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Mid Staffordshire NHS Foundation Trust

Volume 570: debated on Tuesday 19 November 2013

With permission, Mr Speaker, I would like to make a statement about the Government’s response to the Mid Staffordshire NHS Foundation Trust public inquiry.

Let me start by paying tribute to the men and women of courage, without whom this darkest episode in the history of the NHS would never have come to light. I am talking about people such as Julie Bailey and members of Cure the NHS, who stood outside the Department of Health in all weathers because no one would meet them to hear about the inhumane care given to their loved ones; brave whistleblowers such as Mid Staffs nurse Helene Donnelly; and campaigners who suffered tragedies elsewhere such as James Titcombe, who never gave up the fight after losing his son Joshua at Morecambe Bay. They suffered greatly for their selfless determination to ensure that their personal losses were not in vain. All of us in the House are humbled today to stand in the giant shadow of their bravery.

Robert Francis and his team also deserve huge credit. Their diligence and thoughtfulness led to an outstanding reform, which will transform our NHS for the better. Finally, let me pay tribute to all NHS front-line staff for whom reading about these events in the media has been immensely distressing. We owe it to them to make sure that poor care is never again allowed to take root and survive unchallenged in our NHS.

Since our initial response to the inquiry in March, much has happened. Thirteen hospitals have been put into special measures as part of a tough new failure regime. Those hospitals, where poor care had been allowed to persist, are now being turned around, and I thank the Keogh inquiry team for its painstaking work in that area. Independent Ofsted-style ratings of hospitals are under way, led by Professor Sir Mike Richards, the new chief inspector of hospitals. The first 18 trusts are currently being inspected, with quality of care and safety paramount. We have appointed new chief inspectors of adult social care and general practice, whose robust inspections of care homes, domiciliary care and surgeries start next year, and surgical survival rates for 10 major specialties have been published by individual surgeons, making the NHS a world-leader in transparency.

Today the Government are publishing our further response to the inquiry, as well as our response to the Select Committee on Health’s report on the inquiry. Both responses have been laid before Parliament.

The NHS is a moral being or it is nothing. It was set up 65 years ago with the noble ideal that no one should ever be prevented by background or finance from accessing the best care. That is why it remains the most loved British institution, and rightly so. But each and every case of poor care betrays those worthy aims. I do not simply want to prevent another Mid Staffs. I want our NHS to be a beacon across the world for not just its equity but its excellence. I want it to offer the safest, most compassionate and most effective care available anywhere. I believe that it can, but only if there is a profound transformation of the culture in the NHS.

The inquiry shows the devastating effects of overly defensive responses: hurting families, suppressing the truth and preventing lessons from being learned. Failure cannot be addressed when it is covered up, so today I am announcing new measures to promote a culture of openness and transparency. From 2014, every organisation registered with the Care Quality Commission will have a statutory duty of candour. Patients must be told promptly about any avoidable harm, but there will be a statutory requirement to notify any harm that has led to avoidable death or serious injury.

We will consult on whether hospitals that are found not to have been open and transparent with patients or families at the earliest reasonable opportunity should risk having their indemnity from litigation awards reduced or removed by the NHS Litigation Authority. The signal must go out loud and clear from hospital boards and chief executives to all clinicians: if in doubt, report an incident and tell the patient. The professional regulators have agreed to place a new, strengthened professional duty of candour on all doctors and nurses. Failing to inform a patient, not reporting avoidable harm or obstructing someone else seeking to do so will be subject to sanctions, including being struck off.

Inspired by the airline industry, the duty will cover “near misses”—occasions when mistakes were made that could have led to harm and from which we need to learn. Conversely, prompt reporting may be considered as a mitigating factor in a professional conduct hearing. That is not about penalising staff for making mistakes; it is about enabling them to learn from them. The NHS will adopt a culture of learning, as recommended by Don Berwick and his expert committee, and I thank them for their seminal report.

A culture of openness also means learning from complaints. In line with the recommendations of the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart’s excellent review, all patients will be able to access independent help in making their complaint, with clear signs in every ward explaining how to do so. The chief inspector of hospitals will inspect complaints handling to establish whether trusts are genuinely seeking to understand and learn from them; every quarter, trusts will publish the number of complaints received and lessons learned; and the health service ombudsman will dramatically increase the number of cases she looks at in detail.

[Official Report, 22 November 2013, Vol. 570, c. 12-14MC.]It is impossible to deliver safe care without safe staffing levels. All hospitals will be required to monitor their staffing levels on a ward-by-ward basis, analysing precisely how many shifts meet safe staffing guidelines. By the end of this year, this will be done using models independently approved by the National Institute for Health and Care Excellence. No hospital will be able to conceal unsafe staffing from the public because from next June all that data, both at ward and hospital level, will be published alongside other safety data on a new NHS safety website, triggering CQC action if there is cause for concern.

Things are already changing for the better and I am pleased to report that trusts are planning to recruit an additional 3,700 nurses compared with a year ago, but we need to go further to train and motivate staff, particularly the health care assistants and social care support workers who perform so much vital care. Health care assistants and social care support workers will be required to have a new care certificate to ensure that no one is ever asked to perform personal care without adequate training, whether in hospitals or care homes. The title “nursing assistants” will be used widely in hospitals, and paths to nursing careers will be improved. I thank Camilla Cavendish for her excellent work in this area.

We also need to broaden the talent pool going into NHS management positions, in particular by attracting more clinicians and those with good external experience. We have introduced a fast-track leadership programme, sending 50 people a year to a world-leading business school followed by time shadowing top NHS chief executives.

Robert Francis correctly highlighted the failure of regulatory systems to identify quickly what happened at Mid Staffs. Subsequently it has become clear that Ministers put pressure on regulators that may have led them to tone down news about poor care. That is totally unacceptable, so we will strengthen the statutory independence surrounding reports into care quality. The chief inspector will be the nation’s whistleblower-in-chief and nothing must ever be allowed to stand in his way.

The CQC can prosecute when fundamental standards are breached and trusts put into special measures will have a strictly limited time to get their house in order before administration is considered. Foundation trusts in special measures will have their autonomy suspended and action will be taken to ensure that they quickly improve. No trust will be able to progress to foundation status unless it is rated good or outstanding.

Proper accountability must be at the heart of the NHS. I have therefore accepted Professor Berwick’s recommendation of legal sanctions for those found guilty of wilful neglect or ill treatment. There will be a new criminal offence for care providers that supply or publish false or misleading information and a new fit and proper persons test will enable the CQC to bar unfit directors from boards.

Finally, every hospital patient should have the names of a responsible consultant and nurse above their bed. Starting with over-75s from next April, there will be a named accountable clinician for out-of-hospital care for vulnerable older people.

One of the most chilling accounts in the Francis report came from Mid Staffs employees who considered the care they saw to be “normal”. Cruelty became normal in our NHS and no one noticed. The Francis report made 290 recommendations. I accept the principles behind all of them, and wherever possible have adopted the practical solutions suggested by the inquiry. Robert Francis has welcomed today’s announcement as a carefully considered and thorough response to his recommendations, which he says will contribute greatly towards a new culture of caring and making our hospitals safer places for their patients.

Today’s measures are a blueprint for restoring trust in the NHS, reinforcing professional pride in NHS front-line staff and above all giving confidence to patients that after Mid Staffs the NHS has listened, the NHS has learned and the NHS will not rest until it is delivering the safest, most effective and most compassionate care anywhere in the world. I commend this statement to the House.

What happened at Mid Staffs was a betrayal of the NHS and its values. The previous Government rightly apologised, but now is the time to back our words with action. That is why, although I welcome much of what the Secretary of State has just said, it is my job to press him on where we feel he could have gone further and to question why, of the 290 Francis recommendations, 86 are not being implemented in full.

First, let me, too, pay tribute to my right hon. Friend the Member for Cynon Valley (Ann Clwyd), Professor Tricia Hart, Professor Sir Bruce Keogh, Camilla Cavendish, Professor Don Berwick and, of course, Robert Francis. Between them, they have given us proposals that will help to prevent a repeat but, more importantly, as the Secretary of State said, change the whole of the NHS for the better.

Both Francis reports found three primary and fundamental causes of what went wrong: a failure to listen to patients; a lack of properly trained staff; and a dysfunctional culture. I shall take each of those issues in turn.

First, I am sure the Secretary of State agrees with me that patients and their families must always, as Francis recommends, be the first priority for the NHS. That principle unites this House and it must also unite the NHS. Is not Robert Francis right to recommend that the NHS constitution, and the ethos it sets out, should be required reading for all NHS staff? I congratulate the right hon. Gentleman on agreeing to implement the Clywd review in full and change the way the NHS handles complaints.

Secondly, on the issue of staffing numbers and training, the first Francis report found that Mid Staffs made dangerous cuts to front-line staffing over a short period. I welcome the Government’s new focus on this issue, but is it not the case that nurse-patient ratios across the NHS have got significantly worse in the past three years, with 5,890 fewer nurses, more older patients in hospital and bed occupancy running at record levels? It is encouraging that the NHS has plans to recruit more nurses this year, and is introducing more monitoring. The Secretary of State says “things are already changing for the better”, but is he aware that Monitor has warned that trusts are planning major nurse redundancies in the 2014-16 period, far outweighing any increases this year? Will he intervene now to stop that? Further, can he explain why he stopped short of requiring safe staffing levels? Is he further aware that nurse training places have been severely cut in recent years and trusts are being forced to recruit overseas?

Alongside nursing, more action is needed to raise standards across the caring work force. As Robert Francis has said, it is unacceptable that the security guard at the door of the hospital is more regulated, and subject to professional sanctions, than the health care assistant attending to an elderly patient. The development of the care certificate as proposed by Camilla Cavendish is a step forward, but will it not work only alongside a register of those who hold it and an ability to remove it if they fall short? Was not Robert Francis right to recommend a system of regulation for health care assistants and, going forward, will the Government reconsider their decision to rule this out? Overall, although there is progress on staffing today, it does not go far enough and we will continue to challenge the Government on it.

Thirdly, on culture change, Francis’s central proposal is a new duty of candour on organisations and individuals. Extending the duty to organisations is a step forward, but patient groups are disappointed today that it will cover only the most serious incidents. Can the right hon. Gentleman say why it has not been extended to all incidents of harm? Further, it is not clear how an organisational duty alone will help individuals challenge an organisation where there is a dysfunctional culture. Is it not the case that an individual duty as proposed by Francis is essential? This point comes over clearly from the evidence given to Francis from a senior, soon to be retired consultant. He said:

“I took the path of least resistance . . . here were also veiled threats at the time, that I should not rock the boat at my stage in life.”

It is only when an individual is both required to speak out, and protected in doing so, that this House can say it has done enough to safeguard patients.

The duty of openness and transparency should apply equally to all organisations providing NHS services including, as Francis rightly recommends, contractors providing outsourced services. Given that this Government are bringing into the NHS more outside providers, patients will need reassurance that we do not have an uneven playing field where private providers face less scrutiny. So will the Secretary of State extend the duty of candour to all health care organisations, as Francis proposed? His amendments to the Care Bill do not make that clear. And should not he now commit to extending freedom of information law to any provider of NHS services?

On openness, Francis made a direct call on the Government to set an example to the rest of the NHS. He said that

“risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted.”

Given that the Government claim today to be accepting this, should they not show now that they mean what they say by finally publishing the risk register on the current reorganisation of the NHS?

Finally, on openness, the NHS would be more accountable to families with a proper system of death certification. The House will remember that this was a recommendation of the Dame Janet Smith inquiry into the Shipman murders. The report today says that the Francis recommendations on this are not accepted in full. If we fail to act now, might people be justified in thinking that this House has not learned the lessons of tragedies that have gone before? If the Secretary of State brings forward proposals, we will work with him on a cross-party basis to implement them.

In conclusion, I do not believe that cruelty has become normal in the NHS, but there is a much deeper question for us all and that is how, in the century of the ageing society, we do a better job of caring for older people. We should not accept the situation where, as Cavendish says, people are paid less than the national minimum wage. Should we not all set much higher ambitions for the care of older people and, in so doing, learn the most fundamental lesson of all from what happened at Mid Staffs?

Let me take the right hon. Gentleman’s points in turn. First, he will know, because this is what happened after the Bristol inquiry and the Shipman inquiry under the previous Government, that Governments do not always accept every single recommendation. What I have said today is that we accept all the principles behind every single one of Robert Francis’s recommendations. We are implementing 204 in full, and in respect of the 86 that we are not implementing exactly as he said, we are doing everything we can to make sure that we implement the spirit behind them, but we need to make sure that everything we do is workable in practice. Francis himself has said that it is a “carefully considered” response that is a “comprehensive collection of measures”.

On staffing numbers, which is an essential part of what we have to consider, if the right hon. Gentleman looks at the nursing hours per bed, he will find that they have gone up since 2010, not down. We recognise the crucial importance of front-line staff, which is why I gently say to him that we made some reforms to the NHS that meant that there are 5,500 more doctors on the front line and 8,000 fewer managers. What we also need is more nurses. That is why it is so encouraging that in response to what Robert Francis has said and the recognition throughout the NHS of the importance of compassionate care, we are getting a reaction from NHS trusts—not as a result of a direct ministerial decision, but because trusts themselves are recognising the importance of compassionate care. We think that is a very encouraging sign.

With respect to whether staffing levels should be mandatory, we agree that there are minimum recommended staffing levels, but they are not the same for every ward in every hospital. The minimum level might be one in six for an acute medical unit, one in four for a general medical unit, and one on one for intensive care. We took extensive advice on whether it would be appropriate to set a national minimum mandatory number. Not only is the chief nurse and leading nurses from across the country against this; the King’s Fund and the British Medical Association are against it. The BMA said something today in a statement which I never thought I would read in my lifetime—it said that the “Government is right” on this issue.

The right hon. Gentleman also opposed mandatory staffing levels back in 2011, although it is fair to say that in the House his position on this has changed. The important thing is that we allow local discretion to make sure that nursing levels are adequate, and that where they are not, that is exposed quickly so that there is no repetition of what happened at Mid Staffs.

On the regulation of health care assistants, every health care assistant will have to have a care certificate. Effectively, there will be a database which allows employers to check whether someone has such a certificate. That is a kind of register. The other reason for people talking about the regulation of health care assistants is that they want to make sure that if someone fails in their duty of care, they are not able to appear somewhere else in the country. That is why we have a vetting and barring scheme to make sure that that does not happen.

On the individual duty of candour, let us be clear: we want total candour about all avoidable harm, at every stage that it happens, anywhere in the NHS. We decided after much discussion that extending the statutory duty of candour to individual front-line clinicians would be likely to create a huge amount of bureaucracy and damage the culture of openness that we are trying to create, because everyone would constantly be worried about whether or not they were breaking the law. We decided that the right way to achieve the objective is through a professional duty of candour, which is much stronger than the current professional duty states. Critically—this is a key change—we decided to make sure that, just as airline pilots have protection if they speak out, if front-line NHS employees speak out, they too will get protection if there is a professional conduct case, and that openness at an early stage will be treated as a mitigating factor. That is really important in terms of changing the culture.

Finally, we absolutely do need to resolve the issue of death certificates. It is important that we have an independent view to certify deaths. It is a question of finding a practical way to make sure that we do that, but we very much accept the spirit of what Robert Francis said.

Today I hope that we will find a way forward on all the problems that Robert Francis addressed in his response and that we have been thinking hard about. I urge the shadow Secretary of State to join Government Members in saying that this is a moment when the NHS can once again reach forward and aim to be the very best in the world, because the kind of measures that we are talking about are not happening anywhere else, and that is something of which we can all be very proud.

I thank my right hon. Friend the Secretary of State for his statement and commitment. A culture of compassionate and safe care for all in the NHS must be the legacy of the Francis inquiry. It is the least that those who suffered from dreadful neglect, and their loved ones who campaigned for justice, deserve. Staff throughout Mid Staffordshire trust have made firm strides since then in improving that culture with clear results in patient care, but will my right hon. Friend be the patients champion and ensure that the NHS puts patients first and foremost?

That is the central change in culture that we need throughout the NHS. I pay tribute to my hon. Friend in particular, because he has had a more difficult challenge with respect to his local hospital than any hon. Member. He has campaigned for the people who use that hospital and for the staff there with great integrity and courage, which I commend.

I have never believed that there is a conflict or a choice between putting NHS staff first and putting the patient first. I have never met a doctor or nurse who does not want to put the patient first. The trouble is that we have created structures and incentives that make it difficult for front-line staff to do what they joined the NHS to do, which is to care for patients with dignity, compassion and respect. That is what we are trying to do in the changes today.

I am grateful for the kind words about the report from the Secretary of State and from my right hon. Friend the shadow Secretary of State. If I may plug our report for a moment, “A Review of the NHS Hospitals Complaints System: Putting Patients Back in the Picture” is available. I have not yet gone through the tick-list of all the things that we asked for, but I shall be doing that. The Secretary of State has agreed that we can monitor the progress that Sir Mike Richards makes in putting complaints and the treatment of complaints at the top of his list when he visits hospitals around in the country.

May I press the Secretary of State on one point? He said in his statement that “all patients will be able to access independent help in making their complaint”. How exactly will that be done and how will it be resourced? I am grateful to the many thousands of people who wrote to me during the course of the review who complained about similar experiences to mine on the lack of care and compassion. That applies not just to nurses, but throughout the NHS from top to bottom. I hope that this will address some of the many complaints from Stafford and elsewhere.

I congratulate the right hon. Lady on the extremely good report that she produced. I hope she will not find herself in a position of wanting to complain to me about the way in which I have implemented her report on complaints, because we intend to take it extremely seriously. She knows that I basically accept everything she said in it, although we will have to work carefully on the implementation of some things to make sure we get them right. She highlights one of the most fundamental problems. Probably the biggest problem is that some hospitals treat their complaints procedure as a process rather than something that they can learn from. Every NHS patient whom I have met who has had problems only ever says the same thing. They just want to know that the NHS will learn from what has gone wrong. That is all that they are interested in.

The point that the right hon. Lady makes is a very important one. People do sometimes feel that it is them against the system, and taking on a big establishment that might be well funded and is not really interested in hearing what they have to say is a very lonely process. It is vital that everyone who wants it can get independent support. One thing that we will be requiring is a sign, prominently displayed in every ward of every hospital, telling people, first, how they can make a complaint, and secondly, how if they want it they can get independent help and support. That could be a very good role for the new healthwatch organisations, but it may not be them in all cases, so most importantly, we will insist that people everywhere can access that independent help.

Did my right hon. Friend hear my constituent, Debra Hazeldine, this morning on the “Today” programme, with a harrowing description of the way in which her mother was let down and died in Stafford hospital? I agreed with everything she said. Does he acknowledge that, although my right hon. Friend the Prime Minister listened, after correspondence and meetings with him, to my repeated calls and motions for the setting up of an inquiry under the Inquiries Act 2005, which the Prime Minister set up and which has led to a complete shake-up, not only of Mid Staffs but the entire health service, successive Labour Secretaries of State in the last Government disgracefully and repeatedly refused to agree to such an inquiry, and that but for our determined campaign with Cure the NHS, and in particular Julie Bailey, Debra Hazeldine and Ken Lownds and his campaign for zero harm, the 2005 Act inquiry would never have taken place and the Francis report would never have been produced, with all its beneficial consequences, in the Secretary of State’s hands, for the NHS in the national interest? When will the debate take place on this report on the Floor of the House in Government time?

I did not hear Deb Hazeldine this morning, but I have met her on a number of occasions, and she is an extraordinary, powerful advocate for the changes that we need to make in the NHS. I have had discussions with my right hon. Friend the Leader of the House about the possibility of debating this on the Floor of the House, and I would very much welcome the opportunity to do so. My right hon. Friend deserves great credit for the fact that he was one of the earliest people to push for a full inquiry. I hope that the shadow Secretary of State will now accept that it was wrong not to have a public inquiry—it was blocked so many times by the Labour party—because we have learned so much from what Robert Francis has been able to say, and the NHS will be the better for it. Great credit should go to my predecessor, who is sitting here now, who took the decision to have that public inquiry.

Does the Secretary of State not agree that the horrors of Mid Staffs were taking place at the same time that wonderful first-class care, from both a clinical and compassionate point of view, was available in many hospitals throughout the country? Is he confident that the measures that he is putting forward now will ensure that the worst performing hospitals will raise their standards to those of the best?

We have to wait and see, but we have put in place a radical, tough new Ofsted-style inspection regime. The point of that regime is not just to identify hospitals where care is unsafe, but to identify outstanding hospitals, so that hospitals in difficulty have hospitals from which they can learn, and we create a culture, just as we have in schools, where failing schools learn from outstanding schools and have a pathway to improvement. That will make a big difference. As the right hon. Gentleman knows, we now have 13 hospitals in special measures, and I am sure there will be more as the inspection process gets under way. But we will also have the great hospitals that we can learn from, which will mean that this can be a positive process for the NHS.

I commend my right hon. Friend for the thoughtful and thorough way in which he has conducted the reaction to the publication of the Francis inquiry. Does he agree that the most chilling finding of Francis was that professional people whose focus should have been on the needs of their patients found themselves, in Francis’s words, “doing the system’s business”? Is not the central driver of my right hon. Friend’s recommendations to ensure that never again shall we have closed institutions in a closed system where that is possible, and that the key way forward is to throw sunlight into institutions that have too often been unchallenged?

My right hon. Friend, as so often, speaks wisely. This is probably the boldest step towards transparency taken by any health care system anywhere in the world. We will see if he is right, but I think that he is, because sunlight is the best disinfectant. It means that problems are sorted out much more quickly, but it is sometimes an uncomfortable process. It is really important that we as a country understand that exposing poor care in one place does not mean that there is poor care everywhere and that, in fact, exposing it is the quickest way to sort it out.

We need total candour with regard to avoidable deaths. The only way to determine that is through an independent review of medical case notes by neutral clinicians. That exercise took place at Stafford. Will the Secretary of State remind us of the result?

I do not have the results in front of me, but I am happy to supply them. I want to take up the right hon. Gentleman’s point about avoidable deaths, because one of the changes we want to make today is to avoid the temptation, when there is an avoidable death, for people on the front line to say that it was unavoidable. We are trying to create the structures that make it easy for people to speak out if they think that a death was avoidable and to ensure that they are encouraged to do so.

I very much welcome the introduction of a statutory duty of candour, which the Minister of State, my hon. Friend the Member for North Norfolk (Norman Lamb), wrote into our 2010 manifesto. May I ask the Secretary of State about his plans to prosecute if the fundamental standards are breached, which is an important step with regard to corporate criminal accountability? In drafting those standards, will he ensure that advice is sought from the Director of Public Prosecutions, the Health and Safety Executive and others to ensure that the wording is clear and fit for purpose so that when a prosecution takes place there is no hiding behind the language in those fundamental standards?

We will absolutely do that. We are in the process of a very big consultation to ensure that we get the definitions of the fundamental standards absolutely right, but we also want to try to create a culture that means we do not get to that point in the first place. One of the problems we had with the current system is that the definition of success for a hospital tended to be about meeting waiting time targets and financial balance, rather than caring for patients properly. We want to re-engineer the system through the new inspection regime so that a hospital cannot be good or outstanding unless it is delivering good or outstanding care.

What happened at Mid Staffordshire must never be allowed to happen again, but given that safe staffing levels will depend on adequate resources, can the Secretary of State give an assurance that there will be a debate in the House in Government time on the successor arrangements for Mid Staffordshire and for the University Hospital of North Staffordshire?

As the hon. Lady knows, we are going through a process at the moment and the trust special administrator is drawing up detailed plans, so it is premature to say what will happen, but we will of course keep the House well informed and there will be plenty of opportunities for her to question me, or anyone else she wants to question, about any decisions that are eventually made.

I warmly welcome the Secretary of State’s statement, which will help health professionals to get on with their jobs and improve openness and transparency across the NHS. I particularly welcome his recognition of the important role played by the 1.3 million health care assistants across health and social care. In implementing the vetting and barring scheme, will he ensure that individuals looking after people at home or in outside institutions can access that list to ensure that they have health care assistants who comply with the fundamental standards?

That is a very good point. I will take it away and look at whether that will be possible, because there is a powerful logic behind making that happen. As my hon. Friend has mentioned health care assistants, I would like to highlight the brilliant work they do, along with so many NHS staff. It has been a very challenging year for them to read about these examples of poor care, which are as shocking to them as they are to us. I agree that now is the time to get behind the people on the front line, who really want to change the culture for the better.

I, too, welcome the Secretary of State’s statement and the observations made by my right hon. Friend the shadow Secretary of State, but my constituents will be concerned about the impact of whatever the trust special administrator decides is right for Mid Staffordshire on the university hospital and the care they will receive there. Whether as a result of pressures from Cannock Chase or other areas, there is the risk that work will go to the university hospital but that it will not be fully recompensed for what is needed and that—this is a terrible thing to talk about in these terms—the profitable work that would otherwise cross-subsidise that might well go to other areas. Will the Secretary of State look carefully at ensuring that the university hospital is not penalised as a result?

We want to ensure that no hospitals are penalised and that we end up with a solution for the whole local health economy that is sustainable for the long term. The comfort that I think the hon. Gentleman can draw from today’s announcement is that, as a result of the openness and transparency and the rigorous independent inspections that will be happening at all the hospitals his constituents use, poor care, where it exists, will come to the surface and be dealt with much more quickly.

The improved transparency and increased accountability will do much to right the wrongs of the past. When will the health care certificates for nursing assistants be introduced, and has my right hon. Friend considered giving hospital managers discretion to appoint individual nurses to the under-75s?

We are looking at improving care for people in all age groups, but we started the focus on the over-75s because they are the most vulnerable older people. Implementation of the care certificate is a very big change that will apply to several hundred thousand people, so it will not be an immediate process, but we want to get on with it. I think that it will give them a big boost and more professional confidence. We also want to improve the pathway into nursing, which is why we will be encouraging use of the phrase “nursing assistants”, rather than “health care assistants.”

The College of Emergency Medicine has consistently called for an increase in emergency doctors, because there has been a 50% shortfall over the past three years. What plans has the Secretary of State to address that concern?

I met the College of Emergency Medicine yesterday to discuss those issues, among others. We have 300 more doctors working in our A and E departments than we did three years ago, but the hon. Lady is absolutely right that we need more, because 1 million more people a year are going through A and E than there were in 2010. Part of the challenge is to make A and E a more attractive profession for doctors. They might work long shifts and antisocial hours, which can make it unattractive. We need to find a way of dealing with that.

Frank and Janet Robinson’s son John died in 2006 as a result of failings at Stafford hospital. They are my constituents. The inquest into his death lasted only 90 minutes and called only two witnesses. After much campaigning and lobbying by his parents, a second inquest has been granted. It will call 12 witnesses, many of whom were available to the original coroner, and is scheduled to last four days. Does my right hon. Friend agree that had the original coroner’s report into John’s death been more thorough, many avoidable deaths at Stafford and across the NHS could have been prevented?

I agree with my hon. Friend. I hope that he will be encouraged by today’s announcement, because if in such a situation, which was an appalling tragedy, a trust is found not to have been open and transparent about something serious that has gone wrong, the fact that it risks becoming financially liable for any award made will be a major disincentive to trying to cover things up. That is a profound change, so I hope that it will comfort John’s parents to know that the kind of culture they had to fight so hard against will not be allowed to continue.

The Secretary of State is right to highlight the need for fundamental culture change, but it is still the case that some of the most vulnerable people in our hospitals today—those with dementia—stay longer and are more likely to be readmitted and more of them die. My local hospital, Salford Royal, has recently implemented the Royal College of Nursing’s system called the triangle of care, which fully involves patients, carers and their families in the care of those with dementia. Will the Secretary of State take steps to ensure that that kind of system is implemented across the NHS?

I absolutely want to encourage that. I know that the right hon. Lady has campaigned a great deal on the needs of people with dementia, and I share her desire to do much better for them. Salford Royal is one of the best hospitals in the country and we should always learn from what it does, but 25% of people in hospitals now have dementia. The tragedy of what happened at Mid Staffs and of many of the stories of poor care in other hospitals that we read about is that very often they involve people with dementia, because they are the kinds of people who have been deprioritised when hospital managements have decided, for example, that they want to cut nursing inappropriately. We absolutely have to change that culture. There is now a very good system at several hospitals. People with dementia, in particular, must be helped to eat and drink at meal times. Many of us have been shocked by the stories of full trays of food being taken away because someone is unable to eat unaided. That, in particular, we need to stamp right out.

The Cavendish review found too many instances of health care assistants being badly treated and managed by nurses. Health care assistants, now to be called nursing assistants, are on the front line of very many patient experiences. Will my right hon. Friend assure the House that other measures, in addition to the very welcome new certificate for nursing assistants, will provide the extra support to those staff that is obviously needed?

It is really important that we value the work of some of the lowest-paid people in hospitals who are carrying out some of the most important personal care for patients. They need to be managed properly, fairly and decently, given how important that work is. We need to ensure that nurses have the right attitude to the health care assistants who are working for them—as, most of the time, they absolutely do. That is why earlier in the year we proposed changes that we are piloting, so that before getting funding for a nursing degree, people had to spend time, potentially up to a year, on the front line as health care assistants. That will allow them to experience just how important that work is and then perhaps appreciate it a bit more.

The Secretary of State has spoken about staffing levels, which will be of the greatest interest to patients and their families. He said that the situation will vary across wards and that there would be local discretion, with failings being exposed. When those failings are exposed, how will corrective treatment occur? Who will be responsible for ensuring that the corrections and changes are actually made?

We have set up a new inspection regime with a new chief inspector of hospitals under the Care Quality Commission. The CQC will look at the figures that are published every month on a trust-by-trust basis, alongside other safety data such as MRSA rates, bedsore rates, numbers of complaints, and other information that is crucial to its decisions. It is then its absolute duty and responsibility to swoop quickly if it thinks there is any cause for concern.

We now know that poor care was allowed to continue at Mid Staffs because staff were simply too afraid to speak out and, if they did, they were ignored or, worse, their careers were threatened. The high death rates at Stafford hospital were not taken seriously enough at the time and were merely explained away rather than used as an alarm signal that should have triggered further investigations. There was clearly a culture of fear among NHS staff, many of whom witnessed the appalling care of my constituents. Will my right hon. Friend make it his legacy to instil a culture of candour and openness in the NHS whereby concerns are acted on and high standardised mortality ratios are no longer brushed under the carpet to protect the NHS’s reputation but are instead properly investigated so that patient safety finally comes first?

My hon. Friend is absolutely right. These problems of high mortality rates date back very many years, and nothing, or too little, was done to sort them out. We must therefore make sure that we have a system where that cannot happen. Concealing poor care does not protect the reputation of the NHS, because in the end it gets out and destroys public confidence. I hope his constituents will feel that today’s announcements will create a new culture of openness and transparency that gives them confidence, so that if these awful things were ever to happen again—we hope they do not—we would find out quickly and action would be taken.

Having spent nine years as a lay member of the General Medical Council and five years chairing the Health Committee, I have heard little this afternoon that is likely to change the culture inside the national health service. May I refer the Secretary of State to the report on patient safety that the Committee produced in the previous Parliament? We considered the idea of having a statutory ombudsman to whom people could complain and who would have the power to investigate, even anonymously, instead of this situation in which doctors, particularly young doctors working in hospitals, dare not complain about what senior doctors are doing because of the attack on their career structure. We really must get some independence into this. We can have good words, we can talk about candour, and we can wish a lot of things, but changing the culture of the NHS is not done by statements or by legislation in this House; it is done by working inside the NHS. I am afraid that at the moment the system works against changing the culture owing to career structures and everything else. We need some independence in all this so that people can really learn how to change. New Zealand would be a good example to look at.

All I can say to the right hon. Gentleman is that Robert Francis himself stated this morning that we have announced a comprehensive collection of measures that

“will contribute greatly towards a new culture”

in the NHS. He is persuaded that this will make a very big difference.

Independence is a vital part of this change, so what are we doing to create it? For the first time, we will have an independent chief inspector of hospitals who goes anywhere he likes in the system to try to root out poor care. That person will be the nation’s whistleblower-in-chief, and their job will be to find out about these things inside hospitals. We are creating a culture in which it is in the interests of hospitals and doctors to be open and transparent, and that is another significant change. I do not want to underestimate the scale of the challenge we face, but I think most people would say that in the past 12 months we have seen one of the most fundamental attempts to change the culture of the NHS in its 65-year history.

An essential part of being a medical professional is to exhibit a compassionate and caring approach whatever one’s circumstances, as indeed most NHS staff do. What new measures will offer patients assurances that this will be a priority in future?

The biggest assurance that patients will have is that the definition of success as regards how the system views a hospital will be the same as patients’ definition of success. They want to go somewhere that treats them promptly and safely and with decent, compassionate care. That has not been how the system has judged the success of a hospital or its chief executive or board. That is why it is such a profound change to have a new chief inspector and Ofsted-style ratings. I think this will make a big difference, but I do not want to underestimate how big a challenge it is and how long a process it will be fully to make the transformation we need.

The Secretary of State will be aware of people’s disappointment that there is still no proper system of regulation for health care assistants. Does he understand that many members of the public feel that one of the problems with general standards of care in the health service may have been the push—under a Labour Government—for an all-graduate nursing profession? There is a strongly held view among members of the public that that has led to elevating taking exams and inputting data on a computer over providing basic levels of care, which is what they really value in a nurse.

Never has the hon. Lady spoken with so much support from this side of the House—I do not wish to destroy her credibility with her own party! She points to something that the public feel very strongly about and that is an issue in some parts of the nursing profession. We looked carefully at whether we should remove the requirement for graduate qualifications and decided that nurses are now asked to do a great deal more than they were 20, 30 or 40 years ago in, for example, giving people medication and the clinical procedures they are asked to be involved in. We need to make sure that there is the right culture in nursing. That is why I proposed—it was very controversial at the time, although I think it has been quite broadly accepted now—that before becoming a nurse people should spend some time, potentially up to a year, on the front line as a health care assistant to make sure that those going into nursing had the right values and recognised that giving this personal care is a fundamental part of what being a nurse should always be about.

Will the package of reforms and the greater accountability put into effect as a result of the Mid Staffs tragedy have any bearing on other areas such as the all-too-prevalent cases of people being injured or even dying as a result of hospital-acquired infections?

Absolutely, because this is a package designed to deal with all avoidable harm, and hospital-acquired infections are an avoidable harm. It is designed not only to have much more transparency on the levels of harm in our hospitals, but to make sure that there is a culture of openness so that when people spot things that are going wrong, it is in their interests and in those of their hospital that they speak out. The changes are likely to result in—my hon. Friend will be the first to notice this—an increase in the amount of reported harm over the next few months. That will not be a bad thing, because it will mean that hospitals will be reporting harm that up until now they have not reported. We should welcome the fact that that will then mean that this harm will be addressed.

Although health is devolved to the Northern Ireland Assembly, the culture and its consequences identified by the Francis report can nevertheless occur in the health service anywhere in the United Kingdom. What plans does the Secretary of State have to share the lessons learned and actions taken with the Health Minister in Northern Ireland and, indeed, with all the other devolved Administrations?

I am very happy to share any of the lessons we have learned, but I do so from a position of humility, because we still have to address very serious challenges in our NHS in England. It will take us time to sort them out. I am happy to work with any devolved Administrations. Indeed, I would like to work with other countries across the world, because the challenge of how to deliver high-quality, compassionate health care when resources are tight and with an ageing population is one that all countries face.

The Government’s position on the publication at ward level of safe registered nurse staffing levels is a welcome step in the right direction. My right hon. Friend will be aware that I have consistently argued for safe registered nurse-to-patient ratios at ward level, and no manner of enhancements of culture and leadership can ever be used to mask the risk to patients if there are not enough nurses on the ward. Is he aware that some trusts are conflating trained care assistants with registered nurses, and will he reassure me that, in enumerating the number of registered nurses on wards, trusts cannot conflate trained care assistants, welcome though they are, with registered nurses?

My hon. Friend makes a very important point, because in an era of transparency we depend on honesty from the people supplying the information being used. It is not always possible independently to audit every single piece of information. What we have said today is that deliberately supplying false or misleading information will be a criminal offence, which is a much tougher sanction than anything else we are saying today. We think that the most important thing is to establish a culture in which people tell the truth and speak out if there is a problem, because then something can be done about it.

There is a great deal to welcome in the Secretary of State’s statement, not least with regard to transparency and complaints. I welcome in particular the comments on staffing, although, obviously, we used to have more nurses than we have now. Will the Secretary of State look at the vetting and barring service, because my understanding is that use of the service and referrals to it have been declining over the past couple of years?

I have concerns about how much that service is used. My particular concern is not so much whether employers are checking before they employ someone, but whether they are informing the service that an employee should be referred to it for delivering inappropriate care. That is something that we will look at.

I remind my right hon. Friend that the Public Administration Committee is conducting an inquiry into complaint-handling across the public service and that Essex recently had an instance of failure at our local hospital, where complaints were not properly handled. How does my right hon. Friend intend to deliver on his statement that “all patients will be able to access independent help in making their complaint”? May I suggest to him that, rather than setting up a new structure or body, perhaps the ombudsman is the right body to help facilitate those complaints, because it would create a one-stop shop for them?

We have avoided setting up a new structure or body in our response to the recommendations made by the right hon. Member for Cynon Valley. As for how we will make sure that this happens, I agree with my hon. Friend that the ombudsman is the final port of call if someone is not satisfied with the way in which their complaint has been treated. That is incredibly important, and the ombudsman has herself agreed that she will handle vastly more complaints and go into detail a lot more than she does at present, which is welcome. Prior to that stage, however, lots of people feel that complaining directly to the trust, which has to be the first step, is a very daunting and difficult process and that they want independent help. That is why we have said that it will be an absolute requirement for trusts to show people how they can access that independent help and, indeed, to be prepared to make the finance available so that they get that help. There will also have to be signs on every ward telling people exactly how to do that.

The Secretary of State will agree that the ethos and culture of any organisation start at the top. Over the past three decades, the boards have moved towards being composed more of practitioners and businesses than of consumers and patients. Will he consider putting an independent voice, or independent voices, on the boards so that the complaints go to a board that will listen to and debate them? Will he also consider advising trust boards to set up a formal structure up to board level so that complaints can arrive there, be seen and discussed?

The hon. Gentleman is right that reporting back about complaints to board level is a fundamental thing that should happen at every trust. We also need to make sure that all trusts are putting patients first; they will not be able to get a good inspection result from the chief inspector of hospitals unless they do so. The hon. Gentleman will know that the new structure of foundation trusts is designed to make sure that FTs are run for the benefit of their patients by the large number of members who are effectively the governing body of FTs. The hon. Gentleman is also right to say that this is not happening everywhere, and that is why today’s changes will, I hope, make a big difference.

My A and E department has seen a massive 30% increase in patient throughput in recent years and a concerning 16% in recent months. Furthermore, 100 people who do not need medical care are taking up beds. I have recently organised meetings between local government leaders and the chief executive officers of our hospitals to explore other ways of dealing with these problems. Will the Secretary of State accept that more can be done in this respect, and will he tell us what he can do to further that approach?

My hon. Friend is absolutely right to focus on those pressures. We have been thinking about this very hard. Over the summer we announced £250 million to be distributed to the 53 A and E economies where the most difficulty is being experienced in meeting high standards for the public, and we are doing more. We are talking to the College of Emergency Medicine. Anything that my hon. Friend can do at a local level will be greatly appreciated. This is going to be a difficult winter and we need to stand full square behind our front-line staff.

The Secretary of State just said that Salford Royal hospital is one of the best hospitals in the country and we should learn from what it does. What it does is support minimum safe staffing levels for patients and then publish the actual-versus-planned staffing levels on the wards every day. Staffing levels published on websites is a little step forward, but it is not enough. Why do we not learn from what Salford Royal does? I do not think that patients and their families are interested in what the staffing levels were a month ago; they are interested in what they are today.

We have based our recommendation today precisely on what Salford Royal does. It uses the kind of model to ensure minimum recommended staffing levels on every ward that we want every hospital to use. We say that we want those data published monthly, but that is a minimum. Salford Royal publishes them every day, which is very impressive. Given that most hospitals are not using tools anything like as sophisticated as that, it will be a big step up for most hospitals to do that. We want to do it. What is significant about our announcement is that we want to assemble those data for every trust in the country so that they can be compared on a monthly basis and so that people can know how many wards and how many shifts are being safely staffed at their local hospital compared with neighbouring hospitals.

The Secretary of State will know that Medway Maritime hospital in my constituency had the seventh worst mortality rate in 2005 and 2006, yet nothing was done until he put the hospital into special measures. It is now linked with the outstanding Frimley Park hospital, sharing good practice and turning things around, so that my constituents can get good care, while inspections are also on their way. He said that if hospitals do not turn things around in the short term, they will be put into administration, but what does “short term” mean—is it a year or six months?

Our intention is that the maximum period when a hospital is put into special measures should never be longer than a year. After that, if it is not making significant progress, there is the possibility of it being put into administration. The reason for that, precisely as my hon. Friend said, is that we cannot let poor standards and poor care persist over a long period. I am pleased about the progress made at Medway Maritime in recent months; Frimley Park, which is my local hospital, delivers truly outstanding care. He is absolutely right to say that it should never have taken so long to get to the heart of the problem.

The Secretary of State said that it is impossible to deliver safe care without a safe staffing level, which of course depends on resources. Under the coalition’s new funding formula, Hull NHS is due to lose £28 million, and it will not get any money for the A and E winter pressures that are bound to happen. How does he think that that will help safe staffing levels in Hull?

The funding formula is decided independently, and no final decision has been made. The decision will be made by NHS England, which I know is looking at that at the moment. It has to decide equitably across the whole country, based on need, population, social deprivation and other factors. Like the hon. Lady, I am waiting to see what it decides.

Some 14% of the entire NHS budget goes on complaints relating to injury compensation. Of that, a third or £4 billion per year goes to lawyers. That diversion of cash away from the front line to lawyers makes it much harder to get the staffing levels that Francis envisaged. Will the Secretary of State address that as part of the wider issue?

My hon. Friend is right that it is absolutely shocking that we spend more than £1 billion a year on litigation claims in the NHS. The only long-term way of reducing that bill is to improve the safety record of the NHS, so that we do not have the terrible incidents that lead to high claims. The only way to do that is through openness and transparency, which is why today’s measures will make a big difference.

I welcome the proposal on legal sanctions for those found guilty of wilful neglect. In south Wales, police Operation Jasmine has looked at the alleged abuse of elders in care homes. I understand the difficulties, but will today’s announcement help us to hold to account those responsible for corporate neglect in private sector care homes?

Absolutely. The Minister of State, Department of Health, who has responsibility for care services, has been very focused on making sure that there is proper corporate accountability. Today, we have announced the new fit and proper persons test that will apply to all organisations delivering care to make sure that directors of companies responsible for care homes and domiciliary services in which poor care happens are properly held to account. That is vital, because there should be no hiding place for people who send signals to their staff that lead to our reading the horror stories that, sadly, we have read.

To my mind, the issue is about patients having confidence in their local hospital. What can we do to ensure that patients in my constituency have a better understanding of how Derriford hospital is performing and whether it is improving?

This is the heart of the change that we are making this year. My hon. Friend and I know exactly how well all the schools in our constituencies are doing, because there are transparent, independent Ofsted ratings, but we do not know how well our local hospitals are doing. We need an expert to go in and look at hospitals and then tell us, in language that non-clinicians can understand, just how well they are doing, as well as what needs to change when they are not doing well. We will get that with the new chief inspector of hospitals.

I was struck by the Secretary of State saying that cruelty became normal in the NHS. I do not agree with him and I do not think that the public believe that cruelty has become the norm in the NHS. Most people join the NHS as a calling or a public duty: they believe in kindness and the importance of care.

It seems to me that one of the reasons for cruelty—and it does happen—is the stress of under-staffing. I understand that, as a result of the report, the Secretary of State will publish safe staffing levels ward by ward, but that he will not enforce them. The question that the public want answered is why. How can he, as Secretary of State, be happy to know that wards up and down the country are under-staffed and unsafe, and that he is not doing anything about it?

We have had a very bipartisan discussion this afternoon, so I am slightly disappointed that the hon. Lady is twisting my words. I did not say that cruelty became the norm everywhere in the NHS; I said that in places such as Mid Staffs cruelty became normal. If she reads the Francis report, she will find that that is the case.

Trying to duck or run away from that fact is what got us into a great deal of trouble, because we did not deal with the issues in Mid Staffs nearly as quickly as we should have done. On staffing levels, we are doing something that did not happen before. When her Government were in power, we did not know where staffing was unsafe, but now we will know and can do something about it.

Will my right hon. Friend confirm that never again will Ministers duck their responsibility to be open and transparent in the reporting of failures, as they perhaps were in relation to Mid Staffs and potentially were in relation to Basildon hospital before 2010?

My hon. Friend is absolutely right. It is incredibly important that Ministers never, whether deliberately or inadvertently, give a signal to the system that they do not want poor care to be highlighted as quickly as possible. I am afraid that there is evidence that, whether or not former Ministers intended this, it was interpreted that the emergence of bad news stories would be met with a great deal of ministerial disapproval, and that did enormous damage.

Out of Francis has come Keogh, which is leading to seven-day working and more doctors and nurses on the wards at George Eliot hospital. Increasing staffing numbers is important in our NHS, but does my right hon. Friend agree that having the right ratio of staff to suit the needs of individual patients is equally if not more important?

That is absolutely vital. I have been to the A and E department in George Eliot hospital, and reports I have heard say that morale is really turning a corner. I want to back the staff: it is incredibly difficult to work in a hospital that has been put into special measures, knowing that everything is not as it should be. They now have a sense that a corner is being turned and that the problems that they have long worried about are finally being addressed, particularly because of the link with University Hospitals Birmingham, which is one of the best in the country.

I agree with my hon. Friend that safe staffing is one of the measures that matters. George Eliot hospital has some pretty antiquated IT systems that mean staff spend much longer than they should filling out forms, rather than spending time with patients.

Will my right hon. Friend give more details about how we can stop bad leaders and bad providers from working in the NHS? Will he confirm that that change will extend to ambulance trusts as well as to hospitals?

The change will absolutely extend to ambulance trusts. I know that my hon. Friend has had experience of poor leadership of ambulance trusts in her area. It will apply to all organisations registered with the Care Quality Commission. There will be a fit and proper persons test, because where people are responsible for poor care, we do not want them to pop up somewhere else in the system.

There has always been a professional duty on medical professionals to advise patients when errors occur; yet we know that that has not always happened. Although all hon. Members welcome the greater candour, transparency and protection in relation to whistleblowers that this Government are proposing through the fit and proper persons test, does the Secretary of State agree that true culture change will not happen unless the views of junior doctors, the staff generally in all hospitals and everyone in the NHS are made as important as the views of those at the very top?

My hon. Friend is absolutely right. True culture change is incredibly difficult to achieve unless we get behind the people on the front line and get them to want to change the culture. That is the insight in the report that Professor Berwick delivered in August. That is why today’s response is about backing front-line staff to deliver the care that they want to deliver and to be open when they are worried, and about supporting them in what is a very challenging period for the NHS. If we do not back them to do the right thing, then no matter what happens at the top, we will not see change on the front line.

I am sure that my constituents will welcome what the Secretary of State has said about transparency and openness, especially with respect to Kettering general hospital. When somebody goes into hospital, they want to have confidence that they will be treated efficiently and with a great deal of care. They get that confidence not just from statistics on the number of nurses or clinicians on a ward, but from the experiences that they hear about from friends and relatives who have been treated at the same hospital. They also get confidence from hearing examples of where things have gone wrong—some things will always go wrong—and that the complaints have been handled quickly and efficiently, and have not been dragged out. Does my right hon. Friend agree that hospitals should provide examples of good care that has gone right to give local people the confidence that their local hospital is doing the very best for them and that, when things do go wrong, people will put their hands up, admit it and deal with it quickly and efficiently?

Absolutely. It is a sign of great confidence when a hospital is open about things that have gone wrong. When I meet the top chief executives who are running the best hospitals in the country, I am always struck by how willing they are to be open about the problems that they have had. It is often in the less well-performing hospitals that the management feel less confident and willing to talk about the problems. That culture is really important. I hope that today is a step in the right direction.

I thank the Secretary of State for coming to the House and making such a detailed statement. I served under the previous Chairman of the Select Committee on Health, the right hon. Member for Rother Valley (Mr Barron), during the inquiry into patient safety. The Secretary of State has a point. The problem at the moment is that people make a complaint after something goes terribly wrong, but the complaints system is deliberately long, drawn-out and delayed. One never actually reaches the ombudsman. If we are to have a change in culture, we have to stop the managements of hospitals delaying the complaints system deliberately.

I totally agree with my hon. Friend. That is why I hope that what we have announced today will bring about a transformation in the way in which hospitals manage complaints. Some excellent work has been done to help us do that. The heart of the matter is that hospitals should be really interested in the complaints that they receive, because that will enable them to understand where they are not delivering good care and what they can do to put it right. That does not happen everywhere. Too often, the complaints system is treated as a process, in effect, to fob people off, rather than to get to the heart of what people are talking about. We absolutely need to change that.