Capsticks Report and NHS Whistleblowing

Philippa Whitford Excerpts

Wednesday 13th July 2016 Westminster Hall

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

Unfortunately, this has been a repeating story since Bristol Royal Infirmary in the mid-’90s when Stephen Bolsin, the anaesthetist who raised that issue of poor survival of children having cardiac surgery, ended up in Australia. That has been a repeating theme. Regardless of the GMC telling us that it is our duty to step forward, whoever steps forward is always the one who is suspended or loses their job or suffers detriment in some way.

There are a lot of common themes when we look at Morecambe Bay, Mid Staffs and this case. In some of them, there has been the issue of trying to obtain trust status and going for cost savings. As the hon. Member for West Lancashire (Rosie Cooper) said, we have management chasing one goal while staff should be chasing a different goal: clinical quality. We see the stories of bullying and gagging and we see a coalface under pressure, with things going wrong and, if someone whistleblows, inevitably we hear of detriment: destruction to their reputation and perhaps loss of their job.

In an ideal situation we would rarely ever need to have a whistleblower. We need clinical audit, which audits not just the money but the quality of performance to give quality assurance. At one time here in England we had the Commission for Health Improvement, but that was got rid of back in 2004. When NHS Improvement came out, I thought that was like what we have in Scotland, which is called Healthcare Improvement Scotland, which we have had under one name or another since 2000. However, NHS Improvement just looks at the money, so we still have this business that the money is trumping the quality assurance.

That audit needs to be seen and problems need to be put right as soon as they are reported. Complaints should be seen as something that are used and looked at in every directorate meeting, which is something we do locally in my trust. Datix, which is used north and south of the border, is a way of trying to lower that barrier and to get people used to reporting every routine misstep, whether minor or major, bringing down the barriers to doing that and getting rid of any sense of hierarchy.

From our patient safety initiative in Scotland, we do things like using first names in theatre to try to get rid of that “fear of the prof” or fear of the consultant, so that an orderly who notices something going wrong feels able to speak up and say, “That is the wrong leg. I think we should check the paperwork again.” Once we get into a situation of having things going wrong, we need to enable any member of the team to easily draw attention to it. Traditional in surgery—this will be UK-wide—are morbidity and mortality meetings in which the whole unit will review any death or significant morbidity. That does not tend to exist in other specialties but it ought to—we ought to have it for every stillbirth and for deaths in other specialties. Maybe then we would know exactly how many deaths or major detriments were avoidable. That cannot be done with stats—we have to look at the cases. One of the things I set up in my unit was something we called, to make it easier for everyone, the difficult case review. Any team member—it did not matter who—could put a name in the book for the next difficult case meeting so that that case would be looked at.

Whistleblowers need internal support so they can go and not suffer detriment. We have had the Francis report and we have the freedom to speak up, and I commend the Government for setting up the national guardian system—we are doing something very similar—but what comes back from whistleblowers I meet is they are concerned that the person who has been appointed is an NHS manager. We have to have someone who is utterly outside the system. Most of all, we need to change the culture that is close to the frontline. Management must have clinical governance responsibility, not just financial governance responsibility, so that staff get used to raising issues that are then dealt with, learned from and changed, and that management see that as part of their role.

--- Later in debate ---

[The Parliamentary Under-Secretary of State for Health (Ben Gummer)]

It is a great pleasure to respond to this debate that you are chairing, Mrs Main. I echo the compliments paid by the shadow Minister, the hon. Member for Ellesmere Port and Neston (Justin Madders), to the hon. Member for West Lancashire (Rosie Cooper). The hon. Lady has been very brave in pursuing this cause, which she has taken up on behalf of her constituents. I agree that it is striking that this matter would not have come to the fore had she not had very sad and unfortunate personal experience of the failure of care at Liverpool Community Health. I thank her for her persistence in the face of opposition, not just from the usual quarters but from places that might not have been considered to be inimical to a Labour party Member. That is why I particularly commend her for what she has done and for continuing to fight the cause for her constituents. It is absolutely true that as a result of what she has taken up on their behalf, the care being provided is now safer than it would otherwise have been. Sometimes we need to remind ourselves that doing this job is worth while, and she has done that in great measure for herself and other Members of Parliament.

I would like first to offer an apology. It is right that the Government recognise it when things go wrong even if they are not within the direct control of Ministers. Everything in the NHS is the responsibility ultimately of the Secretary of State and of the ministerial team, and I am sorry that the NHS in this instance let down the hon. Lady’s constituents. At the same time as saying that, I hope that she and other hon. Members recognise that it is partly through the measures put in place by the previous Government that we have been able to flush out some of the problems that she identified. It was a Care Quality Commission inspection, under the new regime, that really began to unearth the problems in LCH, and it has been the tougher management of failing trusts that has meant we have been able to bring reform to this trust quickly. Not all is perfect; not everything is right in terms of the CQC or of the Trust Development Authority or its new iteration, but we are a great deal further forward now than we would have been five years ago. To be completely fair, we would have been further forward five years ago than we would have been 10 years before that. We are on a journey, and I appreciate the collegiate atmosphere that has been created in this debate and elsewhere.

I will answer the specific points and questions, because I do not want to reiterate the excellent exposition given by the hon. Member for West Lancashire. She asks who polices HR departments. The simple answer is that the Care Quality Commission, in its well led domain, as it looks at organisations will continue to look at the quality of leadership within an organisation. I will talk in a second about the kinds of thing that I think it should be looking for in the new round of inspections that it will begin in due course.

The hon. Lady asks about the fit and proper persons test. As it is currently constructed, it is for boards to be judging people by the fit and proper persons test. That is the way I think it should be, and there is consensus on that, but clearly those boards need to be properly constituted and know what they are doing. I think that that gets to the crux of what she is saying.

To answer the point made by the hon. Member for Ellesmere Port and Neston about training for non-executive directors, that is, funnily enough, something we are actively looking at to try to improve the quality of boards precisely so that they can ask the questions that are needed, not just in terms of a fit and proper persons test but in order to hold their executive directors fully to account.

The hon. Member for West Lancashire asks about the need for a review, and I know that that is the main purpose of bringing this matter to the attention of the House. I have commissioned NHS Improvement to do a review or at least to ensure that a review happens. As she will be aware, there has been some discussion about the terms of reference for that. I know that Jim Mackey has talked to her about it; she is in communication with him. I, too, am in communication with Jim and I hope that in the course of the next few weeks I or my successor will ensure that that review is as robust as it needs to be. The hon. Lady knows my view on that, which is that I do not want something excessively expensive and excessively long, because that will serve no one’s interests. We need to get the balance right, so that it is timely and good value for money and we are not taking money out of the NHS that would be better spent on her constituents’ care. If we can get to the root cause of these problems in a timely and efficient manner, that will serve her and her constituents well. I commit myself to ensuring that that happens quickly.

The hon. Lady asks about conflicts of interest. As it happens, NHS England is looking at precisely that at the moment. It is an area that we need to be much better in. However, I hope that as we see an evolving NHS, which is far more about collaborative working than the purist approach to competition that was the drive under the original foundation trust mechanism set up in the early 2000s, it will be less of a problem than she correctly anticipates it might be in this instance.

The hon. Member for Central Ayrshire (Dr Whitford) makes a number of important observations about her experience in Scotland, but I am afraid she is wrong on two points. NHS Improvement is not just interested in money; it is very firmly an improvement agency that deals with quality as well as financial performance. She will know that the two do go hand in hand. The best run trusts tend to be those that look after their money as well as their patients. We can see that relationship in the CQC inspections and their relationship with deficits. I suggest that she speak to the director of quality in NHS Improvement, Dr Mike Durkin, who was moved across from NHS England precisely so that NHS Improvement could become a true quality organisation. I am sure she will know him from the past. He is a globally respected expert in the issues of quality and institutional learning.

The hon. Lady is also wrong to say that the national guardian was an NHS manager. She is one of the leading chief nurses in the NHS, and I am sad that she felt unable to continue with that role. The hon. Lady will be pleased to know that her replacement, Dr Henrietta Hughes, is also a clinician—a practising general practitioner. It is very important that we give the right message to whistleblowers, and that is as much the case in Westminster Hall as it is outside in the public space.

[Dr Philippa Whitford]

The feedback that I have had from whistleblowers is that they see the new replacement national guardian as someone who is in an NHS manager role, and they feel that that is not sufficiently independent for the national guardian for whistleblowers. They are talking about the new guardian.

[Ben Gummer]

The new guardian is a practising GP and her office is deliberately set aside from the Department of Health; it is not part of our structures. The purpose of that is to ensure that the person is independent. I hope that that will give confidence to whistleblowers. I have asked her to make a decision on the helpline, because it is important that she makes that decision, not I, in the future.

Finally, I come to the questions asked by the shadow Minister. He talks about FT status. Much was right about the drive for foundation trusts, but a lot of things went wrong. We saw that at Mid Staffs and we have certainly seen it in this instance. I think that he will have noticed a far more considered approach to the FT pipeline in the past few years than previously. I know from experience of my own hospital, which failed to get FT status but is now a very good hospital, that the two do not necessarily correspond.

In all of this, we have to strike an important balance whereby we ensure that hospitals are performing while spending public money properly. The best hospitals and community care organisations do that by energising their staff, eradicating bullying and harassment and ensuring that people are free to speak up and exercise the duty of candour. That is why the thrust from the Department in the past 18 months to two years has been about living the values of the Francis inquiry. We have been putting that into practice in terms of the duty of candour, the whistleblowing apparatus that we have set up, and freedom to speak up.

We are at the beginning of a long journey. There is much to do to make the NHS the world’s largest learning organisation, but we have begun that process. I hope that the report that comes out—the further clinical review for the hon. Member for West Lancashire and her constituents—will be a further step on that journey, not just to correct and expose the failings in her area, but to ensure that the system as a whole, including the Department of Health, learns from them so that they are not repeated elsewhere and we continue to make the NHS the best healthcare organisation in the world.