My Lords, with the leave of the House, I would like to repeat a Statement made by my right honourable friend the Secretary of State in another place.

“With permission, Mr Speaker, I wish to make a Statement about Stafford Hospital, following the Healthcare Commission’s investigation published yesterday. The report details astonishing failures at every level and shows that for patients admitted for emergency care at Stafford there were deficiencies at every stage.

The Healthcare Commission found disorganisation, delays in assessment and pain relief, poor recording of important information, symptoms and requests for help ignored, poor communication with families and patients and severe failings in the way the trust board conducted its business. While the management was obsessed with achieving foundation trust status, the wards were understaffed and patient care seriously compromised.

The report cites incidents where patients were left without food or drink for days because operations were delayed, of nurses who had not been properly trained to use basic, lifesaving equipment and of patients admitted to A&E being triaged by receptionists. It notes that there was a dangerous lack of experienced staff, that observation and monitoring of patients was poor, that essential equipment often was not working and that there were no systems in place to spot where things were going wrong in order to make improvements.

In short, it is a catalogue of individual and systemic failings that have no place in any NHS hospital but which were allowed to happen by a board that steadfastly refused to acknowledge the serious concerns about the poor standard of care raised by patients and staff. I apologise on behalf of the Government and the NHS for the pain and anguish caused to so many patients and their families by the appalling standards of care at Stafford Hospital and for the failures highlighted in this report.

I will set out the actions that we will take in response to this report during my Statement, but I want to begin by summarising the events that lead to the Healthcare Commission’s investigation. The commission became aware of high mortality rates for specific conditions or operations at this trust during the summer of 2007, through its routine analysis and statistics known as hospital standardised mortality ratios, or SMRs, produced by the Dr Foster research unit, based at Imperial College.

Whenever the Healthcare Commission is alerted to unusually high mortality rates, it initially asks the trust to provide further information to explain such anomalies. High standardised mortality ratios are not necessarily an indicator of poor clinical performance, nor do they signify that there have been avoidable deaths, but they do act as a screening tool to identify the need for investigation.

Further analysis showed that there were consistently high mortality rates for patients admitted as emergencies going back several years. The trust repeatedly dismissed the significance of these statistics, saying that they could be explained by the problem that it was having with the recording of data. The accuracy of information coding—that is, the system for cataloguing types of surgical and other interventions—had historically been poor in the trust and the internal group that the trust itself had set up to consider high mortality rates assumed that they could be explained by coding errors. The Healthcare Commission refused to accept this explanation and launched a full-scale investigation in March 2008.

In May of that year, following its first visit, the commission asked to see the chief executive and set out its immediate concerns about poor patient care and inadequate staffing levels. Since then there has been gradual improvement. The Healthcare Commission states that,

‘the Trust deserves credit for progress on infection control and for responding positively to the concerns of the Commission’.

On an unannounced visit in February to the accident and emergency department the Healthcare Commission noted significant improvements. Its visit raised no immediate concerns about the safety of patients admitted to the accident and emergency department. However, the failures are stark and they occurred over a substantial period of time.

Patients will want to be absolutely certain that the quality of care at Stafford Hospital has been radically transformed and in particular that urgent and emergency care is administered safely. I have today, jointly with Monitor, asked Professor Sir George Alberti, the eminent physician and national clinical director for urgent and emergency care, to lead an independent review of the trust’s procedures for emergency admissions and treatment and its progress against the recommendations in the report. He will report in five weeks’ time and his findings will be published to the House.

The Healthcare Commission has told me that it is confident that Stafford Hospital is an isolated case and that, having looked at other trusts with similarly high standardised mortality ratios, it is reassured that a similar succession of serious lapses in care has not occurred elsewhere.

The National Quality Board has been set up to look at how organisations work effectively together in patients’ best interests. It is composed of representatives of the royal colleges, patient groups, regulatory bodies and clinical experts. I have asked the board to look at how we can ensure that any early signs that something is going wrong are picked up immediately, that the right organisations are alerted and that action is taken quickly.

The public and the House will want to know how the problems at Mid Staffordshire could have remained undetected for so long. One of the reasons why the Healthcare Commission began its investigation was that, after having initially been alerted to problems in the trust, it became clear that there had been serious failings for some time. The Healthcare Commission’s report raises serious concerns about why the primary care trusts and the strategic health authority either failed to spot the problems at the trust or, having spotted them, failed to act.

I have asked Dr David Colin-Thomé, the national clinical director for primary care, to review the circumstances surrounding Mid Staffordshire trust prior to the Healthcare Commission’s investigation to learn lessons about how the primary care trusts and the strategic health authority—within the commissioning and performance management system that they operate—failed to expose what was happening in this hospital. His recommendations will focus on what commissioners across England—GPs and PCTs—can learn from this case to be sure that they are advocating effectively on patients’ behalf.

Our principal concern today must be to reassure the families and friends of patients who have died at Stafford Hospital that they will be able to ascertain whether any of the failings detailed in the Healthcare Commission’s report contributed in any way to the death of their loved ones. As the Healthcare Commission has said, it is not possible to determine conclusively from any set of statistics whether there were any avoidable deaths due to poor standards of care. That can be done only through a case notes review. I can confirm that the new leadership of the trust will respond to every request from those relatives and carry out an independent review of their case notes to determine whether or not the care that they or their loved ones received was appropriate.

The failings at Stafford hospital are inexcusable. I hope that we can close this chapter in the hospital’s history by acknowledging and addressing past failings and by ensuring that lessons are learnt by government and the NHS at all levels to make sure that these terrible failures are never allowed to happen again”.

My Lords, the House will be grateful to the Minister for repeating the Statement. The report published by the Healthcare Commission makes truly appalling reading. This is a trust where failure was not sporadic or of short duration, but systemic and long term. The list of failings could not be more damning: chronic understaffing, patients starved and neglected on the wards, a lack of basic staff training, poor record keeping, equipment that did not work, an inexcusable lack of professionalism in A&E and, perhaps most concerning of all, a steadfast refusal to take seriously the complaints and worries of patients and their families. “Quality of care” in these hospitals was a phrase with little substantive meaning.

None of us can feel anything but shame that such a hospital could operate like this in the NHS for so long and, furthermore, that it should be a foundation trust. We need to have confidence now that the right questions will be asked of the right people and that the right lessons will be learnt. The Statement pertinently asks what on earth the strategic health authority and the local PCT think that they have been doing all this time. What kind of performance management has the strategic health authority been engaged in and why does a PCT, if it pretends to be on the ball, continue to commission emergency care services from a trust whose standards of performance, even at an anecdotal level, should have raised serious question marks?

I do not want to personalise this debate, but the chief executive of the strategic health authority, Cynthia Bower, has been appointed as chief executive of the Care Quality Commission, the new health and social care watchdog. Ms Bower allowed herself to be deceived into thinking that the anomalies emerging from the mortality statistics were the results of coding errors, not anything more sinister. How and why did that happen?

Looking forward, is the Minister confident that the process of registering NHS providers by the Care Quality Commission will be sufficiently rigorous, bearing in mind that registration will depend on the quality of care being delivered in a given organisation? Will the new system of quality accounts ensure that failings in basic care, such as those at Stafford, are recognised and dealt with in a timely way?

Those questions remind us that the point of debating a Statement of this kind is not only to talk about a particular NHS trust, but also to look at its implications for public policy more widely. Mid Staffordshire NHS Trust became a foundation trust only last year, yet well before that, in 2007, serious concerns were voiced about mortality rates in the trust. At what point did the Secretary of State become aware of these concerns? Why was the trust allowed to acquire foundation status in the face of an impending investigation by the Healthcare Commission? What questions were asked at that time about the quality of the senior management in the trust? Did Monitor ask those questions before ratifying the trust’s new status?

When the Healthcare Commission wrote to the chief executive at Stafford on 23 May last year requiring urgent action, what did Monitor do about it? The report shows that this was not a case of a corner being turned as soon as the commission flagged up the trust’s shortcomings; as late as September of last year, the commission says that it found,

“unacceptable examples of assessment and management of patients”.

The individuals leading the trust may well have taken some action, but essentially they were in denial. Even when the chief executive resigned a fortnight ago, he said that he was proud of what had been achieved and that it was his decision to leave. Why was it his decision? Did no one ever consider removing and replacing the senior management at an earlier stage? There was no intervention of this kind by anyone. Why not?

Is the Minister prepared to acknowledge that the Government bear some responsibility for this chapter of failures? We have seen in the NHS in the past few years a constant round of organisational change and a dogged obsession with narrow process-related targets. Stoke Mandeville, Maidstone and Tunbridge Wells and now Stafford were all hospitals that were directed towards goals other than good patient care: meeting waiting-time targets, managing organisational change and avoiding overspending their budgets. The Healthcare Commission said, about a year ago:

“A common trend has been trust boards concentrating on some of their activities, such as the delivery of targets or mergers, at the expense of others”.

It also said:

“We have found that the boards of NHS trusts we have investigated are particularly vulnerable to being consumed by the business of healthcare, in the form of mergers, reconfiguration of services, financial deficits, and targets”.

Now that the next-stage review of the noble Lord, Lord Darzi, has ushered in a new era of performance assessment, will the Minister enlist the help of the National Quality Board to look critically at the range and impact of government-imposed targets and ask whether such targets any longer have a place in a system of performance management that should be focused on the overall quality of care delivered by an organisation and the quality of patient outcomes?

The Minister ended by saying that these failures should never happen again. Therefore, what steps will the Government take to avoid the distortion of clinical priorities that process-driven targets too often encourage?

My Lords, the report made me feel sick and ashamed, because I once worked for the National Health Service, an organisation of which I have always been proud. As well as the House sending condolences to the relatives of patients who may have lost their lives as a result of incompetence at Stafford Hospital, I offer my condolences to the Minister, because it cannot be easy to deliver a Statement such as this. However, could she comment on a few points?

The reductions in expenditure that the hospital had to achieve in order to become a foundation trust must have led directly to underqualified staff being employed and corners being cut. Will the Minister comment fully on what the noble Earl, Lord Howe, said about the target culture in the National Health Service? Anyone who still works in the health service will say that this has corrupted the workings of the service. If there is no slack, people cannot work properly in a caring profession; they cannot give patients the time that they need. Targets have brought about this situation.

Will the Minister also tell us how the newly formed Care Quality Commission will function? The Healthcare Commission took a long time to pick up on what was going on at Stafford Hospital, and the new commission must also deal with mental health and social services. Finally, will she reassure the House that the chief executive of Stafford Hospital has not been given a golden handshake and moved off to an equally lucrative post somewhere else in the health service?

My Lords, I agree very much with both the noble Earl and the noble Baroness about the shame that we all feel about this report. I thank the noble Baroness for her sympathy, but it is the people of Stafford who have been failed by this hospital and what has happened.

I will work my way through the points raised by the noble Earl. It is very legitimate to ask what the SHA and PCTs were doing during this period, and why they failed. We know that boards are accountable for ensuring that their PCTs and the regulator hold them to account. In this case, there are undoubtedly lessons to be learnt about why the commissioning process did not adequately draw attention to failures in the care that was being provided. They are also accountable to the regulator, whose alert system will be triggered by the investigation.

There is no doubt that there are lessons to be learnt about why the commissioning process did not adequately draw attention to the failures of care that was provided. That is why we have asked David Colin-Thomé to review the circumstances in Mid-Staffordshire prior to the Healthcare Commission’s investigation, to learn the lessons about how the primary care trust failed to detect and prevent the failures. He has been asked to do this rapidly and he will publish his findings within a month. His recommendations will focus on what the commissioners in England should learn from this.

On a broader level, a substantial World Class Commissioning programme is under way to help commissioners to hold their acute providers to account for the outcomes that they deliver to their patients. The Healthcare Commission acknowledges that the SHA was not aware of the concerns about the quality of services provided by the trust before the Dr Foster Unit published its report in 2007. However, we know that as soon as the SHA became aware of the high HSMRs, it commissioned the University of Birmingham to undertake research into the findings on these in advance of the Healthcare Commission’s investigation. At that stage, the trust was focusing more on the data issues than on the poor quality of care. There will undoubtedly be lessons for the PCT’s performance managers to learn in ensuring that boards are held to account for monitoring the information needed to safeguard the quality of services provided to patients. That is part of the brief for David Colin-Thomé’s review.

The report asked a legitimate question about how the trust was awarded foundation status in the middle of this investigation. Perhaps I may explain the timeline. The Secretary of State supported Mid Staffordshire in proceeding to the Monitor assessment in June 2007, and it was authorised as a foundation trust by Monitor on 1 February 2008. Monitor examined the quality of safety, including the HSMR issues. The concerns at Mid Staffordshire were not known when the trust was authorised as a foundation trust, and Monitor based its judgment on the best information available at the time. I have already said that there had been a trigger in relation to those figures because they were being investigated as part of data collection, rather than as part of a failure of service to patients.

Monitor would not have authorised a trust in the midst of a Healthcare Commission investigation or if it had been aware of, or had serious concerns about, the quality of safety issues. The trust was authorised in the usual way. We have a clear process that works. Ministers approved this in the normal way. Again, we would never have supported an application had there been any indication that there were serious concerns or that a Healthcare Commission investigation was under way.

I repeat that the issues at Mid Staffordshire were not known when the trust was authorised as a foundation trust. Monitor based its judgments on the best available evidence. It would not have authorised foundation status had it known that there were very serious concerns. However, as part of their reaction to this report, Monitor and the Secretary of State have said that they will be reviewing the communication links between the department, which includes the Secretary of State’s office and the Ministers responsible for agreeing that foundation trust status should go ahead, the Healthcare Commission and Monitor to ensure that communications are as good as they can be when considering foundation status.

With regard to what is being done to improve the quality of safety, the noble Earl and the noble Baroness were right to point to the work of my noble friend Lord Darzi and his quality matrix review. Indeed, in the past few weeks we have spent quite some time discussing exactly how the setting of national standards will work at each level and how they will roll down to a local level. If we recall our previous discussions about how those quality standards would work at a local level, there is absolutely no doubt that they would catch this type of issue. They would take on board such things as complaints from patients. It is reprehensible that this trust did not discuss its patients’ complaints; that is disgraceful.

We do not see a trade-off between targets and quality. It is important to remember that the NHS had no targets in the 1980s and 1990s, and hundreds of thousands of people were on waiting lists. People were kept waiting in accident and emergency for 18 hours. But from the centre we have managed to turn that round by setting targets. We must remember that that has been achieved through the remarkable efforts of exceptional people who work on the front line within the NHS. The vast majority of healthcare establishments have met their targets and continue to do so day in and day out.

The next stage review High Quality Care for All, launched by my noble friend Lord Darzi, suggests that there will be no new targets. Until now, every NHS organisation across the country has had targets that have been achieved. We are now turning our attention, rightly, to ensure quality. This report has pointed out to us that there is a great deal more to do.

My Lords, as somebody who has been chair of two district general hospital trusts, I join in with the shame that has been expressed today. It is a shame which undermines and devalues all the good stuff that is going on in the health service. I have read the horrendous report and it is frightening and sickening, which is the word used by my noble friend on the Benches opposite.

I plead, as did my noble friend, that we do not confuse what has gone on in Staffordshire with what happens with targets. This incident is not about targets. I am chair of a big trust and value completely what patient care is about. Targets focus our minds on patients. It is not about having four hours because four hours is a good thing; it is about patients being seen much more quickly and being taken care of through the system. That happens every day in my trust and others. The benefit of all the trusts meeting the targets is that they have better healthcare. It is evident that this trust did not meet its targets; it struggled to do so. I am as astounded as everybody else that it got foundation trust status. My trust is going for that, and the steps that we have to go through are very important and rigorous.

My Lords, I thank my noble friend for her remarks. She is quite right. The process for going for foundation status is rigorous, and we believe that the performance of foundation trusts has thus far been very good. In the previous Healthcare Commission annual health check, 38 out of the 42 organisations rated excellent for both service and financial performance were foundation trusts. I am pleased that my noble friend’s trust is going for foundation status, and I am sure that if her leadership has anything to do with it, it will almost certainly be approved.

My Lords, in the investigation that is to be conducted by my old friend Sir George Alberti, will account be taken of the patently serious failings of management? It is inconceivable that any hospital in this day and age could leave patients without food and fluid for periods as described in the report and that similar failings could possibly have occurred in any hospital in the National Health Service in which I have spent so much of my professional life. May I ask not only that the failings of management, the strategic health authority and local primary care trust be examined by Sir George Alberti, but what on earth was happening to the senior medical and nursing staff in this hospital, who must have been aware of the problems that led to this appalling report?

My Lords, the noble Lord makes a fair point. From reading the report, my understanding is that members of the nursing and clinical staff were making complaints but they never reached the board. That is why the chief executive and the chair of the trust stood down on 3 March. On the good side, in terms of improving the performance of this hospital, this issue was undoubtedly due to a failure of management and understaffing. There is an action plan and increased investment in new staff. For example, there are now 12 matrons instead of three, the number of nurses has been increased significantly, the number of middle-grade doctors has been increased, as has the number of consultants, and 14 more housekeepers have been recruited. It is on the right trajectory, which is our major concern. Can we be confident that the people of Stafford can attend this hospital? I think we can now say that that is the case.

My Lords, is the Minister aware that the Secretary of State’s Statement and her answers to questions seem typical of the way the Government face crises of this sort, with parrot phrases such as “Lessons to be learnt”, “Never again”, “We’re going to set up a review” and “We’re going to have an inquiry”? Surely, the Government ought to have known about this. My noble friend on the Front Bench asked when the Secretary of State was first told about this crisis. We got no answer. That question is crucial because the Government surely should have known and should have had the facilities to find out.

My Lords, the Government would have been alerted to the fact that the Healthcare Commission was investigating, when the investigation started and when it was proceeding, which was last year. I make the point that when the Healthcare Commission visited the accident and emergency department of Stafford Hospital in May last year, it did not wait to write its report but immediately went to the chief executive of that hospital to outline its concerns and start remedial action to improve services to patients. This is not something that we have sat on, nor have we waited around for improvements. Saying that one will learn lessons when things go wrong is exactly the right thing to do. We need to have a rigorous investigation, to be open about its results and to learn the lessons.

My Lords, I am concerned about the apparent lack of a robust complaints system that could be used by patients and their relatives. Can the Minister tell us what has happened in the intervening period since the demise of the local health bodies that used to support patients? What has replaced that external support given to patients when this kind of crisis occurs?

My Lords, as the noble Baroness will be aware, we discussed patients’ complaints at some length in the past year. The system is that a complaint is initially dealt with locally. If the complainer is not satisfied with the response he receives, the complaint then goes up the tree of the health service to be dealt with. That will work, by and large. The problem in this case was that the complaints being dealt with at local level were not being acknowledged and were not being taken as part of the planning process of clinical care within that hospital. That is part of the problem. I understand that the new leadership of the trust will look at the complaints that were made and how they were handled. It will ensure that the board is handling them in a correct manner in the way that we would wish.

My Lords, does my noble friend agree that as well as the major failures in management and clinical practice, about which we have all heard with shame, there were major failures of governance in this hospital? Can she reassure the House about the training that is available to people who sit on the governing boards of foundation hospitals, particularly in relation to listening to patients and the public? When a hospital applies for foundation status, part of the test of whether it should achieve that status should be its communication with patients and the public. If that is not the case, it ought to be.

My Lords, my noble friend makes a very important point. Part of High Quality Care for All is a far greater transparency of the reporting and accountability of the board to its local population. This will be enshrined in the Health Bill which is now going through Parliament. At the moment, a number of trusts are working with Monitor to develop these quality accounts on a pilot basis. This is a part of the overall structures and accountabilities that we need to set up within SHAs to ensure that the boards and PCTs look to their local populations, and that board members are appointed who not only understand that that is a key part of their duty but are given training and support to do it.

My Lords, does my noble friend agree that no one in the House should want to return to the micromanagement of the health service that we are all attempting to escape from? Does she further agree that, despite the criticism of targets, the four-hour target for A&E admissions was widely welcomed by patients and has resulted in a substantial reduction in waiting times? Will she explain what managers are for if it is not to live within budgets? Is not the attempt to blame the focus on budgets and targets the height of irresponsibility on the part of managements at all levels?

My Lords, my noble friend puts his finger exactly on the point. This was a comprehensive failure of management to deal with both the targets and their financial administration. The targets we have set since 1997 have transformed the health service and have given the vast majority of people who use our healthcare enormous confidence in the way that they will be treated in a safe environment.

My Lords, I received a letter from a worried member of the public about that hospital, where a relative had had a bad experience. I wonder how many local Members of Parliament received letters. Can failing hospitals lose foundation status?

My Lords, there are six Members of Parliament—three Conservative and three Labour—in the area of the Mid-Staffordshire Hospital, quite a few of whom took part in the discussion in another place, to which I listened. They have all been concerned about patient care and from time to time have raised issues with the hospital and the department, all of which were dealt with. However, it was not clear until last spring that there was a systemic problem within the hospital that needed attention. I am sorry but I have forgotten the noble Baroness’s second point.

My Lords, it was about failing hospitals losing their foundation status.

My Lords, failing hospitals can lose that status. I have a very long description of how that can happen, and I will happily put that in a letter to the noble Baroness, but it can happen.

My Lords, if all of those MPs knew, what was the board doing? Is not one of the lessons that we learn from this affair that we should stop putting nodding donkeys on boards of trusts if some of them are not competent enough to ask the awkward questions necessary to make sure that trusts function properly?

My Lords, my noble friend is right that we need high quality people serving on our healthcare trusts and boards. By and large, I think that we do but, clearly, there was a problem with the board at North Staffordshire hospital and, as I have said, the chief executive and chairman have gone. The interim chief executive and chair will be looking into the membership of the board, a process that we expect to be robust. They will be looking at the governance of the trust and ensuring that the board is fit for purpose as it moves forward.

My Lords, have the two senior officers who have left that board received golden handshakes or have they been moved to other senior jobs?

My Lords, I beg the pardon of the House as I did not answer that question when it was addressed to me earlier. The chief executive remains suspended on full pay, in line with the standard disciplinary process. The trust is no longer paying the previous chairman and the future of the chief executive, who was suspended, will be determined by the outcome of an investigation.

My Lords, it is clear in the report that, way back in 2003-04, the non-standardised in-hospital mortality rates were high. Has Monitor been asked to look at whether its procedures are assessing the right things? What is being done now to make sure that monitoring of all foundation trusts will be done according to a new set of criteria, given that the criteria clearly failed to pick up problems that were already evident?

My Lords, Monitor considers safety quality, including HSMR, whose importance it recognises as one clinical performance indicator to be looked at when it reviews the clinical governance arrangements for trusts applying to become foundation trusts. To conclude on the clinical guidance governance on applications from trusts, it currently looks at a raft of other areas. Among those are: a discussion with the board, relevant clinical governance sub-committees, a review of the processes, a report of clinical problems, a clinical audit plan and a review of action plans to address issues. It reviews performance data, targets and standards, along with trends, press coverage and complaints covering trend analysis and reporting, including a review of the data from surveys of patient services and staff surveys.

When Monitor took the decision that allowed North Staffordshire to become a foundation trust, it had gone through that process and questions had, indeed, been raised with it on HSMR, but the trust and the board were then concentrating on it being about data collection and coding, not about patient care. I understand that both Monitor and the Healthcare Commission will be looking to make sure that they are more rigorous and that they communicate more obviously to ensure that these things happen in sequence. Better communication might have helped, although the evidence of the report will suggest that it would not necessarily have helped in this case.

My Lords, my noble friend referred in the Statement to the fact that,

“it is not possible to determine conclusively from any set of statistics whether there were any unavoidable deaths due to poor standards of care”,

and that that can be done only through a case notes review. But a lot of figures are being bandied about regarding the potential number of deaths that may have occurred as a result of these poor standards, ranging from 400 to 1,200 and probably any number in between. Does she have any information about what those numbers probably are? In addition, can she confirm that we are talking about Mid-Staffordshire, not North Staffordshire?

My Lords, I confirm that we are talking about Mid-Staffordshire. Sadly, there is no doubt that some patients will have suffered unnecessarily as a result of these shortcomings and failures. Regarding the numbers, the Healthcare Commission said—this was reinforced by Ian Kennedy at the press conference yesterday—that,

“these numbers do not relate to, nor can it relate to people who died. We don’t know that number. We can only know that number if we look at every set of case notes. That number refers to a statistical analysis of mortality rates over and above what you would expect and there are a number of explanations for that”

The new leadership of the trust, however, has promised to respond to every request from relatives and carry out an independent review of case notes to determine whether or not the care of their loved ones, or of themselves, was appropriate.