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14 May 2009 : Column 302WH—continued
Subsequently, since those developments, PROMs for hips, knees, hernias and varicose veins have been rolled out from April 2009. We expect that data in relation to
those first roll-outs should begin to emerge in late autumn. Does my hon. Friend have a view on that? Are we likely to see data and what type of data will be useful?
I understand that the Department has put out a tender for PROMs for chronic diseases, so we intend to pilot and roll out further PROM measures for other conditions. When I became a member of the Health Committee in 2005, I had been actively involved in health care as far as my constituents were concerned since I was first elected to the House, and my general assumption was that the NHS spent most of its money on new hospitals, new theatres in hospitals, new innovations or new drugs of the more expensive kind. For example, we are debating the use of end-of-life cancer drugs and how much more expensive they are. In fact, we spend about 80 per cent. of our money in the NHS on none of those things: we spend it on management of chronic conditions.
Some people have two, three or even four chronic conditions. That is where we spend most of our money, from the taxpayer’s point of view. It is right and proper that we should be looking at that area in terms of how PROMs will work. I will welcome the chronic disease pilot when it comes along. If my hon. Friend is still in post—if I am still in post—when it comes along, I shall be more than interested, as an individual, to see exactly how something that I hope will manage and improve the quality of health care for people with chronic conditions is being piloted.
We do not yet know how much PROMs will cost and who will be evaluating the large investment in them. I return to something that I must have mentioned at least three times now: a lot of the time we do not know, although we should know exactly, how much things cost. So, I hope that these pilots will teach us something before there is any general roll-out.
We understand that other quality measures are now published, including hospital mortality rates for certain conditions and GP satisfaction surveys. I do not know how clinically accurate those surveys are. However, they are certainly having some influence in my locality in terms of access to local GP surgeries that are not tied into the new centres that are being built. That is a good thing.
Something hit the press about five weeks ago in my constituency: a surgery was dubbed by regional BBC television the worst surgery in Britain. That surgery is still using 0800 numbers and nobody can ever get through. There was a massive queue, starting at 8 am, for people to see their GP and, until it appeared on television, if it was raining, people had to stand outside in the rain to get in.
The practice’s first reaction was to open the doors at 8 am, which is hardly rocket science. Nevertheless, it has done that, so at least the good people of Dinnington do not have to wait outside in adverse weather conditions. I hope that that practice has put something a bit more practical in place in respect of people phoning and that it is getting rid of a system that makes it difficult for people to get through on the phone when wanting access to their local GP. Out of all the surgeries in my constituency, that is the only one that I have ever had complaints about in terms of access—and I am going back many years.
I understand that we have no plans for evaluating CQUIN, although that is going into many commissioning processes throughout the NHS at the moment. I would like to hear the Minister’s view on that, if he has a view at this stage. I was at a gathering on Monday down here in London, talking about the NSR, and somebody said—I should have kept my notes—“We are collecting the CQUIN data from nine areas. We are not sure what it is intended for at this stage, but we think that if we are collecting data from nine areas, that must be a good thing.” I questioned whether it is a good thing, if the intention in respect of putting CQUIN into current commissioning is not known. Perhaps my hon. Friend will say what the intention is. I do not know what data are being collected, but I was told about this by somebody who works for the NHS in London. It would be useful if we had that information.
Just prior to the debate, I received a little note from Professor Alan Maynard, from York, who often advises the Health Committee. I often say—with some truthfulness—that he tends to appear at Committee sittings more frequently than some Committee members, but that might be a bit unkind. [Interruption.] I see one or two of my hon. Friends smiling. Professor Maynard’s note said:
“There are some indications that improving does not always save money”.
“contention that improved quality was always cost saving is dodgy”,
because people are likely to grab hold of the low-hanging fruit, which they have had a tendency to do for many years. Once they have got hold of that low-hanging fruit from the lower boughs of the tree, that is taken as evidence that something works. However, the further up the tree they go, the more expensive the fruit might be to get hold of.
Professor Maynard believes that there is no straight read-over and that money might not necessarily be saved. Having said that, that is not the point of the exercise. The point is to put quality rather than quantity on the NHS agenda.
We said in our report that there was no reason why we should not have included quality when we provided quantity during the past decade, but that, by and large, is now a matter for historians to debate. The important point is that what came out of the NSR was an intention to ensure that when our constituents use the NHS, things will not just be done quicker than previously, but the outcome will be clinically better and the quality of that outcome will be measured.
I hope that everyone will understand that, and that those who have a positive view of the NHS and who use it, particularly those who go into hospital, will be able to say in a few years, “It was the best outcome that I could have had,” and not just that it was the quickest outcome or that the nurses and doctors were fine.
3 pm
Dr. Richard Taylor (Wyre Forest) (Ind): It is a huge privilege to speak second after the Committee’s Chairman, Mrs. Anderson, because I do not have to take account of what other hon. Members might have said. I am grateful for that.
My first words are of congratulation for the Department on its response, which is full and in order. I have criticised it previously for fragmenting our reports and making its comments in an order that is amazingly difficult to follow. I have the distinct impression that, unless the word “recommendation” is included, the Department does not respond, but it has responded to these conclusions and recommendations in full, and I am grateful for that.
I welcome the emphasis on quality and leadership, and I shall spend most of my time on those two aspects. The Committee’s Chairman questioned the proof of quality-saving costs. Without proof, it is obvious that, if the quality of care is right, care is likely to be safe, efficient and low cost. Paragraph 36 of the response states:
“High quality and value for money are not competing alternatives; they are one and the same thing. Better care equals better value.”
An obvious example is that cutting down on litigation as a result of better quality saves money.
That quality needs to be addressed is all too obvious. We have recently had examples in mid-Staffordshire, and some time ago, we had examples in Brighton. I fear that poor quality may be more widespread than just two cases. With your permission, Mrs. Anderson, and as time is, thankfully, not tight, I shall read a whole letter that I have received from constituents in the past day or two. It states:
“Dear Dr. Taylor,
A few weeks ago we were devastated by the death of our only son. (We are not saying the standard of care he received wasn’t good in many respects, but there were areas that could have been...improved upon.)
We would arrive to see him, to find him lying in a soaking wet bed, or worse. He was unable to walk at this time so couldn’t get to the bathroom. I offered to take a commode to him, but was told no the nurse would do it. 30 minutes later I asked again but by the time it arrived it was too late. It was made worse by the fact”
“when the cleaner was polishing the floor she went only to the first bed, leaving the other two beds not cleaned under.
Our son had an infection under his nails and was unable to pick things up. This the staff knew about, so why were pills left in the little plastic cup. They would be left from the morning and lunch time. Maybe it was because he had no water jug or cup so he had nothing to drink. His Consultant told us he must drink plenty. He was given a warm drink which he had to drink through a straw, but his dad had to fetch water and a mug most days. He would drink 4 or 5 glassfuls which we had to hold for him. We know he wasn’t the only person they had to look after, and it’s said nurses are rushed off their feet. Lots of working people have long stressful days, and I know people who went into nursing as a vocation but sadly those days have gone. When someone is training for this job, I’m sure they must learn what is expected from them, and the meaning of the word nurse means to take care of and hopefully give a person dignity, which sadly our son didn’t have at times.
We hope that if others of us should need to go into hospital in the future, that the cleaners do what they’re supposed to do and our right to dignity is upheld.”
Thank you, Mrs. Anderson, for allowing me to read that long letter. What does one say in reply? It is not an official complaint, but I will pass it on to the commissioning and providing trusts. Sadly, I have been passing on such complaints for a long time. If they are formal complaints,
there is an investigation, probably an apology and an expression of aims to do better, but I continue to receive such letters.
Today, I received another, much shorter letter. It states:
“1 had an operation November last year to remove a possible...adenoma from my parotid gland. I was extremely unhappy with my treatment...The aftercare was disgraceful—the drain in the wound wasn’t working, but despite me asking numerous times, one was never re attached. I had salivary fistulas and an open wound till mid January, but they just told me to ‘squeeze’ it every day! I was given no guidance on cleanliness, dressing the wound etc. It was appalling.
I asked the surgeon to check my neck in January as I felt that the tumour was still there”.
“refused to listen and explained that the only lump they found was the lymph node, which they removed, so I was wrong, end of story.
I was not satisfied, so I asked my GP...to refer me for another MRI. I received the results of that...and the tumour is still there.”
Why is basic quality lacking? Why are compassion, dignity and communication lacking? Stress and overwork are not an excuse. Demoralised staff are the fault of the leadership. Is there too much emphasis on scientific training for doctors and nurses without adequate training in interpersonal skills, the need for compassion and sympathy, and the importance of dignity to the helpless?
I do not blame the chief executive at the hospital that I am talking about because I have high regard for him, and other chief executives in the area have said that, if anyone could turn things round, he could. Who am I blaming? I am afraid that I am blaming the clinical staff and the clinical leadership, and I will return to that.
Much of the Government’s response is about commissioning, so quality must be written into the contract, and the commissioners must be able to enforce that contract. Will quality observatories in each SHA help? How will they know about the sort of care that constituents do not make formal complaints about because they do not know what to do? If they come to me,I pass those complaints on.
The Government’s response reiterates much that has been said about quality, and paragraph 50—“High Quality Care for All”—sets out the seven aspects of the quality framework, but I am worried that those seven aspects may not pick up the sort of basic lack of quality that I am talking about. One is
“bringing clarity to quality—making it easy to access evidence about best practice by asking NICE to develop and kite-mark quality standards”.
I do not believe that NICE will be able to rule on not leaving patients in wet, soiled beds.
“supporting clinicians to measure quality to support improvement...requiring quality information to be published...recognising and rewarding the delivery of high quality care...safeguarding basic standards through a new independent regulator, the Care Quality Commission”.
Patient-reported outcomes will pick some things up, but they are obviously very limited to start with. I am not sure that commissioning for quality and innovation will help, because we need basic quality before innovation. I am also not quite sure how the NHS constitution will help people such as my constituents, but perhaps the Minister can clarify that.
The only answer is inspirational leadership by all groups of clinical staff, and that is covered by recommendations 21 to 24 of the report. Paragraph 107 of the Government response says:
“Far from taking a centralised approach to leadership development, we believe that leadership should happen at every level of the system and that leadership development should start at the level of the individual. All NHS staff have a responsibility to continuously learn, seek development and career opportunities, spot talent and support the development of others.”
My big question is what has happened to the local leaders? Do the ward sister and the consultants on a ward actually talk to one another? Do they do ward rounds together? Does the consultant tell the sister when the nursing standards are low? Does the sister tell the consultant when a junior doctor is hopeless? Sadly, I suspect that the answer to all those questions is no, and that is what we want to look at—we want to bring back basic quality care. The first allegiance of consultants and nurses on the wards must be to the patient and the other staff. I just hope that the review will address the restoration of basic quality care for all, while remembering compassion, dignity and communication.
3.12 pm
Sandra Gidley (Romsey) (LD): It is a shame that the House authorities have put the swine flu debate on in the main Chamber, because more hon. Members would have been here if they had not. I do not know whether we can make representations so that we can avoid doubling up in future.
Although there were some reservations about the next stage review, it was well received on the whole. Much of the tribute for that must go to Lord Darzi, because the process was very much driven by him. Initially, I thought that it was a brilliant idea to have him conduct the review. Indeed, one could see the light bulbs popping on over some Ministers’ heads as they thought, “Let’s find a doctor and make him a Lord. If he does the review, it will have much more credibility.”
Call me cynical, but that is the way I felt at the time. I thought that the process would surely get buy-in from the whole health service, but GPs initially said, “Ah, but he is a surgeon,” and even surgeons said, “Ah, but he’s the wrong type of surgeon. He’s a tertiary surgeon. He works on a specific bit of the bowel.” I wondered whether it was ever possible to please anybody, and it is partly a tribute to the man himself that he managed to bring the review off.
Various review streams were being carried out in different strategic health authorities, and it must have been an administrative nightmare to bring them together into some kind of cohesive whole. We sometimes underestimate the sheer hard work that goes into something like the review, and I pay tribute to all involved. Although the Committee found fault with some things, there was a consensus that the review was a good thing.
The hon. Member for Wyre Forest (Dr. Taylor) commented heavily on the issue of clinical leadership. I have been on Committee visits and other visits to countries where hospital boards are led by a strong medical component. That arrangement seems to lead to a more clinically driven process, and one cannot overestimate the importance of that. I am talking not just about doctors, and I am glad that the hon. Gentleman also mentioned nurses. I once visited a local hospital in
connection with hygiene, and I was given free rein to go into any ward I wanted, so it was very much a pot-luck visit. What struck me very powerfully was that some wards were run with a rod of iron—the nurse in charge had complete control and authority—but others were not. For the sake of patients, we need to invest heavily in dealing with that.
When I was elected in 2000, people waited at least a couple of years for a hip replacement, and they waited months in a cardiac ward for urgent cardiac surgery, hoping to survive, but we do not see that now. Although we criticise targets, I concede that they might have been necessary at that time to introduce outcome-driven targets, which were probably the only way to focus on what needed to be done. None the less, some targets did skew priorities. Now, however, waiting lists are low, and I hope that budgets will not be affected too much, so we can concentrate on improving clinical care and perhaps have a more clinically driven process.
It was entirely positive that the consultation did not involve just the great and the good and the worthies in their profession—the same old names that we see on every committee. The review went wider and tried to engage health workers in different localities and to involve patients and the public. We could argue about whether it did that as well as it could, but it tried, and that set a useful benchmark for the future. The review’s engagement with the strategic health authorities also meant that the focus could be a little more local. I am not usually a great fan of SHAs, but the engagement with them was useful in this case.
Getting the commissioning right will be crucial to the review’s implementation. It has frequently been noted that people seem to complain about the quality of commissioning wherever one goes in the health service. The Committee’s report highlighted that, saying:
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