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Mr. Tim Rathbone (Lewes) : I have no connection with the tobacco or advertising industries now, although I spent most of my business life in advertising and marketing, and therfore hope that I can speak with some background knowledge.
I yield to no one in my keenness to dissuade people from smoking, in spite of the fact that I have the occasional small cigar--that applies particularly to dissuading young people from smoking. The House will know of my interest in the problems of drug misuse. There is a definite link between the propensity to smoke and the chances of being lured into taking drugs, especially those that are smoked. This debate is not about smoking, but about advertising and its probable effects, particularly on increasing the likelihood of people smoking cigarettes, I feel that I can make the most useful contribution by concentrating on advertising.
The arguments against banning tobacco advertising do not rest on whether a link can be found between advertising and total consumption, although it is significant that there is no good evidence for such a link.
In mature markets, the role of advertising is almost always to focus on brand share--on growth among users, rather than generic market growth. That means manufacturers going after the people who use a product and want to buy it and persuading them to buy their brand. Even among market leaders, brand switching is a more common marketing objective than market building-- that is an important point--whether they are marketing soap, automobiles, the use of energy, airline tickets, toothpaste or cigarettes.
It is interesting to note that 25 per cent. of smokers change brands once a year.
Column 585and say that, when all the evidence shows the contrary? The Government's publication, which we received this week, says that the Smee review
"supports the Government view that there is a relationship between tobacco advertising and total tobacco consumption."
This is not a philosophical debate about advertising and take-up, but about studies directly related to advertising and the tobacco habit.
Mr. Rathbone : I knew that I was right to resist the temptation to give way to the hon. Gentleman earlier. If the hon. Gentleman, who gets frightfully over-excited about his Bill--I do not blame him, as everybody gets over-excited about their own babies--would listen to the arguments--
It being Eleven o'clock, Madam Speaker-- interrupted the proceedings, pursuant to Standing Order No. 11 (Friday sittings).
The Secretary of State for Health (Mrs. Virginia Bottomley) : With permission, I wish to make a statement about Sir Cecil Clothier's inquiry into the circumstances surrounding the murder by Beverly Allitt of four children and the injuring of nine others in the children's ward of Grantham and Kesteven general hospital in 1991. Following the trial and conviction of Beverly Allitt, I instructed an independent inquiry to be set up in May 1993, chaired by Sir Cecil Clothier QC, to examine the issues raised by the case and what lessons for the future could be learnt from them. I have now received Sir Cecil's report. I am today publishing it in full. Copies have been placed in the Libraries of both Houses. I should like to thank Sir Cecil and the two members of his inquiry team, Miss Anne MacDonald and Professor David Shaw, for the efficient and effective way in which they have conducted the inquiry and produced their report. I am sure that all who read the report will welcome it as a fair and thorough account of the events.
From the outset, we must all acknowledge, as the report does, that the tragic events in Grantham were the product of a malevolent, deranged criminal mind. Everything must be seen in that light. Before saying more about the report's findings, I know that Members on both sides of the House will wish to join me in conveying our deep sympathies to all whose lives have been blighted by these tragic events, and particularly to the families of the victims of Beverly Allitt's crimes. The least we owe those families is an explanation of how Allitt's crimes went unchecked for so long and an assurance, from which I hope they will be able to take some comfort, that everything possible will be done to prevent such a tragedy ever happening again.
I welcome the thoroughness of Sir Cecil's report and the speed with which it has been produced. What is important is that his findings and recommendations are absorbed and applied throughout the health service with equal diligence and dispatch.
The report emphasises that the events described were extraordinary and unprecedented in this country. It considers whether prompter action could reasonably have been expected to detect Allitt and stop her doing further harm--and there are criticisms of the speed of the hospital's response. However, its main conclusion is :
"a determined and secret criminal may defeat the best regulated organisation in the pursuit of his or her purpose".
It goes on :
"no measures can afford complete protection against a determined miscreant. The main lesson from our Inquiry and our principal recommendation is that the Grantham disaster should serve to heighten awareness in all those caring for children of the possibility of malevolent intervention as a cause of unexplained clinical events." The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the recommendation concerning coroners. I have placed in the Libraries of both Houses a paper setting out the detailed response to each recommendation. The chief executive of the national health service, Sir Duncan Nichol, has also written today to all health authorities and trusts to draw the report to their attention.
The work that I am now setting in hand in response to the report is in addition to the action that has already been
Column 587taken following the earlier inquiry commissioned by the Trent regional health authority. Action has been taken forward in all that report's 51 recommendations. In particular, changes were introduced to the management at Grantham and Kesteven hospital and responsibility for the provision of paediatric service at Grantham was transferred to the University hospital NHS trust at Nottingham. The Clothier report identifies and criticises failures of management and communications in the hospital, and it is important that lessons are learned from these throughout the service. It draws attention to the failure to take quicker action after the first evidence of possible foul play. However, it refutes any suggestion that Allitt could easily have been detected or stopped.
There are references to the parts played by individuals, but the report concludes that the main failure was collective. It describes a
"general lack in the qualities of leadership, energy and drive in all those most closely associated with the management of ward four". There have been suggestions in the press that the Clothier report makes scapegoats, particularly of individual consultants or nurses. I hope that those fears can now be allayed. The report repeatedly refers to the dangers of hindsight and the temptation to seek individuals to blame and, although it does not shrink from making criticisms where those are considered justified, it is conspicuously fair and balanced throughout.
The report has important things to say about nursing staffing levels in the children's ward at Grantham. At the same time of the events, the specialist children's nurse staffing for ward 4 was below the standard recommended by the region at the time, and also well below the higher standard for two qualified sick children's nurses to be available, which the Department subsequently recommended to health authorities and hospitals.
The inquiry report recommends that the Department of Health should take steps to see that the guidance is more closely observed throughout the health service than the evidence suggests it is at present. There is a steady increase in nurses qualifying as children's nurses, with a 47 per cent. increase over the four years up to 1992-93, and we expect that number to continue to increase. But, as the Audit Commission has confirmed, there is considerable variation across the country in the numbers of registered sick children's nurses working in children's wards.
Sir Duncan Nichol has therefore today instructed district health authorities, in consultation with hospitals, to report by 1 May on the local position with regard to the standard. Further action will be based on that information. The objective needs to be considered in the light of local circumstances, particularly the number of high-dependency children on a ward. As far as the children's ward at Grantham is concerned, the number of registered sick children's nurses has more than doubled since 1991.
Four new consultant paediatricians have been appointed to work at Grantham ; three are already in post, and a fourth will take up post on 1 May. I cannot comment at this stage on the two paediatric consultants mentioned in the report, since they have appeals to me pending under paragraph 190 of the terms and conditions of service for hospital medical and dental staff.
The circumstances surrounding Beverly Allitt's crimes have been exhaustively examined : during a three-month
Column 588trial, under the glare of publicity ; during the regional health authority's own inquiry ; and, in particular, by the independent inquiry chaired by Sir Cecil Clothier. A thorough job has been done to identify the facts and report them to the public.
Ultimately, the responsibility for what happened rested with Allitt herself. If it were not for her grotesque actions, four children would be alive today and nine would be free from the injuries that she inflicted on them. It is the duty of Grantham and Kesteven hospital, and every other hospital, to read, absorb and apply the lessons which Sir Cecil Clothier and his team have so skilfully identified. We must leave nothing to chance in minimising the opportunities open to another Beverly Allitt.
Mr. David Blunkett (Sheffield, Brightside) : I thank the Secretary of State for making the Clothier inquiry report available to me in time so that I could read it before she made her statement. Clearly, party- political rhetoric would not be appropriate or acceptable on this issue. I concur with the Secretary of State, on behalf of myself and my colleagues, in saying that our hearts go out to the families and parents of the children who went through the nightmare on ward 4 at the Grantham and Kesteven general hospital. I must deal with a number of issues that relate to the inquiry's recommendations and the Secretary of State's response. We give a partial welcome to the recommendations and her response. Given that she has rightly come to the House to make a statement and has acknowledged that there are lessons for the whole of the national health service, does she not agree that a statutory public inquiry should have been held openly, so that evidence could have been presented with representation and in a manner that gave full confidence to the parents and the public as a whole?
I should like the Secretary of State to deal with the final area of the terms of reference of the Clothier inquiry and its wider implications. We agree that it was right for Sir Cecil Clothier not to seek scapegoats and pinpoint individuals. Clearly, there are lessons to be learned from the events that are wider than the question of a malevolent presence in the hospital. There were 26 incidents involving 13 children over 61 days. Those incidents were not acted on in a way that would have been expected, irrespective of their cause. Something is seriously wrong when the crash team from the Queen's medical centre is called out four times in the space of two and a half weeks, when the norm is once a year.
As well as the issues related to Grantham and Kesteven hospital, will the Secretary of State take on board the comments made in the Clothier inquiry about radiology and other co-ordination action, which were highlighted at a well-staffed professionally run centre--Queen's medical centre in Nottingham? I ask her to deal particularly with recommendation 10, about which she has spoken, in relation to staffing levels of trained registered sick children's nurses. It recommends that there should be at least two on duty on the ward. The Secretary of State asked Sir Duncan Nichol, the NHS chief executive, to examine the issue and report back. I quote her words from the statement :
"The objective needs to be considered in the light of local circumstances, particularly the number of high-dependency children on a ward".
In responding, perhaps the Secretary of State will reflect on the fact that many of the children affected on ward 4
Column 589were not high dependency when they went into the hospital. They needed nursing and care. They needed to be brought back to health. They were not in the same position as that mentioned in the report of the British Paediatric Association on intensive care nursing facilities, which we dealt with only a few months ago.
Will the Secretary of State reverse her response to recommendation 10 and acknowledge that well-trained nurses and well-staffed wards for children are absolute priorities for the NHS and that it will not be left to the vagaries of the market or decisions of local purchasers? The NHS is far too important for that to happen. Her recommendation and response this morning are inadequate on that point.
Does the Secretary of State also agree that there is a need to review the whole of the occupational health strategy of the NHS to ensure not only that another Allitt could not be recruited but that there would be no necessity for one to be deployed on a ward? The truth is--I hope that the Secretary of State will respond to this--that had there been adequately trained children's nurses available, Beverly Allitt would not have got anywhere near ward 4 of the Grantham and Kesteven hospital, because a state -enrolled nurse would never have been employed in those circumstances.
Will the Secretary of State respond to the fact that there is no recommendation in the report, or a response from her, on the need to train and retrain management to deal with situations that may not arise from a murderer but from inadequacies in procedures and practice on the ward? Does she accept the question that has been put by the parents : was Grantham different from any other hospital in Britain in terms of staffing, qualification, training and the practices and procedures that were adopted?
Does she accept that we know that Grantham was not different? That is why the report must be taken seriously, not only to deal with a potential crisis or malevolent spirit but to put right what is wrong throughout the NHS. In that way, we can ensure that the confidence that is rightly there for all those who work in the NHS can be reinforced, and we can put this tragic incident behind us.
I shall first speak on the nature of the inquiry. It is important that the parents and others involved believe that the full facts have been revealed. I must tell the hon. Gentleman and the House that, having myself been involved in a number of inquiries concerning child abuse, I know the way that an adversarial public inquiry, in the blaze of publicity, can frequently intimidate witnesses, maximise distress and, far from exposing the full facts, result in a report that many believe fails to get to the bottom of these sensitive matters. Debate will continue about the right form of inquiry when such tragic cases of a very sensitive nature take place.
I commend to the hon. Gentleman and the House an editorial from the Solicitors Journal in which it is said that the adversarial system of examination of witnesses in public in such matters has major drawbacks : potential witnesses whose existence is not at present known may be reluctant to come forward if they are to endure public examination, and their evidence then will remain untold ; known witnesses may be reluctant to tell the whole truth and will hold back information. The key criteria to be
Column 590satisfied should be that the inquiry team is competent and independent, that it has access to information, that witnesses are confident to come forward and give their evidence, and that the report is published in full.
Those criteria particularly influenced me in the decision that it was the best form of inquiry to get to the bottom of those desperate facts. Sir Cecil and his team interviewed 94 witnesses, all of whom were willing to come forward. Thousands of pages of documentation were studied. There was no problem in obtaining documents. Had there been any difficulty with the powers under the inquiry, Sir Cecil would, of course, have come back and I would have been able to reconsider the basis of the inquiry. The single and only purpose in my mind as Secretary of State was to establish the facts in the most effective way. The fact that the inquiry was supported by the community health council, Sir Louis Blom-Cooper and others from an authoritative position was encouraging. I believe that the report vindicates the means of the inquiry and establishes it as a good model for the future.
The hon. Gentleman raised a series of other important matters. I shall quote from the report, which I believe is central to the issue of how 26 incidents could have taken place without being identified. Sir Cecil says :
"The idea of a nurse deliberately taking the lives of children under her charge is almost unthinkable."
It was as though the staff there were paralysed from looking to the area they needed to look to for the source of those crimes. Although there has been speculation about her absence record, the report also says that there was nothing to suggest that Beverly Allitt, with all her record of sickness absence, would have been a danger to those children on the ward.
The hon. Gentleman spoke about occupational health. It is an extremely important area. We will provide new guidance, but we must work with other agencies and authorities before we produce that final guidance-- particularly on the question of people with a severe personality disorder-- about the appropriateness of contracting GPs to ask medical questions which may conflict with medical confidentiality about staff who work in the health service. There is more work to be done before that final guidance can go out now that the report is in the public domain. The same applies to staffing.
There has been a 60 per cent. increase in the number of sick children's nurses in training over the past four years. That is a substantial rise. The number of registered sick children's nurses in the wards has risen from 3.5 to 8.4. There has also been a substantial increase in the number of paediatric consultants : the total number of medical staff in paediatrics has risen by more than a third in the past five years. There will be an extra 1,000 qualified children's nurses this year, an extra 1,200 next year and an extra 1, 300 the following year. The challenge is to ensure that those who qualify as registered sick children's nurses stay on children's wards ; if that is to be delivered in practice, more work must be done with the profession.
Sir Cecil Clothier says :
"No single circumstance or individual can be held responsible for what happened. But taken together, the catalogue of lapses from the high standards to which the National Health Service aspires point to lessons which need to be heeded if every effort is to be made to contain such a catastrophe should it strike again."
The chief executive of the NHS has written to people throughout the health service, to be certain that management, nurses, doctors and all concerned study and absorb the lessons of the inquiry.
Mr. Richard Alexander (Newark) : The parents of one of the children involved are my constituents. May I echo the condolence that has been expressed so far? Let me also express the condolences of my right hon. and learned Friend the Member for Grantham (Mr. Hogg), who, although he is present, is unable, by convention, to take part in exchanges such as this because he is a senior Minister.
It is some small comfort to know that, as soon as these dreadful incidents came to light, the health authority took prompt action to try to reassure patients, potential patients and their parents. It is also very satisfactory that four paediatric consultants from the Queen's medical centre in Nottingham--a centre of excellence in our region--are now running that department. It is hoped that that will reassure those who may wish to use Grantham and Kesteven in the future, particularly its paediatric department.
Mrs. Bottomley : I thank my hon. Friend for what he has said. A determined effort has been made to improve services on many fronts at Grantham and Kesteven hospital. The hospital will hold a press conference later today, at which it will report not only changes on the children's ward--my hon. Friend rightly cited the management control from Queen's medical centre in Nottingham--but improvements to services generally. In regard to waiting times and many other matters, it now leads the region.
My hon. Friend rightly commended the work of my right hon. and learned Friend the Member for Grantham (Mr. Hogg). He has been a diligent, dutiful and determined constituency Member of Parliament throughout these events, and has engaged in regular discussions with me--and with others concerned-- about the deep anxiety felt by parents and many others.
The distress felt by other staff at the hospital is formidable. The affair has been a great shock to all concerned, but the staff are determined to put it behind them, and to ensure that the hospital continues to flourish and to serve the community. Above all, I hope that the report will lay to rest parents' deep unhappiness, which has been exacerbated by the feeling of not knowing the full facts about how these events could possibly have occurred.
I am glad that the Secretary of State agrees that understaffing was one of the problems. How will she address the understaffing problems that exist throughout the country ? She has told us that four paediatric consultants have been engaged ; will she tell us the number of hours for which they will work ?
Mrs. Bottomley : I have already made it clear that there has been a dramatic increase in the number of children's nurses being trained, partly as a result of the extremely successful Project 2000 initiative. As the hon. Lady will know, we have put £321 million into that project, which includes a component specifically for children's nurses. That has made it possible to increase substantially the number of sick children's nurses being trained : there will be a 9 per cent. increase this year alone. As I have said, in the past four years there has been a 47 per cent. increase in the number of qualified children's nurses.
Column 592As is made clear in the Audit Commission's report "Children First", we must ensure that, once children's nurses have qualified, they are encouraged to work on children's wards. It is a question not just of supply, but of recruitment and retention. On the basis of the mapping of the present position contained in Sir Duncan Nichol's inquiry report, we shall also want to talk to members of the profession about how we can encourage retention on the children's wards. Consultants are also working at Queen's medical centre, to secure the best possible standard of care and state-of-the-art help for children.
Dr. Robert Spink (Castle Point) : Will my right hon. Friend confirm, in fairness to them, that no individual doctors can be held directly responsible for these tragic events--although, as I am sure she will agree, all doctors must learn from them?
"There was certainly no evidence of lack of clinical skill and conscientious care on the part of the Consultants. The fact that more of the children did not suffer death or permanent injury can largely be attributed to their skill and persistence. Their failure was not to grasp with energy the problem presented by the highly unusual events that they were witnessing and to take systematic and decisive steps to elucidate their cause."
As those matters are subject to an appeal under section 190, I cannot comment further at this stage.
Mrs. Alice Mahon (Halifax) : The whole House will agree that this appalling tragedy is every parent's nightmare. Now that the Secretary of State has published the report in full, may I point out that the parents-- who are the people of whom we should be thinking--desperately wanted a public inquiry, as did their supporters? Surely they have as much right to the upholding of their views as have the professionals, however well meaning was the advice of those professionals. Sometimes, the grieving process is helped if parents can go through events stage by stage. Access to a public inquiry might have provided the whole country with a lesson for the future.
Mrs. Bottomley : It is a question of judgment, and my judgment is that, if 94 witnesses had been interviewed in the glare of publicity, the distress felt by many of the parties would have been exacerbated. Anyone who wished to make evidence public was free to do so. I have made it clear that if we want witnesses to speak freely and openly, we must ensure that they do not feel inhibited--as they frequently do--by the pressure of cross -examination, and the sense that every detail will be reported in the press, if not on television that night. Such an atmosphere is not conducive to free and open speaking.
There had already been a lengthy trial, and all the publicity associated with it ; in a public inquiry, many of those elements would have been repeated. It is important, however, that parents study the report. If they have further questions, the various parties involved will be more than happy to see them. We must find the most effective and speedy way of getting to the bottom of these events. When the hon. Lady studies the report, she will be impressed by the rigour and determination with which the inquiry team undertook its task.
Question again proposed, That the Bill be now read a Second Time.
I was saying that advertising in mature markets, whatever the product or service, is almost always tuned to the development and capturing of market share rather than to market development.
Mr. Rathbone : Will my hon. Friend forgive me if I do not do so? If I do not make headway, I fear that I shall not say everything that I want. I am afraid that it is rather factual, heavy stuff but it deals with the thrust of the Bill.
The Smee report, which has been mentioned, is seen by many proponents of an advertising ban as evidence of a link between developing consumption and advertising, but the opposite is true. Interestingly, the Smee report states that it is most true in the United Kingdom. It categorically states that its own statistical research exercise established that there was no such link in the United Kingdom, and it noted that independent research shows that advertising has no discernible effect on persuading children to start smoking.
These are statements in the Smee report. It is not peculiar, therefore, that Clive Smee has stated his believe that much more work needs to be done before any link could ever be established. It is interesting that many current advertising campaigns for cigarettes are unintelligible for those other than smokers of the brand.
Argument for a ban would lead to much more pressure for such a step if a link were ever established. It is unlikely that it will be, but that is purely conjecture, and it is important to keep a perspective on the issue as a whole.
Advertising is permitted in the United Kingdom, yet cigarette consumption is declining faster here than in any other European country except Holland, where advertising is allowed. That is a considerable achievement, not least because of the positive contribution of the Health Education Authority. I defer to its efforts to improve health in this country, and to reduce the propensity to smoke. It needs our support.
It would be sad if that achievement were put at risk by freezing the market, which would be likely to stop the decline. The Health Education Authority says :
"all available measures which reduce smoking should be taken." I absolutely agree, but an advertising ban would be as likely to have the opposite effect as it would be to have a beneficial effect. That is an extremely important point to make to all hon. Members who are concerned, as I am, about smoking and its effects but who have misunderstood the Bill as making the contribution that it aims to make.
Sir Peter Emery : I rise to interrupt because I know that my hon. Friend would not want to mislead the House. He has quoted conclusively from the Smee report. It has been pointed out, but I must point it out to him again, that, in his conclusion on the effect of advertising on the consumption of cigarettes, Smee says : "The balance of evidence thus supports the conclusion that advertising does have a positive effect on consumption."
It would not be right for my hon. Friend to advance evidence without giving the conclusion of the Smee report. I am certain that he does not wish to mislead the House.