Accountability and Transparency in the NHS

Baroness Keeley Excerpts

Thursday 14th March 2013 Commons Chamber

[Rosie Cooper]

Yes, and if MPs have problems, God help members of the public and patients.

We had to demonstrate that we were really listening to patients. The medical and managerial staff had to take ownership and responsibility for complaints. They knew that at each board meeting they could be questioned and challenged. If we accept that there are large parts of the system that work well and focus our time and resources on areas that do not, we can raise standards and tackle deep-seated problems. As chair, I sought to build in assurance and be transparent about complaints; to solve them, not hide from them, and ensure that everyone was accountable right up through the management structure. I never believed in no blame; I believed in fair blame. Each time a problem was resolved properly, we became a better hospital. We were rightly proud that on the front page of the Liverpool Echo Liverpool Women’s hospital was called an NHS gem. Sadly, the main board’s complaints report stopped after I stepped down as chair.

We do not need to reinvent the wheel or have more reorganisation in the NHS, but we must make the complaints system work. From that important but simple action, culture changes happen and become embedded in the organisation. We then have real change, real transparency, real openness and real accountability—something we can all be proud of.

[Barbara Keeley (Worsley and Eccles South) (Lab)]

A complaints system sounds very useful. When staff knew that complaints were being assessed and reported on every month, what impact did it have on them?

[Rosie Cooper]

In essence, it encouraged a change of culture. They were not operating in a vacuum, where patients did not matter and where the complaint might not ever get resolved—where, if a manager said it was okay, it disappeared. The fact that the light was switched on and that people could ask questions was valued.

There is a huge disconnect between the rules and the enforcement of rules. When local resolution fails there must be another, proper avenue for patients to appeal that decision: just having the NHS investigate the NHS is not the way to improve the health service, or patients’ confidence in it. Currently, the message we send out is that unless people have the financial resources to fight the system in the courts it is easy for families and patients to be ignored.

Chief executives and boards know that the ombudsman investigates only a tiny proportion of the cases referred to it, and it is not as feared as it should be. I say to the Secretary of State that we need an ombudsman service that is properly resourced, has the necessary investigative powers and sanctions, and makes public in its reports its findings to everybody who pays for the NHS, not just to Ministers. Being able to name and shame in the spirit of openness and transparency will be a powerful tool, especially when, in these times of foundation trust hospitals competing to attract business, reputation is the key.

Given that all hospitals will eventually become foundation hospitals, is the Secretary of State willing to say that foundation hospitals will have to report all their statistics openly and that every board meeting should be a public meeting? There should be no hiding; there should be openness and transparency right across the NHS. The light needs to be switched on not just in individual rooms but in the NHS, full stop.

I have on the wall of my constituency office this quote from an editorial in the Liverpool Echo:

“Doing the right things does not automatically follow saying the right things”.

At present, everyone in the national health service is saying the right things. What assurance can the Secretary of State give us that the NHS will do the right things? Frankly, the public do not want any more politics from anybody. They do not want warm words or excuses; they want actions that will lead to real change. No more big reorganisations; we just need to make a difference. He must listen to the people’s complaints. Actually, in Mid Staffs the complaints could not have been any louder.

I said to the hon. Member for Bristol North West (Charlotte Leslie) earlier that we cannot keep on saying that it is somebody else’s fault, that somebody else should be held accountable and that somebody else is going to supervise. This goes to the core of the Department of Health. If we listen to the people and give the ombudsman—the right person for the job—the powers to deliver, we will see a culture change.

[Mr Stephen Dorrell (Charnwood) (Con)]

I want to follow the hon. Member for West Lancashire (Rosie Cooper) on to very similar territory. She and I both sit on the Health Select Committee, which I chair. I want to start where my right hon. Friend the Secretary of State and the right hon. Member for Leigh (Andy Burnham) started, with what happened in Mid Staffordshire. It was shameful, and we will be judged today by whether we show a serious willingness to learn and apply the lessons of the Francis inquiry.

Francis made 290 recommendations, but they amount to just one core recommendation, which is that there needs to be a fundamental culture change through the whole of the national health service. With respect to the shadow Secretary of State, that is the sense in which challenges are posed for the health service way beyond Staffordshire. We have to learn the lessons of Staffordshire and apply them beyond it, as well as demonstrating that we understand what we mean—in the modern jargon, we “get it”—when we talk about the need for a culture change.

My hon. Friend the Member for Bristol North West (Charlotte Leslie) encapsulated that when she used the words “accountability” and “transparency”. I will not follow her down the route that she took in her speech. I want to focus exclusively on what we mean by those two words. They seem to trip too easily off the tongue, without anyone understanding what they mean, and that must change if we are to sustain a culture change in the health service.

My first proposition is that accountability without transparency is entirely meaningless. The ability to see what is going on and how decisions are being made in the health service, and to see the effects of those decisions, is fundamental to the delivery of the objective of culture change. With respect to the right hon. Member for Leigh—and, indeed, to some of the points that my right hon. Friend the Secretary of State made—we have to acknowledge that a lack of transparency lies deep in the culture of the health service, and that it goes back to way before the previous Government were in office. It was present in my time as Secretary of State and well before that, too. I was regularly accused of supporting a gagging culture in the health service, although nothing could have been further from my intention. However, that charge was made against me, against the right hon. Members for Leigh and for Kingston upon Hull West and Hessle (Alan Johnson) and, in truth, against all our predecessors right back to 1948.

The instinct to protect, rather than the instinct to reveal, is deeply embedded in the health service. When something is said to be going wrong, there is an instinct for the wagons to gather round. That is why Francis’s recommendation for a duty of candour is key to the delivery of the objective of greater accountability and transparency.

[Barbara Keeley]

Was the right hon. Gentleman as disturbed as I was to hear that the £500,000 gag at the United Lincolnshire Hospitals NHS Trust was put in place without any sign-off whatever, on the basis that it had involved judicial mediation? The Secretary of State refused to answer my question about this. Does the right hon. Gentleman agree that the Secretary of State really has to stop that, because it involved a very large amount of money, which was used very ill-advisedly?

[Mr Dorrell]

The position I take is the one set out in the Francis report, which was explicitly endorsed by Sir David Nicholson in the Select Committee inquiry to which the hon. Lady has referred. I believe that it would also be endorsed by my right hon. Friend the Secretary of State, but he must speak for himself. That position is that it is hard to imagine circumstances in which the use of public money in the context of a compromise agreement should be governed by a confidentiality clause. In an age when a bill from Pizza Express has to be published on the internet, decision makers should be held publicly accountable for the use of large sums of money in the context of a compromise agreement.

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[Barbara Keeley (Worsley and Eccles South) (Lab)]

I was appalled to read in the Francis report on the Mid Staffs inquiry the stories of the unnecessary suffering of hundreds of people and, indeed, to hear the examples given by my right hon. Friend the Member for Cynon Valley (Ann Clwyd) in this debate. Those Mid Staffs patients were let down and there was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed and fundamental rights to dignity were not respected.

Our Health Committee has taken evidence from Robert Francis, who has said that there was a failure of the NHS system

“at every level to detect and take the action patients and the public were entitled to expect.”

He has summarised his own recommendations as: fundamental and easily understood standards; openness, transparency and candour; accountability to patients and the public; enhanced training for nurses and leaders; and ever-improving measures of performance.

In the short time available, I want to focus on two areas: first, accountability or, indeed, the lack of it in our NHS structures, and secondly—this has already been touched on—the question of what is good practice on patient safety.

The Health Committee is increasingly seeing examples of a gap in accountability in the restructured NHS and I will touch on one small example that we heard this week. We had a session with senior Department of Health staff—the director of mental health, the national clinical director of mental health and the deputy director of secure mental health services—who are responsible for advising Ministers on mental health strategy, for devising mental health legislation and for clinical leadership on mental health. They did not know that patient groups were reporting cuts to community mental health services or that they lacked access to therapeutic services, with very long waits.

[Alison McGovern (Wirral South) (Lab)]

Does my hon. Friend agree that scrutiny to make sure that the dignity of mental health patients is protected is of utmost importance?

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[Barbara Keeley]

Indeed. It is disturbing that the people responsible for advising Ministers on legislation are not aware of what is going on. In fact, they started by trying to tell me that they thought that community services were still expanding, as they had been up to 2010. They did not have a picture of the services. Indeed, they told us that there was no routine collection of waiting times for mental health services and they did not have data on readmissions. They did not even seem to understand the trends involved in those important issues.

The exchange left me feeling very concerned about accountability in our new NHS structures. If staff at the most senior levels of the Department of Health who are responsible for strategy and legislation have no idea what is going on in health services across the country, that is serious. The major restructuring of the NHS seems to us—this has been mentioned by fellow members of the Health Committee—to represent a decline in accountability.

We need to learn from good practice to improve patient safety, which has been touched on by my hon. Friends the Members for West Lancashire (Rosie Cooper) and for Walsall South (Valerie Vaz). A major review is taking place of the 14 hospitals with the worst mortality rates. In recent Health questions, I told the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) that good practice in hospitals with low mortality rates should be investigated alongside the review of high mortality rates and poor practice in the worst-performing 14 hospitals. He did not take that point on board, so I will try again today.

I want to talk about what has been achieved at my constituency’s local hospital trust, Salford Royal NHS Foundation Trust. I visited the hospital recently in the wake of the Francis report and was impressed to hear what it has achieved over the past five or six years. It already seemed to have in place many of Robert Francis’s recommended actions, which I touched on earlier. Salford Royal has taken action on nurse staffing ratios, which my right hon. Friend the Member for Leigh (Andy Burnham) touched on; reducing MRSA infection and pressure sores; the transparency of patient information; and involving clinical staff in quality improvement.

[Mr Jeremy Hunt]

I completely agree with the approach that the hon. Lady is taking. One of the jobs of the new chief inspector of hospitals will be to identify the outstanding hospitals, the safest hospitals and the hospitals with the best compassionate care, so that other hospitals can learn to do the same things.

[Barbara Keeley]

That is very good. I hope that the Secretary of State will make that point to the Under-Secretary of State for Health, the hon. Member for Central Suffolk and North Ipswich, because he did not seem to appreciate it when I made it to him in Health questions.

Let me touch on what other hospitals might find if they start looking at the excellent practices at Salford Royal. I do not underestimate the importance of the terrible examples that we have heard about, but at the same time, my trust has had a quality improvement strategy since 2008, with specific projects that are aimed at reducing falls, unexpected cardiac arrests, surgical site infections, sepsis and other harms. Because harm tends to be caused to patients much more over the weekend—we have seen many examples of that in the cases that we have looked at—the trust has moved back to seven-day working in an attempt to achieve the same standard of care on the weekend and overnight as people receive on a weekday during working hours.

I believe that having the right nurse staffing ratios is vital to patient safety, but that issue keeps being glossed over by NHS leaders and Ministers. I have asked questions about it repeatedly in this House. Salford Royal uses a safe staffing tool to ensure that it works to safe staffing levels. There are minimum staffing requirements throughout the hospital and incident reports are completed if the ratios are not met. Each division reviews its staffing establishment every day and escalates concerns if the numbers fall below the minimum safe level. Salford Royal is a mentor site for nurse rounding which, as we have heard, means that nurses go round their patients each hour to ensure that their needs are being met.

My right hon. Friend the Member for Cynon Valley gave examples that showed the impact of hospital-acquired infections. All the work that is done to reduce MRSA and other infections is crucial. As in the other examples of flattened hierarchies that we have heard about, anyone at Salford Royal can challenge others on issues related to infection control. There is also mandatory training in aseptic non-touch techniques.

Teams design their own quality improvement projects in a clinical quality academy. There has been a specific quality improvement project over the past two years that is aimed at reducing the number of pressure ulcers. Each pressure ulcer is declared, the root causes are analysed and the patients are involved in the investigations. Nurses can monitor the positioning of patients on their hourly rounds and help to turn them if required. Those examples of good patient care can help us to get over the kinds of awful care that have been described today.

My final point is about transparency. Patients and families can check the harm data, because they are shown on a whiteboard at the entrance to every ward. The board records not only how many days it is since the last MRSA infection or pressure ulcer, but provides assessment scores on 13 fundamental nursing standards. Such public reporting to patients and families is important because it aids accountability and helps staff to feel accountable for the standards on their ward. We need that now more than ever.

Unsurprisingly, Salford Royal has achieved the highest rating in the NHS staff satisfaction survey for acute trusts in the NHS. Staff are supported to challenge existing systems and test new ideas to improve standards. I am aware of how much of a contrast that is to what we have heard this afternoon. The NHS is a system in which one area has had a catastrophic failure at all levels of patient safety, while other areas have achieved the highest standards of safety and patient care. We must look at both if we want to understand why that is.

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[Mr Slaughter]

I am grateful for that. I did a company profile for Harmoni. It revealed that, although he might have sold his shares for that amount of money, Dr Goodman is still listed as head of clinical spine. A series of press articles deals with the failings of Harmoni—failures that have caused deaths through under-staffing or poor-quality staffing—and why it is under investigation.

Let me return in the time I have available to my attempts to get to the bottom of the matter. The same day as I read the article in The Guardian, I wrote a short letter to the chief executive of the NHS in north-west London. I said:

“I attach the front page article from today’s Guardian, which you may have seen, regarding the sale of out of hours GP service provider Harmoni to Care UK. The article states that a number of GPs will make substantial sums from the sale.

I note that four of the CCG chairs in NW London declare shareholding or directorship in Harmoni, as does your Medical Director. It would be helpful to know if they are beneficiaries of the sale and by what amount.”

I then asked for assurances as to the future.

A month later I received a non-reply reply, the most relevant sentence of which was:

“Any member who declares an interest in a meeting is expected to take no part in discussions and step out of the meeting.”

I wrote back a much longer reply, in which I pointed out that the chair of the Royal College of General Practitioners had said:

“it is not about excluding yourself from the room whenever there is a discussion; it is about how it will drive your decision-making overall”.

I pointed out that, as a consequence of hospital closures in north-west London, there had been a shift in funding from hospital to primary care, a greater involvement of private companies in the primary care sector, and an opportunity for those companies to increase their profits by cutting back on the level of service offered.

I principally raised the fact that the information that should be provided is not provided on declaration of interest forms, especially the scope and value of any interest. I listed doctor by doctor and CCG chair by CCG chair what those interests were and how they were not adequately declared. I dealt with seven out of the nine CCG chairs and the medical director. That was in a letter on 20 December.

I received a reply on 3 February which said:

“The Cluster does not hold this data.”

So three months on from my original inquiry, I am none the wiser in relation to these matters.

I advise any hon. Member to look at their CCG declarations of interest online—not Hillingdon, because it does not publish them online. I use Hammersmith and Fulham as an example here. The husband of one member is a partner of Drivers Jonas Deloitte. The first thing I found on the website of Drivers Jonas Deloitte was that it had been appointed to sell the Kent and Sussex hospital in Royal Tunbridge Wells when it closes in 2011. Another member is the owner of a provider of home care services. Another is the brother of the director of a design company that holds a number of contracts with NHS organisations. It might be that none of them has a direct financial pecuniary interest now or in the future, but it shows touching naivety, complacency or worse.

Before the 28 members of the joint PCT board made the decision to close the four A and Es in north-west London, I said at the public meeting that if any of them had or was likely to have interest of a pecuniary nature they should not take part in that decision. One of them rather touchingly volunteered the information that they had sold their shares. What world are we living in when a third of GPs on the new CCGs can hold financial interests in anything from land sales to an alternative provider?

I raised the question with the Prime Minister yesterday and mentioned Dr Goodman, although not by name, and his estimated minimum return of £2.6 million. Again, I got a non-reply in reply. Sooner or later the Government will have to address these matters.

There is another story in the Daily Mail today that states:

“In 1981 there were eight NHS press officers in Britain. Now there are 82 in London alone”.

It is not that there is a lack of spending on publicity in the NHS. Indeed, almost £1 million has been spent on a private consultancy firm simply to carry out the bogus and botched consultation on the closure of A and Es.

We are seeing the creation of a second-grade health service in north-west London.

[Barbara Keeley]

A number of months ago, I raised the case of a person who rejoices in the title “NHS head of brands”. There seem to be a whole set of units that keep cropping up.

[Mr Slaughter]

I am sure that all Members will have similar examples. It is an obscenity that millions of pounds are being spent on spin and disinformation while basic information is not being provided even to Members of Parliament after three months and persistent requests. Sooner or later, these issues will have to be addressed.

Of course, our main preoccupation is to maintain our first-rate health service—our blue light A and Es, our stroke centres and our major hospitals—rather than having it replaced by urgent care centres and minor primary care facilities. That is what we face in north-west London and, I am sure, around the rest of the country. It adds insult to injury if the individuals who are making the decisions to sell the land and to transfer services into the private sector are also the shareholders and owners or if they benefit in any other way. This is a corrupt act and it must be addressed by the Government. They cannot continue to turn a blind eye to it.