Mid Staffordshire NHS Foundation Trust

Lord Lansley Excerpts

Wednesday 9th June 2010 Commons Chamber

[The Secretary of State for Health (Mr Andrew Lansley)]

With permission, Mr Speaker, I wish to make a statement on Mid Staffordshire NHS Foundation Trust.

In March last year, the Healthcare Commission’s report on Mid Staffordshire and the appalling failures in patient care that it laid bare shocked us all. Three reports later, and I am announcing today what should have been announced then: a full public inquiry into how these events went undetected and unchallenged for so long. The inquiry will be held in public, including the evidence, the oral hearings and the final report. We can combat a culture of secrecy and restore public confidence only by ensuring the fullest openness and transparency in any investigation.

So why another inquiry? We know only too well every harrowing detail of what happened at Mid Staffordshire and the failings of the trust, but we are still little closer to understanding how that was allowed to happen by the wider system. The families of those patients who suffered so dreadfully deserve to know, and so too does every NHS patient in this country.

This was a failure of the trust first and foremost, but it was also a national failure of the regulatory and supervisory system, which should have secured the quality and safety of patient care. Why did it have to take a determined group of families to expose those failings and campaign tirelessly for answers? I pay tribute again to the work of Julie Bailey and Cure the NHS, rightly supported by Members in this House.

Why did the primary care trust and strategic health authority not see what was happening and intervene earlier? How was the trust able to gain foundation status while clinical standards were so poor? Why did the regulatory bodies not act sooner to investigate a trust whose mortality rates had been significantly higher than the average since 2003 and whose record in dealing with serious complaints was so poor? The public deserve answers.

The previous reports are clear that the following existed: a culture of fear in which staff did not feel able to report concerns; a culture of secrecy in which the trust board shut itself off from what was happening in its hospital and ignored its patients; and a culture of bullying, which prevented people from doing their jobs properly. Yet how these conditions developed has not been satisfactorily addressed. The 800-page report by Robert Francis QC, published in February, gave us a forensic account of the local failures in that hospital and the consequences for patients, but, like its predecessors, his report was limited by its narrow terms of reference.

I am pleased to say that Robert Francis has agreed to chair the new inquiry, and he will have the full statutory force of the Inquiries Act 2005 to compel witnesses to attend and speak under oath. Clearly these are complex issues, and Robert Francis has already said he wants to establish an expert panel that can help support him through this process. However, it is important for everyone that the inquiry be conducted thoroughly and swiftly, with the aim of providing its final report and conclusions by March 2011.

I also want to assure the House, however, that we will not wait to take earlier action where necessary. I can therefore announce today that we are going to give teeth to the current safeguards for whistleblowers in the Public Interest Disclosure Act 1998 by: reinforcing the NHS constitution to make clear the rights and responsibilities of NHS staff and their employers in respect of whistleblowing; seeking through negotiations with NHS trade unions to amend terms and conditions of service for NHS staff to include a contractual right to raise concerns in the public interest; issuing unequivocal guidance to NHS organisations that all their contracts of employment should cover staff whistleblowing rights; issuing new guidance to the NHS about supporting and taking action on concerns raised by staff in the public interest; and exploring with NHS staff further measures to provide a safe and independent authority to which they can turn when their own organisation is not listening or acting on concerns.

In the coming weeks we will introduce further far-reaching reforms of the NHS that go to the very heart of the failures at Mid Staffs. This is not about changes in processes or structures; it is about a wider shift in culture, putting patients at the heart of the NHS and focusing on the things that matter most to them. That includes putting the focus on safety. At Mid-Staffs, safety was not the priority. It was undermined by politically motivated process targets. The first Francis inquiry was crystal clear on that point. It said:

“This evidence satisfies me that there was an atmosphere in which front line staff and managers were led to believe that if the targets were not met they would be in danger of losing their jobs. There was an atmosphere which led to decisions being made under pressure about patients, decisions that had nothing to do with patient welfare. As will be seen, the pressure to meet the waiting target was sometimes detrimental to good care in A & E.”

We will scrap such process targets and replace them with a new focus on patients’ outcomes—the only outcomes that matter. We will empower patients with access to information, giving them the ability to hold their own records, to make informed choices and to interact more readily with clinicians. We will put power in patients’ hands. Ultimately, if patients had been informed and empowered, and if people had listened to them rather than obsessing about centrally mandated processes and targets, these scandalous failings could not have gone unchallenged for so long.

In closing, I want to say a word about the trust itself. It is so important that the hospital and the trust, which have been under such an intense spotlight, should be able to continue to improve services for the patients they serve and continue to rebuild the trust and the fractured confidence of their community. Staffing there has increased, with more than 140 more nurses recruited since March 2009. Processes are more open and transparent, and monthly board meetings are now being held in public. Results are improving: the hospital standardised mortality ratio there is now significantly lower, and the rate of healthcare associated infections has improved. The Care Quality Commission will, in the coming weeks, provide its considered view on that progress, when it publishes the findings of its “12 month on” review.

We cannot and should not underestimate the task still ahead, and the attention of the trust must not be unduly diverted. That is why I am clear that this further inquiry should not cover ground already covered in the first Francis inquiry, and that it should, as far as possible, ensure that it supports all those staff who are working so hard to bring about the necessary changes. When this inquiry has completed its work and I return to the House to present its report, I am confident that we will, for the first time in this tragic saga, be able to discuss conclusions rather than just questions. We will be able to show that we have finally faced up to the truths of this terrible episode and that we are taking every step to ensure that it is never allowed to happen again. That is a basic duty of any Government. For the people of Staffordshire—many of whose relatives suffered unbearably in the closing stages of their lives—and for the nation as a whole, this is the very least they are entitled to. I commend this statement to the House.

[Andy Burnham (Leigh) (Lab)]

I begin by thanking the Secretary of State for Health, the right hon. Member for South Cambridgeshire (Mr Lansley) for his statement, much of which I welcome. It will be hard for the people of Stafford and for the staff at the hospital to hear that their town and their hospital are in the news again today, and it is important to say at the outset—as the Secretary of State did—that this inquiry relates to historical events at the hospital and that the situation there has been improving ever since. I should like to put on record my own personal appreciation of the role played by the new chair and chief executive of Mid Staffordshire NHS Foundation Trust in improving standards at the hospital, rebuilding confidence and rebuilding the important relationships with the local community.

Events at the hospital between 2006 and 2008 represent one of the darkest chapters in our national health service. As the Francis report—which ran to two volumes and more than 900 pages—documented, there were appalling failures at every level, from basic care and human compassion on the wards to a failure in the duty of care at board level towards staff, patients and the whole community.

The NHS and its values are part of what makes our country great, but the NHS is not perfect. When things go wrong, it has a tendency to push people away and bring down the shutters. Yes, it is hard to deal with complaints when they affect matters of life and death, but it is only by holding up a mirror to the national health service that we will get an open, learning health service that learns from its mistakes and ensures that they are not repeated. That is why I took the decision to commission the original Francis report. It is also why, before the election, I signalled the need for a second-stage inquiry, to be held in public, into the actions of the supervisory and regulatory bodies, right up to the Department of Health. I therefore give the Secretary of State the assurance that this new inquiry will have the Opposition’s full co-operation, from the very top right the way down.

We published the draft terms of reference for that second-stage inquiry before the election. Will the Secretary of State therefore explain to the House what questions or areas it will consider that were not covered either by the Francis report or the draft terms of reference that we laid before this House and on which we sought comments from a wide range of organisations? Also, what is different about the inquiry that he has announced, compared with the one that we proposed?

How long will the new inquiry take, and how much will it cost? Will he give the House an assurance—as I think that he did in his statement—that he will ensure that it does not distract the trust from the overriding task of ensuring that the hospital continues to make the necessary improvements? Will he also make sure that the trust’s leadership can continue to focus on improving relations with the local community?

Will the right hon. Gentleman give me an assurance that the recommendations of the original Francis report will continue to be implemented in full while the new inquiry takes place? He will know that Robert Francis concluded in his original report that many people came forward who would not have done if the inquiry had been held under a different status. I gave Robert Francis the ability to come back to me to ask for further powers if they were necessary, but may I ask for the right hon. Gentleman’s assurance today that the status of the new inquiry will ensure that all the people who need to speak to it do come forward and give evidence?

On NHS targets, I was disappointed by the Secretary of State’s comments in his statement, and by those of the Prime Minister a few moments ago, as they appear to be prejudging the inquiry that they have set up today. Trusts up and down the country are implementing national standards safely. Indeed, targets are about patient safety: the four-hour A and E target is the basic minimum that every person in this country can expect when arriving at the door of the NHS.

The targets were implemented and brought in because some years ago, people were waiting for hours on end—almost whole days—in A and E departments. If the Secretary of State is resolved to remove that standard in the NHS, which many of the professional health bodies support, will he therefore give us an assurance that we will not see a rise in A and E waiting times? What mechanism will he implement to ensure that?

The trust’s board allowed staffing to fall to dangerously low levels, with 120 whole-time equivalents lacking from the wards. I put it to the Secretary of State that that was the main reason for the failures at the trust. I am sure that he will agree with me that not all the staff then working at the hospital are to blame, and that there are many good, decent, hard-working people at the hospital who will again find it hard to see their place of work back in the news today. There will also be many staff across the NHS who will feel that there is a daily focus on their failings but very little recognition of the outstanding professional standards that they show, or of the millions of acts of human kindness that take place in our NHS day in and day out.

In closing, may I ask the Secretary of State to give the House an assurance that he will always present a balanced picture and, in this case, be clear that these were isolated events at an isolated hospital?

[Mr Lansley]

I am grateful to the right hon. Gentleman for indicating that he supports this further inquiry, and that he and his colleagues will give it that support. They will know that for more than six years as shadow Secretary of State I always gave both a balanced and positive view of what the staff of the NHS achieve daily on our behalf. That extends to the staff at Stafford hospital, as I have made clear to them when I have visited them in the past. Indeed, I shall be visiting again tomorrow in order to make that even clearer—and I have asked Robert Francis to ensure that as he conducts his inquiry, he does whatever he can not to divert them from continuing to improve care for people in Staffordshire.

The right hon. Gentleman asked what the difference is between the inquiry that I am announcing today and what he said should happen in a second stage Francis report, and I must tell him that there are a number of very serious differences. First, this is an inquiry not under the National Health Service Act 2006 but under the Inquiries Act 2005, so there will be a presumption that hearings will be held in public, and that records of evidence and information given to the inquiry must be made available to the public.

In addition, there will be a power of compulsion in respect of witnesses and evidence. I simply do not accept his assertion that had there been a different legal basis for the earlier inquiry people would not have come forward to give evidence. Either they would have done so or, if they had not been willing to do so, they could have been compelled to do so; that power will be available now. This inquiry will have a power to take evidence on oath and a power under the 2005 Act to make recommendations, if Robert Francis so concludes, concerning not only NHS organisations, which are covered by the 2006 Act, but non-NHS organisations. The terms of reference make it clear that Robert Francis will be able to look more widely. The inquiry will examine, for example, the actions of the coroner and the Health and Safety Executive. Indeed, he will be able to make recommendations in relation to the General Medical Council. He would not have been empowered to do that in an inquiry simply under the 2006 Act.

Finally, may I deal with the right hon. Gentleman’s point about targets? The four-hour target is not a measure of outcome; it is not a measure of the result for patients. The result for patients is about their going to an emergency department and their disease, injury or illness being treated successfully. What happened at Stafford hospital provided evidence—we saw other such evidence in many other places—to suggest that the four-hour target was being pursued not in order to give the best possible care to patients, but in spite of what would be the best possible care for patients. Patients were being discharged when they should not have been, and patients were being transferred to inappropriate wards where there was no provision to look after them.

It is vital that we focus on the result for patients. Like me, the right hon. Gentleman knows that the length of wait in the emergency department is not an irrelevant fact for patients. We are therefore going to consider, constructively, how to scrap the four-hour target as it currently exists, and, as my right hon. Friend the Prime Minister said at Prime Minister’s questions, work on the basis of saying that what the clinical evidence makes clear directly contributes to delivering the best possible results for patients. We will start that process soon, in making that clear to the NHS. Our approach will go beyond the simple question of how long people wait in an emergency department; it will go to the outcomes being achieved in those departments. That is what putting quality at the heart of the NHS actually means; it means quality and results, not just processes.

[Jeremy Lefroy (Stafford) (Con)]

I am most grateful to my right hon. Friend for his statement and for the announcement of an inquiry under the 2005 Act. I am also grateful to him and to the Prime Minister for their support for my constituents over the extremely difficult past year. The Secretary of State will recall that I have written to him on a number of matters in connection with this case, but I should like to raise just one now. Can he assure me that the resources needed both for the inquiry itself and for staff cover will be made available to the trust, so that staff can continue the vital work of restoring public confidence in Stafford hospital?

[Mr Lansley]

I am grateful to my hon. Friend for that question. Although he has only recently arrived in this House to represent his constituents, I know from my personal experience of our conversations, our meetings and my visits to see him and others in Stafford just how diligently and consistently, and in what a compelling way, he has represented his constituents over the past year or so. In reply to his question, I can tell him that although I have made it clear to Robert Francis that we must do this swiftly—and, therefore, without incurring excessive costs—we must do it successfully and achieve a quality result in order to inform everything we need to do to improve the NHS. We need to go beyond the mere structures and the processes—we have seen all that—to find out why people in all those structures were not focusing on patient safety and quality of care, and how they can be better incentivised, encouraged and required to do that in future. I am sure that my hon. Friend knows that we are ensuring that the additional costs that the Mid Staffordshire trust has had to meet in the course of the first Francis inquiry and now, and in supporting the delivery of better care, are being met with additional resources from the strategic health authority.

[Joan Walley (Stoke-on-Trent North) (Lab)]

May I, on behalf of constituents whose families were affected by what happened at Mid Staffs, welcome the continued focus that the new coalition Government are placing on making progress on this issue and on ensuring that what happened before never happens again at Stafford hospital? I pay tribute to the work done by my former colleague David Kidney, who, along with the action group, called for a full public inquiry into this matter; that needs to be put on the record. Will the Secretary of State give me assurances about the make-up of the panel, and perhaps give consideration to making trade union representatives members of it? We need to ensure that all people affected in the provision of care can be properly represented and can be part of that panel in the further inquiry.

[Mr Lansley]

I am grateful to the hon. Lady for her support for the further inquiry. I should say, first, that I share her view that David Kidney sought to get to the bottom of what happened at his local hospital, and pressed for a further, and public, inquiry. The shadow Secretary of State must know that at the beginning of last September Robert Francis came to him in the midst of his first inquiry to raise the issue of the legal base for that inquiry and the question of whether it should be brought under the Inquiries Act. He wanted the terms of reference to be extended sufficiently widely to ensure that at that stage he could have looked beyond the question of what happened, to the question of why the primary care trust, the strategic health authority, the NHS in general, and other organisations, did not intervene earlier and in a better way. On 10 September last year, the then Secretary of State did not agree that that should happen, but had he done so the first Francis inquiry could have achieved much earlier what the second will now have to do.

--- Later in debate ---

[Mr Speaker]

Although we heard about four questions there, I am sure that the Secretary of State will content himself with one reply.

[Mr Lansley]

If I may, Mr Speaker, I shall content myself with saying that my hon. Friend made it clear from the outset that an Inquiries Act inquiry was the right idea. He said that more than a year ago, and had we gone down that route then, we would have been much further towards getting to the whole truth now. Matters relating to the Inquiries Act and the panel membership are ones that will now be determined by Robert Francis. I have published the terms of reference to which he will be working, and under the Inquiries Act issues such as legal representation and its funding are determined under those.

[Robert Flello (Stoke-on-Trent South) (Lab)]

My constituents who were affected will also be following very carefully what happens in this public inquiry, and I associate myself with what has been said about David Kidney, who worked extremely hard and effectively on this horrific issue.

I am concerned that the horrific failure at this hospital is being used as a hook in a most appalling way for the proposals to scrap targets, which the Conservatives have talked about for a long time. In any system there will always be people who try to manipulate it; in a culture of fear and bullying, as there was in this hospital, that is exactly when systems will be manipulated. Will the right hon. Gentleman therefore take into account as wide a spectrum of advice as possible when he is considering the new outcome proposals, to ensure that whatever system he brings in is not also open to abuse and manipulation?

[Mr Lansley]

One of the hon. Gentleman’s friends says that we should take action on the basis of the first Francis inquiry, and we will, and the hon. Gentleman says that we should not take action on targets. The first Francis report made it clear that targets compromise patient care, so we do need to take action.

The hon. Gentleman asked a further question. Robert Francis and I have had two discussions and the terms of reference are very clear. He is looking beyond the structures and processes to how the culture of bullying, fear and secrecy came to pass, what effect it had and how we can move beyond that. The report will be very important, if it is successful, not just for the people of Staffordshire but right across the country in showing how we can move from a top-down, secretive, bullying culture to one that is absolutely open, transparent, focused on patient safety and entirely responsive to the needs of patients.

[Mr Aidan Burley (Cannock Chase) (Con)]

One of the tragedies is that concerns were being raised about Stafford hospital as long as five years ago but little or no notice was taken of them. A constituent of mine, Barbara Allatt, was until recently a student nurse who helped to expose the appalling neglect of elderly patients at the hospital trust, but rather than her concerns being acted on, she was instead needlessly thrown off her training course. In his statement, the Secretary of State outlined new whistleblowing rights for future staff. Will those rights be extended retrospectively so that staff who spoke out previously, and in doing so put their job at risk, will not be punished again?

[Mr Lansley]

Of course, by definition, contractual rights cannot be retrospectively applied, but let me make it clear that I will be issuing guidance in terms that I have set out to the House in my statement today—albeit that we might need to do more. That guidance is entirely intended to move the NHS to an open culture that encourages staff to raise concerns. As I said to the Patients Association yesterday, we must have a culture of challenge inside the NHS under which the offence is not to make a mistake, as mistakes are human, but to seek to cover up or ignore a mistake. That is what happens in the best organisations and it must be what happens throughout the NHS.

[Steve McCabe (Birmingham, Selly Oak) (Lab)]

I welcome the Secretary of State’s promise of early action. Will he tell us how many members of the present board were in post on 18 March 2009 and when he will sack them as he has promised?

[Mr Lansley]

The hon. Gentleman will forgive me: I know that the chief executive, the chair, the nursing director and others have moved on, but I do not know the precise answer and I will write to him about that. In relation to any individuals, I think it is proper that, having asked Robert Francis to conduct a further inquiry that takes account of all that he discovered in the first report and that covers the same period of time—2005 to 2009—he is free to make recommendations that will bear upon people working inside the trust and in organisations, and upon how they discharge those responsibilities.

[Gavin Williamson (South Staffordshire) (Con)]

I thank my right hon. Friend for announcing the inquiry, which will be welcomed by many of my constituents and others. I urge the Department of Health always to listen to the relatives of patients, because relatives were saying that this was a problem far earlier than anyone else. Will the Secretary of State, please, always listen to what relatives and patients say?

[Mr Lansley]

I am glad that my hon. Friend raises this point, because I know from the four occasions on which I have visited Stafford and talked to members of the Cure the NHS group just what a desperate struggle they had to be listened to. We should therefore be clear not only about changing the culture inside the NHS, so that patients’ issues and complaints are treated seriously from the outset in an open and transparent way, but that the patient voice should be strengthened in the NHS. Even people who are literally self-appointed voices for patients should not be dismissed and pushed to the margins. We have to be prepared to listen to patients however their views are brought forward.

[Mr Dave Watts (St Helens North) (Lab)]

The Secretary of State was unclear about his proposals for waiting times. Will he clarify this issue? He seems to be saying that he will do away with waiting times but then introduce a new system. Will the new waiting time be four hours, five hours, six hours, 10 hours or 12 hours?

[Mr Lansley]

I am afraid that the hon. Gentleman does not seem to understand. I was very clear in saying that I am going to abolish the four-hour accident and emergency target. I will issue guidance to the NHS shortly, the purpose of which is to amend the four-hour A and E target, alongside others, to ensure that we deliver better quality. That is not just about the time spent waiting in an emergency department; it is about the quality of the service provided and it is based on clinical evidence.

[Andy Burnham]

That is unclear.

[Mr Lansley]

The point that I am making is very clear. We are not going to focus on narrow process targets in future; we are going to look at the quality and outcomes provided for patients. I will issue future guidance on that.

[Nadine Dorries (Mid Bedfordshire) (Con)]

The report highlights that there was a breakdown of care at almost every level, from basic nursing care up to high levels of communication. Does the Secretary of State agree that when the patient becomes the absolute focus of every level of care delivery, from basic levels of nursing care right up to top levels of management, it will be more difficult for such a culture to grow in terms of process delivery? Will he guarantee that the report will look at putting back into hospitals the approach of making the patient the most important person and of putting the patient at the centre of every element of care that is delivered?

[Mr Lansley]

Yes; my hon. Friend is absolutely right. That is why I have made it clear that that is the first priority for our Department in how we are going to improve the NHS. As a nurse, my hon. Friend will know that what she describes is absolutely how many people across the NHS want to conduct their professional relationships. They have been so frustrated, demoralised and demotivated by not being able to deliver care in the way that they wish—focusing on the needs and expectations of patients.

[Mr Stephen Dorrell (Charnwood) (Con)]

Is not the important issue that the terrible events in Mid Staffordshire are not purely a local issue, terrible though they are for Mid Staffordshire? It is vital that lessons are learned for application right across the NHS. What were the commissioners doing? Where were the regulators? What price professional accountability? Why was all that allowed to happen over so long? Perhaps the most difficult question of all is this: why was it not the first time that this had happened in the NHS?

[Mr Lansley]

My right hon. Friend is absolutely right. That is why we have to move from all those questions to some serious answers—so that we can have the reform that the NHS so badly needs. I know and he knows that this is about not just a different set of structures, but a change of culture and a focus in the NHS on patients and results for patients to the exclusion of other bureaucratic impositions. There is such immense bureaucracy—PCTs, SHAs and regulators—that everything should have worked perfectly, but it did not. Why? Because in all of that, the underlying pressures in the service were not focused on results for patients. We have to drive towards that conclusion.

[Siobhain McDonagh (Mitcham and Morden) (Lab)]

Will the Secretary of State give way?

[Heather Wheeler (South Derbyshire) (Con)]

I welcome my right hon. Friend’s statement. Only yesterday, I wrote to him regarding a constituent in South Derbyshire who had gone through a four-hour wait and was then admitted, to make sure that the four-hour rule was not broken, and had to stay in a ward for six hours and see even more people when he could have been on a bus going home much earlier. There are lessons to be learned across the whole country, and I look forward to the report coming through.

[Mr Lansley]

I am grateful to my hon. Friend. We will take not only the clear evidence from the first Francis report, but evidence from many other places, including that from many of the leading clinical professions that the way in which the four-hour target has been administered has undermined the quality of patient care. We will focus on quality and help the NHS to deliver what it knows is the right quality.

[Harriett Baldwin (West Worcestershire) (Con)]

I welcome my right hon. Friend to his post and thank him for his two visits to Malvern over the past few years to support the new community hospital that will open in October.

My right hon. Friend mentioned the West Midlands strategic health authority. In the past six months, the authority has required our local Worcestershire NHS to divest itself of its community hospitals. At the moment, the authority is proposing to abolish the mental health trust and put it and the community hospitals into a new trust. Secondly, it has asked NHS Worcestershire to cluster with neighbouring NHS organisations. What are my right hon. Friend’s proposals to stop all those reorganisations and focus on patient outcomes?

[Mr Lansley]

The inquiry will look at both the West Midlands SHA and its predecessor bodies. My hon. Friend will know from what I said a couple of weeks ago that proposals for such reconfigurations in the national health service must now answer to the clinical evidence—the clinical base. They must answer to patients—current and prospective patient choice—and to the referral intentions and commissioning intentions of general practitioners exercising responsibility for commissioning. That will change the nature of such decisions from a top-down, unaccountable process to one that is much more locally accountable and effective.

[Mr Peter Bone (Wellingborough) (Con)]

The excellent new Secretary of State for Health was right to praise the men and women of the health service, but when things go wrong there needs to be an early-warning system. Does he agree that standardised mortality rates are an indication that something might be going wrong, and that such indicators should be used more often to investigate hospitals?

[Mr Lansley]

I am grateful to my hon. Friend. First, the Francis inquiry will go on to understand why one of those hospital SMRs, from 2003, indicated the nature of a potential problem. The SMRs are not a sufficient measure of quality across the board. The National Quality Board has already undertaken some work on how we can ensure that hospital SMRs are consistent and meaningful, and beyond that how we can identify the early-warning signs and act on them. As one of the things we derive from that, I shall be working with the quality board and across the NHS to ensure that we act on warning signs, including looking at potential risks either across the system or in relation to individual trusts.

[Dr Sarah Wollaston (Totnes) (Con)]

Will the inquiry cover the sheer volume of bureaucratic paperwork that nursing staff have to complete, which seriously gets in the way of their fulfilling their clinical responsibilities?

[Mr Lansley]

I am grateful to my hon. Friend. The answer is yes.

[Mr Speaker]

I am grateful to Members for their co-operation. We have got to everybody.