[Relevant documents: Third Report from the Health Committee, on After Francis: making a difference, HC 657, and the Government response, Cm 8755.]
I beg to move,
That this House has considered the matter of the Francis Report: One year on.
A year on from the Francis report, let us remember that we stand here today thanks to the courage of a few lonely voices who fought against the odds to be heard as they campaigned against appalling neglect and abuse at the heart of our national health service. They had a truth to be told, they refused to be ignored, they stood up to a mighty system, and when they were turned away by regulators, NHS leaders and Ministers, they just came back speaking even louder—people such as Julie Bailey and Helene Donnelly, both of whom received honours this year, and thousands more who wrote and campaigned for loved ones, not because they wanted a penny of compensation but because they wanted to prevent this tragedy from ever happening again.
The last Government repeatedly refused to set up a public inquiry into what happened at Mid Staffordshire NHS Foundation Trust, but to his enormous credit, my predecessor overturned that decision, with the honourable support of a number of Staffordshire Members. As a result, the voices of their constituents were finally heard, and hard truths were told.
Today, the whole House will want to thank Robert Francis QC and his inquiry team for the thorough and thoughtful job that they carried out. Their remarkable report demanded a monumental response, and I sincerely hope that that is what the coalition Government have delivered. The Care Quality Commission, once ridiculed, is now trusted, with a record number of calls to its whistleblowing helpline. Failing hospitals are being turned around, with stronger leadership and improved staffing levels: there are 3,500 more nurses on our hospital wards since the Francis report, more than 80% of hospitals have taken new action in response to the report, and confidence among NHS staff that their organisation has the right priorities has risen. Of course, there are many more things to do, but it is clear that something profound has changed in the culture of the NHS.
I admire what my right hon. Friend is doing to get a new culture of honesty in the NHS. Does he think that all the major hospitals in the country now automatically report problems and mistakes, so that they can be investigated and remedied?
The truth is that the process takes time, and there are still examples of where candour is lacking. Allegations have recently surfaced in the press, the substance of which makes it appear that that reporting has not happened. There is much work to do, but the signal has gone out loud and clear that if people are open, transparent and honest from the start when something goes wrong, that should not be punished but should be recognised as a way of improving how we look after patients, in the same way as profound changes in the airline industry have made our aeroplanes much safer. We need that change in the NHS.
We also now recognise that however important ministerial objectives and national targets may be, NHS organisations should never prioritise them at the expense of dignity and respect for patients. We now know that the best way to deal with poor care is for people to speak out about it, whether they are a health care assistant, doctor, nurse or even Secretary of State, and that that should never be confused with “running down the NHS”. We also know that failing to speak out about poor care, or to support those who do, is a betrayal not just of patients but of the kindness and humanity of more than 1 million dedicated NHS staff, thousands of whom pledged themselves to compassionate care just two days ago on NHS change day.
What has happened in the past year? Robert Francis asked why the system effectively failed to detect or deal with the problems at Mid Staffs for a shocking total of four years. We have re-established the CQC as a rigorous and independent inspectorate, with three powerful new chief inspectors appointed to speak truth to power. The Keogh review inspected 14 hospitals last summer, and the new chief inspector of hospitals, Professor Sir Mike Richards, has already completed inspections of a further 18 trusts, with 19 more inspections taking place now. As a direct result, 14 trusts are now in special measures—a record in NHS history—and, thankfully, long-standing problems are finally being tackled.
On staffing, the inquiry found
“an unacceptable delay in addressing the issue of shortage of skilled nursing staff.”
The latest figures show that not only are there 3,500 more nurses on our hospital wards since the Francis report, in just a year, but we now have more nurses, midwives and health visitors in the NHS than ever in its history. From this summer, all hospitals will publish their staffing levels monthly, on a ward by ward basis, so that shortfalls are speedily identified.
Robert Francis identified a closed, defensive and secretive culture at Mid Staffs. In response, we have ended gagging clauses and we are making it a criminal offence for trusts to publish or provide specified information that is false or misleading. We are also placing a statutory duty of candour on organisations so that they are required to be honest with patients about poor care, and professional regulators are consulting on a new professional duty of candour that provides protection for staff against being struck off if they are open about the problems they see. I believe that will create one of the most transparent and open health care systems in the world.
I welcome the important steps in the right direction that have been taken with regard to recording and safe staffing on acute hospital wards. The Secretary of State also announced last year that he intended to introduce a system whereby nurse trainees would shadow or work alongside care assistants for up to a year. Is that idea being developed at the moment?
Does the Secretary of State agree that it is important to remember that part of what allowed the Francis report was the release of data on outcomes, and that such data transparency is crucial to understanding where best and worst practice exists, which may not otherwise be picked up?
My hon. Friend is, as ever, absolutely right on this issue, which he has spoken about a great deal. The use of data allows inspections to be meaningful in a way that has not been possible before. We have to ensure that the public are happy that protections are in place on how their data are used, but at the same time we must be bold in using those data, because that saves a lot of lives.
The inquiry condemned the way in which complaints were handled in Mid Staffs. Following the excellent work carried out by the right hon. Member for Cynon Valley (Ann Clwyd) and Professor Tricia Hart, all hospitals will now have to demonstrate to inspectors that they treat complaints as more than just a process and are actively using them to learn and improve.
Doctors have responded to the new climate of transparency by agreeing to a world first: to make England the first country anywhere that publishes surgery outcomes by consultant for 10 major specialties. More specialties will follow.
This point does not quite follow on from what the Secretary of State is saying, but I spent all day yesterday with rugby players and neuropathologists talking about chronic traumatic encephalopathy, which often follows rugby injuries. One big difficulty is that concussion is regularly misdiagnosed, or completely and utterly missed, throughout the whole NHS, and that sports bodies are not taking the matter seriously. Will he seriously consider changing the whole way in which the NHS engages with sports and with that issue?
As the hon. Gentleman knows, I used to be responsible for sport in this country, so I take a great deal of interest in the issue. I will certainly consider his point. We all remember what happened to Fabrice Muamba, and sport has a role to play in raising awareness of conditions that people might not otherwise be aware of.
From listening carefully to my right hon. Friend’s remarks, I noticed that he referred to England. I am not sure that all the lessons from the Francis report have necessarily gone across the border to Wales. That concerns me, because thousands of my constituents are forced to use the NHS in Wales—although their GP is in England, they are registered with the NHS in Wales. Can my right hon. Friend say anything to reassure my constituents that they will soon be entitled to treatment in England, as is their legal right?
I am concerned about that on a number of levels, but I can reassure my hon. Friend that I have taken on board that point, which he has raised with me privately, and I will look into it. I have asked for a solution to be found soon, and certainly before the end of the year, so that his constituents can have that long-standing problem addressed.
Nurses, who were mentioned by the hon. Member for St Ives (Andrew George), have also embraced reform. The inquiry was clear that
“practical hands-on training and experience should be a pre-requisite to entry into the nursing profession”.
We now have 165 nurse trainees spending up to a year as health care assistants before starting a degree—a pilot that will inform how we roll out the programme nationally. The inquiry said the public should always be confident that health care assistants have had the training they need to provide safe care, and on the advice of Camilla Cavendish our new care certificate will provide assurance that health care assistants and social care support workers receive the high-quality, consistent training they need to do their jobs and deliver compassionate care.
Robert Francis also identified particular problems with the leadership of Mid Staffordshire Trust. We have many outstanding leaders in the NHS, but not enough, so we have set up a 50-place fast-track executive programme to attract clinicians and talented outsiders into NHS management, and we have already had more than 1,600 applicants. We are also introducing a new fit and proper persons test for board-level appointments, to help ensure that people with poor track records cannot resurface elsewhere.
The inquiry also heavily criticised my Department for being
“too remote from the reality of the service they oversee”.
We have introduced a new programme, “Connecting”, under which civil servants will spend four weeks every year on the front line. In the past year, Ministers, including me, and senior officials have spent more than 1,300 days working on the front line, leading to what I believe is a real and profound change in the way we approach our work and ensure good advice is provided to Ministers. Those changes have seen a welcome increase in the number of staff who feel that care of patients is the main priority for their organisation, according to the latest NHS staff survey.
If the NHS has listened, so too must we in this House. As constituency MPs, many of us, including me, have championed our local hospitals, sometimes unquestioningly, and sometimes without sufficient regard for the quality of care provided. Too often we have accepted the convenient explanation that individual cases of poor care were the exception, when in our hearts we knew the problem was more widespread. We must be champions for change in our communities, just as the Mid Staffs campaigners were champions for change in theirs.
Nowhere is that more true than in Wales. Although health is a devolved issue, unfortunately failures in care in Wales are now having a direct impact on NHS services in England, with a 10% rise since 2010 in the number of Welsh patients using English A and E departments, leading to very real additional pressure on border town hospitals. What is causing that pressure? Dr Dai Samuel of the Welsh BMA describes standards of care in Wales as follows:
“It’s pretty horrific...the level of care being given to patients is compromised...substandard we are seeing a miniature Mid Staffs every day.”
NHS England medical director professor, Sir Bruce Keogh, and president of the Royal College of Surgeons, Professor Norman Williams, have written to the Welsh authorities calling for action, only to be completely ignored. Professor Williams said that
“an analysis of NHS data in the region has highlighted the fact that the waiting lists for elective cardiac surgery in South Wales are higher than is clinically appropriate... Expert reports suggest that 152 patients have died in the past 5 years while on the waiting lists”.
If that creates pressure in England, it is a tragedy for Wales, yet still the authorities there continue to act as if the lessons of Mid Staffs stop at the border. If the Labour party, which runs the NHS in Wales, will not listen to the Government about this, it should please listen to its own Back-Bencher, the remarkable right hon. Member for Cynon Valley, who, following her own terrible family experience, has campaigned tirelessly to improve standards of care in Wales, particularly with respect to mortality rates at six Welsh hospitals. If there is one outcome from today’s debate, let it be not simply an examination of data methodology in Wales, but a proper, independent examination of mortality rates, allowing UK-wide comparisons. Given the implications for the English NHS, we need leadership from Labour Front Benchers in this place to encourage their Welsh colleagues to do what is right to save lives in Wales, as well as to reduce pressure on the NHS in England.
That highlights a broader, more uncomfortable issue for the House. Clear policy mistakes lay at the heart of why Mid Staffs was ever allowed to happen, but while no one is questioning the integrity or good intentions of Ministers in that period, those mistakes have never been acknowledged by the Labour party, even though the entire tragedy happened on its watch. Labour continues to make a political issue of which party can be “trusted” with the NHS, but cannot see that the refusal—[Interruption.] This is uncomfortable for Labour Members to hear, but lives were lost and I suggest they listen. Refusing to learn the lessons of Mid Staffs is the surest way to persuade the public that Labour does not merit that trust.
Do Labour Members now accept that the Government were right to hold a public inquiry into Mid Staffs, contrary to their wishes, given the many important changes that have come about as a result? Do they accept that Mid Staffs was not just about bad individuals, but about a corporate obsession with system targets that led to poor and unsafe care, and that we must not allow that to happen again? Do they accept that the Government were right to restore expert-led inspections that Labour got rid of 2008, and will they now undertake to support the new chief inspectors in their much more rigorous inspections? Do Labour Members accept that Ministers should never—as was alleged to have happened before—put pressure on regulators to tone down news about poor care? Do they support the statutory independence that we have now granted the CQC? Do they accept that we should never push hospitals to foundation trust status so quickly that they neglect patient care? Finally, and most important, do they accept that exposing and being honest about poor care is not about running down the NHS but is about protecting it and standing up for patients? I hope that when the right hon. Member for Leigh (Andy Burnham) responds he will be able to answer those questions and put to rest the concerns of relatives and survivors of Mid Staffs about his approach to date.
May I reiterate what my right hon. Friend has said about the absolute point-blank refusal, repeatedly and whenever I raised the question of an inquiry under the Inquiries Act 2005, to hold such an inquiry? The previous Government would not hold an inquiry; they totally refused to do so, which was an absolute disgrace. To his credit, the present Prime Minister listened to my arguments, and one of the first things he did when he came to government was set up an inquiry, which now has the capacity to transform the national health service.
We are about to hear from the shadow Health Secretary who will have the chance to put things right on that account. My hon. Friend the Member for Stone (Mr Cash) was extremely courageous, determined and persistent in campaigning for a public inquiry, and with the support of my predecessor and the Prime Minister, that is leading to the profound changes we are seeing today. We would all welcome the Labour party’s support for that.
I opened this debate by paying tribute to a few brave individuals who started a movement in England for safe, effective and compassionate care.
No, I am about to conclude. This afternoon it falls to this House of Commons to stand four-square behind that movement, so that one year of the Francis report becomes a lifetime of change for the NHS. We all want to say two words, “Never again,” but those words derive their conviction from what we do as well as what we say. However contrite we feel now, we should always remember that good people with good intentions stood at this Dispatch Box, and still an unspeakable tragedy was allowed to happen. We cannot rewrite history but we can, and must, learn from it.
This debate is a welcome opportunity to review progress on the Francis report one year after its publication. That publication completed a long process of independent inquiry into the terrible failings at Stafford hospital, and it began in July 2009 with my appointment of Robert Francis, QC. Ever since, the onus has been on us all to learn the important lessons and implement all the recommendations of the Francis report.
First, however, I will say a word about the previous Government’s record. It was the previous Labour Government who introduced for the first time independent regulation to the national health service, following the scandals of the 1990s at Bristol Royal infirmary, Alder Hey and, of course, the Shipman murders. It was that independent regulator which uncovered the problems at Mid Staffs. To listen to the Secretary of State, one would not believe that those were the facts—
I want to make some points at the beginning and then I will give way to the Secretary of State.
Those were the actions of the last Government in dealing with the issues that we inherited. It was the last Government who left the national health service with the lowest ever waiting lists and the highest ever public satisfaction, and no attempt by the Conservatives to rewrite history can take away that fundamental strength in the NHS which the last Government left behind.
I agree with the right hon. Gentleman that his predecessors deserve credit for introducing an inspection regime into the NHS, but would he now agree that it was a big mistake to allow expert-led inspections—the kind of really thorough inspections that could have uncovered what happened at Mid Staffs—to be abolished in favour of generalist inspections, which meant that the same people inspected dental clinics, GP practices and big London teaching hospitals? That was a profoundly important mistake that this Government are right to correct.
It is no good coming all holier than thou and claiming a counsel of perfection from the Government and that all the problems arose under Labour. There was no independent regulation in the NHS under the previous Conservative Government. There were no data of the kind that the hon. Member for Mid Norfolk (George Freeman) mentioned, so that comparisons could be made. Those things were introduced by the previous Labour Government, learning the mistakes of previous failings. This has been a continuous journey in the NHS—when things go wrong, the Government of the time act to make things better. The Secretary of State would do well to remember that before he makes the kind of statements he has made today.
We welcome some of the steps that have been taken, and I want to focus on two in particular on which we have seen an important change of emphasis. First, severe cuts to front-line staffing numbers were a primary cause of what went wrong in Stafford. In the last year, there has been a temporary halt to the cuts to nursing numbers that we saw in the early years of the coalition Government. However, Monitor has warned that this is just short term, and points to further large planned job cuts of close to 7,000 nursing posts in 2014-15 and 2015-16, made worse by severe cuts to nurse training places since 2010, which have forced many trusts in England to recruit from overseas. While we welcome the change of emphasis, we will watch carefully to ensure that recent progress on staffing is not lost.
Secondly, the Secretary of State has been right to focus on the care of older people. Moves to appoint named consultants and GPs for over-75s will clearly help to improve continuity of care. Those are the first steps in the right direction, but we would argue that something much more radical is needed. I believe that the time has come for a fundamental rethink, from first principles, of the way we care for older people, and that is what our commission on whole person care, published yesterday, has begun to set out.
Today, there are quite simply too many older people in our hospitals. Many do not need to be there, but hospital is fast becoming the last resort for people who have lost support in the home—be it support by social care or by the NHS. If we continue as a country on the current path—with further severe planned cuts to social care throughout the rest of this decade—it is a plan for the ever-increasing hospitalisation of frail older people. It is no answer to the ageing society and indeed will make it much harder to address the issues that Robert Francis identifies in his report. Instead, we need a completely new approach, where we start in the home and build a truly personalised service around each individual, their family and their carers. We need an NHS for the whole person, able to see all of an individual’s needs. We need a service where the home not the hospital becomes the default setting for care and, as I will come on to explain, that is what our policy of full integration of health and care is designed to deliver.
To listen to the Secretary of State today, people would be forgiven for thinking that everything in the NHS right now is just fine, everything is being put right and there are no problems. I have to say to him that the complacency he showed in his speech is simply not justified and, in fact, very worrying. May I remind him that hospital A and Es in England have now missed his Government’s target for 32 weeks running? The last 12 months since the Francis Report was published have—taken together—been the worst year in A and E for at least a decade, with almost 1 million people waiting more than four hours. That shows that NHS services have got worse, not better, since the publication of the Francis report.
Does my hon. Friend also recognise the growing problems in the mental health sector, as illustrated by evidence given to the Health Committee only earlier this week? We have seen the loss of 1,700 mental health beds over the last two years.
In a moment.
On all measures, this winter has been just as bad as the last, with some patients waiting hours on trolleys, or held at the door of A and E or in the back of ambulances. A and E is the barometer of the whole health and care system, and that barometer is warning of severe storms ahead.
As it happens, waiting times for A and E departments are now half what they were when the right hon. Gentleman was Health Secretary, but may I gently suggest that rather than trying to turn this debate into a discussion about who had the better A and E performance, he should return to the Francis report, which is what the debate is about and which deals with something that happened on his watch? The country wants to know what his party, and he personally, have learned from the mistakes that were made that allowed Mid Staffs to happen.
Pressure on hospitals, and how we relieve it so that they can care for people properly, is the core of this debate. What we have seen under this Government is an ever-increasing number of frail, elderly people coming into hospital via A and E. The Secretary of State shakes his head, but Francis made specific recommendations on the care of older people in hospital. The point I am making is that under him the number of older people admitted to hospitals as emergency admissions has gone up significantly, and that goes to the heart of the issues raised by the Francis report.
We have an excellent hospital in Salford—it is one of the best in the country—but we also have 1,000 people who are losing their care packages this year. We have pressure on Salford because Trafford has been downgraded and lost its A and E, and we are short of two A and E consultants—even Salford has a problem recruiting A and E consultants. Those are real concerns for people in Salford despite having one of the best hospitals in the country.
I hope that the Secretary of State was listening to my hon. Friend. The point I was making—he did not like it—was that there is plentiful evidence that the NHS has gone downhill in the 12 months since the publication of the Francis report. The chaos in A and E has increased, and pressure on mental health services has reached almost intolerable levels.
Trusts face great difficulties in recruiting sufficient A and E doctors—a central issue in the Francis report, as it addresses safe staffing numbers.
I agree that this is a debate about the whole NHS, and the 111 service is failing people. On Saturday night, I had direct experience of that with my six-month-old grandchild. I phoned the 111 service, but nobody could tell me when I could speak to a doctor. What did I do? I went to A and E.
That is the problem. The Government’s focus is on hospitals. All the while, alternatives to A and E are being degraded and taken away. It is an undeniable fact that it has become much harder to get a GP appointment under this Government. The Patients Association warns that it may soon be the norm to have to wait for up to a week. [Interruption.] The Secretary of State says, “Nonsense.” He should get out and speak to people. The people I speak to tell me they are getting up in the morning and ringing the surgery at 8 am or 9 am, only to be told there is nothing available for weeks. As my hon. Friend the Member for Stockton North (Alex Cunningham) said, they ring 111 and the advice given is to go to A and E.
The Government have created the situation that the Secretary of State will not address. He wants to put it all in his own terms, but this is the reality in the NHS right now and this is what has happened since the publication of the Francis report. He has put more pressure on hospitals, because he has made it harder for people to get a GP appointment, and hospitals today face greater difficulty in meeting their targets. Indeed, as I just said, in the 12 months since the Francis report, hospital A and Es have missed the target 32 times running. These issues go to the heart of what we are debating today.
Constituents across the country will be really concerned that the Secretary of State was shaking his head when my right hon. Friend noted the fact that hospitals are under pressure and that that will have an adverse impact. Macmillan Cancer Support notes that four in 10 people are leaving hospital without enough support from health and social services. That shows there is a crisis across the entirety of the NHS, not just in A and E.
That is what I am saying: A and E is the barometer of the whole system. If there is pressure anywhere, in the end it shows up in A and E. Hospitals become jammed: they cannot admit people from A and E to the ward because people in the ward cannot be discharged home. This is what we are seeing. The Secretary of State is in denial, basically. He is shaking his head and saying that this is nothing to do with the issues raised by the Francis report. I am afraid that this is the real experience of people—staff and patients—up and down the country, and the sooner he wakes up to it the better for us all. If he thinks the situation with regard to getting a GP appointment is acceptable at the moment that is up to him, but those of us on the Opposition Benches find it completely unacceptable. It is simply not good enough and the sooner he pulls his finger out and does something about it the better.
The Secretary of State’s failure even to acknowledge these issues today is a matter of some amazement, given that he could find time to talk on an area that is not his responsibility—the NHS in Wales. There are, of course, important issues that the Welsh Assembly needs to address, but voters in England might appreciate it if he spent a bit more time sorting out problems here rather than pointing the finger over there.
The NHS in Wales is relevant. Thousands of constituents in England have to use the NHS in Wales—the point I made to the Secretary of State—because of the Labour party’s ill-thought-out devolution settlement. Thousands of patients in Wales cross the border to use the NHS in England, too. What lessons should this House draw from the Labour party’s performance in running the NHS in Wales, if the shadow Secretary of State is ever back in my right hon. Friend’s chair at the Department of Health?
I, as part of the previous Government, left the lowest waiting times in the history of the NHS, and A and E was performing much better at the end of the previous Government than it is now. Hospital A and Es have dropped right down, so we do not need to take lessons from the hon. Gentleman.
Let us return to the issue of England and Wales. The mantra or script of Government Members is almost to deny that there are problems in England. Last week, 16 major A and Es in England were below the Welsh average on waits in A and E. Some trusts are seriously struggling, such as in Leicester, in the constituency of my hon. Friend the Member for Leicester West (Liz Kendall), and Great Western Hospitals NHS Trust and North West London Hospitals NHS Trust, where one in four patients were waiting more than four hours.
Another trust below the Welsh average was Barking, Havering and Redbridge, which includes Queen’s hospital, Romford. May I recommend to the Secretary of State that instead of sitting there mumbling away, he read an article on The Guardian website today by Saleyha Ahsan, an A and E consultant who has worked at Queen’s hospital, Romford? She writes:
“Being a doctor in accident and emergency has at times resembled being a medic in a war zone.”
May I remind him that this is the English NHS she is talking about—the one he is supposed to be responsible for? She goes on to say that the severe shortage of A and E doctors is a result of his predecessor’s failure to listen to the warnings from the College of Emergency Medicine about the looming recruitment crisis, because it was obsessed by its reorganisation. Dr Clifford Mann said he felt like
“John the Baptist crying in the wilderness”
because the Government’s reorganisation brought “decision-making paralysis” to the NHS. What does Dr Mann say now? He says that even after the reorganisation these issues cannot be dealt with, because
“there are now a lot of semi-detached organisations to deal with”.
Government Members do not like hearing it, but the fact is that the reorganisation by the right hon. Member for South Cambridgeshire (Mr Lansley) damaged front-line care in the NHS. May I remind the Secretary of State that just 12% of people think standards in the NHS have got better under the coalition, while 47% think they have got worse? Rather than pointing the finger at Wales, the Government need to spend a bit more time sorting out the problems they have created in England.
As my hon. Friend the Member for Easington (Grahame M. Morris) says, an urgent area that needs to be addressed is mental health. Some 1,700 mental health care beds have been cut over the past two years because these Ministers have allowed the first real-terms cut in mental health spending for a decade. As a result, alarming stories are emerging of very vulnerable children and adults being held in inappropriate accommodation, such as police cells. According to Mind, many trusts are reporting more than 100% bed occupancy. One trust in London has had to turn office space into temporary wards with camp beds.
We are also hearing of children being sent hundreds of miles to find an available bed. In a constituency case, my hon. Friend the Member for Leicester West found that there was simply no bed available in the public or private sector anywhere in England on a day when a very vulnerable child needed support. A recent freedom of information request by Community Care found that in 2013-14 10 trusts sent children to young people’s units more than 150 miles away. The furthest distance was 275 miles, from Sussex to Bury. A 12-year-old girl from Hull was sent 130 miles away to a unit in Stafford. Her child and adolescent mental health services team were searching for a bed for two days, and were told that the Stafford bed was the only one available in the country.
On a point of order, Madam Deputy Speaker. I came to have a debate on the Francis report. The shadow Secretary of State is not mentioning the Francis report; he is launching a criticism of the Government’s record since the report, which has nothing to do with it.
Frankly, that is my business and I do not require any help to decide what is in order. The shadow Secretary of State is remaining in order, as the Secretary of State remained in order. I think it is best that we continue with the Front-Bench opening speeches to make sure that we can get in all the Back Benchers who wish to speak in this important debate.
It is interesting that Government Members do not like it, but this is the reality in the NHS right now, 12 months after the Francis report. Patient care is being compromised in the mental health care system. If the hon. Member for Mid Norfolk (George Freeman) does not think that that is relevant, let me quote Professor Sue Bailey, the President of the Royal College of Psychiatrists. She said that mental health units are
“heading for a Mid Staffs scandal”.
If that is not relevant, what is?
Just to put the record straight and to give the shadow Secretary of State the opportunity to rectify something he was responsible for at the time, I accept that there was a Francis report before the inquiry under the Inquiries Act 2005 took place. In the light of the fact that he has himself acknowledged many of the recommendations of the Francis report, will he now accept that it was a grave mistake not to have a public inquiry under the 2005 Act on his watch that of his predecessors as Secretaries of State?
I am pleased that the hon. Gentleman has acknowledged that it was I who appointed Robert Francis to begin the process of an independent inquiry into what went wrong. I shall say more in a moment about what I did, why I did it, and why I stand by what I did, because in my view what I did was help to get to the truth while also helping Stafford hospital to recover.
As my right hon. Friend knows, my wife is a community psychiatric nurse who sees mental health services at the sharp end. Does he agree that the coalition seems to view mental health as a Cinderella service rather than an integral part of the NHS?
My hon. Friend is right: it is the poor relation that has always been on the fringes of the system, and is always the first service to be targeted for cuts. That has happened again in these difficult times. The Government are cutting mental health services more deeply than the rest of the NHS, and that has led to all the problems that I have been describing.
I went to Stafford recently to meet campaigners who are working to support the hospital. One of them told me that because of the lack of available mental health beds, beds had had to be found in the hospital for people who were experiencing serious mental health crises. That is what begins to happen when we do not have adequate capacity on the ground. Government Members say that this is not relevant, but it is directly relevant to all the matters that we are discussing today.
As the right hon. Gentleman knows, I was critical of the last Labour Government for rather bizarrely rolling out the red carpet for the private sector and, indeed, allowing financial targets to distort clinical priorities to an extent which, I think, created the circumstances that led to the Mid Staffs difficulties. He has mentioned integration of care. Does the Labour party propose full integration in terms of the pooling of budgets, and does he support the campaign for a fundamental safety standard in respect of the ratio of registered nurses to patients on acute hospital wards?
I do support that campaign, because I think that we need transparency so that local people can see whether their hospitals have enough staff. I also support the full integration of health and social care into a single service—an even deeper integration than a pooled budget—because I believe that that is the only way in which we will build a service based on the individual. We need a system in which all the needs of one person are clear and the service can start in the home, rather than this fragmented world in which care in the home is being cut and older people are being left at ever greater risk of hospitalisation.
I find it worrying that Government Members seem to be in denial about what I have been saying, and that brings me to the central point that I want to make. I believe that the Government have mishandled their response to the Francis report, and I shall cite three examples in support of my claim. First and most obviously, the Government have failed fully to implement 88 of the report’s recommendations, as they have themselves acknowledged. Secondly, Stafford hospital has, in my view, been hung out to dry. Thirdly, by overtly politicising the whole issue of care failure, the Government have created a climate of fear throughout the NHS—the worst possible response to what Francis said.
It seems to me that the Government have missed the entire point of the Francis report. If we distil the report into a few words, it called for a culture change. A range of measures were proposed with the aim of achieving that change, including a duty of candour for individuals and organisations, regulation of health care assistants, and, crucially, moves to strengthen the patient voice at local level by giving Healthwatch more protection and prominence. Francis recommended that local authorities be required to pass centrally provided funds to local Healthwatch groups, but that recommendation was not accepted. Of the £43 million allocated by the Department last year, HealthWatch groups have received only £33 million, which leaves £10 million unaccounted for. The Patients Association has said that
“vital recommendations have not been accepted and…patient care could suffer as a result.”
We support measures that the Government are introducing in the Care Bill on the appointment of chief inspectors, but let us be clear: they were not recommendations of the Francis report, and, if we are not careful, they will risk reinforcing a much more top-down approach to regulation. The position is not helped, I might add, by the Secretary of State’s new habit of calling hospital chief executives directly himself. Indeed, one of the great ironies of the Government’s reorganisation is that it has left the NHS a more top-down organisation than it was before, with clinical commissioning groups yet to find their voice and NHS England calling all the shots.
Let me quote from the Nuffield Trust’s report, entitled “The Francis Report: one year on”. In his foreword to the report, Francis himself says:
“Perhaps of most concern are the reports suggesting a persistence of somewhat oppressive reactions to reports of problems in meeting financial and other corporate requirements. It is vital that national bodies exemplify in their own practice the change of cultural values which all seem to agree is needed in the health service.”
Robert Francis himself says that national bodies are still behaving in a top-down fashion—one year on.
What with NHS England, the NHS Trust Development Authority, the Care Quality Commission, Monitor, clinical commissioning groups and the Department of Health, is the NHS not in danger of having no clear lines of responsibility? There appears to be no clarity when it comes to who is enforcing good quality of care across the NHS. Is not the use of human resources practice to bully staff one example of something that may fall through the gaps between those various organisations?
My hon. Friend has raised an important point. People are confused about the new NHS, and confused about who has responsibility for what. The Government have created more organisations, not fewer; the NHS is more top-down than it was before; and that is not changing the culture. Robert Francis himself has said that the culture is not changing. The Government are utterly complacent if they think that they have got everything sorted out.
Time is against us, I am afraid.
The Secretary of State is wrong if he thinks that top-down regulation is the only answer. It cannot prevent things from going wrong in the first place. The Secretary of State should accept all the recommendations of the Francis report, including the recommendations that are designed to change the culture at a local level.
Let me now turn to the future of Stafford hospital, and address the point made by the hon. Member for Stone (Mr Cash). If there was one thing that the people of Stafford deserved after what had been a long and painful process, it was the legitimate expectation that, at the end of that process, they would see a fully functioning local hospital that was both safe and sustainable. That is why I believe that the conclusion of the trust special administrator process is both wrong and unfair on them. It will result in a significant downgrade of the hospital, and there is still no clarity in regard to important services such as maternity.
The issue of the future of Stafford hospital goes to the heart of the handling of the inquiry and the decisions made about it. When I arrived at the Department of Health in June 2009, the official advice that I received was that I should not hold any further inquiry into what had gone wrong, because it would distract the hospital from the essential task of making immediate improvements. I could not accept that advice, because I believed that we needed to get to the full truth of what had gone wrong. That is why I appointed Robert Francis to conduct an independent inquiry. However, I stopped short of a full public inquiry because I had been warned that such an inquiry could destabilise the hospital and prevent it from making improvements. The Secretary of State nods.
That is the advice that I was given, but I told Robert Francis that he could come back to me and ask for powers to compel witnesses to appear before him if he felt that that was necessary. He came back to me to say that he felt that he had had all the co-operation that he needed. Indeed, he had had more, because of the nature of the inquiry that I had set up.
As the Secretary of State will recall, after the first Francis report I commissioned a second-stage inquiry into regulatory systems. I did not disagree with the coalition’s decision to upgrade it to a full public inquiry, as that was always a finely balanced judgment, but I did warn at the time that the hospital would need further support, given what a full public inquiry would entail. I do not believe that it has been given that support. Worse, the administration process that it has undergone has been brutal. I do not believe that there is a district general hospital in the land that could survive a three-year public inquiry followed by financial administration. The Labour party’s view—informed by the Lewisham and Stafford examples—is that the Government are misusing the administration powers created by the last Government to drive through reconfiguration on cost rather than clinical grounds, and we will therefore move to delete those powers from the Care Bill next week.
The right hon. Gentleman has alluded to the sustainability of district hospitals. In the light of the Francis report and the dreadful care failings at Mid Staffs, I would suggest—and I am sure that others would agree with me—that part of the problem was that we were trying to offer care over two sites to a relatively small population. The right hon. Gentleman agrees with me that reconfiguration of acute care in particular is on the horizon. Does he also agree that, in view of the political difficulties of acute reconfiguration and the ultimate closures of departments, a cross-party approach is long overdue?
The hon. Gentleman makes a very important call, and I think he is right: hospitals are going to have to change, and the sooner we all wake up to that fact, the better. I would also say to him, though, that hospitals cannot be changed top-down, as I believe his Government are trying to do with clause 119 of the Care Bill: a power to drive through financially driven reconfiguration and create a twin-track route outside of the normal, established process. The normal process creates local oversight and scrutiny at democratic level, and independent judgment on changes from the Independent Reconfiguration Panel. That is the established route and it should not be bypassed. I say that while agreeing with the hon. Gentleman that we do need a cross-party approach.
I believe we owe it to the people of Stafford to support their hospital and maintain as many services there as possible. If the Secretary of State were to visit Stafford and sit down with people on the Support Stafford Hospital group, as I have done, he would hear a real sense of injustice from them that their hospital has been dragged down by a barrage of negative publicity. Will the Secretary of State confirm today whether Stafford hospital will continue to have a maternity service? Rumours and nods and winks are no good; people need to know. What will he do to ensure that the people of Stafford do not have to travel miles to get basic services? I can tell the House that I will continue to argue for the fullest range of safe services at Stafford, as that has been my consistent aim throughout this entire process.
Perhaps the most unseemly aspect of the last year has been an attempt by some to politicise the failing at Stafford. That has created a climate of fear in the NHS that may make it even less likely that doctors and nurses feel able to report mistakes or poor care and achieve the culture change that the Francis report advocated. I would like to remind those on the Government Benches that this stands in stark contrast to the way the previous Government handled the care failures they inherited from the Government before them at Bristol and Alder Hey, and also the Shipman murders. At Bristol, doctors raised concerns but were not listened to. Parents whose children had died or suffered brain damage were ignored. For a long time nothing was done. It was in 1997 that the General Medical Council finally started to investigate what had gone wrong at Bristol. I say to those on the Government Benches, for goodness’ sake please remember and take the long view on these issues. Let us all use these moments by making them a catalyst for change in the NHS.
NHS staff report to me that they now feel a climate of fear and an intensification of the blame culture, with the talk of uncaring nurses, lazy GPs and coasting hospitals. We have seen HSMR—hospital standardised mortality ratio—figures misused by Government spin doctors to generate misleading headlines that have damaged struggling hospitals. It even got to the point where a group of senior clinicians and managers felt compelled to write to The Guardian at the end of last year, calling on the Government to call off the attack dogs. They feel that there is an attempt to magnify the failings of the NHS and run it down, and that it is linked to a drive towards more privatisation.
What the NHS needs to address some of the major issues that the Francis report raised is the ability to collaborate and integrate. The great sadness is that the Health and Social Care Act has placed it on the opposite path, towards competition and fragmentation. We now have the unbelievable spectacle of the Competition Commission intervening for the first time to prevent sensible collaboration between hospitals. The logical consequence of “any qualified provider” is more and more providers dealing with one person’s care. This is a recipe for cost, complexity and fragmentation.
I am clear that the market is not the answer to 21st century care. Instead, we need services based around the individual, starting in the home, with all barriers to integration are removed. That is essential if we are to rethink the care of older people as the Francis report invites us to do, and this shows the big difference between those on this side of the House and those on the Government Benches. They talk about integration but have instead legislated for fragmentation. Only by repealing the Health and Social Care Act will we put that right, put the right values back at the heart of the NHS and build an NHS ready for the 21st century.
I was told by a senior member of the medical profession that the two Francis inquiries were the most important look at the NHS for at least two decades. He was right. The first, which was commissioned by the previous Government, revealed what Robert Francis describes as the
“appalling suffering of many patients”
primarily caused by a serious failure on behalf of the trust board, which did not listen sufficiently to patients or staff and failed to tackle an insidious negative culture involving a tolerance of poor standards. The second report, from the public inquiry commissioned by my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), described how
“a system which ought to have picked up and dealt with a deficiency of this scale failed in its primary duty to protect patients and maintain confidence in the healthcare system.”
It is a tribute to those who fought long and hard against the odds to have the inquiries and reports instituted by the last two Governments that their importance is recognised.
Does my hon. Friend agree that one of the most shameful episodes highlighted by the Francis report is the consistent and persistent neglect of the whistleblowers in the service who tried to raise the issues that were being hidden, and the systemic neglect of their interests? Many of them are still suffering, and this is still going on in Wales today. Will he invite the shadow Secretary of State to acknowledge that the problem is ongoing?
I agree. The treatment of whistleblowers has been a disgrace, not just at Mid Staffs but in many other places. I have seen consultant contracts from way back that have prevented their raising issues even with their Members of Parliament, and I am glad to say that sort of thing is coming to an end. I want to try to focus as much as possible on the Francis report, however, as I believe there are many important lessons that all of us, including me, have to learn.
As the Health Committee has said, as a consequence of the issues I have outlined,
“a healthcare system established for public benefit and funded from public funds risks the undermining of its guarantees of safety and quality.”
It is my sincere hope that we never have the need for another inquiry of this nature. This should mark a watershed in the NHS—a time when patient safety and high-quality compassionate care is the rule, delivered through a positive and caring culture, underpinned by safety and quality management systems through our health service and backed by openness and accountability, which I am sure many Members will speak about later. It is thus that we can respect the memory of those who suffered at Stafford, but also in many other places across the UK, as the work of the right hon. Member for Cynon Valley (Ann Clwyd) has shown.
The Francis reports, and particularly the accounts of patients’ experiences, should be required reading for all medical and nursing students. I ask the Secretary of State to confirm that he will pursue that with Health Education England.
Robert Francis, for whom I have the greatest respect for the calm and understanding way in which he conducted the inquiry, made 290 recommendations, but I shall concentrate on his essential aims. He writes of fostering a common culture of putting the patient first. It is sad that he must write that, but it is necessary. However, before we rush to find fault with a service which has lost its way, let us just consider the society in which it operates, starting with ourselves. Can we honestly say that we always put our constituents’ interests first? What about others in the professional and business worlds? When self-interest and personal fulfilment are so often lauded, why is it that we expect the NHS to be so very different? Saying that is neither to excuse nor to lower the bar, but to understand how difficult it is in some circumstances to maintain that highest of standards. Ensuring that patients come first when dealing with several very ill and distressed folk, perhaps at 2 o’clock in the morning, takes more than just compassion. I am not downplaying compassion in any way—it is essential—but the underpinning of quality and safety systems carried through as second nature is also required. It means ensuring that the leadership is on call to provide extra help as soon as it is needed. It demands the strength to speak out for what is not acceptable and an openness to admit when there are problems. Without the systems and standards, the supportive leadership, the strength and the openness, not even an angel can always put patients first, much as they would wish to.
There has been much debate about staffing levels, and rightly so. Although the problems at Stafford went far beyond numbers, there is no doubt that cuts contributed to them. When I was first selected as parliamentary candidate in 2006, the trust had a £10 million deficit. It wanted to achieve foundation trust status and needed to balance its books, and part of its solution was to reduce the number of nurses. I should have questioned that, as should others, but we accepted the trust’s assurances that it would not harm patient care. I say to all right hon. and hon. Members that one thing that must come out of this report is that each of us must be emboldened to challenge our local trusts when they make statements such as, “This won’t harm patient care”, despite their cutting 100 or more nurses. The approach to staffing management and data publication used at Salford Royal NHS Foundation Trust has been held up as an example of good practice in staffing by the Health Committee and the Secretary of State, so let us act and adopt it everywhere.
I recall that when I was first elected to this House, I was shocked at the tone and content of some of the responses by the NHS to complaints. Not only did they take several months to arrive, but they were sometimes complacent, and they certainly lacked compassion and understanding. That has, for the most part, changed considerably for the better—it certainly has in Stafford. The overwhelming message I receive from my constituents who need to complain is that they are not interested in compensation, but they are interested in a better NHS for everybody. So let us approach the complaints system from their premise, not that of lawyers. That is the responsibility of the chief executive, who should review all complaints, and personally read and sign all response letters. The Secretary of State responds to several complaints each week personally and in this, as in many other ways, he sets the example.
Although I am encouraged by the progress made in treating complaints, I am less confident about accountability.
Does my hon. Friend accept that it is clearly stated in the prime ministerial guidelines of 2005 that when somebody writes to a Minister who has responsibility, including the Secretary of State, the relevant Member of Parliament is entitled to receive a personal letter that comprehensively and efficiently deals with the question at issue? Does my hon. Friend also agree that, regrettably, that did not happen in all instances when matters were raised with regard to Stafford hospital?
I thank my hon. Friend for that intervention and for all the work he has done on this issue. It is salutary for all of us to remember that when we get such a letter it often represents probably another 10 people who did not write to complain because they do not want to affect the NHS. We should treat each letter of complaint as being of immense importance.
I said that I am less confident about accountability, so let me say why. This is not just a question of the resignation of executives within a trust or the NHS when things go badly wrong, although it remains astonishing to me that no one has had the courage to do this given that the failings in Stafford were so clearly systemic; it also concerns the approach of the professional bodies representing nursing and clinical staff. The Francis inquiry saw evidence of poor co-operation with the General Medical Council from other organisations, including royal colleges, even though serious matters of fitness to practise and patient safety were involved; they almost put the practitioners above the patients. Those representing the medical and nursing professions are accountable to the public first and foremost. The best way of maintaining public confidence in their professions is to ensure that they treat their members who are not fit to practise in a firm, fair and swift way; cases of doctors or others being suspended for months or even years are too frequent.
Before I discuss Stafford specifically, may I just make a few remarks about hospital standardised mortality ratios? The Francis report states that Professor Jarman
“made it clear that it is not possible to calculate the exact number of deaths that would have been avoidable, nor to identify avoidable incidents…The statistics can only be signposts to areas for further inquiry.”
I urge all those who handle HSMRs to do so with care. They are extremely important as guidelines, and it was absolutely right that they were the first statistics that showed up the need for the Healthcare Commission inquiry, but to extrapolate numbers from them can be difficult and the evidence does not necessarily bear it. We have seen examples of that happen.
I am grateful to the hon. Gentleman for mentioning that point. Does he agree that an important task of public education needs to accompany the transparency around such statistics, because they are complicated and, as he says, they are a signal but not a whole story in and of themselves? Has he any suggestions as to how we could enlarge that public education and understanding.
I thank the hon. Lady for her intervention, but that task is probably beyond my competence. I agree that we should use HSMRs and respond to their signals, but we should not say that they are the final judgment on specific numbers. Any HSMR that looks difficult and looks as though it needs to be investigated must be investigated—it is much better to do so than not to do so.
I will now discuss my own constituency, which, along with those of my hon. Friends the Members for Cannock Chase (Mr Burley), for Stone (Mr Cash) and for South Staffordshire (Gavin Williamson), has probably been the most affected. The spotlight has been on Stafford hospital for several years now, and it has been an extremely difficult time for those who raised their concerns, such as Julie Bailey and Cure the NHS, which were dismissed in a very offhand way by the NHS system and for which they endured abuse; it has also been extraordinarily testing for the many people working at that hospital and the one in Cannock, who have tried to carry out exemplary care at a time when the spotlight has been on them. They have, by and large, brought excellent care to patients, despite what has been going on around them. Understandably and rightly, the Care Quality Commission carried out an unannounced visit on the very day last week when it was announced that the Mid Staffs trust would be dissolved, so hon. Members can understand the sort of pressures that staff have faced. The great improvement that has been made has been recognised by the CQC and, most importantly, by patients and their loved ones. There is no complacency; there are still instances that should not happen, and the hospital and the trust are determined to ensure that they learn from all those. For Stafford and Cannock, however, it has also been a time of coming together and putting aside differences, as tens of thousands of people have worked together to save our hospitals and their services.
I will not dwell at length now on the process, the administration and the dissolution of the trust announced last week, but I will seek a debate on it, because some of the points made by the Opposition spokesman, the right hon. Member for Leigh (Andy Burnham), are fair in respect of the way the process works—or does not work. I have been critical of it and will continue to be so. I will, however, dwell on the unity. I have marched twice, not only with people who have had wonderful care at Stafford, but with some who have told me that they, too, experienced very poor care at Stafford but wish, for the sake of everyone, to see both patient safety and care improved, and services protected. Last week, the trust’s dissolution was announced, and although most services will continue, I continue to oppose decisions that mean the potential loss of consultant-led maternity services, consultant-led paediatrics and in-patient paediatrics. I will continue to fight for those services, because I believe they are essential in a hospital and a place that is at least 30 km away from the nearest other possibilities for patients. I urge NHS England, in particular, to take the consultant-led maternity review very seriously indeed.
I am most grateful to the hon. Gentleman, to all the Stoke-on-Trent MPs and to the hon. Member for Newcastle-under-Lyme (Paul Farrelly) for the way in which they have approached this matter together with us. We will be working with them under the new trust arrangement, with the University Hospital of North Staffordshire NHS Trust, and it is very important that we work together.
I refer to unity because the only way in which we will develop a health service fit for the 21st century is by showing that same unity of purpose nationally. I pay tribute to my hon. Friend the Member for Bracknell (Dr Lee), who is no longer in his place, for his remark about working together, and I absolutely agree with it. When the Prime Minister and the Leader of the Opposition, and later the Secretary of State and his shadow, have made their responses to the Francis report in the past year, they have been of the highest quality; they have shown a true appreciation of the gravity of the subject and the importance of a mature response.
On the proposed reorganisation of services in Staffordshire, what is the role of the clinical commissioners? I thought that if we moved to a commission-based NHS, commissioners would determine what services were provided at which hospitals.
My right hon. Friend makes an extremely important point. Indeed, the clinical commissioning groups have backed the changes, but the local population has not. The clinical commissioning groups are in a difficult position, because they have a budget, and the budget in Staffordshire, as in many other rural areas, is much lower than the national average for England. They are told that if they want to commission services that cost more than the tariff—as maternity services almost always do because maternity tariffs are simply not high enough—they will have to pay the extra. To some extent, the clinical commissioning groups are caught between a rock and a hard place. They may wish to commission those services, but in doing so they will have to stop commissioning others.
It is in the spirit of unity that I ask both the Secretary of State for Health and his shadow to visit Stafford and Cannock Chase hospitals to speak to patients and staff and to hear first hand what they have gone through. I also urge that same co-operation in approaching the long-term challenges facing our health service. The increasing specialisation of services—62 specialties as against 30 in Norway—is driving up costs and resulting in clinicians knowing more and more about less and less.
In Stafford, we have been told that we cannot continue with our consultant-led paediatric service, because we have too few consultants—five or six as opposed to the eight to 10 that the Royal College of Paediatrics and Child Health says are needed to maintain a rota. By that standard, some 50 or more other consultant-led departments in England should close. Instead of a proper national review with full political co-operation, however, we see the gradual picking off of departments in trusts that have financial difficulties. The same is true with maternity services.
I echo the point made by my hon. Friend the Member for Bracknell and urge the Government and Opposition to come together with the royal colleges and resolve this matter and much else. The British public are not stupid. They understand that they cannot have every service just around the corner. However, they do not understand why a consultant-led maternity department or paediatrics department in one place must close on safety grounds because it does not have a large enough rota, whereas another with a smaller rota remains open. They also understand the need for more services in the community, but the idea of “slashing” hospital budgets, as Sir David Nicholson is reported in The Guardian as saying, is both incomprehensible and deeply worrying to those whose A and E departments are heaving, whose wards are full and whose children face travelling long distances even to receive general treatment.
I thank my hon. Friend and neighbour for giving way, and I commend him for his work on this issue. He will know that Queen’s hospital in Burton has dealt with some of the overflow from Stafford hospital following the closure of facilities and services there. Does he share my concern that the special administrators have not met any of the management at Queen’s hospital, and have ignored its letter of concern, stating that closure of the emergency department will mean that it will require an additional 18 to 34 beds? The hospital has heard nothing in response to that letter.
I am grateful to my hon. Friend for making that point, which is one of the things that needs to be discussed. I am talking about special administrators liaising with other trusts such as the University Hospital of North Staffordshire NHS Trust, the Burton Hospitals NHS Trust, Walsall Healthcare NHS Trust and the Royal Wolverhampton Hospitals NHS Trust. We are part of an integrated health economy; what affects one affects many others in the region.
Many in the profession have put it to me that we are at risk of gradually losing the skills of general medicine and surgery. That is not to downplay specialisms, because they are vital. However, unless we maintain our district general hospitals, with their ability to deal with the majority of non-specialist cases, we will end up with our specialist hospitals being overwhelmed and without doctors with vital general skills.
It would be disingenuous of me to make such points without raising the matter of NHS funding. The Government are right to have maintained NHS funding in real terms during extremely testing times. They are also right to insist that waste is rooted out. Payments of thousands of pounds to locums for a shift are not uncommon. I could cite many other examples, but there is no time. There is little doubt in my mind that we need to allocate a little more of our GDP to health than we do currently, as we are below the level in France and Germany. However, that is a question for lengthy debate on another day.
As I have said in the House before, we need to take the NHS budget out of general Government spending and convert national insurance into a national health insurance, which will still be progressive and still based on payment according to income, so that we can maintain a first-class health service alongside a competitive tax system.
The Francis report is already having an important and positive effect on the national health service and will do so for years to come. I pay tribute to my right hon. Friend the Health Secretary and his team for all they have done on that and the seriousness with which they have taken the matter. The emphasis on the safety of patients and quality of care seems obvious to us now, but sadly it was not always a priority. The report not only provides answers and makes recommendations, but asks fundamental questions about the future of our NHS. I have tried to outline some of those questions today. I urge all parties to come together to tackle them for the good of our nation.
I congratulate the hon. Member for Stafford (Jeremy Lefroy) on his eloquent presentation. The Francis report carries lessons for everyone involved in health care—whether it be hospitals and their boards, regulators, professionals or Governments. However, those lessons need to be learned all over Britain. It is a matter not just for England, but for Scotland, Northern Ireland and Wales.
The letters keep coming. When I gave evidence to the Health Committee the other week, I was asked what had changed. I said that I did not know and could not honestly answer the question. Perhaps I will know when the letters stop coming. Every time I open my mouth, I am punished by yet more letters. I have had hundreds of letters from Wales; and hundreds too from England, Scotland and Northern Ireland. When I was carrying out my review, I received 3,000-plus letters and e-mails, and they still keep coming.
My concern today is for my constituents in the Cynon Valley and those elsewhere in Wales where health is a devolved function. I will not be popular for saying this, but when this House is asked to give yet more powers to Wales, I will ask many questions, because the main things for which the Welsh Assembly is responsible are health and education. I was a keen pro-devolutionist in two campaigns, but in future I will think very carefully before giving any more powers to the devolved Administrations.
Many people were to blame for what happened at Mid Staffs, just as there were many people to blame for the worrying situation that was revealed at several other English hospitals in subsequent investigations by Professor Sir Bruce Keogh. There is nothing to be gained by politicising such catastrophic situations and everything to be gained from being honest about the problem and seeking appropriate solutions. After all, we are talking here about sick and vulnerable people who are often afraid and in pain. Political bun fights here or in the Welsh Assembly are of little interest to them; they just want something to change for the better.
What was so shocking in Mid Staffs of course was that no one spoke out and the warning signs of a trust in meltdown were ignored. Robert Francis has listed some of those warning signs and they read directly across to many of my concerns about the NHS in Wales.
The first warning sign is an accumulation of patient stories that detail adverse incidents, bad practice or neglect. As I have said, I have had literally thousands of those, and they continue to arrive in my office every day from all over Wales and from England.
The second warning sign, said Francis, is the level of mortality statistics. In fact, they appear to be dangerously high in many hospitals in Wales. Confusion remains on how accurate the data are. The system by which they are collected is questionable, to say the least, and there is a backlog in the coding of cases for inclusion in the risk-adjusted mortality index—RAMI—so we are now seeing retrospective alterations in the figures in at least one hospital, thus making it difficult to compare hospitals in Wales, or to compare England and Wales.
I pay tribute to the right hon. Lady for her work in championing patients and in drawing attention to some very unpleasant outcomes in many hospitals across the whole United Kingdom. In relation to the higher mortality rates that she refers to, does she share my concern about the political rebuttal to an e-mail from one clinician in England to another clinician in Wales simply asking for further investigations?
I am grateful to Professor Sir Bruce Keogh for offering to assist. Given his vast experience, the people whom he offered to assist would be sensible to take the offer very seriously indeed.
The Transparency and Mortality Taskforce, which was set up by the Welsh Assembly a year ago, has today announced recommendations on a measure of mortality for Wales. Although I welcome its finally releasing the recommendations, I will await details on their implementation, which is unlikely to start until the autumn of this year. On mortality statistics, the taskforce provides an interesting academic discussion of the pros and cons of using mortality statistics as a measure of service quality and a means to compare hospitals and countries. Of course, none of that is new, but neither approach is impossible.
After almost a year, it is disappointing that a taskforce of 31 members has failed to arrive at the benchmarks on mortality that are urgently needed, so that fair international comparisons can be made between Wales, England and other countries. That was the taskforce’s job. The promise of a further statement in September 2014 appears to put the resolution of this matter even further away; one can only speculate on the reasons for that. Some good intentions may be expressed, but that is not enough, given the high level of public concern.
We continue to have only the published RAMI figures to go on. Six Welsh hospitals have RAMI figures of between 105 and 115, with 100 showing cause for concern, as we all know by now. A figure of more than 100 was described as a smoke signal. If the figure is way over 100, there is a big fire. It is not surprising that people are worried about what is actually going on. This is horribly similar to the murkiness that surrounded the mortality statistics for Mid Staffs.
We now know for certain, however, the position as reported by the Royal College of Surgeons after visiting the University hospital of Wales at Cardiff in April 2013 to investigate poor standards of care. It describes certain parts of the hospital as dangerous. It was worried about people dying on hospital waiting lists while waiting for heart surgery. Even those who got their surgery had deteriorated on the waiting lists. When they got their surgery, they were much more ill than they would have been.
Last week, the Royal College of Surgeons wrote to Healthcare Inspectorate Wales to ask what action has been taken about concerns raised last July in a report about patients dying while waiting for heart surgery. Following its initial report, the Royal College of Surgeons wrote to Healthcare Inspectorate Wales in August to claim that 152 patients had died in the past five years while waiting for heart surgery at the University hospital of Wales and Swansea’s Morriston hospital. I put on record my alarm about the lengthy delay in the promised revisit of the Royal College of Surgeons to those hospitals. It was promised in September, but it still has not taken place.
Other warnings to be heeded, said Francis, should come from complaints made by patients. Well, what do we know about this in Wales? Complaints trebled last year, according to the Welsh ombudsman, but the system for dealing with complaints, let alone learning from them, is highly unsatisfactory, so much so that an inquiry is under way after several high-profile cases. Obviously, we look forward to seeing the outcome of that, mindful that the retiring Welsh ombudsman said in November last year that accountability in NHS Wales has “broken down” and that there is a “lack of challenge” in the system. He asked:
“Where is the voice of the patient in the NHS in Wales?”
The fourth warning sign that Francis mentioned was signals from staff and whistleblowers. Many of them have reached me, too. Some people have told me that they are no longer able to do their jobs properly. I have had several phone calls from consultants who will not even give their names and who say that, if they gave their names, they would be sacked from their jobs.
More people are speaking out openly, and this week a letter appeared in the Western Mail from a consultant paediatrician, who said:
“The intervention of Sir Bruce Keogh, Medical Director of NHS England, expressing concern regarding high mortality rates in several Welsh Hospitals may not be welcome… It deserves to be taken seriously.
Mortality rates are ‘risk adjusted’, which means that the mortality rate is ‘adjusted’ for hospitals that deal with a disproportionate number of seriously ill patients, some of whom, sadly, but inevitably may not survive their treatment. It’s therefore appropriate to review clinical practice in all hospitals whose mortality rates are above 100. The recent publicity relating to high death rates at the University of Wales following liver surgery, where an independent Royal College of Surgeons’ report identified 10 deaths that were deemed ‘avoidable’ highlights the sluggish response of the hospital’s own management to information that should have been spotted far earlier.
A ‘Wales-wide’ investigation...or indeed a ‘health board-wide’ investigation would be too general, and would probably fail to identify clinical practice where there is a need for improvement.
Any review needs to be ‘department-wide’. All health boards have sufficient information available to them that allows identification of individual departments, possibly individual practitioners, where clinical outcome falls below the norm”—
The right hon. Lady is a doughty campaigner and commands the respect of the whole House for her work in bravely highlighting the issue. Does she agree from her experience and the correspondence that she has received that there is a lesson about the need for a different culture in the NHS of respecting the views of patients and whistleblowers, not treating them with contempt as though expressing such views is disloyal? Does she also agree that this saga highlights the importance of integrating data and having a statutory requirement to use the data to highlight the best and worst practices in the interests of patients?
I am grateful to the hon. Gentleman for making that point. In the report that I wrote with Tricia Hart on complaints, we made several suggestions and recommendations, which the Government have accepted. I hope that we have a debate similar to today’s on progress in that area in a few months’ time. Professor Sir Mike Richards has promised to campaign on the issue when he goes round the many hospitals that he visits, but it is not possible to say whether complaints will head his list and whether the way in which they are dealt with will be picked up.
The letter that appeared in the Western Mail went on to say:
“A review should look not only at mortality rates. Complication rates, a high number of complaints from patients and their families, or frequent falling out between consultants within the department, all offer useful markers for identifying potential problem areas.
Careful analysis of departmental practice could lead to a prompt and effective change in practice. The Welsh public should be in receipt of all clinical outcome measurements, department by department.
Hysterical responses, such as BMA Cymru’s description of the perceived criticism as ‘wicked slander’…are unhelpful. Our health boards’ first duty of care is to their patients. Our political leaders and BMA Cymru (my own union by the way) should also be reminded that their first duty of care is to the patients and not to our established and very powerful institutions.
I hope that we have no ‘Mid Staffordshire’ in Wales. Our leaders’ current reaction is worryingly similar to the reaction of NHS management in the North of England, where a refusal to listen to constructive concern delayed essential change for many years, with tragic consequences for many families.”
The letter is signed by Dr Dewi Evans, former consultant paediatrician, Swansea Hospitals, who sent it to the Western Mail before he sent it to me.
Warning lights should flash when the governance of a hospital fails to function or to question quality and performance, and boards are in denial about poor standards, possibly because of political pressures. We have already had examples of this in Wales at Betsi Cadwaladr, and the Welsh Assembly’s Public Accounts Committee has called for a strengthening of performance and accountability procedures across all NHS organisations in Wales. That needs to happen urgently—our boards must raise their game.
Finally, perhaps the greatest step forward in England following the Francis report was the reform of the key regulator, the Care Quality Commission, and the appointment of Professor Sir Mike Richards to the newly established post of chief inspector of hospitals. Sadly, again in Wales, the regulatory system is a shambles. The evidence to the Assembly’s inquiry on Health Inspectorate Wales was shocking. It revealed that the inspectorate was under-resourced, under-skilled, and unable to carry out the annual inspections required, or to follow up its own recommendations. It was unable to hold boards to account. It is startling that its chief executive told the inquiry in November that she was unable to guarantee that there would not be another Mid Staffs in Wales.
I am concerned, too, about the delay in the publication of the report on the inquiry, which was promised in mid-February and should provide the building blocks for the reform of the NHS in Wales. I am sure that it is inconvenient to many for me to speak out in this way about my concerns, but what we all have to learn from the Francis report and indeed from the brave Julie Bailey of Cure the NHS is that we must not stay quiet, however difficult that might be, when we know that there is a risk to patients.
It is a pleasure to follow the right hon. Member for Cynon Valley (Ann Clwyd). I, too, pay tribute to her work in championing patients. The calm silence with which the House listened to her speech speaks volumes, as do the many nods of heads of colleagues around the Chamber.
I declare an interest, as my local hospital, Cannock Chase, is the other hospital in the Mid Staffs trust, so my constituents, like those of my hon. Friend the Member for Stafford (Jeremy Lefroy), have been deeply affected by the fall-out from Mid Staffs and the Francis report. I echo some the comments that have been made: I would not wish a public inquiry or trust special administration on any Member of Parliament, as it is an horrendously long drawn-out process and incredibly stressful for everyone involved, not least the patients who use the hospitals affected and the staff who work in them. However, the outcome is worth it, as today’s debate shows it was, if we learn the right lessons,.
I praise the staff at both Stafford and Cannock Chase hospitals for getting on with the job even when they are not sure what the future will be. I urge the Minister once more to move to the new organisational structure, with Royal Wolverhampton Hospitals NHS Trust running Cannock Chase and University Hospital of North Staffordshire NHS Trust running Stafford, as soon as possible to end the insecurity that the staff at both hospitals have suffered for too long.
I am grateful to the hon. Gentleman for giving way so early in his speech, to which I am listening carefully. He says that the TSA process was worth it. May I press him on that? Does he really think that that was ever going to deliver a fair outcome for his local hospital, given that it followed a three-year public inquiry and the hospital lost patients and staff as a result? In the spirit of the call made by the hon. Member for Stafford (Jeremy Lefroy), should we not all unite to recognise the exceptional circumstances that the local trust has been through? Is it not the case that a TSA process could never capture the exceptional nature of what has happened to the local health economy and, in fact, it looked narrowly at the trust’s finances and sustainability? Should we not call on the Government to look at that?
The right hon. Gentleman asks a number of questions. I am still not clear about his position and whether he thinks that the public inquiry was the right decision or not. The inquiry led to recommendations and the improvements we have seen. To answer his question about whether “the TSA process was worth it”—that was the phrase he used—as we speak in the Chamber today, my local hospital is 50% empty. Cannock Chase hospital was run down by the management of Mid Staffs to near closure, and half of it lies empty. Any building that is half empty has a sword of Damocles hanging over it, and no one from the Opposition complained locally as services were slowly stripped out by stealth over the past 10 years. As a result of the TSA process, Royal Wolverhampton Hospitals NHS Trust will take over running of Cannock hospital, increase utilisation from 50% to 100%, and invest £20 million in refurbishing it. That shows that the TSA process has been fantastic from a Cannock Chase perspective, even though it has been a stressful and drawn-out process.
I praise my hon. Friend the Member for Stafford for his tireless work on this issue and for his technical and clinical knowledge of local services, which is second to none in the House. His campaigning has led us a long way from the point at which A and E, maternity and paediatrics would all be closed, which is a hell of a legacy of public service to the people of Stafford who, I am sure, will return him at the next election for a second term—one which I hope is not dominated by the issue of Stafford hospital, as his first term has been.
As we know, the Government introduced measures in the Care Bill as their legislative response to the Francis inquiry. Those measures include the introduction of Ofsted-style ratings for hospitals and care homes, creating a single regime to deal with financial and care failures at NHS hospitals, introducing a duty of candour, and making it a criminal offence for care providers to give false and misleading information about their performance. It may surprise many that those measures do not already exist. Local parents in my constituency send their children to schools in Cannock that have an Ofsted rating, and they can speak to teachers about any documented problems in the school. Those same parents take their elderly relatives to Stafford hospital and are surprised when they receive appalling care—indeed, some even die suddenly—because there is simply no clear ranking of how that hospital is performing as there is for their children’s school.
Worse still, nursing management and staff had actively been covering up the problems. As we have seen locally, the events at Mid Staffs clearly demonstrate that a culture had been allowed to develop in the NHS in which defensiveness and secrecy were put ahead of patient care. Think about that for a moment: they were put ahead of patient care. In the 21st century, is that not a damning indictment of an institution that was set up to improve the health of its people, but has been encouraged over the years to protect itself and its reputation more than the people it exists to serve? I think that all Members should reflect on that before rushing to defend the reputation of the NHS. We should remember why the NHS exists: to serve the patients, not itself or any political party.
In the time available, I want to talk about two things: prioritising the patient experience and the TSA process. Before doing so, I think that it is worth remembering how we got to this point today. Macmillan Cancer Support’s briefing for this debate, which the hon. Member for Stoke-on-Trent South (Robert Flello) has already quoted, gets it spot on:
“The failure at Mid Staffordshire NHS Foundation Trust to put patients and their priorities at the centre of their work was a key finding from Robert Francis’ report… In particular, the report found that the trust prioritised its finances and Foundation Trust application over providing a high quality of care that put patients first.”
To quote a source that we on the Government side of the House all read regularly, the World Socialist Web Site:
“Under the 1997-2010 Labour government, Stafford was pressured to transform into a Foundation Trust—an initiative aimed at making hospitals semi-independent of the Department of Health by ‘freeing’ them to find private funding sources. In the process, £10 million was cut from the Trust’s budget and 150 jobs lost, leading to nursing staff shortages, overwork and the inability to provide a high-quality service to vulnerable patients. Any excess deaths at the hospital must be attributed to this shift.”
Does my hon. Friend recall—it might be difficult for him as he was not a Member of the House at the time, but perhaps he can refer to previous documents—that when the meeting on granting trust status took place, the then head of Monitor, William Moyes, asked the trust a series of 48 questions, of which 39 were about finance? In other words, that was the priority at the time. That is where things were going badly wrong.
I am grateful to my hon. Friend, who has a longer history in this House than I do, and indeed a longer future. He is right that finance was put far above patient care. People in Staffordshire are still astonished that the trust was ever granted FT status. I asked Robert Francis himself, and he said that he had no idea how, in the climate my hon. Friend has just described, that failing trust, which was bankrupt at the time, was able to shed staff for no clinical reason at all in order to achieve FT status, and that FT status was granted while all those problems were lurking beneath the surface. I would welcome any intervention from an Opposition Member to say why that was signed off.
The Conservatives are not alone in saying that Labour created a culture of targets in the NHS that led to thousands of unnecessary deaths at Mid Staffordshire hospital. It is also being said by the World Socialist Web Site and by independent charities such as Macmillan Cancer Support, which says that the trust prioritised its FT application over providing high-quality care that put patients first. Let us be clear what that means. The management of the Mid Staffs trust shed 150 nurses, many of them my constituents; it sacked them from their jobs, which were clearly vital, given the appalling care that followed, simply to hit financial targets. Those financial targets were not due to budget constraints—to be fair to the previous Labour Government, they did not reduce the NHS budget in Staffordshire. The job cuts were made deliberately to meet an aspirational organisational form. What a strange position to arrive at in the 21st century, where management think that it is acceptable to shed necessary nursing jobs simply to achieve an organisational form, as though that is in some way more important than serving the health needs of patients.
The Francis report is so important because it states for the first time: that the patient, not a foundation trust application, should come first; that there should be a statutory duty of candour, rather than a culture of cover-up; that feedback from patients should be valued and listened to, not ignored, as was the case in Stafford; and that hospitals should be rated, as Ofsted rates schools, and publicly assessed so that patients can make informed choices about their care.
The figures show that NHS care has changed for the better just one year on from the Francis inquiry. The 14 hospitals now in special measures are slowly being turned around, with 650 extra nurses and nursing assistants hired, strong leaders installed and 49 board-level managers replaced. Some 2,400 extra hospital nurses have been hired. Since May 2010, 3,300 more nurses and 6,000 more clinical staff are working on NHS hospital wards overall and—this is the crucial figure—nearly 1.6 million patients have given direct feedback on what they thought about their treatment through the friends and family test.
There is clearly a shift of priorities going on within the NHS, which is to be welcomed, but it would never have happened were it not for the Francis inquiry—an inquiry, of course, that would never have happened under the previous Government. I repeat my earlier point about the importance of not protecting the reputation of the NHS as an institution, but above all else focusing on the care of the patients that it exists to serve.
I think that there has been an extraordinary degree of cross-party support from all Staffordshire MPs for efforts to get the matter on the agenda. When we look at the initial inquiry called by the Labour Government, its extension and then its translation into a full public inquiry by the current Government, and when we consider how quickly we as parliamentarians need to ensure that we hold the Government to account, we must recognise, as the hon. Gentleman says, that it has taken an extraordinary amount of time to get this debate.
At the heart of this debate is the need not only to discuss something that affects the whole country and Wales, as we heard from my right hon. Friend the Member for Cynon Valley (Ann Clwyd), but to see what lessons the three inquiries have to teach us. One of the Francis report’s main recommendations is that it is also for Members of Parliament to question ourselves on how we hold our own trust boards to account. In a way, we need the ammunition to be able to do that. I know that the previous Member for Stafford genuinely tried to get answers on what was happening at the time from the then trust board, but those answers were not forthcoming.
If I understand the situation correctly, the previous Member for Stafford was lied to when he tried to inquire about those issues. How on earth are Members of Parliament, with the scant resources available to us, supposed to get to the bottom of things when we are being lied to?
That encapsulates the problem of Members of Parliament trying to get to the bottom of what is happening but being denied the information. I think that the main thrust of the report is a call for transparency and openness, for freedom of information, so that we can get informed decisions being made at local trust board level on the future direction of policy. The issue is how that is constrained by the available finances. One regret is that the finances do not come into the Francis report to the extent they might. We know that at the local level those in charge of health services are trying to ensure that they deliver a service within the financial constraints.
It may surprise the hon. Gentleman to know that I agree with him, and that the target culture has a lot to answer for. We have moved on from that now, and we are looking at how to achieve the best possible health care within the available resources. As my right hon. Friend the Member for Leigh (Andy Burnham) said, it is important to have integration, cross-cutting services and collaboration. We must move on from the target culture to look at the best possible way to achieve high standards of service throughout the country and stand-alone services in localities.
I want to put on the record my concern that lives were destroyed and that many people and their families were severely affected by what happened as a result of the systemic failures in the Mid Staffordshire NHS Foundation Trust, and specifically at Stafford hospital. There are many lessons to be learned, and we owe it to them to ensure that we move on and get the right hospital services.
For the record, may I say that at the time I supported the call for a public inquiry? I say that from these Benches.
Whatever the mechanism, the heart of the matter is that we must learn the lessons and move forward. It is right to debate the broader issues, values and culture of the NHS. We must recognise that an integral part of that is the procedures to deal with a failing hospital. As we assess progress on the implementation of the Francis report, it is vital to hold the Government to account for their handling of the parallel process—the trust special administrator’s report. It is essential for those of us in Staffordshire to have clarity from the Secretary of State—I am sorry he is not in his place—on future arrangements for health care in Stafford. That is what most concerns me and I shall concentrate my comments on that.
Reference has been made to how fit for purpose the trust special administration process is. Is it just about finances, or is it about the broader health care that should be provided? Changes are being introduced in the Care Bill, which will come to the House on Monday. The Government must address how stuck we are with the TSA and the TSA reports, and whether they are broad enough to deal with breakdown and failure in individual hospitals. Obtaining a resolution on how current hospital services in Staffordshire are being taken forward is urgent. That is part and parcel of how we take forward the lessons that the Francis report identified.
For me, the most important paragraph in the Francis report’s terms of reference is identifying
“the lessons to be drawn from that examination as to how in the future the NHS and the bodies which regulate it can ensure that failing and potentially failing hospitals or their services are identified as soon as is practicable”.
On the trust special administrators, we should aim to identify what needs to be done in advance of a hospital failing. In Staffordshire, we are stuck with a procedure. A report was carried out and sent to Monitor, and there was public consultation, which took place only in the Mid Staffordshire area. It is a great concern that when a hospital—in our case, the University Hospital of North Staffordshire—makes a proposal to rescue some of Mid Staffordshire’s services, there has been no corresponding consultation in that area about the impact of the changed configuration of health services in north Staffordshire. That is a real failing and the Government should take it on board.
My hon. Friend is being generous with her time. There is an issue, which the hon. Member for Cannock Chase (Mr Burley) talked about, of work going across to that hospital. The bizarre situation is that different treatments are at cost, more than cost or less than cost. It may be the case that work that ends up at the University Hospital of North Staffordshire is below-cost work, and that work that ends up at Cannock is above-cost work, so they will be a disparity in funding.
My hon. Friend makes a good point, and I see nods on both sides of the House. We have a tariff system and there are extra needs in more vulnerable and deprived areas. The nonsense in accident and emergency services is that hospitals are criticised and penalised for treating too many patients when we have seen how GP appointment systems are breaking down. That goes back to the recommendation in the Francis report that NHS provision should be looked at in the round and in its entirety. The trust special administrator just looks at the detailed finances and the assumptions that underpin the finances. That is wrong, and that is what we should concentrate on.
Does the hon. Lady agree that there is a serious problem with acute tariffs that have generally been cut by 4% in real terms every year, and have been for some time under this and the previous Government, compared with the tariffs for elective cases that seem to result in much more profitable work for hospitals? The more acute care a hospital provides, which is vital for the local population, the less likely it is to be financially sustainable.
I agree, and in the many meetings that north Staffordshire MPs have had with the University Hospital of North Staffordshire, the hon. Gentleman has made that point, as we all have frequently. We have also said that it is incumbent on us to relay that to the Government, because unless there is a shift and some recognition that the funding assumptions are flawed, no matter who is on the trust board of any new hospital, they will never be able to provide the necessary genuine health care.
I am sorry that I could not be here at the beginning of the debate because of other commitments. Will my hon. Friend pay tribute to the willingness of the University Hospital of North Staffordshire to engage with all MPs across party to resolve the situation? Should we not recognise that in ensuring arrangements for financial stability, there is still a gap of some £15 million to be bridged to ensure that we can proceed on the basis of stability that is needed for the benefit of everyone in north Staffordshire and Stafford?
I am conscious that many hon. Members want to speak. My hon. Friend has pre-empted two points that I want to make, so I will go straight to them.
If we accept that it is the trust special administrator’s report that is taking us forward in north Staffordshire in respect of the application by the University Hospital of North Staffordshire to take over Stafford hospital, there are two aspects to consider. The first is that there is a revenue shortfall of £4 million; and secondly, there is a capital shortfall of £29 million. I raised that matter at Prime Minister’s Question Time last week without realising that I was doing so prior to the written statement having been made available to the House of Commons. It is vital that the Government recognise that this gap must somehow be closed as the University Hospital of North Staffordshire moves forward, possibly under a new name, in taking on responsibility for this. In looking at the figures that have been put forward by the very diligent and committed directors and staff at UHNS, it is vital that the Government take account of the fact that in making a bid to take on services, those people know what they are doing, they have the expertise, and they know what changes will be needed for capital investment in Stoke and in Stafford. The gap should be closed; otherwise, Stoke-on-Trent will end up paying for the cost of bailing out Stafford hospital.
Will the hon. Lady kindly explain to those of us who are not Staffordshire colleagues what the relationship is between the trust special administrator and the clinical commissioning group? It is helpful to try to understand who is running the NHS in Staffordshire, because what is happening there today may well happen in Oxfordshire tomorrow.
It was suggested earlier that we might need a special debate, at length, solely on the trust special administrator, so that we can look at how this is being resolved in Staffordshire, and I would agree with that. There was also a suggestion in a previous debate that we need a debate solely on the Care Bill and its implications for changing that. Lots of different things are going on in parallel, but not in an integrated way. The real failure would be for the Government to allow the two procedures to go forward without understanding the changes made in the Health and Social Care Act 2012 which shift all the responsibility from the Secretary of State down to the commissioning bodies.
The hon. Gentleman is absolutely right. Here we are again trying to find some way of having a centralised Government system, when no matter what anybody says to the TSA or to anybody else, if the local commissioning group chooses not to go ahead and commission the services that the TSA has identified and the Government have said will be funded, those services will not be provided. I cannot understand how we are in this situation where we are not looking at all the implications of what is happening.
When the Government announced last week in a written statement that they had accepted in full the recommendations of the TSA’s report, I expected that, as a result, the UHNS would proceed quickly to implement what had been agreed in the hope that there would be a process to close the funding gap in one way or another.
The problem that I wish to give back to the Government and ask them to comment on in detail—the Secretary of State has had a detailed letter from me about this—is the uncertainty that arises as a result of the comments that were made by the Prime Minister and in a statement about obstetrics-led and consultant-led maternity provision in Stafford. On an emotional level, I absolutely agree that, as my right hon. Friend the Member for Leigh and the hon. Member for Stafford (Jeremy Lefroy) said, we need maternity services in situ that are easily accessible, and not only in Stafford but right across the country. However, my head says that the detailed financial arrangements that we currently have for maternity provision and the model that is apparently proposed do not allow for that kind of option.
We are therefore in a situation whereby people are, rightly, campaigning to have maternity services close to where they live, but the rigid procedures laid down either nationally or locally do not permit the additional funding for that. This is not just about having additional funding but about capacity in the form of trained, expert people able to deliver those services. If neither the funding nor the capacity is there, there is no point in any amount of hoping that we can have such maternity-led services in small district general hospitals, in whatever part of the country. The Government have to address that, but they cannot do so as part and parcel of the way in which they are taking forward the new configuration of health services across north Staffordshire. When the Minister replies, I want a very detailed response to the questions that I have asked the Secretary of State and given to his office, as he is aware; I am grateful for that.
The MPs concerned have met the Secretary of State and the Prime Minister to try to get some clarity on this. Until we get clarity, we cannot proceed to deal with the situation that we now have across mid-Staffordshire and in north Staffordshire. When is NHS England going to report on the further review? May we have a detailed time scale for that? To what extent will that delay the possibility of the UHNS board taking forward the new services? Already, 14 extra ambulances a day are bringing people from Stafford to Stoke-on-Trent, and staff are leaving Stafford hospital. We desperately need certainty about how this is being taken forward. When the Minister replies, the Government must set out in detail how they expect to be able to accept the TSA’s recommendations in full and then add an addendum without there being any mechanism to enable it to be implemented.
Does my hon. Friend agree that the Francis report is all about patient safety? What happened at Stafford is a blot on the history of the NHS from a patient safety point of view. North Staffs hospital has reopened beds to cope with the crisis in A and E and admissions on the grounds of patient safety and therefore already has a deficit. The overriding concern of patient safety must mean that any solution for Stafford involving North Staffs has to be financially stable.
I agree that the Francis report is absolutely about patient safety. It is also about financial viability. Unless the Government respond very speedily, set all this out in detail, and arrange for there to be proper talks on it, there is a real danger that we could end up transporting the tragedy that happened in Mid Staffordshire elsewhere. We need urgent clarity on this at the earliest possible opportunity.
Other aspects that I wished to raise include the whole issue of special needs and the way in which Staffordshire county council is closing down day service centres without having had a proper assessment of what is needed, putting added strain on hospitals. That comes back to the points made in the Francis report about integrating services, and so on and so forth. If this debate means that we can at least get some clarity about the position with regard to the UHNS taking forward services at Stafford hospital, then it will have been worth while.
Order. Before I call the next speaker, although this debate is due to run until 7 pm and obviously there will need to be time for the winding-up speeches, at the moment Members are speaking for 20 minutes or more. We will simply not have enough time to get everybody in if each Member speaks for that long. I am not proposing to set a time limit now, but I ask Members to give some consideration to their colleagues. Watch the clock—this is not a criticism of any previous speakers—and try to come in somewhere between 10 and 15 minutes, which is ample time. If that fails, I am afraid we will need a time limit, but I do not propose one at the moment.
I will certainly watch the clock very carefully, Madam Deputy Speaker.
I want to pick up on one or two of the contributions that have already been made, particularly that by the right hon. Member for Cynon Valley (Ann Clwyd), with whom I agree about statistics. Given how much reliance we need to place on some of the absolutely key statistics about mortality, the manner and timeliness of their collection and publication, and the certainty with which we can then act, are very important.
The hon. Member for Stafford (Jeremy Lefroy) made a fantastic speech; it was very thoughtful indeed. His comments about the need to listen to individual stories and complaints, which is absolutely key, were echoed in subsequent contributions. It is also important, as he said, for chief executives to see and sign responses to letters of complaint and, indeed, for boards to be much more clearly sighted on, and open to, such issues. He also made it clear that it is absolutely key to join the dots between individual cases in order to identify, challenge and take cases forward.
The hon. Member for Stoke-on-Trent North (Joan Walley) made some very important points about the TSA process, which I think we will come back to next Monday or Tuesday. There are issues about how that system has always operated, how it is evolving and how it is being used, and we need to be clear about what should happen before a TSA process even starts. There are too many examples of the NHS not being very good at changing services and making compelling cases to the population. Too often, the case is made behind closed doors and then sold as a finished product to the public, rather than being co-designed by the public and stakeholders such as hon. Members, local councillors and many others. Until the NHS has a culture that is open to that sort of approach, we will always wind up with a crisis in administration, health care or finance that gives the pretext for triggering a TSA process. For those reasons, the hon. Lady is right to raise the issue.
I cannot, because of what Madam Deputy Speaker has said.
My main point is about mental health. It is important that we discuss mental health in the context of Francis, because in their response the Government said:
“Whilst this poor care was in a hospital, poor care can occur anywhere across the health and social care system.”
That is absolutely right and we need to keep it in mind. I very much support the work the Government are doing to change the culture and to have more openness and compassion, and I think that an ethic of learning is part of that.
I want to focus on mental health because we could be in danger of missing it out in all this. I am convinced that there remains an institutional bias in how mental health is treated, and that needs to be tackled. We still have a long way to go to deliver the parity of esteem that this Government have put into legislation, that we have established in policy and that is now accepted, I think, as what we should all aspire to.
Francis talked about
“an engrained culture of tolerance of poor standards”,
which the issue of mental health throws into stark relief, including premature mortality figures that show a huge gap in life expectancy for those with severe mental health problems; the fact that only one in four people with mental health problems receives any treatment; and the absence until next year of waiting time targets, standards, choice and proper measurements for mental health.
The NHS has always treated mental health as a poor relation to physical health and it has a long way to go to catch up, but I welcome the fact that this Government are taking some of those steps. We need to take them as rapidly and as sensibly as we can. Another example is the routine failure to provide NICE-recommended treatments. The iniquity whereby some things are “must dos”, while others just become nice NICE things to do, cannot be right and must be changed. It is good news that my hon. Friend the Minister of State is leading work on changes to standards.
Francis talked about a failure to put patients first in everything that is done. We see that with the 7,700 people who end up in a prison cell, which they call a place of safety. The most recent figures include 41 children, which is a shocking indictment and is surely unacceptable. I just wonder whether the time has come to consider whether to attach a sunset provision to the use of powers under section 136 of the Mental Health Act 1983 so that, over the next three or four years, we work towards no children finding themselves in a prison cell because of a mental health crisis and, in due course, no adults finding themselves in a prison cell—
I am grateful to the Minister for correcting the record from a sedentary position.
There were 350 children on adult wards in 2013-14, including one as young as 12, and the use of restraint has been at a high level. I know that the Minister for care services is championing changes in that area. I very much welcome his leadership on the crisis care concordat. It is very important that the CQC leads on regulation to show that it is not just words, but will be backed by regulatory teeth.
The culture change also needs to be about listening to patients. The evidence again suggests that there is still a long way to go. The Care Quality Commission has found that a quarter of care plans showed no evidence of patient involvement. That cannot be right, whether for a long-term physical health condition or a mental health problem.
We have only just had a tariff for mental health. When I arrived as a Minister with responsibility for it, I found that the task of producing tariffs had already taken five years, having dragged on and on. Yet because of the difference in how we funded mental health services, it was easier to cut them in the past. The picture of spending on mental health is rather more nuanced than it is sometimes portrayed in debates in this place.
Given all that, we might have expected NHS England to ensure that its response to the Francis inquiry and to the Government response recognised that poor care can occur in mental health as well. The chair of NHS England, Malcolm Grant, has put his name to the statement of common purpose that prefaces the Government response to Francis. Yet NHS England has ignored this Government’s mandate to it to deliver parity of esteem. NHS England’s financial experts do not get it: they are delivering Francis’s agenda simply for the acute sector, and taking money away from mental health services through adjustments to how payments are made for them. That cannot be right. I know that the Minister agrees with me, but doing so is not sufficient: there must be a challenge to NHS England’s decision to take away money from mental health, given that both sectors need to make progress and to take steps to deal with the Francis agenda.
I just want to alert my right hon. Friend to the fact that David Nicholson, the chief executive of NHS England, has made it clear to area teams and therefore to clinical commissioning groups that they must take parity of esteem fully into account in financial settlements with mental health trusts. That clarification of the importance of parity of esteem on finances is critical, and I hope that he welcomes it.
I very much welcome that and what the Minister says.
The reason I have raised issues about mental health in this debate is that it would be a mistake for Members to see Francis simply through the lens of acute hospital care. As the Government said in their response to Francis, we need to be concerned right across the piece. That is why I make no apology for focusing my speech on mental health, and why I hope that the Government will continue to drive an agenda of parity of esteem and make it a reality.
I will focus on the impact of the Francis report on my local hospital in Tameside.
Tameside hospital has been a major issue for me, as the MP for Stalybridge and Hyde, and it featured prominently in my election literature in 2010. At the general election, I pledged to work with my hon. Friends the Members for Denton and Reddish (Andrew Gwynne) and for Ashton-under-Lyne (David Heyes), to resolve what we believed to be the serious problems at Tameside hospital by building on their work and statements in the previous Parliament. Securing improvements at the hospital has been a priority for all of us and it will continue to be so. The stance that we have taken, combined with the work of Sir Bruce Keogh, has allowed genuine improvements to take place at Tameside and I am proud of that work.
I regret the journey that there has been in this Parliament towards making Francis a more partisan issue. The Prime Minister’s initial statement on the matter was quite admirable and the work of Sir Bruch Keogh offered a way forward for problem hospitals such as mine. We all stand to lose that if we try to game it for partisan advantage. There is a feeling that the Government have tried to obscure the unpopularity of the NHS reorganisation by doing so. Surely we can all agree that the two matters should not be conflated.
I love the NHS, but I love my constituents even more. If any institution is letting them down, I will not hesitate to call it out. I believe that that is true of all my Opposition colleagues.
The recommendations of the Francis report were, without doubt, an important contribution to improving the quality of health care in England. The circumstances that led to the creation of the Francis inquiry threatened to undermine public faith in the NHS, and a serious and independent investigation into those factors was crucial to maintain people’s trust in the NHS. That investigation was begun by my right hon. Friend the Member for Leigh (Andy Burnham), in whom I have tremendous faith.
The stories of poor care at Mid Staffordshire and other NHS trusts were indefensible and often heartbreaking. I hope that we never see such instances again in the NHS. However, it is important that we also take this opportunity to commend the thousands of doctors and nurses who work tirelessly to provide people in this country with the very best of care. The people who work for the NHS, including those from overseas who choose to come and work in the NHS, do an incredible job and they must always know that we appreciate them greatly.
Following the publication of the Francis report, my local trust, Tameside Hospital NHS Foundation Trust, was one of five trusts that were investigated by Sir Bruce Keogh. It was not the work or recommendations of the Francis inquiry that were of the most immediate significance to my area, but the fact that the publication of the report sparked a chain of events that had a significant impact on the delivery of care at the local hospital in Tameside.
At the time of publication, Tameside had the second worst record for hospital deaths. Data from the summary hospital-level mortality indicator showed that 18% more patients than expected died at Tameside in the 12 months leading up to June 2012. The standards of care at the hospital had been of concern to the public for some time. I should perhaps mention that the information on Tameside hospital was complicated by the legacy of the crimes of Harold Shipman in my constituency. That had a huge impact on how people thought about care at the end of their life and on where they went for that care. That was always a plausible excuse for the mortality scores, but there was a need to push past the excuse and discover the real causes.
In the light of those problems, I cited my concerns about aspects of care at Tameside hospital on the record on several occasions, acting in conjunction with my hon. Friends the Members for Denton and Reddish and for Ashton-under-Lyne. We had already called for the resignation of the trust’s chief executive so that the hospital could improve.
The problems at Tameside were indicative of the broader issues that Francis and Keogh were attempting to address. The confidence of the local community in members of the senior management team had all but disappeared. That led to problems often not being adequately addressed or even acknowledged. The hospital became defensive and saw the issue as one of public relations management, rather than service improvement.
There is a fundamental point that we must grasp if we are properly to understand what factors contribute to the level of public trust. People understand that mistakes are sometimes made. That is the case in all professions and walks of life. However, people cannot understand it—and nor should they—when mistakes happen but no serious attempt is made to address the concerns of patients or clinicians in an open and transparent way to resolve the issues.
Sadly, that is exactly what happened for too long at Tameside hospital. In the worst cases, the hospital management actively tried to downplay the problems raised by patients, family members, elected representatives and even, in some cases, each other. That behaviour is not acceptable and a failure to address it undermines public faith in the NHS.
Putting the spotlight on these hospitals has had some success in breaking through this culture, and Tameside now has a clear set of objectives on which to develop a strategy for improvement. Without the Francis report and the subsequent work of Sir Bruce Keogh, that long overdue process of improvement at Tameside hospital might not have happened. We as local MPs would still be calling for those changes to happen, but we would not have had the expert analysis that the process provided to back up what we were saying.
I am grateful to my hon. Friend for setting out the case. Does he share my confidence that the hospital has indeed turned a corner? Part of that is down to the buddying arrangements with the University Hospital of South Manchester in Wythenshawe and the excellent interim leadership of Karen James.
I endorse those comments entirely and thank my hon. Friend for his contribution. The negative attention that the hospital received as part of the Keogh investigation was undoubtedly the catalyst for the departure of the former chief executive in 2013, and the first step on the road to improvement.
It is important, however, for us to note the limits of Government’s capacity to push this agenda. Of course, Government have to be the ones who set the framework for improvement in the NHS, but cultural changes can properly come only from the front line. What Tameside hospital now has is a set of recommendations to be implemented, a framework for the delivery of those changes, and new leadership which, ultimately, will deliver the improvements that patients in our area need. I still visit the hospital regularly; indeed, I was there on Friday last week, and I am pleased to say that in my view it is certainly turning a corner. I hope the Government maintain their commitment to all the Francis recommendations, and ensure that the high expectations are hardwired into the NHS’s leaders.
Just before Christmas, I was walking my dogs in Stalybridge as usual, and a friend of mine whom I had not seen for quite a long time shouted over to me. He explained that he had been receiving treatment for more than a year at Tameside hospital. Over that time he had been able to witness, in his words, visible improvements to his care and to how the hospital was run and how it functioned, due to the changes facilitated by the Francis report, the Keogh inquiry and, I believe, the work of myself and my hon. Friends. We will not stop that work or feel self-satisfied because of it, but I am pleased that we have been able to make that difference. That, ultimately, is what we should all be trying to bring about by discussing the anniversary of the Francis report.
It is quite difficult at this stage in the saga—the tragedy—of Stafford hospital to recall how it all came about and the difficulties that those of us who experienced it had to endure, the patients and the victims in particular. There was complete and total resistance—indeed, worse than that, a granite-like refusal—to having a proper look at what was going on. It would take much longer than I have available this afternoon to explain exactly the tooth and nail battle that I had to engage in to get the inquiry in the first place under the Inquiries Act 2005.
In a previous incarnation as the Member for Stafford, I had already had Stafford hospital in my constituency for 14 years, from the date of a by-election some 30 years ago in May 1984. I experienced a tragedy in Stafford hospital during that time with legionnaire’s disease, and I came to this House and asked the then Prime Minister, the late Margaret Thatcher, whether she would give us a full public inquiry—equivalent to one under the provisions of the 2005 Act. I did that because I knew it was impossible to get to the root of what was going on unless we had such forensic evidence, with cross-examination on oath and all the other—not paraphernalia, but necessary ingredients as part of the process, to ensure that we could bring to light what was required.
I was absolutely astonished that successive Secretaries of State completely refused, point-blank, to have such an inquiry in the case of Mid Staffordshire. I have to put it on record that the right hon. Member for Kingston upon Hull West and Hessle (Alan Johnson), who is not even in the House this afternoon—perhaps he has some excuse or justification—was the Secretary of State during a lot of the time in question. Patricia Hewitt was also Secretary of State for part of the time when serious problems were going on. The right hon. Member for Kingston upon Hull West and Hessle refused to have a public inquiry. The right hon. Member for Leigh (Andy Burnham) also refused to have an inquiry of the 2005 Act type. Although it is certainly true that he agreed to a Francis inquiry, and that there was also the Alberti report, the Colin-Thomé report and one or two other investigative exercises, none of them had the right ingredients to give them the capacity to get to the root of what was going on.
I am delighted with what my right hon. Friend the Secretary of State has done since then. I was extremely glad that, when we were in opposition, I was able to overcome some resistance to a 2005 Act inquiry from shadow Ministers. The current Prime Minister, then the Leader of the Opposition, listened to the arguments that I and others made and agreed to have a full 2005 Act inquiry, because he understood how important it was, as the Secretary of State does. The consequence has been to enable us to make changes throughout the entire health service that, as Opposition Members have acknowledged today, have enabled us in Staffordshire to be a pathfinder for solving some, if not all, of the problems presented in the health service.
The work of Cure the NHS has included that of my constituent Deborah Hazeldine. She does not get a great deal of publicity, but she was the one who came to me in my office in December 2008, with Julie Bailey, and explained that they were getting nowhere with the complaints and concerns that they were expressing. They asked what could be done about it, and I explained to them that if they did certain things, I thought we would be able to get a campaign moving of the kind that would be needed to get a 2005 Act inquiry. I pay tribute to them, and to Ken Lownds, who has been a tower of strength. He is a man of enormous integrity, knowledge, skill and commitment. I pay tribute to him for what he did to ensure that we got the inquiry, for the evidence that he gave to it and for his continual determined input into improving the health service since the Francis report was produced.
I am delighted that the Francis report came out as it did. It had, I believe, 299 recommendations, and it has been immensely important to the future of the health service. I do not need to go into all the details, but I pay tribute to my hon. Friend the Member for Stafford (Jeremy Lefroy), my next-door neighbour, with whom I worked closely from the beginning. He committed himself to a 2005 Act inquiry when he was in what could be described as the delicate situation of being about to become the Member of Parliament for Stafford but not entirely certain that it would happen. He did it, and he was right, and I pay tribute to him for everything that he has done since.
I am grateful to my hon. Friend for his generous comments. While he is paying tribute to people who have played an important role in getting us to where we are, may I add my thanks to Deborah Hazeldine, and also to Ken Lownds, who was the first person who really talked to me about the important concept of zero-harm health care? I know my hon. Friend will not mind if I also mention campaigners from other hospitals, such as James Titcombe in the case of Morecambe Bay, who have also played an extremely important role in the debate.
I am extremely glad that my right hon. Friend has made that point. The zero-harm policy is so important, and I am grateful for that specific intervention. It will make Ken Lownds’s day. I also pay tribute to people all over the country who have taken up the message and sought to improve the health service in their areas. This has turned into a national campaign, and the Secretary of State deserves great credit for the way he has helped to co-ordinate it.
I was, and remain, completely amazed that the right hon. Member for Kingston upon Hull West and Hessle, and Patricia Hewitt, were not even asked to give evidence to the inquiry. I still find that completely staggering to my way of thinking. I know that the right hon. Member for Leigh was asked to give evidence, and did, but I place the point on the record because I found it extraordinarily difficult to understand then, and I still do now.
I have constantly and repeatedly called for the resignation of Sir David Nicholson. I know he is retiring soon and that that resignation will not happen, but I repeat my concern, as I did in evidence to the inquiry, because the whole target-based policy was very much tied up with his approach to these matters. Indeed, in the last of, I think, about 600 paragraphs of his evidence to the inquiry, he referred in the last two lines to the fact that the Member of Parliament for Stone, Mr Bill Cash, had raised the question of his involvement in target-based policies. He said that there were arguments on both sides of the equation regarding target-based policies, but I do not agree with that. I do not think target-based policies were the right way to go, and I am glad that the hon. Member for Stoke-on-Trent North (Joan Walley) agreed with me. As I pointed out in my evidence to the inquiry, such policies had a terrible effect on the attitude of Monitor regarding the financing issues that provided 39 of the 45 or so questions put by William Moyes to the foundation trust when it received its approbation—something it should never, ever, have got. I say to the right hon. Member for Leigh that through the mechanism of the Department—I cannot point precisely to chapter and verse—the fact that the foundation trust got such status was also the product of a misjudgment by the Government at the time.
I have already referred to correspondence in an intervention, but in the prime ministerial guidelines of 2005, under the previous Government, it was clearly stated that when Members of Parliament write to Secretaries of State and other senior Ministers, they are entitled to receive a full, comprehensive response—personally—from that Minister. I found that wanting during this process. I was glad to note, however, that in the course of evidence to the inquiry, the situation moved from what appeared to be resistance to going down that route, to an acceptance that—to paraphrase from the evidence given by the chief executive of the Department of Health—from now on, when a Member of Parliament writes with a letter from a constituent, and explains that things have not gone properly regarding that constituent’s health problems, there is a mechanism to ensure that the issue is dealt with properly. I will not have to go into all that today, because it has been rectified.
In my evidence, I also raised the issue of whistleblowing. I also tabled amendments to the then health legislation, calling for the repudiation of gagging clauses and providing that any chief executive who endorsed them and got his legal advisers to agree to them should be dismissed. That is another area that has been dealt with, so we are making progress. I very much endorse the views expressed on both sides of the House about having unity across the Floor of the House, as far as we can achieve it, on the central principles.
I agree with what my hon. Friend the Member for Stafford said about the issue, although I have a difference, not of opinion but of emphasis, because my constituency is very rural, and access to the artery of the M6 is not easy. It can be difficult to reach, especially at night, because it can be a long way through small rural lanes, to access the M6 and the University hospital of North Staffordshire or hospitals in Wolverhampton. That is my caveat on that.
We have made enormous progress. I am glad that the Mid Staffs foundation trust is being dissolved, and that—as my hon. Friend the Member for Stafford said—the Prime Minister, at a recent Prime Minister’s questions, backed plans, in as many words, for consultant-led maternity to continue at Stafford hospitals. That service, plus paediatric services, critical care and a 24-hour emergency service, is necessary for constituents in Stone and the rest of Staffordshire. I will work with my hon. Friend to ensure that that is delivered.
That point will have been taken on board by the Secretary of State, who is in his place. One of the good things about the present Secretary of State is that he does listen. He takes things on board and follows them up. Some Secretaries of State do not always do that—they nod, but they do not necessarily do that.
I pay tribute to the hon. Gentleman for his persistence, and to the work of the hon. Member for Stafford (Jeremy Lefroy), who was elected only in 2010; this has been the dominating subject of his time in the House.
As well as concerns about the length and cost of the administration process, the University hospital of North Staffordshire has raised concerns that it has not been able to do its own full due diligence at the same time. We cannot quite put our finger on whether that has been because of the administration process or concerns about competition. Does the hon. Gentleman agree that when such situations arise in future—and hopefully that will be rarely—we will need to speed things up in a collaborative way and that competition issues will not surface?
I am concerned that there should be a maximum degree of co-operation and collaboration, and perceptible unity has been demonstrated across the Floor of the House on the question of achieving co-operation in the national interest. It is extremely good that that is happening. This is not just about us as MPs; this is much, much more important. This is about victims, patient care, zero harm and people having confidence in the health service. It is absolutely essential that across the Floor of the House we achieve the maximum possible amount of collaboration on this matter.
I wrote to Mr Francis in July 2009 to ask for an inquiry under the 2005 Act, and expressed my concerns regarding the Healthcare Commission investigation at that time. In fact, in that January I had submitted a list of questions, which I had put together with Cure the NHS, Ken Lownds, Julie Bailey and Deborah Hazeldine, to ask what the Healthcare Commission was going to do by way of a report. The HCC reported in March and I hope that our intervention at that point was helpful. If those questions had not been asked, I am not quite sure what the HCC would have said. I was concerned that the reviews by Dr Laker, Professor Alberti and David Colin-Thomé were not as independent as I felt they should be. That is what led me to step up my campaign for the 2005 Act inquiry, for the reasons I gave at the beginning of my remarks.
I pay tribute to all those, from all parts of the House, who have helped to address the matters with which the Francis report has so ably dealt. I remain concerned that some people who should have given evidence were not called to do so, but we now have the report. At long last, after calling for a debate on, I think, 15 occasions, we are holding it. I am absolutely delighted that we are making progress nationally to improve the national health service. Long may it continue.
I want to talk about the Francis report, which detailed failures that were a betrayal of NHS values—we have heard repeatedly about those failures in this debate—but before I do so I will speak briefly about NHS change day, which shows so much that is good about the values of the NHS.
This week saw the second NHS change day. It is a front line-led movement, the largest of its kind, with the shared purpose of improving health and care. Its mission is to inspire and mobilise people everywhere—NHS staff, patients and the public—to do something better together to improve care for people. Hon. Members have until 31 March to make pledges for NHS changes, and it may be that Ministers and shadow Ministers will want to adopt some of them. Some inspirational pledges have been made that are making a real difference to care. An example I like is the “Hello, my name is...” campaign by Dr Kate Granger.
In December 2012, Dr Kate Granger was herself an in-patient, and she noticed how infrequently health care professionals introduced themselves. She wrote:
“As a healthcare professional you know so much about your patient. You know their name, their personal details, their health conditions, and much more. What do we as patients know about our healthcare professionals? The answer is often absolutely nothing, sometimes it seems not even their names. The balance of power is very one-sided in favour of the healthcare professional.”
It might seem astonishing that a campaign to encourage health care staff to introduce themselves to patients is needed, but it is an important part of the change in culture that people are trying to bring about.
Some 390,000 pledges have been made for the second NHS change day. It will run to the end of March, so that figure might reach half a million. This is a very good movement inside the NHS to improve care, in addition to the important matters we are discussing today. It is valuable that NHS staff, patients and carers are making pledges to do just that.
It is clear that staffing is one of the most important issues in the Francis report. The report talks about
“a lack of staff, both in terms of absolute numbers and appropriate skills”.
A survey of nurses published by Nursing Times one year on from the Francis report found that more than half those surveyed believed that their wards remained dangerously understaffed. Indeed, 39% of those who responded warned that staffing levels had worsened in the past 12 months. Various numbers have been bandied about during the debate, but that is a key factor. Only 22%—a fifth—of the nurses surveyed reported an improvement. I think it notable that more than half said that their own wards were dangerously understaffed, because that is the same percentage as a year ago. If understaffing was identified as an issue in the Francis report, it is still an issue now.
I believe that one pledge that politicians can make to improve care in the NHS is a pledge to support the Safe Staffing Alliance. The fundamental standard is a ratio of no more than eight patients to one nurse; other key aspects of safe staffing are use of a management tool to work out the safe staffing levels and the publication of staffing levels so that they can be seen by patients and their families. Let me repeat what I have said to Ministers a number of times over the last year, now that they recognise that Salford Royal is an excellent hospital. Salford Royal works out minimum staffing levels with a management tool, and publishes actual versus planned staffing levels on whiteboards on the wards every day. Again and again, we hear about failures in hospitals that, like the failure at Mid Staffordshire, are related to understaffing and the awful position in which it puts nursing staff. In another debate on this subject, the Secretary of State said:
“Salford Royal is one of the best hospitals in the country and we should always learn from what it does”.—[Official Report, 19 November 2013; Vol. 570, c. 1107.]
I hope that he will now start to take his own advice.
People in Salford were thrilled when Salford Royal’s chief executive, David Dalton, was knighted earlier this year. I believe that that was well deserved, because Salford Royal and David Dalton have done a huge amount to improve patient safety and reduce mortality. In its report “After Francis”, the Health Committee said that it had
“been impressed by the approach of Salford Royal NHS Foundation Trust to the development of a staffing management tool. This appears to the Committee to be good practice, and the Committee recommends the adoption of this or similar systems across the NHS.”
Other Members have also mentioned that.
The Health Committee also said—we keep returning to staffing levels—that
“Ensuring adequate levels of both clinically- and non-clinically-qualified staff in all circumstances is therefore a fundamental requirement of high quality care, whatever the financial circumstances.”
As I have said, that is a key point. It is clear to me what should be done to ensure safe staffing levels—we have that excellent example—but it is also clear to me that the Government’s proposal for monthly publication of staffing levels is not adequate. Robert Francis is a convert to the position of the Safe Staffing Alliance and has said that minimum safe staffing levels should be drawn up by the National Institute for Health and Clinical Excellence and policed by the Care Quality Commission. He did not say that in his report, but he has subsequently said it to the CQC.
As we heard earlier in the debate, the Francis report was published as the Government’s NHS reforms took effect. It is clear that the structural changes involved in their unnecessary top-down reorganisation have caused upheaval and created new problems. Many Members have talked about restructuring decisions today. Those decisions are proving impossible to implement in many parts of the country, because there is no one really in charge. The chair of the British Medical Association, Dr Mark Porter, made that point earlier this year. Reorganisation costs are another problem, because they have taken money away from patient care. Change of that kind has not improved care in the NHS and has worked against the recommendations of the Francis report. As we heard earlier, the findings of surveys identify the problems that have been caused: seven out of 10 NHS staff members think that the Government’s reorganisation has had a negative impact on patient care, while only 3% think that it has improved patient care. That is a vote against what the Government have done.
Nothing makes the impact of the reforms clearer than the deteriorating performance of A and E departments and the crisis in recruitment to them. It is interesting to note the Public Accounts Committee report this week, which is in a very similar vein to that of the Health Committee. We know that more patients are waiting in A and E departments for longer than four hours: last year the figure was 1 million, whereas in 2009-10 it was only 345,000. The numbers speak for themselves. We know, too, that emergency admissions have increased by 51% in the past decade, with a 26% rise in admissions of over-85s in four years. That is serious: the biggest cause of pressure on local A and E services is the rising number of frail and older people with multiple long-term conditions.
Some Members have questioned the relevance of this to the Francis report, saying we should not be discussing all these issues, but I disagree. If we are concerned about safety and mortality rates, what happens on admission to A and E is a key factor. The consequences if things start going wrong was well understood by Salford Royal hospital: more people were dying unnecessarily at the weekends because of a lack of consultant cover, so the hospital changed that. Work on safety does not ignore what is going on in A and E or how much consultant cover there is; instead, it takes that into account and does something about it.
I am concerned that the number of frail older people attending A and E will continue to increase and that that situation will worsen as a result of continued cuts to social care budgets. We had a warning about that from Sandie Keene, director of the Association of Directors of Adult Social Services. She said
“it is absolutely clear that all the ingenuity and skill that we have brought to cushioning vulnerable people as far as possible from the effects of the economic circumstances cannot be stretched any further, and that some of the people we have responsibilities for may be affected by serious reductions in service—with more in the pipeline over the next two years.”
Unfortunately, excellent though our local hospital is, we are facing a situation where 1,000 people will lose their care packages this year, and I am very concerned about that.
The Francis report makes some recommendations on mental health, which is in the social care category. One of those suggestions was the training of family members to look after those with mental health conditions better at home, so as to improve their quality of life and help rehabilitate them. I do not see much of that in the report. Would the hon. Lady like there to be more emphasis on family members who are under pressure and are helping others with mental health conditions at home?
Indeed, and our most recent inquiries in the Health Committee are about mental health issues. There is a series of issues that need to be looked at. It is rare in a health debate for me not to mention carers. We need to be realistic about the fact that we are now putting a huge amount of pressure on those carers. Removing social care packages will affect our local hospital, but it will also affect those family members, because in the end who is the person who cares? It is the family member to whom the role falls.
To conclude the point about staffing issues in A and E, we found in our earlier inquiry that fewer than one in five emergency departments were able to provide consultant cover for 16 hours a day during the working week, and the figure is lower at weekends. The whole issue of mortality rates is very much linked to that, and we cannot ignore it. We must keep focusing on the problem with recruitment and the lack of consultant cover.
My right hon. Friend the shadow Health Secretary referred to the warnings by the president of the College of Emergency Medicine. During the time when the college was warning about these issues, Ministers were tied up in knots by the challenges of reorganisation. That is key. Ministers have insisted that they are acting now, but it is clear that those warnings from the CEM in 2010 did not get enough attention until recently. The staffing situation can hardly improve when so few higher trainee posts in emergency medicine are being filled. In the latest recruitment round, 156 out of 193 higher trainee emergency medicine posts went unfilled.
My final point is about the difficulties caused by the cost of the NHS reorganisation reforms. In the past few months the spotlight has fallen on unnecessary spending and waste. We all should be concerned about that. We know that emergency departments are spending £120 million a year on locums, and this could be getting worse. The Health Committee has also recently focused on redundancy costs, which have absorbed £1.4 billion of NHS funding since 2010, with £435 million attributed just to restructuring costs. The scandal of the scale of redundancy payments to NHS staff was made worse when we found out that such a revolving door was in operation. The Health Committee was told that of 19,100 people made redundant by the NHS, 3,200 were subsequently rehired by the NHS, including 2,500 rehired within a year and more than 400 rehired within 28 days. There were reports of payments of £605,000 made to an NHS executive whose husband also received a £345,000 pay-off, with both reported to have been subsequently rehired elsewhere in the NHS. That is a scandal. I know that the Minister said it would not happen again, but that is £1 million that could have been spent on patient care.
Will the hon. Lady give way?
I would prefer not to. That money could and should have been spent on improving staffing, particularly nursing staffing. Those patients and family members who have been let down by NHS failures, of which we have heard innumerable examples, deserve to know that everything possible is being done to avoid such failures in future.
Of all the things I have talked about, safe staffing is crucial, as is transparency and staffing ratios. We increasingly have to take on board the fact that there is a funding gap in both the NHS and social care. Indeed, the chair of the British Medical Association said in his new year statement that the funding gap in the NHS is so bad that if the NHS was a country, it would not have even have a credit rating. That is what we are facing.
No, I do not have time.
Given that situation, we have to learn that precious NHS resources cannot be wasted on reorganisation and redundancies any more, particularly where staff are being rehired. The NHS will reach its 70th birthday in 2018, so let us hope that all the measures we are talking about today, and the implementation of whole-person care under a Labour Government, will help it be in better shape.
Thank you for calling me to contribute to this debate, Mr Speaker. I am sorry that the shadow Health Secretary is not in his place. After repeatedly refusing to take any interventions from me during his lengthy speech, he said that I would have time to make my contribution later, and I wish he was here to hear it, because I will be referring to him and seeking his help and support.
I approach this debate with mixed emotions. I am extremely sorry about the need for the Francis report in the first instance and believe that there remain serious questions about why there was such a long delay before a thorough investigation took place into the lack of care and the misconduct at Mid Staffs. I pay particular tribute to my hon. Friend the Member for Stafford (Jeremy Lefroy) for his contribution earlier and for the role he has played in pursuing this matter right through to the end, and to my hon. Friend the Member for Stone (Mr Cash) for his contribution and for raising this matter from the outset. My heart goes out to those who suffered needlessly and to their families who campaigned for so long. It is also worth remembering that for every one person who went public and put their head above the parapet, there are probably tens who stayed quiet and are probably still silent on issues that will have affronted them.
On a positive note, I am pleased about the progress made over the past 12 months. I am also pleased about the strong action has been taken by the previous Health Secretary and by this one, and about the leadership and determination that the Prime Minister showed at the outset in 2010 in seeking to root out the issues. The present Health Secretary has taken direct action to ensure: that nursing numbers are published; that there is data transparency; that details on surgery outcomes by consultant will be available for inspection; and that named consultants will be available for older patients. Those positive interventions will make a significant difference and will go a long way to preventing any recurrence.
Ultimately, the staff involved deserve the credit for the change, but the Health Secretary has been key to being the patients’ champion. A culture has developed where we can rightly champion the NHS and can even question it. We have now come to a point where we can criticise the NHS without being seen as undermining it. All of the best organisations welcome feedback, particularly negative feedback, because it gives the best chance of putting problems right to prevent any recurrence.However, my mixed emotions are far more complex than that. As I see changes and improvements taking place in England, I remain concerned about what is happening to the national health service in Wales and the impact that that is having on my constituents. It is quite obvious from this debate that the concerns that have been raised are shared by Members on both sides of the House, which is something that we should view positively. However, I am not so sure that those concerns are shared in all quarters, especially by Members on the Labour Front Bench. Again, I must pay tribute to the right hon. Member for Cynon Valley (Ann Clwyd) for her determination and persistence in rooting out these issues wherever they occur—be it in Wales, Scotland, Northern Ireland or England.
It is fair to say that political points can be made about the cuts to the NHS budget in Wales, but I fear that the situation is even more serious and dangerous than that. Any criticism of the NHS in Wales is now dismissed as party political or politically motivated. It is the identical culture that existed at the time of the Mid Staffordshire crisis.
Only two weeks ago, my hon. Friend the Member for Bristol North West (Charlotte Leslie) discovered that Professor Sir Bruce Keogh, the NHS medical director in England, had last November written to his counterpart in Wales, Dr Chris Jones, raising concerns about the mortality rates at some Welsh hospitals—at six in particular. It has now come to light that that action was prompted by the right hon. Member for Cynon Valley. In the e-mail, Professor Keogh, who had investigated 14 hospitals in England for the same reason, offered his assistance. I have a copy of his letter here. It was not a criticism; it merely questioned the data and offered help should there be any need for further investigation.
There was no response from Dr Jones, which is worrying in itself. Most alarming, however, was the response from the Welsh Health Minister when the matter became public. Mark Drakeford rightly pointed out that simple comparisons cannot be made because of the different ways in which data are collected. However, in response to calls for an inquiry, he said that he was “coldly furious” and that it was
“a concerted political attempt by the Conservative Party to drag the Welsh NHS through the mud.”
He even had the audacity to accuse the NHS in England of being in crisis. He clearly felt that attack was the best form of defence. What worries me most is the blatant rebuttal without wider consideration. The politics appear to be more important than the patients. This was a letter from one clinician to another, yet it was a politician using every political tactic possible to undermine its contents.
A pragmatic approach would have been to point out the differences in the collection of the data and to have reassured patients. I suspect that the reality was that the Welsh Health Minister was responding in the full knowledge of all the other statistics on the NHS in Wales, such as those on waiting times and diagnostic delays, which could well contribute to higher mortality rates. Again, a pragmatic approach would have been to announce an investigation, or at least to seek out the root causes of the apparent high mortality rate according to the way in which the data were collected.
It is ironic that the Welsh Health Minister has today announced a change in the way the data are collected. Obviously, that is some shift, but I note that it has come out only after the political games had taken place. It is two weeks since my constituents were alarmed by the accusations that I had dragged the Welsh NHS through the mud.
In researching for this debate, I looked at recent cases that have become public in the NHS in Wales. There are troubling similarities with those that led to the Francis report. Lilian Hopkins received treatment from a local health board that treats patients from my constituency. For several days, a sign was left above her bed that said “Nil by mouth”. That left Mrs Hopkins too weak to lift a glass of water. Her prosthetic limb was not removed for two weeks, when she was left in bed for that time. Screams of pain at night were treated with sedation. At an earlier date, her family had asked for an investigation. It was promised, but not conducted. Three nurses have been arrested for falsifying records.
This is the same local health board where the police are investigating the circumstances surrounding a man who waited four hours in an ambulance outside the hospital, only to die at the same A and E department some hours later. The right hon. Member for Cynon Valley has listed several examples that I could refer to, but these are examples that I have picked up in the past couple of weeks.
The Royal College of Surgeons published a report last July that claimed that 152 patients have died over the past five years while waiting for cardiac surgery across two local health boards alone in Wales. The royal college also stated in its report that 2,000 cardiac operations were either cancelled or not scheduled between January and March last year. The report says that south Wales is the only part of the UK where patients are regularly dying on cardiac surgery waiting lists. It says that the provision of urgent and emergency surgery is simply inadequate.
I should like to be able to report that the situation has improved since the publication of that report last July, but it has not. Some patients are now being sent across the border to England to be treated in the independent sector, which strikes me as emergency action; instead, attempts should be made to identify the culture and issues that potentially parallel the Mid Staffordshire crisis.
I could point to lots of data, but I shall pick up just a few of the differences between Wales and England. Urgent cancer waiting times have not been met in Wales for the past five years. On average response times, in Wales 58% of patients are seen within eight minutes in category A calls. In England, the figure is 72%. One of the most worrying statistics, which Professor Sir Bruce Keogh particularly identified, relates to diagnostic services. In his e-mail, he pointed to the statistic that in Wales 26,000 patients are waiting more than eight weeks for diagnostic services. In England, 9,000 patients are waiting longer than six weeks. We need to bear in mind the difference between the populations: 3 million people in Wales and 50 million in England, yet 26,000 people are waiting for diagnostic services in Wales and 9,000 waiting in England. The statistics speak for themselves.
Peter Watkin Jones, a lawyer involved with the Mid Staffs inquiry, has said that a culture change is needed in the NHS in Wales. Having heard the shadow Health Secretary’s contribution, I do not think he recognises that. Again, I was sorry he felt that attack was the best form of defence. The right hon. Member for Cynon Valley has said that high mortality rates are a smoke signal indicating that something is wrong. The Royal College of Nursing has said that its members do not always have time for training and staff development in Welsh hospitals.
If the right hon. Member for Leigh (Andy Burnham) genuinely wants the lessons of Mid Staffs to be learned, if he wants to ensure that patients in Wales do not have to suffer the same indignity and if he wants to play a positive role in informing health care across the UK, I ask him to agree to make every effort to influence his colleagues in Wales to respond positively to the questions that are being asked, to put party politics aside and to introduce an effective inquiry for the sake of my constituents and those across the whole of Wales; otherwise, everything that he has said today will simply be hollow.
I reread the executive summary of the Francis report yesterday when I was on a train journey, and I decided that in today’s debate I would like to look at one of the most crucial aspects of his findings in respect of what happened at Mid Staffs.
On page 62, at paragraph 1.102, the summary states:
“The senior officials in the DH have accepted it has responsibility for the stewardship of the NHS and in that sense that it bears some responsibility for the failure of the healthcare system to detect and prevent the deficiencies at Mid Staffordshire sooner than it did. There is no doubt about the authenticity of their expressions of shock at the appalling story that has emerged from Mid Staffordshire. However, it is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current Government.”
It goes on to say:
“Where there are perceived deficiencies, it is tempting to change the system rather than to analyse what needs to change, whether it be leadership, personnel, a definition of standards or, most importantly, culture. System or structural change is not only destabilising but it can be counterproductive in giving the appearance of addressing concerns rapidly while in fact doing nothing about the really difficult issues which will require long-term consistent management. While the DH asserted the importance of quality of care and patient safety in its documentation and its policies, it failed to recognise that the structural reorganisations imposed upon trusts, PCTs and SHAs implementing such policy have on occasion made such a focus very difficult in practice.”
It is my contention that we could probably say that of every reorganisation of the NHS, certainly in my three decades in politics.
The summary goes on to discuss the lessons learned and related key recommendations:
“The negative aspects of culture in the system were identified as including: a lack of openness to criticism; a lack of consideration for patients; defensiveness; looking inwards not outwards; secrecy; misplaced assumptions about the judgements and actions of others; an acceptance of poor standards; a failure to put the patient first in everything that is done.”
It goes on:
“It cannot be suggested that all these characteristics are present everywhere in the system all of the time, far from it, but their existence anywhere means that there is an insufficiently shared positive culture.”
Again, it is my contention that that sums up not just the past 30 years but perhaps the past 60 years of our national health service.
The summary goes on to say that achieving change
“does not require radical reorganisation but re-emphasis of what is truly important”.
All parties in the House should recognise that it is not the reorganisation but the re-emphasis of what is important that is significant. Paragraph 1.119 lists how that can be achieved:
“Emphasis on and commitment to common values throughout the system by all within it; readily accessible fundamental standards and means of compliance; no tolerance of non compliance and the rigorous policing of fundamental standards; openness, transparency and candour in all the system’s business; strong leadership in nursing and other professional values; strong support for leadership roles; a level playing field for accountability; information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation.”
I was not surprised by any of that.
The right hon. Member for Sutton and Cheam (Paul Burstow) was a member of the Select Committee on Health in the previous Parliament between 2005 and 2010, and I had the privilege of chairing that Committee. In 2009 the Committee looked at patient safety in the NHS. We visited one of only four hospitals that were part of a patient safety project on how to look after patients inside hospitals, never mind outside. We looked at some of the major issues at the time, such as how different parts of the NHS interacted and their failure to communicate with one another properly. Much of the time they were working with different regulations, and occasionally the inspectorate was not sure what it was responsible for inspecting. This whole restructuring has been going on for a very long time, and it has been more confusing to people working inside.
I am pleased with how the Government have reacted to some of the Francis report’s main recommendations, but I take issue with them on one point. If we are to change the culture inside the NHS, we really need to look at the duty of candour. The Government have accepted the report’s recommendation on a duty of candour for organisations, but they have rejected the recommendation to extend that duty to individuals. I think that is fundamentally wrong.
I spent nine years as a lay member of the General Medical Council, which regulates doctors, and for the first few years I would sit on fitness-to-practise committees. I think that the only way we shall get change is if individuals have responsibility for the duty of candour, not just organisations. I believe that the Government have got that fundamentally wrong. If they really want to tackle the issues that led to the awful situation at Mid Staffs, they need that duty of candour to extend to individuals.
On the Government’s decision on the duty of candour, the Patients Association has stated:
“We question that if individuals are not already motivated by their own professional code, how will a duty on their employer encourage them to come forward?”
That is absolutely right. It continued:
“Without this fundamental change within the NHS, the Duty will just be providing lip service to the issue of patient safety and patients will struggle to see any real improvements.”
That is a big assumption, but on balance I agree. It is something that the Government, no matter who is in Richmond House, need to tackle throughout the NHS.
I have in my hand a copy of the Health Committee’s report on patient safety, which was published in July 2009. We looked at patient safety across the health care system and compared it with what was happening abroad. We visited New Zealand, which has a comparable health system—I accept that the country has only 4 million occupants, compared with our 60-odd million. We looked at why the culture here is the way it is, why people are not open and why they do not learn from mistakes that other health professionals have made. Often those mistakes are not reported because people fear they will get into trouble. We took evidence from the British Airline Pilots Association and learned that any mistake a pilot makes in an aeroplane is whizzed around the world so that other pilots understand it and learn the lessons immediately. That is not the case in our health service.
I want to mention two of the Committee’s findings from New Zealand. The first relates to investigating complaints. I do not think that leaving the duty of candour to organisations, as the Government suggest, will work well. New Zealand has a statutory body—I have mentioned it before in the House—called the Health and Disability Commissioner, which resolves complaints. People can go to the commissioner to request investigations, and they can do so anonymously if they do not want their colleagues to know about it. It is completely independent of the health care system. It works, and it has been working for many decades.
Another area we looked at in New Zealand—again, I accept that it is a very small country—was compensation and redress. I know from my experience of 30 years in Parliament that when people complain about something that happened to them in their local hospital that they are unhappy about, they are treated as if they are going to get into litigation and that it will cost a lot of money; immediately the barriers come up. That culture is not good for our health service, it is costing massive amounts of money for us as taxpayers, and it is certainly not good for the individual concerned. I do not know how many times I have been told that all the patient wanted was an admission that the hospital got it wrong and an apology; they did not necessarily want money. New Zealand has a redress system that some might call a no-fault liability system. Here, it would mean getting rid of lots of lawyers who make massive amounts of money and careers from public money for NHS litigation. Just those two areas hold back changing what is wrong in our system.
I wonder whether my right hon. Friend has had similar cases to a difficult one that I had for months involving someone whose wife died in terrible circumstances at home. He was badly let down by the care she received and he wanted redress. He found that people were happy to have meetings with him and to talk to him, and were sympathetic and supportive, but whenever something was put in writing, it was absolutely dreadful. He was very offended and horrified by everything that was in writing, and that is the chilling effect of lawyers because they checked everything. It ruins the support that can be given after a difficult bereavement and when someone has a real case. Things can be said, but they cannot be written down.
I agree entirely. The system is defensive and people do not get a satisfactory response, but the lessons are not learned. Issues are not reported for fear of the consequences. The Minister is a doctor. He will know that if as a junior doctor he had seen a senior doctor doing something wrong and had gone public about it, it might have affected his career. Some young doctors’ careers have been affected. That is not good for the system, and it is certainly not good for patients.
I am a wholehearted supporter of the national health service and the way it is funded. There is none better in the world, and we can use it without question. It may be different in different parts of the country, but access to health care in this country is second to none in the world for the whole population as opposed to just those with money. Could it better? Yes, and what the Francis report said was a lesson for all of us, and for the national health service. We should change the culture, but we will not do that with reorganisation or by blaming one another in the Chamber for what is right or wrong. That just feeds the politics of the national health service. We must change the culture by putting the patient first, and after 60-odd years it is about time we did.
It is a great pleasure to follow the right hon. Member for Rother Valley (Kevin Barron) who has chaired the Select Committee on Health and who made some extremely important points about accountability. This has been an interesting debate, much of which has focused—understandably, given its title—on what is happening in Staffordshire a year on from the Francis report into Mid Staffs trust. It is also understandable that considerable cross-party concerns have been raised about the NHS in Wales. The Francis report applied to the whole of England, and I want to make some observations as a non-Staffordshire Member of Parliament who has benefited from it.
Much has happened during the last year—for example, the appointment of Stuart Rose, former head of Marks & Spencer, to advise the Government on leadership. His brief is to explore how the 14 NHS trusts placed in special measures can be helped to tackle concerns about their performance. David Dalton, chief executive of the Salford Royal NHS Foundation Trust, is exploring how NHS providers can collaborate in networks or chains, effectively building on an initiative last autumn in which high-performing NHS hospitals were invited by the Secretary of State to provide support for hospitals placed in special measures.
I suspect that much remains to be done to tackle relational aspects of care, including ensuring that patients are treated with dignity and respect and are able to communicate effectively with doctors and other staff. Indeed, the NHS as a whole, including GPs, will probably need to do a lot more in future to support patients to manage their own health and well-being and involve them as partners in care. Sir David Nicholson, the head of NHS England, who retires shortly, has described this concept as “the empowered patient”—in essence, the need for us all to get better at managing our own health problems to reduce the burden on hospitals.
Everyone has had to learn lessons as a consequence of the Francis inquiry, but it is not appropriate or, indeed, fair, continually to castigate those working in the NHS, whether they be nursing staff or managers. On the contrary, we need to ensure that NHS staff are supported to do the job for which they have been trained. Not unreasonably, as in other aspects of life, there will be a close correlation between staff experience and patient experience. Patients receive better care when it is given by staff working in teams that are well led and where staff consider that they have the time and resources to care to the best of their abilities. One reason ward sisters have always been so highly valued is that they are an extremely good example of team leaders, as experienced nurses who have developed, and are able to pass on, a culture in which patients are treated with dignity and respect, and who motivate their colleagues to do the same.
If we are to have an NHS fit for the 21st century, we need continually to attract talent into it. We will not do that if people consider that those working in the NHS are all too often set up to fail. We also need to improve efforts to attract clinicians into leadership roles, as advocated by Roy Griffiths way back in 1983. As a senior and much-respected clinician and physician, Sir Jonathan Michael has been able to achieve as chief executive of Oxford University Hospitals NHS Trust much that I suspect could not have been achieved by a chief executive who was not a clinician. We should value the role of managers in the NHS instead of constantly criticising them. Successful leadership in the NHS needs to be collective and distributed rather than residing in just a few people at the top of NHS organisations. The involvement of doctors, nurses and other clinicians in leadership roles is essential.
The NHS is an organisation that is constantly evolving. The NHS of today is very different from the NHS of 30 years ago, when my father retired as a consultant physician, and the NHS of 30 years ago was very different from the NHS on the day that it began. Both my parents worked in the hospital service on day one of the NHS, my father as a young registrar and my mother as a theatre sister. There is a danger that our perceptions of the NHS, and of what hospitals should look like, become frozen in time, with James Robertson Justice as a snapshot of hospital care. The type and nature of illnesses that hospitals are having to treat changes over the years; so too, therefore, does the hospital layout. I recollect that my father had four Nightingale wards, two male, two female, with 15 beds along each wall and 30 beds to a ward, filled almost entirely with patients dying from lung cancer. Lung cancer is still a killer, but not in anything like the numbers then. We need to recognise that hospitals are changing. In that regard, I very much welcome the work of the Royal College of Physicians through its future hospital commission—an initiative that has not received anything like the publicity and debate that it merits.
The current pattern of acute care is based on the model of district general hospitals providing comprehensive emergency and elective services for relatively small populations—a model developed back in the 1970s. A whole number of factors are changing that model. For example, advances in medical technology mean that it is now possible to treat many patients much more speedily and less invasively. Hysterectomies that might previously have involved a woman patient remaining in hospital for up to 10 days can now be performed through keyhole surgery involving a much shorter stay. There is clear evidence from the Royal College of Surgeons that specialisation can achieve better outcomes. Indeed, the concept of the general surgeon, or surgeon specialising in general medicine, is now pretty much obsolete. Almost all surgeons practising in the NHS today specialise, to the benefit of their patients, in surgery on a particular part of the anatomy.
On the other side of the equation, there are significant demographic changes, resulting in increasing numbers of elderly people. The elderly population is set to expand exponentially as we post-war babies, with much longer average life expectancies than our grandparents, start to reach our 70s and 80s. Many more frail elderly people have long-term medical conditions and an increasing number of people have multiple long-term conditions and—that terrible word—comorbidities.
I therefore very much support the 11 core principles of the Royal College of Physicians’ “Future hospital” report. We need to ensure that NHS patients are at the centre of care—what Robert Francis described as a “patient-centred culture”. We need to ensure that the NHS provides a seven-day-a-week service and that hospital trusts have a 24/7 approach. It is clearly unacceptable that mortality rates are significantly higher for patients admitted into hospitals at the weekend. GP out-of-hours services need to be improved and co-located, and hospital emergency departments need to integrate the urgent care pathway.
At the Horton general hospital in my constituency, an emergency medical unit is being developed to help strengthen the A and E unit and its rapid medical assessment capabilities and to try to ensure that people go to A and E only if they really need to. The links between generalist and specialist pathways are being strengthened, but I suspect that the 24/7 approach will lead to some reconfiguration of services, although that should not necessarily mean that they will become more remote. For example, Horton hospital now has a daily fracture clinic throughout the week and a renal dialysis unit, because it makes more sense for those services to be delivered there. However, emergency abdominal surgery is now carried out at the John Radcliffe hospital in Oxford.
In all of this, we need to remember that whoever is in government, and whichever political party or combination of parties is running the country, we need collectively to face the Nicholson challenge of saving significant amounts of money in the running of the NHS. If we cannot manage the Nicholson challenge, the NHS simply will face a black hole in funding and will fall, more or less, into managed decline.
Indeed, in a recent press report, Sir David Nicholson is reported as predicting that, if the NHS does not pursue a number of reforms, including enhanced primary care, more GPs and more specialisms, it faces
“a £30 billion hole in funding by 2021”,
which is certainly within the political life expectancy of many of us in this House. He also observed, rightly, that
“the NHS is not frozen in aspic for us to worship as some great thing—it will decline and it will die if we don’t recognise the choices that are available to us now”.
Over the past year, following the publication of the Francis report, there has been considerable progress, including towards greater openness and transparency in the health service, including the implementation of a new statutory duty of candour. England now leads the world in transparency and openness about surgeons’ clinical outcomes, so patients can access their surgeons’ outcomes for particular procedures or operations, such as hip replacement. There has been considerable improvement in the Care Quality Commission’s inspection model, the Government have ensured that a named consultant is in charge of someone’s care throughout a hospital stay, and there is clear recognition that the NHS needs to provide a seven-day-a-week service.
We need to move forward with a health service that puts patients at the centre of care. A number of years ago, nursing was made increasingly a graduate profession, but whether one is a graduate doctor or a graduate nurse, patients still need tender loving care. I do not think that my mother, when she was a ward sister, was ever too proud—or considered it not to be part of her role, if necessary—to ensure that patients were comfortable in bed, to give them a bed bath, to make sure that they were eating properly or, if they should die, to ensure that they were laid out with dignity and care.
There have been concerns about health care support workers and we should welcome the recent review by Camilla Cavendish, which has made a number of recommendations on the training of and support given to health care assistants and how that can be improved. Health care assistants do extremely valuable work in hospital. They should be valued and properly regulated.
Last Friday I attended an open day for care workers, which was organised by Oxfordshire county council because, given the ageing population, we are going to need many more health care workers in hospitals and nursing homes and to give domiciliary support.
We have yet to see the full benefits of commissioning and the extent to which commissioners can help improve and monitor the quality of NHS care. One thing that has interested me in this debate is the issue about who actually runs the NHS, because I assumed that once we had commissioning bodies, they would drive where the money was spent. We have also yet to see the full benefits of the new governance arrangements in the NHS, and of ensuring more joined-up working between the NHS and other providers, such as through health and wellbeing boards. Healthwatch Oxfordshire is certainly still getting into its stride as an organisation.
I hope that the House will have an opportunity, in a Back-Bench business or Westminster Hall debate, to discuss the Royal College of Physicians report on the future hospital programme. It is in the process of establishing development sites, which will implement and further develop the recommendations made in its report. I certainly hope that it will consider the Horton general hospital as one of those development sites, not only as one of the smaller general hospitals in the country, but as a hospital that serves a large geographical catchment area.
As Chris Ham, the chief executive of the King’s Fund has observed, high-performing health care organisations
“benefit from continuity of leadership, organisational stability, and consistency of purpose”.
I suspect that, having learned the lessons of Mid Staffordshire, we now need to concentrate on ensuring that there is continuity of leadership, organisational stability and consistency of purpose in the NHS.
Aneurin Bevan’s father died in his arms from coal dust disease, and that drove his passion to establish the NHS when he came into government in 1948. We could put a major fault line down the middle of the Chamber between the two sides in this debate, but we could take away one win if we agreed on one thing underlying the Francis report—the development of a common patient-centred culture.
The Prime Minister mentioned Aneurin Bevan in Prime Minister’s questions today, trying to assume his mantle as the guardian of the national health service, but I assure the House that the right hon. Member for Witney (Mr Cameron) is no Nye Bevan.
Bevan’s “In Place of Fear” clearly set out the principle on which the NHS was founded. It is sometimes worth going back to such principles, as well as looking at its vision for the future. The principle was that
“no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.”
People died in Mid Staffordshire because of lack of means. I compliment the hon. Member for Stafford (Jeremy Lefroy) on an absolutely excellent speech, and on the care and compassion he has shown his constituents during the past few years.
I agree with the Secretary of State that much of the debate is about leadership. I welcome the fact that we will develop more leaders, because leadership in hospitals is a key way forward. I worked in education for many years and I know that, like schools, hospitals reflect the nature and ethos of their leaders. The more leaders we can create, the better the health service we can create.
However, I also agree with my right hon. Friend the shadow Health Secretary. Bevan’s principle in “In Place of Fear” was that no person would be denied medical aid by lack of means in a civilised society, but because of the top-down reorganisation that we currently face, we are in fear. It is no coincidence that several Greater Manchester MPs are in the Chamber for today’s debate, because we are worried about the strategic leadership of Healthier Together, the organisation overseeing the changes in health care across Greater Manchester. Such top-down reorganisation is creating fear. It has sucked £3 billion out of NHS front-line services and in my opinion—I am not talking about winter pressures—it is putting patient care at risk, which is ultimately what the Francis report is all about.
That is no more apparent than in my constituency of Wythenshawe and Sale East. We knocked on 17,000 doors during the short space of a few weeks last month, and the single biggest issue raised was health care, particularly health care at Wythenshawe hospital. First, I want to praise the staff at the hospital, from top to bottom, and the service that they provide. I was born there and I had a minor medical procedure on my toe there recently. The staff were excellent, from top to bottom.
As my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) said, the reorganisation downgraded the accident and emergency facility at Trafford. That decision might have been right or wrong, but because of the rushed nature of the reorganisation and the fact that it was top-down, not bottom-up, it led to a lack of capacity at the neighbouring hospital at Wythenshawe. My right hon. Friend the Member for Leigh opened the Wythenshawe walk-in centre a year or two ago. That has been shut and the services have been transferred to Wythenshawe hospital.
What is happening to Trafford general hospital really grates on me, even though it is not in my constituency, because it was the first NHS hospital. It was opened by Bevan on 5 July 1948. He handed over the keys to the hospital.
The reorganisation has led to Wythenshawe hospital having to take the strain. It is failing the Government’s guideline of treating 90% of A and E patients within four hours. The chief executive of the University Hospital of South Manchester NHS Foundation Trust, which runs the hospital, said that the increased day-to-day admissions meant that 22 extra beds were required. That is a whole ward. To add to the organisational chaos that the top-down reorganisation has created, the hospital is now being investigated by Monitor, the Government regulator. It is almost a self-fulfilling prophesy.
To provide the extra accident and emergency space that is needed, surgical wards are being used. That has led to the cancellation of dozens of operations. At the last count, about 80 operations had been cancelled. The situation has led to nearly 1,000 ambulances having to queue down Southmoor road, which is just outside Wythenshawe hospital, this winter.
In the short week and a half that I have attended this Chamber, I have seen that debates can turn into statistical conventions. However, Members on both sides of the Chamber know—this was made clear by the stories from Mid Staffs—that there are real people in those ambulances and that it is 80 real people who have had their operations cancelled at Wythenshawe. It is not only those people who are affected; their families are affected too. Can we legitimately call ourselves civilised, to use Bevan’s words, when sick people are being denied medical aid today? I do not think that we can.
I am grateful for the Secretary of State for agreeing to meet me to discuss Wythenshawe hospital and the A and E emergency. My litmus test will be Bevan’s test. I hope that that will form the basis of my conversation with the Secretary of State. I will press him on that when I meet him.
I believe that the Francis report is becoming a major turning point in the life of our national health service, which is one of our great institutions and is probably treasured above every other institution that the British people hold dear. The Francis report has moved the NHS from being a rather impenetrable bureaucracy into something that is much more fallible, human and compassionate.
The Francis report highlighted the failings at Mid Staffordshire NHS Foundation Trust and stated that they were very much the result of a failure of leadership. As Francis said:
“The patient voice was not heard or listened to, either by the Trust Board or local organisations which were meant to represent their interests. Complaints were made but often nothing effective was done about them.”
Damningly, he found:
“There is no evidence that the substance of any complaint was ever raised with the Board.”
I shall come back to that point later. He also said:
“Such an approach completely ignored the value of complaints in informing the Board of what was going wrong, and what, if anything, was being done to put it right.”
As Members have been saying, this reflected a culture of denial about failings and complaints not just at Mid Staffs, but across much of the NHS. We know that the problems were wider than this one trust. In a report last year the parliamentary and health service ombudsman, whose office is the responsibility of the Committee that I chair, the Public Administration Select Committee, carried out a survey of 94 trusts from across England and found that only 20% of boards were reviewing learning from complaints and taking resulting action to improve services; less than half were measuring patient satisfaction with the way complaints were handled; and less than two thirds were using a consistent approach to reviewing complaints data. One other finding, from memory, was that only 2% of trusts were considering complaint handling as a strategic issue to consider during a trust board awayday.
Yes, I welcome that. My Committee works closely with the PHSO, Dame Julie Mellor. I paid a visit to the PHSO’s office in London last week and listened to some of the complaints coming in by telephone. We have a lot to learn from the way she is changing things, but there is a lot we need to do to bring the institution of the ombudsman into the 21st century. My Committee is working on a report to be published shortly, which will make recommendations on that.
The role of boards in the leadership of NHS trusts has not been given sufficient attention. Many boards are changing their practices and improving, but the research that we have been given suggests that the chairman of the board of a trust is the most important person in setting the tone of the organisation. We inherited a system where executives took all the decisions and the role of boards was to oversee. No. In the private sector, the chairman of a company, even the non-executive chairman of a company, is the most crucial person for setting the tone, the values and the atmosphere in the organisation. We need to lay much more emphasis on the leadership of trust boards.
The Francis report prompted the NHS, Government and Parliament to question the prevalent management culture in the NHS, and it is the main reason why we are looking not just at the ombudsman, but doing an inquiry into how complaints are handled not just by the NHS, but by Government Departments and across public services. As part of our inquiry we took evidence from Sir David Nicholson, the chief executive of NHS England, and Chris Bostock, head of NHS complaints at the Department of Health.
The ombudsman told us that she found what she called a “toxic cocktail” within some NHS hospitals which combines a reluctance by patients, carers and families to complain, with a defensiveness on the part of hospitals and senior staff to hear and address those concerns. In oral evidence to our inquiry, Sir David accepted that when he said:
“I do think there is a real issue about defensiveness and a lack of transparency in the way that we work”,
and he accepted that complaints are important for learning and improving.
A great deal has been said in this debate about processes, procedures, legal sanctions, rules and accountability, but those are for when things go wrong. What we want in our health service is a culture of listening, understanding, caring, learning and supporting. I shall say a little more about that. Sir David said that the need for openness is not always recognised in the NHS. He went on to say that
“we are publishing lots of data and information and people can connect together through social media and all the rest of it, things are opening out, but the leadership of the NHS…is having difficulty coming to terms with that and”—
a rather nice little understatement—
“is slightly behind it.”
He accepted that that came down to leadership and culture. In a powerful admission from somebody who has been at the heart of the NHS for so long, he said:
“Undoubtedly, in broad terms, the NHS leadership is not equipped to handle some of the big issues that are coming forward, so we need to tackle that leadership. We need to work really hard on the culture of the system overall, because as you are going through that transition the importance of setting the right tone from top to bottom of the organisation is increasingly important…You need to make sure that you are learning the lessons and getting innovation from the system as a whole.”
I am bound to add that, at the end of the session, I asked him about his own leadership. It is a credit to him that he explained that the diagnostic process that NHS leaders go through had been applied to him. He said:
“What it said about me was that first of all I was strong on the pace-setting. Give me a target and I will make it happen…Secondly, the feedback was that I was good at setting out a vision of what the future might look like. My weaknesses were around facilitating and coaching, and actually they are the issues that in a modern NHS will be much more highly prized than perhaps the last one.”
I know that Sir David Nicholson has come in for an awful lot of stick and criticism, but there was a degree of self-knowledge there, and he expressed much regret in front of our Committee for what he had missed.
Francis recommended changes to the law, and the Government are implementing those recommendations. However, I agree with the Select Committee on Health that enshrining duties and standards of care in statute is simply not enough. In fact, statutory changes are almost irrelevant to the day-to-day life of people working in the NHS. The word we hear often is “culture”, and that is what needs to change and is changing. The key change needs to be to attitudes and behaviour within the NHS, particularly among those in leadership positions, who set the tone of the organisation that they lead. Leadership is central to that—not just the leadership of trusts, but leadership across the organisation at all levels.
The Secretary of State is right to emphasise the importance of compassion in the NHS and the need to support those who are required to show compassion every day. Management need to feel and respect that compassion and reflect it in how they treat their staff, otherwise, as one colleague said to me, patients become objects, not people. The way health care staff feel about their work has a direct impact on the quality of patient care as well as on an organisation’s efficiency and financial performance. If those in the upper tiers of management are not also involved in feeling compassion for the patient, they place too great a burden of compassion on front-line staff. The people on the front line need support from those up the management chain, and compassion has to come from the top.
High-quality, patient-centred care depends on managing staff well, involving them in decisions, listening to what they have to say, developing them and paying attention to the physical and emotional consequences of caring for patients. Funnily enough, that point was made by a commercial witness to the Public Administration Committee’s inquiry into complaint handling, Mark Mullen, the chief executive of First Direct. He told us that
“there is a relationship between how you treat your people and how you ask or expect or want your people to treat their customers…it is virtually impossible to create a positive outcome with customers unless you have created a positive relationship with your own employees.”
I wish to leave the House with that serious thought—how NHS staff feel about their work has a direct impact on the quality of patient care, as well as on efficiency and financial performance. That is what this is about.
I am taking a close interest in the NHS leadership academy, which the Secretary of State referred to. It clearly has a clear role to play, although it is very small at the moment. It deals only with potential trust chief executives—senior leadership in challenging roles. It is early days, and we need to involve the academy with trust boards, trust chairs, the leadership of NHS England and even the Department of Health. The academy must give priority to the values of compassion, openness and transparency, listening to and learning from complaints and accepting and learning from failure. It is not about people going off to Harvard, learning how to develop fantastic strategies and coming back with a personal vision that they impose on their organisation. That is not the kind of leadership the NHS needs, and indeed, such leadership does not work in business either. That is true not just for a few leaders, but for every leader of every team in every trust and GP practice in NHS England and the Department of Health. It is a much bigger agenda for the NHS leadership academy than currently envisaged, but we need that ambition if there is to be speedy and permanent change in the culture of the NHS, the attitudes of the people in it, and the way they behave.
There is a great deal of excellent practice in the NHS, as in most large organisations, but it does not seem to be gathered in any systematic way so that learning can be shared. One consequence of that is that there does not seem to be a shared understanding of the kind of leadership that makes excellent practice more likely. Despite the scale and complexity of the health service, there is a common commitment to compassionate, safe, sustainable care among clinicians, managers, trusts, chairs and regulators, which could be the foundation for building a shared understanding of good leadership and practice. None of this will be a quick fix, but many building blocks of good practice are already in place. Gathering that learning together would strengthen and hearten leadership across the NHS. I believe that that is the real role of the NHS leadership academy as it builds its capacity, and I look forward to its developing in the future.
I welcome this debate because it has given us an opportunity to reflect, to learn and, hopefully, to not make some of the same mistakes again. I pay tribute to hon. Members who were directly involved with the events surrounding Mid Staffs. Their persistence in protecting their constituents and changing the culture has been remarkable and something we should all learn from. I particularly pay tribute to the hon. Member for Stafford (Jeremy Lefroy) for telling us how the staff at Stafford hospital have learned and are working as hard as they can to make changes, so that they can deliver an excellent service to all their patients.
The Francis report, published a year ago, made stark reading. It exposed the dreadful practices that no one should ever have to endure, with shocking stories of patients left in their own excrement, unfed, and pleading for water. My heart genuinely goes out to patients and their families who suffered such poor treatment at the hands of an NHS that was seemingly driven by apathy, not by quality of care.
One year on, have we learned the lessons that were so hard won? Robert Francis made many recommendations about how the NHS should put patients at the centre of care. He spoke of a structure of fundamental standards and measures of compliance. He discussed openness, transparency and candour throughout the system, all underpinned by statute. He also raised the need to improve support for compassionate, caring and committed nursing. A recent report by the Nuffield Trust reviewed the progress made, and there is some good news. Nursing is receiving a significant degree of attention, especially in ensuring fundamental standards of care, and the handling of patient complaints locally has been given renewed attention by the chairs of local clinical commissioning groups.
I think that complaints and compliments are key to improving practice, and like many Members, I use the Sheffield-based social enterprise website, Patient Opinion, which to date has shared 65,000 patient experiences of care and received millions of hits from the NHS, MPs, commissioners and the general public. There is clearly a desire for patients to share their experiences, and an NHS that wants to listen and learn. Is it not worrying, however, that an independent organisation is fulfilling that role? Although I am a huge advocate of Patient Opinion and fully support its work, the voice of patients and accountability should also come from within the NHS, not just outside it. In practice, under this Government patients still have little say in how their health care is commissioned or provided. As my right hon. Friend the Member for Leigh (Andy Burnham) stated, more than £10 million of the £43.5 million allocated to Healthwatch branches is still unaccounted for, so how can Healthwatch fulfil its role?
The Nuffield Trust also identified bad practice. I am saddened to hear that some national bodies have persisted in the behaviours towards hospitals that contributed to the problems identified by the Francis report. That suggests that there is still a fundamental lack of co-ordination between different NHS bodies, and elements of the system-based culture that led to the failings in the Mid Staffordshire trust, but while this is saddening, perhaps it should not be surprising.
For the changes Francis recommended to be implemented, they need to be fully adopted by the Government. Instead, the Government have spent £3 billion on a top-down reorganisation that nobody wanted and nobody voted for. Almost 1 million patients have waited more than four hours in A and E in the last 12 months and, as has already been pointed out, hundreds of mental health beds have been lost in the last two years. Last year, a third of people referred for counselling gave up because the waits were too long. Patients are still suffering at the hands of the Government.
If we do not urgently change the culture of the NHS to become more patient-centric, patients will continue to suffer. There needs to be a fundamental culture shift in the NHS that has not yet been achieved, and will not be achieved while the Prime Minister continues to put profits ahead of patients. The recent proposals to sell off our medical records are a perfect example of how “supposedly” patient-centred the Government are. Data collection and monitoring are essential, so it is a shame that the Government are stopping the collection of some datasets, such as health inequalities.
Staffing cuts are preventing patients from being at the centre of care. How can we provide patient-centred care when the Government are side-stepping the need for adequate levels of staffing, in terms of both volume and skills mix? How can we expect nurses to put into place systems, such as having a named nurse, when their numbers have been cut by around 7,000 since 2010? The Royal College of Nursing has said that it wants to deliver patient-centred care, but without the right skills mix in place, it is difficult for it to do so.
Continued “efficiency savings”, driven by a Prime Minister who promised not to cut the NHS, make it virtually impossible for patients to receive a service suited to their needs. A continual focus on savings suggests to me that the Government have not learned from the Francis report. Patients are not always seen as individuals with individual needs and wishes. Our changing society means changing patients, and changing patients have changing needs. Today, nearly two thirds of people admitted to hospital are over 65, and an increasing number are frail or have dementia. Too often, hospital buildings and staff are not equipped to deal with people who have multiple complex needs.
One of my concerns is that patient experience is still variable. We need to understand why experience differs and how we can make it consistently excellent for all. Will the Government commit to identifying and tackling the causes of inequalities in patient experience? Do they have the conviction to look at the needs of the patient and how they can be best met, rather than looking at existing provision and how patients can be shoehorned into it?
The problem is not necessarily what has been addressed by the Government, but what has not. The blame culture fostered by the Government leads to fear and finger pointing, rather than improved patient care. The Government need to commit to re-introduce a culture of learning, support, and quality patient care in the NHS. A blame culture will not get us anywhere: listening to patients, and taking their needs seriously, will.
Thank you very much, Bob.
I want to make three points. First, I want to consider the context of the Francis report. I have the honour of serving on the Health Committee; we have held several inquiries and had the opportunity to meet and question Robert Francis on several occasions, so I am pleased to participate in this debate to consider where we are, one year on.
I also want to touch on mental health. As often happens when one speaks at the tail end of the debate, that has been raised by other hon. Members, but the issue is close to my heart. The third issue I want to discuss is the impact on social care. Although the Secretary of State kept implying that Francis is about acute hospitals, in fact his recommendations extend across the spectrum. The ideas and proposals in the 290 recommendations are just as valid for mental health and social care as they are for acute hospitals.
Clearly, the failings at Mid Staffs were absolutely shocking. I am sure that Members on both sides of the House who believe in the values of the NHS will, like me, have been appalled by those terrible events, but it is important not to conflate those terrible events with a wider diagnosis of the state of the NHS. We should think of the tremendous dedication and effort put in by the hundreds of thousands of NHS staff—I think the NHS is the biggest employer in Europe outside of the red army; it is a substantial employer—who make it such a national treasure that is ingrained in our psyche. I want to place on record the thanks of Labour Members, and, I think, the whole House, for their efforts.
We should remember that most hospitals provide very high standards of care, and have dedicated and compassionate staff. I am not just talking about doctors and nurses, but ancillary workers, cleaners and support staff. I worked in a pathology department as a medical scientific officer for a number of years. We should remember that the NHS is an integrated service that relies on all of its elements to perform at a high level and deliver a high-quality service.
Clearly, what happened in Mid Staffs was alarming. There were unacceptable practices, including, as other Members have said, professional failings. The hon. Member for Stafford (Jeremy Lefroy), in a terrific speech that was considered, thoughtful and non-partisan, alluded to those professional failings. My right hon. Friend the Member for Rother Valley (Kevin Barron), a former Chair of the Health Committee, made the point strongly that many Labour Members feel there should be a duty of candour on individuals. That is one of the recommendations of the Francis report that was rejected by the Government but could well make a difference. There were clear signs that changes needed to be made and we need to ensure that failures are never repeated elsewhere.
When care failures are uncovered, the priority above all else is to make a candid assessment of what went wrong and what needs to be done to fix it. Francis was clear on the need for cultural change. That is exactly what happened in the wake of the Mid Staffs scandal. Despite attempts by some Government Members to undermine Labour’s commitment to the NHS, for the record we should be aware that it was the then Secretary of State, my right hon. Friend the Member for Leigh (Andy Burnham), who is now in his place, who called in Robert Francis to lead the initial review into what had happened so that we could find out what went wrong and learn lessons for the future.
I accept the point made by the hon. Member for Stafford that we should not hark back to previous Administrations, but my recollection, as a relatively new Member from 2010, is that that was not something we engaged in. It was a huge issue for Labour, and for me personally, that people were dying due not to lack of care in a hospital setting, but to the length of waiting lists—people were dying on waiting lists. After 1997, the NHS was transformed. Spending had tripled to £104 billion when Labour left office. Under Labour, 100 new hospitals were constructed, and the Labour Government employed 89,000 more nurses and 44,000 more doctors than had been employed in 1997. The transformation of the NHS under the last Government was reflected in public satisfaction with the service, which rose from record lows before 1997 to record highs.
There was a bit of contention during Prime Minister’s Question Time, and subsequently during the opening speeches in the debate. The Secretary of State suggested that the number of nurses had risen, but my information from the Royal College of Nursing and FactCheck indicates that that is not the case. I hope that the record can be corrected, because staff numbers are a key issue. A number of Members have referred to it today, and Robert Francis cited staffing as a causative factor.
It would, I think, be irresponsible to assume that a combination of implementing the Francis recommendations—even all of them—and talking down the last Government will be sufficient to ensure the provision of high-quality care throughout the NHS. The truth is that the combination of cuts in alternative services—I am not just talking about the replacement of NHS Direct with the 111 service, the reduction in the number of walk-in treatment centres, the difficulties in gaining access to GP services and, indeed, the cost and disruption caused by the top-down reorganisation—is more likely to contribute to failures in care. It will certainly increase the pressure on accident and emergency departments.
The Francis report made it clear that the “overwhelmingly prevalent factors” in the failures at Mid Staffordshire
“were a lack of staff, both in terms of absolute numbers and appropriate skills”.
It was made clear that ensuring that our hospitals are adequately staffed is key to ensuring that standards of care are high. That point was made by the hon. Member for St Ives (Andrew George), who I know has been campaigning on the issue for some time. A year on from the Francis report, a survey found that 39% of nurses believed that the staffing position had become worse rather than better, and 57% said that their wards remained dangerously understaffed. I hope that the Minister has noted that, because it must be cause for concern.
The hon. Member for Stafford told us that when he was first elected the NHS trust was running a deficit of £10 million, and the focus of the hospital management was on reducing the deficit in order to secure foundation trust status. What went through my mind then were figures given to the Select Committee, according to which nearly a third of NHS trusts are predicting deficits towards the end of the current financial year, and the possibility that similar pressures will be applied as a result. We are now seeing the spectre of clause 119 of the Care Bill, which we are to debate next week on Report and Third Reading. If it paves the way for rapid hospital closures—Labour Members fear that predatory private health care interests may seize the opportunity—that will be very dangerous. We must examine that issue very seriously.
According to evidence from the survey conducted, I think, by the RCN, not only are hospital wards increasingly understaffed, but nurses are being burdened with work that is preventing them from doing their jobs. I am sorry to fire statistics at the House, but, according to that evidence, 86% agreed that the amount of non-essential paperwork had increased in the last two years. There has thus been an historic recent increase in administrative duties. That has been keeping nurses in their offices or at their nurse stations, standing in front of computers or photocopying machines, instead of being available on the wards providing the TLC—that direct health care—that patients require.
Just this week the president of the Royal College of Psychiatrists warned the Government that the mental health sector is heading towards its own Mid Staffs-type scandal. I am very concerned about that. The figures for that field were given earlier, but the fact that the budget for mental health services is reducing in real terms should be a cause for concern. This Government gave a commitment to parity of esteem as between physical and mental health. That was promised and loudly trumpeted as a significant step forward, but in truth it has failed to materialise. There is a clear funding imbalance between acute providers and non-acute trusts, which will disproportionately impact on mental health services in the wake of the Francis report.
I also want to touch on the tariff reduction. In 2014-15 there will be an overall reduction in the tariff price—essentially, the price that hospitals are paid for procedures and operations they perform—of 1.5% for acute providers and 1.8% for non-acute trusts. A third of NHS trusts are predicting they will be in deficit at the end of the financial year, and this tariff reduction will only compound that problem. This means the efficiency target for mental health and community trusts is in practice a fifth higher than for acute trusts, so perhaps it is no wonder that we have a chronic bed shortage, highlighted by various newspapers and the BBC, with children and adolescents travelling long distances to access appropriate care and sometimes temporarily being put in police cells. This is not acceptable, and there are real concerns that programmes introduced by the last Labour Government to make talking therapies available to people with mental health conditions are not getting the priority they deserve. Last year half of all patients referred for counselling did not see a specialist, with a third giving up entirely because the waits were so long.
As I mentioned in an earlier intervention, 1,700 mental health beds have been lost over the last two years, and services are under such pressure that people with mental illnesses are ending up either in police cells or presenting at accident and emergency departments, as the right hon. Member for Sutton and Cheam (Paul Burstow) said. Those are completely inappropriate locations.
I want to mention the cuts to social care since 2009 and the impact they are having on the ability of the service to deliver quality care in the light of our review of the Francis recommendations. We should not forget that since 2009-10 some £1.8 billion has been cut from local authority budgets for adult social care. The cumulative spending power of my own local authority, Durham county council, is being reduced by 17.3% under this Government.
Areas such as mine with a legacy of coal mining or industry have higher care needs. These are the areas that are being hardest hit by cuts to local government. It is simply not possible to make cuts of this significance to local government without it having an impact on standards of care. Some 76% of community nurses agree that social care cuts have resulted in increased work pressures, with just 15% thinking that patients are receiving adequate support from social care services. Cuts mean that an increasing number of those with care needs are going without any support—the figure I have seen is about 800,000—and those receiving support are not even having basic needs met. We know about the 15-minute visits, and councils are now having to introduce or increase charges for services that may well have been free before or might be free in other parts of the country.
Care in the home and in the community is declining, and people are turning to their local hospitals—this is the point I am trying to make—as the default option. That means that those who should be taken care of at home are staying unnecessarily in hospital beds. Accident and emergency is the coal face—the pressure point—and any failures in the system show up there, putting even more pressure on an already burdened system. In “The Francis Report: one year on”, Robert Francis said that there needs to be
“a frank discussion about what needs to be provided within the available resources…It is unacceptable to pretend that all can be provided to an acceptable standard when that is not true.”
I agree with him. It is no good telling people that care standards will be improved or maintained while removing the support that is required to provide high standards of care, particularly social care. In conclusion, I agree with the Health Committee that legislation and regulatory bodies can only do so much to ensure that care standards are met if the necessary staff and resources are not available.
I now have to announce the result of Divisions deferred from a previous day.
On the motion relating to the draft Marriage (Same Sex Couples) (Jurisdiction and Recognition of Judgments) Regulations 2014, the Ayes were 360 and the Noes were 104, so the Question was agreed to.
On the motion relating to the draft Marriage of Same Sex Couples (Registration of Shared Buildings) Regulations 2014, the Ayes were 363 and the Noes were 100, so the Question was agreed to.
On the motion relating to the draft Marriage of Same Sex Couples (Use of Armed Forces’ Chapels) Regulations 2014, the Ayes were 366 and the Noes were 103, so the Question was agreed to.
On the motion relating to the draft Consular Marriages and Marriages under Foreign Law Order 2014, the Ayes were 367 and the Noes were 100, so the Question was agreed to.
On the motion relating to the draft Marriage (Same Sex Couples) Act 2013 (Consequential and Contrary Provisions and Scotland) Order 2014, the Ayes were 365 and the Noes were 103, so the Question was agreed to.
On the motion relating to the draft Overseas Marriage (Armed Forces) Order 2014, the Ayes were 368 and the Noes were 98, so the Question was agreed to.
I now call Alex Cunningham.
Thank you, Mr Deputy Speaker. It is an especial pleasure to follow my near neighbour in the north-east of England, my hon. Friend the Member for Easington (Grahame M. Morris), and I agree with everything he said. I was particularly interested in his reference to the reduction in tariff costs, which made me think about the new hospital we were planning to replace the Hartlepool and North Tees hospitals. That is yet to be delivered, despite its being crucial to health care in the area we both represent. I am hoping that we may soon hear from the Government that they are going to approve the assistance we need to deliver it, which will help us cope in that part of the world with the reduction in the actual tariffs.
Our national health service is for millions one of the world’s success stories of the second half of the 20th century, with teams of dedicated people—from porters and reception staff to nurses and consultants—who have risen to the challenge of change and innovated to do the best for our people. As a result, the NHS has survived and largely prospered despite the often unnecessary burden and restrictions placed on it by Government.
I am pleased to have learnt this afternoon that the future of the health service is in good hands: during this debate, I heard from my great niece, Meghan Quarne, who has just managed to secure a place at the Edinburgh medical school, so I am one very proud great-uncle this afternoon.
Yes, the NHS has been a success story, but there have been many failings that have devastated families, health professionals and politicians. We must never minimise the impact of failures that have occurred under different Governments at, for example, Bristol, Alder Hey and Mid Staffs. We must take action to ensure that we improve what we do in the NHS.
I also recognise that a number of trusts have been placed in so-called special measures. That is good not because of the things that are going wrong, but something is being done about the problems so I look forward to seeing the improvements that we all desire.
Of course it does no one any credit to play the political blame game. Members from current and previous Governments must recognise that things do go wrong, sometimes badly, and that everyone should work co-operatively to drive the improvements that we all want. That said, we must also recognise that the NHS is still a success story. It is treating more people with more complex conditions as well as the routine ones. However, the Francis report exposed an organisational subculture within parts of the NHS that was guilty of persistently compromising patient safety, jeopardising the quality of care and tarnishing the experience of the NHS as a first-class health care system.
In the most extreme examples, the failings identified in the Francis report have resulted in patients dying needlessly owing to dehydration and exposure—yes, severe neglect. It is unquestionable that such deficiencies resulted in suffering being needlessly caused to large numbers of patients. The report highlighted a wide-ranging and complex mix of failings, which included a board that was more focused on finance than on the quality of care received by patients; chronic understaffing that impacted on the ability to provide the care required; and a culture of poor practice and neglect that many staff felt powerless to challenge.
There can be no doubt that the situation was utterly abhorrent and should never have been allowed to arise, let alone be repeated. The NHS Confederation was candid, but accurate, in describing the failings at Mid Staffordshire as
“a nadir for the health service.”
In short, there are lessons to be learned from the ordeal—lessons that need to be learned quickly and thoroughly. The recommendations made by the Francis report some 13 months ago were therefore squarely aimed at addressing and improving that frame of mind within trusts through increased levels of transparency and by placing greater focus on the quality of care being delivered.
Although it is important that we recognise that genuine culture change is a slow and evolutionary process that could take time, particularly when some of the changes in question are centred on sensitive issues such as the ability to raise concerns, it cannot be an excuse for risking further neglecting patients by failing fully to address each of the core concerns that were identified.
It is therefore disappointing that the Government have taken an inconsistent, scattergun approach to the report’s findings, ploughing ahead with a damaging top-down reorganisation of the NHS, cutting thousands of nurses and delivering a crisis in A and E. That course of action is destined to weaken and destabilise the NHS, not remedy the problems that have already been diagnosed. It must be a matter of concern that the recommendations that Francis made appear to be some considerable way off becoming a reality.
With the health service’s resources being limited in the face of rising demand for health care, coupled with an increasingly complex system of commissioning services that can involve many layers of bureaucracy and administration, it is more important than ever that the Government acknowledge the limitations that exist to transforming the culture of the NHS through legislation alone.
Although the Government accepted the report’s recommendation to introduce a duty of candour to organisations, they rejected the recommendation to extend that duty to individuals. My hon. Friend the Member for Easington mentioned that earlier. However, those individuals—the leaders and professionals in the NHS—are central to transforming care.
All parts of the NHS—from the ward to the board—have a role to play in creating a more open and honest health service. Every member of staff, regardless of role or seniority, should therefore see providing dignified, compassionate care to all patients as central to their duty. The vast majority of them do so, but I am still apprehensive because an organisational duty alone will not help individuals challenge an organisation with a dysfunctional culture. A simple duty on an employer will not encourage employees to come forward if they are not already motivated to do so by a professional code of conduct.
It is worth noting that an inherent tension remains between prioritising the quality of care delivered to patients and pushing the importance of financial performance. This is particularly true if increasing front-line staff numbers is viewed as the main route to improving safety and quality at the expense of an unnecessary and complicated reconfiguration of care pathways and services.
The Francis report identified one of the root causes of the terrible failures at Mid Staffordshire as a fundamental lack of staff, and many people have talked about that. Although some of the failings were the result of unprofessional behaviour on the part of individuals, the factor overwhelmingly responsible for many of the failings was a lack of staff. Yet, despite this finding, there are now thousands fewer nurses and front-line staff in the NHS than in 2010, with 7,000 front-line staff being made redundant between 2010 and 2013.
Achieving the excellent results and care that patients demand and deserve is dependent on a number of factors, and adequate staffing is certainly central to achieving that goal. However, excellent care requires not only the appropriate number of staff but, importantly, staff with the correct mix of skills. Those skills include a range of factors, including leadership, staff engagement and appraisal.
Although I appreciate the attraction of nationally set minimum ratios of nurses to patients, it is important that we recognise that this is an over-simplification that does not necessarily represent the safest way forward. Not only would a minimum staffing level remove the flexibility required to meet the changing needs of patients, but a nationally set minimum would run the risk of being seen to constitute a ceiling rather than a floor. Instead, appropriate staffing and the best mix of skills are perhaps best determined locally, based on robust evidence and local circumstances.
I well remember that, when I was a non-executive director of the North Tees and Hartlepool NHS Foundation Trust, we had a fantastic chief nurse—her name was Smith—who led a tremendous team. She inspected the wards. She took a team of people on to the wards. They talked to the patients. They looked under the beds. They dragged their hands across the top of the wardrobe units to test their cleanliness. They did a full and thorough check. They talked to the staff. They put nurses at the centre of patient care—something that is absolutely critical today.
Although there has been a small increase in the number of hospital-based nurses in the past year, a paper from the NHS regulator, Monitor, analysing foundation trusts’ plans for 2013 to 2016, shows how temporary increases in nurse numbers this year, 2013-14, will be outweighed by larger cuts to nurse numbers over the next two years. Indeed, the paper suggests that hospitals are planning to “significantly reduce nurses” from next April and that the temporary rise this year is just
“a short term fix for operational pressures”.
Specifically, the analysis shows that, although trusts are planning to increase nurse numbers by 2% this year—around 3,400—that will be followed by 4% cuts in 2014-15 and around 6,900 will go the year after.
There has never been any excuse for neglect by nursing staff. There has never been any excuse for what happened at Mid Staffs. But if, as Francis said, a lack of staff was fundamental to the Mid Staffs failure, that is surely the central lesson for us all, including the Government, to learn.
It is 10 years after the trust lost its three-star rating and went down to zero. It is nine years after most people monitoring hospital performance knew what the problems were. Whistleblowing began in 2007—the Royal College of Nursing knew that, but others did not.
I should like to focus on recommendation 11 of the report that came out three and a half years ago. It deals with the candour required of staff, and it says that clinicians and their views should be represented at all levels of the hospital and the trust. A contrast to what happened at Mid Staffs is provided by a hospital in Seattle—the Virginia Mason medical centre—that decided, first, that if it made mistakes it would admit it and, secondly, that any member of staff could stop the process if there was a significant problem. I recommend a book by Charles Kenney called “Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience”, which should be read—or a summary should be made available—by virtually everyone concerned with organised health care in this country.
Some of the lessons are simple but rarely put into practice. Let me make an analogy. My brother-in-law, Christopher Garnett, ran the London to Edinburgh line for the Great North Eastern Railway, and members of staff would say that he was the only manager who got on the train and asked everyone what he could do to help make their job more effective; they were used to managers telling staff what they could do to make the manager’s job more effective.
The Virginia Mason medical centre looked at what it was doing, and it discovered that nurses spent a third of their time with patients. After changing how they worked, nurses spent 90% of their time with patients. Dr Gordon Caldwell of Worthing hospital in my constituency said that people should be in hospital only if it is doing them some good. They should have a named doctor and a named nurse, but he discovered that, probably throughout the health service—partly but not entirely because of the European working time directive—a patient’s doctor and nurse probably did not speak to each other about the patient more than once a week. That is not good enough.
There is a series of issues, but the key one is empowering front-line staff. Dr Kim Holt, a clinician and leader of Patients First, with whom I am involved, warned in advance that Haringey children’s services were no longer staffed by the right number of qualified senior clinicians. She made it plain that the baby Peter case was not just about a failure to bring together the child’s records from the different parts of the health service to which the family had taken him. She said that the locum, who ended up with all the blame, could not possibly have done the job that she was asked to do. Kim Holt suffered under her employer—the trust. She stood up to it, and would not be bought off and silenced. I pay tribute to her for that.
I could speak at length about this, but I should like to end with a request both to the people at the top of the health service in England and to Ministers. I suggest that Ministers and NHS England meet the group of clinicians that Kim Holt can bring together with Roger Kline at Patients First, listen to their stories and ask where in the process of NHS management, each complaint or disciplinary case has got to. That involves managers, nurses, midwives, doctors and others. The Department of Health should make sure that that happens, but not necessarily in public. It should ask each of the managers involved what they have done all the way through each case and whether they would like to revise what they are doing. There are still too many whistleblowers being bullied, bribed, bought off or sacked 10 years after the Mid Staffs events told us what could go on.
It is a pleasure to speak in this important debate. Members on both sides of the House have shown that we are determined to learn the true lessons from the appalling failings at Mid Staffordshire and to understand what needs to change to prevent them from happening again.
We have heard many serious and thoughtful contributions, but I want to start by paying tribute to the hon. Member for Stafford (Jeremy Lefroy), whose calm, considered, thoughtful and dignified approach to the issue and the work he has done on behalf of his constituents is a lesson to us all. My right hon. Friend the Member for Cynon Valley (Ann Clwyd) hit the nail on the head when she said that there is nothing to be gained by politicising these issues, but everything to be gained by understanding the lessons and being open about the problems so that they can be tackled properly.
My hon. Friend the Member for Stalybridge and Hyde (Jonathan Reynolds) and my right hon. Friend the Member for Rother Valley (Kevin Barron), along with many other hon. Members, emphasises the importance of openness. As a constituency MP, I have seen how the NHS too often tries to sweep patient complaints and mistakes under the carpet, ignoring them and pushing patients away. Being open early on, admitting mistakes and learning the lessons is a much better way forward.
A number of hon. Members spoke specifically about the process that Mid Staffordshire hospital is currently going through. My hon. Friend the Member for Stoke-on-Trent North (Joan Walley) and the hon. Member for Stafford rightly said that there is a lack of clarity about the process and the timetable. I hope that the Minister, when he responds, will give those hon. Members and their constituents much greater clarity on what will happen.
My hon. Friends the Members for Rotherham (Sarah Champion) and for Wythenshawe and Sale East (Mike Kane) raised important points about making the system more accountable and how that is much harder since the NHS reorganisation, with all the different bodies—a point I will return to in a minute. My hon. Friends the Members for Worsley and Eccles South (Barbara Keeley), for Easington (Grahame M. Morris) and for Stockton North (Alex Cunningham) rightly talked about staff shortages and the serious impact they can have on patient care. If we are to get to the root of the problem, simply publishing data every month is not good enough. I was really pleased that the right hon. Member for Sutton and Cheam (Paul Burstow) talked about mental health. We have been talking mostly about physical health, but he was right to raise those concerns.
In the time available I cannot do justice to all the points raised today, or to the Francis report’s 290 recommendations, so I will focus my comments on the two most fundamental challenges we now face: first, ensuring that the views of patients, their families and the public are heard and acted on, at every level and at all times; and, secondly, ensuring that there is clear leadership to make the service changes we need to improve safety and quality at a time of unprecedented pressures on the NHS. Unless we do that, there is a risk of the failings in Mid Staffordshire happening again.
I am grateful to the hon. Lady for giving way, unlike her colleague earlier. In the spirit with which she has opened her contribution, and in relation to the comments made by the right hon. Member for Cynon Valley (Ann Clwyd), the comments of the Royal College of Surgeons and the example I highlighted of worrying cases in the NHS in Wales, will she make every effort to influence her colleagues in the Welsh Government, and indeed the Welsh Health Minister, to conduct a Keogh-type inquiry into the NHS in Wales?
Wherever there is evidence of poor care, it must be looked into. The hon. Gentleman did not mention that the Welsh Assembly has ordered a specific independent inquiry by experts outside Wales into aspects of care at the Princess of Wales and Neath Port Talbot hospitals, which I welcome.
Of all the lessons to be learned from Mid Staffordshire, the most important one is that the primary cause of the failures was the hospital and the trust board not listening to patients and their families, and not putting their needs and concerns first. Sir Robert Francis rightly says that there must be fundamental changes to ensure the real involvement of patients and the public in all that is done and to secure a common patient-centred culture throughout the NHS.
National Voices, a coalition of more than 130 patient, user and carer organisations, says that a concerted drive to listen to patients and carers must be a top priority for all trust boards and care organisations. It emphasises that over and above regulation, which it says has
“an important but limited role in ensuring quality and safety.”
Ministers have rightly spoken about the need for effective regulation and have taken some welcome steps, but the Care Quality Commission and the new chief inspectors will not be the main way of preventing the sort of failings we saw at Mid Staffordshire. Regulation identifies problems when they have begun, rather than preventing them from happening in the first place. Regulators cannot be everywhere all the time, but patients and their families are, which is why their views must be heard from the bedside to the boardroom, and at the heart of Whitehall.
The Labour Government made important progress. They published, for the first time, data on stroke and cardiac care. That helped to improve standards for patients and was a powerful incentive for staff to make changes. The next step is to provide systematic and comprehensive patient feedback. That must move from being the exception to being the norm.
The Government’s friend and families test is welcome as far as it goes but, as National Voices says,
“it is a crude measure on which the NHS would be unwise to place too much reliance.”
It asks only whether patients would recommend an NHS service to others, but not why, and it does not provide the detailed, real-time feedback that patients want and staff need to improve the quality of care. Developments such as the patient opinion and care opinion websites offer a powerful way forward. They enable people to tell the story of their NHS or care experience online, in writing or on the phone. That gives patients a voice, allows other people to see what is being said about a service, and in a simple and cost-effective way provides staff with a direct incentive to improve.
The Secretary of State said we must all be champions for change, and hon. Members may remember that I wrote to everyone saying that as a Member of Parliament they should sign up because it is a great way for us to understand what is really going on. I have asked my hospital trust and other services to do the same. That will be a powerful way of making change happen.
We must also look at how staff are trained to ensure that they always put patients first. Places such as Worcester university are leading the way: patients and families help to interview people who are applying to be nurses and health care assistants; they help to develop the content of courses so that they include what really matters to patients; and they take part in teaching students. Ministers should have spent the last three years championing such initiatives instead of reorganising the training structures as a result of the Health and Social Care Act 2012.
Individual patient voices are not the only ones that must be heard. We need a strong collective voice for users. The Francis report recommended investing in patient leaders to speak out on behalf of the public, to help to design services locally, and to hold them properly to account. Ministers claimed that that is what Healthwatch would do, but their rhetoric is simply not matched by the reality: national Healthwatch has nowhere near the same power, authority or levers to change services as NHS England, the Care Quality Commission or Monitor.
Local Healthwatch bodies are also weak. They were late out of the starting blocks and are woefully understaffed. Last week, we heard that £10 million of the £40 million budget that was promised for local Healthwatch has gone missing, despite the explicit recommendation in the Francis report that
“Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch”.
If Ministers are serious about giving patients a strong voice locally, they must look again at the support that Healthwatch is getting on the ground.
A strong patient voice is more essential than ever before because of the huge pressures on local services. Across the country, the NHS is struggling to cope with the increasing number of frail elderly people ending up in hospitals that were designed for a different age. Twenty per cent. of hospital beds have older people in them who need not be there if they had the right support in the community or at home. Half a million fewer people are receiving basic help to get up, washed, dressed and fed as council care budgets are cut to the bone. Mental health services, especially for children, are under intolerable strain as money for vital community services is being diverted to cope with pressures elsewhere in the system. This is not good for patients and families, it puts staff under pressure, and it ends up costing the taxpayer far more as people end up in more expensive hospital care or, in the case of mental health patients, being transported hundreds of miles around the country.
The NHS needs radical change, not to its back-room structures but to its front-line services and support. Improving safety and quality means that some services must be concentrated in specialist centres and others must be shifted out of hospitals into the community and towards prevention, fully integrated with social care. Under the previous Government, plans had been drawn up to reorganise services in every English region through Lord Darzi’s next stage review, but rather than pushing forward with those plans and making the changes that patients want and need, Ministers scrapped them simply because they were developed under the previous Labour Government. Instead, they embarked on a huge back-room NHS reorganisation, wasting precious time, effort and resources.
As several hon. Members have said, the new NHS structures are utterly confusing, with no clear lines of accountability or responsibility. There are now 211 clinical commissioning groups, 152 health and wellbeing boards, 27 NHS England local area teams, four NHS England regional teams—I am not sure what they are doing—23 commissioning support units, and 10 specialist commissioning units, alongside Monitor, the Care Quality Commission and NHS England. Can you make sense of that, Mr Deputy Speaker? Who is providing the leadership? Who is to be held to account? Across the country, people are doing their contract negotiations for next year, trying to make changes to services, and they say to me that there is no clear leadership in the system. That must change.
We have heard a lot about changing the culture in the NHS. That culture is about behaviour and the millions of personal interactions that happen every single day in the NHS. Getting those right will not happen through regulation alone but by giving patients and the public a powerful voice in every part of the system. This issue has had too little attention since the Francis report was published. Crucially, the culture is about leadership, and leadership comes from the top.
I warn Ministers not to be complacent about saying that the bullying culture has gone. On Friday, I met the chief executive of a trust who showed me an e-mail from the NHS Trust Development Authority, which is quite close to Ministers’ doors. I will not be able to say exactly what it said because it contained swear words, but it said, in effect: “Open the beep beds; just beep do it.” That was in an e-mail to a chief executive. The bullying culture is still going on. Ministers need to get a grip, particularly on what is happening at the NHS Trust Development Authority, which is causing real problems in the system.
This is more pervasive than something that happens at the highest level. When members of my trade union, Unite, from the Yorkshire ambulance service raised legitimate concerns about the impact on the service of privatisation and de-skilling, the reaction of management was to de-recognise the trade union. That is outrageous.
This is not leadership; this is not what we want in our health service.
Real leadership is about setting a vision and working with staff and patients to make it happen. Yesterday Sir John Oldham published the report of his independent commission on whole-person care, which was drawn up with people who have worked in the system and sets out the reforms that we need to ensure that our NHS and care services are fit for the future. Across the NHS, patients and staff are crying out for clear leadership. Until we get this right, we will not really have learned the lessons from the failings of Mid-Staffs.
The publication of the Francis report was an incredibly humbling day for our national health service. It was humbling not just for those of us in this place who care about our NHS, but for the many staff who work tirelessly to look after patients and for everybody involved in looking after people as part of our health and care system.
The central plank of the report highlighted the fact that a culture had developed at Mid Staffordshire that was not in the best interests of patients. Targets and bureaucracy had got in the way of delivering high-quality care, and far too often the management of the trust did not listen to the concerns of patients or to the sometimes valid concerns of front-line members of staff.
Robert Francis made a number of recommendations in his report. The Government accepted the principles of the report and we have made great progress in implementing many of the proposals, which I will come on to later.
It is important that all parts of our health and care system learn lessons from things that have gone wrong in our health service. Front-line staff need to learn lessons where appropriate and managers need to learn to listen and respond to the concerns of front-line staff. We need to create a culture that is open and learn how to put things right in the future in order to improve patient care. That is what good health care is about, whether someone works on the front line of the service or whether they are involved as a commissioner, a manager or a Minister.
There have been many good contributions to the debate and I will do my best to touch on as many of them as I can in the time available. In particular, there has been strong advocacy for the local NHS. I pay particular tribute to my hon. Friend the Member for Stafford (Jeremy Lefroy) for his work and tireless advocacy over many years—including before he became an MP and certainly during his time in this place—on behalf of his local patients and the local hospital and staff who look after them in Mid Staffordshire. Without his long-standing efforts and those of my hon. Friend the Member for Stone (Mr Cash), we would not be where we are today and that part of the world would be less better represented. Importantly, they are the people who have asked consistently the difficult questions and allowed us to get to our current position of not just tackling poor care at Mid Staffordshire and putting right the challenges that that has thrown up, but looking at how we can improve pockets of bad care elsewhere in our health and care system.
Most hon. Members have focused on two particular themes, the first of which is the need to learn lessons from the Francis inquiry into what happened at Mid Staffs, for the benefit of the wider health and care system. We heard some very good speeches, particularly from the right hon. Member for Rother Valley (Kevin Barron), my right hon. Friend the Member for Banbury (Sir Tony Baldry) and my hon. Friend the Member for Worthing West (Sir Peter Bottomley). They discussed the broader lessons that can be learned and the importance of an open culture, of supporting clinical leadership and of recognising that perhaps staff are the best advocates of what good-quality patient care looks like in our health system.
In his constructive contribution, my hon. Friend the Member for Cannock Chase (Mr Burley) noted that the challenges and difficulties faced in Mid Staffordshire arose because the management in particular were blinded by targets, financial incentives and drivers, and lost sight completely of what matters most in a hospital at all times, which is delivering high-quality, good patient care. The biggest lesson we can learn, as my hon. Friend made clear, is that we need always to make sure that the delivery of high-quality care is the first and only driver of what happens on the ward. It should never be about meeting a financial target. Of course, the two are not always mutually exclusive, but in this case it is very clear that things went very badly wrong at that trust.
As was pointed out by the shadow Minister, the hon. Member for Leicester West (Liz Kendall), a significant speech was made by my right hon. Friend the Member for Sutton and Cheam (Paul Burstow), who talked about the importance of parity of esteem between mental health and physical health. He did a lot in his time in government, and he has always been a keen advocate of that. I know that he is very proud, as the Government are, that the 2012 Act has for the first time enshrined in law genuine parity of esteem between physical health and mental health. That was touched on by the Francis report, and the Government can be proud of doing that. As he will know, we have also invested £450 million in improving access to treatment in mental health services. I know that he took that forward in government, and he can be very proud of that record.
Through the Minister, may I pose a question to my hon. Friend the Minister of State who has responsibility for care services? He told us that Sir David Nicholson had issued a clarification about area teams not doing enough to deliver parity of esteem, but that has not materially changed how the finances are arranged, with money being taken away from mental health to pay for Francis delivery in acute care. Will that be addressed?
My right hon. Friend is absolutely right to say that the first step in addressing financial disincentives for mental health, which have been in the system for many years—in fact, for decades—was to establish parity of esteem in law. He helped to achieve what for the first time has been done under this Government. The next step is of course to make sure that other measures are in place to encourage and incentivise the system to spend money appropriately. Members on both sides of the House agree that we should take pressure off acute services, and nowhere is that more important than in mental health. It is important to invest in improving access to psychological therapies and talking therapies to support people, and to put in place early intervention for those with mental health problems. That is quite important, so the Government are investing money in it.
It is also important to collect proper data on mental health for the first time. For many years, data have not been collected effectively to ensure that we know what good mental services look like, but the Government will make sure that we can deliver that.
I thoroughly agree with the Minister about collecting data on mental health so that we can make proper judgments about the quality of services, but why has the Department of Health scrapped the annual survey of expenditure on adult mental health services?
It is very difficult for me to stand at the Dispatch Box and take any lessons from the right hon. Gentleman and the previous Government on mental health issues. Only this Government have taken serious steps to improve parity of esteem and enshrine it in law, and only this Government are investing in mental health on the ground, with £450 million that is particularly focused on talking therapies. If the previous Government had any interest in mental health, they had 13 years to make investments and to improve data collection to drive better commissioning, but they took no steps towards doing that, and I am afraid that their record on mental health was abysmal and very poor. Unfortunately, patients paid the price for that.
We are very proud of our record on mental health, but it will take several years to turn around the fact that there was no parity of esteem in the past. Investment is now going in on the ground and things are being put in better order. My right hon. Friend the Member for Sutton and Cheam played his part in that, and the 2012 Act was a huge step forward in delivering those improvements.
I will try not to get drawn away from the topic of the Francis inquiry, Mr Deputy Speaker—we are talking about the broader health and care service—but I mentioned mental health, which we can be proud of, because it was mentioned by Francis in his report.
It is also important to talk about some of the wider lessons that can be drawn from the Francis inquiry. The right hon. Member for Cynon Valley (Ann Clwyd) and my hon. Friend the Member for Vale of Glamorgan (Alun Cairns) spoke particularly about the need, apolitically, to make sure that the whole of the United Kingdom draws such lessons. I have had very productive meetings with counterparts in Scotland, and Wales can also learn lessons about the importance of transparency and openness, and about recognising potential areas of poor care.
I hope that shadow Ministers will take up those matters with their counterparts in Wales, because such a situation can only be to the detriment of patients there. That is not a political point, but one about good care. It is important for us to deliver that in the system at the moment. It is also important because English patients are treated in Welsh hospitals. My right hon. Friend the Secretary of State is very excited about that point, which is why he is a very strong advocate of the needs of English patients and why he takes a particular and important interest in what happens in Wales, quite rightly drawing comparisons between the two systems.
Robert Francis found, as we have discussed, that individuals and organisations at every level of our health service let down the patients and families whom they were there to care for and protect. That was a systemic failure on the part of everyone concerned and cultural change was needed throughout the system. To prevent the same thing from ever happening again, the Government are changing the culture by requiring transparency and openness, by empowering staff and supporting strong leadership, and by embedding the patient voice and listening when something goes wrong.
I have listened carefully to the Minister’s response to the various contributions that have been made throughout the debate since 1.15 pm. I hope that he will respond to the points that I made about the current situation in Mid Staffordshire and north Staffordshire before he goes on to the generalities of the Francis report. Does he accept that it was a bombshell when we heard last Wednesday that the recommendations of the trust special administrator had not been accepted in full? We are in a state of limbo. Will he tell the House what is the state of play of arrangements in north Staffordshire and Stafford? We need to know that and cannot deal with the uncertainty.
Again, I will not deviate from the general theme of the debate and try your patience, Mr Deputy Speaker. The recommendation of the trust special administrator was that consultant-led services were to be transferred away from Stafford and that there would be a midwife-led unit for Stafford. I am sure that Members on both sides of the House are great proponents of midwife-led units and of increasing the choice that is available. The Secretary of State has made it clear that he accepts the TSA recommendations in full and that local commissioners will have to do a health economy review to assess whether capacity is available elsewhere, before services are moved in the way that was envisaged by the TSA. The Secretary of State has asked NHS England to work with local commissioners to identify whether consultant-led obstetrics could be safely sustained at Stafford hospital. That only happened last week. We will update the House in due course and perhaps statements will be made by NHS England.
I say to the Minister and the Secretary of State that the use of the phrase “in due course” causes great concern. The new arrangements need to be in place in September 2014. Any delay to the acceptance in full of the recommendations in the TSA report will cause great uncertainty. The Government need to show that they are doing what the Francis report recommended and leading by example. Will they do that in the case of north Staffordshire and Mid-Staffordshire?
We are leading by example. As I outlined, the Secretary of State has accepted the TSA recommendation in full. A process is now under way involving NHS England and local commissioners. That was initiated last week. It is important that those conversations happen and that an update is brought forward in a timely manner. That is the right thing to do. It is not appropriate to rush decisions and processes because of a political agenda, rather than an agenda of benefiting the local patients and women concerned. I am concerned as a doctor and as a Minister that we must do the best thing by patients. Rushed decisions are not always the best thing for patients, because conversations need to happen between local commissioners and NHS England. I hope that the hon. Lady will be a little patient, because I am sure that the right decision will be made in due course.
There are three key areas in which the Government have taken forward the recommendations of the Francis inquiry: encouraging a culture of transparency and openness in the health care system; empowering front-line staff and encouraging good leadership in the NHS; and putting the patient at the heart of everything that the NHS does. As we have discussed, the patient was not at the heart of everything that was done at Mid Staffordshire for a period. That is why we have to learn the lessons and ensure, as best we can, that that cannot happen again.
On transparency and openness, it is important to highlight how we have already delivered on the recommendations of Robert Francis’s report. The CQC has appointed three chief inspectors for hospitals, social care and general practice who will ensure not only that the organisation is complying with the law, but that the culture of the organisation promotes the benefits of openness and transparency. Importantly, we now have clinically led inspections for the first time, which means that people who really understand what good care looks like will be in charge of the inspection process. That clinical leadership in the inspection process and at the heart of what the CQC does has to be of benefit to patients, and the Government are proud that we have delivered that.
We have also introduced a new statutory duty of candour on providers, which will come into force this year. It will ensure that patients are given the truth when things go wrong and that honesty and transparency are the norm in every organisation.
The right hon. Gentleman might wish to intervene in a moment, but first I will respond to his good points on the importance of the duty of candour. There is some disagreement between us, because he said that there should be a duty on individuals. He will be aware from his time at the General Medical Council that there is already a duty on professionals to act in the best interests of patients and raise any concerns about the quality of care. As a body, the GMC has learned lessons from Mid Staffordshire and reviewed its processes, but it is important to recognise that many front-line professionals at Mid Staffordshire tried to raise concerns. The culture at the trust was such that those in management positions did not always listen to them. If we want to support whistleblowers and people’s ability to speak out freely for the benefit of patients, that has to be done at organisational level. Health care professionals are already under a duty through their professional obligations, which I hope reassures the right hon. Gentleman.
The right hon. Gentleman has been in the House for many years and will remember that problems of people not being able to speak out freely in their organisations date back to the Bristol heart inquiry. Professor Kennedy, who oversaw that inquiry, noted that it was the cultural problem in that hospital provider that prevented people from speaking out. The problem was not that people were not prepared to speak out—they recognised their professional obligations; it was that there was a wish at a senior level not to recognise problems. That is what we need to tackle. We are now almost 15 years on from the Kennedy inquiry into Bristol—I was a law student at Bristol university at the time—and the NHS has perhaps not learned the lessons that it needs to. I am sure that putting a duty of candour on to NHS organisations will begin to get us where we need to be.
Will the Minister consider what I said about how an independent statutory commissioner could examine complaints about patients’ care, as happens in New Zealand? Will he get back to me about whether he thinks that is a good idea? The people who work in the institutions that he is talking about have no faith that anything can be changed.
I will talk about complaints a little later, but the right hon. Gentleman has made some important points. When we consider how to improve the delivery of care in our health service, it is important that we examine international comparisons. The system in New Zealand includes a different form of compensation, and perhaps that is partly why it has a more open culture—there could be many other factors. It is acknowledged much earlier in the process that something has gone wrong, and there is a genuine attempt to explain the situation to the family and say sorry. That is what good health care is all about.
No matter how good, well trained and dedicated staff are, things will sometimes go wrong in a health service. When they do, it is important that we are open and honest with patients and that we do our best to put things right if we can, or explain and apologise if we cannot. That is why we believe that the duty of candour needs to exist at organisational level. Of course, I am happy to write to the right hon. Gentleman, or meet him if he would like to talk through some of the issues that he raised today. He makes good points, and I know that he does so on a completely apolitical basis because he has the best interests of the health service at heart. We might disagree on other issues, but on this one it is worth having a meeting to discuss his views further.
Subject to the passage of the Care Bill, a new criminal offence will be introduced to penalise providers who give false or misleading information where that information is required to comply with statutory or other legal obligations. It means that those directors or other senior individuals, including managers, who consent to, connive in, or are negligent regarding an offence committed by the provider could be subject on conviction to unlimited fines or even custodial sentences. We must ensure that managers and those running the health and care service in a health care provider provide information in an honest and transparent way that is always in the best interests of patients.
Importantly, we are introducing through the Care Bill a single failure regime to ensure that failure is not only about the financial sustainability of the trust, but about whether a health care provider is providing good care, and the quality of that care. One problem in the past with the trust special administration regime has been that it is rarely used. When it is used, however, it is important to ensure that it is there to protect patients. Often in the past it was used only in a way that focused on financial failure. One important lesson to learn from Mid Staffs is that there should be a failure regime that also considers quality of care. Hospitals are not just about good accounts; they are primarily about delivering good care, which is why we need a single failure regime. My right hon. Friend the Secretary of State has been a tremendous advocate for the importance of quality of care in trust, and he should be commended for that. Thanks to him, we are now ensuring that we improve the TSA regime in that way.
The Minister is outlining the legislative and regulatory changes that arise from the Francis report, but does he agree with the Health Committee, which attaches far more importance to the leadership academy mentioned by my right hon. Friend the Secretary of State? Is not the quality of leadership much more important to the day-to-day care that is delivered throughout the health service, and will the Minister say a bit more about that?
I am not sure whether my hon. Friend has seen my brief, but that was exactly the point I was coming to. He is absolutely right and he highlighted the issue earlier in a strong contribution to the debate. It is important to empower front-line staff to be advocates for patient care and to take leadership roles in hospitals. Clinical leadership is at the core of everything that needs to be done, and we must promote strong leadership throughout a health care organisation, and throughout the sector.
We amended the Enterprise and Regulatory Reform Act 2013 so that a person has the right to expect their employer to take reasonable steps to prevent them from suffering detriment from a co-worker as a result of blowing the whistle. That has supported clinical workers and front-line staff in raising concerns and as whistleblowers. We established the NHS Leadership Academy in 2012 as the national hub for leadership development and talent management. Since it launched its NHS fast-track executive programme in January, there have been more than 1,600 applicants. We are also introducing a new fit and proper person test for directors of registered health care providers, which will allow the CQC to insist on the removal of directors who are responsible for poor care. Those strong steps are in place, and there are others, which I would be happy to discuss another time with my hon. Friend, to embed not just clinical leadership but good leadership throughout our health and care services.
Importantly, in delivering high-quality care and embedding good leadership, we must focus much more on outcomes rather than targets. That goes to the centre of what Robert Francis said, and is led by good clinical leadership. What matters in the health service is that we deliver high-quality care based on good outcomes of care for patients, and we must listen to patients about what good care looks like. The Government are delivering those things, which are at the centre of what Robert Francis recommended as lessons to be learned from Mid Staffs.
Finally, I mention the important issue of embedding the patient voice and listening when things go wrong. As the shadow Minister outlined, the Government have introduced the friends and family test, through which nearly 1.6 million patients have already given instant, real-time, feedback to the NHS about their care. Patients are saying what their experience of care is like. It is not about ticking a box or meeting a target; patients are feeding back information and saying, “Yes my care was good” or “No, my care was not as good as it could have been, and this is how it could be improved.” Good care is about ensuring that we deliver clinical excellence through clinical leadership, listening to patients, and ensuring that we feed back their experiences into delivering better services and a better experience of care. Those are things the Government are doing.
Through the chief inspectors of hospitals, social care and general practice, we are putting proper clinical leadership into the inspection process. We are also ensuring that all feedback from patients, whether concerns voiced on the ward or complaints made once they are back at home, makes a difference. I pay tribute in particular to the work done by the right hon. Member for Cynon Valley on the complaints process, on which there were valuable lessons to be learnt. I thank her for her efforts, which have made a big difference. We are still working on further measures we can put in place to ensure that complaints are listened to. This is all about listening to patients, learning lessons and delivering better care.
We are proud of our record in government in listening to patients and ensuring that we develop proper clinical leadership. We are also proud that, as a result of the Francis report and the measures put in place by my right hon. Friend the Secretary of State, we are beginning to deliver much greater transparency in our health service. It is also important that we have that transparency in the back office. I disagree with what the shadow Minister said about not needing to reorganise the back room. We have to deliver more transparency, better procurement and improvements in how we run the hospital estate. If we do that properly, there will be more money to deliver high-quality patient care.
The coalition Government—I know the Minister of State, Department of Health, my hon. Friend the Member for North Norfolk (Norman Lamb), agrees with me strongly on this—want to see a more productive NHS that is patient-centred and does not waste money in the back office that should be spent on patient care. I make no apologies for organisational steps such as the removal of many of the bureaucratic processes in place under the previous Government, thus saving £1.5 billion a year already. That is good, because it means that more money goes to the front line to deliver high-quality patient care.
The 65th year of the NHS was perhaps its most challenging—certainly in recent memory. The Francis inquiry threw up many challenges for our health and care system, but I believe we are meeting those challenges. Our Government are ensuring that our NHS remains a health service of which we can all be proud, not just today but for many years to come.
Question put and agreed to.
That this House has considered the matter of the Francis Report: One year on.