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Mid Staffordshire NHS Foundation Trust

Volume 506: debated on Wednesday 24 February 2010

With permission, Mr Speaker, I wish to make a statement on the report of the independent inquiry into the Mid Staffordshire NHS Foundation Trust, which I am publishing today. Copies have been placed in the Vote Office.

In July last year, I commissioned Robert Francis QC to conduct this inquiry. I asked him to establish what went wrong at Stafford hospital and why; what lessons can be learned; and what further action is needed to ensure the trust is delivering a sustainably good service to its local population. In particular, I asked his inquiry to focus on listening to patients and their families. I said at the time that the full impact of what happened at Stafford hospital would be understood—particularly in the NHS at local and national level—only when we heard clearly the voices and experiences of those most affected.

The Francis report fulfils all those aims. I wish to thank Robert Francis for his thorough report, and the painstaking way in which he has conducted this investigation. Over 900 pages and two volumes, his report lays bare a dysfunctional organisation at every level and appalling failures of basic care over the period between 2005 and March 2009. The report confirms the severity of the then Healthcare Commission’s assessment of the trust in March 2009. In his covering letter to me with the report, Robert Francis says:

“The overwhelming number of accounts given by those affected should surely put to rest the views, still harboured by some, that the Healthcare Commission’s report painted an unfair picture of how the Trust was performing. There can no longer be any excuse for denying the enormity of what has occurred.”

Let me be clear: the care provided was totally unacceptable and a fundamental breach of the values of the NHS. Since March last year the Government’s first priority has been to help the trust to take immediate steps to improve patient safety, care standards and public confidence. Last July a new chair and chief executive were appointed and, with a new board and senior team, they are making progress, as confirmed by the Care Quality Commission’s three and six-month reviews. However, as their local hospital hits the news again today, I appreciate that doubts about safety will be in the minds of people in Stafford. In advance of this statement, I therefore asked the Care Quality Commission for its latest assessment of both the Mid Staffs trust and the wider NHS. I will place a copy of its letter in the Library. The Care Quality Commission confirms that the trust is safe to provide services, although further improvements are still needed, and says that it does not believe that there is any other hospital in England with problems on the scale or of the magnitude seen at Mid Staffs.

There have been many calls for a full public inquiry into events at the trust and the wider regulatory system. When I came into this job I gave those calls very careful consideration. In particular, I spoke to the four Members whose constituencies are served by the trust. It was clear to me that a further process of inquiry was needed to establish the full picture and to help the healing process. However, I had to balance that with not distracting the trust from the overriding need to make immediate improvements in patient care. It was that consideration which led me to establish the inquiry in the form that it has taken, rather than as a full public inquiry. I did not believe that a lengthy, adversarial inquiry would be in the best interests of health care in Staffordshire. The chairman was able to ask me for further powers if he felt they were needed, but he did not do so, and I believe that his report supports the approach that we have taken. He concludes:

“I am confident that many of the witnesses who have assisted the Inquiry by written or oral evidence would not have done so had the Inquiry been conducted in public.”

More than 900 members of the public and 82 current and former members of staff contacted the inquiry directly or indirectly, and 113 witnesses gave oral evidence. That evidence revealed an organisation with a culture

“not conducive to providing good care for patients or a supportive working environment for staff”.

The board did not consider patient complaints, clinical governance or quality at its meetings. Meetings were held in private, and Robert Francis describes the organisation as working in isolation from the wider NHS community and as having a closed culture. As he has said today, the board

“lost sight of its fundamental responsibility to provide safe care.”

That dysfunctionality extended to the way targets were managed in the trust and the failure to put in place adequate staffing levels to provide safe patient care.

The management of the trust cut staffing to dangerously low levels, at one point leaving A and E with a third fewer nurses than were needed to provide safe care. A work force review in March 2008 disclosed that the trust needed to increase its nursing establishment by 120 whole-time equivalents. There was an intimidating and bullying management style. Among staff there were failures of professional standards and clinical leadership. Some staff were praised, but the report finds a “lack of compassion” and an “uncaring attitude” among others. Time and again throughout the report, there are unacceptable examples of poor care, neglect and disregard for patients’ dignity. At times, as Robert Francis says, that could be described as rudeness, hostility or even abuse.

The trust has already taken disciplinary action to hold individuals to account. The trust and the professional regulatory bodies, the General Medical Council and the Nursing and Midwifery Council, are investigating a number of clinical staff potentially implicated by those events. Today I have written to the chairs of both bodies to ask them to consider the report in detail and work with the trust to determine whether further action is needed against any individuals. I have asked for their response by 12 March.

In total, Robert Francis makes 18 recommendations. Together with the new board of the trust, the Government accept all the recommendations in full. I will take the four recommendations that apply to my Department in turn.

First, Robert Francis recommends that I consider steps to improve accountability among executive and non-executive directors of trusts. The board that presided over the failings at Mid Staffs has been replaced, and other managerial staff have been suspended. However, it is a long-standing anomaly in the NHS that the robust professional regulatory system for clinicians is not matched by a similar scheme for managers and non-executive directors. We must end the situation where a senior NHS manager who has failed in one job can simply move to another elsewhere. That is not acceptable to the public and not conducive to promoting accountability and high professional standards, so today I am announcing that I will consult on a new system of professional accreditation for senior NHS managers.

Secondly, Robert Francis asks me to consider asking Monitor to de-authorise Mid Staffs as a foundation trust. The report makes it clear that Mid Staffordshire has not been deserving of the foundation trust status that it has held for the past two years. At the same time as setting up the inquiry, I proposed to create a new power for Monitor to de-authorise foundation trusts, to make it clear that this status has to be continually earned and is not a one-way ticket. That provision was subsequently endorsed by this House. I can tell the House today that I accept Robert Francis’s recommendation to consider asking Monitor to de-authorise Mid Staffs. My strong view, in the light of the report and the support that the trust is likely to need in the medium and long term, is that I will ask Monitor to consider de-authorising when the powers come into effect in the coming months. I will therefore ask the CQC, Monitor and others to give me their views of the trust’s long-term clinical and financial prospects, and I will consider initiating the process in the light of their responses.

Thirdly, Robert Francis asks me to review how comparative mortality statistics are compiled, as well as the methodologies that underpin them, to improve public confidence in and understanding of them. One of the principal reasons why the Healthcare Commission launched its review in 2008 was that it was not satisfied with the trust’s explanation of its high hospital standardised mortality ratio. The inquiry has consulted a range of experts on the issue, and Robert Francis concludes:

“it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number or range of numbers of deaths were caused or contributed to by inadequate care”.

However, as he points out, there is no shared methodology for HSMRs, nor any clear account of how they should be used and interpreted. The result is confusion for patients and the public. I therefore welcome and accept the recommendation to establish an independent working group to examine and report on the methodologies in use. The NHS medical director, Professor Sir Bruce Keogh, has already established that group, which includes the key parties involved in developing and using HSMRs, as well as leading academics and others. The group has committed to developing a single HSMR for the NHS.

Fourthly, the report calls for a further independent examination of all the commissioning, supervisory and regulatory bodies, in relation to their monitoring role at Stafford, with the objective of learning lessons about how failing hospitals are identified. I accept that recommendation, and can tell the House that Robert Francis has agreed to chair the further inquiry. We are publishing draft terms of reference today, and we welcome views on them.

In addition to accepting all the report’s recommendations, there are further steps that I will now take to learn the lessons of this and prevent a repeat. First, let me make clear today to all foundation trust boards my strong presumption that their meetings should be held in public and that governors should have access to all papers in the trust. The decision of the board at Mid Staffs to hold more meetings in private on achieving FT status is a direct contradiction of what this House intended when it passed the original foundation trust legislation.

Secondly, I am today accepting the National Quality Board’s recommendations to improve early warning systems in the NHS, and I am publishing its report today. Thirdly, a group has been established to advise me on updating whistleblowing guidance. Statutory protection for whistleblowers is enshrined in the NHS constitution, but events at Stafford hospital reveal the need to ensure that staff feel able to exercise that right.

Fourthly, I want to see a much greater focus in the NHS on measuring patient satisfaction and staff satisfaction—key indicators of good quality care. In December, I announced that a growing proportion of a hospital’s income will be linked to patient satisfaction, rising to 10 per cent. of its payments over time. Fifthly, I brought forward the new system of provider registration in the NHS to ensure essential levels of safety and quality. The CQC has already announced today its intention to register Mid Staffs, although it will place conditions where further improvement is needed.

In conclusion, the Francis report delivers a damning verdict on a dysfunctional organisation. It was principally a local failure, but I accept that there are national lessons to be learned—and they will be. Last year, the Prime Minister apologised to the people of Staffordshire. On behalf of the Government and the NHS, I repeat that apology again today. They were badly let down. I pay tribute to the people who had the courage to come forward and tell their stories and to expose the failures of the past, in order that they could protect others in the future. Robert Francis said that many of the patients who gave evidence to the inquiry

“were motivated because they do care about the hospital, and demonstrated by their actions that they can be a part of mending the fractured confidence.”

That sentiment is shared by all those who came forward, and indeed by the majority of people who complain about the NHS. They do so because they want it to be better. I want their voices to be heard loudly and clearly in this trust, and across the NHS.

Today, Sir David Nicholson has written to every NHS chief executive and chair, urging them to read this report and to review their standards, governance and performance in the light of it. When the NHS fails—as it did the people of Staffordshire—it is right to confront it with its failings. At times, there is a tendency in the NHS to push complaints away. I believe very strongly that it is only by facing up to failure—and by holding a mirror up to the NHS—that we can ensure that it is a learning organisation and prevent any repeat.

Since events at Stafford, Lord Darzi’s next stage review has established a major drive to build an NHS that places a relentless focus on quality. For the vast majority of patients, the NHS provides a good standard of care. The CQC’s latest patient survey showed that 93 per cent. of patients rated their overall care as good or excellent. When things go wrong, however, we must face up to them and do everything in our power to ensure that such events can never happen again. I commend this statement to the House.

I am grateful to the Secretary of State for making an oral statement today, and for giving me advance sight of it. I want, once again, to express our deepest sympathies to the patients who suffered and to the relatives who saw them suffer. My right hon. Friend the Member for Witney (Mr. Cameron) and I have had occasion to talk to those relatives in Stafford, and the stories of their experiences were harrowing. Today’s report, the second volume in particular, sets out the most compelling—indeed, horrific—character of many of the sufferings of the patients and their relatives.

I pay tribute to the work of Julie Bailey and Cure the NHS, and to their determination and persistence in holding the hospital trust and the Government to account for their failures in relation to this hospital, and in securing this further investigation. The Secretary of State will recall that, when the Healthcare Commission published its first report, his predecessor instituted an internal Department of Health inquiry under Dr. Colin-Thomé and another under Professor Sir George Alberti. We told the Government then that that would not meet the need of the people of Stafford for a clear investigation in public into what had happened. When the Secretary of State announced this inquiry by Robert Francis, we told him again that it would not achieve that aim. This is the fourth report, and none of them has diminished the need for a public inquiry under the Inquiries Act 2005, in which evidence can be taken in public and under oath. We can combat a culture of secrecy and bullying only by ensuring the fullest openness and transparency in any investigation.

The whole House will, none the less, be grateful to Robert Francis for fulfilling his brief in a thorough and objective manner. We find no fault with his work, but we do object to Ministers setting up report after report with constrained terms of reference that are designed more to focus on local management than to get to the full truth and the full context of the tragedy at Stafford hospital by analysing in addition the failure of national and regional scrutiny and of NHS performance management.

In my evidence to Robert Francis, I urged him to recommend a further investigation into the role of the external monitoring and performance management agencies, and I am glad that he has taken this advice and made that recommendation today. Such a further investigation is essential, because many of the serious questions that we and the relatives of those who died have been asking the Government for the past year remain unanswered.

Why did the primary care trust fail to ensure that standards were up to scratch when it commissioned services from the hospital? Why did the strategic health authority, which was charged with performance management of the hospital when it was an NHS trust, fail so abjectly in that task? Why did the Department of Health simply wave through the foundation trust application at the very time that clinical standards were so poor? Why did it take so long for the scrutiny by the inspectorate to establish that the high mortality rates were occurring, and to undertake an investigation into them? What are the problems with national policy and decision making on patient and public involvement that resulted in people failing to listen to patients raising their concerns in Stafford? And what are the problems with the whistleblowing procedures and practices in the national health service that prevented or inhibited front-line staff from speaking out about poor standards of care?

The Francis report provides a powerful analysis of the impact of the Government’s top-down targets on patient care at Stafford hospital. When the scandal was laid bare by the Healthcare Commission last March, the then Minister of State, the right hon. Member for Exeter (Mr. Bradshaw), said that

“this was not a problem about targets”.

However, the Francis report—on page 165—states:

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

Will the Secretary of State now acknowledge that Ministers were wrong to deny that targets were part of the problem at Stafford, and that they are wrong now to maintain that they are not the issue? Will he therefore move to abolish top-down political targets, so that the NHS can focus on patient safety and quality of care as an absolute priority?

In this Parliament alone, I have had to stand at this Dispatch Box on four occasions to respond to issues of failing hospitals: Stoke Mandeville in 2006; Maidstone in 2007; Mid Staffordshire last March, and again today; and Basildon and Thurrock in December. Each time, Ministers have insisted that these are isolated cases and blamed local management principally, but the themes have become too frequent and too familiar for this simply to be a coincidence: waiting time targets prioritised over patient care; clinical priorities distorted by Government targets; a focus on financial issues at the expense of patient care; senior management at board and strategic health authority level putting targets and policy processes ahead of a focus on quality care for patients; primary care trusts focused on cost and volume, and not on quality; and front-line staff finding their attempts to voice concerns going unheard or, even worse, suppressed. That is not good enough. We cannot go on like this.

We must be committed to establishing a full public inquiry into the tragedy at Mid Staffs. It must be an inquiry with a remit broad enough to ensure that no stone remains unturned and no lesson is overlooked. That would restore confidence among the public in and around Stafford. We will learn the lessons across the NHS, and we must do so up to and including the Department of Health. Action must be taken on the results.

For our part, we would abolish top-down political targets and the pointless bureaucracy that surrounds them. Instead, we would focus relentlessly on the results for patients. We will make patient experience and outcomes central to accountability. We will ensure that the quality imperative drives NHS services so that when complaints are made, the inspectorate receives, understands and acts on them. We will make quality and safety the central drivers of NHS performance and we will see through the changes in leadership, strategy and reform in the NHS that will give the public the confidence that when they go to hospital, they are there to be cared for and to be treated—and never to be harmed.

Order. This is an extremely important and sensitive matter. Nevertheless, both the Secretary of State’s statement and the initial response from the shadow Secretary of State have exceeded the time allowed for such exchanges, so I would ask the Secretary of State to provide economical replies and for others to take note in order that we can all make some progress.

Thank you, Mr. Speaker. The shadow Health Secretary began by extending his deepest sympathies to the patients and families affected, and I am sure that that will be echoed across the whole House and across the country. Today is another difficult day for those people, but we hope that this report will allow their voices to be heard at least more clearly than they have been hitherto.

The hon. Gentleman paid tribute to the work of Cure the NHS, which campaigned to have the events at Stafford hospital thoroughly investigated, and I believe that the report published today meets that requirement for a thorough investigation into those events. He asked whether the initial inquiries were internal to the Department of Health and he called for an independent inquiry, but that is the inquiry that I commissioned. As I said in my statement, when I came to this Department, I believed that a further process of independent inquiry was necessary. I commissioned it; I set it up; and I will deal with what it tells me today.

I do not think it is possible to read the Francis report and conclude that it does not tell the full truth or reveal the whole picture of what happened at the hospital. We now move forward from the inquiry to consider the actions of the regulatory and supervisory bodies. I have made it clear to Robert Francis that, should he need further powers to conduct that part of his work, he can come back to me and I will consider the request.

I draw the shadow Health Secretary’s attention to the draft terms of reference issued today, which state:

“The Government’s presumption is that the inquiry will be held in public, but this decision is a matter for the Chair.”

I would welcome the hon. Gentleman’s comments on those draft terms of reference, but I believe that they meet the tests that he put before us a few moments ago.

The hon. Gentleman also asked about the PCT, the SHA and the Department of Health. He is quite right to do so: he is quite right to ask questions about those bodies, their role in what happened and why things were not spotted sooner. That is precisely why we are setting up the second stage of the inquiry—so that those searching questions can be asked of those organisations.

The hon. Gentleman asked me about targets, suggesting that they were the problem. Let me quote the Francis report:

“As will be seen, the pressure to meet the waiting target was sometimes detrimental to good care in the organisation. This is inconsistent with the guidance about targets published by the Department of Health. It is vital that this target must not in any way jeopardise the quality of care offered to patients.”

If the hon. Gentleman reads the Francis report in full, as I am sure he will, he will see that the failure of the trust was the implementation of targets within it, and, indeed, the failure to provide adequate staffing levels on the wards to ensure that care could be delivered safely and meet the standards that other trusts around the country are able to meet. That is the conclusion I draw from the inquiry.

The hon. Gentleman asked what steps we can take to ensure that this does not happen elsewhere in the NHS. With an organisation on the scale of the NHS, I am sure that he and I would accept that things will go wrong and problems will occur. The right thing to do is to face up to them and take action to prevent them from happening again. In this particular case, I believe that we have faced up to the enormity of what happened at the Mid Staffordshire NHS Foundation Trust. It has been laid bare today in a very detailed report of more than 900 pages. I can assure the hon. Gentleman that I take my responsibility to act on the report’s findings with great seriousness. That is precisely what I will do.

I thank the Secretary of State for early sight of his statement. This is an utterly shocking scandal, which is a stain on the good name of the NHS. It demonstrates again horrifying evidence of patient neglect, which should never feature in the national health service. I welcome the recognition in the statement that there are national lessons to be learned, but the focus of the inquiry was none the less on this particular trust.

It seems to me that the inquiry was not designed to ensure that the full wider lessons could be learned. It was not designed to hold anyone to account, which it specifically says, as the terms of reference did not permit investigation into the role of any of the external agencies. It was also held in private. The inquiry was not able to consider the reports of any of the individual cases through a separate process because they were not ready in time. The report itself confirms that disappointing numbers of staff came forward to give evidence. That is not good enough. It is not the fault of the inquiry, but the fault of the process created by the Government. The bottom line is that the report will not satisfy the families of those who lost their lives and it will not bring an end to demands for a full public inquiry. I also pay tribute to the work of Julie Bailey and the organisation Cure the NHS.

Do not the findings reinforce the need to learn wider lessons about the causes of the failures that took place in the hospital: the focus on process at the expense of outcomes; the failure to listen to those who receive care; staff disengaged from the process of management; insufficient attention to the maintenance of professional standards; a weak professional voice in management decisions; abuse of vulnerable elderly people; and a lack of transparency? The key point is that none of those findings can be said to be unique to this particular trust. The hon. Member for South Cambridgeshire (Mr. Lansley) highlighted other failing hospitals that the House has debated.

There is surely a need for a full public inquiry, and it should surely first consider the pay-off to the chief executive and the fact that people are too often rewarded for failure. This chief executive received £400,000. I have a copy of the private investigation into his actions. Surely it should be published in full—it is heavily redacted, which amounts to a cover-up of the full findings of the investigation. It points to a case for disciplinary action, yet there was a very substantial pay-off to this chief executive.

A public inquiry should also look at the role of targets. The statement rightly said that blaming targets in their entirety would let management off the hook, but not looking at targets lets the Government off the hook, given that targets played a part in the failures of this hospital.

It is also essential to look fully at the role of regulation. I am pleased that there will be a further inquiry into that, but it should surely be held in public and should look at the complex web of regulation that we have created. The fact that we have five different national organisations with some responsibility for patient safety has resulted in no one taking proper responsibility for it. In Basildon, for example, there were 21 visits by seven different organisations in the year before the final report emerged. We need to look at the devastating report into the role and failure of regulation that was commissioned by the NHS Confederation last summer. It showed that we have ended up with paper safety rather than real patient safety and a tick-box culture.

A public inquiry should also look at the process for securing foundation trust status, which provided a false reassurance to people that the hospital was performing to a high standard. Finally, do we not owe it to the families of those who have lost their lives to have a full examination in public of the wider lessons that need to be learned from this scandal?

I agree with the hon. Gentleman that this is a shocking report that damages the name of the national health service. He asked why the report did not allow consideration of wider national issues, but he will have seen that the report does comment on national lessons to be learned. There were four recommendations in the report, which I spelled out in my statement, and I responded to those points. I did agree with the chairman that he could comment on what he wanted to comment on. However, we wanted the inquiry to focus primarily on the trust and the voices of the patients affected by the terrible events in the trust, so that we could get to the bottom of the failings and allow the trust to move on—which is, I believe, what we must do.

I wanted to get to the bottom of events as quickly as I practically could. I was also anxious that the trust should not be debilitated by a protracted inquiry that would divert it from its main job. I believe that we have got to the bottom of what happened locally; I now want the trust to move forward, and I believe that it is moving forward under the leadership of the new chair and chief executive. However, I accept Robert Francis’s recommendation that we look more closely at the bodies that have a supervisory, regulatory and commissioning role in relation to Mid Staffordshire NHS Foundation Trust. As the hon. Gentleman will know, we have already embarked on that task. David Colin-Thomé has done some work in examining the role of the primary care trust, but we must now put that work on a proper footing—knowing what we know from the first inquiry—so that we can learn the lessons at a national level, and I can assure the hon. Gentleman today that that is what we will do.

The hon. Gentleman said that the failings were not unique to this particular trust, and rightly observed that what went wrong in this instance was caused by a focus on process rather than on people. The words “focus on process” were used by Robert Francis, and they are at the heart of what went wrong. There was a failure to understand and respond to the public about what matters, and to see each patient as an individual deserving of the very highest standard of care—the care that we would all want our own families to receive.

The hon. Gentleman was right to say that the failings described in the report are not unique to the Mid Staffordshire NHS Foundation Trust, but it must also be said that the scale on which they occurred make the events in that trust unique. I sought an assurance from the Care Quality Commission that no other NHS trust exhibits problems on the scale of those found at Mid Staffordshire, and it gave me that assurance today, but let me also assure the hon. Gentleman that we remain constantly vigilant, and will ensure that every possible action is taken to deal with poor performance and poor quality in the NHS.

The hon. Gentleman asked about the Garland report on the former chief executive of the trust. I understand that he did not receive £400,000, but received his notice period and no more than his contractual entitlement.

The hon. Gentleman also asked about targets. The suggestion is that targets are there to distract people in the NHS from patient care, but they are essentially about the basic minimum that every person who arrives at the door of the NHS should be able to expect. They are fundamentally about people and the quality of care that should be given to every single person, regardless of their background or what they bring to the door of the NHS. In this case, the trust grotesquely failed to manage the pressure involved in delivering that basic standard of care to every person who arrives at the door of the NHS, which is what so many other trusts throughout the country manage to do.

Let me remind the hon. Gentleman what happened before there were targets for accident and emergency departments. The previous Government, in fact, suggested a four-hour target because there was chaos in A and E departments in the early and mid-1990s, and the present Government retained that target because basic minimum standards must be available to every patient who arrives at the door of an accident and emergency department.

The hon. Gentleman asked for a proper safety structure rather than “paper safety”. I can tell him that I take my responsibilities in respect of the new registration process extremely seriously. He will know that I have expedited the introduction of that system, which I believe directly responds to the concern that he has expressed.

Finally, the hon. Gentleman asked for a full inquiry into all these events. I believe that the second inquiry that I am setting up today will meet his demands. I invite him to comment on the draft terms of reference, and if he believes that they can be strengthened, I shall listen to his comments.

What the hon. Gentleman has asked for, I will carry through. We will ensure that there is no repetition of these events in the national health service.

I must tell my right hon. Friend that I am not surprised by the contents of the report—although I have not read it yet—in view of the evidence taken a few months ago by the Select Committee on Health about patient safety, part of which concerned the Mid Staffordshire NHS Foundation Trust. When we debate the subject in Westminster Hall next month, it will be possible to flesh out these matters a little further.

My right hon. Friend said that more groups were being formed to examine a number of issues, including whistleblowing. May I ask him to look again at the recommendations in the Health Committee’s report on patient safety? We suggested that there should be a system of whistleblowing like the one in New Zealand, which seems to be far more efficient and provide people with far more access. As my right hon. Friend pointed out in his statement, people in the NHS do not feel that they are able to blow whistles in an appropriate manner, even when there are horror stories such as those about what was happening to patients in Stafford hospital.

The Chair of the Health Committee has made a fundamentally important point, and he is right to press me on this issue. I believe that at times there is a failure at local level in the NHS to exercise the openness and transparency for which the House of Commons regularly calls.

I recall the debates on the foundation trust legislation. At the heart of that proposal was the replacement of national accountability with a greater degree of local accountability. It is impossible to say that that fundamental founding vision of what it meant to be a foundation trust was fulfilled in the Mid Staffordshire trust, and the issue of whistleblowing is an important aspect of that.

I do not believe that there is any Member in any part of the House who does not believe in the principle of whistleblowing. I do not believe that any of us would tolerate in our constituencies circumstances in which staff did not feel that they could come forward. We would want any member of the NHS to feel able and free to bring to our surgeries concerns about the trust in which he or she works. I believe that that goes for every Member of this House: no one who does this job wants to push away problems rather than addressing them directly.

We have put that requirement in the NHS constitution, and I repeat it today on the Floor of the House. We fundamentally uphold the right of NHS staff to raise concerns, and if their local trust does not have a culture that supports that, the position must be changed.

Order. These are extremely important matters. Let me repeat Mr. Speaker’s earlier remarks. If I am to call every Member who wishes to ask a question, I must urge Members to ask brief questions and the Secretary of State—please—to give one brief answer.

As the Secretary of State knows, from day one I have called for a full public inquiry under the Inquiries Act 2005, and I am glad that that request has been reiterated from my party’s Front Bench today. Does the Secretary of State accept that many people feel that they did not obtain full justice from the report? The inquiry was held in private; furthermore, the very fact that the Secretary of State has arranged a further report from the same QC indicates that there should have been a full public inquiry in the first place.

Does the Secretary of State agree that the self-assessment question—the issue of the emphasis placed by the people in the regulatory system on targets and money-driven rather than patient-focused care—is the key question that must be looked into in relation to Stafford, and that in order to get that right—

Order. I think that the hon. Gentleman has had his money’s worth.

And he deserves to do so, Mr. Deputy Speaker. I am grateful to him for the role that he has played in bringing his concerns to me and to the Minister of State, and for the discussions that we have had.

The hon. Gentleman asked about “full justice”. As the Prime Minister said earlier, individuals can make their complaints directly through a process of investigation. As for the fundamental question of whether it was right to hold a private inquiry, I have two points to make. I have to balance the need to ensure that the hon. Gentleman’s local trust takes immediate steps to improve the quality of care that it provides for his constituents. I see that as my fundamental duty: above all else, I must help people today in the quality of care they receive. I accept that others may not agree, but it was my judgment that an inquiry of this nature was more likely to get to the bottom of the issues more quickly, so that the trust could focus on the job of improving patient care. I also refer the hon. Gentleman to Robert Francis’s comment that he believed he received more from the public and staff because of the nature of this inquiry. The same level of privacy is clearly not justified in a national inquiry, however, which is why I say in the terms of reference that the presumption is that it should be conducted in public.

First, may I congratulate Cure the NHS on its work? I am delighted that the Secretary of State is determined to learn the lessons from Stafford so that the whole NHS can benefit. It is absolutely right that hospital trust boards must always meet in public. It is also right that the Mid Staffordshire NHS Foundation Trust should be de-authorised, but will the Secretary of State ensure that hospital managers do not profit from their failures and that other hospitals looking to apply for trust status, such as the University hospital of North Staffordshire, do not make the same mistakes as Stafford by putting financial issues and staffing levels before patient safety?

May I echo my hon. Friend’s comments about Cure the NHS? Although this process is, of course, very difficult for all those affected at the local level, I can say without fear of contradiction today that the actions that it has taken are now leading to changes in the national health service that will prevent a repeat situation from arising either locally or elsewhere. A number of changes that will benefit patients everywhere have already been made.

I had to reread the passage in the report that stated that on receiving foundation trust status, the trust began holding more meetings in private, because that beggars belief. As anybody who debated the FT legislation knows, that fundamentally contradicts the vision for foundation trust status. I repeat to all foundation trusts today that we expect meetings to be held in public wherever possible. I also very much hear what my hon. Friend says about the importance of not jeopardising the quality of patient care. Patient safety is the paramount and overriding priority of every NHS hospital, and of every NHS organisation. Everything else comes second to that.

In thanking the Secretary of State and the Minister of State, the right hon. and learned Member for North Warwickshire (Mr. O'Brien), for their unfailing courtesy in keeping Staffordshire Members informed, may I ask the Secretary of State to insist that the inquiry he has announced today be held in public, and to reflect upon the words of a widow who came to see me after having lost her husband, probably unnecessarily: what is crucial is that confidence and trust in the trust must be restored now, so that the area and the people the trust serves can look upon it with confidence and trust?

I thank the hon. Gentleman again for the manner in which he has helped us address these issues; his courtesy is always appreciated. I entirely agree that confidence is the key issue. This is another difficult day for the hospital, but I believe that from today the trust can begin to move forward, because we have now inquired fully and in depth at the local level. I believe the trust is making progress under Antony Sumara and Sir Stephen Moss; that is reflected in the report and in the reports that I hear locally from Stafford, and we need to do everything we possibly can to support them. There are 140 extra staff at the trust, and it has received about £4.5 million from the West Midlands strategic health authority. Support is going into the trust, therefore. We are considering whether we should initiate a process of de-authorisation, but we would only do so because we may be able to get more support more quickly to the trust, in order to build the confidence that the hon. Gentleman rightly calls for.

Even after four inquiries, it is still impossible not to be shocked by the record of failure of care in this case. We now know, beyond peradventure, what happened, and I think we know why it happened. What we do not yet know enough about is how it could have been allowed to happen. That is why there is a valid case for a fifth inquiry, into the regulatory structure, and I am glad the Secretary of State has announced that today. May I make one further point? There is one group of people who bear no responsibility for what happened: the patients. If we have one overriding obligation now, it is to make sure both that that hospital, which has failed them, pays for the errors of the past by being supported by the national health service, and that patient care in that hospital is as safe and effective as possible.

I entirely agree. My hon. Friend is right that there have been earlier inquiries, and I commissioned this extra report in order to hear loud and clear the voices of his constituents and those of other hon. Members who have spoken, and of my hon. Friend the Member for Stafford (Mr. Kidney), the Under-Secretary of State for Energy and Climate Change. The report is a thoroughly depressing read. When we hear and read stories of how patients were treated—and of patients doing their all to help staff, such as by taking the linen home to wash it—we know that there has been a basic failure of care for the constituents of my hon. Friend and of other Members, and there must be the most thorough investigation of that at local and national level. That is what I believe I am delivering to my hon. Friend and other colleagues in this House, and to their constituents. In the Francis report today, I believe we have the most thorough local investigation, and that will be followed by the second-stage inquiry, conducted in public wherever possible, so that we can get absolutely to the bottom of these issues, and people can finally feel that the issues they have raised have been fully investigated.

As a member of the medical profession, I was staggered and saddened by the low profile and lack of effectiveness of staff whistleblowers in Stafford. I therefore welcome the Secretary of State’s promise to update whistleblowers guidance. The Public Interest Disclosure Act 1998 and the work of Public Concern at Work need far more publicity. Does the Secretary of State agree that we still need to consider extra measures to support whistleblowers, who are still terrified of going through the normal channels? That is the whole point of my private Member’s Bill.

May I say to my hon. Friend that my door is open to him to talk about his Bill and how we can deliver what we both want, which is to improve the culture in the NHS so that whistleblowers can come forward without fear of repercussions and recriminations? I cannot say today that that culture exists in all parts of the NHS, but I can say unequivocally that that is the culture I want to see in every corner of our national health service. If he is willing to work with me towards achieving that, I am sure that we have a completely common purpose.

May I put a very simple point to my right hon. Friend? What clearly stands out from all this wealth of erudite and important words that we have heard in this House and everywhere else is that the hospital was terribly understaffed. If a company or any other organisation were so seriously understaffed, it would never get anywhere. I therefore have a suggestion. It involves one piece of paper, and I ask him not to resist it on that ground. In fact, such a piece of paper might already exist but have insufficient prominence. If we had one piece of paper on which hospitals had to list current staffing levels against the agreed requirement in the critical matter of doctors and nurses, we would all know whether or not there were sufficient staff to do the job. If such a piece of paper had been available, we could have avoided this whole situation.

I agree with my hon. Friend that that is, in many ways, the main message that comes out of the report. I was shocked to read that the work force review of March 2008 found a shortage of 120 whole-time equivalents, as well as one consultant in A and E when there should have been four, and 37 nurses when there should have been 55. Herein lie many of the problems the trust faced. It simply had an inadequate work force to deal with what needed to be done on a daily basis. That led to intolerable pressure on the wards, which in turn led to unacceptable treatment of patients. It is absolutely clear to me that this is unacceptable. That is one of the main messages that comes out of the report—and indeed, Robert Francis describes the trust as chronically understaffed.

The Secretary of State has said that one of his priorities is an early-warning system to ensure that what happened at Mid Staffs is not repeated elsewhere. The Dr Foster report identified seven hospitals with consistently high mortality rates. Is the Secretary of State going to order an investigation into those hospitals to make sure that their management is not leading to a possible repeat of what occurred at Mid Staffs?

The hon. Gentleman will know that action has been taken in respect of Basildon and Thurrock University Hospitals NHS Foundation Trust. He may not be aware that further steps are being taken against Tameside Hospital NHS Foundation Trust in Greater Manchester. Where action needs to be taken in order to intervene, we are taking that action. I should repeat to him the view of the Care Quality Commission, which is that there is no evidence to suggest that problems of this magnitude are replicated elsewhere in the NHS. I also say to him that I am not complacent on these issues: how could one ever be? Since what happened in Bristol, we can say with some confidence that we have, with the support of those on the Opposition Benches, begun a process whereby we are shining a spotlight on data in the NHS that in times past simply were not available. A wealth of data are now available to inform the public about standards at any particular trust. Many of the data are available on the NHS Choices website, but they can be improved so as to build a better understanding and appreciation of the picture at any trust. The hospital standardised mortality ratio—the HSMR—is not, in and of itself, a verdict on a trust; it is a trigger in respect of whether further action is required. As we have said today, we need further understanding of that target and an improvement of its methodology so that it is clearly understood across the NHS.

I welcome the Secretary of State’s commitment to hold a further inquiry into the regulatory bodies, in particular Monitor. He is talking about asking Monitor to de-designate the trust as a foundation trust, but a more fundamental question is how the hell Monitor ever came to designate it as a foundation trust in the first place, in the middle of this scandal. That was a lamentable performance by Monitor, which was supposed to look into all aspects of the situation and then make a recommendation to the Secretary of State. It seems that he can legitimately say that Monitor is not doing its job at all, and that some of the people at the top of Monitor ought to be leaving, under his new dispensation.

I thank my right hon. Friend for his question, and his welcome for the second stage inquiry under Robert Francis. The questions that he has just put before the House will be very much at the centre of that second stage investigation. The problem may have been that undue prominence was given to financial matters, rather than quality of care, when the foundation trust application was being considered. I say that without having had the further inquiry conducted, but those are precisely the matters that it will examine. I am grateful that my right hon. Friend supports the step that we are taking by carrying it out.

If the Secretary of State cares about patients, will he ask NHS London to think again about its deeply misguided plans for reconfiguring health care services in north London?

I do care about patient safety, and I say again that it is the overriding concern for every NHS organisation in the country, including NHS London. However, I would ask the hon. Lady to open her mind to the possibility that at times changes to hospital services are necessary to enhance standards of patient safety. The National Audit Office recently pushed Ministers on the reform of major trauma services, which implies a reconfiguration of hospital services. The lesson in the Mid Staffs case is that the trust was acting in isolation without sufficiently well developed clinical networks in its surrounding community. I say to the hon. Lady that sometimes patient safety may be enhanced, rather than diminished, by the reorganisation of services.

May I return to the issue of HSMRs, which the Minister mentioned in his statement? He told us that there is no “clear account of how they should be used and interpreted. The result is confusion for patients and the public”. He will know that people in east Lancashire are routinely told that the reconfiguration allegedly saved 200 lives. We know that academics and clinicians are reworking the methodology, but when will we get the results of that study, so that it can be applied across the NHS as a whole?

That is a very important piece of work, which is why I said in my statement that Professor Sir Bruce Keogh is already making progress on it. However, it is very important for the voices of the royal colleges, other professional bodies, and organisations across the health care world to be listened to in that work. When it is produced it will succeed only if it has support from, and is owned by, all those bodies. We will do this as quickly as we can, but in producing an HSMR measure in which the whole system has confidence we might need to take time to ensure that we carry out those discussions with all those concerned.

May I pursue the question put to the Minister by my hon. Friend the Member for Wellingborough (Mr. Bone) by asking him specifically about Kettering General Hospital NHS Foundation Trust, which was one of the seven on the list? Many people in Northamptonshire are unnerved by the possibilities that might arise from the situation in Kettering. I wonder whether the Minister will reassure them by saying what specific action he has taken with regard to that trust?

I would ask the hon. Gentleman to refer his constituents to the statement made by the Care Quality Commission today. I will place its letter, which gives assurances about the NHS as a whole, in the Library. I should say to him that there is a need for constant vigilance on safety standards in the NHS. The HSMRs are not, of themselves, evidence of failure—but they can provide a trigger for inquiry into whether standards are sufficiently high at any one hospital. I encourage him to continue to ask questions and to work with his local trust to ensure that standards are sufficiently robust at his local trust; that is exactly what I do with my local hospital. However, we need a better measurement of mortality ratios so that we can all be clear about, and have confidence in, what they tell us about our local hospitals.