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Mr. Hague: I am grateful for the continued opportunity to speak a little longer, but I hope that the Minister will reply soon.
I believe that there is a need for a public inquiry. We know—and no doubt the Minister will enlarge on this—something of the Department's approach and its reasoning for not allowing such an inquiry. An internal memo from Professor Donaldson, the chief medical officer, to Health Ministers, dated 30 July 2001, appeared in The Northern Echo. It referred to the carefully worked out terms of reference for the investigation. I have been a Minister, and I know what "carefully worked out terms of reference" means in a civil service memorandum: it means that the terms of reference have been drawn up to limit the scope of the investigation. That is the tone and the meaning of the memorandum, which states:
- "There is some pressure from the Cabinet Office not to challenge the Judicial Review"—
- "so that an adverse judgement on holding inquiries in private is not registered. This relates to another high profile matter where the intention is not to have a full-scale public inquiry."
- "Capitulation"—
- "would be disastrous. Not only would we end up with three public inquiries"—
- "but all these are 'problem doctor' cases . . . There might be 50 such cases a year and we cannot be forced to accept such a precedent. The damage to the NHS of regular public inquiries would be immense."
- "A further argument is that there is little further to be learned that has not been learned from other major inquiries into health service failures."
In a response to e-mails to The Northern Echo, the Secretary of State himself said:
- "I am deeply concerned. When things goes wrong we need to learn the lessons. That is why openness is so important."
The inquiry should also have power to determine the role of the General Medical Council, and terms of reference enabling it to examine all the circumstances before and after the employment of Neale at the hospital, not just during his employment. I believe that the inquiry should be conducted in the presence of the press and the public.
The investigation announced by the Department of Health does not meet those criteria. It is said that the victims can attend the inquiry, and can go out and tell the press what has been happening. Is that the form of openness that is now to be preferred in our society? Should not the press be free to report the proceedings, and report them straight? Must it rely on rumour and the passing on of news at second hand, when the matter involved concerns the public to such a huge extent?
The terms of reference that the Department announced for the investigation are inadequate, as they extend only from 1985 to 1995, which is not sufficient to catalogue the inadequacy of the system since 1995 and prior to Neale's appointment in 1985. The investigation may well fail to cover the NHS pay-off and reference, and the GMC claims that it did not receive a complaint from NHS management until February 1998. All that is beyond the scope of the investigation that has been announced.
The investigation will not be able to take evidence from private patients, even though they paid for treatment because of waiting lists or because Neale told them that
that was a better way to go. The inquiry's enhanced terms of reference look only at local NHS services, but the Neale case goes wider than Yorkshire, has implications for the NHS and GMC as a whole, and has highlighted serious deficiencies in health service procedures. We must ensure that all the lessons are learned.Everybody affected by Neale feels that there has already been too much foot dragging. Everything has been done a bit late, and we have had to campaign to get anything. To get an investigation, an action group had to be formed and lobbying had to take place. Throughout the history of this case, officialdom has dragged its feet; everything has been done behind time, when it was too late. It is not surprising that the people affected now want an inquiry out in the open. Ministers have nothing to fear from that. The case extends over a long time; no one is saying that today's Health Ministers bear responsibility for the origin of the problem. That is not their fault as Ministers, but it will be their fault if every lesson for the future is not learned in a fully open and transparent way, which is why we need a public inquiry into this appalling and disgraceful scandal.
7.6 pm
The Parliamentary Under-Secretary of State for Health (Yvette Cooper): I congratulate the right hon. Member for Richmond, Yorks (Mr. Hague) on securing this debate and raising an issue that is important and serious both for those who came into contact with Mr. Neale, including the right hon. Gentleman's constituents, and for NHS patients generally.
The right hon. Gentleman made a series of points which I shall try to address as best I can. The Government take these matters very seriously indeed and are determined to ensure that procedures are in place to minimise the risk to patients as far as possible. However, millions of patients have received the highest-quality care from the NHS; it is important that we do not lose sight of the excellent service provided by the vast majority of NHS staff, and I welcome the right hon. Gentleman's opening remarks about the excellent service provided by the NHS in his constituency.
There is universal agreement that patient safety must have priority. Any concerns about the conduct or competence of health professionals treating NHS patients must be properly investigated. Of course no system can be foolproof: when mistakes happen, a service is found wanting, or a professional is found to be incompetent, we must ensure that we learn the lessons necessary to avoid any future repetition to the extent that we are able to do so. That may involve local or national investigations, and of course there are differences of view about how best to approach these issues.
In the case of Mr. Neale, there were clearly great failures in the system. I agree that the case is serious and involves all kinds of unacceptable failings in the system in the mid 1980s through to the mid 1990s. From what we now know, there appears to have been a series of mistakes that badly let down those patients who went to Mr. Neale expecting at the very least a reasonable standard of treatment. Mr. Neale let them down in the way in which he treated them, and the NHS let them down by failing comprehensively to protect them.
The right hon. Gentleman set out a chronology of events and problems at different stages in the employment of Mr. Neale. I hope that the right hon. Gentleman will
forgive me for not wanting to pre-empt the results of the inquiry that we have launched to ensure a thorough investigation of what went wrong with the NHS systems that were then in place to protect patients. We are determined to learn the lessons of what went wrong in this case, as well as those of other incidents, in order to improve substantially the quality of care for NHS patients and give them the confidence that the right systems are in place to afford them the protection that they need. At this stage, it is important that Ministers do not pre-empt the diagnosis of the problem or the suggestions that result from the inquiry. However, I should like to respond as far as I can to the points that the right hon. Gentleman raised in terms not only of the inquiry itself but of the broader themes that are raised by the events that took place in relation to Mr. Neale.As the right hon. Gentleman mentioned, the Secretary of State for Health announced on 13 July last year a full independent investigation into the way in which the NHS had handled complaints about Mr. Neale's activities in the 1980s and l990s. Of course, the NHS has moved on considerably since 1997 and the proposed inquiry was intended to look not only at the systems that were in place at the time but at the extent to which improved systems could deal with the deficiencies exposed by the case. The right hon. Gentleman raised issues about whether the inquiry should be public. As he mentioned, those issues are to be the subject of a judicial review that is due to start on Tuesday 5 February, so there will shortly be full scrutiny of the Secretary of State's decision to hold an investigation into this case other than by way of a public inquiry. As is so often the case in such circumstances, a view must be taken about the right approach for achieving the best outcome. That may involve, as it has in this case, a decision about the relative merits of a public inquiry, as opposed to a private one. Both attract arguments for and against, but in the end, it is a matter of judgment in each case on the basis of the particular circumstances that it involves. It is almost inevitable that the final decision will not satisfy everyone.
In general terms, the decision to hold an inquiry in private was based on the Secretary of State's concern that the systems that were then in place in the NHS for handling complaints should be thoroughly investigated, that the inquiry should be scrupulously fair and that the outcome should restore public confidence in the complaints system as quickly as possible. It was my right hon. Friend's view that those aims would be achieved most effectively by an independent inquiry that took evidence in private and published a report of its findings and recommendations. Following representations, he agreed that the inquiry proceedings could be attended throughout by all the witnesses, affording them the opportunity to hear what was said not only by their legal advisers but by other people.
In making his decision, the Secretary of State has taken account of the many relevant factors and weighed carefully the arguments on each side. He has given special consideration to the views of the group supporting the victims by agreeing to significant modifications to the form that the investigation should take. All the information has been comprehensively stated in the evidence provided for the judicial review by the chief medical officer. It is obviously difficult to attempt to
paraphrase or reproduce that careful analysis, which is extensive, but I can say that it covers the benefits of quicker resolution and of being better able to get to the truth if more people are comfortable giving evidence in private because there are sensitive areas of care. Clearly, the matter will be considered by the judicial review and it would be unwise for me to attempt to anticipate or pre-empt the task that will shortly be before the courts.The right hon. Gentleman expressed concerns about the inquiry's terms of reference. In particular, he mentioned the ability to subpoena witnesses. The Secretary of State has considered the matter and we are not aware of evidence of problems with getting witnesses to testify in similar cases, but my right hon. Friend has said that, if there is evidence that that proves a problem in this case, he is willing to reconsider whether additional powers need to be given.
The right hon. Gentleman raised concerns about the inquiry's terms of reference and scope. Ultimately, its scope will be a matter for the inquiry itself to determine. The terms of reference give the members of the inquiry quite wide scope in deciding the most important issues that need to be investigated. They state that the inquiry will need to investigate
- "the concerns or complaints raised concerning the appointment, practice and conduct of Richard Neale in respect of his employment as a consultant in the NHS.
To investigate the actions which were taken for the purpose of (a) considering the concerns and complaints which were raised; (b) providing remedial action in relation to them; and (c) ensuring that the opportunities for any similar future misconduct were removed.
To assess and draw conclusions as to the effectiveness of the policies and procedures in place.
To make recommendations informed by this case as to improvements which should be made to policies and procedures which are now in place within the health service, (taking into account the changes in procedures since the events in question)."
It is important that we do not think that we need to wait until the inquiry ends before making improvements to the NHS. Many improvements have already taken place but it is critical that we establish a learning culture in the NHS. It must be able to learn from problems, difficulties and failings continuously, not simply when high-profile problems are covered in the national media.
Time after time, the blame culture has led to failures in the NHS, as the Bristol inquiry has recently shown. We have set out to change that culture to one of trust, where there is greater openness and partnership between patients and professionals and where lessons may be learned when things go wrong.
I want to respond to some of the broad themes that arise from the right hon. Gentleman's chronology of the events surrounding Mr. Neale's case. From the evidence we have seen, it is clear that one of the major concerns raised by Mr. Neale's case is the failure to pick up on the clinical problems with his practice, which subsequently formed the basis of complaints to the General Medical Council. Those were simply not picked up early enough. Nor was the extent of the problem recognised despite a series of
investigations. It is clear that we need to ensure not only that systems are in place to identify clinical problems early but that they are responded to properly, openly and effectively.The changes over the past five years or so are aimed at creating a culture change. They focus on improvements in quality and patient safety, reform of professional self-regulation and guidance for professionals. They are aimed at preventing to the extent possible those failures that have led to cases such as that of Mr. Neale.
The introduction of systems of clinical governance places a clear responsibility on the organisation to deliver and continuously improve patient care—it is the mechanism for ensuring, among other things, that NHS organisations can demonstrate that they are meeting the statutory duty of quality set out in the Health Act 1999. We need to have systems in place for local reporting and picking up adverse events, providing the mechanism for identifying and responding to cases of persistent poor practice by individual health professionals.
Improvements include the establishment of the Commission for Health Improvement to review and report on quality improvement in health care organisations. Its principal role is to improve the quality of patient care in the NHS across England and Wales. CHI undertakes clinical governance reviews as well as investigating serious service failures in the NHS when requested to do so.
An office for information on health care performance will be established within CHI with responsibility for publishing relevant information for patients. We are taking steps to publish information about the "success rates" of individual consultants—a move that might have brought some of Mr. Neale's practices to light earlier—building on national audit work already in train. Information about cardiac surgery will become available in 2004, with other specialties following.
In line with the findings of "An Organisation with a Memory" we have established the National Patients Safety Agency to provide a single national system of reporting and analysis of adverse events and near misses that occur within the NHS, and to ensure that effective learning takes place to make the NHS a safer place for patients. We will be taking further steps to rationalise the number of bodies inspecting and regulating health and social care.
We also need to reform the NHS complaints procedure to ensure that there is a procedure in place that can flag up patient complaints, particularly when there are persistent complaints around the same health professional, as was the case with Mr. Neale. The purpose of the reforms in which the Government are already involved is to ensure that the procedure is more independent and responsive to the needs of patients while maintaining the confidence and support of NHS staff. We are aiming to send out guidance to the NHS and commence training in early summer with a view to the reformed procedure being implemented later this year.
We have also established the National Clinical Assessment Authority to help NHS employers assess the small minority of "poorly performing doctors" and make recommendations about whether and under what circumstances they will continue to practise in the NHS. It is important that we do not simply identify the problems, but have proper systems in place to assess those
problems effectively and accurately and respond to them, as well as giving NHS employers guidance in being able to respond at local level.Another major concern in the case of Mr. Neale is the failure of the regulatory system to respond effectively and appropriately when it was found that he had effectively been struck off the medical register in Canada. The right hon. Gentleman made important points about that. If patients are to be protected, we must ensure that professionals are not simply able to move around to escape proper scrutiny or effective regulation. That was a matter of serious concern for the Government in the light of the Neale case.
We have already acted quickly to free up the General Medical Council procedures. In August 2000, we introduced some interim reform measures that significantly improved the GMC's ability to act quickly to protect the public and to make sure that NHS employers know when the GMC is considering a case. New procedures enable the GMC to take into account certain criminal convictions of a doctor when abroad. In the spring, we will extend the GMC's powers to enable it to take into account disqualifying decisions taken by authorities outside Europe, as was the case with Mr. Neale. The GMC will not have to re-prove the case against a doctor, which has been the problem in the past in handling cases such as that of Mr. Neale.
In the spring, we will also announce our proposals for the radical overhaul of all the GMC's fitness-to-practise procedures. That will improve the independence of the hearings in relation to GMC members, who in future will be responsible for the investigation and prosecution of cases but not the hearing of the case. We expect that the new arrangements will speed up the disciplinary processes, which have been subject to frustrating delays in the past, and make the processes and outcomes more understandable to the public.
The establishment of a new council for the regulation of health care professionals, as proposed in the NHS Reform and Health Care Professions Bill, will also help to strengthen and co-ordinate the system of professional self-regulation. I believe that it is essential that professional self-regulation commands public and patient confidence. The new council will work with the regulatory bodies to build and manage a strong system of self-regulation that is open and transparent; that responds; that allows robust public scrutiny; and that explicitly puts patients first. The council should provide for greater integration and co-ordination between the regulatory bodies and the sharing of good practice and information.
The right hon. Gentleman also referred to concerns about Mr. Neale's practice in the private sector. He may be aware that, under the Health Act 1999, the Secretary of State does not have the power to set up an inquiry that would cover that. He is also right that we need better regulation of the private sector. That is why it is right that we will introduce in April regulation of independent health care through the National Care Standards Commission, which will set national minimum standards for the private sector. All providers will be required to meet core standards, and standards specific to the particular services that they provide, which will be patient centred and will specifically address clinical treatment.
In drafting those regulations, patient safety was the foremost consideration. Currently, when health authorities register and inspect premises, they take no account of the quality of services provided, and those who own or manage hospitals accept no responsibility for the treatment either. The patient enters into a contract with the doctor, not the hospital.
After 1 April, those who run the establishment will be held responsible for the quality of the services provided. They will be required to have in place policies and procedures for clinical governance, and to have a formal complaints system. If patients are dissatisfied with the outcome of the complaints procedure, they may approach the National Care Standards Commission direct.
The right hon. Gentleman discussed in detail some of the harrowing cases that came to light as a result of the events surrounding Mr. Neale, which have certainly proved distressing. That is why it was also felt important to offer additional treatment and support to those former patients of Mr. Neale. The care programme for members of the support group for ex-patients of Richard Neale started at the end of April last year. The initial clinical assessment phase has involved in-depth consultations with more than 100 of the women concerned.
The process is ongoing, and I understand that more than 70 referrals have been made for further expert assessment and investigation, and, if appropriate, treatment. The majority of referrals have now been seen by Mr. Paul Hilton, urogynaecologist and clinical director for
women's services at the Royal Victoria infirmary, Newcastle. The few remaining will be seen in the coming weeks.I share the right hon. Gentleman's concern that the safety of patients in the NHS should be paramount. As I have said, we have already introduced since 1997 a series of practical and effective measures to try to improve the clinical governance system and the way in which the NHS responds to mistakes and problems, enabling it better to identify problems at an early stage, and in particular to learn lessons from them. We must recognise that sometimes, things will go wrong, but we must also ensure that lessons are learned at an early stage, rather than many years later, after too much further damage has been done.
It is important that the inquiry fully investigates the problems relating to Mr. Neale's treatment of patients, his employment in the NHS and the systems then in place. It must make recommendations about problems in the systems at that time, so that we can better improve existing systems.
The inquiry was set up after great consideration, with terms of reference and conditions that the Secretary of State believes will best provide us with a thorough investigation and speedy answers. They will enable the NHS to learn effectively from the tragic events, and I hope that we can ensure that the events and actions surrounding Mr. Neale do not happen again.
- Adjourned accordingly at twenty-nine minutes past Seven o'clock.
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