Francis Report

Ann Clwyd Excerpts

Wednesday 5th March 2014 Commons Chamber

[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.

[George Freeman]

The right hon. Lady is a doughty campaigner and commands the respect of the whole House for her work in bravely highlighting the issue. Does she agree from her experience and the correspondence that she has received that there is a lesson about the need for a different culture in the NHS of respecting the views of patients and whistleblowers, not treating them with contempt as though expressing such views is disloyal? Does she also agree that this saga highlights the importance of integrating data and having a statutory requirement to use the data to highlight the best and worst practices in the interests of patients?

--- Later in debate ---

[Ann Clwyd]

I am grateful to the hon. Gentleman for making that point. In the report that I wrote with Tricia Hart on complaints, we made several suggestions and recommendations, which the Government have accepted. I hope that we have a debate similar to today’s on progress in that area in a few months’ time. Professor Sir Mike Richards has promised to campaign on the issue when he goes round the many hospitals that he visits, but it is not possible to say whether complaints will head his list and whether the way in which they are dealt with will be picked up.

The letter that appeared in the Western Mail went on to say:

“A review should look not only at mortality rates. Complication rates, a high number of complaints from patients and their families, or frequent falling out between consultants within the department, all offer useful markers for identifying potential problem areas.

Careful analysis of departmental practice could lead to a prompt and effective change in practice. The Welsh public should be in receipt of all clinical outcome measurements, department by department.

Hysterical responses, such as BMA Cymru’s description of the perceived criticism as ‘wicked slander’…are unhelpful. Our health boards’ first duty of care is to their patients. Our political leaders and BMA Cymru (my own union by the way) should also be reminded that their first duty of care is to the patients and not to our established and very powerful institutions.

I hope that we have no ‘Mid Staffordshire’ in Wales. Our leaders’ current reaction is worryingly similar to the reaction of NHS management in the North of England, where a refusal to listen to constructive concern delayed essential change for many years, with tragic consequences for many families.”

The letter is signed by Dr Dewi Evans, former consultant paediatrician, Swansea Hospitals, who sent it to the Western Mail before he sent it to me.

Warning lights should flash when the governance of a hospital fails to function or to question quality and performance, and boards are in denial about poor standards, possibly because of political pressures. We have already had examples of this in Wales at Betsi Cadwaladr, and the Welsh Assembly’s Public Accounts Committee has called for a strengthening of performance and accountability procedures across all NHS organisations in Wales. That needs to happen urgently—our boards must raise their game.

Finally, perhaps the greatest step forward in England following the Francis report was the reform of the key regulator, the Care Quality Commission, and the appointment of Professor Sir Mike Richards to the newly established post of chief inspector of hospitals. Sadly, again in Wales, the regulatory system is a shambles. The evidence to the Assembly’s inquiry on Health Inspectorate Wales was shocking. It revealed that the inspectorate was under-resourced, under-skilled, and unable to carry out the annual inspections required, or to follow up its own recommendations. It was unable to hold boards to account. It is startling that its chief executive told the inquiry in November that she was unable to guarantee that there would not be another Mid Staffs in Wales.

I am concerned, too, about the delay in the publication of the report on the inquiry, which was promised in mid-February and should provide the building blocks for the reform of the NHS in Wales. I am sure that it is inconvenient to many for me to speak out in this way about my concerns, but what we all have to learn from the Francis report and indeed from the brave Julie Bailey of Cure the NHS is that we must not stay quiet, however difficult that might be, when we know that there is a risk to patients.