Francis Report

Kevin Barron Excerpts

Wednesday 5th March 2014 Commons Chamber

[Kevin Barron (Rother Valley) (Lab)]

I reread the executive summary of the Francis report yesterday when I was on a train journey, and I decided that in today’s debate I would like to look at one of the most crucial aspects of his findings in respect of what happened at Mid Staffs.

On page 62, at paragraph 1.102, the summary states:

“The senior officials in the DH have accepted it has responsibility for the stewardship of the NHS and in that sense that it bears some responsibility for the failure of the healthcare system to detect and prevent the deficiencies at Mid Staffordshire sooner than it did. There is no doubt about the authenticity of their expressions of shock at the appalling story that has emerged from Mid Staffordshire. However, it is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current Government.”

It goes on to say:

“Where there are perceived deficiencies, it is tempting to change the system rather than to analyse what needs to change, whether it be leadership, personnel, a definition of standards or, most importantly, culture. System or structural change is not only destabilising but it can be counterproductive in giving the appearance of addressing concerns rapidly while in fact doing nothing about the really difficult issues which will require long-term consistent management. While the DH asserted the importance of quality of care and patient safety in its documentation and its policies, it failed to recognise that the structural reorganisations imposed upon trusts, PCTs and SHAs implementing such policy have on occasion made such a focus very difficult in practice.”

It is my contention that we could probably say that of every reorganisation of the NHS, certainly in my three decades in politics.

The summary goes on to discuss the lessons learned and related key recommendations:

“The negative aspects of culture in the system were identified as including: a lack of openness to criticism; a lack of consideration for patients; defensiveness; looking inwards not outwards; secrecy; misplaced assumptions about the judgements and actions of others; an acceptance of poor standards; a failure to put the patient first in everything that is done.”

It goes on:

“It cannot be suggested that all these characteristics are present everywhere in the system all of the time, far from it, but their existence anywhere means that there is an insufficiently shared positive culture.”

Again, it is my contention that that sums up not just the past 30 years but perhaps the past 60 years of our national health service.

The summary goes on to say that achieving change

“does not require radical reorganisation but re-emphasis of what is truly important”.

All parties in the House should recognise that it is not the reorganisation but the re-emphasis of what is important that is significant. Paragraph 1.119 lists how that can be achieved:

“Emphasis on and commitment to common values throughout the system by all within it; readily accessible fundamental standards and means of compliance; no tolerance of non compliance and the rigorous policing of fundamental standards; openness, transparency and candour in all the system’s business; strong leadership in nursing and other professional values; strong support for leadership roles; a level playing field for accountability; information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation.”

I was not surprised by any of that.

The right hon. Member for Sutton and Cheam (Paul Burstow) was a member of the Select Committee on Health in the previous Parliament between 2005 and 2010, and I had the privilege of chairing that Committee. In 2009 the Committee looked at patient safety in the NHS. We visited one of only four hospitals that were part of a patient safety project on how to look after patients inside hospitals, never mind outside. We looked at some of the major issues at the time, such as how different parts of the NHS interacted and their failure to communicate with one another properly. Much of the time they were working with different regulations, and occasionally the inspectorate was not sure what it was responsible for inspecting. This whole restructuring has been going on for a very long time, and it has been more confusing to people working inside.

I am pleased with how the Government have reacted to some of the Francis report’s main recommendations, but I take issue with them on one point. If we are to change the culture inside the NHS, we really need to look at the duty of candour. The Government have accepted the report’s recommendation on a duty of candour for organisations, but they have rejected the recommendation to extend that duty to individuals. I think that is fundamentally wrong.

I spent nine years as a lay member of the General Medical Council, which regulates doctors, and for the first few years I would sit on fitness-to-practise committees. I think that the only way we shall get change is if individuals have responsibility for the duty of candour, not just organisations. I believe that the Government have got that fundamentally wrong. If they really want to tackle the issues that led to the awful situation at Mid Staffs, they need that duty of candour to extend to individuals.

On the Government’s decision on the duty of candour, the Patients Association has stated:

“We question that if individuals are not already motivated by their own professional code, how will a duty on their employer encourage them to come forward?”

That is absolutely right. It continued:

“Without this fundamental change within the NHS, the Duty will just be providing lip service to the issue of patient safety and patients will struggle to see any real improvements.”

That is a big assumption, but on balance I agree. It is something that the Government, no matter who is in Richmond House, need to tackle throughout the NHS.

I have in my hand a copy of the Health Committee’s report on patient safety, which was published in July 2009. We looked at patient safety across the health care system and compared it with what was happening abroad. We visited New Zealand, which has a comparable health system—I accept that the country has only 4 million occupants, compared with our 60-odd million. We looked at why the culture here is the way it is, why people are not open and why they do not learn from mistakes that other health professionals have made. Often those mistakes are not reported because people fear they will get into trouble. We took evidence from the British Airline Pilots Association and learned that any mistake a pilot makes in an aeroplane is whizzed around the world so that other pilots understand it and learn the lessons immediately. That is not the case in our health service.

I want to mention two of the Committee’s findings from New Zealand. The first relates to investigating complaints. I do not think that leaving the duty of candour to organisations, as the Government suggest, will work well. New Zealand has a statutory body—I have mentioned it before in the House—called the Health and Disability Commissioner, which resolves complaints. People can go to the commissioner to request investigations, and they can do so anonymously if they do not want their colleagues to know about it. It is completely independent of the health care system. It works, and it has been working for many decades.

Another area we looked at in New Zealand—again, I accept that it is a very small country—was compensation and redress. I know from my experience of 30 years in Parliament that when people complain about something that happened to them in their local hospital that they are unhappy about, they are treated as if they are going to get into litigation and that it will cost a lot of money; immediately the barriers come up. That culture is not good for our health service, it is costing massive amounts of money for us as taxpayers, and it is certainly not good for the individual concerned. I do not know how many times I have been told that all the patient wanted was an admission that the hospital got it wrong and an apology; they did not necessarily want money. New Zealand has a redress system that some might call a no-fault liability system. Here, it would mean getting rid of lots of lawyers who make massive amounts of money and careers from public money for NHS litigation. Just those two areas hold back changing what is wrong in our system.

[Barbara Keeley]

I wonder whether my right hon. Friend has had similar cases to a difficult one that I had for months involving someone whose wife died in terrible circumstances at home. He was badly let down by the care she received and he wanted redress. He found that people were happy to have meetings with him and to talk to him, and were sympathetic and supportive, but whenever something was put in writing, it was absolutely dreadful. He was very offended and horrified by everything that was in writing, and that is the chilling effect of lawyers because they checked everything. It ruins the support that can be given after a difficult bereavement and when someone has a real case. Things can be said, but they cannot be written down.

[Kevin Barron]

I agree entirely. The system is defensive and people do not get a satisfactory response, but the lessons are not learned. Issues are not reported for fear of the consequences. The Minister is a doctor. He will know that if as a junior doctor he had seen a senior doctor doing something wrong and had gone public about it, it might have affected his career. Some young doctors’ careers have been affected. That is not good for the system, and it is certainly not good for patients.

I am a wholehearted supporter of the national health service and the way it is funded. There is none better in the world, and we can use it without question. It may be different in different parts of the country, but access to health care in this country is second to none in the world for the whole population as opposed to just those with money. Could it better? Yes, and what the Francis report said was a lesson for all of us, and for the national health service. We should change the culture, but we will not do that with reorganisation or by blaming one another in the Chamber for what is right or wrong. That just feeds the politics of the national health service. We must change the culture by putting the patient first, and after 60-odd years it is about time we did.

--- Later in debate ---

[Dr Poulter]

We are leading by example. As I outlined, the Secretary of State has accepted the TSA recommendation in full. A process is now under way involving NHS England and local commissioners. That was initiated last week. It is important that those conversations happen and that an update is brought forward in a timely manner. That is the right thing to do. It is not appropriate to rush decisions and processes because of a political agenda, rather than an agenda of benefiting the local patients and women concerned. I am concerned as a doctor and as a Minister that we must do the best thing by patients. Rushed decisions are not always the best thing for patients, because conversations need to happen between local commissioners and NHS England. I hope that the hon. Lady will be a little patient, because I am sure that the right decision will be made in due course.

There are three key areas in which the Government have taken forward the recommendations of the Francis inquiry: encouraging a culture of transparency and openness in the health care system; empowering front-line staff and encouraging good leadership in the NHS; and putting the patient at the heart of everything that the NHS does. As we have discussed, the patient was not at the heart of everything that was done at Mid Staffordshire for a period. That is why we have to learn the lessons and ensure, as best we can, that that cannot happen again.

On transparency and openness, it is important to highlight how we have already delivered on the recommendations of Robert Francis’s report. The CQC has appointed three chief inspectors for hospitals, social care and general practice who will ensure not only that the organisation is complying with the law, but that the culture of the organisation promotes the benefits of openness and transparency. Importantly, we now have clinically led inspections for the first time, which means that people who really understand what good care looks like will be in charge of the inspection process. That clinical leadership in the inspection process and at the heart of what the CQC does has to be of benefit to patients, and the Government are proud that we have delivered that.

We have also introduced a new statutory duty of candour on providers, which will come into force this year. It will ensure that patients are given the truth when things go wrong and that honesty and transparency are the norm in every organisation.

[Kevin Barron]

rose—

[Dr Poulter]

The right hon. Gentleman might wish to intervene in a moment, but first I will respond to his good points on the importance of the duty of candour. There is some disagreement between us, because he said that there should be a duty on individuals. He will be aware from his time at the General Medical Council that there is already a duty on professionals to act in the best interests of patients and raise any concerns about the quality of care. As a body, the GMC has learned lessons from Mid Staffordshire and reviewed its processes, but it is important to recognise that many front-line professionals at Mid Staffordshire tried to raise concerns. The culture at the trust was such that those in management positions did not always listen to them. If we want to support whistleblowers and people’s ability to speak out freely for the benefit of patients, that has to be done at organisational level. Health care professionals are already under a duty through their professional obligations, which I hope reassures the right hon. Gentleman.

The right hon. Gentleman has been in the House for many years and will remember that problems of people not being able to speak out freely in their organisations date back to the Bristol heart inquiry. Professor Kennedy, who oversaw that inquiry, noted that it was the cultural problem in that hospital provider that prevented people from speaking out. The problem was not that people were not prepared to speak out—they recognised their professional obligations; it was that there was a wish at a senior level not to recognise problems. That is what we need to tackle. We are now almost 15 years on from the Kennedy inquiry into Bristol—I was a law student at Bristol university at the time—and the NHS has perhaps not learned the lessons that it needs to. I am sure that putting a duty of candour on to NHS organisations will begin to get us where we need to be.

[Kevin Barron]

Will the Minister consider what I said about how an independent statutory commissioner could examine complaints about patients’ care, as happens in New Zealand? Will he get back to me about whether he thinks that is a good idea? The people who work in the institutions that he is talking about have no faith that anything can be changed.

[Dr Poulter]

I will talk about complaints a little later, but the right hon. Gentleman has made some important points. When we consider how to improve the delivery of care in our health service, it is important that we examine international comparisons. The system in New Zealand includes a different form of compensation, and perhaps that is partly why it has a more open culture—there could be many other factors. It is acknowledged much earlier in the process that something has gone wrong, and there is a genuine attempt to explain the situation to the family and say sorry. That is what good health care is all about.

No matter how good, well trained and dedicated staff are, things will sometimes go wrong in a health service. When they do, it is important that we are open and honest with patients and that we do our best to put things right if we can, or explain and apologise if we cannot. That is why we believe that the duty of candour needs to exist at organisational level. Of course, I am happy to write to the right hon. Gentleman, or meet him if he would like to talk through some of the issues that he raised today. He makes good points, and I know that he does so on a completely apolitical basis because he has the best interests of the health service at heart. We might disagree on other issues, but on this one it is worth having a meeting to discuss his views further.

Subject to the passage of the Care Bill, a new criminal offence will be introduced to penalise providers who give false or misleading information where that information is required to comply with statutory or other legal obligations. It means that those directors or other senior individuals, including managers, who consent to, connive in, or are negligent regarding an offence committed by the provider could be subject on conviction to unlimited fines or even custodial sentences. We must ensure that managers and those running the health and care service in a health care provider provide information in an honest and transparent way that is always in the best interests of patients.

Importantly, we are introducing through the Care Bill a single failure regime to ensure that failure is not only about the financial sustainability of the trust, but about whether a health care provider is providing good care, and the quality of that care. One problem in the past with the trust special administration regime has been that it is rarely used. When it is used, however, it is important to ensure that it is there to protect patients. Often in the past it was used only in a way that focused on financial failure. One important lesson to learn from Mid Staffs is that there should be a failure regime that also considers quality of care. Hospitals are not just about good accounts; they are primarily about delivering good care, which is why we need a single failure regime. My right hon. Friend the Secretary of State has been a tremendous advocate for the importance of quality of care in trust, and he should be commended for that. Thanks to him, we are now ensuring that we improve the TSA regime in that way.