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Paterson Inquiry

Volume 671: debated on Tuesday 4 February 2020

This morning the independent inquiry into the issues raised by the disgraced surgeon, Ian Paterson, published its report. The inquiry was tasked with reviewing the circumstances surrounding the jailed surgeon’s malpractice that affected so many patients in the most appalling way. As the report states, between 1997 and 2011, Paterson saw 6,617 patients, of whom 4,077 underwent a surgical procedure in the independent sector. Between 1998 and 2011, Paterson saw 4,424 patients at the Heart of England NHS Foundation Trust, of whom 1,207 underwent mastectomy.

The report contains a shocking and sobering analysis of the circumstances surrounding Ian Paterson’s malpractice. It sets out the failures in the NHS, the independent sector, and the regulatory and indemnity systems. As a result of these failures, patients suffered unnecessary harm. Their testimony in the report makes harrowing and appalling reading. As such, it is with deep regret that we acknowledge the failure of the entire healthcare system to protect patients from Ian Paterson’s malpractice and to remedy the harms.

Nothing I can say today can lessen the horrendous suffering that patients and their families experienced and continue to go through. I can only start to imagine the sense of violation and betrayal of patients who put their trust in Ian Paterson when they were at their most vulnerable. That the inquiry reports today—World Cancer Day—makes this all the more poignant. I apologise on behalf of the Government and the NHS for what happened, not least that Ian Paterson was able to practise unchecked for so long. I pay tribute to the bravery of all the former patients who came forward to tell their stories to the inquiry, and whose anonymised accounts have been recorded in the report. The report will make for difficult reading, as it highlights the human cost of our failure to detect and put a stop to Ian Paterson’s malpractice.

There was a catalogue of failings that resulted in harm to thousands of patients, causing devastation to countless lives. Some of these patients were let down several times, not least by the providers and the regulatory system that should have protected them, and by the failure of the medical indemnity system to provide any kind of redress at the first time of asking. From the outset, Bishop Graham wanted patients and their families to be central to the inquiry’s work and to be heard. It was right, therefore, that patients and their families saw the report first, early this morning, shortly before it was presented to Parliament.

Two aspects of the report are particularly striking to me: that the various regulatory bodies failed in their main tasks; and the absence of curiosity by those in positions of authority in the healthcare providers in the face of concerns voiced by other healthcare professionals. The report presents a tangled set of processes. Accountability was not exercised when it should have been. Some of the problems arose from not following through on established procedures, as opposed to insufficient procedures being in place.

We must take full responsibility for what happened in the past if we are to provide reassurance to patients about their protection in the future. I am therefore very grateful that the suite of recommendations, based on the patient journey, presents a route map for Government. The recommendations are extremely sensible and we will study them in detail. I can promise the House a full response in a few months’ time. That response will need to consider the answer to some very important questions that cut right across the healthcare sector. Unequivocally, regardless of where patients are treated and regardless of how their care is funded, all patients should be confident that the care they receive is safe, that it meets the highest standards with appropriate protections, and that they are supported by clinicians to make informed decisions about the most appropriate course of care.

I am very aware that this is not the first time that regulatory failure has been highlighted in an inquiry report. We have done much to make the NHS a safer system in recent years: revalidation, a reformed Care Quality Commission, and work by the Independent Healthcare Providers Network to establish the medical practitioners assurance framework to oversee medical practitioners in the independent acute sector. In the case of Ian Paterson, the system did not work for patients. Recent events at Spire Healthcare show that there are still serious problems to address. Patient safety is a continual process of vigilance and improvement. The inquiry does not jump to a demand for the NHS and the independent sector to invent multiple new processes; it says that they must get the basics right, implement existing processes, and ensure that all professional people behave better and take responsibility.

Last summer, NHS Improvement and I published a new patient safety strategy, led by the national patient safety director, Dr Aidan Fowler. It focused on better culture, systems and regulation—very sensible and familiar words, yet all things that this inquiry says were not delivered. What we need now is action across the NHS and its regulatory bodies, and the same determination to change in the independent sector.

We are absolutely committed to ensuring that lessons are learned and acted on from the findings of this shocking inquiry, in the interests of enhancing patient protection and safety both in the NHS and the independent sector. For today, I apologise again on behalf of the Government and the NHS, and send my heartfelt sympathy to the patients and their families for the suffering they have endured.

I thank the Minister for advance sight of her statement. I welcome her apology on behalf of the Government and the national health service. I agree that the issues raised in this report are, as she says, shocking, serious and harrowing. Our thoughts are naturally with all the innocent victims of Ian Paterson. As the Minister rightly acknowledged, today is indeed World Cancer Day. We all know that a cancer diagnosis is frightening. When we hand ourselves, or a loved one, over to the care of a medical professional, we are literally trusting them with our lives. For that trust to be callously betrayed for financial gain is unforgivable, and indeed, as it has been found, criminal. I associate myself with the Minister’s remarks in paying tribute to all the patients—all the victims—for their bravery in speaking out. I thank all those who have represented them, including the various legal firms such as Thompsons, and thank Bishop Graham for putting together this report.

The findings from the inquiry were published at 12 noon today, so the House will want time to fully digest and reflect on the recommendations. However, I think we all agree that while we cannot undo the awful harm that Paterson’s criminal action has caused to so many, lessons must be learned and changes made so that something so heinous does not happen again. This report must not remain on a shelf to be forgotten, because it is clear that this was not just the action of one rogue lone surgeon; systemic organisational failures were at fault as well.

Fundamentally, it is time that we addressed the question of safety in private healthcare providers and the way in which clinicians are able to operate in private providers with little oversight. Paterson worked under the so-called practising privileges model, effectively as a self-employed contractor whereby people get a fee on top of their NHS salary for each funded NHS operation carried out in the private sector. Moreover, private hospitals would often, and still often, incentivise referrals from consultants by giving them, for example, shares in those private hospitals. This model creates financial incentives to distort clinical decision making and can lead to over-treatment, as we saw in the Paterson case. Indeed, as the Minister said, earlier this month something similar happened at Spire Healthcare when it was forced to recall hundreds of patients amid concerns over operations carried out by another surgeon.

The inquiry makes a number of recommendations and it is right that we reflect on them, but what is clear is that we need full transparency and accountability. I hope the Government mandate health bodies to quickly implement many of these recommendations. The fight that patients had to go through for compensation is, quite frankly, shameful. Surely it is time that private hospitals employed surgeons directly and required them to be fully liable for their actions. In that way, we would resolve the liability loophole.

About a third of all private hospital income now comes from the NHS for hip replacements, hernia procedures, cataract procedures and so on. Yet safety standards in the private sector leave much to be desired. Unlike in an NHS hospital where there are multi-disciplinary teams on standby to deal with potential complications post-op, in the private sector, post-operative care for patients is often left in the hands of a single junior doctor—a resident medical officer often working many hours, 24/7. In private hospitals there are few critical care facilities available if something goes wrong. Indeed, many patients are often referred back to an NHS hospital when complications occur. In 2018, the previous Secretary of State, the right hon. Member for South West Surrey (Jeremy Hunt), wrote to the private hospital sector telling it to get its house in order on patient safety.

Patient safety must always be a priority. If this demands legislation to change the regulation of private hospitals, I hope the Minister can bring such legislation forward. We would work with her constructively to ensure that it finds its way on to the statute book. It is time to take these issues in the private sector seriously, and we will be happy to work with the Government on that front.

The hon. Gentleman raises many issues that we can agree on. I am not here to defend the private sector, but I would like to reiterate that women were affected both in the national health service and in the private sector. It does not take into consideration the suffering of those women in the NHS if we just focus on one particular area.

The CQC has had a duty with regard to the private sector since 2015. These cases took place between 1997 and 2011. In 2012, the CQC introduced the revalidation system for doctors, with responsible officers attached to each organisation and an appraisal process that consultants and doctors go through to assess their performance. That happened in 2012 and was introduced by the General Medical Council.

In 2014, we instructed the CQC to appraise the private sector in the same way and hold the private sector to the same standards as the NHS. As I said, I am not here to defend the private sector, but in the CQC examination it came out as good, and I believe that Spire scored 85%.

The hon. Gentleman is right—this is about patient safety and all providers raising their game. As I said, healthcare providers and healthcare professionals have a responsibility to speak out. The time that it took from complaints being made about Paterson to action being taken was too long. We need people in the NHS and the private sector to speak up, to listen and to act more quickly. That is one issue we want to take forward. I will take all his points on board. There is much we agree on. As I said, I am not here to defend the private sector, but women in the NHS suffered as well.

I thank the Minister and shadow Minister for the tone and content of their comments.

Scores of women and their families in Solihull have been dramatically affected by Paterson, who chose—for want of a better word—to experiment on his patients, seemingly for personal profit, ruining and shortening lives. They want to know that this can never happen again, with proper measures taken and recommendations followed. Does the Minister have confidence in the new whistleblowing procedure at Spire Healthcare? Is she, like me, disquieted to hear that the same hospital is currently reviewing 217 cases regarding another doctor, Habib Rahman, who is under suspension?

My hon. Friend is right; Rahman has been suspended. He is not practising at the Spire group. However, he is still in a non-patient facing role at the trust, and we are querying that.

My hon. Friend is right to say that this has been harrowing, and many women were affected. I do not think I can give him a guarantee that this would never happen again, because for that to happen we would have to have somebody reviewing every single appointment, operation and case that any doctor undertook. We have a process in place now that was not in place then. The CQC was not inspecting the private sector then, and it was not inspecting the NHS robustly enough. That has now changed. We also have the revalidation system, brought in by the General Medical Council in 2012 after Paterson. It is really important to point out that Paterson is in jail and has been for some time. This inquiry came after Paterson had gone to jail, and the purpose of the inquiry is learning, so that we can look at the recommendations and improve our service to patients in both the NHS and the private sector as a result.

Having been a breast cancer surgeon for 33 years, I find this case heartbreaking, and I can only apologise on behalf of the profession. The hon. Member for Leicester South (Jonathan Ashworth) highlighted that the way in which women were treated after the event and the fact that they had to fight for help and compensation added insult to injury.

As the Minister said, this was not a failure of processes not existing; it was a failure of processes that were not enforced. This scandal went on for 14 years, which highlights a failure to listen to people who raised concerns early on and the fact that there was a power differential between Paterson and people who were raising concerns. It should have been striking that his rate of surgery was so much higher among his private patients than his NHS patients. His practice was not being looked at within NHS quality audits, which might have shown that up. What will the Government do to ensure that all units are taking part in national audits, which faded away over the last decade, and in Getting it Right First Time, so that units cannot just opt out? Will that be rolled out to the independent sector, to ensure that units take part in national audits?

Breast cancer is a multidisciplinary team specialty, but we have to do a 360° appraisal only every five years. To me, that is the most telling and most important part of appraisal, and the Government should look at that part of appraisal being made more frequent and, again, being extended to private hospitals.

The Health Service Safety Investigations Body is currently envisaged as working only in NHS hospitals and for NHS patients treated in independent hospitals. Surely the Government recognise that the Bill legislating for that will need to be amended, to ensure that the HSSIB can investigate across the piece.

Once again, we come back to whistleblowers who have raised concerns, have not been listened to and have been suffering detriment, and an opportunity to stop Paterson many years earlier has been missed. What reforms are the Government planning genuinely to support whistleblowers? I am presenting a private Member’s Bill tomorrow, because we need a root-and-branch reform of how whistleblowers are treated.

The hon. Lady raises a wide range of issues, which I will try to go through. First, I reassure her that, at the time Paterson was practising, the CQC was not investigating or assessing the private sector; that was introduced in 2015. Whistleblowing was in an entirely different place from where it is now. We now have 500 lanyard-wearing national guardians across the NHS, and we encourage people to raise their concerns with those national guardians, the guardians to listen and the trust to act quickly on the concerns raised. I think it is fair to say that since 2012, when the CQC introduced revalidation, a number of regulatory processes have been put in place. There was shockingly little at the time that Paterson was practising. The system is now much more robust—and yet, I completely take her point; much more still needs to be done.

We are learning the lessons from Getting it Right First Time. In fact, that is a subject of discussion within the Department. We are looking at how the lessons have been applied and what we can learn.

The hon. Lady is right about revalidation and 365° appraisal every five years. As she will know, the CQC is an independent body. It introduced revalidation and appraisal. Our job is now to ask the CQC to make that system more robust and look at how to improve it, because that is an important part of the equation, ensuring that something like this does not happen again. I say here and now at the Dispatch Box that I would like the CQC, as a matter of urgency, to look at how it can make that system more robust and effective, so that we can quickly identify doctors—not those like the hon. Lady—who are not up to standard, who are outliers and who should not be practising.

We will look at the hon. Lady’s point about the HSSIB. I do not think that there is a role for the HSSIB in the private sector. The private sector is a matter of personal choice. It is our job to ensure that healthcare reaches the same standard across the board, whether it is in the private sector or the NHS. The CQC does that, and that is how we hold the private sector to account. Then it is down to patients to make the choice about where they wish to be treated; that is their independent choice. That is a matter of consent, which is something else we need to look at—how do conversations about consent take place? Does the patient have the capacity to take in the information being given to them? Are they making an informed choice? Do they have enough information about the surgeon they are seeing to make the right choice? Those are the issues we need to focus on.

If patients are to be kept safe, several things need to be true. First, as the hon. Member for Central Ayrshire (Dr Whitford) said, medical professionals who have concerns about the practice of other medical professionals need to have their concerns properly listened to. Is it not therefore a matter of serious concern that four of the six whistleblowers in this case—one of whom I have the privilege to represent in this place—found themselves subject to fitness-to-practise reviews after reporting their concerns?

Secondly, is it not right that medical organisations—public or private—need to act on those concerns? It is profoundly troubling that concerns were reported to the Heart of England NHS Foundation Trust in 2003, but it did not suspend Paterson until 2011.

Thirdly, is it not important that regulators do what they need to do? It is also profoundly troubling that concerns about Paterson’s malpractice were reported to the GMC in 2007, and his suspension by the GMC came only in 2012.

I would like to make an apology. I mentioned the CQC in response to the hon. Member for Central Ayrshire (Dr Whitford)—the acronyms!—but it was the GMC.

My right hon. and learned Friend is absolutely right. I reiterate that Paterson is in jail, and that the processes now in the regulatory framework did not exist at the time Paterson was practising. The culture towards whistleblowers is very different now from what it was then, as demonstrated by the roll-out of the national guardians scheme. The national guardians are there for whistleblowers to go to. We want—we absolutely want—people to report when they think somebody is acting inappropriately, or a surgeon or doctor is not practising to the standards they should be. We want to know that as soon as possible. There will be no investigations of whistleblowers’ fitness to practise; that will apply to the people they are reporting. I do not think the national guardians scheme has had enough press or that people are aware enough of it. It is about speaking up, listening and then the trust acting on the information it has. One of the outcomes of this report will be that we can reassure both healthcare professionals and the public that we want them to speak up. We actually want them to be a whistleblower because only by doing that can we guarantee patient safety.

I think all of us are shocked to hear that patients have been let down yet again over these events. I was surprised that the Minister did not refer in her opening comments to the Health Service Safety Investigations Bill. I want to back up what the hon. Member for Central Ayrshire (Dr Whitford), who speaks for the SNP, said. Along with her, I was involved in the draft scrutiny of the Bill in the previous Parliament, and it is very clear now that the Bill needs to be extended to include the private or independent sector. I very much hope that the Minister will be able to give us good news about when the Bill will be brought before the House.

I hope the Bill will be brought before the House in the autumn. As I have said, we got the report only this morning, and we need to look at the recommendations. I am sure her suggestion will be one of the recommendations that we will look at in detail. I got the report myself only a couple of hours ago, so we need to study the recommendations. We will report back to the House in three to four months’ time about the report itself.

Like my hon. Friend the Member for Solihull (Julian Knight), my constituency neighbour, I too have many constituents who suffered at the hands of Ian Paterson. On Saturday, I met survivors of this awful ordeal, and there are no easy words. I thank the Minister and the shadow Secretary of State for their sobering words. Will the Minister join me in commending the survivors for their bravery, and does she agree that there have been serious failings on the part of the Spire hospital? What assurances can we give the survivors that we will take heed of this report, and what more should we do to ensure that this is never allowed to happen again?

I thank my hon. Friend, and if I did not do so in my opening statement I would like to thank the patients, the survivors and the groups that have helped those survivors. I also thank Bishop Graham James, who has provided us with such a thorough and detailed report, with seriously robust and practical recommendations to take forward. Again, I can only give my assurance that we will read this report and study it carefully. If there is anything we can do as a result of the recommendations that will enhance and guarantee patient safety, we will, because patient safety is a paramount concern for us in the Department of Health and Social Care. It is absolutely at the top of our agenda, and we will be taking this forward.

In the Minister’s statement, she referred to two striking aspects of the report: the failures of a number of regulatory bodies, and the absence of general interest in the concerns raised by the very people in a position to take action. Sadly, the inquiry suggests that such a case could occur again. Given that the Government have promised to provide a full response to the inquiry in three to four months’ time—I believe that is what she said—how will the Government work with the devolved Administrations to ensure that all health services can take up the same safeguards?

I am sure we will work with the devolved Administrations in the normal way we do with all healthcare policy. Again, I give my assurances that we will be taking the recommendations and studying them seriously.

Ultimately, this is all about behaviour—not just the criminal behaviour of Ian Paterson, but the behaviour of the professionals and the wider health establishment that came into contact with him. I associate myself with the comments of my right hon. and learned Friend the Member for Kenilworth and Southam (Jeremy Wright) about the behaviour towards the whistleblowers. Frankly, they faced intimidation, and we saw exactly the same thing at Gosport when whistleblowers reported to the Nursing & Midwifery Council. I would like to put it on record that it is high time this Government challenged the self-regulatory aspects of both the NMC and the GMC, if we are really to consider and improve patient safety.

I thank my predecessor in my post for her comments. She did an amazing job, and I am sure she will have been involved in this at the time. She is absolutely right: whistleblowers, we want you! We want them to speak up and to speak out; we want people to listen; and we want to act. However, she is also right that there is still a culture among staff within the NHS and the independent sector of reluctance to speak out, to listen and to act, and we need to change that culture. The culture now has to be that we want whistleblowers to speak out, and we want trusts to listen and to take their concerns seriously, because we want to act.

What has happened is horrific, and my heart goes out to all the people who have been affected, but surely this could not have happened without the collusion of others. It is not just a question of turning a blind eye; there must have been others involved. What has been done to investigate those individuals? Is the Minister clear that whistleblowers have a sufficient pathway to independent investigators outside an organisation? Quite often, it is very difficult within an organisation and it takes someone very brave to go to a senior manager and whistleblow. Is she confident that whistleblowers have access to independent ears to bring their concerns to light?

The national guardians scheme involves 500 healthcare professionals, who are identified by their lanyards alone to show that they are people to whom whistleblowers can speak both independently and in complete confidence. I think that is important because those people are in the NHS—the private sector has rolled out its own similar system—and people can see them, identify them and act immediately. Sometimes things are left for another time or place, but when people see somebody act inappropriately or in a way they should not, we want to know that they speak out about it immediately.

I will say it again: we want people to speak up, we want trusts and the private sector to listen, and then we want to act. It is the case that we can change this culture and let whistleblowers know that we will protect them. We also have a line at the Department for people to ring in on, because we want to hear from them.[Official Report, 12 February 2020, Vol. 671, c. 10MC.] There is only one way we can guarantee patient safety, and that is to know where inappropriate practice is taking place so that we can stop it. We absolutely open our door to whistle- blowers, and we want to hear what they have to say.

Can the Minister explain under what circumstances this criminal behaviour was finally exposed? Has anybody from the regulatory side been sacked as a result of their abject failure to discover it earlier?

There was actually quite a long process. As I say, Paterson practised between 1997 and 2011, and there was quite a long process of reporting and of concerns being raised about his behaviour and his practice. Eventually, somebody listened; I believe that it was a new chief executive at the Spire hospital trust at the time.[Official Report, 12 February 2020, Vol. 671, c. 10MC.] Somebody spoke out to him, he looked at the history of what had happened and he decided to take action. That is not good enough, however, because reports had been made on a number of occasions previously. In fact, there were two reports. One, by a consultant, looked at 100 of his cases in 2011, but no action was taken. Another report, by another NHS consultant, downplayed and focused on the wrong elements of Paterson’s care, and it took somebody to speak to a new chief executive for action to be taken. The process was all wrong, but that is how it was then, and it is very different now.

As I have said, the GMC has introduced revalidation and appraisal. We have been speaking to it, and we want it to make that process more robust so that we can assess doctors in a more appropriate and frequent way. The CQC is holding the private sector to account, as well as the NHS. Those of us who have been here for more than a few years know that a few years ago the CQC was not the organisation that it is today, and it is now much more robust and effective. We therefore hope that we can pick up cases such as this as they happen. However, the only way to crack patient safety in this country is if somebody who is practising alongside a surgeon, doctor or nurse speaks out, and for those to whom they speak to listen, so that we can act.

I thank the Minister for her remarks. I welcome her mention of culture and cultural change, but I wish to push her a little further. She spoke about cultural change in relation to whistleblowers, but that is after something has gone wrong. I would like junior clinicians to feel able to challenge senior clinicians before something has gone wrong. Is anything happening to shift the culture, so that a culture of learning is encouraged among senior clinicians, and so that they welcome challenges and questioning from junior clinicians, in order to prevent something such as this from happening?

I am totally with the hon. Lady, and as a nurse myself, I know that that happens with senior nurses, not only senior doctors, because there is the same culture of fear, and of not wanting to challenge a superior who is more experienced in what they are doing. Such a change cannot happen overnight. It will take time, but I think it is already happening as a result of increased confidence. We have recently had a few inquiries, and I think patients now have more confidence to speak out. Under the national guardians scheme, whistleblowers have more confidence to speak out. I think that cultural change is happening, and last week I visited a hospital where I saw that in process.

Our job is to ensure that we introduce whatever needs to be put in place. No one is God. When I trained as a nurse, doctors were like God, but that is not true; that is not the case. This has been a long road, and we need to challenge that culture even further. Those who have been practising for some time are esteemed, and we value their experience. We value those people, but we must also break the culture that means they are not to be challenged. Making the revalidation and appraisal system more robust is one way to do that.

I thank the Minister for her heartfelt apology for what has happened, and for her commitment to patient safety. Does she agree that there are clear commonalities between this case and other tragedies, such as those at Morecambe Bay and Shrewsbury and Telford Hospital NHS Trust? As the hon. Member for Central Ayrshire (Dr Whitford) said, there is an imbalance of power between male consultants, and in this case female patients, who often just accept what they are told by a more powerful figure.

This day is about the victims of Paterson and the women he treated, and I do not want to detract from that by going down another road and talking about another inquiry. My hon. Friend is right: often women are those most affected by these issues, which is why I spoke about the importance of consent. We as a Department must consider how such consent is gained, and I think the Cumberlege report, which we are expecting to come to Parliament soon, will help with that.

No amount of money can repair the suffering of Paterson’s patients and their families, but an inability to pay for treatment or support that might mitigate that suffering can make an already horrific situation even more difficult. Will the Minister look at the adequacy of medical indemnity cover for healthcare professionals, whether they work in the NHS or in the private sector?

The Government are currently undertaking a review of the clinical negligence indemnity cover market, to determine whether wider regulation is an appropriate means of addressing concerns in the market. As part of that they are consulting on the viability of introducing professional or financial regulation, or a combination of both.