Mid Staffordshire NHS Foundation Trust

Andy Burnham Excerpts

Tuesday 19th November 2013 Commons Chamber

[Andy Burnham (Leigh) (Lab)]

What happened at Mid Staffs was a betrayal of the NHS and its values. The previous Government rightly apologised, but now is the time to back our words with action. That is why, although I welcome much of what the Secretary of State has just said, it is my job to press him on where we feel he could have gone further and to question why, of the 290 Francis recommendations, 86 are not being implemented in full.

First, let me, too, pay tribute to my right hon. Friend the Member for Cynon Valley (Ann Clwyd), Professor Tricia Hart, Professor Sir Bruce Keogh, Camilla Cavendish, Professor Don Berwick and, of course, Robert Francis. Between them, they have given us proposals that will help to prevent a repeat but, more importantly, as the Secretary of State said, change the whole of the NHS for the better.

Both Francis reports found three primary and fundamental causes of what went wrong: a failure to listen to patients; a lack of properly trained staff; and a dysfunctional culture. I shall take each of those issues in turn.

First, I am sure the Secretary of State agrees with me that patients and their families must always, as Francis recommends, be the first priority for the NHS. That principle unites this House and it must also unite the NHS. Is not Robert Francis right to recommend that the NHS constitution, and the ethos it sets out, should be required reading for all NHS staff? I congratulate the right hon. Gentleman on agreeing to implement the Clywd review in full and change the way the NHS handles complaints.

Secondly, on the issue of staffing numbers and training, the first Francis report found that Mid Staffs made dangerous cuts to front-line staffing over a short period. I welcome the Government’s new focus on this issue, but is it not the case that nurse-patient ratios across the NHS have got significantly worse in the past three years, with 5,890 fewer nurses, more older patients in hospital and bed occupancy running at record levels? It is encouraging that the NHS has plans to recruit more nurses this year, and is introducing more monitoring. The Secretary of State says “things are already changing for the better”, but is he aware that Monitor has warned that trusts are planning major nurse redundancies in the 2014-16 period, far outweighing any increases this year? Will he intervene now to stop that? Further, can he explain why he stopped short of requiring safe staffing levels? Is he further aware that nurse training places have been severely cut in recent years and trusts are being forced to recruit overseas?

Alongside nursing, more action is needed to raise standards across the caring work force. As Robert Francis has said, it is unacceptable that the security guard at the door of the hospital is more regulated, and subject to professional sanctions, than the health care assistant attending to an elderly patient. The development of the care certificate as proposed by Camilla Cavendish is a step forward, but will it not work only alongside a register of those who hold it and an ability to remove it if they fall short? Was not Robert Francis right to recommend a system of regulation for health care assistants and, going forward, will the Government reconsider their decision to rule this out? Overall, although there is progress on staffing today, it does not go far enough and we will continue to challenge the Government on it.

Thirdly, on culture change, Francis’s central proposal is a new duty of candour on organisations and individuals. Extending the duty to organisations is a step forward, but patient groups are disappointed today that it will cover only the most serious incidents. Can the right hon. Gentleman say why it has not been extended to all incidents of harm? Further, it is not clear how an organisational duty alone will help individuals challenge an organisation where there is a dysfunctional culture. Is it not the case that an individual duty as proposed by Francis is essential? This point comes over clearly from the evidence given to Francis from a senior, soon to be retired consultant. He said:

“I took the path of least resistance . . . here were also veiled threats at the time, that I should not rock the boat at my stage in life.”

It is only when an individual is both required to speak out, and protected in doing so, that this House can say it has done enough to safeguard patients.

The duty of openness and transparency should apply equally to all organisations providing NHS services including, as Francis rightly recommends, contractors providing outsourced services. Given that this Government are bringing into the NHS more outside providers, patients will need reassurance that we do not have an uneven playing field where private providers face less scrutiny. So will the Secretary of State extend the duty of candour to all health care organisations, as Francis proposed? His amendments to the Care Bill do not make that clear. And should not he now commit to extending freedom of information law to any provider of NHS services?

On openness, Francis made a direct call on the Government to set an example to the rest of the NHS. He said that

“risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted.”

Given that the Government claim today to be accepting this, should they not show now that they mean what they say by finally publishing the risk register on the current reorganisation of the NHS?

Finally, on openness, the NHS would be more accountable to families with a proper system of death certification. The House will remember that this was a recommendation of the Dame Janet Smith inquiry into the Shipman murders. The report today says that the Francis recommendations on this are not accepted in full. If we fail to act now, might people be justified in thinking that this House has not learned the lessons of tragedies that have gone before? If the Secretary of State brings forward proposals, we will work with him on a cross-party basis to implement them.

In conclusion, I do not believe that cruelty has become normal in the NHS, but there is a much deeper question for us all and that is how, in the century of the ageing society, we do a better job of caring for older people. We should not accept the situation where, as Cavendish says, people are paid less than the national minimum wage. Should we not all set much higher ambitions for the care of older people and, in so doing, learn the most fundamental lesson of all from what happened at Mid Staffs?

[Mr Hunt]

Let me take the right hon. Gentleman’s points in turn. First, he will know, because this is what happened after the Bristol inquiry and the Shipman inquiry under the previous Government, that Governments do not always accept every single recommendation. What I have said today is that we accept all the principles behind every single one of Robert Francis’s recommendations. We are implementing 204 in full, and in respect of the 86 that we are not implementing exactly as he said, we are doing everything we can to make sure that we implement the spirit behind them, but we need to make sure that everything we do is workable in practice. Francis himself has said that it is a “carefully considered” response that is a “comprehensive collection of measures”.

On staffing numbers, which is an essential part of what we have to consider, if the right hon. Gentleman looks at the nursing hours per bed, he will find that they have gone up since 2010, not down. We recognise the crucial importance of front-line staff, which is why I gently say to him that we made some reforms to the NHS that meant that there are 5,500 more doctors on the front line and 8,000 fewer managers. What we also need is more nurses. That is why it is so encouraging that in response to what Robert Francis has said and the recognition throughout the NHS of the importance of compassionate care, we are getting a reaction from NHS trusts—not as a result of a direct ministerial decision, but because trusts themselves are recognising the importance of compassionate care. We think that is a very encouraging sign.

With respect to whether staffing levels should be mandatory, we agree that there are minimum recommended staffing levels, but they are not the same for every ward in every hospital. The minimum level might be one in six for an acute medical unit, one in four for a general medical unit, and one on one for intensive care. We took extensive advice on whether it would be appropriate to set a national minimum mandatory number. Not only is the chief nurse and leading nurses from across the country against this; the King’s Fund and the British Medical Association are against it. The BMA said something today in a statement which I never thought I would read in my lifetime—it said that the “Government is right” on this issue.

The right hon. Gentleman also opposed mandatory staffing levels back in 2011, although it is fair to say that in the House his position on this has changed. The important thing is that we allow local discretion to make sure that nursing levels are adequate, and that where they are not, that is exposed quickly so that there is no repetition of what happened at Mid Staffs.

On the regulation of health care assistants, every health care assistant will have to have a care certificate. Effectively, there will be a database which allows employers to check whether someone has such a certificate. That is a kind of register. The other reason for people talking about the regulation of health care assistants is that they want to make sure that if someone fails in their duty of care, they are not able to appear somewhere else in the country. That is why we have a vetting and barring scheme to make sure that that does not happen.

On the individual duty of candour, let us be clear: we want total candour about all avoidable harm, at every stage that it happens, anywhere in the NHS. We decided after much discussion that extending the statutory duty of candour to individual front-line clinicians would be likely to create a huge amount of bureaucracy and damage the culture of openness that we are trying to create, because everyone would constantly be worried about whether or not they were breaking the law. We decided that the right way to achieve the objective is through a professional duty of candour, which is much stronger than the current professional duty states. Critically—this is a key change—we decided to make sure that, just as airline pilots have protection if they speak out, if front-line NHS employees speak out, they too will get protection if there is a professional conduct case, and that openness at an early stage will be treated as a mitigating factor. That is really important in terms of changing the culture.

Finally, we absolutely do need to resolve the issue of death certificates. It is important that we have an independent view to certify deaths. It is a question of finding a practical way to make sure that we do that, but we very much accept the spirit of what Robert Francis said.

Today I hope that we will find a way forward on all the problems that Robert Francis addressed in his response and that we have been thinking hard about. I urge the shadow Secretary of State to join Government Members in saying that this is a moment when the NHS can once again reach forward and aim to be the very best in the world, because the kind of measures that we are talking about are not happening anywhere else, and that is something of which we can all be very proud.