanted was a debate on the Bill’s contents. Does he not now regret having brought forward such an amendment, because it has precipitated our going down into the gutter of partisan politics?

[Andy Burnham]

I agree with the hon. Gentleman, which is why I am not opportunistically opposing the Bill. I have tabled a reasoned amendment to put on the record the very serious concerns people have about funding for local authority care in England, the way the new cap will work and, in particular, the proposed clause on hospital reconfiguration—the Lewisham clause. I cannot let those concerns pass without making clear our position on them from the Dispatch Box. That is why we have taken that stand. That is why I am seeking to introduce my remarks in a non-partisan way.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 26th November 2013 Commons Chamber

[Norman Lamb]

First, it is worth us all recognising that there is an increase in the number of frail elderly people in our society living with chronic conditions and that that is putting additional pressure on accident and emergency departments. The numbers have increased by over a million a year since 2010. However, the fact that there has been a reduction of 50,000 in the number of delayed discharges demonstrates that the social care system is doing incredibly well, and we should pay tribute to social care workers across the system who are doing so well to ensure that that improvement is taking place.[Official Report, 4 December 2013, Vol. 571, c. 13MC.]

[Andrew George (St Ives) (LD)]

Bottlenecks in A and E are certainly not new, and they are not aided by the mantra that acute hospitals should be able to manage with fewer acute beds. On my hon. Friend’s point about shared and integrated planning, is he prepared to go further and push the Government in the direction of shared and integrated budgets as between health and social care?

[Norman Lamb]

I thank my hon. Friend for that question. We are creating a pooled budget in 2015-16 with this £3.8 billion fund. I can remember in opposition frequently making the case for integrated care and not really getting much of a positive response from the then Government. As the Chair of the Select Committee, my right hon. Friend the Member for Charnwood (Mr Dorrell), said, the great thing is that this Government are actually doing it.

Mid Staffordshire NHS Foundation Trust

Andrew George Excerpts

Tuesday 19th November 2013 Commons Chamber

[Mr Hunt]

I am very happy to share any of the lessons we have learned, but I do so from a position of humility, because we still have to address very serious challenges in our NHS in England. It will take us time to sort them out. I am happy to work with any devolved Administrations. Indeed, I would like to work with other countries across the world, because the challenge of how to deliver high-quality, compassionate health care when resources are tight and with an ageing population is one that all countries face.

[Andrew George (St Ives) (LD)]

The Government’s position on the publication at ward level of safe registered nurse staffing levels is a welcome step in the right direction. My right hon. Friend will be aware that I have consistently argued for safe registered nurse-to-patient ratios at ward level, and no manner of enhancements of culture and leadership can ever be used to mask the risk to patients if there are not enough nurses on the ward. Is he aware that some trusts are conflating trained care assistants with registered nurses, and will he reassure me that, in enumerating the number of registered nurses on wards, trusts cannot conflate trained care assistants, welcome though they are, with registered nurses?

[Mr Hunt]

My hon. Friend makes a very important point, because in an era of transparency we depend on honesty from the people supplying the information being used. It is not always possible independently to audit every single piece of information. What we have said today is that deliberately supplying false or misleading information will be a criminal offence, which is a much tougher sanction than anything else we are saying today. We think that the most important thing is to establish a culture in which people tell the truth and speak out if there is a problem, because then something can be done about it.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 22nd October 2013 Commons Chamber

[Mr Hunt]

I hope that the hon. Gentleman will be pleased that something is happening under this Government that did not happen under the Labour Government: we are putting those hospitals into special measures and sorting out the problems, including the long-term problems with A and E such as the GP contract—a disaster that was imposed on this country by the Labour Government.

[Andrew George (St Ives) (LD)]

6. What the current (a) highest, (b) lowest and (c) mean average registered nurse-to-patient ratio is on acute hospital wards.

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

As my hon. Friend is aware, we do not hold information on registered nurse-to-patient ratios on acute hospital wards. Local hospitals must have the freedom to decide the skill mix of their work force and the number of staff they employ to deliver high-quality, safe patient care.

[Andrew George]

I am grateful to my hon. Friend. The Government should be monitoring the situation, but he will be aware of the concern, which I have consistently highlighted, about inadequate registered nurse ratios in acute hospital wards, and of the Health Committee’s report into the Francis inquiry, which made recommendations in that regard. In inspecting hospitals, what objective measure should the Care Quality Commission use when looking at safe staffing levels on acute hospital wards?

[Dr Poulter]

The CQC is working with the National Institute for Health and Care Excellence and NHS England to devise tools to do exactly that. As my hon. Friend will be aware, the number of front-line staff required, whether nurses or doctors, to look after a patient who is in a cardiac intensive care unit will differ from the number required in a rehabilitation setting. The tools that the chief inspector of hospitals will be able to apply are being developed.

Accident and Emergency Departments

Andrew George Excerpts

Tuesday 10th September 2013 Commons Chamber

[Mr Hunt]

The decision on which 53 areas to concentrate the resources was not made by me; it was made by NHS England, talking to Monitor and the NHS Trust Development Authority, on the basis of where, in their professional assessment, the highest-risk areas are. That is a sign that hospitals in the north-east are performing extremely well. In the past few months I have visited Newcastle, and I thought the hospital was absolutely fantastic; I did a stint on the front line there. There are some outstanding hospitals across the country, and there is very good NHS provision in the north-east. That is probably the reason.

[Andrew George (St Ives) (LD)]

I wish my right hon. Friend well in his quest to reintegrate a fragmented service —a trend which was largely started under the previous Government—but given the fact that the ambulance service provides a very good bolster, and indeed support, and helps to remove pressure from many A and E departments, how much of the £500 million will be made available to support ambulance services in their support of A and E departments?

[Mr Hunt]

Quite a lot of the money will help ambulance services indirectly because it will be intended to reduce the number of blue light calls by, for example, providing primary care alternatives to A and E by better integrating health and social care economies, but the long-term change that we announced last week, which I think will make a real difference to ambulance trusts, involves IT. In this day and age it is crazy that an ambulance can answer a 999 call and go to someone’s home not knowing that they are a diabetic who has mild dementia and who had some falls last year. That information could be incredibly helpful to paramedics and we want to make sure that, with patients’ consent, they have it at their fingertips.

Managing Risk in the NHS

Andrew George Excerpts

Wednesday 17th July 2013 Commons Chamber

[Andy Burnham]

The Keogh report exposes alarming ratios at my hon. Friend’s hospital and others. We have been warning the Government for months—years, in fact—about cuts to nursing numbers. It is neither right nor fair to criticise nurses for being uncaring when too many of them are unsupported and are working in conditions in which they have to make compromises that they would rather avoid.

Staffing emerged as the main concern arising from the Keogh report, but the problems go way beyond 14 trusts. The CQC says that one in 10 trusts in England does not have adequate staffing levels. Can we agree today that the staffing in all hospitals must urgently be brought back up to adequate levels, as defined by the commission, with clear benchmarks set for the future? [Interruption.] I am pleased if the Secretary of State is agreeing, because that represents progress, so I look forward to finding out how his plan will be delivered.

[Andrew George (St Ives) (LD)]

The right hon. Gentleman will remember that yesterday I drew attention to the fact that all but one of the 14 hospitals Keogh reviewed had staffing and skill mix issues that needed to be dealt with, but it would be quite wrong to suggest that that has happened only in recent years. Graham Pink drew attention to the problem in the early ’90s, and it also happened during Labour’s years in government. I think that it would be good for this debate if the right hon. Gentleman at least acknowledged that it has been going on for more than three years.

[Andy Burnham]

I will acknowledge that. A moment ago, I mentioned the Francis report, which I commissioned, which revealed the dangerous cuts to front-line staffing that the hospital pursued as the primary cause. I accept what the hon. Gentleman has just said. Rather than always pursuing central regulation as the solution, if local communities had identifiable benchmarks that they could use to check up on their local hospitals, surely that would be progress we could all get behind.

On the duty of candour, the Government are legislating for a duty on organisations, but not on individuals. I think that we all agree that changing the culture of NHS organisations is essential if we are to move forward. The Francis recommendation is a necessary part of bringing about that culture change. Rather than being a threat to staff, as some have argued, it would protect them when they make known any concerns. Will the Government look at that again and legislate for the full Francis recommendation in the Care Bill? That is incredibly important in the light of yesterday’s report by Sir Bruce Keogh. He revealed—this will shock anyone who has not spotted it yet—that some trusts were telling members of staff what they could and could not say to his review. Surely we can all agree that is fundamentally unacceptable.

Hospital Mortality Rates

Andrew George Excerpts

Tuesday 16th July 2013 Commons Chamber

[Mr Hunt]

Improving leadership is vital throughout the NHS. All Governments must take responsibility for what happens on their watch, and I have taken responsibility today for those 14 hospitals and all their serious problems. The right hon. Gentleman should accept that between 2005 and 2010 his Government received 142 letters about his hospital which they did nothing about, and introduced a regulatory system that did not expose poor care and ensure that it was addressed.

[Andrew George (St Ives) (LD)]

I welcome Sir Bruce Keogh’s important report. However, although I admire my right hon. Friend, I totally dissociate myself from his ill-judged attempt to drag this important issue into the gutter of partisan politics and petty point-scoring. I expect better of him than that.

It is clear from annex A of the report that in all but one of the 14 hospitals, problems relating to staffing levels and the staff mix need to be addressed, and ambition 6 recommends action to address them. As my right hon. Friend knows, I campaign on this issue. What will the Government do to ensure that staffing levels are adequate in our acute hospitals?

[Mr Hunt]

Tackling failure in our NHS is not an easy path to take, but it is the right thing to do for patients. If my hon. Friend believes that all the care problems in the NHS started in 2010, I think he is the only Member who does. [Interruption.] Opposition Members must bear their share of the responsibility for the failures that they did not sort out. Staffing is indeed a problem that needs to be sorted out in many trusts, which is why we commissioned the review and why we are sending in turnaround teams to do just that.

Oral Answers to Questions

Andrew George Excerpts

Tuesday 16th July 2013 Commons Chamber

[The Parliamentary Under-Secretary of State for Health (Anna Soubry)]

Absolutely. I would be delighted to come along and visit the school. May I give full credit to the right hon. Gentleman for his campaign and to the Silver Star charity, which does great work? That is why it is so right that we put public health back in local authorities, where it should always have been and where it was, historically. This sort of local action is very much the way forward, so I congratulate the school and the right hon. Gentleman again.

[Andrew George (St Ives) (LD)]

Further to the question raised by the hon. Member for Walsall South (Valerie Vaz), I have met the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter) regarding safe staffing levels and I provided a substantial file of evidence on behalf of the Florence Nightingale Foundation in support of its 1:8 registered nurse to patient ratio. What part of that evidence are Ministers unconvinced by?

[Mr Jeremy Hunt]

I am sure the evidence to which the hon. Gentleman refers is very persuasive, but I am sure he would agree that a ratio such as 1:8 cannot be applied uniformly across his local hospital or across all local hospitals. It can vary from day to day, depending on the level of illness and the age of the people going into particular wards. The best hospitals have computer models that change the numbers of nurses operating in different wards on a daily basis. Other hospitals do not do that, except on a quarterly basis. That is the change that we need to make.