Accountability and Transparency in the NHS

Charlotte Leslie Excerpts

Thursday 14th March 2013 Commons Chamber

[Charlotte Leslie (Bristol North West) (Con)]

I beg to move,

That this House believes that in the wake of the Francis Report it is clear that accountability and transparency are of paramount importance to patient safety and trust in the NHS; and further believes that across the NHS individuals found to have breached those principles should face the appropriate consequences.

I would first like to thank the Backbench Business Committee for granting the debate; I realise that it did not have much time left to allocate in the Session and so am particularly grateful to its members for giving the House the opportunity to debate this timely and important issue. I would also like to thank all the Members who supported the motion, particularly my hon. Friends the Members for North East Cambridgeshire (Stephen Barclay), for Bracknell (Dr Lee), for Totnes (Dr Wollaston) and for Southport (John Pugh) and the hon. Member for Vauxhall (Kate Hoey). I must also thank all those who have contacted me, including the Patients First group. I am sorry if we are unable in the time available to do justice to all the information we have been given, but rest assured that this is the beginning of the scrutiny, not the end.

This debate is neither about playing party politics, nor about only the future of one man, David Nicholson; it is about transparency, and about a deadly cover-up in our NHS and how we can ensure that never happens again. As one concerned former nurse wrote to me:

“Please don’t let me read those meaningless words, Lessons Have Been Learned”.

It sometimes seems that politicians can dodge taking responsibility so long as they say quickly enough that “lessons have been learned”, but learning lessons is not the same as simply uttering a phrase. The truth must be revealed, and consequences faced, if accountability and transparency are to be anything more than just words.

Let me make it clear that refusing to play party politics is not the same as letting people evade responsibility and that statesmanship is not the same as letting people off the hook. We owe it to those outside this Chamber. We owe it first and foremost to those patients who were, in some instances, killed in our hospitals, and we owe it to their grieving families, for whom no amount of politicians saying that “lessons have been learned” can bring back their mum, dad, sister, brother, child or friend.

After patients and their families, we also owe it to those dedicated doctors and nurses who were struggling to raise the alarm against a system that systematically suppressed their concerns. Many of them retired early in protest at what they were being asked to do, and some of them tried whistleblowing and were met not with thanks from the authorities, but intimidation and gagging. We will hear about some of that later.

I must congratulate the Prime Minister and the Secretary of State for Health on their appointment of Don Berwick to ensure that the basic requirement of “Do no harm” is embedded in health care. Don Berwick, an adviser to President Obama, is an internationally renowned authority on health care. The Institute for Healthcare Improvement, which he co-founded and chaired for 21 years, is a world-leading centre of medical improvements based on proven success. I am delighted that the Prime Minister has put him right at the heart of improving our health care system.

The tragedy, however, is that Don Berwick’s wisdom and recommendations are not new; they have been delivered before. They were delivered to the previous Government in no uncertain terms back in 2008, when David Nicholson was chief executive of the NHS. Instead of implementing them urgently, the previous Government were uncomfortable with what they revealed about their NHS, so they decided to suppress those truths. They suppressed a report by Don Berwick and his institute along with two other damning reports by international experts—RAND and Joint Commission International—that contained burning recommendations to be implemented with all urgency.

[Alan Johnson (Kingston upon Hull West and Hessle) (Lab)]

If the hon. Lady turns to page 1,281 of volume 2 of the Francis report, she will see that, far from the reports being suppressed, every one of them was seen by Robert Francis. He states:

“As part of his work leading the working group, Sir Liam”—

Sir Liam Donaldson, the former chief medical officer—

“commissioned reports from three highly respected US-based organisations”.

Francis concludes that section by stating:

“Indeed it is clear that the NSR”—

the next stage review, the Darzi review—

“sought to address many of the concerns raised in these reports.”

[Charlotte Leslie]

rose—

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

Order. Before the hon. Lady responds—[Interruption.] I am sorry, but does the Opposition Whip have something to say?

[Mr Deputy Speaker]

Thank goodness for that.

We need short and concise interventions, because many Members wish to speak and I do not want to have to reduce the time limit further, but that is what will happen if we are not careful.

[Charlotte Leslie]

I congratulate the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson) on seeking to defend his Government’s record. I will address his point fully later in my speech.

Don Berwick’s report was commissioned by Ministers, led by Lord Darzi and with the support of David Nicholson, to celebrate the 60th anniversary of the NHS. It states:

“The NHS has developed a widespread culture more of fear and compliance… It’s not uncommon for managers and clinicians to hit the target and miss the point”.

It highlighted the inadequacy of quality-control mechanisms in the NHS, stating that the priorities that are emphasised by these assessments are

“seen as being motivated by political rather than health concerns”.

It also highlighted the anger felt by many conscientious medics at Government changes to their employment and at being pressurised to put targets ahead of patients:

“The GP and consultant contracts are de-professionalising... Far too many managers and policy leaders in the NHS are incompetent, unethical, or worse.”

The report warns that

“this… must be alleviated if improvement is to move forward more rapidly over the next five to ten years.”

But those warnings were ignored, and we know that the improvements never happened. The report’s conclusion on a decade of health care reform is that

“the sort of aim implied by Lord Darzi’s vision…is not likely to be realised by the 1998-2008 methods.”

Don Berwick’s report was not alone; let me reveal what the other two reports said. They referred to

“the pervasive culture of fear in the NHS and certain elements of the Department for Health”

and stated:

“The Department of Health’s current quality oversight mechanisms have certain significant flaws”.

Perhaps the most damning indictment of all is that the politicians are responsible:

“This culture appears to be embedded in and expanded upon by the new regulatory legislation now in the House of Commons.”

Instead of being acted on with urgency, this was all buried. We know of the existence of Don Berwick’s report and the other reports only because a medic was so concerned that Berwick’s warnings and solutions had been buried that he tipped off a think-tank, Policy Exchange, which had to use a freedom of information request to bring them to public light in 2010, two years later. They were not even available to the Health Committee.

Let us get one thing clear. The NHS is a huge, monolithic organisation with an exceptionally difficult and, some might say, almost impossible task. In reality, things will go wrong, sometimes very wrong. The crime is not so much that things were going wrong, bad as that is, but that instead of immediately focusing on tackling it, the priority was to cover up an awful truth that was uncomfortable for Ministers and chief executives. All too often, Dispatch Box appearance mattered more than the reality of patients’ lives, leaving whistleblowers and patient groups such as Julie Bailey’s, which was disgracefully dismissed by David Nicholson as a “lobby group”, screaming into a vacuum, often at great personal cost. The crime is the smothering of the truth which costs lives—the deadly silence.

What was the cost of suppressing Don Berwick’s urgent prescription for the NHS? The clinical director of NHS Scotland recently suggested that in following Don Berwick’s recommendations it has experienced an estimated 8,500 fewer deaths since January 2008. We may well ask what was the cost in lives for our NHS of the previous Government’s decision to bury the truth. Across the 14 trusts now being investigated as well as Mid Staffs, there were 2,800 excess deaths between the time that the reports by Don Berwick and others were presented to Ministers and their final revelation in 2010. If the previous Government had been urgently implementing Don Berwick’s recommendations for those five years, who knows how many of those lives might have been saved?

How was this allowed to happen? I have put in freedom of information requests asking what meetings took place to discuss the reports and who was present. Although David Nicholson was working closely with Lord Darzi on the next stage review, he said in front of the Health Committee that, incredibly, he

“knew nothing about the reports”.

That is the Select Committee, so we must take him at his word. The question that then remains is who did read and suppress these vital reports. Was it Ministers? Was it officials? If officials, how was this allowed to happen? If the Department of Health is to move away from a culture of cover-up, I expect a full and accurate response to my request to know who was responsible, and I ask the Secretary of State to assist me in that.

Former Labour Ministers will complacently say, as they already have, that these reports fed into Lord Darzi’s next stage review and informed the report, “High Quality Care For All”. I ask the House whether a document that starts with the then Secretary of State, the right hon. Member for Kingston upon Hull West and Hessle, beamingly saying

“On its 60th anniversary the NHS is in good health”

reflects the content of the reports that we have just heard about. It certainly does not. Indeed, while the Department of Health claims that it “drew heavily” on the three reports in putting together “High Quality Care For All”, a source close to the authorship of those reports said that they found that claim to be “disingenuous at best”. David Flory, the deputy chief executive of the NHS, later told the Francis inquiry that he at least had some responsibility for what happened to the reports, as he had read them, but insisted that they were “caricatures”. That would help to explain why they were not acted on, but it makes the Department of Health’s insistence that it “drew heavily on them” rather odd.

Further indication that the documents were not acted on is the fact that they raise issues almost identical to those highlighted five years later in the Francis report. If Don Berwick’s warnings had been acted on five years ago, there would be no need to ask him to come back now to step in to sort things out and implement his recommendations.

[Alan Johnson]

I wonder if the hon. Lady is coming to the point that Francis, a QC, in the course of a two-year public inquiry that produced two volumes, looked at all these documents and said that many of the issues within them had obviously been acted on. During a two-year review, Francis drew completely the opposite conclusions to those that the hon. Lady is drawing.

[Charlotte Leslie]

I find various elements of the Francis report rather strange, not least that the current chief executive, David Nicholson, is minuted as dismissing the activities of Julie Bailey as merely “lobbying” as opposed to expressing widespread concern about patients, and that this minute was dismissed in evidence, with David Nicholson saying that he could not recall ever having said something like that and thought that he could not possibly have done so. The fact that we are asking Don Berwick back five years after he initially gave his recommendations to Labour Members speaks far louder than a few sentences in the Francis inquiry with which people may beg to differ. However, I will not be distracted by the right hon. Gentleman but go back to my speech.

I will now reveal how crucial mortality data, which Harvard university says should have triggered an “aggressive investigation”, was ignored, and, when it became too prevalent to ignore, was, like so many whistleblowers, discredited. David Nicholson said in response to the Health Committee that he did not know that the Dr Foster mortality data existed until he became chief executive of the NHS in 2006. He also said he did not know there was a problem with the mortality rate at Mid Staffs until 2009. Again, that is the Select Committee, so we must take him at his word. It is odd, however, as we know that David Nicholson attended a presentation in Birmingham in 2004 at which the Dr Foster ethics team gave a presentation on the real-time monitoring tools that it was using to show mortality alerts and the hospital standardised mortality rates.

There are also records of Dr Foster telephoning chief executives of health authorities in 2005 to tell them about the mortality alerts. David Nicholson is named on that list of those getting calls, as chief executive of Birmingham and The Black Country strategic health authority. Between 2005 and 2009, there were 8,000 log- ons to the Dr Foster site from members of staff at West Midlands SHA. We even have a press release from Dr Foster from as early as 2005 congratulating Walsall hospital in, yes, West Midlands SHA, for its improvement in relation to this very same mortality data. The Dr Foster data were published in the “Good Hospital Guide” from 2000 onwards and in national newspapers from 2001 onwards. It is therefore incredible that that was not known about by someone such as David Nicholson, or indeed Ministers and others.

By May 2007, however, people were aware of the data. The then chief executive of West Midlands SHA, Cynthia Bower—Birmingham and West Midlands SHAs play a strangely prominent role in this story—received alerts that there were issues with high mortality rates in the health authority. But instead of taking urgent action to find out what was going wrong, she commissioned the university of, yes, Birmingham to write a report to discredit the data, at a cost of £120,000 to the taxpayer. Stunningly, the British Medical Journal—the journal of the union, the British Medical Association—is on record as allowing the author of the Birmingham report to publish his findings in the BMJ four months before official publication to coincide with the publication of the Healthcare Commission report, in order to discredit the data. A fact little publicised by Ministers and chief executives is that the Birmingham report was severely flawed. Harvard later did a study and found that the data were so watertight that on receiving the alerts,

“it would have been completely irresponsible not to aggressively investigate further.”

Yet again, the reaction to bad news was to bury it, or expensively discredit it, rather than act.

This went all the way to Government. I have seen an internal briefing for the right hon. Member for Exeter (Mr Bradshaw), then a Health Minister, in which officials brief him to stress that the mortality data were not known about until 2007. However, in that very same briefing it is revealed that they know this to be untrue, because they make specific reference to the data being published as far back as 2001 in the “Good Hospital Guide”.

This is only a drop in the ocean of a catalogue of attempts to cover up the awful truth. It is utterly wrong that no one should be held to account for such negligence in their duty to protect patients. The “Code of Conduct for NHS Managers” says that managers must

“make the care and safety of patients my first concern and act to protect them from risk”

and

“accept responsibility for my own work and the proper performance of the people I manage”.

If talk of accountability in this Chamber is to have any credibility at all, especially for those individuals who buried loved ones while Government, departmental and NHS individuals buried the truth, actions must have consequences. To scapegoat is not the same as ensuring that those responsible are held to fair account. Those who do not have a voice—the patients and their families—deserve accountability and more than just words.

Don Berwick is right. We must convert our anger over what has happened into action. That is what Julie Bailey did, without whom this debate and a push for a culture change in the NHS would probably not be happening. It is what my right hon. Friend the Secretary of State did this morning in banning gagging orders. Will he confirm whether that measure will be retrospective? I believe that this Government have secured a good base from which to put clinicians—not managers and politicians —at the heart of setting the priorities of our NHS.

[Rosie Cooper (West Lancashire) (Lab)]

Although I appreciate and endorse everything the hon. Lady has said about accountability and the managerial code of conduct, who does she think should enforce the code and ensure that it is being followed? Beyond the board and the chief executive, how will organisations be policed?

[Charlotte Leslie]

I believe that Francis is right: a regulatory organisation for managers is needed.

We must be brave. There must be a cultural clean-out and a new start, including a new head of the NHS Commissioning Board, who does not appoint a deputy who faces possible investigation for gagging whistleblowers —unless, of course, Dame Barbara Hakin deregisters from the General Medical Council beforehand—and who does not seem systematically to appoint those who had contact with West Midlands health authority or Birmingham, but has the trust and faith of doctors, nurses and patients, and epitomises this new era of transparency and accountability.

I believe that with Don Berwick’s help—albeit about five years later than it could have happened—we are now beginning to step in the right direction to ensure that never again can the NHS be too loved to be scrutinised or too holy to be questioned, and that this debate will go some way to breaking what has been, for more than a decade, a literally deadly silence.

--- Later in debate ---

[Dr Lee]

Despite that, nothing changed, did it? The CQC has a terrible reputation in my profession, and to have handed the matter over to it—when it was run by someone who was implicated at Mid Staffordshire—is not a defence.

Let me broaden the discussion to something that I may know something about: practising medicine in organisations run by the Department of Health. I can tell the House that the prevailing atmosphere is one in which attention is not drawn to problems. There is a fear for jobs down the line. Let me give an example. When I was a junior doctor, I misused a photocopying machine in a hospital. Within hours, I received a phone call from a middle-grade doctor telling me that if I did that again, it would affect my reference. The phone call, I was told, had been authorised by the then consultant general surgeon at St Mary’s, Ara Darzi. I reflected on that at the time. It made me feel rather intimidated. [Interruption.] The prevailing mood in hospitals was that seeing or doing something wrong could adversely affect a person’s future career.

[Charlotte Leslie]

Does my hon. Friend share my regret that Opposition Members are groaning in that way? What he is describing has been very evident for very many years. One need only speak to a doctor to learn that there is a culture of fear. Nearly every doctor knows someone who has tried to speak out against something that has happened. People know that if they do that, there will be counter-allegations against them. The groaning and expressions of surprise from Opposition Members are very sad, because it reveals just how little they were actually talking to clinicians on the ground who have been complaining about this for a decade. I received an e-mail from the spouse of a clinician who said that over the past 15 years the management styles encouraged by the previous Government had made that clinician ill.

[Dr Lee]

Of course my hon. Friend is right.

--- Later in debate ---

[Alan Johnson]

The Secretary of State is right. Of course there need to be safeguards to ensure any system has a backstop to stop people misusing targets. The guidance from the Department of Health was very clear. In no way must the pursuance of targets interfere with the need for good patient care. The Stafford chief executive must have translated that into saying it was fine to put receptionists on triage nursing. With all due respect to the Secretary of State, I do not think that he or any of his successors or predecessors can make regulations to meet every eventuality, including for someone like that chief executive of the Mid Staffs trust.

[Charlotte Leslie]

In some ways I agree with the right hon. Gentleman, in that I think targets and ensuring that things are happening is not the main cause of what went wrong. Does he agree, however, that targets along with what many medical professionals criticise as the de-professionalising of the work force through the consultant contract, the working time directive and the new deal was a toxic combination?

[Alan Johnson]

The principal point about targets is that they reduced waiting list times. They changed a situation in which people were dying while on waiting lists, which was a disgrace in a civilised country like ours.

The Francis report also gives no comfort to those who expected him to offer up Sir David Nicholson’s head on a plate. The irony is that they choose to make this attack on an NHS that is learning the lessons of Stafford and an individual, Sir David Nicholson, who has done more than anyone to make quality of care the organising principle of the NHS. I, like my three successors as Health Secretary, consider Sir David to be part of the solution, rather than part of the problem He is not perfect—none of us is—but he is a good public servant who is committed to the NHS, its patients and staff. If he knew what was going on at Stafford, or colluded in the awful events there, or if any of his edicts, policies or pronouncements were in any way responsible for what happened, I would agree with his detractors. No one knew what was going on at Stafford; not even the press, who pride themselves on fearlessly exposing wrongdoing. Not a single question was raised by local MPs in this House about what was happening at Stafford, and Francis has something to say about the way they passed on complaints.

--- Later in debate ---

[Charlotte Leslie (Bristol North West) (Con)]

This has been an excellent debate. I thank the Secretary of State, who has been here for the duration of the debate—as indeed has the shadow Secretary of State. I think there can be general agreement that there has been a catastrophic failure of leadership. That was well and forensically expressed by my hon. Friend the hon. Member for North East Cambridgeshire (Stephen Barclay). It is worth nothing that although there may have been instances—there certainly have been—of clinical failures, it is only possible to hold to account those managers who have a medical qualification registered with the General Medical Council.

We had a blast of reality from the moving and extraordinarily memorable speech by the right hon. Member for Cynon Valley (Ann Clwyd). I thank her, and the people who wrote to her, for sharing their tragic stories. We had powerful and thoughtful speeches from Members involved in the Mid Staffs tragedy, including my hon. Friends the Members for Cannock Chase (Mr Burley), for Stafford (Jeremy Lefroy) and for Stone (Mr Cash). The debate benefited from the experience of Members who have worked directly in the NHS, including my hon. Friends the Members for Totnes (Dr Wollaston) and for Bracknell (Dr Lee), and from the political experience of those such as the right hon. Member for Holborn and St Pancras (Frank Dobson). I thank everybody for their contributions.

This has been an important debate, in that it has finally provided a voice for many people who have been kept silent for so long. Another lesson that we can draw from it is that it is not systems but people who care in our health service. We can take away from the debate the many mechanisms of accountability and transparency that have been suggested, as well as suggestions of how we can nurture the professionalism and the best instincts of those who work in our NHS. Let that be a mission for all of us. We must also really ensure—perhaps in contrast to what has been done before—that patients are at the very heart of what the NHS is all about.

The debate has been enormously important, and I hope that it marks the beginning of a consensus and of a cross-party drive to ensure that the scandals and tragedies that we have seen throughout our health system never occur again. I also hope that this marks the forming of a platform for the many people out there who do not have the benefit of parliamentary privilege. It is our duty to ensure that their silence—in many cases, a deadly silence—is ended by this debate and that a new era of transparency and accountability, which should be seen in by a new set of personnel in our NHS, begins here.

Question put and agreed to.

Resolved,

That this House believes that in the wake of the Francis Report it is clear that accountability and transparency are of paramount importance to patient safety and trust in the NHS; and further believes that across the NHS individuals found to have breached those principles should face the appropriate consequences.