Managing Risk in the NHS

Jeremy Hunt Excerpts

Wednesday 17th July 2013 Commons Chamber

[Andy Burnham]

Thank you, Mr Deputy Speaker.

Alarming patients, demoralising staff and casually trading figures about deaths in the pursuit of political advantage is no way to run the NHS, and those are not the actions of a responsible Government. Today people are asking what kind of Government this is, if they are willing to cause further damage to fragile hospitals for their own self-serving political ends. Yesterday the Secretary of State told the BBC that he had no idea who had put the 13,000 figure in the public domain. Does he seriously expect us to believe that?

[The Secretary of State for Health (Mr Jeremy Hunt)]

Yes.

[Andy Burnham]

He seriously expects us to believe it? Why are we being told that those responsible were representatives of Conservative Central Office? [Interruption.] Yes, that is what is being said. The Secretary of State should go back and check his facts. If he does not have control of his advisers, it will not be the first time, will it? We have heard this before, have we not? “I do not know what the advisers are doing.”

The “my adviser is out of control” defence may have worked for the Secretary of State once, but it will not work for him twice. He must take responsibility for his own advisers, and for the advisers at Conservative headquarters. We were told explicitly that that is where the briefings came from, and the Secretary of State owes the House a full answer. He owes it to the House to put that on the record. [Interruption.] I will not put the name in the public domain, but I have a name. I will send it to the Secretary of State immediately after the debate, and he must come straight back to me, having asked that person whether or not he briefed the press. If the Secretary of State agrees to that, let us leave it there. I have a name, and I will put it to him straight after the debate. He must take responsibility.

--- Later in debate ---

[Andy Burnham]

I will acknowledge that. A moment ago, I mentioned the Francis report, which I commissioned, which revealed the dangerous cuts to front-line staffing that the hospital pursued as the primary cause. I accept what the hon. Gentleman has just said. Rather than always pursuing central regulation as the solution, if local communities had identifiable benchmarks that they could use to check up on their local hospitals, surely that would be progress we could all get behind.

On the duty of candour, the Government are legislating for a duty on organisations, but not on individuals. I think that we all agree that changing the culture of NHS organisations is essential if we are to move forward. The Francis recommendation is a necessary part of bringing about that culture change. Rather than being a threat to staff, as some have argued, it would protect them when they make known any concerns. Will the Government look at that again and legislate for the full Francis recommendation in the Care Bill? That is incredibly important in the light of yesterday’s report by Sir Bruce Keogh. He revealed—this will shock anyone who has not spotted it yet—that some trusts were telling members of staff what they could and could not say to his review. Surely we can all agree that is fundamentally unacceptable.

[Mr Jeremy Hunt]

indicated assent.

[Andy Burnham]

I am glad that the Secretary of State nods. Does that not make the case, however, for a duty of candour on individuals, which would have allowed staff to say to management, “No, I’m going to speak to the Keogh review and I won’t face action afterwards because it is my duty to do so”?

--- Later in debate ---

[The Secretary of State for Health (Mr Jeremy Hunt)]

I beg to move an amendment, to leave out from “House” to the end of the Question and add:

“welcomes the Government’s swift action in response to the Francis Report; notes the rapid establishment of reviews on key components of the Report’s findings, including the Cavendish review on healthcare assistants, the Clwyd-Hart review on complaints and the Berwick review on patient safety; further notes the drive to improve standards through the appointment of a Chief Inspector of Hospitals, the introduction of Ofsted-style ratings and the recruitment of specialist hospital inspectors; regrets the Opposition’s continued refusal to support these practical measures to expose and improve poor care; welcomes the watershed decision to expose and investigate 14 hospitals with high death rates through the recent Keogh review; further notes the Government’s decisive action to drive improvements in these hospitals by placing 11 hospitals in special measures; and applauds the Government’s wide-ranging efforts to introduce greater transparency and accountability in the NHS.”

I am honoured to see you, Mr Speaker, in your place for my speech. The right hon. Member for Leigh (Andy Burnham) talked about yesterday, and I for one hope that he has had a chance to reflect on Labour’s shockingly inappropriate behaviour. Let me give him one fact to think about: on a day when a review described appalling failings at 14 hospitals, my speech mentioned patients 19 times—his mentioned them just twice. Does that not say it all about Labour’s attitude to the NHS?

[Andy Burnham]

I listened carefully to what the Health Secretary just said about our speeches. Does he think it appropriate for a Secretary of State introducing a report on mortality rates in the NHS to begin, within seconds of getting to his feet, by making political attacks on the previous Government? On reflection, was that the right thing to do?

[Mr Hunt]

It is funny how the Labour party decided to make the NHS its main campaigning issue for the past three years, yet the moment people start to scrutinise its own record on the NHS it says the NHS is being used as a political football. What does that say about Labour’s approach to the NHS?

I want to consider the specifics of the motion before looking at the wider issue of risk. The motion mentions the Francis inquiry. One of this Government’s first acts on coming to power was to set up the full public inquiry into Mid Staffs that families had been denied by the right hon. Gentleman’s Government for too long. We are implementing it, and fast. That is why a new chief inspector of hospitals started work yesterday, just five months after the report was published. [Interruption.] The right hon. Gentleman says that a chief inspector of hospitals is not in the report, but how are we going to make sure that the report’s recommendations are implemented throughout all 266 NHS trusts? That will be done because we will have independent inspection of hospitals, which has not been done before because the situation was so undermined by the previous Government. That is how we are going to make sure that Francis actually happens.

We intend to implement the spirit of everything that Robert Francis proposed, even if the details may vary in places from his 290 recommendations. Francis himself endorsed that approach when that he said that the Government have indicated their

“determination to make positive changes to the culture of the NHS, in part by adopting some of my recommendations and in part through other initiatives.”

Francis talked about five themes, so let us look at the progress being made on them. First, on information and transparency, yesterday showed that this Government are determined to root out, once and for all, an NHS culture of solving problems behind closed doors. This is about not just the decision to hold a public inquiry into Mid Staffs, which the right hon. Member for Leigh and his colleagues rejected doing 81 times, but the Keogh review, which reported yesterday that 14 hospital trusts have excess mortality rates. This is the first time the NHS has ever conducted such a review. We have also published individual surgeon outcomes—the first country in the world to do so across an entire health system. The independent rating of hospitals will start this autumn, so for the first time people will know how good their local hospital is, just as they do for their local school.

Francis also mentioned standards. The new chief inspector of hospitals—a position that Labour still refuses to support—began work yesterday. In Professor Sir Mike Richards, we have a new whistleblower-in-chief whose sole job is to drive up standards and root out poor care. He will be supported by a team of expert inspectors, in stark contrast to the generalist inspection model set out by the right hon. Gentleman’s Government in 2009. That is plain common sense. We have put it right. The work of the inspectors will be informed by the independent review of hospital safety that is being conducted by Professor Don Berwick, who will advise on how to embed a culture of patient safety throughout the NHS. He will report back later this summer.

[Derek Twigg]

Yesterday, when I asked the Secretary of State whether mortality had fallen before 2010, his answer was:

“According to Professor Jarman…it has been falling slightly.”—[Official Report, 16 July 2013; Vol. 566, c. 944.]

The Keogh report states that it had fallen by 30% over 10 years. Figures from the House of Commons Library, which were sourced from the NHS, show that there has been a significant fall in deaths within 30 days of non-elective hospital procedures. Will he correct the record?

--- Later in debate ---

[Mr Hunt]

I am afraid that that intervention sums up where the spin is happening. The 14 hospitals were investigated by Professor Keogh because they had excess mortality rates. The Labour party thinks that that started in 2010, but it goes right back to 2005 in those hospitals and earlier than that in many of them. That is the ugly truth that Labour refuses to confront: 14 hospitals had high mortality rates for years and years, and Labour did nothing to sort it out.

The Francis report—

[Derek Twigg]

Will the Secretary of State give way?

[Mr Hunt]

I am going to make some progress. The Francis report also talked about leadership.

[Andy Burnham]

Will the Secretary of State give way?

[Mr Hunt]

I will give way in a moment.

The right hon. Member for Leigh talked about leadership. I want our NHS to attract the brightest and best leaders that this country has to offer. I have asked the NHS leadership academy to develop a new leadership programme to support clinicians to become clinical chief executives and to fast-track professionals from outside the NHS into leadership roles. We urgently need more talented managers in our NHS, and that will make a big difference.

[Andrew Percy]

I want to take my right hon. Friend back to the comments of the right hon. Member for Leigh, which I found shockingly complacent. I will give the example of Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, which is one of those that is in special measures. Our mortality rates started to go up in 2007 and started to fall in 2011, but our nursing numbers have been increasing over that whole period. I find it shockingly complacent for somebody to suggest that there is not an issue or to downplay those figures. In my area, that has potentially cost hundreds of lives.

[Mr Hunt]

My hon. Friend makes an important point.

I say to the shadow Secretary of State that it is a question not just of whether he responded to the warnings that he received, but of whether he received the warnings that he should have received in the first place because the inspection system might not have been up to scratch.

[Andy Burnham]

I mentioned a moment ago that when I saw the mortality data in late 2009, action was taken at Basildon and a review was ordered of all hospitals in England, so I did respond.

The Secretary of State needs to correct for the record something that he said a moment ago. He implied that the mortality ratio had not come down at the 14 hospitals. If I have got him wrong, he needs to be clear about it. Yesterday, a group of Back-Bench MPs was informed by Sir Bruce that mortality ratios at the 14 hospitals had fallen since 2005 by between 30% and 50%, but that they were still above the average for England. Overall, the mortality rate is down at all hospitals, but the 14 hospitals have rates that are above the average. Will he correct that point because it is incredibly important?

[Mr Hunt]

Let me help the right hon. Gentleman out. Those 14 hospitals were investigated by Professor Keogh because they had excess mortality rates that go right the way back to 2005. Labour cannot be in denial. Professor Brian Jarman said that under Labour, there was “total denial” in the Department of Health over the issue of excess mortality—

[Several hon. Members]

rose—

[Mr Speaker]

Order. We must try to preserve some sense of order and decorum in this debate. The Secretary of State can be expected to answer only one intervention at once. It is unseemly and arguably discourteous of other Members to jump up and try to interrupt the Secretary of State when he is dealing with the previous intervention. Let us deal with that first. Members must show some sensitivity to that.

[Mr Hunt]

Thank you, Mr Speaker. Let me make some progress.

On leadership, there has to be accountability for failed leadership through the introduction of a national barring list for unfit managers, similar to the one that we have for teachers.

[Chris Kelly (Dudley South) (Con)]

The Dudley Group NHS Foundation Trust is one of the 14 trusts that were reviewed by Sir Bruce Keogh. Will my right hon. Friend confirm what changes this Government have made to provide central accounting in the NHS for compensation payments that were inherited from the Labour party, under which there were no financial consequences for unacceptably poor performance and weak leadership, such as that experienced in my constituency?

[Mr Hunt]

This is the appalling fact: we have inherited from the previous Government a system of compensation payments with no significant financial penalty on trusts that have to pay out litigation claims. The focus on patient safety, the biggest discipline of all that any trust should have is to reduce patient safety incidents, should be the thought of having to pay compensation. That disincentive was removed. Absolutely, we will look at that.

[Grahame M. Morris (Easington) (Lab)]

Will the right hon. Gentleman give way?

[Mr Hunt]

I am going to make some progress and I will give way more later.

Francis also talked about compassionate care. We are going to follow the advice of Camilla Cavendish’s study on training for health care assistants, so we can be sure that no one is giving basic care to our NHS patients without proper training on how to treat people with dignity and respect. We have also proposed that, subject to pilots that are starting in September, every student who wants to receive NHS funding for their nursing degree will first work for up to a year as a health care assistant, so that before they open the textbooks they learn real care and compassion at the coal face.

[Mr Andrew Smith (Oxford East) (Lab)]

Will the right hon. Gentleman give way?

[Mr Hunt]

I am going to make some progress and then I will give way.

In addition, in September the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart will present their recommendations on how we can turn NHS complaints handling into an engine for improving compassionate care.

The right hon. Member for Leigh mentioned nursing numbers. Getting the right number of staff on wards does matter, and where that is not happening for hospitals in special measures it will be sorted out. However, to suggest that that is the only issue, or indeed the main issue, is completely to misunderstand what has gone wrong. Eight of the 11 failing hospitals had increases in nurse numbers since 2010, but they still needed to go into special measures. Training, values, clinical safety and, above all, leadership are often as important.

Labour has been calling for mandatory minimum staffing numbers. Let us look at what the experts say about that idea. Robert Francis said:

“To lay down in a regulation, ‘Thou shalt have N number of nurses per patient’ is not the answer. The answer is, ‘How many patients do I need today in this ward to treat these patients?’”

He also said:

“The government was criticised for not implementing one, which it is said I recommended, which I didn’t.”

[Mrs Cheryl Gillan (Chesham and Amersham) (Con)]

I am grateful to my right hon. Friend for giving way, because he knows that Buckinghamshire Healthcare NHS Trust was included in the statement yesterday. The trust welcomes his leadership and the opportunity to improve its performance, so that it can give the best possible care to patients in Buckinghamshire. Does my right hon. Friend agree that training goes to the heart of quality, particularly of agency staff? Would he like to say something about the competence, quality and checks that are made on agency staff, which will help to improve the health service across the country?

[Mr Hunt]

My right hon. Friend makes an important point. There are many locums who work extremely hard and are very committed. However, it is true that one feature of a number of the failing hospitals in yesterday’s report was that they had a high proportion of locum staff. It is harder to build up a sense of teamwork if there is a huge turnover in the people working in NHS organisations, and I know that many will reflect on that.

[Liz Kendall (Leicester West) (Lab)]

Will the right hon. Gentleman give way?

[John Pugh (Southport) (LD)]

Will the right hon. Gentleman give way?

[Mr Hunt]

I will make some progress and then give way, because I want to come on to one of the main things that the right hon. Member for Leigh said, which was to criticise an NHS reorganisation that has put 8,000 more people on the frontline of the NHS.

The right hon. Gentleman said that that reorganisation cost £3 billion, when he knows full well that the National Audit Office shows that it will be half that amount. It will save £5.5 billion in this Parliament alone. For the avoidance doubt, it is that £5.5 billion saving that means we are now employing 1,000 more health visitors, 1,400 more midwives and 5,600 more doctors than at the previous election.

The right hon. Gentleman talked about the risk register. Let us look at what he said about publishing the risk register when he was Health Minister in 2007. These are his own words:

“Putting the risk register in the public domain would be likely to reduce the detail and utility of its contents. This would inhibit the free and frank exchange of views about significant risks and their management, and inhibit the provision of advice to Ministers.”—[Official Report, 23 March 2007; Vol. 458, c. 1192W.]

I agree with him.

The right hon. Gentleman is right that pressures on A and E are building, so why does he oppose changing the GP contract to make primary care more accessible? Why does he criticise the extra £2 billion being put into joint commissioning by health and social care systems to reduce the number of delayed discharges? Why does he tell the NHS Confederation he supports the reconfiguration of services and then refuse to support every difficult reconfiguration, such as at Trafford or Lewisham?

[Dame Joan Ruddock (Lewisham, Deptford) (Lab)]

Is the Secretary of State aware that in the league table of the busiest A and Es in London, St Thomas’s, Queen Elizabeth and King’s occupy the second, fourth and sixth places? Does he really think there is no risk in moving tens of thousands of patients from Lewisham A and E to those three utterly overburdened and full-to-capacity hospitals?

[Mr Hunt]

I take the risks the right hon. Lady talks about very seriously, and we need to be very careful in managing any change, but there are also big risks in not making change. South London Health Care Trust is one of the worst-performing in the country, and it was used by her constituents. I have a duty to sort out these problems in the NHS, which have been left unsorted for many years.

The right hon. Member for Leigh said we should look at our record since 2010. Let us look at that record: the numbers of people waiting longer than 18 weeks, 26 weeks and 52 weeks to start treatment are lower than at any time under the last Government; as I said, we have 5,600 more doctors; and we have a £650 million cancer drugs fund, giving more than 30,000 people access to cancer drugs—his Government refused to set up such a fund; the number of mixed-sex wards is down by 98%; and hospital infection rates have halved. These are real achievements for a service under great pressure, and we should recognise the hard work and dedication of the NHS staff who have delivered them.

[Mr Graham Stuart]

My right hon. Friend will have heard me earlier referring to the work of Professor Sheena Asthana and will know of my concerns about the allocations underpinning some of the risks in the NHS. Will he agree to meet Professor Sheena Asthana and me, perhaps over the summer recess, to discuss the matter further?

[Mr Hunt]

I would be delighted to do so. I have studied her work and am an admirer of it, so I would be more than happy to meet my hon. Friend to discuss further the issues he wants to raise.

I want to turn to the substance of the motion, which is about risk for the NHS. Two big risks face the NHS. They face not only the NHS, but all major health care systems. The first is financial sustainability and the second is an ageing population. The litmus test for the success of the NHS in the next 65 years will be whether it confronts those huge challenges while looking after people with dignity, compassion and respect. I believe that there are three pillars on which we must build to make that possible. The first is a radical transformation of out-of-hospital care. We know that a consultant is responsible for us when we are inside hospital, but who is responsible for a vulnerable older person when they leave hospital? Too often, their care falls between the cracks, with no one being accountable. The NHS could lead the world in this, but we have made it impossible for GPs to look after people proactively because of how the GP contract works. We need to change that, so that in an integrated, joined-up system of care, there is always an accountable clinician or named GP and the patient knows who it is. In the consultation on the changes to the NHS mandate for next year, therefore, I have asked NHS England to ensure a named clinician responsible for every vulnerable older person.

The second of the three pillars we need to reduce risk in the NHS is technology. The technology revolution has transformed many other sectors, but has barely touched the NHS. A and E departments cannot access GP notes and so give medicine without knowing people’s medication history. Ambulances pick up the frail elderly without knowing whether they are diabetic or have dementia. This has to change. Technology can also cut costs. Retail banks have reduced their costs by a third, and we need those precious savings for the NHS, which is why I have said I want the NHS to go paperless by 2018 at the latest, with online prescriptions and booking of GP appointments by 2015. Technology is also a vital key to delivering integrated care, which is why data sharing will be a key condition of accessing the £3.8 billion joint health and social care fund announced by the Chancellor in the spending review.

The final pillar to help the NHS cope with new risks is science. It might surprise hon. Members that I mention that today, but the UK has a long track record as a world leader in medical science. We were the first to unlock the secrets of DNA in 1953; we did the first combined heart, liver and lung transplant; we invented in vitro fertilisation, alongside many other advances, and we must play to those strengths. Science can transform our understanding of disease, and help us deliver truly personalised care. Our aim is by 2015 to put the UK at the forefront of the genome revolution worldwide, and I have set up Genomics England, led by Sir John Chisholm, to deliver that vision.

In conclusion, the NHS faces many risks, but it also delivers many successes day in, day out. No organisation anywhere in the world has more staff dedicated to the noblest ambition anyone can have—to be there for us and our loved ones at our most vulnerable.

[Mr Andrew Smith]

rose—

[Mr Hunt]

I am concluding now. We owe it to those people to tackle head-on the risks the NHS faces alongside health care systems in every other country. We do so with confidence and optimism that by confronting failure, nurturing excellence, and supporting the brilliant work of people on the front line, we will be able to deliver an NHS that remains the envy of the world.

[Several hon. Members]

rose—