North Middlesex University Hospital NHS Trust

Joan Ryan Excerpts

Tuesday 12th July 2016 Westminster Hall

[Joan Ryan (Enfield North) (Lab)]

I beg to move,

That this House has considered the performance of North Middlesex University Hospital NHS Trust.

It is a pleasure to serve under your chairmanship, Ms Vaz. North Middlesex University Hospital NHS Trust serves two thirds of my constituency and more than 350,000 people living in Enfield, Haringey and the surrounding areas. I am grateful for the opportunity to bring this important matter before the House.

The situation at the hospital is, frankly, a scandal. It operates the busiest emergency department in London, which is attended by more than 500 people a day, yet the Care Quality Commission has rated safety at the emergency department as inadequate. Medical care, including older people’s care, at the hospital also requires extensive and immediate improvement. The senior leadership team at the trust and the Government have serious questions to answer about how patient safety at North Mid has been allowed to have been put at grave risk.

What has been happening at the hospital has major implications for my constituents, for residents in north London and for health services across the capital and beyond. My speech will consider all those issues and the steps that need to be taken to ensure the safety of patients and the quality of care. I will call on the Government to give assurances that services at the hospital, including those provided by the accident and emergency department, will be protected and improved in the short and long term.

Before I get to the heart of the matter, I should make two important points. First, the many concerns and criticisms that I will raise about what has happened at the hospital are not directed at the front-line staff—the doctors, nurses and trainees who work there. They are overworked and under-resourced, and have been doing a challenging job in incredibly difficult circumstances. The CQC has made it clear that:

“Most staff were competent and endeavoured to provide good care and outcomes for patients.”

However, just like the patients, the front-line staff have been badly let down by poor management and a lack of leadership at the hospital, and by the Government’s health policies over the past six years, which have left the national health service on its knees.

My second point is one that I believe is shared by all London MPs whose constituents have been affected by the performance of the hospital. Although all of us have raised concerns about how North Mid has been operating, we were not made aware of the true extent of the crisis at the hospital until the CQC issued a warning notice at the beginning of June, requiring the trust significantly to improve the treatment of patients attending the A&E. That was almost two full months after its unannounced inspection of the hospital in April.

Many recent revelations about the chaos at North Mid have been exposed only because of the press via leaked documents, yet it appears that the terrible situation has been an open secret in health circles for a significant period of time.

[Mr David Lammy (Tottenham) (Lab)]

I hesitate to interrupt my right hon. Friend, who is laying out the story so comprehensively. Is she as concerned as I am that many health professionals knew what was going on, but that MPs in the three boroughs covered by the trust were kept in the dark?

[Joan Ryan]

That was exactly the case and I am very concerned. It is not an exaggeration to say we were kept in the dark. All of us across Enfield and Haringey have, over the past year, raised the issue of North Mid in the Chamber at a local level and with Ministers at various times. We received no information until a recent meeting with the Minister, who, I am pleased to say, is here today. Prior to that, there was almost no answer to the points that we raised, other than to brush them aside with answers such as how much better the NHS is doing now than ever before. The phrase “kept in the dark” absolutely covers the situation, with those in the know including the likes of NHS Improvement, NHS England, the General Medical Council, Health Education England and, no doubt, the Department of Health. However, but for the actions of the General Medical Council and Health Education England, the situation for patient safety could be even worse.

I have had a number of meetings with the senior leadership teams at North Mid and at the Enfield clinical commissioning group, and many of the problems I will discuss today were not thought noteworthy enough to bring to my attention. If they were brought to my attention, the exposure of those problems was minimal, such that they did not raise the alarm bells that they should have.

In May, the severity of the situation at the hospital was discussed at a high-risk summit, involving several north London hospital trusts, clinicians and other stakeholders. MPs were not even informed that the summit was happening, never mind informed of the outcomes. I would be interested to know whether the Minister thinks that that state of affairs is acceptable given that our constituents have to suffer the consequences of the failures at the hospital. Even as of today, despite numerous requests, we have received no minutes of the high-risk summit and no account of what was discussed in any detail whatever.

Would the Government be willing to bring in early warning measures to ensure that MPs and constituents are kept properly informed about impending healthcare crises in their communities, rather than being notified after the crisis has hit? To do our job on behalf of our constituents—to safeguard their safety and interests in the use of and access to one of the most important public services any of us can imagine—we need some kind of early warning system. It is clear that very many people knew about the situation, but nobody who is accountable to the public at a local level was properly informed. I look forward to the Minister’s response to that point.

I am pleased to see my hon. Friend the Member for Edmonton (Kate Osamor) in her place, as the hospital is just inside her constituency, although it serves a large number of my constituents and constituents from Hornsey and Wood Green. I think it also serves practically the whole of Tottenham—my right hon. Friend the Member for Tottenham (Mr Lammy) is in his place, as is the hon. Member for Enfield, Southgate (Mr Burrowes). I am pleased to say that we have been working cross-party on the issue. Frankly, I will work with anyone—other hon. Members involved would do the same—who is willing to put the hospital first.

The CQC’s damning report into North Mid was published on Wednesday 6 July, and its inspection of the emergency department and two medical wards at the hospital was in response to a

“number of serious incidents…which had raised concerns about the standards of care”.

Between March 2015 and March 2016, there were 22 cases at North Mid’s A&E department where patients experienced serious or permanent harm or alleged abuse, or where a service provision was threatened. The CQC found that people were waiting far too long to be assessed on first arriving at the hospital, to see a doctor and to be moved to specialist wards in the hospital. The main experience of anybody turning up at the hospital’s emergency department was to wait, wait and then wait again.

The report tells of a lack of respect and dignity in how patients were treated, including a time when there was only

“one commode available in the whole of the ED”—

emergency department—

“to serve over 100 patients.”

Most people reading this will find that shocking.

Resources had been so stretched that, by the time the CQC issued its warning notice to the hospital in June, only seven of 15 emergency department consultants were in post, and seven of 13 middle-grade emergency doctors. As a consequence, junior doctors and medical trainees have been left unsupported by senior staff in A&E at night, including in emergency paediatric care. Junior doctors have been asked to perform tasks for which they are not yet qualified, and there have even been reports of receptionists with no medical training being used to triage patients, at least to the extent of deciding whether they should go to urgent care or the emergency department.

In February, A&E staff were so overwhelmed that patients, many of whom had already been waiting for hours, were told that they should go home unless they thought their illness was life-threatening. How can anyone be expected to know how ill they are without seeing a doctor? We have self-service checkouts in our supermarkets, but self-service A&E? I think not.

[Tulip Siddiq (Hampstead and Kilburn) (Lab)]

I thank my right hon. Friend for securing the debate. Even though the hospital is not in my constituency, much of what she describes happens in hospitals in my constituency and just outside it. At Central Middlesex hospital, which is just outside my constituency but serves many of my constituents, healthcare provision has also been affected by cuts. A recent inspection by the CQC similar to the one that she is describing highlighted a lack of experienced medics for seriously ill patients. Does she agree that such staff shortages threaten patient safety?

[Joan Ryan]

I do indeed, and I am grateful to my hon. Friend for that intervention. One point that I argue most strongly is that, although the MPs concerned are banding together to defend our hospital and fight for adequate and safe service, it is obvious that this is not just about North Mid—North Mid is just the first point where the crisis has hit. This is an issue around outer London, across London and probably nationally, particularly for district general hospitals.

[Andy Slaughter (Hammersmith) (Lab)]

I am delighted that my right hon. Friend has secured this debate, which resonates across London and probably outside it. We recognise the point about waiting, especially in ambulances outside hospitals. People are waiting for up to four hours and then being admitted just before the four-hour mark, so that it is not registered against the time limit, and then waiting again. That is happening even before the planned closures of accident and emergency departments. As one clinician said to me just today, there is no credible clinical evidence that out-of-hospital services can deliver on the scale necessary, but that is all we are being offered as an alternative.

[Joan Ryan]

I agree with my hon. Friend. Again, that demonstrates that this is not just about North Mid; it is just that North Mid has reached the crisis point before anywhere else.

The CQC has also raised concerns about the lack of equipment within the department, from missing monitors and missing leads for cardiac machines to trolleys in resuscitation rooms that are not fully equipped. I cannot imagine the distress of a patient with chest pains who is connected to a cardiac machine to monitor their progress, only to find that the staff member cannot connect it up to get an instant read-out because the leads are not there. Even a chute meant to carry specimens from the emergency department to the pathology unit was out of operation for six whole weeks. According to the CQC,

“this caused major delays to the speed in which results were returned to the department, thus slowing down the time in which some patients could be treated.”

That is unacceptable.

All those problems have been exacerbated by a lack of effective clinical leadership and a culture of bullying at the hospital, meaning that staff do not feel confident in raising concerns and have even

“stopped reporting incidents of staff shortage as management had not responded to them in the past”.

A quality visit report by Health Education England from March 2016 found that none of the medical trainees interviewed would recommend the emergency department to their family and friends for treatment, principally because they felt that the department was unsafe. The postgraduate trainee junior doctors at the hospital would not themselves recommend the hospital or the emergency department to their family and friends—what an indictment.

The General Medical Council, which oversees the standard of training for doctors, has threatened to ban North Mid from providing postgraduate training because standards have been so poor. The loss of junior doctors would leave the A&E so badly understaffed that it would effectively close. The future of North Mid’s emergency department is at risk.

I note that the chief inspector of hospitals—Professor Sir Mike Richards, whom a number of us are due to meet tomorrow—has said that since the CQC’s inspection in April, “some progress” has been made to improve the situation, although there is

“still much more that needs to be done.”

A new clinical leadership team has been put in place, and there have been moves to appoint more senior doctors. However, in almost every instance, the new appointments are short-term, with the doctors taken on loan from other hard-pressed local hospitals for up to six months. The situation is safe at the moment, given the number of doctors in the A&E, but the measures are only a sticking plaster, as many of the doctors are on a three to six-month loan. What measures are the Government willing to put in place to support North Mid and ensure that it has the consultants and doctors it requires on a permanent, long-term basis?

The CQC also states that North Middlesex University Hospital NHS Trust

“has supplied an action plan setting out the steps it will take to address the concerns identified in the Warning Notice and report.”

Does the Minister agree that the action plan should be published in full and updated regularly with the measures taken to improve patient safety at the hospital?

Tellingly, the CQC says that previous serious incident investigations and subsequent action plans at the hospital have not always been shared with staff in a timely manner, which has

“meant that in certain circumstances, reports were received when actions should already have been taken in order to mitigate against a future occurrence.”

Given the analysis of how things have been kept in the dark, which we have explored, and that statement from the CQC, the Minister will understand why I ask for a fully published action plan and regular reports on progress. This is about implementation and outcomes.

Surely the Minister will understand that without full transparency, many of my constituents and those of my colleagues who are here today will have little confidence that the required improvements have been made and are being sustained. As I said earlier, the trust’s shocking mismanagement and poor leadership have played a big part in creating the mess at North Mid, but the chief executive, who I understand is stepping down, is not solely responsible for what has happened. The Government cannot be let off the hook when they have done so much to undermine healthcare provision in Enfield.

The tipping point for the crisis at North Mid was the closure of the A& E department at Chase Farm hospital in my constituency. In 2007, the then Leader of the Opposition—the current Prime Minister, for now—posed outside Chase Farm hospital and promised to protect the emergency department on site. By 2013, his Conservative-led Government had ripped the heart out of the hospital, closing both the A&E unit and the maternity services. It went from a 480-bed hospital to one with 48 surgical beds. Those of us who campaigned against the closure at the time said that the decision would put huge pressure on North Middlesex hospital, Barnet hospital, our ambulance services and GP surgeries right across Enfield. We were right.

[Andy Slaughter]

My right hon. Friend describes exactly our experience in west London, where two A&E departments have closed and two more are intended to close, despite assurances having been given that they would not. We have heard nothing at all since February 2013 about what those plans will be. I was told just this week that the next report is not going to be in September, so until another report is done we will not know exactly what services there will be. People are waiting in limbo for years, and meanwhile there is a drain of staff and expertise from hospitals, so their closure becomes a self-fulfilling prophecy.

[Joan Ryan]

And that is exactly what happened at Chase Farm hospital. It was under threat for so long that it had no stability and it was no longer an attractive place for staff because they had no security. I hope I am wrong, but my fear is that in cases such as my hon. Friend outlines, no news is definitely not good news.

One year after the closure of Chase Farm’s A&E department, the CQC reported that services at North Mid were struggling with the additional workload. We know now that the hospital has had to manage an increase in A&E patients of between 20% and 25% as a result. That is unmanageable and unsustainable for an A&E department; many would bend, if not break, if put under such strain. The situation was so bad that by February 2016 only 67% of patients were seen and treated within the national four-hour target at North Mid, compared with an average of 88% across England.

Our local health services and the emergency department at North Mid would have been better placed to cope with the closure of Chase Farm’s A&E department if other promises to improve primary care had been fulfilled. In November 2013, the Prime Minister stood at the Dispatch Box and said:

“Enfield is…getting an increase in primary care funding. That is part of our plan of not cutting but expanding our NHS.”—[Official Report, 20 November 2013; Vol. 570, c. 1226.]

But many people in Enfield find it really hard to get a doctor’s appointment when they need one. Over the last six years, 12 doctors’ surgeries in Enfield have closed and only one new practice has opened. That is why, even though Enfield is now the fourth-biggest borough in London, we have fewer GPs per head than almost anywhere in the capital. That situation is not sustainable.

Will the Minister join me in calling for a proper plan for at least 84 more GPs in Enfield over the next four years, as recommended by the Royal College of General Practitioners? Will he support my calls to improve health funding across the board in Enfield? As he will know, Barnet, Enfield and Haringey Mental Health Trust anticipates a £13 million deficit by 2016-17; Enfield Council needs to deliver a saving of £24 million in adult social care by 2020 because of reductions in funding from central Government; and per capita spending on public health in Enfield is only £43 this year, far lower than the average across London and in England. Given that cutting preventive services piles pressure on hospitals, does he seriously believe that allowing the current situation to continue will take the strain off North Mid—or will it in fact do the exact opposite?

It should come as no surprise that I and many of my constituents have very little faith that the NHS is safe in the Government’s hands. The financial crisis in the NHS is a major reason why North Mid did not have enough equipment, consultants, doctors and nurses to cope with demand. The inability to recruit permanent staff has meant that many hospitals, including North Mid, have been forced to drain their resources on expensive agency workers and locums. One might have thought that, in the light of such circumstances, the Government would be bending over backwards to encourage people to join the medical profession—but no. Instead we are witnessing the sorry situation of a Government fighting with junior doctors over contracts and removing bursaries for nurses. What a slap in the face for the future front-line staff we so desperately need.

The Government also plan to make £22 billion of efficiency savings by 2020. I know that savings must be found, particularly in back-office services, but efficiencies on such a scale simply cannot be achieved without putting patient care at risk. I am also concerned that the Government’s methods to implement those cuts—described using woolly phrases like “the rationalisation of clinical facilities”, “the consolidation of trusts” or “the introduction of transformation and sustainability plans”—will result in takeovers, mergers and the downgrading of services. Even before the crisis at North Mid was revealed, plans were already afoot to launch an NHS pilot programme, involving the Royal Free London NHS Trust, to look at options to link hospitals including North Mid together and to merge clinical and support services. At the same time that it was announced that the chief executive of North Mid was going on leave, we learned that an acting chief executive was being appointed from the trust and that David Sloman, the trust’s chief executive—a very good chief executive, I might add—would be taking on the role of accountable officer on an interim basis. I fear for the future of service provision at North Mid as a consequence.

Local residents remember to their cost that the A&E and maternity units at Chase Farm were shut only a few months before the Royal Free London NHS Trust took over Barnet and Chase Farm hospitals in 2014. Chase Farm has been left as little more than a cottage hospital. North Mid cannot suffer the same fate; that would have terrible consequences for health services across North London. Think how much further people in Enfield would have to travel to get emergency hospital treatment, and how much pressure it would put on A&E departments at hospitals such as University College hospital in Euston, Barnet hospital and the Royal Free hospital in Hampstead.

What assurances will the Minister give my constituents, first that North Middlesex hospital will not be taken over by the Royal Free London NHS Trust by stealth, using this crisis as the back door to a merger; secondly, that constituents will be consulted fully on all future proposals for North Mid; and thirdly and most importantly, that its key services will be protected and improved in the short and long term? The performance of North Middlesex University Hospital NHS Trust must be a wake-up call for the Government. I urge the Minister to use every tool at his disposal to help North Mid make the immediate improvements required in the quality of care provided to patients. The Government must ensure that the hospital and our health services have the funding and support they need so that this situation never happens again. I look forward to the Minister’s response.

--- Later in debate ---

[Mr David Lammy (Tottenham) (Lab)]

I am grateful to have the opportunity to speak in this debate. The hospital serves almost the entirety of the constituency of Tottenham and has done ever since the closure of the Prince of Wales hospital in my constituency in the 1980s. It is important to emphasise that North Middlesex hospital is located in a strategically essential area. It serves not only the boroughs of Enfield and Haringey, but some of Barnet and Waltham Forest. Many years ago, when I was a Minister for Health, a neighbouring hospital, Whipps Cross, was a general hospital that on occasion struggled considerably with its emergency department, so I cannot emphasise enough that it is critical for the broader health economy of north-east London that the North Middlesex survives, flourishes and does well.

The concern that has been raised in this Chamber is really about how the situation has got to this stage over such a length of time, with so many Members of Parliament ringing alarm bells in a context where all of us have privately said, “We must tread carefully. We don’t want to talk down the hospital.” We say, “The chief exec seems to be…” as we whisper among ourselves. We do not want to talk down the hospital, but it has now got to the point at which we have to be absolutely frank about what has been happening at that trust, as we have heard, and we must ask some very hard questions about what has been going on.

I hope that the Minister will assist me on this point. There have been successive risk summits, meetings have been held, and the chief exec has asked for support, but I am not clear why support was not provided. In the old days, Members of Parliament would have been able to contact the strategic health authority and there would have been a clear line of leadership. We literally had two bodies to deal with: the strategic health authority and the chief executive of the trust. Frankly, chief executives went if they were not up to the job, and emergency teams were brought in to run the hospital. I did that as a Minister responsible for emergency care. I saw it happen in a range of trusts across the country as, under the Tony Blair Government, we pushed for the first targets of four-hour waits. I am struggling to understand how things have got to this level.

Life expectancy in a constituency such as mine is among the lowest in the country: men reach 74, six years behind the average life expectancy. We have homelessness and we have had two riots in a generation. The issues are clear, but what is not clear is who was in strategic charge? Why were meetings held in successive years? What is the role of NHS Improvement? Is it ever the case that anyone there would contact a Member of Parliament to say what they are doing to improve a trust? What is the role of NHS England’s London office? The individuals there are paid a hell of a lot of money—hundreds of thousands of pounds. Have they got a responsibility to contact a Member of Parliament to ask for a meeting or a conference call to speak to us about what is happening in the trust?

What is the role of Health Education England, which has been concerned about training and qualifications? We know the role of the General Medical Council, but has it been nobbled not to withdraw doctors by NHS England or any other body? What we have are numerous quangos. I have not even mentioned the clinical commissioning group. We have CCGs, HEE, NHS Improvement, NHS England London and the chief executive. The Government came into office determined to reduce the number of bureaucrats, but—my God!—each of us has at least 10 or 12. Then there are all the staff that work under them. Meetings have been held, but what has been done?

I have done the Minister’s job, so I feel for him. When I did his job, we did a lot of the running of the NHS from Whitehall. The Minister’s party came in and I understand why they said they could not run it from Whitehall, but we now have all these bodies and I am not clear what they have done. As a former Minister, I want to hear more of what they have been up to. I hope that the Minister will answer the question asked by my right hon. Friend the Member for Enfield North (Joan Ryan). Given that there have been CQC reports—the one that we had on the 6th is not the first—and risk summits, what is the obligation to inform Members of Parliament and therefore our constituents? At what point does that kick in? Or is it expected that that should be done solely by the trust? If it is, that is problematic if it is a failing trust in which the chief executive has been put on emergency leave. I have the CQC report before me and it says that safety at the hospital is inadequate, and so is responsiveness. As to whether it is well led—leadership is also inadequate, which is presumably why the chief executive has been put on emergency leave. Overall the hospital is inadequate. Under the headings of caring and effectiveness, it requires improvement. That is pretty damning. It does not get much worse than that.

Many hon. Members are concerned—and my right hon. Friend the Member for Enfield North, the hon. Member for Enfield, Southgate (Mr Burrowes) and I certainly are, having been around for a few years. We campaigned to get the PFI that put millions—I think it was £150 million—into building a brand new hospital. It is therefore deeply frustrating that we now have such an uphill struggle. Chase Farm has been mentioned and I will not discuss it again, but the Minister will recognise that we all rang alarm bells about the implications of closing emergency there. Money was put into the trust; yet it has got to its present situation.

I heard yesterday about the case of Mrs Alice Morfett, a 92-year-old lady who still went shopping in Morrisons. She had a heart operation in Barts and she was recuperating on the T3 ward. In the morning she told her daughter about her concern about a male nurse’s behaviour; she could not understand why he kept wanting to touch her chest. Her daughter said she did not believe Mrs Morfett and thought the anaesthetic had not worn off, but her mother complained about the nurse rubbing against her chest. After that Mrs Morfett was scared to ask for help. No one was summoned to help her. The next day, after an hour of asking for someone to take her to the toilet, Mrs Morfett tried to get out of bed herself and she fell. She ended up with huge open wounds; my constituent sent me a photo of the terrible wounds her mother suffered. Mrs Morfett died a couple of weeks later, and her daughter believes that she died as a result of her injuries. Mrs Morfett said to her daughter, “Please don’t let them get away with it; they have to pay for what they’ve done to me.” I do not lightly raise constituency case work in this way. I have used this letter because it is the latest one I have in a stream of letters from constituents about what is happening in the trust.

[Joan Ryan]

Such incidents are what the CQC calls “never” events because they should never happen: a patient dies, and it is not necessarily from medical issues or natural causes. I am sure that my right hon. Friend knows that the CQC report notes that one patient lay dead in a cubicle for four and a half hours last December because there were not enough doctors even to do the hourly rounds. It does not get much worse than that.

[Mr Lammy]

No, it does not, and that cuts to the critical issue of safety at the hospital. In fact, the problems at the hospital have been going on for well over two years. What happened to the hon. Member for Enfield, Southgate, who lay in the hospital with a burst appendix and who frankly would not be here but for a stroke of luck, says it all. How have we got to the situation where the local Member of Parliament is about to die of a medical emergency after waiting without being seen for 11 hours? He has been friendly—[Interruption.] Well, that is what happens with a burst appendix. The hon. Gentleman is looking well, but he is not that young. People die of a burst appendix if they are not treated.

--- Later in debate ---

[Ben Gummer]

Ideally, if things are going wrong and that has been noted within the hospital, the hospital chief executive or commissioners should inform local people, but in the past—and over the two and a half to three years since we instituted the special measures regime—it has taken a Care Quality Commission investigation to highlight poor standards of care so inadequate that the hospital needs to be placed under special measures. At that point, before the public are informed, Members of Parliament are informed by the CQC and what was Monitor and the Trust Development Authority, but is now NHS Improvement.

[Joan Ryan]

rose—

[Ben Gummer]

Before I take the right hon. Lady’s intervention, I will explain why Members were not informed, and it is by no means an excuse. The core problem around emergency medicine and paediatrics was to do with the training places and the relationship between the General Medical Council, which looks at and regulates the quality of training, Health Education England and NHS Improvement. Because this case did not go through the traditional special measures route, which is governed by the CQC and NHS Improvement, things did not happen at the pace I would have expected and nor were Members talked to when they should have been.

The first thing I want to ensure, once we have receipt of the review I asked for this morning, is that we have a similar standard approach, were this to happen again. We have to assume that it might, because things in a large system do go wrong. We need to learn from this scenario over the past year, where Members have been let down, and ensure that it does not happen again. We can move with greater celerity and ensure that Members are informed at the earliest possible opportunity.

--- Later in debate ---

[Joan Ryan]

I appreciate the Minister’s expression of regret and his acknowledgement that something went badly wrong, but I take issue. A CQC report in 2014 noted added pressures in A&E that we are all aware of. I only came back into Parliament in May 2015, and over the past year a number of Members, including me, have raised the issue several times in the Chamber. We were given no information. The CQC report is very welcome, but for it to take more than three months to be published means it is of no use as a warning note with any detail. [Interruption.]

[Valerie Vaz (in the Chair)]

Before the Minister responds, there is a Division.