Accountability and Transparency in the NHS

John Pugh Excerpts

Thursday 14th March 2013 Commons Chamber

[Mr Dorrell]

I have a lot of sympathy with what my hon. Friend says. The successful delivery of a culture change that supports real transparency would build on the fact that it is not only a right but an obligation for a registered doctor or nurse who sees care being provided that falls below proper standards to raise their concerns and, if no action is taken, for those concerns to be raised with the regulator. Change will be required right through the health service if that professional obligation is to be made real.

[John Pugh (Southport) (LD)]

My right hon. Friend has mentioned the instinct to protect and to circle the wagons. Would he accept, however, that that is not exclusive to the NHS, and that it also exists in the police service, for example? It also existed in Parliament during the expenses scandal. It is an institutional feature of many kinds of organisation.

--- Later in debate ---

[John Pugh (Southport) (LD)]

I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on calling for this debate, which I want to widen and, I hope, put on a more consensual footing.

I have a constituent whose grown-up son tragically died of leukaemia some time ago. He went to the doctor many times and was diagnosed as a young, healthy man with glandular fever. A blood test was made far too late, and he died. After the funeral, the mortified doctor wrote to the parents and apologised frankly for her failure and her error. There was no litigation or talk of system failure; there was simply a frank admission of individual human error and a sincere apology, which was accepted.

In many cases of NHS failure, there is no one individual to blame, so people talk of systems and cultures, which we have talked about constantly today. No one individual can be held entirely to blame for the system, so it always seems that no one person is to blame or is prepared to take the blame—even those who manage and design the system, such as Sir David Nicholson.

When a hospital performs badly, and the one in Mid Staffs is simply the most telling example, some of the reasons lie in external factors: in the targets imposed on it, in the requirements made of it—becoming a foundation trust is one it could have done without—and in directions that impaired it. The NHS reorganisation certainly got in the way, according to Francis. When outcomes are poor, it can be hard to determine exactly how to apportion blame and responsibility. Do we blame those who witnessed what went on and did nothing; those who failed to notice worrying trends; those who did notice them but covered them up; or those who could have intervened from on high but did nothing? In one sense, they are all responsible—and some are more responsible than others. But we live in a very harsh and judgmental climate, as was said earlier, and we forget that people at every stage have mixed motives—good and bad—for not kicking up a fuss, for covering up, for not intervening. Some are good—usually, they are bad—but in most cases institutional or personal reasons outweigh the concern for patients. There are quite legitimate fears that the hospital or branch will be criticised or seen as underperforming, which will be bad for morale in hospital, or that one’s career will be in jeopardy—a legitimate concern—or that one is getting a colleague into trouble. Institutional or personal goals get separated from the avowed patient-centred mission of the NHS. Frankly, that is all too human an outcome, and it has always happened to some extent. The NHS is full of very good people, but it is not yet staffed by saints. All of us at some time cover up for colleagues.

However, we always try to find in an institution a way of correcting for this, which is why we have professional standards in the medical profession and an NHS constitution. It is why we need true accountability, good complaint-handling, protection for whistleblowers, duty of candour, the learning of lessons and, of course, proper redress. That is why we have had legislation on the NHS constitution and increased democratic scrutiny, introduced by both Governments, which I applaud. I am not entirely certain what has happened to the NHS redress Bill, but I applaud that too.

However, we build other sorts of incentives into the system, and it is as well to record them. They appeal to a different aspect of human nature, a more selfish side, perhaps out of realism, perhaps because of an ideological conviction that that is how people work. We model hospitals on profit-making institutions. We make survival dependent on competition with other profit-making institutions, which have gagging clauses in their contracts for good reasons—their competitors. We try to modify clinician behaviour not always by appealing to clinical judgment, but by appealing to the pocket. Therefore, we should not be surprised if the moral atmosphere, at times, becomes a little cloudy. We, as legislators, are partly responsible for that.

If we turn the NHS into a set of businesses united by a corporate brand, should we be surprised if occasionally, individual branches put their interests ahead of those of their patients, choosing to satisfy those who pay—the Government—rather than the patients they serve?

There are many good things that we can do and would wish to do. We can make the complaints process easier. We can assign accountability better, so that an individual’s job and survival in an organisation depends on serving the patient, not on always doing what the institution necessarily requires. We can ban gagging orders, and I applaud the Secretary of State’s move in that direction. We can improve inspection, not by making it more ferocious—we do not need to do that—but by linking it better to improvement. Above all, we need to start thinking about what we want the NHS to be. If we are unhappy with the culture, exactly what sort do we want to have? Do we want the moral enterprise that Bevan envisaged—a contract on behalf of the hale and hearty, to protect the sick and vulnerable—or a set of businesses that sink or swim depending on how good they are at getting state funding? We can either rediscover the moral purpose of the NHS, or regard it as an organisation that brings to book from time to time the businesses that work within it, independently of the Secretary of State.

Frankly, I know which I prefer, but I have to record that currently we exist in a strange kind of moral limbo. We are judging an institution that looks very different from the original NHS, according to the high standards and moral mission Bevan set. I have a lot of sympathy with the remarks of Harry Cayton of the Professional Standards Authority, who said in The Times only this week that the NHS must rediscover its “moral purpose”. We exist in a kind of moral fog, a state of limbo, and if we want to know who is accountable for that, it is us.

--- Later in debate ---

[Valerie Vaz]

Let us look at what is going to happen in 18 days’ time when the Health And Social Care Act 2012 comes into force. I do not want to rerun the arguments about the Act, but let us look at what is to come. Let us look at the accountability of the structures under the Act. The NHS Commissioning Board becomes the conduit for everything, including the flow of money, and all the strategic decisions filter down. If anyone cares to look at the Department of Health website and the new structure, they will see a series of concentric circles. Parliament, the Department and the Secretary of State all appear to be in the outer circle, running round in circles. Where is the accountability in that?

I have to tell the Secretary of State—although I am pleased to see him here, this is a Back-Bench business debate—that section 75 regulations were signed off, under a negative resolution, by a Minister who is not accountable to the House. Section 75 says that everything has to be tendered except for technical reasons, or reasons of extreme urgency. That had to be changed to state that contracts can be tendered if the relevant body is satisfied that the services to which the contract related are capable of being provided only by that provider.

Regulation 10 previously said that commissioners may not engage in anti-competitive behaviour; otherwise, Monitor will be after them. Sorry, those are my words. That was changed to say that commissioners must not be anti-competitive unless it is in the interests of patients.

What of the future? I pay tribute to the right hon. Member for Charnwood (Mr Dorrell), who made an excellent speech. I want to draw attention to a report that our Select Committee produced on complaints and litigation in June 2011. I urge the Secretary of State, if he cares to listen, to read that report and consider all the recommendations. Even then, we called for all providers to have a duty of candour to patients. We also said that we found it striking that the Government did not mention complaints in the information revolution consultation and were surprised that they did not see how complaints information could help people see what is going on. My hon. Friend the Member for West Lancashire (Rosie Cooper), who is no longer in her place, was right to say that complaints can provide information about what needs to be put right.

Mr Deputy Speaker, I am not sure whether you are aware that the NHS litigation bill has now reached £1.3 billion. I urge the Secretary of State to look into the reasons why that is happening. We have to redress negligence, but there are other reasons why that bill is rising. There are remedies that do not involve money or changes in structures or reorganisations.

[John Pugh]

Does the hon. Lady acknowledge that that is what the NHS Redress Act 2006 was supposed to do? I am genuinely puzzled, and I hope that the Minister will resolve this puzzle for me, about how much of that Act has been formally enacted.

[Valerie Vaz]

I cannot answer that; I am not on the Front Bench.

We all agree that there is no place for gagging clauses if lessons are to be learned about patient care. I agree that the Government have made an important announcement today, but let me remind the Secretary of State that the NHS issued management directions in 1999 and 2004. I am concerned that the NHS still needs reminding about these gagging clauses. We must get away from a system in which whistleblowers are driven out of their jobs on spurious disciplinary issues. At Mid Staffs, doctors and nurses are under disciplinary reviews, but as yet I have not heard anything about whether managers will also be held to account.

Action plans that arise from complaints are a vital part of organisational learning, but they are only of value if they are followed through to implementation, and it was clear from evidence to us in the Select Committee that that did not happen at Mid Staffs.

Publication of complaints data must be obligatory for all care providers, including foundation trusts and private providers with NHS contracts. We must move away, as the hon. Member for Southport (John Pugh) said, from the blame and victim culture and reduce the emphasis on disciplinary procedures. We must put more emphasis on retraining and risk management.

We should enshrine accountability for patients at board level, making boards more diverse, not just comprising the usual suspects. Private providers, as my right hon. Friend the Member for Leigh (Andy Burnham) said, are not subject to FOI; they must be. The register of GPs’ interests must be open to clinical commissioning groups. It should not be up to the public to ask whether GPs have declared their interests. Every decision must be associated with a list of GPs’ interests.

I have spoken to the chief executive of the Royal Orthopaedic hospital, who said that he ensures that doctors, nurses and managers are all on an equal footing, which is an example of good practice. His phrase is that there should be “no gap between board and ward”. He puts his patient groups on the board, every ward gets rolling visits and board members even feed the patients.

In my own way, I have also been accountable and I have published on my website a table of all the complaints my constituents have come to me about so that they can see what sort of things are going on at the Manor hospital. The chief executive of the hospital is undertaking a patient survey and ensures that he looks at all the responses.

I hope that I have outlined some positive aspects as a way of moving forward and that we will continue to have an accountable, transparent and unique NHS that is the best in the world.