My Lords, with the leave of the House, I would like to repeat a Statement made in the other place by my right honourable friend the Secretary of State.
“With your permission, Mr Speaker, I wish to make a Statement on patient safety in the NHS. Last week, the regulatory bodies took action in respect of two NHS foundation trusts, Basildon and Thurrock, and Colchester, and I wish to update the House on this.
Separately, questions have been raised about safety standards at other NHS and foundation trusts. I wish to answer those questions directly and inform the House of the further steps that the Government are taking to improve regulation and safety standards.
First, let me set out some important points of context. In 1999 the Government established an independent regulator for the NHS. In tandem, the Department of Health has sought to shine a spotlight on patient safety in the NHS over the past decade by encouraging systematic publication, analysis and comparison of a range of clinical data. This followed the Kennedy inquiry into events at Bristol.
This drive has brought more transparency and a greater focus on safety standards. At all times, patient safety is our overriding concern, and there are signs of significant progress in the NHS as a whole. Overall there was a 7 per cent reduction in the hospital mortality rate in England last year. But there is never any room for complacency. Patient safety must be the subject of a continuous process of improvement. However, there is considerable variation in standards across the NHS from one hospital to another, and in some cases it is unacceptably wide.
This is the case in respect of Basildon and Thurrock NHS Foundation Trust. A year ago, surveillance of data by regulators identified a high hospital standardised mortality ratio at the trust. Since then, they have worked with the trust on a detailed improvement plan. That focus brought improvements and, over the course of this year, the HSMR has fallen. However, following unannounced inspections, the Care Quality Commission has raised further concern with the foundation trust regulator, Monitor, about care standards and the rate of improvement. It agreed that progress was not sufficient and it was felt that the trust was unable to deliver the improvements necessary within an acceptable timescale. A decision was therefore taken to intervene and use formal powers by installing a new clinical leadership at the trust. Two senior professionals from high-performing trusts will provide experienced medical and nursing support to ensure early implementation of agreed clinical and nursing changes. A programme delivery office has also been established to oversee delivery. I can assure the House that, as a result of this action, I expect to see immediate improvements and will provide regular updates on progress.
Monitor has also taken action in recent days in respect of Colchester Hospital University NHS Foundation Trust. Last Friday, the regulator used its statutory powers to remove the chairman of the trust. Monitor had, over a period of time, raised a series of concerns with the trust in relation to performance and governance. It concluded that they have not been adequately addressed and decided that new leadership was necessary to bring those improvements that patients have a right to expect. I wish to make it clear to the House that the CQC has informed me that no similar action is necessary at any other trust at this stage. As part of regular monitoring, however, it has identified a small number of trusts where action is needed to address concerns and, over the weekend, there has been further analysis of safety in the NHS.
Twelve NHS and foundation trusts have been claimed to be ‘significantly underperforming’ in relation to safety and a number have high standard mortality rates. While I welcome the shining of a spotlight on safety standards, it is important to place this finding in context. Given that deaths in hospital have reduced overall by 7 per cent, it is possible that the trusts with a high rate are not showing the same level of improvement as the rest. That said, it is vital that these questions are investigated and answered.
It is also important to point out that the report by Dr Foster has analysed a more limited set of clinical and quality data than the CQC. The CQC therefore provides the authoritative voice on these issues, and takes a wider view.
The report highlights a number of trusts where there have been issues but many had already been identified and action is in hand. I can assure the House, however, that where legitimate concerns have been identified they will be followed up and updates will be provided as and when necessary.
Patient safety must at all times be the highest priority for my department, the NHS and every single hospital in the country. I expect every trust in England to investigate all serious incidents and unexpected deaths and report them to the national reporting and learning system. This will be mandatory as part of a new registration requirement. Following events at Mid Staffordshire Hospital, hospital standardised mortality ratios for all hospitals in England have been published on NHS Choices since April 2009. From next April, the Care Quality Commission will introduce a stronger inspection regime that provides an in-depth analysis of trust performance in real time. This will also be available online for the public to inspect. However, as a result of concerns expressed, I have asked the department to speed up the implementation of this new system and will bring it in from January.
Already, 90 per cent of CQC inspections are unannounced. I wish to see this at least maintained in any new system and more unannounced visits to trusts that are giving cause for concern. All trusts will be required to screen for MRSA when admitting patients through accident and emergency. Many already do, and I am asking the department to speed up 100 per cent adoption. I will also shortly bring forward plans to link hospital payment more closely to safety and quality.
In conclusion, Lord Darzi’s next stage review made it the mission of the NHS to focus relentlessly on safety and quality. All trusts must constantly review performance and, where necessary, raise their game. Progress has been made but where it is not quick or good enough, we will not hesitate to take action. I commend this Statement to the House”.
My Lords, that concludes the Statement.
My Lords, the House will be grateful to the Minister for repeating the Statement. The fact that positively glares at us as we listen to this very disturbing announcement is that the deficiencies evident at these two hospitals are not newly discovered findings. They have been known about for many months and, in the case of Basildon and Thurrock, for at least a year. Although we are told that there has been progress in that hospital since then, when the CQC inspected the trust, it clearly uncovered deeper failings which it deemed sufficient to trigger a complete change in the clinical leadership. That lack of clarity and transparency as to the true situation at the trust prior to the CQC inspection is extremely concerning. When did Ministers first become aware that things were seriously amiss at Basildon and Thurrock as regards its poor standards of nursing and infection control? Was there an opportunity to get to grips with the situation sooner? If press reports are right, there were concerns about Basildon as far back as 2001, when the RCM described conditions there as “third world”. There have been several disturbing reports about the trust since then. In passing, I wonder why the hospital has the word “University” in its name. It is a word that tends to give a misleading impression to the public.
As regards Colchester, we understand that the action taken by Monitor did not relate to hygiene standards, but higher than average mortality rates were a factor along with deficiencies in management and leadership. Will the Minister give us any further details to put the drastic action taken by Monitor into better context?
It is reassuring to hear that the CQC does not believe that similar action is called for elsewhere in the NHS, yet at the weekend Dr Foster published data which tended to suggest that that assessment might be premature. I was unclear about what the Minister was saying about Dr Foster's findings. Was she saying that the mortality figures quoted by Dr Foster were out of date, or that they failed to give a balanced picture of the overall standard of care in those trusts? If it is the latter, it seems odd to presuppose that the so-called wider view offered by the CQC is inherently more valid than performance measures that focus on individual factors or areas of activity such as mortality rates. I am not sure of what Dr Foster stands accused. Equally, it seems strange to seek to excuse hospitals of apparent poor performance on the grounds that the overall trend in performance across the NHS is improving and that in any case everything is relative. That smacks of defensiveness on the part of the Government. In fact, it steers perilously close to complacency.
In a debate of this kind it is easy to sound negative about clinical standards across the entire NHS. I do not for a minute wish to do that because I am personally aware of many superbly run hospitals which deliver a standard of care second to none. Nevertheless, we have recently had a string of announcements about poorly performing hospitals, each of which has been characterised as an isolated case, such as Stoke Mandeville, Maidstone and Tunbridge Wells, Mid-Staffordshire and, now, Basildon and Thurrock.
The mix of failures at each hospital is unique, but there are recurrent common themes: waiting time targets prioritised above safety and hygiene; a focus on financial issues and ticking boxes at the expense of quality in patient care; and senior management showing a lack of proper leadership, with front-line staff finding that their concerns are not being acted on. I worry that the assessment methodology that the Healthcare Commission relied on, of self-reporting by trusts and prearranged inspection appointments, has not delivered a true picture of those trusts whose standards have subsequently been shown to fall well below what is acceptable. Does the Minister agree that the assessment methodology to be adopted by the CQC needs to move away from that model and to rest much more on what patients actually experience during their time in hospital and on unannounced inspections?
Will that be done? If so, how will it be done? For example, what system can be put in place to enable the CQC to monitor patterns emerging from complaints and from hospital outcome data rather than from how well or badly a hospital is adhering to process-based targets? How can we ensure that the concerns of front-line staff are listened to rather than swept under the carpet?
Finally, I was a little surprised to hear that the CQC feels that it is currently in a position to accelerate the introduction of what the Statement describes as the,
“in-depth analysis of trust performance in real time”.
Is it sufficiently resourced to do that earlier than next April? Something tells me that we shall return to these matters on future occasions, but in the mean time, it is right to wish both Monitor and the CQC well in fulfilling their respective roles.
My Lords, I, too, am grateful to the Minister for repeating the Statement made in another place earlier. Before turning to the substance of that, I also wish to acknowledge the tremendous amount of very high-quality work done in most hospitals and trusts throughout the United Kingdom. It is always tempting when there is an incident of this kind to lose perspective and work it up into something with which to create panic. I do not believe that we should do that. It is our job as responsible parliamentarians to look at the facts in context and abstract from them relevant conclusions.
That said, at the time of the revelations about failures at Mid-Staffordshire and in light of the failures at Tunbridge Wells, both of which were trusts approved by the CQC, my colleague in another place, Norman Lamb, said that it was time to look at the role of regulators. In view of these two latest incidents in Basildon and Colchester, there is an even more compelling case to look at the role of Monitor, sitting as it does alongside the CQC, and the interventions of Dr Foster. As the noble Earl, Lord Howe, observed, there remains a suspicion from all the reports into these incidents that the role of targets is detrimental to clinical priorities. Time and again, in each of the reports, staff make the point that they are having to change their practice to ensure that the hospitals meet targets and fulfil those things that are more likely to be monitored. These may not necessarily be the things that are in the best interests of patient care.
The Statement repeated by the noble Baroness mentions the number of unannounced visits. All noble Lords present this evening were also present during the passage of the Health and Social Care Bill when we debated at length the role of unannounced visits. I take little credit, but I remind noble Lords that that was a point which some of us felt was essential to rooting out poor practice. I, too, ask the Minister whether she can confirm that the CQC, in meeting the accelerated timetable, will continue to have the resources to conduct unannounced visits in all trusts.
It is also worth noting something that was not in the Statement but is none the less important. In Basildon and Thurrock, it was Mencap which drew to people’s attention the fact that four of the people who died had learning disabilities. That happened as a result of Mencap’s campaign, Death by Indifference, which has focused attention on poor clinical services being received by people with learning disabilities. I ask the noble Baroness whether, in the programme of work to bring about change that she has outlined, care of people who have learning disabilities will be part of the improvement.
I will focus briefly on what is at the heart of many of the problems. There are three different bodies, each producing information about the quality of work in trusts. There is CQC, Dr Foster—an organisation co-owned, incidentally, by the Department of Health—and Monitor, each producing its own ratings. Just this last weekend, Dr Foster produced a report which indicated that 12 trusts were in the lowest of its five bands of rating for safety, but one of those—St Helens and Knowsley—has been rated as excellent by the CQC. It seems rather strange that we have three different bodies, each producing vastly differing assessments of what is going on in the same hospitals.
In January 2008, Monitor, in its evidence to the Health Select Committee in another place on the Health and Social Care Bill, said:
“The requirements to meet national standards and targets and monitor and improve quality are a significant element in the Terms of Authorisation”—
for a foundation trust. It continued:
“We have developed a detailed approach to ensuring compliance with these elements of Authorisation. We are working closely with the Healthcare Commission”.
Monitor went on to say:
“For example we have worked successfully with the Healthcare Commission on specific investigations of clinical performance, The Health Protection Agency and the Department of Health on Healthcare Associated Infections and independent auditors on waiting time management. We believe this has provided a robust regime for assuring quality in NHS foundation trusts and should form the basis of the regime going forward”.
Does the Minister agree that that was perhaps misplaced optimism on the part of Monitor and that, in light of these events, following events in Mid-Staffordshire and Tunbridge Wells, it is now time to have a look at the inspection regime in order to bring clarity and consistency to the three different bodies monitoring hospitals? Does she further agree that the criteria for that ought to be to ensure consistency in patient safety and to restore the confidence not just of the public but of the NHS professionals who work in those institutions and who have a right to know that their hospitals are good?
I thank the noble Earl and the noble Baroness for their remarks. I shall try to work my way through the questions that we are addressing this evening. The noble Earl asked when Ministers become aware of these matters. He asked me exactly the same question when we discussed these issues in relation to Mid-Staffordshire. The answer is almost exactly the same; Ministers become aware through Monitor and the CQC—the regulators—that concerns are being expressed about hospitals. Indeed, both the CQC and Monitor took co-ordinated action with regard to Basildon and Thurrock trust, which included the unannounced visit. An action plan was then produced. I have been looking at the timeline of exactly what happened and in what order—I should be happy to share that with noble Lords—which shows that there was enormous co-ordination, which led to the actions that were taken.
The noble Earl asked about mortality rates being out of date and whether they gave a complete picture. The HSMRs are quoted by Dr Foster, but they relate to 2008-09. Since then, the trusts’ own data—I refer to the trusts that were mentioned; I shall come back to the Dr Foster report—suggest that significant improvement has been made. HSMRs are important for alerting further investigation, but as we have discussed previously in the House, on their own they are not a sign of a good or a bad trust; they are a signal that further investigation may be needed.
The noble Earl and the noble Baroness, Lady Barker, referred to the different factors that the CQC will use as we move forward into the new regime. As noble Lords know, that will kick in in April. The annual health check is not at all a tick-box exercise. It will include follow-up inspections of trusts and the analysis of thousands of pieces of information from surveys of hospital patients and of 150,000 NHS trusts and data on waiting times, access to services, cancer survival rates, treatment of stroke and heart patients, mortality rates, infection rates and information on spot checks. I assure the noble Baroness that those checks will continue and will be a very important part of the work of the CQC. The annual health check will also include information from reviews of specific issues such as safeguarding children and information from public groups such as the local involvement networks; in other words, it will be a 360 degree analysis, taking on board all the major formal and informal factors.
That leads me to the point about the difference between Dr Foster and the CQC. We are encouraging a culture of openness and challenge within the NHS, particularly in relation to patient safety data. That is a good thing. Dr Foster’s report uses NHS data, but interprets them in a particular way, using a particular methodology. Some trusts are, indeed, challenging that—and that is their right. Those conversations will no doubt continue. But we set up an independent regulator precisely to be the authoritative voice in these situations. The CQC looks at a much broader range of data than Dr Foster does. It also carries out unannounced inspections, as it did in relation to Basildon and Thurrock. So we are not setting up these ways of looking at patient safety in opposition to each other; we are saying that there are different voices—many voices—which will be heard in a culture of challenge. But the CQC is the body to which we look for patient quality and standards. The analysis that it carries out is the one that we will use to establish whether or not trusts need investigation, irrespective of whether they have assured us that they are not experiencing the kind of failings that we have seen in Basildon and other trusts. While I can see why people might find that confusing, it is a sign of a healthy culture that is challenging the issues on patient safety at all times.
The noble Earl mentioned Colchester Hospital University NHS Foundation Trust. On Wednesday, Monitor used its formal intervention powers at Colchester to remove the chair, with immediate effect, and appointed Sir Peter Dixon as interim chair, with effect from today. The foundation trust was found to be in significant breach of its authorisation by failing to comply with healthcare standards and to exercise its functions effectively, efficiently and economically. There were serious and wide-ranging concerns about its governance and leadership. Monitor has done exactly what it was set up to do—to deal with concerns that it had.
I had anticipated that the noble Earl would raise the issue of targets. He may anticipate my answer. We have been clear that no achievement of targets or foundation trust status should be at the expense of patient safety. The targets set from the outset by this Government have reduced waiting lists and increased the speed with which people are treated in accident and emergency. We know that we need to do more, which is exactly why the proposals of my noble friend Lord Darzi in High Quality Care for All set out a vision of the next step, which is making quality the organising principle of the NHS. The noble Earl asked whether the CQC was sufficiently resourced to carry out this job. There are sufficient resources to undertake real-time assessment of providers’ quality, using self-assessment and a range of inspection tools, which I have already mentioned.
The noble Earl and the noble Baroness, Lady Barker, talked about patient and staff voices. I hope that I have demonstrated that both matters are built into the continuous monitoring and assessment of hospitals and that both are very important indeed. The noble Baroness, Lady Barker, asked about healthcare-acquired infections. The results have been dramatic; we have reduced them.
I am told that I should stop talking, although I wanted to deal with all the questions raised.
We have done a great deal of work to support people with learning disabilities and have recently launched Valuing Employment Now. We must take, and are taking, more care in this area to support Mencap and work with it to ensure that its aims are built into the work that we are doing in hospitals.
My Lords, the Minister has on a number of occasions used the phrase “patient safety” in the context of this Statement and the questions on it. Is she aware of the considerable concern, indeed alarm, in Suffolk, where I live, at reports that the emergency coronary facilities in Ipswich Hospital will be closed and that patients who have heart attacks will be transported either to Colchester, which is not flavour of the month, or to Addenbrooke’s or Papworth in Cambridge, which would be a very long journey? This is a very serious issue for people in Suffolk. If the Minister is not briefed on the subject, I should be grateful if she would urgently write to me.
My Lords, it is certainly true that I am not briefed on the issue. Obviously, patient safety is at the heart of the work that we do, and recent surveys show that 93 per cent of patients rate their overall experience as good or excellent. However, I will undertake to find out specific details for the noble Lord and write to him.
House adjourned at 8.46 pm.