NHS in London

Tom Brake Excerpts

Thursday 24th March 2016 Westminster Hall

[Dr Huq]

My hon. Friend puts it very well. Ealing has also been hit by the closure. I have no hospitals within my constituency boundary, but Central Middlesex was one of the nearest. It was performing well and had had lots of investment—it was a brand new shiny thing. I used to be a hospital radio DJ there in the ’80s. We were not allowed to play certain songs, including “My Way” by Frank Sinatra, because it is too much about the end for terminally ill people to listen to. Anyway, the hospital is now completely different from what it was like in the ’80s. It is tragic that the A&E there is being downgraded in favour of Northwick Park.

I saw the Minister’s brow furrow when I mentioned the boundaries. The hospital, which is in the constituency of my hon. Friend the Member for Brentford and Isleworth (Ruth Cadbury), is in south-west London. Perhaps we can think more creatively about crossing boundaries, because an ambulance will not usually take someone there even if it is nearer than Northwick Park. That was the point I was trying to make.

[Tom Brake (Carshalton and Wallington) (LD)]

On the subject of thinking imaginatively, does the hon. Lady agree that it is important the Government recognise that if more joint working is to take place between, for example, the Epsom and St Helier University Hospitals Trust and the Royal Marsden NHS Foundation Trust—a proposal that I understand is being considered—capital funding might be needed to facilitate the process?

[Dr Huq]

Yes, I certainly do. I do not know the St Helier hospital well, but I believe it is renowned as a teaching hospital. The business plans must account for such things; there is often too much short-termism.

The implementation of the closures listed is well under way. The A&E departments at Central Middlesex and Hammersmith shut their doors in September 2014, despite assurances from the Conservative party during the 2010 general election campaign that that would not happen. The closures have negatively affected waiting times at Northwick Park hospital in Harrow. That hospital is a considerable distance away from a lot of my constituents; as the crow flies, it is pretty far from East Acton to Harrow. I do not like to churn out loads of statistics, but Northwick Park does have the dubious distinction of the worst A&E waiting times on record in England—

--- Later in debate ---

[Dr Huq]

The hon. Gentleman makes an interesting point, and I would include community pharmacies among those community services. There is a lot of worry among pharmacists in my constituency.

[Tom Brake]

I wanted to make that point, too. It looks like up to one in four community pharmacies in my borough—a total of 11 pharmacies—are going to close. That is a bizarre policy, given that the Government have rightly been pressing Members of Parliament to encourage our constituents to go to community pharmacies. Now they propose to close a large number of them.

[Dr Huq]

I completely agree with the right hon. Gentleman.

Junior Doctors: Industrial Action

Tom Brake Excerpts

Thursday 24th March 2016 Commons Chamber

[Ben Gummer]

I agree wholeheartedly with my hon. Friend, which is why it would be helpful to have an unequivocal condemnation of the strike from the Labour party, which would send a message from this House that the withdrawal of emergency care is wrong.

[Tom Brake (Carshalton and Wallington) (LD)]

A junior doctor at St Helier hospital states that

“this contract is unfair, unsafe, uncosted, unevidenced, ineffective, unassessed for impact and risk, and unnecessary.”

With doctors depressed and demoralised, and with the revelation in David Laws’s book that the NHS required £15 billion to £16 billion, does the Minister agree that the failure to resolve this dispute is putting a huge amount of unnecessary pressure on the NHS, and that the Government and the BMA must settle?

[Ben Gummer]

This is what the Liberal Democrats have come to: quoting the books of their own losing candidates—a very odd situation. I think it sad for the right hon. Gentleman to come to this House not having read Sir David Dalton’s letter, which refutes every single one of the points he quoted at the beginning of his question. The fact is that the contract will be fairer and safer—better for patients and better for doctors.

Community Pharmacies

Tom Brake Excerpts

Tuesday 23rd February 2016 Westminster Hall

[Derek Thomas (St Ives) (Con)]

I beg to move,

That this House has considered community pharmacies.

It is a pleasure to serve under your chairmanship, Mr Streeter. In a letter to community pharmacies on 17 December, the Department of Health discussed the potential for far greater use of community pharmacies and pharmacists. The letter refers to the role of community pharmacists in preventive health, support for healthy living, support for self-care for minor ailments and long-term conditions and medication reviews in care homes, and as part of a more integrated local care model. That is exactly the right direction. As an MP representing a Cornish seat where every effort is being made to integrate health and social care, I see community pharmacists as essential players in a new national health service equipped to meet the demands placed on it by modern society.

Westminster Hall debates are rarely secured in order to praise the Government and celebrate all that is good. I would love to be able to do so, but—wait for it—in the same letter to which I just referred, the Department set out its plans to reduce its funding commitment to community pharmacists by £170 million. Therein lies the problem. We have a front-line NHS service that is valued and depended on and able to embrace new clinical responsibilities and meet the demands of an ageing population, but it is unsure about its future.

[Tom Brake (Carshalton and Wallington) (LD)]

Does the hon. Gentleman share my concern? As Members of Parliament, we all, I suspect, refer constituents to pharmacy services, because we know the impact that that has on reducing the pressure on the NHS. If we cannot refer them to smoking cessation services, cholesterol testing and blood pressure testing, the NHS and hospitals will have to pick up the burden.

[Derek Thomas]

I welcome that intervention. That is exactly the point that I hope to make, particularly for independent pharmacists in rural areas, where it is much more difficult to access acute services and GP practices.

--- Later in debate ---

[Derek Thomas]

I thank the hon. Gentleman for that intervention. In my experience so far of looking at this subject, I have found that those in the pharmacist community do not feel that they have been properly consulted or engaged with. Pharmacists believe that they have many of the solutions that the Government wish to see.

Before I conclude, I will read one final letter that I received on Monday from a GP in my constituency. Dr Rebecca Osbourne writes:

“As you will no doubt be aware, General Practice is facing a crisis with too few GPs managing an ever-growing demand. Demand for appointments outstrips availability of doctors and allied surgery staff, and patient needs are increasingly complex with an ageing population with multi-morbidity.

A good Pharmacist helps to take some of the pressure off a local surgery—offering advice about self-limiting conditions, and prescribing over the counter medications for presentations that do not need to be taken as ‘on the day’ appointments with a GP; patients who are on complex medications can receive education and advice from their pharmacist regarding their regime, including the importance of compliance, which can further reduce the burden elsewhere in the system; vulnerable patients, whether elderly or experiencing mental ill-health, have an extra professional keeping watch over them, and a pharmacist may be better placed than a GP”—

it was a GP who wrote this—

“to see a trend developing or a change that requires further attention.”

[Tom Brake]

I do not know whether the hon. Gentleman is aware from the conversations he has had with pharmacists that they often do things that are outside the terms of their contract. A couple of examples were cited to me. First, a pharmacist was involved in spotting someone who was having a cardiac arrest in their pharmacy, and then in helping someone else who had fallen outside the pharmacy and damaged their face quite severely. If we lost pharmacists and their extra input, that would have a significant impact on patients in a way that has really not been explained so far.

[Derek Thomas]

I thank the right hon. Gentleman for that intervention. What I have learned from many patients and from the pharmacists themselves is that patients see pharmacists as the first port of call for health, so there is no doubt that there will be times when pharmacists are picking up things that otherwise would have to be picked up in A&E.

Junior Doctors Contracts

Tom Brake Excerpts

Thursday 11th February 2016 Commons Chamber

[Mr Hunt]

My right hon. Friend is absolutely right. He talks about x-rays, which illustrates the point that this is not just about doctor presence but the presence of those who are able to do x-rays, MRI scans, CT scans, get results back from laboratories and so on. A whole suite of things are necessary for seven-day care. He is also right to point out that there are huge savings if we get this right. For example, if someone gets an avoidable pressure ulcer because they have not had the care that they should have received over a weekend, they are likely to have to stay in hospital for over 10 days longer. That will cost the NHS several thousand pounds more and that is why, in the end, this is the right thing to do economically as well as ethically.

[Tom Brake (Carshalton and Wallington) (LD)]

There are huge pressures everywhere in the NHS. For instance, GP out-of-hours services are under an incredible strain and cover is very limited in some parts of the country. What is the Secretary of State doing about those pressures and the additional strain that could be triggered by an exodus of doctors, following the imposition of the doctors’ contract? Will he entertain the idea of a commission, as advocated by my right hon. Friend the Member for North Norfolk (Norman Lamb) and by others on both sides of the House, to find a long-term consensual solution to the growing health and care challenges that we face?

[Mr Hunt]

The trouble with commissions is that they tend to take rather a long time to come up with their conclusions, and we need to sort out these problems now. That is why the Chancellor promised an extra £3.8 billion for the NHS next year, and why we said that we want 5,000 more GPs working in general practice, which will help out-of-hours services. We have a five-year plan that the NHS has the funding to implement, and that will transform out-of-hospital services. I hope that those developments will address the right hon. Gentleman’s concerns.

NHS and Social Care Commission

Tom Brake Excerpts

Thursday 28th January 2016 Commons Chamber

[Tom Brake (Carshalton and Wallington) (LD)]

My right hon. Friend may be coming on to this point, but what I want to understand is how the commission, and the output of that commission, can help with some of the very difficult hospital reorganisations that we all face in our constituencies—mine being St Helier hospital—and how we can ensure that we strike the right balance between acute services and care in the community. How will the commission help with that?

[Norman Lamb]

My right hon. Friend comes to the central point. As someone once said, the NHS has the status of a national religion. In this partisan atmosphere in which we all work, there is a danger that anyone who proposes a change to the NHS will get condemned from on high, because of the political points that can be scored in so doing. If we are to think about what we need from a modern health and care system that focuses on prevention, and to make changes in a rational way, we must give Government the space to think afresh about how we can sustain the system and guarantee care for those who need it. We have a choice now: we continue to drift until, ultimately, the system crashes, or we grasp the nettle and come up with a long-term solution.

All parties should commit to the proposal. If we want a good example, we should look at the commission of Adair Turner, which was established by the Labour Government to look at the long-term sustainability of pensions in this country. He managed to secure cross-party buy-in. He came up with proposals that led to change and reform. It was a process that gave people the space to look at a very difficult challenge and to come up with solutions. That is one model we could follow. It should be strictly time-limited. Somebody made the point that we are talking about not a royal commission, which goes into the long grass for three or four years, but a time-limited commission of up to one year with the aim of coming up with solutions that are then implemented. It should engage with the public, with patient groups and, critically, with staff, who, as the right hon. Member for Sutton Coldfield (Mr Mitchell) said, often feel that they are under intense pressure and that they are not listened to by Governments of all political persuasions. They, together with unions and civic society, should be centrally engaged with this commission. At the end of the process, we should seek to come up with recommendations that can then be implemented and can give everyone in this country the assurance that there is a long-term settlement for the NHS and for care.

Finally, let me raise one or two things that the commission needs to consider. It needs to look at the divide between the NHS and social care and at the adequacy of funding. How much as a society are we prepared to pay to ensure that we have a good, well-functioning health and care system? At the moment, funding for our health and care system comes through three different channels: the NHS, local authorities and the benefit system. Does that make sense? Should we look again at that system?

We also need to look at how we, as a country, are spending money on our older people. Are we spending it effectively enough? Are we targeting it at those older people who most need Government help? We need to look at intergenerational fairness and at where the money comes from—a point very well made in a recent book by the respected former Cabinet Minister, David Willetts. We also need to consider how we can give power to people to help them to self-care. David Wanless, when he reported for the Labour Government, made the point that his projections about how much extra money the system would need was based on people being engaged in their health—I am talking about self-caring more effectively. That has not happened in the way that he proposed.

We also need to consider the case for a dedicated health and care tax, which can be varied locally. Even protecting NHS spending results in disproportionate cuts in other areas of Government spending, distorting sensible, rational decisions. As this is an area on which spending inexorably rises, there is a case for carving out such a tax.

Mental Health: Out-of-Area Placements

Tom Brake Excerpts

Thursday 3rd December 2015 Commons Chamber

[Norman Lamb]

Such a story makes one weep and leaves one feeling that there is a degree of incompetence somewhere. I will come to that point. Much of what I want to see happen can be done by better organisation, rather than by providing more money. I strongly believe that we need more investment in mental health services, but a lot can be done just by organising things much better.

[Tom Brake (Carshalton and Wallington) (LD)]

Will my right hon. Friend commend the work that South West London and St George’s Mental Health Trust has done with a number of local authorities in the area, including mine? The police work with a nurse, to ensure that if the police are dispatched somewhere where a person has a mental health problem, there is someone who is able to assess them immediately and ensure that they go to a place of safety, as opposed to going to a police cell.

[Norman Lamb]

Absolutely. My right hon. Friend is talking about something called street triage—I am sure that the Minister is familiar with it—which we introduced in many areas of the country over the past two to three years with a bit of pump-priming grant. Some pioneering areas, such as Leicestershire, just went ahead and introduced it before the national pilots started. The evidence is dramatic. Where we have that collaboration between the police and mental health services, with a nurse embedded in the police team, we achieve amazing results. We completely reduce the number of people being taken in under that legislation, because the nurse can find alternative solutions or provide care at home. Where it is necessary to take somebody to a place of safety, the numbers having to go into police cells falls dramatically. That innovative work was very much part of the crisis care concordat that I pioneered when a Minister, the aim of which was for the first time ever to set standards in mental health crisis care.

[Norman Lamb]

I agree. My own county of Norfolk, with its widely dispersed rural communities, suffers from the same challenges. Sometimes having a nurse in a car with a couple of police officers does not work in a big rural area. However, we can do other things, like having a nurse embedded in the police operations room so that whenever an issue arises they can speak immediately by telephone or, if necessary, get a resource to the scene. Depending on the geography, there are ways of dealing with those challenges. We need to be much smarter in doing that. I applaud the innovation across the country.

Our whole approach in the crisis care concordat was rather different from the traditional Government approach, which is sort of to impose a straitjacket. The crisis care concordat said, “These are the principles. You come up with your plan for implementing them, working with the police, mental health services and the local authority, in a way that works for your locality.” That generated the most amazing degree of innovation across the country, and real progress has been made. Although I initiated it, I have enormous admiration for the people on the ground who got on and did it. It was inspiring.

[Tom Brake]

Will my right hon. Friend give way?

[Norman Lamb]

I will give way, but then I really ought to make some progress.

[Tom Brake]

I want to return to the point my right hon. Friend started with. We had an issue in Sutton where the mental health facility is based on what had been the Sutton hospital site—it was shut down mainly because Legionnaires’ bacteria were discovered. Patients now have to travel to Springfield hospital. As we see more people being treated at home, which is what we want, and therefore fewer people in acute crisis, how does he deal with the fact that, because hopefully fewer people will need to be treated in specialist centres, there is likely to be a smaller number of them?

[Norman Lamb]

My right hon. Friend makes a good point. Again, it means that we need to think afresh and innovate. The third sector has been very good at coming up with concepts such as crisis houses, where at quite low cost a facility can be provided in a locality where someone can go at a moment of crisis. They therefore might not need a formal hospital admission, and it might be a much more therapeutic place to be as they get through their crisis. I recently visited the Hertfordshire Partnership NHS Foundation Trust, which, in addition to crisis houses, has host families that someone can go to be with, if that is appropriate, for a week or however long is necessary. That might be exactly what is needed, rather than the cold, clinical environment of a hospital ward. That sort of innovation is what we need in order to ensure that we have services that meet patients’ needs.

I want to share with the House the testimony of a constituent who has experienced an out-of-area placement. It has been anonymised, for obvious reasons, but it is very powerful none the less. It is quite shocking. It reads as follows:

“I was admitted to accident and emergency at Norfolk and Norwich Hospital on a Wednesday afternoon, following a suicide attempt. I regained consciousness the following day, having been transferred to the Acute Medical Unit, and it was quickly decided that I needed to be admitted to a mental health ward.

I had previously been on Glaven Ward at Hellesdon.”

That is the mental health hospital in Norwich. My constituents continues:

“At this point I was very woozy, suffering from a dangerously low mood, and angry that my suicide attempt had failed. I was at grave risk of making another attempt on my life. Throughout the Thursday and Friday efforts were made to find a mental health bed.”

That is what happens in the system.

“My parents were frantically trying to find out what was happening, as they were desperate for me to be looked after locally. For a time we were told that I would be going back to Glaven Ward at Hellesdon, but the news kept changing between there and a unit in London.”

London is between 120 and 130 miles away from Norwich, and further away from my constituent’s home.

“I was expecting to go to Hellesdon on Friday morning, but we were then told later that day that I would be going to south London. During the Friday, I twice walked off the ward and out of the hospital, without my absence being noticed, and went down to the Watton Road”—

which is near the hospital—

“with the intention of walking in front of a bus or a lorry. The main reason I didn’t go through with it was that I did not want the vehicle to swerve into an oncoming car and cause death or injury to someone else.

Meanwhile, my parents resorted to contacting the crisis team, as they could not get any information from the bed team. A member of the crisis team took responsibility for finding out what was happening and he was able to let me and my parents know that I would be transported to south London later that Friday evening.

Finally, after more uncertainty”—

this is really shocking—

“two men arrived to take me to London. At 10 pm, feeling suicidal, frightened and confused, I got into the back of a private ambulance (which was no more than a pretty austere minibus) and was driven away from the Norfolk and Norwich Hospital. Throughout the three-hour drive, I was spoken to just once by one of the two men, and felt more like a prisoner being transported than a patient.”

That is the way our NHS deals with someone who is acutely ill. It is really shocking. It ought not to be accepted. My constituent went on:

“At 1 am, by now completely disorientated, I arrived at the front door of the mental health unit in south London. After lots of knocking at the door, someone answered, and I was handed over with a quick ‘good luck’. I was booked in and shown to my room. I felt isolated and scared. My room was nice, but the unit felt like a prison. The internal doors were like cell doors, and there was a tiny outdoor area, fringed by a high fence with spikes on the top. It was a mixed ward, both in terms of sex and in terms of illness: people with depression and anxiety were alongside those with psychosis, personality disorders and acute problems.”

It is really shocking that a whole load of people with completely different conditions were thrown together like that. It is probably the least therapeutic environment imaginable. That is about containing people, not caring for them, and it ought to be a thing of the past.

[Norman Lamb]

It is absolutely critical that that happens —not only monitoring but proper treatment. As I will go on to describe, that is not what happened in this case.

The constituent continues:

“The following morning, I had a meeting with my named nurse. Extraordinarily, it was the only real conversation I had with him until I was discharged back to Norfolk 10 days later.”

That is not therapeutic care—it is neglect. I have asked whether there are any contractual requirements on the private provider who provided that “care” and received a substantial sum of money for it. I have been told that it was understood that there would be therapeutic care but no apparent requirement that that should be undertaken in return for a substantial amount of public money being spent on his care. He goes on:

“The care was unacceptable. It felt as though I was being kept in a holding facility, and my mental health deteriorated, with my suicidal thoughts increasing. In stark contrast to Glaven at Hellesdon, the staff were holed up in an office with a heavy steel door that you couldn’t see into. I was being checked up on every 15 minutes, as I was a suicide risk.

But I rarely had a conversation with a member of staff. My parents came down from Norfolk twice to see me, and were horrified by what they encountered—both the level of care and my deterioration. They were constantly contacting Norfolk and Suffolk mental health trust to try to get me moved back to Hellesdon. The stress made them both ill.”

That shows the impact there is on families as well. He continues:

“Thankfully their persistence paid off, and after 10 days, I was told that I was going to be recalled. I had a brief period of uncertainty, as I didn’t know whether I would be going to Hellesdon, King’s Lynn or Great Yarmouth.

Eventually, I was told it would be Glaven at Hellesdon, and I got into a taxi with a member of staff and was driven from south London to Glaven Ward.

When I arrived there, I cried, mainly through relief. I was greeted with compassion and understanding by the staff, and—after 10 wasted and expensive days—my recovery finally began.”

That experience, sadly, is repeated day in, day out across the NHS. It is a scandal that it continues. One of the things I will put to the Minister when I conclude is that I want his commitment to end this practice, because it is intolerable that it continues in this day and age.

I mentioned cost. An analysis has been done by the national confidential inquiry into suicide and homicide by people with mental illness, which, having looked at 29 providers, says that the cost of out-of-area placements went up from £51.4 million to £65.2 million in 2014-15. That is an extraordinary amount of money to spend on an unacceptable practice, demonstrating that with smarter use of the resources available it should be possible to bring that practice an end.

The national confidential inquiry also found that being treated out of area increases someone’s risk of suicide. The pattern is most apparent in England, where suicides by in-patients and patients recently discharged from hospital have fallen, although suicides following discharge from an out-of-area ward have increased. The annual number of suicides after discharge from a non-local unit has increased from 68 in 2003-07 to 109 in 2008-12. Experts have warned that mental health patients are at the highest risk of taking their own lives in the first two weeks after being discharged from hospital, and these figures confirm that. When we are talking about a risk of people actually losing their lives, surely we have to see the absolute importance of bringing this practice to an end.

I want to refer to a recent report by the Independent Mental Health Services Alliance called “Breaking Down Barriers: Improving patient access and outcomes in mental health”. It says that we must prioritise something that I have argued for consistently—the introduction of comprehensive waiting time standards in mental health so that someone with a mental health problem has exactly the same right of access to treatment as anyone else. It also says that people who end up in an out-of-area placement, sometimes a long way from home, get “lost in the system”; they are almost forgotten about. They are away from the commissioners and the normal provider, and they can sometimes languish in these centres for far too long. That, again, is completely intolerable.

The report also refers to the problem of delayed discharge. It says:

“We have found that between 2013/14 and 2014/15, the average number of days of delayed discharge per month for trusts providing mental health services increased by 22.2 per cent. This indicates that delayed discharges are having an increased impact on patients’ access to appropriate care.”

In other words, if beds are clogged up by people who are ready to leave and go home or to go to another facility, but they cannot because nothing else is arranged for them, then someone else at a moment of crisis cannot get access to a bed and is shunted off, sometimes to a place a long way from home. That is a completely unacceptable practice.

The report refers to children and young people’s mental health services. The Minister will be particularly aware of the acute concern about children being shunted off, often to places hundreds of miles away from home—an intolerable practice. I know that that has happened in the south-west, where there has been a particular shortage of beds for children. A team within NHS England undertook an inquiry that came up with recommendations for eradicating that problem. The taskforce’s report, “Future In Mind”, which we published shortly before the general election, pointed to the absolute need to care for people close to home and to have better crisis support to avoid admissions where possible. Yet the practice continues, and it must be a priority for the Minister to bring it to an end.

One of the things that “Future In Mind” sought to address is the perverse incentive that exists in the system with the awful tiering of care within children’s mental health services. If a child is put into tier 4 from tier 3 because it is judged that they need more acute in-patient care, then the financial responsibility for their care is transferred to NHS England. There is therefore an incentive for local commissioners to push them into the top tier, which is precisely the opposite of what ought to be happening. We ought to be focusing our incentives on preventing deterioration of health, not shunting people into the most acute care, too often away from home. Imagine what it must be like for the parents of, say, a 14-year-old child who is taken to a unit 100 miles or 200 miles away from home. It is really shocking, and I hope that the Government will feel the need to commit to eradicating that practice as quickly as possible.

When the issue came to my attention as a Minister, I asked my officials to provide me with data to find out what was happening around the country. I was confronted by freedom of information requests by campaigning organisations and by news reports of shocking things that were happening in the system, but I had no information on which to base my own judgment. I was told by the officials that they did not collect data on the issue. The Government are operating in a complete fog, and we have to rely on campaigning organisations to make inquiries under the Freedom of Information Act 2000.

Incidentally, I urge the Minister to use what powers of persuasion he has to argue against undermining the Freedom of Information Act. At the moment, a process is under way that runs the risk of doing precisely that. It seems to me that freedom of information is a really important way of holding the Government to account.

I was faced with having no information or data on that practice, so we initiated a process to collect such data. We have now collected those data. They are still in experimental form, but they are better than nothing. The data show that there is extraordinary variation around the country. That brings me back to the point that this is about not just extra money, but good practice. It is about learning from areas of best practice. We now discover that many mental health trusts have no out-of-area placements, but they are funded in broadly the same way as those in areas that have a persistent and unacceptable problem.

There is a three-month delay before the data are published, so the latest data are those from the end of August, but 2,198 people were in out-of-area placements at that time. We are not entirely clear about whether the drift upwards is caused by the collection of more data or by a worsening of the problem. I do not want to draw the wrong conclusion from the numbers, but they certainly do not appear to be going down.

I want to raise with the Minister the issue that the data are incomplete because some private providers refuse to return data. Under their contractual dealings with the NHS, they are obliged to return those data. When I was a Minister, I raised that matter with officials and with the information centre. Surely, it is completely unacceptable. I have no difficulty with a good private provider providing a good service, but they must absolutely play by the same rules as everybody else.

[Tom Brake]

To return to my right hon. Friend’s earlier point about freedom of information—in fact, there is a case for extending it—is it not right to ensure that private companies doing public work are covered by FOI in exactly the same way? That applies to the health sector, as well as to many other sectors.

[Norman Lamb]

I agree. There should be a level playing field, which there is not at present. We now have the unacceptable situation that data are incomplete because some private providers refuse to play ball. That leaves one suspicious, because if they do not provide data about how many people are held, it is impossible to hold the system to account or, indeed, to hold such private providers to account. The Minister must find a way to hold those providers to account and to ensure that they return the data they are obliged to provide.

A horrific number of people are still sent a considerable distance away from home. In August, 501 people were sent more than 50 km away from home. Surely that practice is intolerable, given what I have said about the increased risk of suicide, the fact that it does not provide therapeutic care and that it can lead to someone being confined for 10 days at enormous cost to the public purse. It seems to me that this is the most outrageous misuse of public money.

There are areas where that problem is persistently at its greatest. In August, the Devon Partnership NHS Trust had 45 people in out-of-area placements. The caveat is that we do not know precisely where responsibility lies, and whether this is a commissioning or a provider issue. However, that is the local provider, and one would normally expect such people to be in a bed provided by the local provider. The figure of 45 people means that significantly more than one person a day is shunted more than 50 km away from home, which is outrageous.

Oral Answers to Questions

Tom Brake Excerpts

Tuesday 17th July 2012 Commons Chamber

[Mr Lansley]

I will gladly write to the hon. Lady about when we were first aware of the consortium. I think it was several weeks ago; indeed, the document referred to prominently in the press on Sunday had been on websites for some weeks, so there is nothing new about that. We knew about it. I reiterate the point that I and my right hon. Friend made yesterday: even though under a Labour Government, in the 2006 legislation, powers were given to trusts to take their own decisions on the employment of staff, they must do so in negotiation with the staff side. We would expect that. From my point of view, the South West Pay Consortium is rightly looking to maximise flexibility, but I have made it clear to the pay review body that we believe that the flexibility it needs can be delivered through negotiations and “Agenda for Change”. It will not and should not require the reduction of pay for staff.

[Tom Brake (Carshalton and Wallington) (LD)]

T9. The clinician-led “Better Services Better Value” review has condemned the accident and emergency unit, and the maternity and children’s wards at St Helier hospital, because it expects out-of-hospital services to be expanded instead. Will the Secretary of State meet me to discuss local concerns that the £5 million allocated to provide the out-of-hospital services will be totally inadequate to the task?

[The Minister of State, Department of Health (Mr Simon Burns)]

I am grateful to the right hon. Gentleman for that question. As he knows, any proposals for service changes will be subject to the Secretary of State’s four tests and a full three-month public consultation across south-west London, which I am sure the right hon. Gentleman and his constituents will take part in. My right hon. Friend the Secretary of State will be more than happy to meet him to discuss the matter further.

Selective Dorsal Rhizotomy

Tom Brake Excerpts

Wednesday 18th April 2012 Commons Chamber

[Chris Heaton-Harris (Daventry) (Con)]

A couple of years ago, like every other candidate in the general election I was eagerly watching my local press—for me, mainly the Daventry Express—to see what stories were making local headlines. In the run-up to the election, the Daventry Express and its sister paper the Northampton Chronicle and Echo both rather brilliantly covered the story of Holly Davies, a young girl from Daventry who was suffering from cerebral palsy and whose family were raising £40,000 so that she could go to America for a life-changing operation that would enable her to walk freely for the first time in her life. A few months later Holly, who could barely walk before the operation, returned from the St Louis children’s hospital a completely different girl. The procedure she had is called selective dorsal rhizotomy, or SDR, and Holly was operated on by the world’s leading expert surgeon in this field—Dr Tae Sung Park.

Dr Park is without doubt one of the world’s leading paediatric neurosurgeons, has received a host of honours for his surgical innovations and clinical research, and has literally been the pioneer in this field. St Louis school of medicine in Washington university, where Dr Park is the Shi Hui Huang Professor of Neurological Surgery, is ranked third in the US, while the St Louis children’s hospital is ranked fifth in the US for overall performance in medicine. Those world-leading institutions would not allow the SDR operation to be practised if it did not work or if it had significant complications. They know that it works. Indeed, SDR is so successful that every single medical insurance policy that can be bought in the States covers the procedure because it is realised that spending money up-front on these individuals saves a great deal more expense in the future—a point I wish to heavily underline in this debate.

Dr Park has operated on people from 48 different countries and a number of those countries have trained or are training surgeons to offer this procedure. Indeed, SDR is currently performed in Germany, Sweden, the Netherlands, Italy, Poland, Korea, Japan, Hong Kong, Canada and Mexico. As of 30 March 2012, 145 people from the United Kingdom have been operated on in St Louis—120 from England, 18 from Scotland and 7 from Wales.

So what is this miracle operation, selective dorsal rhizotomy? Of all the surgical procedures currently performed on patients with cerebral palsy, SDR has probably undergone more thorough scientific scrutiny than any other, including the various types of orthopaedic surgery. Accumulated evidence and my constituent’s experience indicate that SDR is an excellent option for selected patients with spastic cerebral palsy.

SDR involves the sectioning, or cutting, of some of the sensory nerve fibres that come from the leg muscles. There are two groups of nerve roots that leave the spinal cord and lie in the spinal canal. The ventral spinal roots send information to the muscles and the dorsal spinal roots transmit sensation back from the muscles to the spinal cord. In the operation, the neurosurgeon divides each of the dorsal roots into between three and five rootlets and stimulates each electronically. By examining the electromyographic responses from muscles in the lower extremities, the surgical team can identify the rootlets that have caused the spasticity. The abnormal rootlets are selectively cut, leaving the normal rootlets intact, which reduces the number of mixed messages from the muscles, resulting in a better balance of activity in the nerve cells in the spinal cord and thus reducing spasticity.

Let me tell the House what that means in human terms. Last year, I was fortunate enough to meet for the first time Holly’s mum, Jo Davies, who wanted to talk to me about Holly’s new post-operation life. I shall read a few lines from “Holly’s Diary” a few years after her operation:

“September 2011—and Holly is starting school. She has her school shoes, bought from Clarks, not from Northampton General Hospital—and she loves them! It is such a small thing, but something I really never thought she would be able to do. I used to worry about school shoes—I know this sounds silly but the NHS would only give you one pair of boots at a time and this was either going to mean her having pink boots for school or black boots for home. Not very fair on a little girl—but now we don’t have to worry. She is wearing normal school shoes, has flashing trainers for the weekend and now even has a pair of ‘Ugg’ boots!

We recently posted a video of Holly on her Facebook page as people were asking how she was doing. It isn’t until you watch the before and then after videos that you see the amazing progress she is making. Dr Park even commented on her video and was really pleased with what he saw and has assured us that more improvements will be seen in the next 3 months.”

[Tom Brake (Carshalton and Wallington) (LD)]

May I draw to my hon. Friend’s attention the success of the operation for my constituent Dana Johnston, and encourage him to commend the work that she and her family have done with Support4SDR to campaign on the issue?

[Chris Heaton-Harris]

I happily commend their work. I have met Dana and her mother—a very powerful lady who has fought hard for her daughter’s rights and saved a lot of money so that she could have the procedure.

To return to the diary:

“Just these last couple of days she has started to learn to run. Prior to SDR her running technique was no faster than my normal walking pace and she had a swing to her hips that made it look like she would trip at any moment. I now need to walk very fast and sometimes even jog to keep up with her run and she has less swinging of the hips. She is still a long way off the speed and ability of her friends when it comes to running but she is definitely getting better at it.”

The next point is very important:

“Holly has also grown in confidence. She speaks out at school, joins in with activities more and is a nightmare at the park. She climbs up climbing frames that even her 7 year old sister would be wary over. It really is hard to believe that without the operation she would not be able to do these things.”

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[The Minister of State, Department of Health (Paul Burstow)]

I congratulate my hon. Friend the Member for Daventry (Chris Heaton-Harris) on securing the debate and bringing this very important matter to the attention of the House. The contributions of other hon. Members demonstrated just how strongly people feel about the issue. He outlined with great clarity the huge impact on the lives of children and of their families. Such debates are often prompted by casework but, interestingly and quite rightly, they can be prompted by the diligent work of local journalists reporting in the local press, which is testament to the importance of our local papers.

As my hon. Friend is aware, cerebral palsy is a brain condition that affects movement, posture and co-ordination. It might be seen at or around the time of birth or might not become obvious until early childhood. Some children will have lower limb spasticity, which can cause problems with walking and sitting, as well as discomfort, cramps and spasms. Sadly, there is no cure for cerebral palsy and as no two children are exactly the same, which means that they will not be affected by cerebral palsy in exactly the same way, treatment programmes vary widely.

Occupational therapy, speech therapy, medication and surgery all have a role to play in reducing the impact of the condition, but, because all children with cerebral palsy have movement problems, physiotherapy, to which the hon. Member for Strangford (Jim Shannon) referred, is undoubtedly the bedrock of the condition’s good management.

NHS physiotherapy services, including post-surgery physiotherapy for children with cerebral palsy, are provided on the basis of assessed clinical need, but initiatives such as the self-referral-to-physiotherapy pilots, the allied health professional referral-to-treatment revised guide and the AHP service improvement project are all supporting improvements to access and outcomes, and I will certainly look further at the point that my hon. Friend made about ensuring the provision of such access, when treatment has been delivered outside the NHS, so that people receive the appropriate aftercare.

My hon. Friend also made powerful references to several cases and, in particular, to the one from his constituency, that of Holly Davies, whose life, from my hon. Friend’s own testimony today and from her diary entries, has clearly been transformed by undergoing selective dorsal rhizotomy, SDR, under the care of Dr Tae Sung Park—whom my hon. Friend rightly described as one of the world’s leading paediatric neurosurgeons—at St Louis children’s hospital in Missouri.

Dr Park and his colleagues have pioneered the use of this procedure, which has benefited many thousands of children from throughout the world. We also heard today how Holly’s family have worked tirelessly to raise both awareness of the procedure and the funds to send their daughter to the USA to receive the treatment, and I can well understand the frustration, expressed by hon. Members in this debate, at the sense that the NHS might in some way be denying people access to the procedure.

Of course, those of us who are parents—even those of us who are not—want the best for our children, and in many cases SDR has been shown to improve a child’s comfort and quality of life. Even the simplest day-to-day tasks, such as standing and walking, can be made easier due to the increased flexibility in their limbs, so SDR is a major surgical procedure that aims to reduce the amount of information, as my hon. Friend rightly described, that the sensory nerves carry. As he also said, after the procedure patients need long-term physiotherapy and aftercare, and it is important to ensure that such continuity of care is part of the service that they receive.

The current technique, in which only those nerve rootlets that contribute most to the spasticity are divided, was introduced as far back as 1978, but it is important to stress that SDR is not a cure for cerebral palsy, nor is it suitable for the treatment of abnormal movements or of balance problems. Indeed, it is suitable only for appropriate children, as Members have acknowledged in this debate, after assessment by clinicians. It is therefore unlikely to be suitable for other types of cerebral palsy.

As my hon. Friend will be aware, the Department does not make central decisions or directions on the funding of treatments; it is for local commissioners to decide whether to approve funding for treatments, based on proper consideration of the clinical evidence and—it is important that I stress this—the patient’s individual circumstances.

[Tom Brake]

Given that the Minister and the hon. Member for Daventry (Chris Heaton-Harris), who opened the debate, have identified that a relatively small number of children would benefit from SDR, what role will specialist commissioning or, indeed, the NHS Commissioning Board play in looking at treatment throughout the whole country for those young people?

[Paul Burstow]

My right hon. Friend makes a rather important point. One of the opportunities that the Health and Social Care Act 2012, which we have taken through the House, provides is through the establishment of the NHS Commissioning Board. For the first time, all specialised commissioning will be done in one place and at one level, and, although no decisions have yet been made about the area under discussion, it is one of many, involving rare conditions or where specialist expertise needs to be brought to bear, in which the board can contribute to driving improvement.

Parliament has given the job of assessing the clinical evidence to the National Institute for Health and Clinical Excellence in order to provide clinicians with guidance on the safety and efficacy of procedures. NICE does so through its interventional procedures programme, which is different from the more recently published guidance, to which I shall turn in a moment. NICE’s interventional procedures guidance protects patient safety and supports people in the NHS in the process of introducing new procedures. Many of the procedures that NICE investigates are new, but it also looks at more established procedures of the sort that we are discussing and at issues of safety and how well procedures work. By providing guidance on how safe procedures are and how well they work, NICE makes it possible for new treatments and tests to be introduced into the NHS in a responsible way. NICE’s interventional procedures guidance has a slightly different, but equally important, purpose from that of its other guidance products. Interventional procedures guidance does not provide advice on whether treatments are clinically and cost effective, but it does provide advice on whether such procedures are safe and efficacious enough to use in clinical practice.

As my hon. Friend said, NICE published its updated interventional procedures guidance on SDR for spasticity in cerebral palsy in December 2010 in the light of the emerging evidence base from this country and around the world. NICE’s guidance states that the procedure may be used provided that normal arrangements for clinical governance and audit are in place. While the evidence suggested that the operation can improve the comfort and mobility of some people who have cerebral palsy, it was recognised that there are none the less serious risks that would have to be mitigated and managed as part of the procedure, not least in relation to harm to bladder function and walking ability. NICE was clear that if appropriately trained health care professionals wish to offer this treatment, they must fully explain to the families what is involved and that further surgery and intensive aftercare may be needed. NICE is also aware that the surgical techniques used within this procedure are still evolving, and that is why it has made recommendations about further ongoing research, although my hon. Friend made a very powerful case about the evidence base that has developed in the United States over many years of the treatment’s use in that country.

My hon. Friend will be interested to know that NICE is currently developing clinical guidelines on the management of spasticity in children and young people that will provide guidance to the NHS on whether SDR represents a clinically and cost-effective use of NHS resources. NICE consulted on the draft guidance last October. The draft guidelines explained that the available evidence for the procedure shows that it is most likely to be effective in children with particular symptoms, but that the evidence of sustained benefit was not currently available or weak. That is another area where it says that there is a need for research.

I assure my hon. Friend that I will ensure that this debate is provided to the decision makers within NICE so that they can see the additional material that he has brought to the House’s attention and the contributions of other hon. Members. That is very important. I hope that others who are championing this cause have taken the opportunity to respond to the consultation on the draft guidance. I understand that the final version of the published guidance will come out in June this year.

My hon. Friend referred to the work of Kristian Aquilina in Bristol and touched on the work of Support4SDR. I strongly commend the work that both are doing to raise awareness of SDR as a treatment. I know that in December they had a very productive meeting with officials from my Department, not least Dr Sheila Shribman, the national clinical director for children and young people. I gather that the meeting was useful and that a number of avenues were set out for further pursuit and exploration. Throughout the health and social care system, more information for patients and their families and clinicians can help to ensure that more informed decisions are made. The key challenge for Mr Aquilina and Support4SDR will be to increase the awareness of SDR as a possible treatment for some children with cerebral palsy. At the meeting, a number of possible avenues were suggested, not least engagement with the Royal College of Surgeons, working closely with the Council for Disabled Children, and updating the relevant section of the NHS Choices website. My officials stand ready to continue to engage and to work with those wishing to pursue this.

The issues spoken of tonight are very important because of the impact that cerebral palsy can have on children and their families and the hope of a better future that can be offered by appropriate treatment, which, for some children, might mean SDR. Raising public awareness about the procedure is undoubtedly part of what tonight’s debate has done. I commend my hon. Friend and others for contributing to that and for continuing to do so beyond the debate. I hope that the debate will be a contribution to NICE’s deliberations.

Clearly, promoting SDR as a safe procedure for appropriate children can be done only at a clinician-to-clinician level, so I urge my hon. Friend and others to continue to work with Support4SDR and Mr Aquilina carefully to document and spread the results of this surgery. The compelling stories of those mentioned in the debate, whether it be Holly, or Dana—the constituent of my right hon. Friend the Member for Carshalton and Wallington (Tom Brake)—or Finlay, or many others, all bear testament to how this can make a difference to people’s quality of life. I look forward to seeing the work that is produced by NICE and others in the coming months.

Question put and agreed to.

Candour in Health Care

Tom Brake Excerpts

Wednesday 1st December 2010 Westminster Hall

[Tom Brake (Carshalton and Wallington) (LD)]

It is a pleasure to serve under your chairmanship this morning, Mr Gray. I congratulate my hon. Friend the Member for Poole (Mr Syms) on securing the debate and on lucidly and concisely setting out precisely why the Government should look carefully at a statutory duty of candour. I have not heard any effective arguments against it, but I will come on to some arguments from opponents. My hon. Friend set out why the duty would boost public confidence and he rightly pointed out that an apology—as we have probably all experienced—often, first, helps to secure closure for a family if a loved one has been involved in a tragic accident, and, secondly, can defuse a difficult situation that could end up in the courts for years afterwards. He has rightly set out the reasons why a duty of candour is a necessity.

My hon. Friend started by quoting from the Liberal Democrat manifesto, and I would expect nothing less in the coalition, so there is no need for me, as a Liberal Democrat, to do so. He also mentioned that the proposal has been carried through to the coalition agreement and, subsequently, into the NHS White Paper, which—although it perhaps does not contain a proposal as specific as a duty of candour—certainly makes it clear that hospitals need to be open about mistakes and always tell patients if something has gone wrong. One development to which he did not refer was the fact that legal aid will no longer be available in cases of clinical negligence, which I hope the Minister will pick up on in her response. I wonder whether that will have an impact and whether that strengthens the case for a duty of candour.

As I said in my opening remarks, there are opponents of a duty of candour. A briefing has been sent to Members by the Medical Protection Society, which is a

“leading provider of comprehensive professional indemnity and expert advice to…health professionals around the world.”

The briefing states that the society is committed to promoting openness in health care and supports the principle in the NHS White Paper that hospitals should be open about mistakes and always tell patients if something has gone wrong. However, it goes on to say that the MPS strongly believes that a change in culture would be more effective than a statutory duty. However, I agree with Action against Medical Accidents, which also briefed me for the debate. It said that perhaps the MPS is missing the point: it is not a question of a duty of candour or a change in culture, as it is perfectly possible to have both. Indeed, the duty of candour is one way of supporting and underpinning a change of culture, so that health care organisations are always open and honest with patients when things go wrong. The MPS says that it has been advocating that change in culture, and it is true that a number of organisations have been advocating it for the past 50 years or so, but the desired change has not happened. I am not sure how much longer one can wait for it.

There is an issue about guidance and about how seriously organisations take guidance when they are statutorily required to do other things. There is always a risk that guidance gets left aside while organisations focus on statutory duties. As the MPS said, it is correct that there is a professional duty for doctors and nurses to be open with patients in the event of a mistake, but there is a wider issue about there being no statutory duty on all health care organisations to promote and support that practice in their organisations. As my hon. Friend the Member for Poole said, the medical professionals may want to be open but, unfortunately, they are being advised by managers, who are not subject to the same professional codes and perhaps believe that less openness is the best course of action. My hon. Friend referred to the Stafford case, and, as I understand it, it was a legal officer who sought to suppress the doctor’s report in that case. When the General Medical Council was asked to confirm how many cases it had brought against a doctor specifically for a breach of this part of its code, it confirmed that it has not brought a case against a single one.

My hon. Friend also referred to the very sad case of Robbie Powell and the sterling efforts that the family have made. I am pleased to see that Mr Powell has joined us here today.

[Mr James Gray (in the Chair)]

Order.

[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.

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[Tom Brake]

I thank my hon. Friend for his intervention, and I entirely agree. A duty of candour must not be restricted simply to hospitals, because, as he rightly says, GPs in primary care and other health care providers regrettably also make mistakes. A duty would need to encompass more than simply hospitals, as was initially proposed in the coalition agreement.

I entirely support the points that my hon. Friend the Member for Poole made in opening the debate. There is strong, overwhelming evidence in support of a duty of candour. Guidance has not done the job, and a duty of candour really would open up the system and make sure that families and those who have suffered are, and know they are, entitled to receive information about an accident. That would make it much easier for them to arrive at closure. Regrettably, under the current system, people must all too often use great energy and perseverance to extract with great difficulty information that they should be entitled to from the outset.

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[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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[Anne Milton]

I did not point a finger at the SHA; I pointed out that SHAs were performance managers. Where performance fails, one must ask oneself what was happening in the management of that performance that it could fail so abysmally. The hon. Lady must not forget that the GP consortiums will involve a much wider range of professionals in commissioning decisions than just GPs, including a lot of people involved in care. They will not necessarily consist only of NHS professionals. Voluntary bodies and other organisations that provide care will also have input.

The sad truth is that when things go wrong, relatives want to know what happened, as my hon. Friend the Member for Poole pointed out, but they do not always find out. They want the truth and honesty, but we often see precisely the opposite. Doors close, the shutters go down and NHS organisations resort to a defensive stance, sometimes quite aggressively. My hon. Friend mentioned his constituents the Byes and the Powells, who have campaigned endlessly for the truth and continue to campaign. I pay tribute to all the people, some of whom we do not know about, who use their own tragic circumstances to ensure that the same thing does not happen to others. Their efforts should never be underestimated.

[Tom Brake]

The Minister said that the NHS sometimes adopts an aggressive stance. I remind her of my question to her about the possible impact of withdrawing legal aid in clinical negligence cases. Often, families use such cases as a way of trying to secure an apology because one has not been forthcoming. If that option is not available to them, it reinforces the need for a duty of candour.

[Anne Milton]

The hon. Gentleman pre-empts me by a second; I was about to come to legal aid. My experience is that even with legal aid, the courts are rarely an option for most people. Allowing discretion on the reporting of near misses would, I fear, open another minefield beyond which people could hide, as he also mentioned.

I have certainly brokered meetings between NHS organisations and my constituents to try to bring them together and make the NHS organisations stop feeling so defensive. I have been an advocate for people in my constituency just so they could hear what happened. I should think that many hon. Members rely on personal relationships, particularly within hospital trusts, for such purposes. Maybe they know a supportive medical director to whom they can say, “Look, this family, this couple or these relatives just want to know what happened; this isn’t going to go anywhere.” That is a leap of faith. The NHS organisation has to say, “Fair enough.” When that happens, closure can follow.

The hon. Member for Southport rightly pointed out that accidents occur across the NHS and mentioned, in particular, the failure to diagnose in general practice. That is an ongoing, rumbling issue that I hear about not only as a constituency MP, but as a Minister. I thank him for recognising that the solution to getting to a situation where we have effective measures in place to ensure candour is a dilemma. It is not an easy decision. He is also right to point out that the NHS is not alone in protecting itself. My goodness me, we know a lot of professions that close their doors when one of their members is under attack—the legal profession is one. People just want the truth, but sadly the shutters go down and the doors close, and closure cannot be achieved.