Accountability and Transparency in the NHS

Stephen Dorrell Excerpts

Thursday 14th March 2013 Commons Chamber

[Mr Stephen Dorrell (Charnwood) (Con)]

I want to follow the hon. Member for West Lancashire (Rosie Cooper) on to very similar territory. She and I both sit on the Health Select Committee, which I chair. I want to start where my right hon. Friend the Secretary of State and the right hon. Member for Leigh (Andy Burnham) started, with what happened in Mid Staffordshire. It was shameful, and we will be judged today by whether we show a serious willingness to learn and apply the lessons of the Francis inquiry.

Francis made 290 recommendations, but they amount to just one core recommendation, which is that there needs to be a fundamental culture change through the whole of the national health service. With respect to the shadow Secretary of State, that is the sense in which challenges are posed for the health service way beyond Staffordshire. We have to learn the lessons of Staffordshire and apply them beyond it, as well as demonstrating that we understand what we mean—in the modern jargon, we “get it”—when we talk about the need for a culture change.

My hon. Friend the Member for Bristol North West (Charlotte Leslie) encapsulated that when she used the words “accountability” and “transparency”. I will not follow her down the route that she took in her speech. I want to focus exclusively on what we mean by those two words. They seem to trip too easily off the tongue, without anyone understanding what they mean, and that must change if we are to sustain a culture change in the health service.

My first proposition is that accountability without transparency is entirely meaningless. The ability to see what is going on and how decisions are being made in the health service, and to see the effects of those decisions, is fundamental to the delivery of the objective of culture change. With respect to the right hon. Member for Leigh—and, indeed, to some of the points that my right hon. Friend the Secretary of State made—we have to acknowledge that a lack of transparency lies deep in the culture of the health service, and that it goes back to way before the previous Government were in office. It was present in my time as Secretary of State and well before that, too. I was regularly accused of supporting a gagging culture in the health service, although nothing could have been further from my intention. However, that charge was made against me, against the right hon. Members for Leigh and for Kingston upon Hull West and Hessle (Alan Johnson) and, in truth, against all our predecessors right back to 1948.

The instinct to protect, rather than the instinct to reveal, is deeply embedded in the health service. When something is said to be going wrong, there is an instinct for the wagons to gather round. That is why Francis’s recommendation for a duty of candour is key to the delivery of the objective of greater accountability and transparency.

[Barbara Keeley]

Was the right hon. Gentleman as disturbed as I was to hear that the £500,000 gag at the United Lincolnshire Hospitals NHS Trust was put in place without any sign-off whatever, on the basis that it had involved judicial mediation? The Secretary of State refused to answer my question about this. Does the right hon. Gentleman agree that the Secretary of State really has to stop that, because it involved a very large amount of money, which was used very ill-advisedly?

[Mr Dorrell]

The position I take is the one set out in the Francis report, which was explicitly endorsed by Sir David Nicholson in the Select Committee inquiry to which the hon. Lady has referred. I believe that it would also be endorsed by my right hon. Friend the Secretary of State, but he must speak for himself. That position is that it is hard to imagine circumstances in which the use of public money in the context of a compromise agreement should be governed by a confidentiality clause. In an age when a bill from Pizza Express has to be published on the internet, decision makers should be held publicly accountable for the use of large sums of money in the context of a compromise agreement.

[Mr Jenkin]

I accept my right hon. Friend’s challenge about openness and transparency in the way the health service reacts outwardly, but that is a means to an end. There is also a lack of honesty and openness between people working in the health service, and the mistrust between levels of management and institutions inhibits the proper flow of information and the ability of people to trust each other in the context of saying what is wrong and putting it right. People in the health service dare not tell their senior management what is wrong.

[Mr Dorrell]

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

[John Pugh (Southport) (LD)]

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

--- Later in debate ---

[Mr Dorrell]

I agree with my hon. Friend, but I hope he will forgive me if I do not follow him down the road to the police service in the three and a half minutes I have left.

My key objective is to enable Members to recognise that this is a deep-seated cultural issue, that we need to create a more open culture, and that a duty of candour is fundamental to that. I say to the right hon. Member for Leigh that we need to ask ourselves occasionally: accountable to whom? Surely in the first instance, the health service must be accountable to the patient. How can it ever be right for a failing in care provision that has been acknowledged and discussed not to be described to the patient? That duty of candour to the patient is fundamental to the culture change that I am describing. However, we have to remember that, within the tax-funded health care system, there is a duty not only to the patient but to the taxpayer. Although I do not want to go too far down this road, the challenge for the right hon. Member for Leigh when he speaks about competition and decisions about the use of public money is that commissioners and providers must be accountable for value as well as clinicians being accountable for quality.

In my remaining time, I want to pose this challenge for those elected to this House. The challenge of culture change has to apply right through the health service, but people looking into this debate from outside will, I suspect, conclude that thus far that challenge has not been fully responded to. There is a deep-seated culture here that pretends that the problems all started under this or that lot, or that every success is the result of achievements made by one particular side, but the truth is that this deep-seated requirement for culture change has been addressed by successive Governments over a protracted period.

We should not forget that waiting time targets were invented before I was Secretary of State for Health. Quality of care requires access to care as well as to high-quality clinical outcomes. We should not forget that deep in the pathology of what happened in Staffordshire, the health economy there was out of control. It was running sustained deficits and management was required to bring that health economy under control. There is no choice between quality on the one hand and management on the other. We need to develop a culture within the health service that allows managers to address questions of both quality and value, because unless we address both, we will deliver neither. That is the core challenge facing the health service over the period ahead.