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NHS: Mid Staffordshire NHS Foundation Trust

Volume 744: debated on Monday 11 March 2013

Question for Short Debate

Asked By

To ask Her Majesty’s Government what plans they have to implement the recommendations of the Francis report into the Mid-Staffordshire Hospitals NHS Foundation Trust.

My Lords, even though the hour is late, the weather is inclement and the speaking time allocated to each noble Lord is short, I am grateful to all noble Lords who are to take part in this debate. I recognise that, although the Minister will have to reply to the debate on behalf of the Government and that the Government will eventually respond to the Francis report, the report spans several previous years. I hope the Minister can tell us when the Government will produce their full response and what form it will take. Will they make a financial assessment of the implementation of the recommendations?

Compassion, care and co-operation are the magic of the NHS; so said the leader of the Opposition at, I am led to believe, a Labour Party conference. The report by Robert Francis on Mid Staffs Hospital suggests that that magic is gone, not only from Mid Staffs, but, judging by the daily reports from more and more hospitals of poor quality care, from other hospitals too. The culture that brought about the disaster at Mid Staffs may well be more widespread. At the same time, there are hospitals that provide excellent, high quality, compassionate care, and we must not forget that.

None the less, Francis has to be right when he says that a cultural change is required. We need a culture that cares for patients and puts the quality of patient care and safety first, with a shift from compliance to targets and from financial probity to patient care. The words “patient safety” appear on virtually every page of the report. That such a degree of harm and suffering was inflicted on patients and that doctors and nurses were part of the culture is hard to comprehend. As a doctor who worked in the NHS only, I recognise the words of another clinician, the noble Lord, Lord Darzi, who wrote in the Times on 4 March that for doctors, nurses and other clinical professions, professional pride defines who they are. That clinicians had become part of a culture of bullying, secrecy and gagging is difficult to fathom. To change this culture, the Francis report, which extends to 1,800 pages, makes 290 recommendations covering the spectrum of the regulation of healthcare, including patient and public involvement and complaints handling. If the recommendations are implemented in full, what effect does the Minister think it will have on the reforms in the Health and Social Care Act?

One of the key recommendations of the report, which the Government rejected from the outset, is to merge the financial regulator Monitor and the quality regulator CQC, both of which failed in Mid Staffs. Experience has been that the two organisations have not been able to work together in a co-operative way, so why have the Government been so quick to reject the Francis recommendation? Francis expects that all organisations, including the Department of Health, should report annually on progress towards implementing his recommendations. Will the Minister say who in the Department of Health will have the responsibility of making sure that that happens? I cannot help but feel that patients and the public will expect the Government to take the lead.

In the Statement that followed publication of the report the Government announced the establishment of a post of chief inspector of hospitals. The CQC in its response added a chief inspector of social care. Does this fundamentally change the function, nature and the management of the CQC? What is the role of its board and chief executive vis-à-vis the chief inspector and his army of inspectors?

The Secretary of State is inviting other regulators to inform him how they will make the processes and system of accountability more stringent. From the many briefs your Lordships have received in advance of today’s debate, all the regulators and the so-called quasi-regulators see themselves as having a key role in making sure that high-quality patient care is delivered and is safe. They all also suggest that they may carry this out by inspections. If they and their managers now see the Francis report and its recommendations as the new targets, then they miss the point. I hope the Government do not. No amount of inspections by expert inspectors and regulators on their own will provide the safeguards needed, nor improve patient care. The culture change that is required will allow well trained health professionals to provide the patient care that the majority of them are capable of providing and let others provide the support that enables them to do so. Of course their performance should be monitored and their shortcomings dealt with.

On a personal note, last week I came across brilliant, compassionate, world-class quality care when I had surgery to restore my sight. Now I can see noble Lords in their full glory—some of it is a pleasant sight. All the professionals and non-professionals I came across in that hospital—I do not mind naming it; it was Moorfields Eye Hospital—were world class and brilliant. The culture that was exposed at Mid Staffs does not exist everywhere else and the response therefore must be proportionate. I did not see any of the Mid Staffs culture in that hospital.

I would be concerned if all the regulators, commissioners and others—I counted 21 organisations whose briefs I read as a response to the Francis report—now wish to monitor and inspect hospitals. Bureaucrats only increase bureaucracy. Does the Minister agree that a clear direction is required from the top as to the role of each organisation in the implementation of the recommendations of the Francis report?

I come now to the patient safety recommendations in the report. Two words appear frequently. Francis felt failures at Mid Staffs were a result of systems failures. Others have agreed, if only to absolve themselves or their organisations from blame. Other industries such as the airline, nuclear, transport and offshore industries are familiar with the concept of systems failures. They also know that the same system is operating throughout the industry and if it fails in one place it is likely to fail elsewhere too. For example, the 787 Dreamliner was grounded because two planes showed faults. The next step in any systems failure is to carry out root cause analysis, implement the learning and make changes to make the system safer. If the Francis report is a root cause analysis of a systems failure, then a systems change is required.

Francis also recommended establishing a national system of reporting and learning from patient safety incidents. Who will be responsible for making sure that this is done? The Government are also asking Sir Don Berwick to advise them on the implementation of a strategy of no harm in the NHS. Sir Don Berwick, previously administrator of US Medicare and Medicaid, is a friend, and we worked together previously. Can the Minister confirm or say otherwise that the advice Sir Don Berwick gives will be published in full and will be implemented?

The Francis recommendations are far reaching with very wide implications. Unless the Government take a lead and give clear direction on the way forward, we run the risk of chaos reigning. I look forward to the Government’s studied and considered response in due course and hope that then we will have a longer debate at an earlier time.

My Lords, it is a great pleasure to follow the noble Lord, Lord Patel. Of course, I must defer to him, as he knows far more about the National Health Service than I do. I have been a patient but do not have anything like his depth of knowledge.

There is not much that we do not know about Mid Staffs. A lot of it dates back a fair number of years. The Francis findings were amazing, and the taking and recording of the evidence was truly a wonderful job done. There was a complete failure of management. Nobody had any confidence in anybody else there. However, time has gone by and things have been done since, and I feel quite cautious about how much we should generalise out of the experience of one hospital. I think we should treat this with caution.

Much has been done since. There have been changes in the management and governors of the trust. It is well recorded that there have been significant improvements from a very bad position. Of course there is always more to be done, but that is a condition of all our lives; there is no end to continuous improvement and never will be.

This takes me to the 290 recommendations in the Francis report. I do not feel at all capable of dealing with those. As the noble Lord said, we await the Government’s response. In fact, there are rather more than 290 recommendations, if you add in the bullet points. There are some 10 bullet points within some recommendations. To me, the trust’s most important decision and most important choice is who to appoint as its chief executive, with the necessary knowledge and the team-building skills that go with that knowledge. Hospitals are complicated and continuous operations. No two patients present in the same way. Mid Staffs provides 48 distinct services.

The new chief executive has her chairman and his governors, six executive directors and four heads of clinical directorates: 10 people in executive positions. Of these 48 services, 40 are medical and the other eight finance, administration, and so on. I must be careful to point out that the trust and Mid Staffs are not exactly the same thing. The trust employs close to 3,000 employees, so the 48 services, with the 3,000 employees, are the management responsibility of the 10: the executive directors and the heads of the clinical directorates. Clearly with that number of employees and that number of services, there is a need for a detailed and well understood middle management structure. After all, there are 120 consultants, all professionally qualified and all of a certain seniority.

I will end with one example of how one needs to look at the middle management—the 800 in admin and estates—and the person within that system who is responsible for bed linen. That person needs to hold a budget, and needs to be sure that the supplies of bed linen are as they should be, that the laundry works as it should, and that the linen is available. If one looks back to the Francis report and tries to find how the reports that have been done have tackled these very detailed problems of middle management—MRI, ultrasound, X-ray, or what you will—there is not much to be found. I therefore urge us to concentrate our minds on the management, the staffing, and the leadership of individual hospitals, and not to widen our look too greatly.

My Lords, I, too, thank the noble Lord, Lord Patel, for introducing this debate with his usual panache.

As Roy Griffiths said in 1983, when he was looking to change the management structure of the NHS,

“if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”.

I think she would have been more concerned today about finding someone in charge of the care of the patients in the corridors of the Mid Staffs hospital. She would have been looking for anyone able to explain what had been happening to the patients for so long and would have found no one.

The Francis report outlines a huge number of recommendations that include changes in the culture and much about policing the service to detect poor behaviour, but to my mind, beefing up the complaints system, while very important, comes a bit too late. We need to think more about preventing the need for the complaints, and there is one crucial omission; while there is a strong focus on the responsibilities of the managers and the board, none of these people, try as they might, can be on the wards all the time, every day of the week. They visit from time to time. The doctors, too, come and go as they rush to their clinics or operating theatres. The people on the wards all the time are the nurses, and this is where we have to focus hard.

I am in no position to criticise the nurses themselves—they do a fantastic job, and I have personal reasons for being enormously grateful for what they do. My aim in pointing at the nurses is much more to do with the way in which nursing careers are organised. This is where I believe some changes are needed. We need to bring back the old-style career-grade sister who was in charge of the ward. Many years ago when I was a young doctor—I am sorry that I sound like an old fogey—the sister in charge really was in charge. She was usually a mature woman—there were few men in those roles—and she ran her ward with a rod of iron. Both the patients and the doctors ran scared and were loath to cross her, but she knew everything about every patient, and the doctors relied on her implicitly. She would not have countenanced the sorts of behaviour that were described so vividly in the Francis report.

What has happened to that post? Now the role of ward sister is not regarded as a career post at all. It is simply a rung on a ladder, and after a year or so they are promoted to teaching or more managerial roles. It is just a stepping stone to bigger and better things that are not so closely engaged with the patients.

Consultant friends tell me that it is unusual for them to find a nurse, let alone the sister, to accompany them on their ward rounds, or indeed to find anyone to tell them what has been happening to their patients. The solution, to my mind, is not the heavy hand of top-down monitoring and punitive complaints procedures, but the placing on each ward of sisters or charge nurses in clinical career posts—I stress clinical posts—who are given full responsibility for what goes on in their wards and are awarded accordingly. My view is that they should be given exactly the same salary as a consultant, since that would be commensurate with their level of responsibility. It would be a post that commands all the respect that you would expect of someone in such an important position. I recognise that this idea might not meet with the approval of the nursing professional bodies, but I ask the Minister to consider this proposal sympathetically. It seems to me to be the only way in which Florence Nightingale and her lamp may be able to find someone in charge of the patients’ well-being.

My Lords, I, too, thank the noble Lord, Lord Patel, for bringing this important issue to the attention of this House, and for so eloquently outlining all the areas of concern shared by all noble Lords.

The negligent treatment of patients at the Mid Staffordshire hospital is inexcusable. To an extent, we are all culpable, as we let a culture develop across the NHS that fails to keep the patient central. I know that, as noble Lords have said, this is not the same everywhere, but there are certainly quarters in some hospitals where one can identify this still. We are now obliged to build a system to prevent its repetition. Given the time restrictions, I will limit my comments to a specific viewpoint. I am taking the perspective of the patient.

Our systems should be more proactive in seeking out patient perspectives and more responsive in addressing their complaints. At Mid Staffs, the patients were speaking out about the abusive environment and many warning signs were apparent, yet no one was listening, these signs went unnoticed and any criticism was oppressed. Not only was the abuse suffered intolerable but it is unacceptable that this inquiry would not have happened without significant public pressure over several years. The inability of the hospital and the Government to act swiftly when presented with these conditions of appalling care must be reflected upon.

Putting patients and their needs at the core of our health service is one step that we can take towards correcting this. Many changes need to take place. We must stop designing our patient safety systems on what fits well with our institutions. Instead, the core of how we protect patients should be built around the patients themselves. Three areas of focus are needed to make this happen.

We need to ensure that patients, families and carers are empowered to speak out when they receive negligent care. I support the swift adoption of the recommendations to create an accessible complaints system. I note the point made by the noble Lord, Lord Turnberg, that we should not need a complaints system, and I hope to goodness that we will soon be in a position in which we will not need one, but until that time I believe that we do. Every patient should know how they can have a voice and should be secure in knowing that there will be recourse for any problems that they raise. I ask my noble friend the Minister to commit to a complaints system that is responsive and responsible, that all patients are aware of, and where complaints are thoroughly investigated and will be received by the board. Will the Minister confirm that such a system could be implemented anywhere that NHS money is spent: private, not-for-profit and NHS trusts alike?

Patients should automatically be given all information regarding the level of care that they have received, including information about any lapses in the quality of care or mistakes made. I therefore welcome the recommendation of the establishment of a statutory duty of candour. Health workers, be they senior consultants or junior nursing assistants, must feel that they can talk with their patients if something goes wrong. This creates an open dialogue between patients and their carers and ensures that mistakes are addressed in an open, well informed manner. Will the Minister confirm that there will be a statutory duty of candour?

In addition, patient organisations must be listened to and action taken. Local Healthwatches should use the tools they have been given to work on behalf of patients to make sure that negligent care is caught early and corrected. They need to ensure that Healthwatch England and the CQC are informed immediately where systemic abuse and intolerable care are identified.

Even if every one of the 290 Francis recommendations were to be instituted immediately, a more fundamental culture change must happen throughout health and social care facilities. Noble Lords have already referred to this cultural issue. Solutions, as seen through the perspective of patients themselves, should be core to the strategy. Through efforts to give patients information about their care, empowering them to speak out and then listening to their voice, we will be able to help prevent these tragedies in care repeating themselves.

My Lords, I am most grateful to my noble friend Lord Patel for calling this timely and important debate. As vice-chair of the parliamentary group for children and young people in care and leaving care, I am aware of some of the issues around caring for vulnerable people.

Indeed, in reading the Francis report, I recalled another report by my noble friend Lord Laming at the beginning of the past decade into the death of Victoria Climbié. A member of staff of Haringey social services said that they were providing a conveyor-belt service for children and families and were overwhelmed. The principal social worker for Victoria Climbié, Lisa Arthurworrey, was a young, inexperienced, newly qualified social worker with an excessive case load who was poorly supervised. Alas, she and her colleagues were not able to take the necessary steps to prevent the death of that eight year-old child.

In my experience, particularly of child and family social work and of staff in children’s homes, it is vital to value those who work directly with such vulnerable people and to provide them with the training and support they need to do the right job. If one wishes to create a culture of care, many factors are involved. However, a crucial element of that is providing a caring environment in which one takes care of and values one’s workforce. One needs to select the right people and offer good continuous professional development, including training and supervision, and ensure that the voice of that workforce is listened to. I was particularly pleased to see the Francis report emphasise this need for a strategy for the workforce. I was also pleased to note the detail regarding the regulation of healthcare assistants. I would be grateful to the Minister if he could say a little about progress towards registering these assistants. It is encouraging that there is now talk about registering staff in children’s homes. This has already happened in Wales and Scotland and plays an important part in protecting vulnerable people in those settings.

As for the vital necessity of caring for the workforce, I would be grateful if the Minister would indicate what more might be done to make more public the state of morale within the NHS workforce, including, for instance, easily accessible information on staff turnover and sickness and absence rates. Having read the Francis report, if I go into hospital the first thing I will try to find out is the state of staff morale in that hospital. In discussions on the Health and Social Care Bill, we were given information from the King’s Fund or the Nuffield Trust indicating the wide disparity in workforce morale in different trusts. This needs to be addressed if we are to change the culture to one of more consistent care.

Finally, and I say this hesitantly, my sense of what is sometimes the most dispiriting thing for people working in the health service, having spoken with them over the years, is the sense that there is another huge reform coming through. It can seem that each time there is a new Government or a new Secretary of State, there is a new transformation of the health service. Respectfully, therefore, I request that the Minister perhaps encourages his colleagues to think twice before embarking on any major new reforms of the health service. I would respectfully say the same thing to the opposition Front Bench. Given that experience of the concerns expressed in the past, I would be grateful if they would attend to that.

My Lords, I am particularly grateful to the noble Lord, Lord Patel. For 40 years I was a Staffordshire Member of Parliament, and for the first 27 of those years, the Stafford Hospital looked after a large part of my constituency. It was a good hospital; I do not remember receiving a single serious complaint in those 27 years, and I visited regularly. In 1997 we had boundary changes, and from then on only a handful—relatively speaking—of my constituents went to Stafford; the others went to Wolverhampton, Walsall and Dudley.

I was devastated when I, as chairman of the Staffordshire MPs, took colleagues whose constituents had been affected, to see successive Secretaries of State. The terrible, tragic stories would have moved the stoniest of hearts. It is an indictment going far beyond Stafford that in his report, Mr Francis had to put at the top of his list of recommendations what we should all automatically take for granted: that it is the duty of the health service to put patients first. We should not need to be told that.

In his report, Mr Francis makes a number of comments about leadership. He recommends that there should be a staff college—I hope that my noble friend will agree that that will happen. He also talks about governors being given proper training. He is not quite so explicit when it comes to board members, and I did raise that subject when we had a brief question and answer when the Statement was given a few weeks ago. Everyone concerned with the running of the hospital, and with being part of the leadership needs to have proper and adequate training for that role.

I have to touch on a rather contentious matter, because the fact is, if leadership is going to be effective, it has to command confidence and respect, and it has to enjoy the support—not merely official, but explicit and implicit—of all those people over whom leadership is being exercised. There is, of course, a famous phrase that the buck has to stop somewhere. One has to recognise that during part of this terrible period, Sir David Nicholson was in charge in the Midlands. We have to accept that he is the chief executive of the National Health Service now. I have to ask the question, and I think it would be wrong if this question was not raised in the Chamber this evening: can we have trust and confidence in Sir David Nicholson to deliver a health service that is truly worthy of our great country? I believe that he should be examining his position very carefully. This happened on his watch. We are told that 1,200, or thereabouts, died unnecessarily. Somebody, Charles Moore I think it was, wrote in the Telegraph the other day about the Prime Minister going to Amritsar where fewer than 400 people were killed; 1,200 died during that period. I have to say to your Lordships: is this really the man to carry forward our health service for the next few years?

My Lords, I had not originally intended to take part in this short debate but on Friday I was encouraged to do so by the Royal College of Physicians—incidentally, after I had gone away for the weekend without any briefing material. As the noble Earl knows, that college has made detailed comments and recommendations related to the inquiry, along with a number of other professional bodies, including the BMA, the Royal College of Nursing and many others, as the noble Lord, Lord Patel, said.

I want to consider just a few ways in which the blatant failures of care at Mid Staffs might have been prevented or at least brought into the public domain much earlier. These suggestions relate mostly to points made by the professional organisations that the noble Lord, Lord Patel, has just mentioned, as well as by the Francis report itself. First, GPs could be more involved by listening to their patients or their relatives, and thus be more in touch with their in-patient experience. GPs can act as strong advocates for their patients through their contact with consultants and managers. If they are aware of the reality of patients’ experience, clinical commissioning bodies will be more discriminating.

Secondly, clinical and managerial staff with concerns should be encouraged to come forward and not be intimidated. Whistleblowers should be encouraged to speak out at regular open meetings where innovative ideas by NHS staff could also be put forward and discussed. There is a wealth of ideas waiting to be tapped among staff at all levels, which could be used to improve patient experience and outcomes, and often cut costs at the same time.

Thirdly, auxiliary staff should be registered. This would mean that they had to receive training of a set adequate standard. This would improve not only the quality of their work but their morale, and give them vocational pride and recognition. Those who wished should be given the opportunity of career advancement through gaining further qualifications.

Fourthly, the best features of community health councils should be brought back. Current arrangements through the CQC, or its equivalent in 2008, for voicing patient concerns clearly did not function in Mid Staffs. An up-to-date CHC-like organisation would give patients and their relatives ready access to a representative, truly independent, body where they could freely voice any concerns that they had about their hospital experience. CHCs had the right to speak directly to NHS authorities, to visit any NHS entities and attend trust meetings. CHCs’ own meetings were open and transparent, and were often reported in the local, and sometimes national, press. CHCs were of course of uneven quality and received barely adequate funding. However, they could prove to be an embarrassment to NHS administrators when unwelcome truths were openly discussed. Perhaps it is understandable why they were abolished by the previous Government in 2003. As the noble Earl will remember well, I strongly opposed their closure at the time. I remind him that he also opposed their abolition. As I recollect, we were then in agreement, although from opposite sides of the House.

My Lords, I, too, thank the noble Lord, Lord Patel, for introducing this debate and for the measured way in which he did so. It behoves us not to begin a blame game but rather to pick up the recommendations of this superb report and act upon them. It is far more profitable. A few of us who were sat in another place during the time that this was going on raised the sorts of concerns that are now being raised with hindsight.

In the time available, I should like to concentrate on recommendations 185 to 213, which affect nursing and healthcare support workers. What concerns me about this report—and indeed these recommendations—is how we can prioritise and implement them, because trying to prioritise and implement 290 at the same time is, quite frankly, an impossible task. As was said by the noble Viscount, Lord Eccles, time has not stood still since Mid Staffs. The Nursing and Midwifery Council has produced new standards for pre-registration nursing training, which are widely welcomed by patient groups, by the higher education institutions, by professionals and by providers.

As we move to a fully graduate nursing profession, I trust we will not waste time re-opening the issue of a graduate nurse workforce, as indicated by Ann Clwyd in another place. Francis quite rightly recommends a greater emphasis on recruiting caring as well as intelligent students, but believing these two qualities to be mutually exclusive is disingenuous. With less than 25% of current nurses being graduates, it was not graduate training that caused a lack of care at Mid Staffs. The quality of the placements where nurses receive their practical training requires urgent attention, as does the quality of mentorship they receive.

The 50% practical placement is fundamental to the development of a well trained workforce, yet far too often students are dissatisfied with the quality of the experience they receive on their placements. Fewer placements are now in hospital settings, particularly acute hospital settings, and staff are often too busy to give of their time. Learning is not seen as a corporate activity and, more worryingly, core competencies are sometimes neither practised or observed before being signed off. At the core of this problem is the outdated view that all registered nurses can be good mentors, and that somehow mentorship can be added to very busy schedules with little training or additional time. That must change. If we want our nurses to be inspired to be more patient-centred, then the practical learning settings must be of the highest possible standard. Mentors must care for their students, and be valued by their employers.

Francis also recognised that throughout our health and care system more and more care is delivered by untrained and unregulated healthcare assistants. Regulation 209 is perhaps the most powerful statement made by Francis, stating that,

“no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor”.

We do not in fact allow anyone to work on a gas fire without proper training, yet we allow people to work on those who are in the greatest need.

The first step—I hope the Minister would agree—is to have mandatory training by the end of this Parliament, with standards for all healthcare support workers who provide direct physical care approved by the NMC, or another body which the Secretary of State approves. Without mandatory training, it will be unlawful for employers to engage these workers. To the Minister, who is worried about registration, I suggest that an immediate step toward independent registration would be that by the end of this Parliament every employer who provides direct physical care will be required to keep a register of all their employees who deliver care. Their training records should be available for inspection by the CQC, Monitor and Healthwatch England, or its regional equivalents. Surely patients and their families have the right to know at least that those who care for them are at least appropriately trained, and that their employers will be held responsible for their deployment.

My Lords, I join other noble Lords in thanking my noble friend Lord Patel for having secured this important debate. I declare my own interest as professor of surgery at University College, consultant surgeon at University College Hospital, and a member of the General Medical Council. There can only be one north star guiding the way we operate in the National Health Service and the way we deliver care, and that must be our patients. In his report, Sir Robert Francis refers to a deterioration in cultures and values. We must find ways to ensure that the cultures and the values that must attend the delivery of healthcare are rapidly restored in our healthcare system.

One way that this may be achieved is by revisiting the question of professionalism. All of us in the health service today work in multidisciplinary teams and, quite rightly, those teams are comprised of clinicians, nurses, other therapists, healthcare assistants and indeed managers who help us to utilise effectively the resources available for healthcare. Those teams can work only if there is mutual respect, but there must also be professionalism.

With regard to clinicians—and I talk here particularly about consultants in hospitals—we need to move to a position where once again consultants are accountable for the management of, and delivery of care for, the patients for whom they have responsibility. They must have the authority to deliver that responsibility for care, and with that responsibility and authority they must be held accountable for the outcomes of their patients. That is very clear. Ultimately, it is vital that patients and the public generally recognise, and are able to have confidence in, the fact that when they are admitted into hospital they will be managed and be under the care of a named healthcare professional—a consultant—who will take that responsibility, have that authority and be held accountable.

In terms of the management of the ward environment, it seems sensible to return to the ward being under the leadership of a named senior nurse—a sister or a charge nurse. Their name might appear at the entrance to the ward, and the name of the consultant responsible for the individual patient’s care might appear under the name of that patient at the head of the bed, so that there is no doubt about who has responsibility for both the ward setting and the individual care of the patient.

In the Francis report, we also see reference to broader questions of culture and values. Part of restoring professionalism will be revisiting once again the contract of employment for healthcare professionals—both consultants in hospitals and general practitioners in primary care. We need to move away from the consultant contract being principally one of contractual obligation and take it back to a place where it is one of vocational commitment, where patients can be absolutely certain that there will be continuity of care and that those with named responsibility for their care will be available to ensure that that is discharged.

The other important area for restoring the culture and values in our healthcare system is leadership. In this regard, in his report Sir Robert Francis has paid attention to the possibility of the staff college model. At University College London Partners, where I have an involvement, I am patron of the UCLP staff college. There, we have taken a model built on the Army staff college at Shrivenham, and we have a faculty from that institution attending our staff college to help to develop the leaders in our healthcare system. The model is simple. It focuses, first, on the self-reflection of those offering themselves for leadership positions so that they might question whether they have the ability to do that, and it then develops a leadership culture that puts at its head responsibility for those whom one is leading to ensure that they are developed to deliver the necessary care for the patients.

The development of leadership, culture and values must also attend the entire period of postgraduate training for all healthcare professionals. In this regard, I should like to ask the Minister what role the local education training boards will play in particular, in conjunction with the medical royal colleges and the General Medical Council, in ensuring that the curriculum for postgraduate training includes appropriate emphasis on culture, values and the development of leadership.

My Lords, I thank my noble friend for securing this debate but I have to say that, with such an emotive and tragic subject, the time given is totally inadequate.

Some time ago, I had the honour to chair a meeting in your Lordships’ House of some of the next of kin of those who had died in Mid Staffordshire hospital in such distressing circumstances. They were honourable people, who told us of their experiences. The Patients Association, of which I am a member, was involved in organising this meeting. I hope that the Members of your Lordships’ House who attended were as convinced as I am that hospitals should not be places of fear and bullying but that patient safety should be the top priority, with patients being the focal point and with enough trained staff to care for them with understanding and compassion.

With the ongoing system of cruelty for so long a period at Mid Staffordshire, I wonder what the hospital chaplains were doing. They should be a support to both patients and staff. Why did they not notice the inadequate patient care and speak out? Perhaps they, too, were silenced and shunned.

The Francis report states the need for a “duty of candour”. There should be transparency, the need to report wrongdoings, and communication with patients and their next of kin when things have gone wrong. I brought amendments concerning this during the passage of the Health and Social Care Bill. Now, with the recommendation in the Francis report, I ask the Minister: what is going to happen about this? The report must not become just a talking exercise; action is needed. The NHS, throughout the country, must have the highest standards for all patients.

Sixteen babies and two mothers died at University Hospitals of Morecambe Bay NHS Foundation Trust. As stated in the Sunday Times,

“In both cases”—

of Stafford and Morecambe Bay—

“managers are accused of covering up patient deaths as they chased the prize of foundation trust status”.

Many people have lost confidence in the NHS. Patients should be treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty. In addition, they want safety and clean hospitals at all times.

I ask the Minister: is the NHS in safe hands? There is much to do to restore the public’s confidence in the NHS so that it can flourish. We need it.

My Lords, like other noble Lords, I express my gratitude to the noble Lord, Lord Patel, for introducing this debate so eloquently. I would like to address some of the recommendations in the Francis report that relate to education and training.

Recommendation 155 requires the General Medical Council to set out a standard requirement for routine visits to acute hospitals that train doctors. It asks for postgraduate deans to assume responsibility for managing the process, for royal colleges to support visits and provide relevant specialty expertise, and for the presence of lay and patient representatives on visits—something that the Royal College of Surgeons has done since 2006. Such visits should be co-ordinated with the work of the Care Quality Commission.

There is a sense of déjà vu about some of these recommendations, because before 2005 hospitals were visited regularly by colleges—some would say too regularly. None the less, the purpose of visits was to inspect and accredit training posts. After each inspection, the visiting team met with the chief executive, the medical director and the clinical tutor and talked about any deficiencies that it had found on its visit and the impact that these would have on service provision. Where problems were discovered the trust was advised that a follow-up visit would be required to ensure that the recommendations were implemented.

I was president of the Royal College of Surgeons in 2007 when the college was asked by Mid Staffordshire NHS Trust to undertake an invited review of its surgical services. Our report did not offer “false assurances” to the trust, as it suggested. Rather, the report identified a lack of leadership, an absence of essential protocols, and issues around attitude and the competence of at least one surgeon. These were all issues likely to impact on patient safety and were just the sort of concerns that could have been picked up in the old-style college visits, where face-to-face interviews of trainees were carried out, with the assurance of confidentiality. The trainees were thus able to speak freely about their training and to flag up any concerns they had. That process did not prevent the tragedy of Bristol, but we have learnt lessons since then.

In his evidence to Francis, Mr John Black, my successor as president, said:

“In the course of such a visit the nature of the service would be investigated as much as the training, because we cannot provide a high standard of training unless there is a good service”.

One junior trainee in his final year in accident and emergency medicine, Dr Turner, said that the pernicious effect of the four-hour waiting target created substandard care in the A&E department. Nurses were bullied into moving patients before they breached the four-hour target, often transferring patients to inappropriate wards and some without their medication. Reports of nurses emerging from management meetings in tears were all too common. Dr Turner’s complaints to his educational supervisor in the trust got nowhere. He identified a lack of commitment to education in a department which had only one consultant despite a college recommendation for four. The ability to express concerns to an external visiting body in confidence is essential if whistleblowing on substandard care is to have any effect.

Restoration of properly structured and co-ordinated college visits are long overdue and I welcome recommendation 155, which seeks to link the regulation of hospitals using professionals and the quality assurance of education and training. Triangulating data about the quality of education and the quality of care would help to paint a fuller picture of the patient’s experience in hospital. The first report of the Royal College of Surgeons on Mid Staffordshire in 2007 mentioned a lack of leadership. In his evidence to the House of Commons Health Select Committee on the Francis report on 5 March last week, Sir Bruce Keogh made this observation:

“I have been on the council of the RCS on two occasions and I have watched the leadership organisations of various tribes...and interest groups slowly feeling that they have been relegated to the position of commentators rather than participants”.

My question to my noble friend is: what steps do the Government propose for bringing these leaders back into the mainstream of NHS delivery and how can we ensure that the doctors and nurses rediscover their voices and act as advocates for patients?

My Lords, I also pay tribute to the noble Lord, Lord Patel, for raising this critical issue. What happened at Mid Staffs was a terrible violation of the trust that the public invest in our NHS. Appalling accounts of patients being left to lie in soiled sheets for long periods of time, unable to reach their water or feed themselves, and being denied privacy and dignity even in death, reveal a frightening gulf between what we have the right to expect from our NHS and what patients there were exposed to. What underpins this disgraceful treatment of patients is the failure of the Mid Staffs foundation trust board which, in Robert Francis’s words,

“failed to tackle an insidious negative culture involving a tolerance of poor standards and disengagement from managerial and leadership responsibilities”.

Focusing on finance, figures and top-down operational targets, the trust board neglected its patients’ well-being and overlooked its most basic duty. In the short time available I would like to focus on the issue of governance and the critical role that it plays in bringing about the change in culture so desperately needed.

First, to outline very briefly the failings of the trust and the trust board, despite clear warning signs, the board and other trust members did not take in the severity of what was happening and gave little attention to the concerns coming from patients and staff. On top of a poor complaints system, those in charge ignored issues and were slow to react to matters, if they reacted at all. According to the report—I find this one of the most damning and chilling phrases—the trust’s culture was one of,

“self-promotion rather than critical analysis and openness”.

The perverse values and priorities of the senior leadership resonated throughout the organisation, generating a culture characterised by a lack of openness to criticism, a lack of consideration for patients and defensiveness.

The trust board and trust members had a responsibility to cultivate and uphold a positive culture that places patient care, high clinical standards and quality of practice as paramount priorities. Their blatant failure to do so is a clear signal that action must be taken and I give my full support to the recommendations in the Francis report. In particular, I highlight the importance of ensuring that governors receive proper training and guidance in their roles, with greater emphasis on their personal accountability. Quality accounts, which Francis talks about, with complete and accurate information on a trust’s level of compliance with the fundamental and enhanced standards of care should be made openly available on its website, be audited by the CQC and be accompanied by a signed declaration of all directors certifying the accounts’ validity.

I will draw very briefly on my own experience of chairing a public body. What I have learnt to be critical to effective corporate governance is that all board members should go out, be curious, ask questions and above all listen. All board members should go out on visits, talk directly to front-line practitioners without the management being present, ask to see service-user feedback, and ask what has been done about the issues raised which fall short of expected standards. The board recently reviewed all the service-user feedback to assess its adequacy, and looked at all the complaints, their nature as well as their number, how they were dealt with and how they were being fed in to a cycle of continuous improvement. I make this point simply to emphasise that this is not an add-on or a nice to-do. This is at the very heart of effective corporate governance. An interesting article from the King’s Fund, which was published just before the Francis inquiry report, looked at the way in which boards operate in the NHS. It concluded that behaviour in the boardroom is key to the effective management of quality.

It is only through efforts to create an open, transparent and accountable system of governance that a sustainable and fundamental change in culture will come about. I urge the Government to accept the report’s recommendations, and to take urgent action to instigate these much needed changes.

My Lords, like others I congratulate my noble friend Lord Patel on initiating this debate. I declare an interest as a member of the General Medical Council, like the noble Lord, Lord Kakkar. That interest, of course, translates into a responsibility. So many organisations, including the GMC, have a responsibility to study Francis, to understand what went wrong, and to play their part in putting it right for other parts of the National Health Service. In particular, the GMC needs to consider its own leadership role in driving standards up; it must be not just the policeman but the coach of professionalism and high standards. It must address that tremendously dangerous disengagement from management that we saw illustrated and which defines professionalism, not as the noble Lord, Lord Kakkar did, but very narrowly as care of one’s own patient rather than responsibility for the whole clinical environment. One of the chilling things about Francis was how many people who were not bad people felt either disempowered or “aresponsible” in terms of what they could see going on elsewhere in the hospital.

The noble Lord, Lord Willis, said that as parliamentarians we had some responsibilities, too, in not having discussed the issues of values and cultures. We may not have spent many hours on that. However, we have certainly spent many hours on structures and funding systems—thousands of hours of debates in both Houses. I contend that much of the energy that has gone into reorganisations has sapped energy from the absolute fundamentals of what the NHS is about. Francis gives us the opportunity not to turn this into 290 new boxes to be ticked, but to look at the fundamental purpose and values of healthcare that need to be subscribed to, understood by and championed by those responsible for governance and professional leadership and those responsible as managers. I was brought into the NHS 30 years ago by a hugely talented and committed NHS manager, Alasdair Liddell, who died tragically and suddenly on New Year’s Eve last year. The commitment of managers to the values of the NHS, as well as to cost-effectiveness, efficiency and everything else, is hugely important.

There are other two things that I will say quickly about my first experience in the NHS in Bloomsbury. One is to echo what has been said about complaints. I chaired a complaints panel that looked at every complaint that came into those hospitals. It was a goldmine in improving service and efficiency. To ignore that goldmine is hugely damaging. There are very few heroes in the Francis report, but the complainants are heroes. They gave the opportunity to put things right beforehand.

Secondly, of course we have to look at death rates, but we have to look, too, at those doctors and whether they would recommend a hospital to their colleagues. We had a unit at UCL with pretty well the highest death rates in the country. It was the unit in which every doctor in London would have wanted their family treated, because it took the patients who would otherwise have gone to a hospice.

My Lords, my noble friend Lord Patel opened this debate with a characteristically thoughtful and compelling contribution highlighting many of the recommendations of the Francis report.

In the early days of the NHS, the administrative responsibilities in major hospitals were often undertaken by the hospital secretary, with a small but dedicated staff, reaching decisions based on the advice of senior medical, clinical and nursing staff, including matron. Do any of your Lordships remember when matrons, respected and admired, visited each ward in the hospital at least weekly?

Plainly, massive technological developments in medical and nursing care, the problems of an ageing population and the escalating cost of new effective drugs and procedures have imposed heavy financial, administrative and clinical burdens on hospitals, so that costs have risen exponentially. Hence, consecutive Governments have introduced increasing numbers of managers to the service in the hope of promoting efficiency and financial control but, sadly, some of them have treated the NHS as if it were a business, which it is not.

I have worked with some very able NHS managers. Many in the higher echelons have been individuals of vision, merit and exceptional capability, but at lower tiers, I have met with some unfortunate management-speak, leading to circumlocution, obfuscation and confusion, with failure to identify and promote clinical priorities. The Francis report plainly showed that managerial pressures, in efforts to obtain foundation status and to meet targets, gravely diluted standards of care.

Clearly, some clinical staff failed to fulfil their primary professional responsibilities, and their standards must have been gravely eroded. Who knows, perhaps the obsessional managerial virus pervading at higher levels infected some of the doctors and nurses. The accumulated evidence of much unacceptable—indeed, disgraceful—performance is compelling. A critical message to emerge from this inquiry is that the safety of patients and the maintenance of fundamental standards of care are obligations that must transcend particular policies and must permeate all activities within the system.

Would things have been different with a powerful, respected and authoritative chairman of medical staff and a matron able to bring the managers into line? Clearly, too, the public were never adequately consulted. Community health councils, widely respected, were abolished for obscure reasons, to be replaced by failed local patient and public health forums, and then by LINks, which were even less effective.

Will Healthwatch be any better? Would Healthwatch have prevented the horrors that we learnt about through the Francis inquiry? Somehow, in Staffordshire, obsessional managerial attention on artificially generated governmental targets betrayed patients and, perhaps, clinical staff, confounding the hallowed founding principles of the NHS.

How I agree with other noble Lords who have said how crucial it is to have the authoritative role of the nursing sister and well qualified nurses, but also how necessary it is to have qualified and properly trained supporting staff carrying out nursing services under the supervision of nurses.

Does the Minister agree that the overriding principle of the service must be to provide high-quality, medical investigation, treatment and care, delivered with skill, competence, compassion and full personal support, with competent management, even when in times of financial constraint, insistence upon such fundamental principles leads to a failure to achieve targets? Whenever, for pressing financial reasons, services need to be reduced or withdrawn, such changes must be achieved with the informed consent of healthcare professionals, so that the overriding principle of providing high-quality healthcare is maintained. This is the most important recommendation at the core of the splendid Francis report. Our patients, their families and the nation deserve nothing less.

My Lords, I recognise that Robert Francis performed an important public service in his first report by identifying appalling failures at the Mid Staffordshire trust. However, as others have said, things have moved on since then. Frankly, I found Francis’s second report much more of a curate’s egg. His call for candour and more transparency in the NHS deserves our support, as does identifying board members and managers who are not fit and proper persons. The CQC needs to improve its effectiveness, especially in its use of provider registration, but I hope the Government will see the 290 recommendations as an à la carte menu from which they can select judiciously.

I want to raise three key questions. First, is there good evidence in this second report that the behaviour at Mid Staffordshire was widespread? I have read very carefully the 115-page executive summary—probably the largest executive summary I have read in my life. I did not find in that summary compelling evidence about the widespread failings that have been identified across the NHS. After the expenditure of £13 million on producing this second report, I would have expected to be more convinced than I was. Without appearing complacent, we must avoid tarring 1.3 million NHS staff with the Mid Staffordshire brush, particularly if we do not have the evidence to do so.

Secondly, is it right to concentrate such huge new efforts on monitoring and regulating hospital care? We know that too many people in acute hospitals should not be there. The estimates vary from 25% to 40%. The NHS operating framework has identified this problem for some time. I found nothing in the Francis report touching on this issue. If we now put huge amounts of regulatory effort into hospital care, presided over by a new, shiny chief hospital inspector, we miss a critical point for the future sustainability of the NHS. If we really want to hold David Nicholson to account, we should concentrate on what is being done to change the commissioning of services so that many fewer elderly people are admitted to and moulder in the medical wards of acute hospitals. That is the real systemic failure.

Lastly, I would like us to question whether the answer to failed regulation is more regulation. I question the good sense of new criminal sanctions for staff and board members. We already struggle to get good board members for what can seem a rather thankless task. Will there really be more whistleblowing if staff think they might send a colleague to jail? We need a better rating system for hospitals, but also for GPs and community services, with more publicly available standardised comparable data for the NHS service providers. This is a topic that the Government rejected amendments on during the passage of the Health and Social Care Bill. Perhaps they might like to think again on this issue.

The case for merging the CQC and Monitor has not been made out. Let us use the bits of this report that improve the NHS for patients and their families, but avoid a political virility contest on how many of the 290 recommendations are accepted.

My Lords, I, too, thank my noble friend Lord Patel for raising this debate, especially for the way in which he introduced the positive side of his recent care to show how it is possible to have a patient pathway that results in high-quality care.

The 294 recommendations demonstrate the depth of the inquiry that has taken place, which must provide some comfort to the relatives and friends who witnessed the very distressing care that was given. The Government now have the responsibility to respond as to how these recommendations are to be met. The relatives, public and professions will be interested in the outcomes, for nobody could wish the same situation to happen again. This is said after any inquiry, of course, but this in-depth report requires commitment to meet the recommendations and necessary changes that will result in safe, high-quality care being given with compassion and respect. It is true that the nursing profession has emerged under a cloud, which means that the 20-plus recommendations relating to nursing require intense scrutiny and consideration for implementation.

My first point is to focus on a patient-centred culture. Having researched previous inquiries, very little or nothing is mentioned about culture. However, as has already been said this evening, unless everyone from the top of the organisation—the chairman and the board—to the ward sister who is in charge of the ward, is aware of the values and standards that are set, and unless they are open, transparent and activated, we will have another Mid Staffs. To avoid this, there must be strong cultural leadership. Do the Government intend to grasp this specific recommendation, which requires more than written codes and standards? It requires practical, behavioural and experiential learning in a multi-professional context within bespoke learning environments.

High-quality and safe care delivery is dependent on nurses who are well prepared, in theory and in practice, with enough time to deliver holistic care with compassion and respect. This is possible only if the workforce plans are such that there are sufficient numbers of registered nurses to supervise the non-registered support workers, as the report clearly shows. Recognising that workforce planning has to be contained within budgetary constraints, it would nevertheless be helpful if minimum staffing ratios of registered nurses to non-registered nursing support workers could be established, along with, I hope, the recommendation that NICE be charged with the responsibility for assisting in this development. I trust that the Government will agree.

It is a long overdue recommendation that every person giving personal care should be trained, which was also taken up by the noble Lord, Lord Willis, in his report. Work in progress for the training of healthcare support workers, which is soon to be published for consultation, will be a welcome step towards, I hope, mandatory training programmes that will lead to registration.

The report also recommended the regular updating through post-registration training following appraisals for registered nurses, which is a necessity. While examining the recommendations from this report, we must also remember that there is an army of excellent nurses, midwives and health visitors spread over the country who are delivering high-quality and safe care, day after day, to the satisfaction of those for whom they care. However, it is vital that there is regular updating though post-registration training, as this is of such importance in this time of rapid developments in medical science. Moving into the integration of health and social care requires understanding the patient pathway from the beginning to the end, with nurses playing a vital part in that smooth transition from one part of the service to the other.

My Lords, this has been an excellent debate. No one reading this report or its predecessor could be in any doubt about the suffering caused to many patients and their families by neglect and the lack of a caring attitude. I want to use my brief four minutes to make one plea to the Government, which is for a considered response. Mr Francis has produced a very large report, which I suspect in reality will be read by very few people, with a huge number of recommendations. I am afraid that he has fallen into the trap of so many inquiries, where instead of going for a few focused recommendations we have this huge canvas to consider.

Like the noble Lord, Lord Patel, my great fear is that we may be in danger of creating a massive bureaucratic edifice in dealing with what essentially was a failure in one trust. It is worth repeating that Mr Francis said that what happened in Mid Staffordshire was caused by a serious failure on the part of a provider trust, which did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the trust’s attention. Like my noble friend Lord Warner, I find it difficult to see the threads between what happened in Mid Staffordshire and the general attack that seems to be taking place on the NHS.

I understand the points made about whether the target-based performance approach impacted on quality of care and, indeed, on the involvement of clinicians in their organisation. I defend targets. I remind noble Lords that in 1997 we had the spectre of very long waiting lists. There was a patient charter that said patients should be treated within 18 months—even that was not being met. The result of the target approach has been to reduce waiting time limits to 18 weeks. When one had long waiting times, patients suffered and some people died. I do not think we should ignore it.

Equally, I have listened to the very eloquent speeches made by noble Lords tonight, who have spoken of the changes that need to be made in the NHS. They are valid comments. However, I am struck by the fact that noble Lords have really rather ignored the reality of everyday life in the NHS at the moment; the imposition of another massive structural change and an unprecedented squeeze on resources.

I declare an interest as a foundation trust chair and can say that, seen from the front line at the moment, we have a system under extraordinary pressure. Patient numbers are up, primary care accessibility is problematic and cuts in local government services reduce their ability to take patients out of hospitals and into their homes or care homes. Everywhere systems are under huge pressure. I think it is grossly unfair to ignore those pressures while, as the Secretary of State has consistently done in speech after speech, pointing out to the NHS its alleged deficiencies, without acknowledging the impact of the resource cuts or the uncertainties of the changes being brought about. As my noble friend Lord Warner pointed out, they will do nothing to deal with the big issue we all face, which is the number of frail elderly in our hospitals who ought not to be there.

Therefore, my plea to the noble Earl, Lord Howe, is that rather than thinking that the Government have to respond to each of those recommendations, they think seriously about the essential leadership they can give to allow for caring attitudes to be free in the health service, and to ensure that impossible pressures are not put on the system, from which it can only fail.

My Lords, in thanking the noble Lord, Lord Patel, for his excellent and incisive introduction to the debate, it is right for me to begin by reiterating the Government’s apology to the patients and families of Stafford Hospital for their suffering and for the way that the system allowed such horrific events to go on unchecked and unchallenged for so long. It is also right to remember that the vast majority of staff in the NHS are dedicated and committed to providing high-quality and compassionate care for patients. I, for one, have much admiration for the work that they do.

We are very grateful to Robert Francis QC and his team for their hard work. It is now our responsibility to use these findings to improve the NHS and the way that we work. We are currently giving careful thought to the key messages in the report and reflecting deeply on what we need to do. I regard this debate as an important ingredient in that process. I listened particularly to the salutary warnings from the noble Lords, Lord Warner and Lord Hunt of Kings Heath, in this area.

The overriding theme of the report is about culture and the need for everyone across the health and care system to reflect on the report’s findings and recommendations and act to challenge and change the culture of the NHS to place patients and compassionate care at its heart. We are absolutely clear that this report needs to be a catalyst for change. We need to ensure that the quality of a patient’s care is given as much weight as their clinical treatment.

We are also in a far better position than before to prevent the sort of catastrophic failures of care seen at Mid Staffs because we now have a system which is working together to protect the patient in a way that did not happen before. Francis’s report outlines the serious consequences that occur when regulators do not communicate with each other properly and work in silos rather than in partnership. The reforms will enable us to allow for stronger and better regulation. From April 2013, Monitor will be the sector regulator for healthcare in England, and with the Care Quality Commission it will jointly license providers of NHS-funded care. Both have new duties to work more closely together and promote the interests of people who use healthcare services. The Care Quality Commission will have a new chief inspector of hospitals with powers to ensure that the system acts quickly to tackle unacceptable care. We are currently considering Francis’s specific recommendations on regulation in more detail, including their legal and financial implications. I say to the noble Lord, Lord Patel, that we have not rejected Francis’s recommendations to merge Monitor and CQC; that is still being considered.

We intend to provide an initial response to the report by the end of this month. The intention is that it will be a collective response across the system to demonstrate that we are working together with partners about the way in which we are doing that. It will focus on themes rather than being a line-by-line response to each of the recommendations. It will reflect the importance of the focus on culture and patient voice. It will begin to demonstrate that national partners, including the Department of Health and arm’s-length body partners, are acting together and taking action to ensure a greater focus on quality of care as well as quality of treatment, greater clinical input into policy making and a closer connect to patients. The whole system needs to put patients at the heart of what it does above all else.

In Francis’s letter to the Secretary of State, he states that the failings at Mid Staffs were,

“primarily caused by a serious failure on the part of a provider Trust Board”.

My noble friend Lady Tyler was right that the role of the trust board should not and cannot be underestimated. The board is key to ensuring that staff have the right support to be able to provide the very best care for patients. Board members need to provide good leadership and be able to model compassionate care so that it can be felt throughout the organisation. Members of the board therefore have an integral and challenging role in making sure that quality and safety is at the forefront while ensuring the care is patient-centred.

It is not surprising that the theme of safety has been prominent in this debate. Patient safety is paramount, but managing safety and developing a culture around this is a real challenge given the number of people the NHS treats on a daily basis. We are looking at how we need to do things differently. The patient safety expert Don Berwick will review our approach to patient safety and advise on how we can create the zero-harm safety culture that Francis was talking about and indeed, Cure the NHS, the patient group instrumental to ensuring that Mid Staffs was looked at in the first place, has also championed ideas on this.

It is clear from this report that during previous times of change in the NHS patient care and safety have suffered. What is also clear from the Francis report is that the system needed to be restructured precisely because patient safety was falling through gaps. I take the point made by a number of noble Lords about regulatory burdens, and we have commissioned a review by the NHS Confederation to consider how bureaucratic burdens on providers of NHS care can be reduced. The focus of the review is to consider how to reduce the burden of inspection and data collection on the providers of care so that they can focus more on the delivery of safe and effective compassionate care. That is why one of core objectives for the NHS Commissioning Board, as set out in the mandate, is to ensure the NHS provides safe care for patients, and it will be developing a new patient safety strategy to deliver on this.

The noble Lord, Lord Patel, talked about safety to a large extent and referred to Don Berwick’s work. The national reporting and learning system, as he knows, is now owned by the NHS Commissioning Board and allows the board to fulfil its legal duty in the 2012 Act to establish and operate systems for collecting and analysing information relating to the safety of the services provided by the health service. I think that is integral to its role. Don Berwick will review our approach to patient safety and the Francis report, and his job is to advise the NHS on the delivery of a sustained and robust patient safety culture.

The noble Baroness, Lady Hayman, to whom I listened with great care, spoke very appropriately about people recommending a hospital to their relatives. That was a point well made. The friends and family test, which has been designed, is a simple and comparable test that provides a mechanism to identify poor performance. It is designed to encourage staff to make improvements where services do not live up to expectations. It should prove a useful mechanism.

The noble Lord, Lord Patel, asked in what respect the work of the chief inspector would impact on the CQC. The CQC has already said that it will move to a differential approach to inspection, with the better use of experts and with more attention paid to what patients say. The chief inspector post will focus this work so that performance is better understood and more easily identified and then acted upon quickly, which is particularly important.

The noble Lord, Lord Rea, spoke about whistleblowing. The Government’s reforms will deliver an emphasis on local clinical leadership and oversight, clinically led commissioning, greater transparency on outcomes, and oversight by local health and well-being boards and local Healthwatch. These reforms will make it much less likely that trusts will either want or be able to behave in a way that does not promote the highlighting of concerns or issues by staff, patients or the public. In turn, that should promote a culture where concerns are not just raised but acted upon.

This theme was picked up by my noble friend Lord Ribeiro. We recognise that there is work to be done to ensure that all staff are empowered to speak out and protect patients without the fear of victimisation for doing so. The noble Baroness, Lady Masham, reminded the House of her championing of a duty of candour. We are looking very carefully at that recommendation.

My noble friend Lady Tyler made the very good point that board members have to be engaged on this and to the fullest extent. My right honourable friend the Secretary of State has written to all trust chairs highlighting the seriousness of the report and asking them to hold listening events with all staff to talk about the lessons that we can learn from Francis.

The noble Baroness, Lady Hayman, emphasised the important role of managers, and I listened with equal respect to my noble friend Lord Eccles on that score. The Professional Standards Authority for Health and Social Care recently published national standards of behaviour and competence and a code of conduct for top NHS managers. I believe that patients and the public expect them to embrace those standards and indeed to live by them.

The theme of leadership was picked up by many noble Lords. Good leadership in the NHS embraces many things such as compassion and care and places quality and safety at the heart of all decisions. Leaders are needed at all levels. We are doing more to ensure that all staff have the opportunities to become leaders or to demonstrate leadership skills in their existing roles. The government reforms will deliver an emphasis on local clinical leadership and oversight, as I have mentioned.

My noble friend Lord Cormack and the noble Lord, Lord Kakkar, also picked up the theme of leadership. The Leadership Academy is one organisation that has been established to train and develop new leaders and to run a number of core programmes to support clinicians, nurses and managers in leadership roles. I hope the noble Baroness, Lady Emerton, will take comfort from the fact that, as we consider Francis’s 290 recommendations, we are engaging with a range of key stakeholders, including the professional bodies, such as the royal colleges, to identify what more we need to do in response to Francis, including the values that pertain to good leadership.

We will consider very carefully the recommendations of the inquiry in the area of nurse training. We are particularly keen to establish whether more vocational ways of becoming a nurse can enrich the nursing workforce while maintaining the high academic standards that modern nursing requires. I say to my noble friend Lord Willis that we want to be guided by the profession. The country’s top two nurses, Jane Cummings and Viv Bennett, will do two things in this area: they will make sure that recruitment to university undergraduate programmes is based on values and behaviours, as well as technical and academic skills, and will work with national organisations to agree stronger arrangements to ensure effective training and recruitment.

My time is up, although I have much more to say. If noble Lords will allow, I will follow up this debate with letters to those noble Lords whose points I have not had time to address. Meanwhile, once again I thank all speakers for some extremely important contributions, which will in form the Government’s thinking over the weeks ahead.