Francis Report

George Freeman Excerpts

Wednesday 5th March 2014 Commons Chamber

[Mr Hunt]

Yes, it is. I will come on to that, but we are making good progress with the pilots.

[George Freeman (Mid Norfolk) (Con)]

Does the Secretary of State agree that it is important to remember that part of what allowed the Francis report was the release of data on outcomes, and that such data transparency is crucial to understanding where best and worst practice exists, which may not otherwise be picked up?

[Mr Hunt]

My hon. Friend is, as ever, absolutely right on this issue, which he has spoken about a great deal. The use of data allows inspections to be meaningful in a way that has not been possible before. We have to ensure that the public are happy that protections are in place on how their data are used, but at the same time we must be bold in using those data, because that saves a lot of lives.

The inquiry condemned the way in which complaints were handled in Mid Staffs. Following the excellent work carried out by the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart, all hospitals will now have to demonstrate to inspectors that they treat complaints as more than just a process and are actively using them to learn and improve.

Doctors have responded to the new climate of transparency by agreeing to a world first: to make England the first country anywhere that publishes surgery outcomes by consultant for 10 major specialties. More specialties will follow.

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[Andy Burnham]

I, as part of the previous Government, left the lowest waiting times in the history of the NHS, and A and E was performing much better at the end of the previous Government than it is now. Hospital A and Es have dropped right down, so we do not need to take lessons from the hon. Gentleman.

Let us return to the issue of England and Wales. The mantra or script of Government Members is almost to deny that there are problems in England. Last week, 16 major A and Es in England were below the Welsh average on waits in A and E. Some trusts are seriously struggling, such as in Leicester, in the constituency of my hon. Friend the Member for Leicester West (Liz Kendall), and Great Western Hospitals NHS Trust and North West London Hospitals NHS Trust, where one in four patients were waiting more than four hours.

Another trust below the Welsh average was Barking, Havering and Redbridge, which includes Queen’s hospital, Romford. May I recommend to the Secretary of State that instead of sitting there mumbling away, he read an article on The Guardian website today by Saleyha Ahsan, an A and E consultant who has worked at Queen’s hospital, Romford? She writes:

“Being a doctor in accident and emergency has at times resembled being a medic in a war zone.”

May I remind him that this is the English NHS she is talking about—the one he is supposed to be responsible for? She goes on to say that the severe shortage of A and E doctors is a result of his predecessor’s failure to listen to the warnings from the College of Emergency Medicine about the looming recruitment crisis, because it was obsessed by its reorganisation. Dr Clifford Mann said he felt like

“John the Baptist crying in the wilderness”

because the Government’s reorganisation brought “decision-making paralysis” to the NHS. What does Dr Mann say now? He says that even after the reorganisation these issues cannot be dealt with, because

“there are now a lot of semi-detached organisations to deal with”.

Government Members do not like hearing it, but the fact is that the reorganisation by the right hon. Member for South Cambridgeshire (Mr Lansley) damaged front-line care in the NHS. May I remind the Secretary of State that just 12% of people think standards in the NHS have got better under the coalition, while 47% think they have got worse? Rather than pointing the finger at Wales, the Government need to spend a bit more time sorting out the problems they have created in England.

As my hon. Friend the Member for Easington (Grahame M. Morris) says, an urgent area that needs to be addressed is mental health. Some 1,700 mental health care beds have been cut over the past two years because these Ministers have allowed the first real-terms cut in mental health spending for a decade. As a result, alarming stories are emerging of very vulnerable children and adults being held in inappropriate accommodation, such as police cells. According to Mind, many trusts are reporting more than 100% bed occupancy. One trust in London has had to turn office space into temporary wards with camp beds.

We are also hearing of children being sent hundreds of miles to find an available bed. In a constituency case, my hon. Friend the Member for Leicester West found that there was simply no bed available in the public or private sector anywhere in England on a day when a very vulnerable child needed support. A recent freedom of information request by Community Care found that in 2013-14 10 trusts sent children to young people’s units more than 150 miles away. The furthest distance was 275 miles, from Sussex to Bury. A 12-year-old girl from Hull was sent 130 miles away to a unit in Stafford. Her child and adolescent mental health services team were searching for a bed for two days, and were told that the Stafford bed was the only one available in the country.

[George Freeman]

On a point of order, Madam Deputy Speaker. I came to have a debate on the Francis report. The shadow Secretary of State is not mentioning the Francis report; he is launching a criticism of the Government’s record since the report, which has nothing to do with it.

[Madam Deputy Speaker (Dawn Primarolo)]

Frankly, that is my business and I do not require any help to decide what is in order. The shadow Secretary of State is remaining in order, as the Secretary of State remained in order. I think it is best that we continue with the Front-Bench opening speeches to make sure that we can get in all the Back Benchers who wish to speak in this important debate.

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[Andy Burnham]

My hon. Friend has raised an important point. People are confused about the new NHS, and confused about who has responsibility for what. The Government have created more organisations, not fewer; the NHS is more top-down than it was before; and that is not changing the culture. Robert Francis himself has said that the culture is not changing. The Government are utterly complacent if they think that they have got everything sorted out.

[George Freeman]

Will the right hon. Gentleman give way?

[Andy Burnham]

Time is against us, I am afraid.

The Secretary of State is wrong if he thinks that top-down regulation is the only answer. It cannot prevent things from going wrong in the first place. The Secretary of State should accept all the recommendations of the Francis report, including the recommendations that are designed to change the culture at a local level.

Let me now turn to the future of Stafford hospital, and address the point made by the hon. Member for Stone (Mr Cash). If there was one thing that the people of Stafford deserved after what had been a long and painful process, it was the legitimate expectation that, at the end of that process, they would see a fully functioning local hospital that was both safe and sustainable. That is why I believe that the conclusion of the trust special administrator process is both wrong and unfair on them. It will result in a significant downgrade of the hospital, and there is still no clarity in regard to important services such as maternity.

The issue of the future of Stafford hospital goes to the heart of the handling of the inquiry and the decisions made about it. When I arrived at the Department of Health in June 2009, the official advice that I received was that I should not hold any further inquiry into what had gone wrong, because it would distract the hospital from the essential task of making immediate improvements. I could not accept that advice, because I believed that we needed to get to the full truth of what had gone wrong. That is why I appointed Robert Francis to conduct an independent inquiry. However, I stopped short of a full public inquiry because I had been warned that such an inquiry could destabilise the hospital and prevent it from making improvements. The Secretary of State nods.

That is the advice that I was given, but I told Robert Francis that he could come back to me and ask for powers to compel witnesses to appear before him if he felt that that was necessary. He came back to me to say that he felt that he had had all the co-operation that he needed. Indeed, he had had more, because of the nature of the inquiry that I had set up.

As the Secretary of State will recall, after the first Francis report I commissioned a second-stage inquiry into regulatory systems. I did not disagree with the coalition’s decision to upgrade it to a full public inquiry, as that was always a finely balanced judgment, but I did warn at the time that the hospital would need further support, given what a full public inquiry would entail. I do not believe that it has been given that support. Worse, the administration process that it has undergone has been brutal. I do not believe that there is a district general hospital in the land that could survive a three-year public inquiry followed by financial administration. The Labour party’s view—informed by the Lewisham and Stafford examples—is that the Government are misusing the administration powers created by the last Government to drive through reconfiguration on cost rather than clinical grounds, and we will therefore move to delete those powers from the Care Bill next week.

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[Jeremy Lefroy (Stafford) (Con)]

I was told by a senior member of the medical profession that the two Francis inquiries were the most important look at the NHS for at least two decades. He was right. The first, which was commissioned by the previous Government, revealed what Robert Francis describes as the

“appalling suffering of many patients”

primarily caused by a serious failure on behalf of the trust board, which did not listen sufficiently to patients or staff and failed to tackle an insidious negative culture involving a tolerance of poor standards. The second report, from the public inquiry commissioned by my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), described how

“a system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system.”

It is a tribute to those who fought long and hard against the odds to have the inquiries and reports instituted by the last two Governments that their importance is recognised.

[George Freeman]

Does my hon. Friend agree that one of the most shameful episodes highlighted by the Francis report is the consistent and persistent neglect of the whistleblowers in the service who tried to raise the issues that were being hidden, and the systemic neglect of their interests? Many of them are still suffering, and this is still going on in Wales today. Will he invite the shadow Secretary of State to acknowledge that the problem is ongoing?

[Jeremy Lefroy]

I agree. The treatment of whistleblowers has been a disgrace, not just at Mid Staffs but in many other places. I have seen consultant contracts from way back that have prevented their raising issues even with their Members of Parliament, and I am glad to say that sort of thing is coming to an end. I want to try to focus as much as possible on the Francis report, however, as I believe there are many important lessons that all of us, including me, have to learn.

As the Health Committee has said, as a consequence of the issues I have outlined,

“a healthcare system established for public benefit and funded from public funds risks the undermining of its guarantees of safety and quality.”

It is my sincere hope that we never have the need for another inquiry of this nature. This should mark a watershed in the NHS—a time when patient safety and high-quality compassionate care is the rule, delivered through a positive and caring culture, underpinned by safety and quality management systems through our health service and backed by openness and accountability, which I am sure many Members will speak about later. It is thus that we can respect the memory of those who suffered at Stafford, but also in many other places across the UK, as the work of the right hon. Member for Cynon Valley (Ann Clwyd) has shown.

The Francis reports, and particularly the accounts of patients’ experiences, should be required reading for all medical and nursing students. I ask the Secretary of State to confirm that he will pursue that with Health Education England.

Robert Francis, for whom I have the greatest respect for the calm and understanding way in which he conducted the inquiry, made 290 recommendations, but I shall concentrate on his essential aims. He writes of fostering a common culture of putting the patient first. It is sad that he must write that, but it is necessary. However, before we rush to find fault with a service which has lost its way, let us just consider the society in which it operates, starting with ourselves. Can we honestly say that we always put our constituents’ interests first? What about others in the professional and business worlds? When self-interest and personal fulfilment are so often lauded, why is it that we expect the NHS to be so very different? Saying that is neither to excuse nor to lower the bar, but to understand how difficult it is in some circumstances to maintain that highest of standards. Ensuring that patients come first when dealing with several very ill and distressed folk, perhaps at 2 o’clock in the morning, takes more than just compassion. I am not downplaying compassion in any way—it is essential—but the underpinning of quality and safety systems carried through as second nature is also required. It means ensuring that the leadership is on call to provide extra help as soon as it is needed. It demands the strength to speak out for what is not acceptable and an openness to admit when there are problems. Without the systems and standards, the supportive leadership, the strength and the openness, not even an angel can always put patients first, much as they would wish to.

There has been much debate about staffing levels, and rightly so. Although the problems at Stafford went far beyond numbers, there is no doubt that cuts contributed to them. When I was first selected as parliamentary candidate in 2006, the trust had a £10 million deficit. It wanted to achieve foundation trust status and needed to balance its books, and part of its solution was to reduce the number of nurses. I should have questioned that, as should others, but we accepted the trust’s assurances that it would not harm patient care. I say to all right hon. and hon. Members that one thing that must come out of this report is that each of us must be emboldened to challenge our local trusts when they make statements such as, “This won’t harm patient care”, despite their cutting 100 or more nurses. The approach to staffing management and data publication used at Salford Royal NHS Foundation Trust has been held up as an example of good practice in staffing by the Health Committee and the Secretary of State, so let us act and adopt it everywhere.

I recall that when I was first elected to this House, I was shocked at the tone and content of some of the responses by the NHS to complaints. Not only did they take several months to arrive, but they were sometimes complacent, and they certainly lacked compassion and understanding. That has, for the most part, changed considerably for the better—it certainly has in Stafford. The overwhelming message I receive from my constituents who need to complain is that they are not interested in compensation, but they are interested in a better NHS for everybody. So let us approach the complaints system from their premise, not that of lawyers. That is the responsibility of the chief executive, who should review all complaints, and personally read and sign all response letters. The Secretary of State responds to several complaints each week personally and in this, as in many other ways, he sets the example.

Although I am encouraged by the progress made in treating complaints, I am less confident about accountability.

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[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?