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Dr. Howard Stoate (Dartford): I agree with the hon. Gentleman that there have been improvements in the past few years. In my area and, I have heard, in other areas, consultants are now much more likely to write directly to patients, rather than to their GP, who will receive a copy, setting out the precise details of the proposed operation. The patient therefore has a written record from the consultant, which is surely to be welcomed.
Dr. Fox: Of course, that is to be welcomed. There is extremely good practice by some doctors in some areas. That is not the problem; it is that such procedures are not followed throughout the health care system. Any attempt to improve practice in both the private sector and the NHS is to be greatly welcomed.
Naturally, we have strong reservations about parts of the Government's approach, including the abolition of community health councils and the establishment of patients forums and patient advocacy liaison services. In recent days, our arguments on those matters have been well rehearsed. For example, we believe that the abolition of CHCs is ill thought out, expensive and vindictive. There is no reason for us to repeat those arguments today.
We are, however, concerned about one or two specific matters that I should like the Minister of State to address. The first relates to the National Institute for Clinical Excellence. The Government response refers to
- "NHS bodies being directed to fund treatments recommended by NICE from January 2002"—
- "NICE guidance will no longer need the approval of the Secretary of State for Health before dissemination".
It is rather unclear what is meant by some of the statements in the Government's response on the future training of health professionals. For example, it says that the Government are
- "supporting people from non-traditional backgrounds to move into medicine."
- "greater public involvement in the selection of those entering training as health care professionals"?
I would also welcome clarification, which I thought the Secretary of State was going to give us, of the Government's plans for information. The Government response says that by summer 2002 there will be
- "guidelines about sharing information with patients and parents of young children".
We look forward to the Government's plans for the reform of the GMC. The Secretary of State was right to say that Bristol acted as a catalyst to that reform, but it was, in any case, well under way. I welcome Professor Kennedy's positive approach to the concept of the maintenance of professional self-regulation. He says:
- "For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and discipline."
I hope that when the plans are published there will be a clear separation of the disciplinary and investigatory aspects of the GMC. I suggest that it would be very useful if the Government included time limits for investigations, or at least for those conducted under normal procedures. There is a serious problem with lengthy investigations undermining professional self-confidence, removing staff unnecessarily from the NHS and costing a lot of money.
The Secretary of State alluded to the issue of clinical negligence. Professor Kennedy was bold in his assessment and suggested remedies. His report says that the clinical negligence system
- "should be replaced by an alternative system for compensating those patients who suffer harm arising out of treatment from the NHS."
- "an open and non-punitive environment in which it is safe to report and admit sentinel events."
In 1999-2000, the average time from claim to payment of damages of £10,000 was five and a half years, which is not satisfactory. The debate has centred on medical practitioners and patients, and the effect on them of such a slow process. There is concern that the rise in litigation and its formal nature may adversely affect medical practitioners in their work and relationships. I have
first-hand knowledge of patients and doctors who have been devastated by the slowness of the process, and it has to be tackled.The disproportionate amount of money spent on legal costs and the costs of settlement in smaller-value cases deprive the system of resources that could better be used to compensate patients or more widely deployed in the NHS. Many patients would like remedies other than compensation. The National Audit Office pointed out that a package of measures may be necessary to satisfy patients, perhaps including an apology, an explanation, access to remedial treatment, counselling, meetings with medical staff to explore what went wrong, an explanation of action taken to prevent it from happening again, and the provision of support. How many of those measures are missing in the sorry and tragic saga in Bristol?
We therefore welcome this debate and have issued our own consultation document, which has received a good welcome and thoughtful responses. I hope that the House can take a consensual view of what measures we need to introduce in this complicated area. We cannot allow the compensation culture or, even worse, the blame culture, to swamp our medical systems. Health spending is for health services, not lawyers.
We must still make a full remedy available to those who have been harmed in the health care system, which is why we find it hard to agree with Professor Kennedy's recommendation that we abolish the right to sue for medical negligence. We believe that that goes too far, but we are interested in conciliation, mediation and tribunal methods of achieving that goal. We are also worried about no-fault compensation, given the experiences of other countries, but we maintain an open mind on that.
Naturally, we agree with much of the Government's response and join them in thanking Professor Kennedy and his team for all their work. Many further issues have been raised and no doubt we shall consider them in detail in forthcoming legislation. There will be an inherent tension between inspection bodies and setting guidelines and standards on the one hand and what the Government describe in the report as the "freedom to innovate" on the other. All other countries suffer that tension, and we shall be no exception. Over time, we shall want to look in detail at the Government's responses and shall want to co-operate constructively, where we can, in the legislation that will flow from the report.
Finally, producing better and safer care is the best tribute that the House can pay to those who suffered so much in the Bristol tragedy.
2.25 pm
Mr. Frank Dobson (Holborn and St. Pancras): I very much welcome the Government's considered response to the Kennedy report and congratulate my right hon. Friend the Secretary of State on the progress that has already been made in implementing many of its important proposals.
Basically, the report spells out two things: what happened in Bristol and what needs to be done to prevent it from happening again anywhere else in this country. I congratulate all those involved in conducting the public inquiry, which has been extremely thorough and intellectually rigorous. That covers both aspects of the inquiry—the historic inquiry into what happened and the forward look at how best to avoid it in future.
I congratulate in particular Professor Ian Kennedy—now Sir Ian Kennedy—on the way in which he conducted the inquiry. When he was recommended to me, I knew that he was a great scholar and intellect. When I met him, I discovered that in addition he was questing and awkward, in the best sense of the word. I got the clear impression that he was extremely humane and understanding, so I was pleased to have the opportunity to ask him to chair the inquiry. My hopes and expectations, and those of everyone involved, were exceeded. He therefore deserves great congratulations on his contribution, not just to sorting out what happened in Bristol, but to future changes and improvements in people's treatment in the national health service.
After years of representations by concerned professionals and parents whose children had died or suffered brain damage, for a long time nothing was done—there was no response. It was 1997 before the General Medical Council finally started to investigate what had happened in Bristol, although concerns had been expressed in the mid-1980s.
In early May 1998, before the GMC concluded its inquiries, I met the Bristol heart children's action group, which represented parents whose children had died or suffered brain damage. I was deeply impressed, and deeply depressed, by the grief that the parents had suffered. I was deeply impressed and depressed by their dissatisfaction with the way in which they had been treated before, during and after what had happened to their children. I was deeply impressed and depressed by their disillusion with the personal, clinical, professional and management arrangements surrounding what had happened to their precious children: their children had been failed, and they had been failed. I explained that once the GMC had concluded its deliberations I would set up an inquiry.
The first time I met the group, we discussed the form that the inquiry should take, as there were various alternatives. I gave them a memorandum produced by Sir Cecil Clothier QC, the former ombudsman, which set out the merits, as he saw them, of a private inquiry with a public report, on the lines of the Nurse Allitt inquiry that he had carried out. I suggested that the parents should discuss the various alternatives with their colleagues and lawyers, and that they should then come back and meet me again.
I reflected on what the parents had said and its significance, and within minutes of their leaving my room I concluded that the only proper response was to establish a public inquiry with full statutory powers—that, in the circumstances, only that would suffice. Preparations started before I met the parents again and before the GMC came to its final conclusions.
Considerable pressure, one way or another, was brought to bear on me not to hold any inquiry at all, and certainly not a great big public inquiry, because of all the problems that it might cause. As a measure of the change that has occurred since then, I do not believe that any of those who tried to persuade me not to proceed would want to do that now. I am pleased that the culture in the NHS and the profession has changed and things have moved on.
By the time the General Medical Council announced its disciplinary decisions, in the middle of June 1998, I could announce the establishment of the public inquiry and the appointment of Professor Ian Kennedy to chair it.
The report confirms in detail what seemed fairly obvious in 1998 from a distance: there had been failures at every level—by individuals and of the system.Surgeons had let down the children. The local NHS management had let down the children and their parents. The national health service advisory machinery on clinical standards, such as it was, had let down the children and the parents. NHS regional management had failed. NHS national management had let them down. Sadly, the professional bodies, including the royal colleges, had also failed to tackle this difficult problem.
It was not just a question of technical failure. There was an enormous failure of attitude, and a failure to take the right approach to patients and parents. They had been let down by the NHS and the professions, who were there only to serve them. It was not a question of failure against new, more rigorous and demanding criteria. It was a failure against Florence Nightingale's century-old immortal question, "Who is in charge here?" The answer was, "Nobody." Everybody was responsible, so nobody was responsible.
In terms of clinical standards, it must be recognised that at that time the NHS, as an organisation, was letting down patients and the professions. The professions were trying to set, monitor and raise clinical standards, but that was not working well, partly because of some of the professional attitudes spelled out in the inquiry report, and partly because within professional organisations and between professional organisations there was no clear definition of responsibility for identifying things when they went wrong, and for doing something about it.
Most of all, the NHS as an organisation made little or no contribution to the setting, monitoring and raising of standards of treatment and care. That had become blindingly obvious to me within a few weeks of becoming Secretary of State. That was why, even before the Bristol inquiry was established, we published a White Paper in December 1997 that was intended to assist the professions in what they were trying to do by way of improving standards. The National Institute for Clinical Excellence was established to set standards.
A duty of clinical governance was being imposed on the boards of NHS trusts. It is difficult to believe that for 50 years the NHS had operated a management system in which senior management had no responsibility for the clinical standards of the organisation that they were supposedly managing. All they had was a duty to break even at the end of the financial year—a duty that they frequently failed to discharge. They had no duty in relation to clinical standards, so they were given that duty. The Commission for Health Improvement was set up to make sure, through a process of inspection, checking and advice, that standards were met.
All doctors, we said, would be required to be subject to external clinical audit. National service frameworks were established to cover heart disease, cancer, the treatment of older people, mental health and diabetes. Patients and GPs, as my right hon. Friend the Secretary of State observed, were to be given information about the success rates of treatment in their local hospitals.
The medical profession was already moving to introduce the concept of revalidation, so that every effort could be made to ensure that doctors were up to date in
their knowledge and continually updated themselves. That was a difficult concept for the medical profession to take on, but members of the professions were doing that and continue to do so.As my right hon. Friend pointed out, there have been further developments since the Bristol inquiry was established. One of the most important was the work by the then new chief medical officer, Sir Liam Donaldson, who started to consider how the NHS could learn from things that had gone wrong, and to apply to the NHS the approach of the aviation industry. The aviation industry has never sought to learn just from crashes; it has also always tried to learn from near-misses.
In the NHS there was hardly a process of learning from the crashes, and no process of gathering information and learning from the near-misses. Eventually, Professor Donaldson produced his report entitled "An Organisation with a Memory", and now my right hon. Friend has proceeded with the establishment of the national patient safety agency, which will help the professionals learn from things that have gone wrong, not just in their hospital or their unit, and not just from their own mistakes. They will be able to learn from the problems and mistakes of other professionals, and to identify procedures that appear to be intrinsically dangerous and should be avoided, or procedures that could be improved by minor changes.
Such developments have been endorsed by the report of the inquiry. In most cases the report recommends that the functions of the bodies that I and my right hon. Friend the Secretary of State have set up should be extended, their powers strengthened and their independence enhanced. I am sure that we all want that to happen. I am glad that there now seems to be a consensus in the House about the establishment of the Commission for Health Improvement and the National Institute for Clinical Excellence, as well as the introduction of other proposals that some people described at one stage as time and resource-consuming bureaucracy. All those changes were intended to help NHS professionals to make it easier to do their jobs as well as they would like. That is what they want and why they took up their professions in the first place. They are entitled to demand from us a system that helps them to carry out their professional tasks and does not hinder them.
A huge range of issues were raised in the report. I should like to concentrate on two of them. First, a major change in attitude is required in the medical profession. I think that it is already under way. Secondly—this may be more difficult—a change in public attitude and a major change in the law are required. First, as my right hon. Friend pointed out, there must be a much more open approach to patients and they must be more involved in decision making. Part of that openness concerns personal relations between professionals and patients, but another part of it is the publication of data, in relation to which there are dilemmas and difficulties. It is no use anyone pretending that there are simple, easy and quick solutions to the problem. Indeed, I do not think that anyone is suggesting that; at least, I have not heard anyone do so.
If one is a dedicated professional, the crucial issue is that the data should reflect the truth. The simplest truth is this: "When I did this operation, did the patient live or die?" That is a plain simple fact. Oddly enough, previously, and during the time in which I have been a Member of the House of Commons, NHS data did not
distinguish between deaths and discharges. It was only as a result of pressure exerted by me and others that that distinction began to be made. The difference between death and discharge is simple and straightforward, and involves no element of judgment. The minute that we start trying properly to make allowances for the advanced—or otherwise—nature of the condition being dealt with, or for the general health of the patient being operated on, some elements of judgment come into the data.We will have to allow that to happen, but it is crucial that it is done fairly. If the process is unfair to the professional, it is bound to mislead patients; it cannot do otherwise. Unfair data would do no one any good. They would undermine confidence and give false impressions of the brilliance of some and the inadequacies of others. If an impression is false, it is worse than useless. None the less, we must try to make a start, and the profession, including cardiac surgeons, has gone far in that regard. The extent to which professional bodies have taken on the problem and are addressing the dilemma, however difficult it may be for their individual members—after all, those are the people whom they represent—is commendable. They have carried progress on the matter a long way and they need our encouragement. Provided that they are willing to publish the data, we are going down the right road.
Then we come to the question of the personal involvement of patients in decisions affecting their treatment or that of their children. There must be greater understanding in the profession, or at least in some of it, about how patients and parents feel. Some people at least are lagging behind and must make a greater effort to put themselves in the position of the confused and not especially well-informed patient. If the patient is a child, those in the profession must try to imagine themselves in the perturbing and deeply disturbing circumstances of the parent. There is a difference between our concern for our own health, however good or bad it is, and our anxiety about the health of our children. Many people are fairly cavalier about their health, but I know no one who is cavalier about the health of their child, so a different approach is needed when dealing with parents—a more concerned and understanding approach than in respect of adults.
That is part of the professional task, and the majority of people in the profession are now involving patients more and are doing their best. Some of the most distinguished and well-known surgeons and physicians in this country are well known not only because of their success rate, which can be demonstrated by any data, but because they involve the patients, who get to love them because of that involvement. That is good for patients. It makes them feel better, improves the success rate and gives everyone greater satisfaction.
Again, I point out that we must recognise the difficulties. It is difficult for professionals who hope that they know what they are talking about in a very difficult sphere to explain the complexities of what is happening to someone who does not have their long experience and medical education. It is difficult to try to talk about the risks and odds that are involved. We cannot expect people to do that task easily without it having been included in their medical and nursing education and training. We must ensure that it is included. Imagine the difficulty for the doctor or nurse who is trying, as an individual human being, to say to a parent, "The child that you have brought
into the world and who you dote on has a 60 per cent. chance of dying—even if my operation is a success." Imagine saying to a parent after an operation, "Although your child is still alive, I don't think that I've succeeded and I think that he will die", and then saying later, "I've failed; he died." We must recognise that that is not an easy task and provide all the encouragement, help and training that is necessary to give people the ability to cope with those huge stresses, on top of carrying out a complex, difficult, demanding and lengthy operation. It is not easy, and we must try to help.On public attitudes and the law, I believe that everyone understands that the patient may die if a surgeon gets something wrong. Equally, everybody understands that, if a surgeon gets things right, a life may be saved. I regret to say that, in our blame culture, there is a tendency to lose sight of the fact that the patient can die even if the surgeon gets things right. In recent times, there has been a massive increase across the board in the number of people who look for somebody to blame when something goes wrong and assume that someone must be at fault. People were at fault in the Bristol case. That is clear beyond any doubt, but it is not always so. We must therefore encourage doctors, nurses and other professionals to draw attention voluntarily to the things that go wrong and not to be frightened about being sued or damaging their career because they tell the truth.
That must happen not only because, as the shadow Health Secretary pointed out, failure to do so is expensive but, more important, fear of telling the truth is bad for patients. The national patient safety agency will not work if people are frightened to report things that have gone wrong. The threat of litigation could put them off.
Nowadays, doctors are told to tell all, come clean and apologise, and that many people will be satisfied. That would be best for patients, and many would be satisfied. However, doctors who pick up their cars from the hospital car park, drive down the road and bump another car are told, "You shouldn't admit that it was your fault or your insurers and everyone else will be after you." We are asking people in the clinical professions to do something that is contrary to the culture outside the hospital. We must therefore tackle the culture not only in the hospital but outside it.
I had a slogan: keep doctors out of courts and lawyers out of hospitals. I once made the unseemly suggestion that the only place for a lawyer in a hospital was on the operating table. Apart from visiting, that still broadly applies. We must change the law and take seriously what happens outside the hospital if we are to improve what happens inside it. I strongly support the report's recommendation 119 to replace the current inadequate, slow, unsatisfactory, grotesquely expensive and lawyers' pocket and handbag-lining system of dealing with clinical negligence.
The system's main fault is that it is bad for patients' safety. My right hon. Friend the Secretary of State said that patients and their safety must come first in the NHS. They must also come first in our legal system. I welcome the chief medical officer's work in bringing people together to try to find a compensation system that is fair to those who have suffered but does not damage others who will be treated in future. When the Government present their proposals and we consider them, we should revert to the point that patients and their safety must be the top priority.
I have always felt strongly that we must resist the compensation culture that the United States would wish us to accept. Professor Kennedy also feels strongly about that. Unless we tackle the problem, it will undermine the impact of the inquiry's proposals, the changes that have already been made in the health service and the professions, and those that are in the pipeline.
I shall not attempt to cover other aspects of the report, but revert to what happened in Bristol. The performance of surgeons in operations on children's hearts in the Bristol royal infirmary was, to put it at its mildest, not as good as it should have been. Anxieties were expressed in the professions as early as 1984. In 1987, anxiety was expressed in the news media. From the time of his appointment in 1988, Dr. Stephen Bolsin, the consultant anaesthetist, expressed concern. Over the years, his anxieties grew, as did his efforts to get others to take them seriously.
For seven years, there was no outside investigation of the Bristol unit's performance. The representations that were made and the anxieties that were expressed at that time take up no fewer than 97 paragraphs in the inquiry report and are described as "confusion" and "muddle". Individuals and systems failed. Failings by individuals do not excuse system failures; system failures do not excuse those of individuals. The General Medical Council found individual doctors guilty of professional negligence. The inquiry found the system under which they worked equally if not more guilty.
Sir Ian Kennedy's foreword to the report summarises what happened in stark and simple terms, which I shall quote:
- "There were failings both of organisations and of people. Some children and their parents were failed. Some parents suffered the loss of a child when it should not have happened. A tragedy took place. But it was a tragedy born of high hopes and ambitions, and peopled by dedicated, hard-working people. The hopes were too high; the ambitions too ambitious. Bristol simply overreached itself. Many patients, children and adults benefited; too many children did not. Too many children died."
That brings me back to my first meeting with the representatives of the parents in early May 1998 when they made clear their wish for an inquiry that would put on record for them what had happened in Bristol. It was as important to them that the inquiry proposed ways in which to ensure that other children and parents did not suffer as they had suffered. That meeting took place 10 years after Dr. Stephen Bolsin first expressed anxiety about what was going on.
As the representatives of the Bristol parents got up to leave my office, one of the mothers asked, "Mr. Dobson, do you mind if I kiss you?" I replied, "Not at all. I like being kissed." She kissed me and I asked her whether she minded telling me why she wanted to do that. She replied that I was the first person in an official position to sit down and listen to what she and her fellow sufferers had to say. For 10 years, nobody had listened. That must never happen again.
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