Future of the NHS

John Pugh Excerpts

Monday 9th May 2011 Commons Chamber

[Dan Jarvis]

Although I am new to this business, if hon. Members and the Secretary of State had such faith in the reforms, it is confusing to me why they were not put in the manifesto and the people of this country given the opportunity to vote on them at the general election.

GPs will be substituting the calculator for the stethoscope. That is bad for the NHS and bad for patients. Given how far we have come, would not the first year of the Secretary of State’s tenure in the Department of Health have been better spent, for example, on a concentrated investment of effort in cancer care? We must fight the war on bureaucracy, but not at the expense of the war on cancer.

Would not the Secretary of State have better spent his time learning from our European partners how to educate our constituents about the dangers of an unhealthy lifestyle—diet, drink and drugs—and their effect, particularly with regard to cancer treatment? We need to address why a cancer sufferer in Barnsley is less likely to survive than a sufferer in Barnet. These are the NHS reforms that would make a positive difference and that the country expects us to deliver. Instead, in my constituency, the scale and pace of the Government’s cuts are making it virtually impossible for Barnsley hospital to plan ahead. Budgets are being cut while patient numbers are going up.

The Government are proposing the biggest reorganisation of the NHS since its inception—

[John Pugh (Southport) (LD)]

rose—

[Dan Jarvis]

I have almost finished so I shall keep going.

The reorganisation is one for which the Government have no mandate. That raises the question, as I said, of whether the Secretary of State deliberately chose not to include these drastic reforms in the manifesto because he knew how unpopular they would be. The NHS is the pride of its staff, its patients and our country. We all deserve better.

--- Later in debate ---

[John Pugh (Southport) (LD)]

This is déjà vu. In the last Parliament, it seemed like every other Opposition day debate was a health debate, normally called by the Secretary of State as the then Opposition spokesman. I trust that his enthusiasm for these debates is undimmed, although given that he has left us, possibly it is.

The Opposition allege that the Bill prepares the ground for the complete privatisation and fragmentation of the NHS through the introduction of an open market, pricing and competition regulation and the general disengagement of Government. However, the often very pained response of Ministers—this was certainly true in the Bill Committee—is that they are building and improving on previous policy, linking clinical decision making to cost control and adding a dimension of accountability that has not existed hitherto. All those statements are true. I noticed that in the Bill Committee, Ministers talked all the time about “refracting mirrors”, “Opposition fantasies” and “deliberate distortions”. In turn, the Opposition talk of “hidden agendas”.

On reflection, I have come to the conclusion that there has to be an explanation for this strange phenomenon, this persistent conflict between interpretations of the same legislation, this clear non-meeting of minds.

[Grahame M. Morris]

Will the hon. Gentleman give way?

[John Pugh]

I was just about to give the answer, but I will give way.

[Grahame M. Morris]

Is there not a simple solution? It is the Government’s Bill, so why did they not explicitly rule out price competition in the Bill?

[John Pugh]

I have a different explanation, which is that both interpretations can be sustained by a reading of the Bill. It is a kind of Jekyll-and-Hyde thing. I have a vision of the Bill being drafted during the day by a sane, pragmatic Dr Jekyll-like Minister, but during the night some rabid-eyed Mr Hyde with right-wing ideology breaks into Richmond House and changes many of the sentences. That is the only way I can explain the fact that the explanatory notes to the Bill provided in Committee explained very little.

The House might know that I am a long-term critic of the Bill and the White Paper before it. At the annual Liberal Democrat conference in October, I and the Minister of State, Department of Health, my hon. Friend the Member for Sutton and Cheam (Paul Burstow) went around with a double act on the Bill—him for, me against. This is not, therefore, as the hon. Member for Easington (Grahame M. Morris) might think, a hissy fit following poor election results. Like nearly everyone in the House, I do not disagree with the Bill’s objectives: more clinical involvement, less bureaucracy and more local accountability. Like everyone else, I am concerned not about its objectives, but about its likely effects. I have met no one who takes issue with the Bill’s avowed intentions, but I have met many who dread its consequences.

According to one reading of the Bill—the Mr Hyde version—the eventual outcome of the Bill will be that the NHS opts out of direct health provision and becomes simply a funding body; NHS hospitals, services and clinics become indistinguishable from private ones; everyone competes on business terms for a slice of whatever funds the Government have allocated for health purposes; and what health care a person gets depends on what can be purchased on their behalf in a largely unconstrained, privately run health market. That is a perfectly consistent view of how a health service can be run, but in our country any party that advocates it commits political suicide. Furthermore, of course, it is likely to accentuate health inequalities and overall costs.

The question for us is this: what will prevent such a situation from arising out of a Bill that appoints a competition regulator along the lines of Ofgem to promote competition, that blurs many of the lines between private and public provision, and which removes the Government’s duty to provide a comprehensive health service? Hence the importance of today’s debate, which, knockabout apart, is crucial to the wider debate on the Bill. To be alarmed by the prospect I have set out is not to oppose competition in principle. The previous Government set up competition and collaboration panels to encourage a degree of challenge in the system. In fact, if hon. Members look at their record, they will see that they were knee-deep in competition initiatives. Neither is holding these concerns to be alarmed by the presence of private business in delivering NHS services. There is not a person here who has not used a private optician or a private pharmacist when they need it. There is a long tradition of involvement by the private sector in the NHS.

Rather, to be concerned about the proposals is to be alarmed by the fear of an unconstrained, uncontrolled market in health—this is a point that has been made previously—partly because it can lead to fragmentation, potential conflicts of interest, profiteering and so on, but mainly because identifying competition as the main engine of improvement in health care ignores the simply enormous gains in service quality, cost reduction, efficiency and patient experience that can be gained through co-operation, collaboration and integration of services.

The NHS is built on the principle of co-operation, in which we, the hale and hearty, make a moral compact to support the lame and the sick. To make commercial competition the main driver of improvement in the NHS, even if it is not competition on price, would be a serious mistake. It would be to subscribe to a perverse and misguided form of social Darwinism. Competition is a mechanism; it is not an end in itself. The role of competition in the NHS, as seen by the Government, is the real issue. The problem is made a lot worse by the hopeless lack of clarity over how European competition law will apply. We struggled with that issue in Committee. We did not resolve it, and I do not think that we will do so.

[Owen Smith (Pontypridd) (Lab)]

Does the hon. Gentleman share my concern that in today’s debate, as in the long period we spent together in the Bill Committee, the Government have failed to clarify how competition law will apply? Indeed, they have sought repeatedly to imply that it will not bite any harder on the NHS. Does not that verge on disingenuousness from the Government, if not downright dissembling?

[John Pugh]

I think that that is a bit unkind to the Government. I have been to the Library and borrowed some very big books on EU competition law, and the main conclusion that I have drawn is that the law is not at all clear when it comes to the provision of public services. But that adds to the risks created by the legislation, and gives rise to the awful thought that the fate of our local services, about which we all care, could be decided not by the NHS, not by the Government and not by the public but by case law—European case law, at that—and in the courts.

If we subject clinical services to the same regime to which we have subjected non-clinical services, we will not get the innovative social enterprises strengthening existing provision that people would like to see; we will get large companies financed by private equity muscling in and challenging tendering processes, backed up by legal teams and looking for every weak link or failure to comply with EU regulations. Indeed, that is already happening with non-clinical services.

That is why there is a problem, and it is why private equity is licking its lips. We cannot additionally expect the private sector to come into this game to bid for the unprofitable, high-risk, complex work and not cherry-pick. That is not what businesses do. Good businesses pick cherries, because they need to make a profit. To suggest, as Clare Gerada of the Royal College of General Practitioners has done today, that there is not a problem of untrammelled competition in the legislation is entirely to miss the point. We are not anti-private sector, and we are not anti-competition; we want to see a level of robust pragmatism supported by those with a lifetime’s experience of running health services, and a recognition that good health care is essentially a collaborative exercise. If we cannot get that recognition and the acceptance of the professional bodies for what is embodied in the Bill, everything we say here and every amendment that we make will be utterly pointless.

[Several hon. Members]

rose—

Oral Answers to Questions

John Pugh Excerpts

Tuesday 26th April 2011 Commons Chamber

[Paul Burstow]

I certainly agree with the right hon. Gentleman that prevention is undoubtedly the right way forward, but earlier diagnosis is also very important. That is why we continue, as a Government, to support the roll-out of NHS heath checks for people aged 40 to 65 as a way of ensuring that we detect more readily and earlier so that we can provide the appropriate support.

[John Pugh (Southport) (LD)]

Just 10 minutes ago, I met representatives of Diabetes UK, who want to see greater emphasis on integration and co-operation between and within services in the NHS Bill. Can I assume that they will not be disappointed?

[Paul Burstow]

As my right hon. Friend the Secretary of State has already indicated in today’s exchanges in this House, we are committed to listening and reflecting during this pause, and to ensuring that we come back with substantive improvements to the Bill to deliver its central purpose of improving health care for the people of this country.

NHS Reform

John Pugh Excerpts

Monday 4th April 2011 Commons Chamber

[Mr Lansley]

No, I do not accept that for a minute. The right hon. Member for Wentworth and Dearne, who sits on the Opposition Front Bench, has freely acknowledged that I have met and talked to many people in the NHS over the course of seven and a half years, and that I am passionately committed to the NHS. If one set of beliefs lies at the heart of the reforms and the Bill, it is the belief in the NHS as a free, comprehensive, high-quality service that delivers some of the best health care anywhere in the world. We will never achieve that without the clinical leadership that is essential to delivering high-quality health care.

[John Pugh (Southport) (LD)]

I thank the Secretary of State for having the grace and courage to respond to legitimate concerns. Given the agreement that exists in the House—not about the effects of the Bill, on which there is no agreement, but about its aims—does he agree that we should not get hung up about whether substantial changes will in future be referred to as “tweaking”, “surgery” or, possibly, “surgical tweaking”? Is not the main thing to get a Bill that carries the broad support of Parliament, NHS professionals and the country? We do not need to sell this Bill better; we need to take the spectre of salesmanship out of the NHS.

[Mr Lansley]

The hon. Gentleman and I know one another well enough to know that we share a commitment to the NHS and that I am determined. Perhaps I sometimes get very close to all of this because I am very close to the NHS. I spend my time thinking about this subject and I spend my time with people in the service. I spend my time trying to ensure that the Bill is a once-in-a-generation opportunity to get it right for people in the NHS—they want to be free. The British Medical Association made it clear that it wants an end to constant political interference in the NHS. We can do that only if we secure the necessary autonomy for the NHS, and if we make accountability transparent, rather than having constant interference from this place or from Richmond house.

NHS (Public Satisfaction)

John Pugh Excerpts

Wednesday 30th March 2011 Westminster Hall

[Tony Baldry (Banbury) (Con)]

The hon. Member for Leyton and Wanstead (John Cryer) makes his own points in his own way. Both my parents started to work for the NHS on the day it came into being: my father as a doctor and my mother as a nurse. Throughout the 60-plus years of its existence there has been enormous pride in the NHS, among those who work in it and among the community as a whole.

The interesting notion advanced by the Opposition is that because people are generally satisfied with their doctors, all is well with the NHS. Of course people are overwhelmingly happy with their GPs. By and large, we have freedom of choice over our GP, and if we are not happy with services we change our GP. It is of concern that a recent survey of NHS users found that one in five failed to get a prompt GP appointment when they asked for it, but that notwithstanding it is not surprising that nine out of 10 patients are satisfied with their GP surgeries. That is not the point. The point is that we have an ageing and more complex population who will rightly make increasing demands on the NHS. Unsurprisingly, most people have greatest contact with the NHS in the last years of their lives.

[John Pugh (Southport) (LD)]

I do not want to put the hon. Gentleman off his stride, but is he not slightly missing the point made by the hon. Member for Leyton and Wanstead (John Cryer), which was not simply that people are satisfied with the NHS but that they are progressively more satisfied, which is a more surprising finding, is it not?

[Tony Baldry]

I have not missed the point at all. The point being made by the hon. Member for Leyton and Wanstead is that nine out of 10 people are satisfied with their GPs, so somehow all is well with the NHS and nothing need change. If my hon. Friend the Member for Southport (John Pugh) had read the report of the Public Accounts Committee, chaired by the former Labour Minister of State, the right hon. Member for Barking (Margaret Hodge), he would know that it concludes that although the previous Government increased the amount of money going into the NHS that did not lead to greater outputs. The report makes sobering reading, and I am concerned that more parliamentary colleagues have not read it and that it has not received the attention in the House that it deserves.

--- Later in debate ---

[John Pugh (Southport) (LD)]

Putting aside his conspiracy theory, I congratulate the hon. Member for Leyton and Wanstead (John Cryer) on initiating this important and timely event. I say that it is timely, but it is not timely for the poor Minister, who was unwell yesterday, and who does not look too good today. I understand that his colleague, the Minister of State, Department of Health, the hon. Member for Sutton and Cheam (Paul Burstow), is now also smitten, so the casualties from the Committee considering the Health and Social Care Bill are on the increase.

There may be good reasons for substantial change in the NHS, and one of those that has been given is not that the public are not satisfied with the NHS, but that they should not be satisfied with it. It must be conceded, of course, that the case for radical change is lessened a little if the public are increasingly satisfied with what goes on. The hon. Gentleman has drawn attention to, and put beyond all doubt, the fact that the public are satisfied with the NHS, and we should have that important truth out in the open. Whatever we do in policy, it is important that we are evidence-led, and a wanton disregard for evidence when making policy is wicked and morally irresponsible.

If we ignore the conspiracy theory aspects of the hon. Gentleman’s contribution, it is clear that he has done the House a service by drawing attention to the truth that the public are broadly satisfied with the NHS. We cannot be as confident, however, about the explanations for that. It is most unlikely that public satisfaction is unconnected with things such as decreased waiting lists and increased investment. It is also most unlikely that it is unconnected with the dedication and skill of NHS staff, which remain no matter what politicians decide in this place.

However, satisfaction can be linked to other things, such as sentiment. Some years ago, research into the NHS produced some rather puzzling outcomes. If people in general were asked about the NHS, they had a fairly negative view, but if they were asked about their personal treatment at the hands of the NHS, they were thoroughly satisfied. That was explained by the way in which the media portrayed the NHS and the way in which stories about the NHS appeared in the media.

Another interesting bit of data, which the hon. Gentleman did not allude to, indicates that we are talking not just about a switch in what the media, and therefore the public, are saying. Reports about the NHS by NHS workers themselves have been increasingly positive. Worryingly, there was a stage when a lot of them would give a rather bad account of what was going on in the NHS when they were asked about it. Recently, the data have shown quite conclusively that people working in the NHS speak more positively about it. Such people are more immune to changes in media tone.

The debate so far, however, has been not so much about whether people are satisfied, which we can all take as read, as about whether they should be satisfied. Clearly, that depends not on whether they are satisfied with the NHS, but on whether the NHS actually does its job, which is to make people more healthy, not more satisfied. To give an example, people often feel very satisfied and contented with small maternity units, but such units sometimes have higher infant mortality rates, and outcomes are actually less satisfactory.

Patient-reported outcome measures—PROMs—sometimes show a different picture from clinical outcomes. We have mentioned independent treatment centres, and a lot of evidence seems to show that people are very satisfied with them, although the satisfaction is more to do with the catering and reception arrangements than with the clinical outcomes.

The moot question, therefore, is whether patients have reasonable grounds for dissatisfaction or satisfaction with NHS, whether or not they actually express any—always bearing it in mind that what the public are reluctant to fund, they should not complain about. However, the real question, given the funding that the public have set aside for the NHS, is whether the NHS has delivered the outcomes that people could rationally expect.

When pressed on the issue, senior Government politicians, up to and including the Prime Minister, talk about three issues: cancer and heart disease outcomes, bureaucracy and unimpressive productivity, which are presented as legitimate gripes. It is sometimes tempting to believe that politicians need to find faults in public services because they like reforming them, and I am sometimes inclined to think that we should redefine public services as anything a politician wants to reform. However, there is a need to find out whether there are any real grounds for dissatisfaction with the service we currently have. Unless we can find genuine grounds for people to be dissatisfied, whether or not they are, we should not have overly radical disturbance or upheaval in the system.

Can we make a case for public dissatisfaction? Let me briefly take the three issues I mentioned in turn. We certainly should not bang on about the cardiovascular field. I had the unnerving experience the other day of listening to the Prime Minister at Prime Minister’s questions tell the House how poor our outcomes were when set against those of comparable countries. Later, I attended an event organised by the British Heart Foundation to celebrate world-beating progress. That was a very puzzling experience. The King’s Fund has adequately exposed the myth about heart disease outcomes, and no one in the Department of Health should embarrass the Prime Minister any longer with briefings that disappoint and depress those who are better informed on this issue.

Last week, the Prime Minister notably stuck to the safer ground of cancer outcomes. To be fair, despite sharp falls in mortality among males and excellent progress on breast cancer treatment, we do not seem to excel our peers, and there is clearly work to be done. When looking at the issue, however, we should not use just the old research done by Professor Coleman 10 years ago, because the data on the issue is quite weak. If there are poor outcomes on cancer, however, it is not obvious why it therefore follows that structural and organisational upheaval is the solution, particularly as the prime cause of poor cancer outcomes, as far as I can tell, is late referral by GPs, and the prime solution is a more integrated service and strong regional clinical networks. It is a fact that we spend less on the treatment of cancer than the countries we compare ourselves with.

Turning to the other flaws, there are legitimate objects for criticism from time to time. On bureaucracy, I assume that everybody here understands that the administrative costs of running the NHS compare very favourably with those of running health systems in other parts of the world; that is not a debateable point. Even if those costs are higher than we would wish, they certainly compare favourably.

It is quite true, as the hon. Member for Banbury (Tony Baldry) and the Public Accounts Committee have said, that productivity has not increased linearly or proportionally with investment, but that is true of business sectors, too. That is a common phenomenon; every extra pound does not give us the same amount in increased productivity. The wonder is that people expect life to be that simple. If that is a real problem, however, it is a poor argument for giving GPs all the money to spend, especially when the National Audit Office research, which has been quoted, shows that giving GPs extra money under the contract would not necessarily give us a vast increase in overall productivity. If we drew a graph showing the rise in income and the outcomes at GP surgeries—I can give hon. Members copies of the PAC report—we would find a phenomenon similar to that described by the hon. Member for Banbury with respect to hospitals. There does not, therefore, seem to be quite as clear-cut a case as one might wish to justify a case for public dissatisfaction, and the public might have a case for not being as dissatisfied as all that.

I want to refer Members to an excellent document from the Commonwealth Fund, which contains up-to-date research on many health systems across the world that are comparable to that in the UK. The research includes a number of indicators that are very favourable to our system, and this is copper-bottomed research. It shows that the UK has lower than average spending; that, according to UK citizens, our system needs less changing than those of our peers—that is what people in our country say and what people in other countries do not say to the same extent; that it inspires the greatest confidence in terms of effective treatment; that it requires the citizen to fork out the fewest additional payments; and that it is among the best for quick appointments, access and diagnosis. It is not perfect, and I have not undermined the case for all sorts of changes in the NHS, but as we say in Lancashire, “Mustn’t grumble.” There is a case for looking at what we have delivered and perhaps celebrating it.

As Government, as parties and as politicians in general, we can certainly make a case for reform, and that case can be made independently of this debate. What I cannot convince myself of at the moment—indeed, none of us can—is that the public are dissatisfied with the NHS. They are not. Nor can I convince myself that they have grounds for dissatisfaction that go beyond those one would find in any health service, anywhere in the world at any time.

[Hugh Bayley (in the Chair)]

It might help Mr Anderson and Mr Morris if I say that the two Front Benchers have each agreed to speak for 10 minutes, which leaves a further 20 minutes for debate: 10 minutes for each of you. Mr Anderson.

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

It is a pleasure to serve under your chairmanship, Mr Bayley. I pay tribute to my hon. Friend the Member for Leyton and Wanstead (John Cryer) for securing this important debate on public satisfaction with the NHS. Some important issues have been raised by my right hon. and hon. Friends, but I will not rehearse them. Suffice it to say that we are having this debate because information has been released as the result of a debacle in the Department, and I am delighted that the information is now available. There may be a good reason for the Secretary of State wanting to keep the contents of the satisfaction report under wraps. It confirms the outstanding NHS legacy that Labour passed to the Health Secretary in 2010. He inherited a national health service that was rescued from 18 years of Tory mismanagement, and now enjoys the highest rate of public satisfaction in its history.

The Ipsos MORI survey, to which my hon. Friend the Member for Leyton and Wanstead referred, states:

“Public satisfaction with the running of the NHS remains very high at 72%. This high level of satisfaction has now been sustained for over a year making the public’s perception of the NHS a real success story.”

The real reason why the Health Secretary hoped that his Department had not published that report is that it shows him to be completely out of step with the British public. He cites his former boss, Lord Tebbit, as his political hero, but he does not understand what the public so value about the NHS. Instead, he is doing to it exactly what he did to the utilities in the 1980s, when he was working for his hero, Lord Tebbit, by applying 1980s privatisation principles and policies to the health service.

Current polls of public satisfaction with the NHS are all the more important when we consider that the revolution—that is what it is—now under way in the NHS was not described or set out for the British people until some months after the general election. The Conservative manifesto said the Conservatives would

“defend the NHS from Labour’s cuts and reorganisations”,

yet the Government are delivering a real-terms cut in spending, and a radical reorganisation that will undermine the NHS.

Nowhere did the Health Secretary explain his plan to apply 1980s-style privatisation mechanisms to the NHS; to create an economic regulator for health in the form of Monitor, costing upwards of £500 million over the lifetime of this parliament, an issue that was raised by the hon. Member for Banbury (Tony Baldry) in respect of the Government’s commitment to reduce bureaucracy; to expose the NHS to European competition law, which also applies to our utilities; or to handing the £80 billion NHS budget to private bodies with GPs as figureheads, but to which freedom of information provisions will not apply.

Instead, the Health Secretary spent the previous six years as Opposition spokesman doing everything possible to avoid giving any indication of his plans for radical change for the NHS. I am sure that there was no mention of removing the private patient cap to allow uncontrolled focus on profit-making in hospital trusts, a mechanism that will push NHS patients to the back of the queue.

The Secretary of State’s coyness had paid off, because the public, who are overwhelmingly satisfied with the NHS service that Labour had rebuilt over 13 years in government, did not suspect a thing. Health was not raised once in the last prime ministerial debate before the general election.

I want to focus my remarks on how public satisfaction, and in some areas dissatisfaction, might apply to the Health Secretary’s proposals in the Health and Social Care Bill. Now that the Ipsos MORI survey has found its way into the public domain, we may consider its implications for the current upheaval planned by the Secretary of State. Three specific polls in the survey give a clear indication of public preference for the future of the NHS, with between 63% and 65% agreeing with the following statements: first, the

“NHS provides good value for money to taxpayers”;

secondly, the

“NHS provides patients with the best treatment possible”,

and thirdly,

“people are treated with dignity and respect when they use NHS services.”

In-house NHS provision of a high quality is favoured by the public, but the Tory-led proposals in the Health and Social Care Bill threaten that. Over time, as the private sector wins contracts from NHS bodies, the NHS provider that is displaced will have to close, and there is a risk that we will be left with private companies competing with one another for multi-million pound contracts. That is the Lansley vision of the NHS, and it is completely out of step with British public opinion.

[John Pugh]

People were asked whether major changes or only minor changes were needed in their local health system. The figures for the UK show that 62% believe that only minor changes are needed, which is by far the highest figure on the graph of most of the comparable systems.

[Grahame M. Morris]

I thank the hon. Gentleman for that intervention. His point is a good one, and was well made. There is no need for the revolutionary change that we are facing.

Time is limited, so I shall conclude. Without polling and without understanding the facts, the Government would take a reckless step in the dark. If they do not consider public opinion in their annual surveys, they may end up with a shock in the biggest survey of all—the one planned for May 2015.

NHS Reorganisation

John Pugh Excerpts

Wednesday 16th March 2011 Commons Chamber

[John Pugh (Southport) (LD)]

I am glad to be called to speak. I had a hand in drafting both amendments and the motion in that it is taken from the Liberal Democrat conference. I appear to be responsible for the lot, so I may be a parliamentary first.

I begin by stating the blindingly obvious: the Health and Social Care Bill is in trouble. There is hostility to it from the professions, anxiety about it among the public, concern in the Cabinet and an unease that can be felt spreading in all sections and all parties in this House and the other place. That is just a fact, and it matters more than the political knockabout here or any loss of face, because the effects of the policy—for good or ill, for better or worse—announced with unseemly and misguided haste last June are going to be felt in every home in the country.

[Nadine Dorries]

I thank the hon. Gentleman for having the good grace to give way. Would he describe the 5,000 GPs who agreed to be part of the pathfinder consortia as “uneasy”? It appears to me that they are incredibly enthusiastic to get going.

[John Pugh]

I think it is Hobson’s choice.

This is not the first health reform—the last Government introduced more “step changes” than could fill an episode of “Strictly Come Dancing”—but it is certainly the biggest, the most expensive and possibly the most risky. The Secretary of State seems to have chosen for himself a path on which future generations will either put up statues to him or burn him in effigy. However, it is no longer his Bill; it is our Bill. No Secretary of State currently commands a majority in this House.

This Parliament may act like all the others hitherto—and, sadly, it usually does, as it has largely done today—but it is not like any other Parliament. There is no party in this House with a majority, so we should dump the tribalism, the point scoring and the political games. We can get round to doing what we have to do and what we need to do. We have the chance to scrutinise, to seek to amend and improve—and, if unsatisfied, the chance to reject the Bill on Third Reading. That applies to Members of all parties. It is not just “top-down reorganisation” of the health service that we should have dropped with the coalition; we should have dropped “top-down legislation”, whereby MPs simply become pawns in a wider political game, and conviction takes second place to coercion.

There has never been a Secretary of State who has looked at the NHS and found it to be perfect and incapable of improvement. That is largely because we demand so many incompatible things of it that any incarnation is unlikely to satisfy all. Each successive Secretary of State suggests proposals for reform, rather like the Flying Dutchman in a hopeless and sadly doomed pursuit of the ideal format for the NHS. I have to say that the current Secretary of State is probably better equipped for this eternal task than any others: he is committed, passionate, well informed—probably the best informed Secretary of State we have had for some time—and he is brave. He voyages on, undeterred by the siren voices of think-tanks from right and left and the warnings about costs and practical difficulties, and unfazed by the lack of enthusiasm, if the polls are to be believed, among the NHS crew and staff. Of course, as a Liberal Democrat I am disinclined to believe polls at the moment. He carries on, unmindful of the uncharted nature of the course he has set. In Committee, we found real gaps in the understanding of how things will proceed. It is not that he is unaware of the possible danger, but the big danger is that any potential shipwreck will cause us all to be engulfed if costs overrun, if productivity falls, if hospitals close, if waiting lists grow, if morale declines, or if the NHS appears to be denatured, privatised, and not safe in our hands. That is why Parliament’s role is so important in this context, and why good argument rather than the Government machine must prevail.

[Greg Mulholland (Leeds North West) (LD)]

I pay tribute to the work that my hon. Friend is doing on the Bill. Does he agree that, as with the forestry decision, the coalition shows its strength when it actually listens to the concerns that are out there, and is that not exactly what we need the Government to do at this stage?

[John Pugh]

Indeed. In the circumstances that my hon. Friend cites, both coalition parties listened to the voices that they heard and took serious note of them.

It would be unsafe to draw any conclusions from the voting patterns today. Political gamesmanship and party loyalties will prevail. However, it is not necessary to hang around the Lobbies much to see that a corrosive unease is spreading through Government ranks, even in the most unlikely quarters, and to see how opposition hardens with every defiant, unbending rebuttal from the Richmond house bunker. We must accept that the Committee, for all its forensic talent, will not solve the problem; we must concentrate on Report and Third Reading, and on the debates that will take place offstage beforehand.

This is our Bill, not the Secretary of State’s. It will not come about unless we vote for it. Even the most calculating, the most tribal, the most ambitious of us—but not, possibly, the most stupid—must see the clear risks as well as recognising the opportunities. If we get it right, reform can take place with the grain of professional and expert opinion, without Ministers’ ceasing to be ambitious for the NHS, and with broad political support in the House and in the country, and arguably it will work better as a result. However, it will require dialogue.

It is a profound irony that the Government want to abolish what they call the command and control model of the NHS by means of a command and control model of legislation. Indeed, they issued a Command Paper over the Christmas period, but then Richmond house does not do irony. If Parliament is to help the Government to climb out of the hole into which they threw themselves last June when the White Paper announced the liberation of the NHS, we need genuinely constructive, open dialogue, and we need it to start here. Perhaps, in order to liberate the NHS, we need to liberate Parliament a little bit first.

--- Later in debate ---

[Andrew George]

I am grateful to my right hon. Friend. Indeed, that is a very encouraging indication of the fact that the Secretary of State is prepared to listen. As far as I am concerned, however, he is not prepared to go far enough in reassuring me on those points, because taking the word “maximum” out of the clauses relating to price competition and the role of Monitor, the market regulator, is still insufficient. We have not got time to debate that today.

There are several issues, through which I shall canter in the few moments I have left, about the Bill’s objectives and what we want to achieve. First, we want to drive patient choice and innovation. I do not think that anyone would disagree with that, but we do not need to demolish the core—or at least the institutional architecture—of the NHS and PCTs, and alienate the majority of clinicians against achieving such innovation and patient choice.

Again, I think we all agree that giving power to communities and patients is highly desirable. However, although GPs will be given responsibility for commissioning services through the consortia, I do not think that they are particularly asking for that. Having spoken to many of them and listened to the national debate, I believe that they are reluctant, or at best resigned to taking on those roles, feeling that they have to follow that course.

If we want decentralisation, why will we end up with the ludicrous centralisation of commissioning NHS dentistry and dispensing? Indeed, every contract for a GP surgery will be centrally commissioned from an NHS commissioning board in Leeds. That is absurd. It does not even achieve what it is claimed that the Bill wants—decentralisation.

Many attempts have been made to argue that the Bill will cut bureaucracy and managers. I am not sure that that will happen. A big focus of today’s debate is the impact of competition, which will be unleashed. Once the private sector has its foot in the door, the genie will be out of the bottle. It is clear that everything, including designated services, in my view, will be open to contest. Although it is claimed that the Bill will result in fewer managers, I think that it is a dream come true for litigators, lawyers and management consultants.

[John Pugh]

Will my hon. Friend give way?

[Andrew George]

I am afraid that I do not have time.

The idea that the Bill will drive integration and social care is more wishful thinking because there will be less coterminosity between commissioning boards and local authorities under the Government’s proposals for an increased number of commissioning bodies than we have now.

Much rethinking needs to be done, and I hope that Government Front Benchers are listening.

Neuromuscular Care (North-West)

John Pugh Excerpts

Wednesday 9th February 2011 Westminster Hall

[Graham Evans]

I thank the hon. Gentleman for that intervention. I wholeheartedly agree. When someone is suffering from a condition, there is nothing quite like having people trying to help who understand what they are going through, both physically and mentally. So I wholeheartedly agree.

As I was saying, the “Building on the Foundations in the North West” report found that three out of four neuromuscular patients and their families have no access to a key worker or a care co-ordinator. About 6.5 regional care advisers are needed to serve the estimated 8,000 people —which is up from an earlier estimate of 6,500 people—in the north-west area who have a neuromuscular condition. Many of those people are simply not known to providers of health services.

The report also found that neuromuscular patients have very limited access to treatment, in particular to ongoing physiotherapy. Specialist physiotherapists are required to support outreach clinics and to provide training and professional development for community physiotherapists. In the north-west, two fifths of neuromuscular patients said that they do not receive enough physiotherapy.

Another finding of the report was that there is no dedicated physiological service for neuromuscular patients, despite the importance of such a service as part of multidisciplinary care for that patient group, who have rare and very progressive conditions. Those conditions are often genetic, there are no known cures and there are only limited treatments available. Greater support at the transition from paediatric services to adult services is needed, given the evidence that services are removed or greatly reduced when patients leave paediatric services, even though their needs may well increase given the progressive nature of many of these conditions.

[John Pugh (Southport) (LD)]

I thank the hon. Gentleman for giving way and I congratulate him on raising an important subject. In fact, he highlights a very significant problem. If I understand him correctly, he is saying that we need an adequate clinical network for the rare disease that he is speaking about and a range of providers need to be joined seamlessly, as it were, in some way for the good of the patient. Normally, we expect the strategic health authority to identify the failures to provide such a seamless service and to somehow levy the PCTs to deliver it, which the patients expect and deserve. Is he saying that the central problem is how such a service will progress under the new arrangements, when PCTs, SHAs and other such organisations, which are mandated to resolve these problems, no longer exist?

[Graham Evans]

I thank my hon. Friend for that intervention. He makes a very good point. The new arrangements are a threat, but they are also an opportunity, because services are currently provided by the PCTs but not all of them understand these neuromuscular conditions. The new arrangements are a real opportunity for the Muscular Dystrophy Campaign to get its point across, so that we get off on the right foot when the changes come in. However the GP-led consortia really need to understand and appreciate what is required. It is about having a holistic approach. Shortly I will discuss an excellent neuromuscular centre in Cheshire, which makes a huge difference to patients. It encompasses physiotherapy and the other aspects of care that make life so much more comfortable for those people who have muscular dystrophy.

[John Pugh]

I apologise to the hon. Gentleman and to you, Mr Davies, because I will not be able to stay for the duration of the debate. Consequently, I will not find the answer to the problem that I have just referred to.

[Graham Evans]

Okay. I thank the hon. Gentleman.

--- Later in debate ---

[John Pugh (Southport) (LD)]

I have the temerity to believe, Mr Davies, that this debate might finish early, so I will make a brief contribution. I congratulate the hon. Member for Weaver Vale (Graham Evans) on introducing the topic. His preamble was very touching—I have a vision of him as an enormously public-spirited child, raising money for charity. He has clearly carried that public-spiritedness into later life and into politics. I disagree with him, however, about the poshness of Wolseley cars—there were certainly some fairly ordinary Wolseley cars in my day.

I want to elaborate on my intervention on the hon. Gentleman. He explicitly said in his articulate presentation that he has some concerns about the abolition of the specialist commissioning bodies that were set up by the strategic health authorities. Such concerns have been generally well recorded by a number of people with an interest in a variety of rare diseases, not just those of a muscular kind. Although renal problems are not particularly rare, the SHA in my constituency has dealt with the huge problem of elderly people needing renal services by saying that those services need to be in Southport where the demand is. A facility has been produced that is beyond the cost limits of the primary care trust: in fact, it is a regional facility and has been established on the basis of a regional strategy.

The case has been well made across the piece that we need specialist commissioning groups. They have been necessary to deal with rare diseases and to construct the necessary clinical networks. Often, people need not a specialist secondary care facility, but adequate facilities and therapies in the primary care setting. Moreover, those facilities need to somehow integrate, talk to one another and form a clinical network.

What will happen when the SHAs and, presumably, the commissioning units that they set up go? I hope that the Minister will solve that problem. There are two possible answers to the question. The first is that we do not know. The other answer—the Minister may wish to enlarge upon this—is that we will get outposts of the national commissioning board that will do very much the same job as the SHAs. If we have regional commissioning groups, which are generally aware of what is required in the region, we replicate the existing solution, which may be perfected and improved in the process. Few would have problems with that. Some would question the necessity to deconstruct then reconstruct everything, but such a solution is acceptable to many who are concerned about a range of rare diseases, including those that the hon. Gentleman has spoken about. Therefore, my single, simple contribution to this debate is to pose the Minister a question: is that the solution to the problem and, if not, what is?

--- Later in debate ---

[John Pugh]

The hon. Lady’s point seems slightly tangential. If her argument is that what is wrong with the arrangements is the current ignorance of GPs about referral pathways, that situation has pre-existed these arrangements and may succeed them. It is an independent issue, is it not? It is not about structures.

[Emily Thornberry]

As the structures currently stand, it is understood by GPs that they can receive back-up, through the specialised services national definition set, from the various networks that have already been established. If the national health service is to be grabbed by the ankles, turned upside down and shaken hard, the problem is that in the ensuing chaos, GPs will be distracted and, in the short term, people with muscular dystrophy might not get the services that they deserve. That is a legitimate concern, which it is only right to lay at the Minister’s door, because it is this Government who will be putting the national health service through that process.

As I have already asked, will the Minister confirm that specialist neuromuscular services will fall under the remit of the national commissioning board? How will the board work with other services, such as community nursing, speech and language therapy, and continuing care and physiotherapy, which I understand will be commissioned by GPs? How will that work, and how will people with muscular dystrophy not fall between the gaps? Will the Minister provide more information about regional commissioning—already mentioned during the debate—which might arise under the national commissioning board? It would be reassuring for many to learn that the national commissioning board might have regional hubs, but we have yet to hear that stated specifically. If it were to be stated this morning, it would be good news for many people.

The other issue that I know the Minister shares my great passion for and interest in is the importance of increasing integration of services. People with the conditions we are discussing are clearly exactly the sort of people who need integrated services, so that they can have assistance in hospital—hopefully as an out-patient—and care in the community. There is a continuing disconnect between social care and health care. We all know that when those services do not connect properly, people end up as an emergency admission. We have already heard that £68.5 million is spent across England on unpaid emergency hospital admissions for people with muscle disease.

It is clear that savings can be made, and the holy grail for all of us is to ensure that there is better integration between the various services—both between primary and secondary care, and social care and health care. The challenge in the near future is to consider exactly how the Health and Social Care Bill will help with that integration. There is concern that, in fact, it will do the opposite.

It is important that the legacy is protected. The Muscular Dystrophy Campaign has been working constructively with the 10 NHS specialised commissioning groups across England, and significant progress has been made on improvements to neuromuscular services and on an increase in the number of muscular dystrophy care advisers. In the context of the changes to the national health service and the cutbacks in funding, there is concern that a lot of that good work may fall by the wayside. This morning would be a timely moment for the Minister to reassure us that the legacy will not be lost. Will he reassure me that the work being carried out by the regional specialised commissioning groups will not be put in jeopardy following the proposed reforms for their abolition?

Health and Social Care Bill

John Pugh Excerpts

Monday 31st January 2011 Commons Chamber

[John Healey]

Well, my hon. Friend is right in this respect: people will come to see clearly that they cannot trust the Tories with the NHS; they will come to see clearly what these changes really mean for their services; and they will come to see clearly what the future of the NHS holds.

[John Pugh (Southport) (LD)]

I cannot follow the previous contribution, but the right hon. Gentleman has mentioned democratic accountability, so will he accept that in 10 years of Labour government, nothing was done about democratic accountability in the NHS? We simply had rule by quangos.

[John Healey]

No, I do not accept that, but I will tell the hon. Gentleman that the measures in this Bill will undermine many of his principal concerns and policy priorities about opening up the NHS to the public and to Parliament. I hope that he will take a close look at what the Health Secretary really plans.

General Practitioners

John Pugh Excerpts

Thursday 20th January 2011 Ministerial Corrections

[Dr Pugh]

To ask the Secretary of State for Health what proportion of doctors working in GP practices in England are partners in the practice where they work.

[Official Report, 26 July 2010, Vol. 514, c. 833W.]

Letter of correction from Mr Simon Burns:

An error has been identified in the written answer given to the hon. Member for Southport (John Pugh) on 26 July 2010.

The full answer given was follows:

[Mr Simon Burns]

As at 30 September 2009, there were 35,719 general practitioners (GPs) (excluding GP registrars and retainers) in England. Of these, 28,607 (79.6%) were partners in the practice they worked in.

The correct answer should have been:

Swine Flu

John Pugh Excerpts

Monday 10th January 2011 Commons Chamber

[Mr Lansley]

May I reiterate to the right hon. Gentleman that the amount of vaccine supplied to the United Kingdom is determined by manufacturers on the basis of discussions with not only the Department, but others, and that the vaccines are ordered by individual GP surgeries? The total amount of vaccine was 14.8 million doses, which is comparable to the level in previous years. Although GP surgeries have shortages, because of the preparations made during the pandemic in 2009 and given that the principal strain of flu circulating is the H1N1 strain—it is not the only strain, but it is the most relevant to guard against for many in the at-risk groups under the age of 65—we made it clear that we would back up GPs who had any shortages with access to our stockpile of H1N1 vaccine. Orders have come in and they are being filled.

[John Pugh (Southport) (LD)]

Governments do not control diseases yet, but in my constituency elective surgery has been cancelled and pharmacies have run out of vaccine. What is the serious long-term alternative to the over-provision of last year and the localised under-provision of this year?

[Mr Lansley]

I do not think one can say that there was over-provision during the pandemic, because one could not have been at all clear about the nature of the progress of H1N1. However, what that meant is that we have the stockpile of vaccine available to back up the NHS this year. My hon. Friend makes a very good point, because there is clearly an issue to deal with regarding how this is properly managed. Before Labour Members start talking from a sedentary position, they might wish to re-examine the 2007 flu review. It was conducted by the Department of Health under the previous Administration and recommended that there should be central procurement of flu vaccine in England, but the previous Administration did nothing about it.

Candour in Health Care

John Pugh Excerpts

Wednesday 1st December 2010 Westminster Hall

[Mr Robert Syms (Poole) (Con)]

It is a pleasure to serve under your chairmanship, Mr Gray. I start with an apology: I cannot possibly do justice in this debate to all those who have suffered as a result of mistakes made by the national health service. I know that a lot of people are paying attention to this debate, and I will do my best to make the case for a duty of candour in health care, particularly a statutory duty. That would be progress.

In the House, if an hon. Member makes a mistake, however outrageous, everybody thinks that it is fair enough as long as they apologise quickly. I want to put forward the arguments for why honesty is the best policy and why it is best to acknowledge that mistakes are made in medicine and in the health service. That is part of the medical process. If people inform relatives, put their hands up and say, “We made a mistake,” that is a far better way to proceed than what seems to have happened in the past.

I would like to thank Peter Walsh from Action against Medical Accidents for assisting me as I prepared for this debate. Over the next few weeks, Ministers are due to decide on their preferred option for honouring a commitment to require openness when things go wrong in health care. During the 2010 general election, the Liberal Democrat manifesto stated:

“We will: require hospitals to be open about mistakes, and always tell patients if something has gone wrong.”

I do not often quote from the Liberal Democrat manifesto, but it is probably important to do so under current circumstances and the coalition. That pledge was also included in the coalition programme for government:

“We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong.”

That has clearly been lifted from the Liberal Democrat manifesto. The White Paper, “Liberating the NHS”, stated:

“We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong.”

That shows consistency running from the original Liberal Democrat manifesto to the coalition programme for government and the White Paper produced by the Department of Health.

Those commitments have been widely interpreted and welcomed as going some way towards the introduction of a statutory duty of candour in health care. Such a move has been advocated for many years by patient groups and others, including the ex-chief medical officer, Sir Liam Donaldson. Recently, Ministers have made it clear that as well as the possible introduction of an explicit statutory duty of candour, they are also considering not altering or adding to the statutory regulations, but merely issuing new or refreshed guidance to existing regulations contained in the Care Quality Commission (Registration) Regulations 2009.

It is implied that that is more likely to be the favoured option because there is an extreme reluctance to add or alter statutory regulation. I will speak about those two options, with a view to encouraging support for the introduction of a statutory duty of candour. Action against Medical Accidents has campaigned on that matter for a number of years, and representatives from that charity met with a Health Minister to try to put forward their case about the right way to proceed.

Put simply, the situation is unacceptable. It comes as a shock to most people, particularly patients and members of the public, to know that health care organisations are in breach of no rules and will face no sanctions if they cover something up or decide not to inform a patient—or, in the case of a fatality, their relatives—that something went wrong during an operation or health care.

Probably more by accident than design, the current system tolerates cover-ups and denials. People ask how that can happen in a modern, ethical health service, and the vast majority of people would agree that honesty with patients and their relatives is a moral and ethical requirement. There is an abundance of guidance on the issue, and best practice dictates that honesty, or being open, is the only course of action.

We know that there are a million incidents in the national health service each year, about half of which cause some harm. Within those cases, there are many serious incidents, so it is a large problem. When something goes wrong, most people want someone to explain what happened to their relative, mother, father or daughter. In part, such behaviour is part of the professional code for individual doctors and nurses, and is recognised as a central component of an open and fair patient safety culture. However, the failure to be open and honest when things go wrong is not uncommon.

Although many trusts or PCTs do act openly, a significant minority tell patients nothing. Something must be done to provide parents and relatives with a flow of information and an honest approach. Patients and their families are unfairly denied crucial information about what happened during their health care procedure, and they may never learn the truth. If they do, they are often deeply traumatised by the initial dishonest response to something going wrong. It is not unusual to find people who have spent decades campaigning under difficult circumstances to find out what happened to one of their relatives.

If patients suspect that something has gone wrong but have to fight to get the truth, they lose all confidence in the health care system and are more likely to take legal and disciplinary action. The NHS and health care organisations have failed to develop a learning culture and the ability to learn from errors and make things safer. Instead, they have developed a culture of defence or denial; they do not want to see themselves in the newspapers.

The situation in England became even worse when the previous Government introduced the Care Quality Commission (Registration) Regulations 2009, which came into force in April 2010. That introduced a statutory requirement on health care organisations to report anonymously incidents that caused harm to the national incident reporting system. However, it did not include an equal requirement on the organisation to inform the patient or their relatives.

Therefore, an organisation is not currently in breach of the regulations if it covers up an incident from patients or relatives. It may be bad practice, but there is no real sanction as long as it sends an anonymous report to the system. An organisation will be ticked off if it does not send a report for the purposes of national measurement, but it will not be ticked off it fails to be open and honest with a patient or their relatives. Let me draw the Chamber’s attention to a document produced by Action against Medical Accidents entitled “The need for a statutory duty of candour in healthcare.” It is a good article for those who want to look at the more detailed requirements involved.

I pay tribute to my constituents, Derek and Joan Bye. As MPs, we deal with many constituents, but Mr and Mrs Bye have had to put up with a horror story following the death of their daughter, Helenor Bye, who died on 27 April 1978 in south Wales. There was a catalogue of medical errors. The parents were lied to, records were altered and their MP, John Morris, then the right hon. Member for Aberavon, held a debate in the House of Commons on 27 November 1979, volume 974, columns 1253-64. He called for a public inquiry, although that was turned down.

The situation was compounded by the fact that body parts were taken from Helenor Bye, some of which have been returned over the years. The last time body parts were received by the parents was in 2005. They have been through the most horrific period because of what happened to their daughter, what happened subsequently and, more importantly, because all along the line they felt that they were being lied to and that people were not being open and honest. Mr and Mrs Bye have become doughty campaigners for a more honest and honourable system of health care. They have also campaigned on their concerns about the drug Epilim. I cannot do justice to that campaign today, but if any journalist wants to know what can go wrong, I advise them to look at the case of Mr and Mrs Bye. They have had a very rough time.

Action against Medical Accidents calls for a change in the law and the introduction of a statutory duty of candour. It is called “Robbie’s law” because of the case of Robert Powell, who died on 17 April 1990, aged 10. His parents have campaigned for over 20 years to try and get justice. Similar things happened to them, such as changed medical records, and there was a catalogue of events, but they still do not feel that they have justice. Their campaign has continued under several Secretaries of State. The case is currently with the Welsh Assembly, and Mr and Mrs Powell are waiting to hear whether there will be a public inquiry into what happened to Robbie. Will Powell, who feels passionately about putting right what happened to his son and getting to the truth, has been a doughty campaigner for a long time. I pay tribute to him.

All the people whom we are talking about are, in their own way, fighting for the truth, not only to find out what happened to their loved ones, but so that such things do not happen again to someone else. This debate is about setting out a context and a better way of doing things, so that we have a much more honest and honourable system and families do not have to spend 10, 20 or 30 years going through absolute hell. Mr Bye told me that the start of the healing process is learning the truth and knowing what has happened to one’s relative. That is a very important point.

The Government have two options to consider. They can go for an explicit duty or for more guidance. Ministers often go down the guidance route. When the NHS constitution was being debated in the previous Parliament, the then hon. Member for Wyre Forest, Dr Richard Taylor, who served with me on the Health Committee, raised the issue of openness and whether we could go further down that route. He was informed by the then Minister of State, Mike O’Brien, “No, we can do it all through guidance,” yet guidance so far has not produced the results that we need.

Department of Health officials met representatives of Action against Medical Accidents and other stakeholders on 16 November 2010, when the two options were discussed in some detail. I shall go through the pros and cons of both. Option 1 is no new statutory duty but refreshed guidance in respect of the existing CQC regulations. The pros of that are that it would require no new legislation or change in the regulations.

[Dr John Pugh (Southport) (LD)]

Is not the difficulty with guidance the fact that guidance is already in place and any other guidance would simply reiterate what it says? Clearly, guidance by itself is not doing the trick in this case.

[Mr Syms]

The hon. Gentleman makes a very important point, because we have to change the whole culture of the national health service and I am not sure whether guidance will do that.

An argument can be made that the existing CQC regulations, backed up by clearer guidance, could be interpreted as making it a requirement to be open. For example, regulation 17 has been cited. It says that service users should be provided with adequate information and support in relation to their care or treatment. The guidance could clarify that that includes telling them if something has gone wrong. However, one of the cons is that, as the hon. Member for Southport (Dr Pugh) said, that would be in effect no different from the current situation. Such guidance and the existing regulations already existed when the policy to introduce a requirement was agreed. They were clearly not seen as sufficient then.

Given that the Department of Health was of the firm opinion previously that the existing regulations, even with the guidance alongside them, did not constitute a statutory duty to be open with patients when things go wrong—because at that stage they were not supporting a statutory duty—it is hard to see how that could be credible now.

Such a measure would be unlikely to be enforceable. Lawyers would no doubt have a field day if, given the above, the CQC tried to impose sanctions on a trust based on such a tortuous and dubious interpretation when the opportunity to be clear and specific had not been taken. Even if such a measure were enforceable, the CQC would be unlikely to give it a high priority, given the number of clear statutory obligations already spelt out in the regulations themselves, rather than developed by supporting guidance.

Option 1 would not have anything like the same impact as introducing a specific statutory duty, if it had any impact at all. The Department of Health would be trying to say, “This has always been the case, but we didn’t realise it and didn’t think it was important enough to make it clear.” That option would fail to deliver positive opportunities for sending a clear, unequivocal message about the importance of being open and would fail to support a major culture change. It would not deal with the bizarre situation whereby there has already been, since April 2010, a statutory obligation to report anonymously to the national incident reporting system patient safety incidents that cause harm, but there is no equal requirement to tell the patient or a relative. It would send the message that being open with patients is not important enough to justify a minor amendment to the regulations.

Option 2, which I prefer and think should be given serious consideration by the Government, is to introduce a specific statutory duty by amending the existing CQC registration regulations. That would send a clear, unequivocal message about the importance of being open, which would support and underpin other initiatives to develop a more open and fair culture. It would be enforceable. The CQC has confirmed that it would be practical for it to enforce such a measure. Of course, it would be a condition of registration with the CQC. It would have real impact: boards and management could not escape noticing the change or recognising the need to comply. At the moment, even when doctors or nurses want to be open with patients, sometimes the management of PCTs or of hospitals are less keen. We must send a clear message so that the whole organisation undergoes a major culture change in how it deals with patients.

Option 2 would balance out the existing statutory regulation where it is a statutory obligation to report anonymously patient safety incidents that cause harm but there is no equal requirement to tell the patient or a relative. It would not add to the regulatory burden on health care organisations, and I think that it would enjoy public confidence, which is a very important thing to have in this area. That option would be relatively easy to achieve. The con is that it would require a change in the regulations, so there would possibly be some legislation.

In my opinion, option 2 is the best way to go. It is not something that is supported only by a few oddbods; such a change has the support of many people, including many senior people in the medical profession. I know that there are concerns about compensation and litigation, but the evidence from the United States, where many insurers now do insist on a more honest system, is that when people receive an apology, they are less likely to sue. When they find out what happened to their relative, they accept that mistakes are sometimes made and they are less likely to pursue lengthy and costly legal action.

People are sometimes pushed into legal action by the sense of injustice that they feel when their relative has undergone harm or perhaps died in the course of treatment. They feel a sense of injustice and are then driven to take that action. Of course, many of the costs to the NHS are from the legal fees, not necessarily the money paid out in compensation.

I shall go through a list of some of those who would support a statutory duty of candour. I have already mentioned Sir Liam Donaldson, the ex-chief medical officer, who formally recommended a statutory duty in 2003. Harry Cayton, chair of the Council for Healthcare Regulatory Excellence, has also supported such a duty. The late Claire Rayner, who was a doughty campaigner on behalf of patients, and a former nurse, supported it. Professor Aidan Halligan, the former deputy chief medical officer for England, who is currently chief of safety at Brighton and Sussex University Hospitals NHS Trust, is completely supportive of the proposal. There is also Sir Graeme Catto, the immediate past president of the General Medical Council; Sir Donald Irvine, a past president of the GMC; Sally Taber, director of Independent Healthcare Advisory Services; Cure the NHS; Patient Concern; and Sufferers of Iatrogenic Neglect. There is broad support in the LINks—local involvement networks—organisation for the view that what has been described is an important thing to do.

In recent years, we have become aware of a major disaster at Stafford hospital. It has affected not one or two people, but hundreds of them. Of course, it has been the subject of much debate, many statements in the House and a lot of real concern, but had there been a statutory duty of candour, the management of Stafford hospital would not have been able to get away with the poor standards of treatment and nursing and the fact that many hundreds of people lost their lives. Such a duty is a very important and practical measure, and if the NHS is to mean anything to the people of this country, being open and honest with those who have suffered as a result of what are sometimes unavoidable accidents is the best way to proceed.

There are clear benefits to introducing a statutory duty, and there is an historic opportunity in that regard. I listened to my right hon. Friend the Secretary of State talking over the weekend about more transparency. Introducing such a duty would be a brave step, because all the advice from people in the Department of Health would be, “Careful, Minister. Don’t do anything that might have long-term costs.”

However, in the modern age—an age of freedom of information, when thousands of documents appear on the internet—it is not unreasonable that a cornerstone of the NHS in this century should be that people are up-front and honest, and tell the truth when something goes wrong. Things inevitably do go wrong—not necessarily deliberately, but simply because that is the way of the world and medical science. People can then understand what has happened to their relatives.

As my constituent Mr Bye said, “The start of the healing process after the loss of a loved one is to know the truth of what happened.” It is a very poor thing if Governments cannot tell the truth. One has to acknowledge that truth has not always been the essential component of the NHS that it should be. I propose that the Government give serious consideration to a statutory duty of candour, because that is the best protection for those who use the health service and for higher standards. The best protection is that all of us believe in honesty in public life.

--- Later in debate ---

[Tom Brake]

I am sure that Mr Powell will be listening carefully to what is said and reading the remarks in Hansard later. That family have played a major role in bringing this issue to our attention and are working with AvMA to promote what they hope will become Robbie’s law.

The MPS has provided information that I think works against its case. Its research shows that, at the moment, a third of doctors are not prepared to be open and honest when an accident occurs. If so many doctors feel constrained from or concerned about being open when an accident has occurred, it supports the case for a culture of candour. The MPS also refers to states in the United States where there is a duty of candour and where it perceives that there may be a difficulty in enforcing the duty. In his remarks, my hon. Friend the Member for Poole made it clear that the Care Quality Commission has confirmed that it could and would enforce a statutory duty, and would be in a position to do so, if that were part of its regulations.

Another issue that the MPS raised, which we need to respond to, is that the proposed duty would not include near misses. It is arguing against the duty of candour, but at the same time saying that it would be a problem if near misses were not included. I understand that there is a general agreement that, although it might the norm for near misses to be reported to the patient, there would be discretion in cases in which reporting a near miss might cause unnecessary harm. There is recognition that the near miss issue needs to be addressed carefully.

One important fact is that, whether it is a duty or a requirement, it must apply to all health care organisations. If there was one thing in the coalition agreement that was slightly remiss, it was the fact that it referred only to hospitals, but there is a wider health body that we need to include. I am sure that the Minister will clarify in her response that the duty of candour, or the requirement, would need to apply not only to the patient but, sadly, if the patient has died as a result of the accident, more widely to include family members. It should not be strictly restricted to the person who had the misfortune of suffering the accident.

[Dr Pugh]

My hon. Friend mentions hospitals, but does he not accept that there are severe diagnostic failures at primary care level? Failures to refer can seriously imperil life, so they, too, need to be encompassed in the duty of candour.

--- Later in debate ---

[Dr John Pugh (Southport) (LD)]

I thank the hon. Member for Poole (Mr Syms) for introducing this important and timely debate and for putting the Government’s dilemma so succinctly and accurately. I also pay tribute to my hon. Friend the Member for Carshalton and Wallington (Tom Brake), who has done as much as anybody in this place to raise the issues of a duty of candour and patient rights.

I do not know whether anybody caught Ian Hislop’s programme about do-gooders on the BBC this week, but in it he described the creation of the journal The Lancet. It was set up by a young doctor, who, among other things, wished to expose some of the deficiencies in the appalling surgical practices at that time. He was greeted with wholesale acrimony from much of the medical profession and he was successfully sued. That shows that there is resistance in most businesses and professions to acknowledging error.

In an excellent book published some time ago, the sociologist Erving Goffman suggested that people in all organisations—whether in health, business, teaching or policing—have a vested interest in supporting their colleagues, playing as part of a team and working together to minimise the reputational loss that their organisation can suffer. He analysed in particular detail how that can happen in health services right across the world, although it must be said that such things do not always happen for bad reasons. People have duties of loyalty to colleagues and a genuine concern for the organisation to which they belong—for its reputation and, where admitting to errors might seriously imperil it, for its very survival.

People inside organisations often recognise that mistakes will happen in their organisations. I have worked in the teaching profession all my life, and I have not always been very overt about my colleagues’ deficiencies, even when that sometimes has involved people suffering from alcoholic intoxication when they should not. There are therefore circumstances in which people cover up. There is also probably a belief in many organisations that the internal resolution of problems is the best way to proceed.

However, there is a huge downside; confidence is eroded by simply taking such a path. Worse still, false confidence persists; in other words, there are palpable and demonstrable errors in organisations, but nobody finds out about them until it is too late. Errors remain uncorrected, and poor performance is undeterred or, in some cases, it worsens.

That is where the duty of candour fits in, because it will, on a voluntary or simply a request basis, lessen the problems. There is an enormous amount of evidence not only that patients want the NHS to be candid with them, but that the NHS finds it hard to be candid. The Department of Health itself spoke of a culture of denial in the NHS—denial about error and, more seriously, about negligence.

No one believes that things will necessarily improve if nothing is done. No willing provider entering the frame will find it easier to be more candid than NHS organisations; in fact, they might have other motives for covering up. They might be answerable to others apart from members of the public, such as shareholders and the like. There is therefore a genuine concern to get things right.

Every Member of the House of Commons has probably come across a case, or several cases, where they feel that things have gone badly wrong. In my intervention on my hon. Friend the Member for Carshalton and Wallington, I mentioned primary care. A young man in my constituency—he was a relative of a friend of my daughter’s—went to his GP five times to complain of listlessness, a lack of energy and so on. He was brushed off with suggestions that he needed more rest and less stress. He was told that he perhaps had glandular fever, but no blood test was done. Eventually, when one was done, it was discovered that he had late-stage leukaemia. My children attended his funeral. That clearly was a failing.

I am also familiar with the ongoing case in my constituency of a TV soap star with a disabling condition that was brought on by receiving the wrong diagnosis and the wrong treatment. Similarly, I had the long-running case of a lorry driver with severe hypertension who was prescribed Viagra for other complaints, even though Viagra increases blood pressure. The thought of a lorry driver being prescribed a drug that can imperil not only him but members of the public is quite disturbing.

A woman in my constituency was falsely diagnosed with cancer and treated for it until, on the spur of the moment, she decided to request a check of the X-rays. Staff then found that the X-rays that they had been using, and which they had assumed were correct, were those of another person. That woman had spent a year in absolutely harrowing circumstances. More disturbingly, we do not know whose X-rays were assigned to her. Presumably, that person was not given the treatment that this woman was wrongly given.

Each of those cases leads to a prolonged complaints procedure, involving the ombudsman and the Care Quality Commission. In other cases, as other Members have indicated, there have been accusations that records have been altered. The whole process is inordinately cumbersome and difficult. To some extent, it exists because there is no candour where candour would probably be the solution.

On top of that, there are the systemic failures—the Mid Staffordshires, the Bristol heart babies and so on. To be fair, the Government recognise that this all comes with the territory of running the modern health service, and they are, to some extent, endeavouring to deal with the problems. Lots of things are going on, and we all want to applaud and support what the Government are doing on quite a few issues. We also applaud the previous Government for having initiated some of these things.

Incident reporting has got better, which is wholly desirable. Complaints are monitored, which is good and a move wholly in the right direction. There is more intensive recommending of procedures. The NHS is more of a learning body than it ever used to be; good practice is disseminated, while bad practice is identified and controlled. There is a general beefing-up across the piece of NHS guidance—particularly to the secondary care sector—about things not to do, things that will help and things that will avoid mishap.

Right across the profession, there is a constant stressing of professional ethics, as spelt out by the General Medical Council or whoever. In the past few days, we have had the phenomenon of publicising outcomes, with efforts by Dr Foster and, presumably, the Department of Health to see that outcomes are properly tracked.

[Mr Syms]

It is interesting that it is sometimes non-NHS organisations such as Dr Foster, rather than the NHS itself, that put their finger on the things that go wrong. The NHS is a wonderful organisation generally, but most of my constituents would be surprised that there is not a duty of candour already. One reason why we have not got one is that we find out that we do not only when we actually have a problem.

[Dr Pugh]

Dr Foster is probably doing what the Government will eventually get around to doing, and it will presumably prompt the Government to do that more expeditiously.

In some cases, private organisations may find it slightly easier than the Department of Health to progress such matters, but a lot of internal consultations and procedures will need to take place. Such organisations do not need to be answerable for how they treat the bodies within the NHS. A recent key development is the Government’s willingness to ensure immunity for whistleblowers, and to encourage whistleblowing when appropriate. That is a good thing, but there is evidence that whistleblowers still take genuine risks. For instance, they may not be sacked or redeployed, but they may experience difficulties getting employment elsewhere in the health service. I know of cases in which genuine whistleblowers have regretted the professional outcome that has resulted.

Such Government measures are self-evidently to the good, but they are not the same, equivalent to or a substitute for a duty of candour. Frankly, not all errors will be reported and not all complaints will get bottomed out. As others have said, guidance is ignored, professional ethics can be flexibly interpreted, and outcomes, whether published by Dr Foster or others, often come too late or are too general for individual cases. As I pointed out, although whistleblowers may have temporary immunity, that may not last. The Department of Health spoke of a culture of denial; but if such a culture exists, it needs to deal with it.

The argument against a statutory duty of candour—that, in a sense, the simple duty to be open with patients or relatives when requested is otiose or redundant—is not sustainable. It cannot be used as a genuine reason for Government reticence or hesitation. I therefore ask why the Government are hesitating when they are going ahead with so much else. A duty of candour is a disincentive to cover up, and it takes away the risk for whistleblowers.

Statutory duties are important. I give a parallel example. Local authority reporting officers, usually directors of finance, have the job of identifying when a council is spending money in a reckless and improvident way. They have always been in that position, but prior to there being a statutory duty to show the council the red card they were often bullied by the political establishment. As a result, they unwillingly had to consent to the deployment of council resources in ways that were reckless. Without a statutory duty, the same sort of thing can happen in health institutions. People can be put under a lot of pressure, and unless they can say, “But I have the statutory duty to report this,” they will find themselves in appreciable difficulties.

If we all believe in transparency—and we do at the moment—the duty of candour must be part of it. It keeps patients informed of their genuine situation. It is entirely in line with what the Secretary of State says again and again—it is a good quote, which I paraphrase, about no action being done to me without my consent. That is the gist of what he says. Why, then, do we hesitate, given the coalition agreement? The Liberal Democrats are clearly on board, and many Conservative Members genuinely support it. Indeed, the coalition agreement is emphatic.

I have the perception that somewhere in the background in the Department of Health the voice of Sir Humphrey can be heard. Just as the Minister is about to initiate a statutory instrument on the subject, someone in the civil service—I do not accuse the permanent secretary—says, “That is a very brave decision, Minister.” The Minister is thus persuaded that his decision may not be as positive as appeared at first sight.

If one thinks about it, a candid admission of error or, worse still, of negligence is intrinsically damaging and potentially expensive. I have seen stats suggesting that the potential damage to the NHS, if every person who had a complaint pursued it legally to the nth degree, might be a bill of something like £10 billion. That is half of the internal savings that the NHS needs to make.

However, the stats also show that litigation costs against the NHS are far less than that. The unnerving feeling inside the Department of Health is that if it goes for a statutory duty—I believe that it should—that picture might change dramatically, as the number of complaints that end up in successful and expensive litigation mushrooms.

[Tom Brake]

Does my hon. Friend agree that, because the information is now in the public domain, another consequence might be that the number of accidents will reduce because people will take the necessary action to ensure that such things do not happen?

[Dr Pugh]

One sincerely hopes so. I was a member of the Committee that considered the NHS Redress Act 2006, which I believe is not yet in force. The sort of thinking suggested by my hon. Friend was behind that Act, but the same forces that are delaying the duty of candour are probably responsible for delaying its implementation. I cannot recall there being much dissent among the parties as to the merits of that legislation. The idea was that complaint costs would reduce if we had an open policy of admitting errors, patients surrendering none of their legal rights but simply being given the apology and the explanation that they wanted.

As the hon. Member for Poole said, people who wish to pursue a complaint against the NHS if they believe that their treatment has gone wrong are not looking for money. They are looking not only for an explanation and an apology; they are looking for an assurance that whatever happened to them or their relative will not happen to others.

Prior to the NHS Redress Act 2006, we looked hard at the costs of litigation in the NHS. Yes, it cost the NHS a lot of money; and, yes, something could have been done to reduce it. The really depressing thing, however, was that the bulk of the money went into the lawyers’ pockets on either side. The NHS is not about helping to boost lawyers’ profits.

The 2006 Act seemed to offer an alternative to litigation, which everyone would support, but the nagging fear in the Department of Health was that it would become a platform for litigation—that if someone admitted a fault it might be a sound basis for taking legal action. Are those fears well grounded? I believe that we do not precisely know, but we all have our own feelings on the subject. People cite the Michigan case in the United States, where they went outright for a duty of candour, and litigation costs to the health service have declined.

The duty of candour is not something that can be piloted, and once it has been done one cannot withdraw it. To go ahead with it is almost an act of faith. I am very keen on the concept of evidence-led policy, but I see evidence-led policy debates taking place in the Department of Health. If we go ahead with a statutory duty of candour—and I firmly believe that we should—it will be a statement about what sort of NHS we want.

I conclude by quoting Sir Liam Donaldson, the former chief medical officer for England. He said,

“To err is human, to cover up is unforgivable”.

Regardless of the risks, I doubt whether the Government want to do what is unforgivable.

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[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to serve under your chairmanship for the first time Mr Gray congratulate my hon. Friend the Member for Poole (Mr Syms) on securing this debate. As Chairman of the Regulatory Reform Committee, he is no doubt acutely aware of some of the issues that exist around regulation, not least those that exist around the duty of candour. His humility and recognition of the impossible task that we face here today—to truly reflect the pain and suffering of those who have suffered as a result of medical harm—does him considerable credit.

We take candour and openness in the NHS extremely seriously. Everybody does, because it is a vital issue. As anyone who has ever been treated knows, a health care system is not just about how quickly someone is seen or how quickly their stitches come out; it is also about trust. Trust is fundamental—between patients, the patient’s family and health care professionals—and we must do everything we can to ensure that that trust is upheld.

As my hon. Friend may be aware, one of the early references to a statutory “duty of candour” was included in “Making Amends”, a 2003 report, which I know hon. Members have referred to. It was a consultation paper from the then chief medical officer, Liam Donaldson, and it set out proposals for reforming the approach to clinical negligence in the NHS, suggesting

“a duty of candour requiring clinicians and health service managers to inform patients about actions which have resulted in harm”.

The paper also proposed to foster an environment of openness and honesty among all NHS staff; it encouraged “integrity”, which is a word that we perhaps do not use often enough, and it proposed exempting those who report adverse events or medical errors from disciplinary action, unless there are serious extenuating circumstances. It is a key belief of the coalition, and I would hope all Members of the House, that the focus should be on the performance of the organisation rather than on penalising individuals who bring matters of concern out into the open. The hon. Member for Southport (Dr Pugh) has already mentioned whistleblowing. I think that the point is that this debate is not necessarily about the protection of whistleblowers or a right to whistleblow; it is perhaps about a duty to whistleblow.

It is important to note the good work that is currently being done to promote candour. The previous Government should be congratulated for providing staff with advice and support to help them to communicate with patients, their families and carers following harmful incidents. The Health Act 2009 requires all NHS organisations to be aware of the NHS constitution, which places a duty on NHS staff to acknowledge mistakes, apologise for them, explain what happened and put things right. The professional codes of practice for doctors and nurses contain a similar duty.

As somebody who trained as a nurse and worked in the NHS for 25 years, I think that professional codes of practice and professional standards are not talked about often enough. We look for someone to blame: we look for the organisation to blame; we look for the board to blame, and we look for the chief executive to blame. What we do not talk about is individual professional standards and I feel particularly strongly that we need to do everything that we can to raise those standards right up.

The National Patient Safety Agency has been running its own campaign to promote candour in the NHS, as the hon. Member for Leicester West (Liz Kendall) said. That campaign, entitled “Being Open”, is a long-term process rather than a short-term push. It encourages the provision of verbal and written apologies to patients, their families and carers; it promotes continual communication with those involved in incidents, and it requires thorough record-keeping of all “Being Open” discussions and documents.

However, we all know that still more needs to be done, as hon. Members have said and as I know myself from my own constituency casework; I have a number of people who have continually fought to try to get the truth about what happened to their relatives. The recent White Paper, “Liberating the NHS”, states that

“we will require hospitals to be open about mistakes, and always tell patients if something has gone wrong”.

It is quite simple: we expect the NHS to admit to errors; apologise to those affected, and ensure that lessons are learned to prevent errors from being repeated.

In one year, the NPSA receives notification of more than one million incidents. Most of those incidents result in no harm and we welcome the high level of reporting. However, the incidents that result in harm obviously cause distress and anguish for the patients and families involved. In those cases, it is even more important that the lessons are learned and that organisations are open with those who have been affected.

[Dr Pugh]

I want to ask about the future of the NPSA. If it is going to be brought within the national commissioning body, will a Chinese wall be established between the NPSA and the other operations of that body? It crosses my mind that risks can allegedly be increased or decreased by commissioning decisions themselves.

Under those circumstances, the NPSA has got to be free to impute itself, as it were, if the national commissioning body is going to be part and parcel of the same organisation. So, can the Minister assure me that there will be no conflict of interest when the NPSA is placed within the national commissioning body, which may itself—through its commissioning procedures—be one of the risk factors?

[Anne Milton]

The hon. Gentleman is absolutely right. That is terribly important. It is not only important to have Chinese walls and be seen to be separate; it is important to be separate. I will come to that point in detail in a minute.

Measuring openness is not as straightforward as measuring reporting. We welcome high levels of reporting, as they are an indicator of an open and supportive culture of patient safety, but there are still reasons why people within the NHS and organisations shy away from openness. Without a doubt, professionals who strive for excellence are reluctant to admit errors. The higher up the tree one is, the harder it is to say, “I’ve made a mistake.” All of us face that issue in our professional lives.

People may have unfounded concerns about possible admissions of liability, even though apologising when something has gone wrong is not in any way an admission of liability. The fine line between the two sometimes prevents people from saying what relatives want to hear: “I am so sorry this happened.” That is not necessarily saying, “I have made a mistake.” It is such a shame when professionals resort to a defensive stance, often encouraged by myths about where liability lies. Also, at times, they may fear reprisal, blame and even bullying.

We are considering options for introducing a requirement for openness and will make a decision in due course. The hon. Member for Southport felt that we were hesitating, and was concerned about possible evidence of Sir Humphreys in the Department. We are considering, not hesitating. It is important to get it right. Members have discussed the three options, but I will run through them quickly and mention a few relevant issues.

The first option is using what is in the existing Care Quality Commission registration requirement regulations. It is already mandatory for NHS trusts to report all serious patient safety incidents. We could also require organisations to demonstrate that they have met the openness requirement, which would not require new legislation. It makes sense to use existing means to detect and investigate trusts that are not as open as they should be. The counterargument is that that approach is not specific enough, and that the wording of the guidance would need to be made more explicit. We have seen many cases in which guidance has failed.

The second option involves introducing a new legal, statutory duty of openness explicit within the CQC regulations. That would send a clear signal about the importance of openness and provide patients and campaigners with a single clear duty that they could use to demand full disclosure. However, the Government want to create new legislation only when absolutely necessary, although when necessary, it should be done. We would need to ensure that any new legislation or new approach was not counter-productive. We want to make it easier for staff to come forward; we do not want new legislation to have unintended consequences.

The third option involves incorporating an openness requirement into the new NHS contractual, performance and commissioning processes, to which the hon. Members for Leicester West and for Southport referred. It certainly appears possible to pursue openness through the new commissioning arrangements. For instance, it could be written into standard NHS commissioning board requirements that providers commit to being open. The hon. Member for Leicester West asked whether the NHS commissioning board would have time to take a role on patient safety. In many ways, safety underpins all commissioning decisions. Any decision on any service commissioned should have safety wrapped around it. That is fundamental.

As with any complex matter, each of the options has its pros and cons. It is imperative that a decision on the issue is not rushed. I reassure the hon. Lady that campaigners and organisations have good access to officials within the Department, and I am sure that all their views will have been taken into account when a decision is made, because we are aware of the importance of getting it right. It is terrible to think that the first duty of the NHS is to do no harm. Safety wraps around everything that we do.

The hon. Lady also mentioned the decision to abolish strategic health authorities. I understand that SHAs are the performance managers of trusts, yet that did not help in Staffordshire. In many ways, bringing commissioning decisions closer to the patient within general practice will mean that decisions about care and its consequences rest where they should.