House of COMMONS



health Committee



patient safety



WEDNEsday 3 June 2009






Evidence heard in Public Questions 957 - 1179




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Oral Evidence

Taken before the Health Committee

on Wednesday 3 June 2009

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Jim Dowd

Sandra Gidley

Dr Doug Naysmith

Dr Howard Stoate

Mr Robert Syms

Dr Richard Taylor


Witnesses: Dr Peter Daggett FRCP, Consultant Physician, Stafford Hospital and Mr Howard Catton, Head of Policy and Implementation, Royal College of Nursing, gave evidence.

Q957 Chairman: Good morning, gentlemen. Could I welcome you to the eighth session of the Committee's inquiry into patient safety? Would you, for the record, introduce yourselves and tell us the current position you hold, please?

Dr Daggett: Good morning, Mr Barron. I am Peter Daggett, I am a consultant physician at Stafford and I have worked there since 1982.

Mr Catton: Good morning. My name is Howard Catton and I am head of policy at the Royal College of Nursing.

Q958 Chairman: Thank you and welcome once again. I have a question to both of you. To your knowledge what efforts were made by staff to draw attention through official channels to the extent of dangerously unsafe care at Mid-Staffordshire?

Dr Daggett: I and my colleagues have been raising concerns with management at all levels for some considerable time and certainly around 2006 when I think the present problems arose. Your clerk has a dossier of some written information, copies of letters and e-mails going back even further than that. We did try consistently and at all levels over an extended period of time and a large number of comments were made. I will quote from one or two things. One of my colleagues, a cardiologist, said, "I have over the last few years completed incident forms highlighting failures of care. These were either downgraded to minor events by nurse managers without discussion with me and they are not investigated. I have persistently complained to the medical director at meetings that incidents were not properly investigated." There are many other examples like this. One of my colleagues who is a gastroenterologist wrote a long letter in 2006 to the middle management again indicating that the lack of nurses on his ward was of considerable concern and a danger. There is no doubt that considerable concerns were flagged up over an extended period of time by many people.

Q959 Chairman: Howard, I know you do not work in the hospital itself but how would you approach that question?

Mr Catton: Our experience has been the same. For a long period of time nurses were reporting concerns; between 2005 and 2008 we believe there is in the region of 500 or so incident or accident forms. There was a particular period at the end of 2007 where there were about 200 within a six month period. The concern which has been reported back to us is that people felt those incident forms were going into a black hole or into a waste paper basket. There is one example which was reported to us where a nurse said she did see an incident form in a senior manager's waste paper basket. People were reporting concerns but they did not feel that those concerns were being taken seriously. I think that led to a loss of confidence in the fact that anything was happening and there was no reporting back mechanism either in terms of incident forms that were put in. There is a particular concern for us in relation to nurse staffing levels because a significant amount of those incident forms, as Dr Daggett has said, related to concerns over shortage of staffing.

Q960 Chairman: Whose fault was it that information from staff went unheeded?

Dr Daggett: I do not think it was an individual's fault and I do not think it would be helpful to apportion blame. The systematic fault was that information provided to middle management - that is the directorates - was perhaps not acted upon as quickly and as forcibly as it should have been. When it reached the senior management level, ie the chief executive, he took the view that there were other more pressing matters and did not think it was significant.

Q961 Chairman: Was the nature of the trust itself - its size and level of staff turnover and other matters - a factor in making it difficult to raise issues?

Dr Daggett: I think the answer that is yes and the reason I say that is that if I go to one of my medical management colleagues and have a robust discussion with him about some management or political issue and then three hours later I need help in the ICU with patients it is quite awkward. I think because we work in a small hospital closely with clinical colleagues who have taken on this very difficult task of management - I could not do it -we tend to perhaps give them a more gentle ride than we should have done.

Q962 Chairman: I was a lay member of the General Medical Council for a considerable number of years and there is an issue in terms of good medical practice about what a doctor should or should not do. Do you think in any way that that was compromised by the way the hospital was run from your perspective as a professional?

Dr Daggett: I am not aware of anything dangerous happening that would cause me to contact the General Medical Council. I think it was a quality issue, that is patients may not have been treated as well as they should have been in terms of respect and dignity and that is, I think, entirely down to lack of nursing care. The nurses we have got are very good and I have never seen an example of bad nursing, just not enough of it. I do not think the care given by doctors was actually dangerous but it was too fast.

Q963 Dr Naysmith: Going back to something you said, Dr Daggett, you said that complaints were being submitted through middle management and at that level they were being thrown in the waste paper basket or discarded in various ways and were disregarded. If that was going on for quite a while there must have been people who knew that that was wrong and that complaints should be treated properly. I know you do not want to blame any individual - that is fair enough - but if at the level of middle management complaints were not being passed on did that not worry you and some of your colleagues and did you not want to do something about it?

Dr Daggett: I do not think they knew. I have just seen a staff survey where the question was asked of the staff at the moment, "How many of you have seen feedback from any sort of incident form?" and 80 per cent said "Never". We have only just realised that this has happened. I think that incident forms, when there was a paper system, went into a black hole, as my colleague said, and I do not think they were acted upon. The system has now changed; it is not electronic and much more transparent. I have recently spoken to the person in charge of this and she assures me they are now acted on and a manager is identified to deal with all electronic incident reports within 48 hours and feedback provided. This is one of the useful changes that has resulted from the HCC report,

Q964 Dr Stoate: The Secretary of State recently said in the House that "one of the great mysteries of Stafford" was that nobody went outside the official channels to blow the whistle. You are saying to us that forms were filled in, they were basically set fire to or chucked away or something happened to them and they never went any further. That is almost incredible. Why did nobody say, "This is getting us nowhere; we need to go further. Why are the local press not involved? Why are we not talking to the BMA? Why are we not going to the Royal College of Nursing? Why are we not blowing the whistle outside?" Surely someone thought to do that.

Dr Daggett: I will answer that but I would like to raise something that surprises me, that there has been no comment made anywhere else about this problem. The HCC did ask doctors if they had objected and I certainly said I had and there was written evidence of that. I have read the report in some detail and I can see no comment made about that. So the fact that doctors and nurses did raise concerns appears not to have got into the HCC report.

Q965 Dr Stoate: That is my point. Doctors and nurses were raising points, they were filling in incident forms, they were passing things on but clearly things were going nowhere and no-one thought to say, "Things are going nowhere; that is unacceptable, we must take it up elsewhere". No-one, for example, seems to have contacted the local Members of Parliament and said, "We are really frightened and worried about what is happening in our hospital". As a local Member of Parliament in my district I can assure you I get plenty of contacts from local doctors, nurses, patients and others and if I have concerns I am at the chief executive's office within hours. That is the way it works; that is what MPs do. Why was nobody doing that in Stafford?

Dr Daggett: As regards the correct channel I think those were all followed and gone through.

Q966 Dr Stoate: They were not, were they? They went to middle management and then disappeared.

Dr Daggett: The middle managers did speak to chief executives and that did not result in any satisfactory outcome.

Q967 Dr Stoate: Nothing actually happened despite a large number of problems and complaints.

Dr Daggett: I think that is right, but the whistleblowing policy is actually quite interesting. The hospital PCT and the SHA policy says that there is a provision to disclosure to the prescribed regulator. You can go to the Audit Commission in relation to public sector finance; the Serious Fraud Office, the Health and Safety Executive; the Environment Agency if there are environmental issues; the Charity Commission; the Occupational Pensions Regulatory Authority; and the Data Protection Registrar. There is no mention made of approaching the PCT or the SHA directly. In fact one of my colleagues did approach the PCT directly about lack of staff and other factors and was told that this would be resolved internally within the hospital management. He then went to colleagues he knew who were medical members of the PCT and was told the same thing. One of the very useful things that I hope this Committee can do is to codify the way that consultants and nurses can actually contact the next layer up, the PCT or the SHA, because at present there is no defined route of doing that.

Q968 Dr Stoate: I am amazed that nobody anonymously approached somebody outside, for example a Member of Parliament or scrutiny committee of their local council and said, "I am very concerned, do you think you could look into this but I do not want to give my name". Surely somebody would have done that.

Dr Daggett: I think perhaps they did and certainly the Stafford MP Mr David Kidney spent some time working in the hospital and his website indicates that he was very satisfied with what he saw.

Q969 Dr Stoate: He must have been the only one who was. I have a letter here from Dr Pradip Singh who submitted this in evidence. You said earlier that you did not think that patient safety had been particularly compromised by some of these issues, but just to quote from him: "I personally reported dozens of serious adverse clinical incidents resulting from abysmal secretarial support in my department, grossly abnormal result, eg CT scan showed possible pancreatic cancer when not shown to consultants for weeks or months". How could that not have affected patient safety outcomes if possible pancreatic cancer was not even being reported to the consultant for months?

Dr Daggett: I think that is a very specific case. The large majority of the consultants, in regard to this matter, look at their results as they come in on a day to day basis. Dr Singh's practice is different; he is a busy man.

Q970 Dr Stoate: He says here, "Many clinicians have felt frustrated for a long time". He says, "I circulated these issues to my consultant colleagues and I was suspended from work on flimsy ground without following elementary rules of natural justice" et cetera. The point is that he is saying that he did talk to his consultant colleagues and still nothing happened.

Dr Daggett: He most certainly did. We all talk to each other as well as our managers and our nursing colleagues. However, it is a very big step to go from internal dissent to effectively a vote of no confidence in an entire hospital management structure which is what it would have involved.

Q971 Chairman: Howard, the Secretary of State referred to a survey of nurses showing that 87 per cent would blow the whistle even if they suffered reprisals and 77 per cent say that the culture for raising concerns in their work is better than it was three years ago. How does that compare with what your members tell you?

Mr Catton: You are referring to a survey of 5000 nurses just a few weeks ago before our conference. Out of that 5000 survey 78 per cent - nearly 80 per cent - said that they were concerned about victimisation or personal reprisal if they were to report their concerns to their employers. Less than half felt confident their employer would protect them if they spoke up and out of those people who did report incidents again half have not had any feedback. I think what our survey showed us - which reflects what has happened at Mid-Staffordshire - were two things. One is a lack of awareness of whistleblowing policies and procedures. People did report incidents but they reported it at the lower end of the policy of procedure, filling out an incident form. The awareness of taking it to a prescribed body or an MP does not appear to have been there. People were concerned about what the implications may be for them. By that I do not mean that people thought it would be as crude as "If you speak out you'll be fired" although obviously you will be aware of recent Panorama events and there is an issue there in terms of speaking out. I think it is a more subtle and insidious culture, particularly that was prevalent at Mid-Staffordshire. People were told that the big prize was foundation trust status - the organisation's survival depended on that - I think that contributed, as well as the fact that we in nursing had a particular problem that there were no middle nurse managers. There were very few ward sisters but between ward sisters and the director of nursing there was a virtual vacuum in terms of nursing leadership. If nurses are filling in incident forms that middle tier of nurse managers are absolutely critical to building up a bigger picture about what is happening across the clinical area; they would be integral to dealing with complaints when they were raised. Those staff simply were not there. Then at board level we had a board who were closed, who were focussed on foundation trust status as well. This is partly the question that Dr Stoate raised as well about why were people not speaking out; they were but at a low level. Then there were these really strong forces in terms of leadership, policy, foundation trust status and the culture which constrained against people taking action more publicly.

Q972 Dr Naysmith: Can I ask why there were no nursing middle managers? Was that a deliberate policy?

Mr Catton: I mentioned the relationship between the staffing levels and incident forms. Almost 40 per cent of incident forms that we were aware of related to staffing levels. Between 2003 and 2008 there was virtually a year on year reduction in the number of nursing staff, somewhere in the region of 200 whole-time equivalents which equates to around about 300 heads. In terms of accident and emergency they took out 17 staff. It is incredible that the board did not undertake some sort of impact assessment about what the implications would be of taking out that number of nursing staff. We provided to the Committee before and could again some very strong evidence from both the UK and around the world about the relationship between nurse staffing numbers and experience and morbidity and other quality care indicators like nutrition and pressure sores and all the rest of it.

Q973 Dr Naysmith: Was that for financial reasons that they were taken out?

Mr Catton: The £10 million savings that the trust sought to achieve was a greater figure than they needed to achieve foundation trust status and it is our experience in Mid-Staffordshire - but it is also our experience elsewhere - that nurse staffing budgets tend to be close to the top of the list when organisations are looking at financial savings, hence why we make the point about the relationship and the link between nurse staffing levels and patient outcomes. Whilst this is tragic in this case, it does provide an absolute example, in reality, about what that impact is on patient care.

Q974 Chairman: Howard, could I just ask you in view of the circumstances, do you think your members' professional responsibilities were compromised at Mid-Staffordshire Hospital?

Mr Catton: Our general secretary has visited Mid-Staffordshire on more than one occasion. We also had nurses who work at Mid-Staffordshire who spoke at our conference recently as well. Those nurses spoke very passionately about wanting to provide high quality patient care but they identified three factors: leadership, resources and infrastructure as confining and constraining their ability to deliver high quality patient care. Nurses also have a responsibility to their employer; they also have a responsibility to their professional code of conduct. Their professional code of conduct includes two principles that are pertinent to Mid-Staffordshire and indeed to nursing across the piece. One is about protecting patient confidentiality, the other one is about speaking out when there are risks in the environment of care to patients. They are both absolutely important principles. The patient confidentiality principle is a cardinal principle and therefore to breach that principle nurses have to show that they have tried every other means of raising a concern or an issue before they breach patient confidentiality in terms of the greater public disclosure. I am aware that the Nursing and Midwifery Council have set up a meeting this week to talk about producing more guidance for nurses who have to make those decisions in terms of balancing those two principles. That is difficult enough, but when you are doing that without nursing leadership in a middle management position and when you have a board who appear to have an attitude which is that nurses can stretch and make do or that we can take more out of the nursing budget and more out of nursing staff then I think it puts those nurses in an unenviable position.

Q975 Chairman: I accept that but if anybody fails in their professional duty it is not the system that is taken to their regulatory board, it is the individuals concerned. It struck me, as somebody who has sat on a medical regulatory body for a length of time, that there must have been, without going into detail, a lack of professional responsibility potentially in these patients that did not surface for whatever reason.

Mr Catton: Those nurses who were at the clinical face raised those concerns and nothing happened and there were no senior nurse managers to see that there was a pattern emerging to raise it with the trust board. The nursing voice of the trust board was weak as well. Within terms of the nursing structure that we have there, there are some pretty major problems which meant that the more junior staff were on their own. Those nurses are absolutely sorry for what happened at Mid-Staffordshire. There are questions about why they did not raise questions as well, but equally there are questions about what the PCT was doing - they were spending the public pound - what questions they were asking and why they did not have more information about nurse staffing levels. I do not believe they picked up on the fact that there was not an impact assessment plan for taking £10 million out of the budget. The SHA's performance as the performance manager, again were they asking for this information on nurse staffing levels? I know that Monitor have recently emphasised the importance of quality but Monitor's most recent circular to trusts asked them specifically to re-look at staffing levels in light of future financial projections and moving from a period of growth to flat cash into deficit as well. Those nurses have done an awful lot of soul searching. There are lessons that can be learned from this as well. Nurses will stand up and take their responsibility but I think it is only fair and reasonable that that is alongside some of the other bodies and organisations I mentioned.

Q976 Dr Taylor: Peter, in your submission you have said that the Clinical Risk Management Committee was told in March 2001 that staff shortage should no long trigger an incident report. Who said that? Who told you that you could no longer consider staff shortages?

Dr Daggett: This committee met in 2001 and this statement was made. I think you have a copy of that letter there. That directive came from a middle grade medical manager and as far as I know it was not actually rescinded but it was ignored. Even during 2001 the level of staffing was not regarded as a serious matter.

Q977 Dr Taylor: What was the cohesion like between consultants and nursing staff? In the old days if a consultant was bothered about what was going on it would be the ward sister the old fashioned matron he would have gone to. What was the sort of liaison between doctors and nurses?

Dr Daggett: It was actually very good. I have copies of correspondence going back to 2002 and 2003, after this episode. There are sisters writing to me and me writing back and saying, "Look, we are all agreed; it is not good enough" but the mantra from the management has always been that on the one hand there is no money and more recently that there is no gain without pain. We were told that things would improve and indeed following the appointment of the new director of nursing things did improve and they improved before the HCC report. That is one reason I think why many people felt there was no need to take it any further because the trust board and particularly the director of nursing had taken the view that the level of staffing was inadequate therefore our complaints and warnings had been noted. Things were improving and indeed they still are. The HCC report is a great stimulus, if you like. I have always worked very closely with the ward sister on my ward; I need to know her opinion. The doctors and nurses, with very few exceptions, have always got on well as a team.

Q978 Dr Taylor: During post take ward rounds are you able to have a nurse with you?

Dr Daggett: This is a hot potato. I cannot do a post take ward round without having a nurse who can tell me her view of how the patient is, but because the nursing level has been so very low for such a long time it has become the norm not to have a nurse. The matter that Dr Stoate referred to where a colleague was suspended related directly to that. I am told that this colleague said that he could not safely conduct a ward round without a nurse being present and at that point said, "I will be in my office if I am required" and the next thing I knew he was suspended. I do not know all the background but that is the information I was given and I have no reason to doubt it.

Q979 Dr Taylor: Has the replacement of the director of nursing made a big difference?

Dr Daggett: It has made a remarkable difference. I do not want to embarrass the lady by saying how much we approve of her but we do. She is reliable, she is not a soft touch, she does what she is asked and she initiated the staffing review as a result is suspect of the trust being aware of the consultant's concerns. That was in 2006 when she was appointed. Very soon after things started to improve slowly and therefore, as I have indicated, it has achieved the desired effect and her good work continues.

Q980 Dr Taylor: Again from your description and your submission the director of nursing is really the only clinical member who sits on the trust board.

Dr Daggett: There is a medical director. The last medical director was a pathologist but again a respected colleague who was always entirely approachable. The new medical director is a gynaecologist, also a clinician, so there are two clinical members of the trust board.

Q981 Dr Taylor: Could you put your finger on the main things that can be done to reduce harm to patients in general?

Dr Daggett: First of all the incident reports and other expressions of concern from the nurses and doctors should be managed in the same way as complaints from patients, ie taken seriously immediately and actioned in the same way complaints now are. That would go a long way to stop the misappropriation of information which has definitely happened in the past. I think when there is a major concern individual nurses and doctors should have right of access to the trust board. It is true that consultants can go and see the chief executive, but consultants by and large have got fairly thick skins and do not mind going to see an important man who may not approve of them. I think the nurses at present will feel very inhibited going to the chief executive. I think it should be in the letter of appointment that if you do have serious doubts you have right of access to the trust board to put them directly to them. The trust board are honourable and truthful people and I think if they are presented with information in that way they might have acted more quickly. Finally, I have to put my hand up and say "mea culpa"; we should not have accepted the mantra that there is no money and we should have said there has to be otherwise there is going to be a fiasco.

Q982 Dr Taylor: Howard, does the RCN have a policy on nurses accompanying doctors on ward rounds?

Mr Catton: We do not have a specific policy but generally I would say that we would absolutely expect that that would normal practice. The strength of the multi-disciplinary working between doctors and nurses and others is a critical factor in delivering high quality care. The reality of doing a ward round, I suspect, is that medical colleagues would feel limited if they did not have a nursing input into that in relation to the patient's condition over the previous 24 or 48 hour period. May I also offer some views in terms of what could be done?

Q983 Dr Taylor: Yes.

Mr Catton: Firstly in relation to whistleblowing, we have mentioned that we think there are policies and procedures in place but they are on the shelf and people are not aware of them. We think it would be very helpful if chief executives and boards gave unequivocal guarantees and commitments to their staff that if they speak out in good faith about patient concerns they will not suffer any detriment. I think that would be aided by more directors and chief executives walking the patch and meeting the clinical staff on a regular basis. Organisations need to have a central register of all concerns that are raised, but a register in a format which is accessible and lends itself to scrutiny by executive and non-executive members. Critically there needs to be some mechanism to ensure that there is feedback to staff, that their concerns have been heard and what action has or has not been taken, and the clinical leadership piece which we have already spoken about. More generally in relation to quality, I guess we are very aware at the RCN that we may bang on about nurse staffing levels somewhat and we wanted to try to say something a bit more helpful about how you could an organisation really take notice about nurse staffing levels given the critical link between nurse staffing and patient outcomes. Two relatively simple indicators which would not involve a massive data collection - it is data which is already there - for trusts to be aware of, what your nursing establishment is and what your actual staffing level is so that if there is 15 per cent or 20 per cent discrepancy due to frozen posts or people on sick leave that people are aware of that. Secondly, the ratio between registered nurses and non-registered nurses. For general medical and surgical wards the Royal College of Nursing has said that we think a 65:35 ratio is about where that split should be and was very interested and pleased to see that Dr George Alberti made reference in his report to the fact that that ratio between registered and non-registered slipped to 50:50. In terms of boards having some high level indicators about nurse staffing but which are meaningful and easily collectable, we would propose those two.

Q984 Charlotte Atkins: Dr Daggett, first of all, how were patient complaints dealt with at Mid-Staffordshire? Was there a proper process or were they dumped, just like the staff complaints were dumped?

Dr Daggett: I am not an expert on that but I can give you an opinion.

Q985 Charlotte Atkins: Please do.

Dr Daggett: Until, I guess, 20 years ago complaints came to the hospital and were sent directly from the chief executive to the consultant and in my case I dealt with that within 48 hours because I could get the notes out. If there was a problem I rang the patient up and said, "Look, I'm very sorry, come and talk to me". The large majority of complaints were just a request for information, misunderstandings. In the days when consultants had the autonomy to do that I think that was actually dealt with much better because sitting down with a patient with a cup of tea, apologising if necessary and explaining if something had been done wrong was the way forward. At the moment I think the complaints go first to the chief executive, they are then sent into PALS, the letter is then sent to the consultant concerned who then calls for the notes and is required to respond within two weeks which I think is too long. The system I think is universal throughout the country and I do not think the Mid-Staffordshire system is likely to be different from anywhere else in the country but it is too unwieldy and bureaucratic and it certainly prevents complaints being ignored. There is a temptation, if something unpleasant lands on your desk, to put it in your in-tray and deal with it later. The majority of consultants do take complaints seriously and act much more quickly than the PALS system allows them to.

Q986 Charlotte Atkins: Were you aware of a large number of complaints coming in either from individual patients or relatives or indeed from the local MPs?

Dr Daggett: I do not have that information. All I do know is that if a complaint comes to me directly I deal with it straight away. I will probably live to regret this, but recently I have not had complaints. I work on a ward that has been partially immune from what has been happening where we have a rather different ethos and although clearly we get things wrong and we do get complaints, I have not had a large number so I cannot really make any comment on that.

Q987 Charlotte Atkins: You mentioned the issue about the complaint going to PALS (the Patient Advice and Liaison Service). Do you think the fact that PALS is part of the hospital rather than being independent of the trust is a problem here?

Dr Daggett: I would doubt it. The person in charge has worked in the hospital for a long time and we regard her as being independent. I know she is paid by the trust and owes loyalty to it, but she acts as a patient's advocate and I have never known the PALS service come down firmly on the side of the doctors without a very good reason. The other problem I think with the PALS service is that once the consultant has provided a report that is then transcribed by a manager and signed by the chief executive. The manager knows a little about the case because he has read the report; the chief executive, with few exceptions, knows nothing about the case, he is just asked to sign the letter. That seems to me to be a recipe for dissatisfaction.

Q988 Charlotte Atkins: I know as a Staffordshire MP that the Local Involvement Networks (LINKS) are not working effectively in Staffordshire. Do you think that would be a factor in terms of not giving support to patients who may be raising complaints?

Dr Daggett: Again I am afraid that is outside my experience. Everybody deals with complaints and unpleasant episodes in a different way. I have always done it my way which I accept may not be entirely approved of, but I believe it works. I cannot answer a question about LINKS I am afraid.

Q989 Charlotte Atkins: Howard, can I just ask you to comment about the issue of how you would expect patient complaints to be dealt with at hospital level?

Mr Catton: We would expect there to be a very clear governance process with identified lead officers, with a governance committee for scrutiny for overview, for seeing patterns and themes that emerge, for reporting to a board level with clear standards in terms of action that people are either required to take in terms of investigation or dealing with the problem but also feedback and liaison with whoever the complainant may be, and the principles informing both patient and staff complaints or incident forms to be similar obviously because you would want to read across between the two. I have mentioned the fact that there were no modern matrons - whether we call them modern matrons or not - or that tier of nurse management would play a critical part in terms of investigating complaints, dealing with them and making sure that they were followed through. There is a real capacity deficit there in terms of dealing with complaints because those staff were not in place.

Q990 Charlotte Atkins: So the lack of middle management in the nursing structure would impact on the effectiveness of dealing with patient complaints.

Mr Catton: Absolutely because I think that a lot of those complaints that were raised at a ward level may then normally be passed through to that middle management structure and then equally the investigation of those complaints and any action that comes out of them, that nursing management structure would be integral to leading on that and to report back.

Q991 Charlotte Atkins: Are you aware of any issues around complaints from your own membership within the hospital?

Mr Catton: The general comment that I would make is that as valuable as PALS are, nurses talk to us about PALS providing services more around signposting information and advice and support, it is not about providing the necessary independence that goes with the scrutiny of health services. Equally the variability in what LINKS are doing and their effectiveness is something that has been reported back to us.

Q992 Charlotte Atkins: Were your members raising with you any issue about the fact that they felt that patient complaints were being suppressed in any way?

Mr Catton: I am not aware that that was raised directly with our members.

Dr Daggett: If I could just come back on that, as regards the patient complaints I think far from it. The PALS service (which we regard as independent but internal) pursue complaints until they have been dealt with. I would be most surprised if any are being suppressed.

Q993 Charlotte Atkins: I was not suggesting that PALS would suppress, I was talking about the hospital management suppressing it, ie that they were swept aside and not taken seriously. The very point you made yourself about the chief executive signing off a letter without actually knowing anything about the substance of the complaint is worrying I think.

Dr Daggett: I agree.

Q994 Mr Syms: We have gone through several changes in patient complaints and the government, in their wisdom, decided to get rid of the community health councils. Do you think that we would have learned about what was going on earlier had that structure stayed?

Dr Daggett: I never quite understood what community health councils were for. They gave people a chance to let off steam and were a useful safety valve, but if you look in the local newspapers they are full of observations about the hospital for years and years and years and actually the local newspaper I think fulfils pretty much the same function as community health councils.

Q995 Mr Syms: Would you have a view, Mr Catton?

Mr Catton: I think there was variability in relation to community health councils as well since the variability we have got with LINKS. I think that effective public/patient involvement needs a degree of independence. I think it needs access to information in the first place and it needs to be presented in a way which is understandable and can be scrutinised. I think that if you want genuine and meaningful public/patient involvement you need to resource it as well and there are currently weaknesses across those issues.

Q996 Mr Syms: Dr Daggett, you have worked in a hospital for a number of years. We have heard from ministers that things are improving and one accepts that. However, there are also many calls for a public inquiry. How do you feel about that? Do you think a public inquiry would be helpful for the community?

Dr Daggett: I think it would. It would lance the boil and given people a chance to say what they need to say. I think it would be a good thing and I have a sense of déjà vu. I started my career 25 years ago representing the hospital at the legionnaire's disease inquiry and I was asked to go because I was young and vigorous; I will leave you to decide why they have asked me this time.

Mr Catton: We have called for an independent inquiry but which is held in private. The reason for that is that I have referred to the deeply engrained and insidious culture that we believe staff have been working under for a number of years. We think if an independent inquiry were held in private it would provide an arena in which staff would feel able to speak much more fully and frankly about their experiences, but the findings of that inquiry should be made public.

Q997 Dr Naysmith: Dr Daggett, what role do you think the board played at Mid-Staffordshire? Could I ask you first of all, is there any kind of formal organisation for senior clinicians and consultants like yourself to make your views known to the board?

Dr Daggett: We have directorates of medicine, surgery and so forth. There is a hospital management board, the Hospital Modernisation Board. There is also a Consultant Staff Committee which is the equivalent of a community health council - it is a talking shop - where we are able to go and give our opinions and let off steam, but that has no right of access to the trust board. As far as I know, nobody has right of access to the trust board and coming back to the point I made earlier I think perhaps they should. The chief executives that I have worked with over the years have been approachable to various degrees and I have spoken to them informally as have my colleagues, but there is no right of access for the consultant body or indeed the nursing body directly to the trust board.

Q998 Dr Naysmith: Are your colleagues happy with that? My experience of senior hospital doctors is that they can be fairly forceful in making sure that their opinions get heard at the place where decisions are made. Is that not happening at all at Mid-Staffordshire?

Dr Daggett: It comes back to the fact that it is a small hospital. Because we have to work in a small community I think we argue rather than fight and perhaps in retrospect we should have fought.

Q999 Dr Naysmith: Do you get any feedback at all from board meetings? Do you know what goes on at board meetings and do you get an indication that any of your concerns have been dealt with?

Dr Daggett: Again it is sent back down the chain of command. Information from the trust board is provided, I guess, when necessary to the hospital management board on which the clinical directors sit and they then pass it down to the individual consultants usually by sending out the minutes of the hospital management board which clogs up your mail box for three weeks.

Q1000 Dr Naysmith: So the minutes were circulated.

Dr Daggett: Yes.

Q1001 Dr Naysmith: There is no question of secrecy.

Dr Daggett: No. Everything from the hospital management board was circulated. I do not think anything from the trust board director was circulated.

Q1002 Dr Naysmith: Has the foundation trust governance model made any difference? Or does it not make any difference at all?

Dr Daggett: I have not seen any difference but I am not a political animal. Many of my colleagues take a greater interest in that but I have not seen any changes so far.

Q1003 Dr Naysmith: You have not seen any difference?

Dr Daggett: No.

Q1004 Dr Naysmith: Do you agree with the Healthcare Commission that the board was too concerned with finance and targets?

Dr Daggett: Yes, I agree with them.

Q1005 Dr Naysmith: You agree wholeheartedly with that statement.

Dr Daggett: I do not agree with the entire HCC report, but I agree with that statement.

Q1006 Dr Naysmith: Howard, do you have any observations?

Mr Catton: Yes, we do. We undertook a survey of members working in foundation trusts back in 2007 (we can provide more details to the Committee afterwards) but the headline from that was that at that point in 2007 of the 46 foundation trusts that we talked to nurses in, they were concerned that the big business ethos was squeezing out patient care. That is how they described it and they were concerned about lack of transparency, the justification being that matters were commercially sensitive. They also make an interesting observation that foundation trusts appeared to fear Monitor more than they did strategic health authorities. That focus on achieving foundation trust status, it being the ultimate prize and organisational survival being dependent on it, was absolutely for us evident within Mid-Staffordshire along with the lack of transparency, the commercial confidentiality and the lack of clinical leadership issues. The other thing I think I would add is that there were mixed messages to staff. When the £10 million was announced staff were told there really would not be clinical posts cut; there were. When clinical floors were introduced people were told that this was for effectiveness and for efficiency and it would not undermine patient care. We had a situation with one ward sister in charge of three wards - nearly 80 beds - and patient care was affected. I think the messages that the trust board gave did not match the reality of the experience of nursing staff. You obviously saw the impact that had on moral and I think the trust board lost their staff along the way which is obviously a critical issue in terms of the health or not of an organisation.

Q1007 Sandra Gidley: Dr Daggett, can you just clarify something you said earlier? You said that information to middle management was not acted on. Can you clarify what you mean by "middle management"? I thought you then went on to say "the board" as though you were referring to the board as middle management.

Dr Daggett: When I use the expression "the board" I mean the trust board, the chief executive, the director of nursing, the medical director and so forth. The next layer down is called the hospital management board.

Q1008 Sandra Gidley: So it is the hospital management board you were referring to.

Dr Daggett: Yes.

Q1009 Sandra Gidley: You also said that you have not witnessed examples of poor nursing care; it was a quality issue. Would you care to elaborate on that?

Dr Daggett: I have never seen a nurse on a ward deliberately neglect a patient or mistreat them. I have seen patients left, as the report suggests, un-nursed because there is no nurse and in the past it has been possible, as we have just heard, to have one ward sister looking after 80 beds. That sister and her two or three staff nurses cannot properly nurse 80 patients; they cannot even nurse 40 patients. I have never seen a patient deliberately mistreated or deliberately ignored.

Q1010 Sandra Gidley: Would you take issue then with the submission we have had from an organisation called Cure the NHS? I will quote from it: "During the eight weeks I cared for my mother I had to feed vulnerable patients as there was no-one else to feed them". I think you have probably explained that. "I saw confused patients physically and verbally abused daily. Patients continually fell and no-one was around to help them. Staff did not seem to understand the risk and how to manage it." The bit that worries me there is, "I saw confused patients physically and verbally abused daily". That is not a lack of nursing; that is poor nursing care. That is abysmal nursing care if that is true.

Dr Daggett: If true that would be cause for concern but I doubt very much that it is true.

Q1011 Sandra Gidley: Why would you doubt this person's submission?

Dr Daggett: I have never come across any suggestion, apart from this, that that is the case.

Q1012 Sandra Gidley: You have personally never witnessed anything of that nature.

Dr Daggett: I have personally never witnessed anything other than a few nurses doing their best in difficult circumstances.

Q1013 Sandra Gidley: So reports we have had the tablets and medication were not given on time, that bathrooms and commodes were not always cleaned, that patients were neglected and left soaking in their own urine developing sores, that is all down to lack of nurses.

Dr Daggett: That is a sin of omission; I have never seen a sin of commission.

Q1014 Sandra Gidley: Is it not sometimes easy to excuse that with lack of nurses? Surely some of these patients and some of their representatives would have said something, would have raised complaints to consultants. I cannot believe the nurses were happy with this and you say you were not happy with this, but why did this not go anywhere?

Dr Daggett: All I can say is that on my ward that has never happened.

Q1015 Sandra Gidley: Are you able to answer for the other wards?

Dr Daggett: I cannot answer for other wards.

Q1016 Sandra Gidley: In fairness I do not think your ward is one of the ones which is featured heavily in the report, which is probably why you are here and not somebody else.

Dr Daggett: No, it is because I am old and expendable!

Q1017 Sandra Gidley: The point I am coming to here is that surely every health professional has a professional responsibility - be they a nurse, be they a doctor - to do their best for their patients and this clearly was not happening. We have been to other hospitals which have a regular system of case reviews. This is not something that is allowed or disallowed by management; this is something the clinicians themselves decided to do because it was good practice but this does not seem to happen in this hospital. Why is that? Why did clinicians themselves not take some sort of lead on this? There are some things the clinicians could have done themselves, why did they not?

Dr Daggett: I think they should have done and we have now changed our system. We will now be having such reviews.

Q1018 Sandra Gidley: Surely the doctors and consultants do not exist in isolation. A lot of them must have practised in hospitals that did have these good systems in place. Why did this suddenly all disappear into the ether when they came to work in Staffordshire?

Dr Daggett: I cannot answer that.

Q1019 Sandra Gidley: Can I just ask a question of Howard Catton? I cannot believe that the nurses were happy with leaving patients in these conditions. We continually hear that it is all about clinical leadership and we did not have this tier of leadership, but I am sorry, I just do not buy that. Surely the nurses too had some sort of personal and professional responsibility and they should have been doing something. If the board would not listen, is there not a mechanism through the RCN or somewhere else where the RCN can act as advocate? Did that happen? Were you listened to?

Mr Catton: The type of nursing care that you have described is unacceptable and I would not for one minute try to condone that. I think that there were a range of factors at play here. I have talked about staffing levels, I think that was critical; there is only so much you can stretch and make do. If you do not have the staff with the experience then that is a problem. We have not talked about training and development either. There was a lack of training and development.

Q1020 Sandra Gidley: You do not need to be trained and developed to know that it is wrong to have a patient in a urine soaked bed. I am sorry, that is basic training, it is not development.

Mr Catton: Absolutely.

Q1021 Sandra Gidley: My question to you was, should there be some other mechanism for nurses to raise these problems?

Mr Catton: Yes.

Q1022 Sandra Gidley: Was there? Was it used? If not, should there be something?

Mr Catton: As I said, that nursing care is unacceptable. There is a really powerful concoction of ingredients here in terms of the oppressive culture, staffing levels, training, lack of leadership, lack of resources as well which came together; it is not just one of them. There were staff who left during this time because of the environment that was there. I think there have been lessons for the Royal College of Nursing as well as for other organisations as a result of Mid-Staffordshire. We have recently set up our own whistleblowing lines so that nurses can phone us directly with concerns which they might have. I think the other issue here as well - it is an issue about wider policy - is that if the trust had focussed on quality as much as they did finance then we would probably not be sitting here today. There are some big policy levers that you could use to get them to focus on quality: pay them more for quality rather than just volume; make sure that it is a commissioning contract; make sure it is part of SHA's performance management processes and procedures. I am slightly concerned that we are hearing now that quality accounts may not be accounts but may be quality reports as well. I think there are some big things that we can do with the policy levers that are available to us to make quality be at least an equal partner to finance as well.

Q1023 Sandra Gidley: I do get concerned when I hear people talking about policy levers because I think a lot of this stuff is basic. My final question is, do you think there has been a lot of buck passing by everybody in this and that the clinicians themselves must take a portion of the blame for what has happened.

Mr Catton: From what I have heard from the nurses, as I said, at congress, from what I know the discussions our general secretary has had, those nurses have stood up and have said that there has been unacceptable care here as well. I do not think that nurses are trying to duck it, but I do not think it is fair, right or proper just to say that doctors should have spoken out and nurses should have spoken out without looking at what the other responsibilities of significant bodies were as well.

Q1024 Sandra Gidley: It is certainly part of the picture and that is the part of the picture we are looking at at the moment.

Mr Catton: I think it will be enormously helpful if the nursing and midwifery regulator provide further guidance and advice to nurses about how to speak out and if we get trust boards giving that categorical and unequivocal commitment to support people who speak out.

Q1025 Sandra Gidley: Dr Daggett, have doctors said sorry?

Dr Daggett: Have doctors said sorry?

Q1026 Sandra Gidley: Yes.

Dr Daggett: No, because we have done nothing wrong.

Q1027 Sandra Gidley: We have heard the nurses have said they are sorry, why have the doctors not said sorry?

Dr Daggett: I do not think we have done anything wrong; there is nothing to apologise for.

Sandra Gidley: Others can judge whether they agree with that comment.

Q1028 Chairman: Dr Daggett, could I ask you about your call for a public inquiry? What would we learn from a public inquiry that we have not learned from the Healthcare Commission report and the subsequent reviews that have been done of the different parts of the hospital that were having problems?

Dr Daggett: Mainly so we can find the genesis of the financial problems. This whole sorry business has resulted from the hospital having insufficient resources and I have never understood how that arose. I think some sort of inquiry might get to the root of that.

Q1029 Chairman: You said it would be so that people could get it off their chests, so that they could talk out.

Dr Daggett: Again I think that would be helpful and if people who feel aggrieved can come and give an opinion in public there is much to be said for that. What interests me is to establish the genesis of the financial difficulties. I do not understand because I am not an accountant, but somebody must understand it and be able to work out exactly where the money went and indeed where it is coming from now.

Q1030 Chairman: We would not learn any more about how the patients were treated.

Dr Daggett: No.

Q1031 Chairman: Howard then replied about the issue of a public inquiry and he said he did not think there should be a public inquiry but that nurses would be happy to talk out not in a public inquiry but to talk privately and confidentially and then let that come out to the public about what they felt about the situation. There seems to be a conflict here. They do not want to get it off their chest in a public inquiry. What do you say to that?

Dr Daggett: I think that Howard's suggestion is perfectly sensible but the virtue of a public inquiry is that relatives and patients who have been affected will be able to speak in public.

Mr Catton: To be clear, an independent inquiry held in private for the reasons we have said but with the findings made public.

Q1032 Dr Naysmith: Dr Daggett, there is evidence that the money that went to Mid-Staffordshire was not all that different from money that went to other hospitals and they managed to provide good care on a similar budget. Why do you think it is that Mid-Staffordshire did not manage to do that?

Dr Daggett: We were told that there had to be a £10 million saving for reasons which I do not understand.

Q1033 Dr Naysmith: Why did you not ask what the £10 million was for?

Dr Daggett: We were told that it was because other agencies required the funds to distribute to other hospitals. Whether that is true or not I do not know and that is why some sort of inquiry might be helpful.

Chairman: Could I thank you both very much indeed for coming along and helping us with this inquiry this morning.

Witnesses: Mr Ben Bradshaw MP, Minister of State for Health Services, Department of Health, Professor Sir Bruce Keogh, NHS Medical Director and Mr David Flory, NHS Finance Director, gave evidence.

Q1034 Chairman: Good morning gentleman. Could I thank you for coming along. I have to say that you are the third minister we have had in front of us on this inquiry. Could I first of all ask you if you could give us your name and the current position that you hold?

Mr Bradshaw: On my right is David Flory who is the Director of NHS Performance and Operations and on my left is Sir Bruce Keogh who is the NHS Medical Director. I am the Minister of State.

Q1035 Chairman: Mid-Staffordshire's annual health check ratings for quality of service between 2005 and 2008 were "fair", "fair" and "good". Given that the annual health check completely failed to bring to light unsafe care in this particular case, how do you know there are nor other trusts doing just as badly?

Mr Bradshaw: On those ratings themselves, for the period you referred to the trust only scored "fair" on quality, which is the second lowest. It was only in 2007/08 that they were given a provision rating of "good" and I had a conversation with Anna Walker (the outgoing chief executive of the Healthcare Commission) about this because I asked her exactly the same question as you have just me and she said it was made clear in that report that it was a provisional rating because they were already under investigation and it was subsequently reduced to "weak". One has to accept that the Healthcare Commission ratings are based on a range of measurements, not just restricted to emergency care and one of the things that has been overlooked in a lot of the discussion about Mid-Staffordshire Trust is that no-one, as far as we are aware, is making any serious complaints about the quality of elective procedures, for example, a large bulk of a hospital's work. I think it is also fair to say that the procedures of the Healthcare Commission and now the Care Quality Commission have been constantly evolving, they have been constantly improving and they have constantly been becoming more sophisticated. It was indeed the growing sophistication of the Healthcare Commission's procedures with use of HMSRs and other alert systems that finally alerted them to the potential problems that were there at the hospital.

Q1036 Chairman: Do you think the new check by the Care Quality Commission - we are going to have registration as opposed to these annual checks - is going to strengthen the situation in terms of trusts doing what they say they are doing?

Mr Bradshaw: I think it is part of a significant strengthening of the regulatory framework that was established by the setting up of the Care Quality Commission, the first integrated regulator in this country with much stronger powers than the Healthcare Commission (powers of intervention, powers of suspension, of removal of registration, of closure of wards and even whole hospitals if they see fit). I think it is also very important to remember that the Healthcare Commission could have put Mid-Staffordshire Hospital into special measures if at any stage it had found - not only before but during its investigation - that it felt that patients were in danger. It did not do that although it has used those powers, as I am sure the Committee is aware, in three other cases.

Q1037 Chairman: You said about the powers that the CQC has got; will they be able to do a deep investigation into a situation if it ever came to light as in Mid-Staffordshire?

Mr Bradshaw: Absolutely. It would be able to do such an investigation and it has already, as I am sure you are aware, committed to going back into Mid-Staffordshire in three months' time to have a full re-investigation, in six months' time and there is even discussion of a year's time re-visit as well.

Q1038 Chairman: How does registration differ from the tick list we have had in terms of asking trusts how well they are doing?

Mr Bradshaw: Bruce may want to outline some of the details in terms of clinical quality and other requirements that will have to be met for a hospital or providers not just in healthcare but in social care for the first time to be registered with the ultimate sanction of loss of registration which is loss of right to practise. I do not know whether Bruce would like to spell out some of the particular clinical measurements that you might be interested in.

Professor Sir Bruce Keogh: I think the Care Quality Commission are in the process of working out some of the details of that, but one of the things that became clear - as you will know from Lord Darzi's review - is that we needed to have a very clear definition of quality. We have that and that is around the three domains of clinical effectiveness (that is essentially clinical outcomes for patients), patient experience and safety. The Care Quality Commission have also added access into that in terms of the way that they assess these organisations. So all of these four domains will be assessed with respect to defining quality for registration. The details of those questions still have to be resolved.

Q1039 Dr Taylor: Minister, some of us visited Luton and Dunstable Hospital a week or so ago and we were very impressed by their achievements. They are one of the pilot sites for the Safer Patients Initiative. Certainly I got the impression that there they have a chief executive who worked extremely well with a medical director who has the confidence of the staff and nursing chiefs who again were working together. So you have there real cooperation between the three key elements. From what we have heard about Mid-Staffordshire this same sort of cooperation certainly did not exist and there were blockages between messages getting to chief executive level from both nurses and medical people. What can you do to ensure that hospitals work like Luton and Dunstable where it really seems to be working with high quality care?

Mr Bradshaw: If anything your description of what went wrong at Mid-Staffordshire was an under-assessment of how dysfunctional and dreadful that hospital was managed. You are right about Luton and Dunstable but I would not regard Luton and Dunstable as an isolated case. The vast majority of hospitals and their boards perform their roles properly and effectively. However, you are right about the work that is going on at Luton and Dunstable; it is a model that is being rolled out across the NHS and it is one that we very much welcome.

Q1040 Dr Taylor: How can you get the personalities that do not appear to want to work together to work together? I am looking at Bruce really about this. How can you ensure that there are medical directors that take their staff with them and are really able to talk to the nurses, talk to the chief executives? How do you do that?

Professor Sir Bruce Keogh: It is not always an easy issue but I think it boils down to good leadership at a managerial and a clinical level. I think leadership is about aligning people to a set of common goals. Liam Donaldson did a good piece of work looking at the characteristics of high performing clinical teams. The first thing was that they had good clinical leadership. The second thing was that their managerial targets were expressed as clinical benefits so that there was a relationship between the two. The third thing was that they measured what they did. The fourth thing was that they compared what they did with others so that they knew what they were doing so that there was an alignment within the managerial and clinical community within the organisation. I do not think we have seen that alignment in Mid-Staffordshire. I think there were uncharacteristic reporting lines, particularly from the divisional structure. The medical director is in a fairly isolated position. The heads of the divisions do not have direct accountability to the medical director, they report to the chief operating officer. That deprives the clinical community of an easy access, if you like, into the trust board. In a sense there are issues around attitude and professional culture which need to be coupled with organisational structures. I think it has been a combination of both of those breaking down in Mid-Staffordshire. There are other issues about Luton and Dunstable and I have to say that a lot of credit for what goes on in Luton and Dunstable has to be down to Stephen Ramsden the Chief Executive whom I think has displayed exceptional leadership. He was one of the first to engage with the health foundation and the Safer Patient initiative and then following Safety First, as you know, that led into the Patient Safety Campaign which is sponsored by the NHS Institute, the MPSA and the Health Foundation. Stephen has led that, if you like, from the bottom up so that now 92 per cent of trusts are part of the Patient Safety Campaign. There are only up to a year next week so they will be announcing the progress that they have made at the NHS Confederation in Liverpool next week. I think what is very important about what Stephen has done is that he has set about embarking on a culture change so this safety initiative is led from the bottom up. That will bring long term sustainability; it will bring clinical and managerial ownership, enthusiasm and I hope will lead to innovation.

Mr Bradshaw: I just want to add one thing which may be obvious but it is adherence to guidance. There is clear and comprehensive guidance out there for trusts as to what their duties are and it is that guidance that needs to be adhered to and was not adhered to in the case of Mid-Staffordshire.

Q1041 Dr Taylor: You are confident, Minister, that Mid-Staffordshire was an isolated incident. What should we be looking for in case there are other trusts across the country that could be going the same way? How would we be picking them up?

Mr Bradshaw: This issue of whether Mid-Staffordshire was an isolated incident was dealt with by the Healthcare Commission itself, by the independent regulator, who made clear both in the report and subsequently to it that they went back and did a very careful check of other trusts that had similar high levels of hospital standardised mortality rates and other indicators that may be a cause for concern and they satisfied themselves (Anna Walker is on the record as having said this; she may well have said it in her evidence to your Committee) that there were not any other trusts that gave rise to similar concerns. The Care Quality Commission subsequently confirmed that.

Mr Flory: This links back to the point that was made earlier which is that the role of the Care Quality Commission is not simply one of a periodic review, an annual inspection based on an element of self-assessment. Registration is a constant thing; when it is awarded it is not for the whole year, it needs to be maintained and the standards that underpin it need to be maintained. Alongside that the Care Quality Commission will continue to run in the way that the Healthcare Commission did with alert systems with more real time data to flag up when there are potential problems - that is what triggered the work at Mid-Staffordshire - and indeed the Care Quality Commission are undertaking across the country a range of risk summits with all relevant NHS organisations and other relevant stakeholders in order to take a view, based on the evidence available, on where they need to potentially keep a closer eye, where there are maybe some early signs and questions that need to be followed through. Their role is not one about turning up once a year and going away; it is much more continuous in that sense and the alert system is a really important part of it.

Mr Bradshaw: They have committed to publishing those alerts on a quarterly basis.

Q1042 Dr Taylor: The standardised mortality rates are obviously one thing that alerts; what are the other things that alert you to a hospital that is not performing adequately?

Mr Bradshaw: These are questions that you may also want to put to the Care Quality Commission if you have not already, but in the example of Mid-Staffordshire what alerted the Healthcare Commission was not just the high HSMRs because I think everybody accepts that HSMRs in isolation are not enough to tell you that there is a problem. That is one of the reasons that they have not been used in a way that we have now decided to use them and publicise them because they can be skewed for particular reasons. However, in combination with other alerts the system is becoming ever more sophisticated. It was the combination of the level of patient complaints, the level of patient complaints upheld and the staff survey and more that finally caused the Healthcare Commission to begin asking searching questions. As you know from their report, having not been satisfied with the answers they go they eventually decided to have a full investigation. The Care Quality Commission is using, as I understand it, an even more sophisticated suite of alerts and these are developing all the time. As far as I understand it, it is probably the most sophisticated alert system of any healthcare system in the world.

Q1043 Mr Syms: Nobody has mentioned the strategic health authorities who clearly have a role in the hierarchy. The information must be playing between the hospitals, PCTs and strategic health authority, and we know there are some excellent examples of chief executives, (certainly in the southwest we have a very good one in Ian Carruthers), but they did not seem to pick this up either. I wonder what the Minister feels about that. There ought to be some justification for having these organisations. If they cannot pick up real problems in a hospital, what are they there for?

Mr Bradshaw: I think we need to be very clear and remind ourselves that both the Healthcare Commission report and the subsequent reports by David Colin-Thomé and George Alberti lay the blame for Mid-Staffordshire fairly and squarely with the management of that hospital. It is very important that we do not allow the management of the hospital off the hook for their responsibility. However, David Colin-Thomé did say in his report that he felt that both the SHA and the PCT could have done more. He also made clear that in the performance framework context of that time it would not have been reasonable to have expected them to do more and they did not fail in their duty to do what their job was at the time. However, since then of course the performance management responsibilities of SHAs and PCTs have been considerably enhanced. I think there was no specific criticism of the SHAs or the PCTs in either report, rather an acceptance that they could have done more but it would be unfair to have expected them to have done that. The system has changed and the system changed before Mid-Staffordshire came to light and it is part of an evolving improvement of performance management across the NHS.

Q1044 Dr Naysmith: Carrying on in that vein, is world-class commissioning not just another tick-box exercise that people go through without paying a lot of attention to, and is that not part of the reason why the PCT failed as a commissioner?

Mr Bradshaw: I would love you to put that question to the PCTs because I think they would throw their hands up in absolute horror to have world-class commissioning described as a tick-box exercise.

Q1045 Dr Naysmith: Some people have described it as that.

Mr Bradshaw: It is an extremely rigorous system in order to address the problem that we have acknowledged has been there.

Q1046 Dr Naysmith: What happened to world-class commissioning then at Mid-Staffordshire?

Mr Bradshaw: It did not exist. World-class commissioning is only a year old.

Q1047 Dr Naysmith: They knew about it; they knew it was coming in. Bristol have been preparing for it for the last 18 months.

Mr Bradshaw: Indeed, and the preparation and the introduction of world-class commissioning has been because of the recognition that commissioning has traditionally been a weakness across the NHS and that is being addressed through world-class commissioning. If you look at the assurance ratings that were published a couple of months ago - which I am sure you have or, if not, they are available in public - it has been a very gruelling and demanding process. The assurance and performance framework that accompanies it will mean that failing and weak PCTs' performance is rigorously addressed by SHAs and in extreme, rather like failing providers, those PCTs will face takeover. We have been absolutely clear about that.

Q1048 Dr Naysmith: The criticism has also been made that the SHAs are more focussed on pushing trusts into becoming foundation trusts than on performance management of them. There seems to be some evidence coming out of Mid-Staffordshire that that was the problem there, that the SHA wanted the hospital trust to become a foundation trust and that is what it was focussing on.

Mr Bradshaw: David will want to say something about the specifics of that, but the SHAs - as the rest of the NHS - has, as their prime responsibility, patient safety and quality. If you are saying to me that SHAs should not be helping and encouraging and supporting trusts that want to become foundation trusts I do not accept that. If you look at the evidence of the overall performance of foundation trusts it is significantly better than the performance of non-foundation trusts. The improvement that we have seen in recent years of performance across the NHS among providers has been among all providers but it has actually been foundation trusts who have improved more quickly than the rest. The vast majority of trusts that scored "double excellent" on the Healthcare Commission health check are foundation trusts. Of course people aspire to become a foundation trust and you would expect the SHA to encourage them. However, you would not expect that process to ignore the absolute overriding importance of patient safety and quality of care.

Mr Flory: It is certainly the case now with 121 foundation trusts in the country that their overall performance has improved significantly in getting that status. In Lord Darzi's report last summer he emphasised the importance of when organisations are ready and can pass all the tests for them to progress to foundation trust status, the role of governors locally and the membership structure locally brings a whole new local accountability that non-foundation trusts do not have. There are a lot of reasons why the organisations themselves and the systems round them want to move to foundation trust. We see different rates of progression to foundation trust status in different parts of the country. In the West Midlands region now - the West Midlands Strategic Health Authority area - of 26 trusts (either hospital trusts or mental health trusts which are eligible to go to foundation trust status) 11 of them already are foundation trusts and there are still eight hospital trusts and three mental health trusts to make that journey. The evidence in the West Midlands is not one of rushing through to foundation trust at all costs; it is a more measured process. Indeed, I have had conversations with them about bringing forward perhaps more quickly some of the high performing organisations that are not yet foundation trusts. In that region I would not say it is a question of pushing everybody to foundation trust at all costs.

Q1049 Dr Naysmith: Do you not think it has any validity, the suggestion that in Mid-Staffordshire at least part of the problem was that the focus was on getting the finances right and neglecting some other matters?

Mr Flory: I think that getting the finances right is a crucial and essential part of getting trusts to foundation trust status and what we observed is that clinical viability and excellent and improvement tends to go hand in hand with financial viability and improvement and excellence; the two things are side by side. However, what is really important as trusts are assessed now is that a lot of improvements have been made to the process of assessing trusts and approving them for foundation trust status all through the system. I think that process now absolutely considers non-financial issues.

Q1050 Dr Naysmith: It cannot possibly be right that you only look at finances and neglect other matters.

Mr Bradshaw: We accept what you say. It is in the Healthcare Commission report. The Healthcare Commission made that specific criticism of the management of Mid-Staffordshire Hospital but at the same time it said it was absolutely no excuse for failing to provide quality clinical care. There are hospitals going through the foundation trust application and approval process all over the country that are getting their finances in order and doing all of that while at the same time providing steadily improving, excellent and safe care to their patients. That is the distinction you have to make, not to let this management off the hook. Yes, they were paying too much attention to the foundation trust application and disregarding other important things, but that is not what they should have been doing; it is not an excuse.

Q1051 Charlotte Atkins: The South Staffordshire PCT is paying for those patients to go into that hospital. Why were they not picking up on the fact that they were not getting value for money, that they were not getting the proper nursing care and they that they were not getting the outcomes they would expect from a good hospital? What I do not understand is why they seem to be blinded themselves to what was clear from patients that there were real shortcomings? What is wrong with the route which demonstrates that PCTs are not picking up on these problems? They should be the front line here because they are the ones who are actually spending their money on patients in the hospital and if they are not getting appropriate care they should be the first organisation to pick up on it. I do not buy this idea that it is just because PCTs were being reorganised at the time.

Mr Bradshaw: I absolutely agree with you and so did David Colin-Thomé in this report. There are two separate issues here. There is the specific issue of why Stafford PCT and PCTs in general are not better and tougher commissioners which we have also discussed in some detail. There is also the kind of broader issue which we may come onto later as to why there was not more noise around about this hospital. One of the things that has struck me - and I am sure every member of this Committee - is that if this level of service was going on in my hospital there would be the most extraordinary noise both in the media landscape locally, in Parliament, in the health community locally and in local government. What was going on at this hospital, until the Healthcare Commission decided to launch its investigation, was not what you would have expected given what we now know about the level of care there. Maybe that is an answer that only a political geographer can really provide answers to but that is one of the great things that has mystified all of us through this.

Q1052 Charlotte Atkins: Should we also be looking at the failings of the PCT alongside the failings of the hospital?

Mr Bradshaw: David Colin-Thomé dealt with this in his report about the failings of the PCT in that he thought they could have done more. If there had been more noise around before the Healthcare Commission investigation began then you might have expected them, in order for them fulfil their duties at the time, to have done that but I do not think that he found any evidence that they had failed in their then existing duties to commission better or more properly.

Q1053 Charlotte Atkins: I would not expect the PCT to wait for noise. I would expect the PCT to be in there investigating and challenging rather than waiting for noise from newspapers or the media. I would expect the PCT to be in there long before there is any noise at all.

Mr Bradshaw: That is the expectation on the world-class commissioning.

Q1054 Dr Stoate: Minister, it is quite clear from the evidence we have received - which has been a huge amount - that this board failed and that it had been failing for some time. You, like me, have already expressed the disbelief really that there was not more noise, that people were not blowing the whistle and were not phoning the local Member of Parliament who, I entirely agree with you, would have taken action if he or she had known exactly what was going on. I also accept your reassurances that it seemed that this particular failure was an isolated case but I do not see how we could know that. My worry is that if this were happening in other parts of the country and if the local health economy were not blowing any whistles, I am not sure how we would know. I want to tease out how you can be sure that this is an isolated case and that we are not going to see more things coming out the woodwork in the future.

Mr Bradshaw: I do not want to repeat what I have already said about what the Healthcare Commission said about it being an isolated case. The Healthcare Commission, as regulator - and now the Care Quality Commission - have their own systems in place to satisfy themselves as the independent regulator that that is the case. I suppose as far as we are concerned as the performance managers - although not strictly the performance managers of foundation trusts - we would say that the performance management systems that are now in place and were in place before the Mid-Staffordshire investigation both around the increased and clearer responsibility on primary care trusts (which we have just described), the clearer responsibility and the assurance framework for strategic health authorities to performance manage hospitals should give reassurance that from the performance management side the SHAs and the PCTs would have a handle if such a situation were to arise now. Both the combination of a better performance management system and a better, rigorous, more powerful regulatory system I suggest should provide confidence that this was and is an isolated case.

Q1055 Dr Stoate: I am pleased about that but surely it still relies on a system. What we were hearing this morning was that where complaints were being made and where incident forms were being filled in they were effectively being buried by middle management. Are you confident that the new regulatory systems can prevent that happening? Reports are being passed up by nurses and doctors that are utterly ignored or lost.

Mr Bradshaw: I think that is a very important question because it is not just about performance management, it is not just about regulation, it is about changing the culture in and around the health service. One of the things that I do not think has really been paid enough attention to was the government's response to both the David Colin-Thomé and the George Alberti reports which are content rich, a lot of new stuff in there including issues around complaints. One of the biggest concerns we have - this came through in the Healthcare Commission report and in the subsequent reports - is the way that this hospital completely failed to deal with complaints properly and how complaints were not taken seriously. Just the changes that have already been introduced previously but also since those reports on complaints (that every trust has to publish the number of complaints they have, the number that are upheld, the number that are resolved, the figures are now being put on the NHS website so that people can compare how individual hospitals perform on complaints, duties on primary care trusts to satisfy themselves that hospitals are dealing with complaints properly and so on) I think will help change the culture. The new absolute legal protection for whistleblowers (not so new, it has been there for several years but it is still bedding in); the trends are improving every year on the number of people using that new legal protection and the role of public protection at work (the independent charity that we have contracted to provide independent advice to people). All of this will help change the culture but it is also about inquiries like this encouraging that culture change.

Q1056 Dr Stoate: You are absolutely right that we need a culture change - nobody denies that - but why therefore can it be justified for the vast majority of foundation trusts to have their board meetings in secret?

Mr Bradshaw: We have made quite clear in our response to the David Colin-Thomé and George Alberti reports that we think boards should meet in public. We are absolutely explicit in our response. I am sure you have read our response, it is not very long and it is quite pithy. There will of course be occasions where a board, for whatever reason, is discussing something of some commercial confidentiality and so on, but certainly this ministerial team has always made quite clear that our view is that NHS boards should meet in public.

Q1057 Dr Stoate: That is your view and it is certainly my view as well, but why is not a requirement - apart from very sensitive or financially commercially sensitive issues - that they meet in public?

Mr Bradshaw: We do not have the power to require that of foundation trust boards.

Q1058 Dr Stoate: Should we not have? I am very concerned that if they want to they can lock the doors and get on with it and I am not sure that that is the culture you are looking for.

Mr Bradshaw: We have been as clear as we can be as to what our views are and I think Monitor have been as clear as they can be. If there are still foundation trust boards that are not or never meeting in public then that is something that those boards themselves need to address. However, we are considering at the moment - not just in the context of foundation trust boards meeting in public or private but also in relation to some other issues we may come to discuss in a moment about personnel matters and foundation trust management and boards - whether we may need to take further powers.

Q1059 Dr Stoate: Are you prepared to take further powers if necessary to ensure that they do open up?

Mr Bradshaw: We are prepared to consider what extra powers we think the government may need to take to ensure that we have a system where, given that ministers are responsible and accountable to Parliament as I am here today, yet we do not currently have the powers to make the effects and the changes that we might need to do to satisfy committees like this.

Q1060 Sandra Gidley: Just to back to your comment, Minister, about the lack of noise about this, the submission from the Cure the NHS group says, "In January 2008, we contacted the Secretary of State, Alan Johnson, David Kidney MP, Tony Wright MP, Bill Cash MP. We wrote and told them that patients were being denied their basic human rights. Their advice was to talk to the hospital management and the board of governors." So it was flagged up at quite a senior level. Was it just kicked back by the secretary of state at the time?

Mr Bradshaw: No, it was responded to in the way you would expect a secretary of state to respond to any representation like that. The point I was making - and I will make more explicitly now - is that one of the first things we did of course when we knew that there was a problem with Mid-Staffordshire was to do a check of all of the correspondence that we had received in the department, all the parliamentary questions that were asked, the debates (there were no debates) and all the local media reporting of this. It was quite clear to us that the vast majority of the noise - as we are calling it - only began when the Healthcare Commission launched its investigation. The vast majority of the complaints, the representations, the campaigning groups and so forth got up steam after the Healthcare Commission investigation began. Before that - and this is one of the things that I think is very odd about this - there was nothing untoward about the volume or nature of the complaints and representations that were made.

Q1061 Sandra Gidley: So this was a single complaint which was probably akin to others you received from time to time about other hospitals in the country. It did not ring any alarm bells.

Mr Bradshaw: There was nothing unusual about the nature or the volume of complaints that we received about Mid-Staffordshire before the Healthcare Commission began its investigation.

Q1062 Sandra Gidley: There was nothing usual about it?

Mr Bradshaw: The nature and the volume of the complaints and representations that we received before the Healthcare Commission began its investigations were not out of kilter with the number, volume and nature we receive about other trusts.

Q1063 Sandra Gidley: How many complaints about a hospital would a minister have to receive before it raises alarm bells?

Mr Bradshaw: You are asking me to put a figure on it. What we can do is to provide this Committee, if it would be helpful, with the details of exactly how many MPs' letters, exactly now many representations, exactly how many complaints or letters we had from members of the public and we can give you those figures. We can also give you comparative figures with other hospital trusts in the country. I am happy to do that.

Q1064 Sandra Gidley: Does the government not have to take some responsibility? There was a big focus on the financial balance and achieving targets and any chief executive knows which are the hanging offences and which are not. For a number of years the most important thing was that a trust should achieve financial balance. Has that not sent a message to trusts such as Mid-Staffordshire that patient safety is not a top a priority?

Mr Bradshaw: No, I totally reject this argument that it is all about targets and financial balance. That is to completely let the management of this hospital off the hook. The vast majority of hospitals in this country - including mine and including probably the honourable lady's - do an excellent job of balancing their books, an excellent job of providing care. They do not do so by compromising patient safety or the quality of care. As David intimated earlier, there is a very, very strong correlation between hospitals that are well-run, that are well-run financially and the quality and safety of the care provided. There is a very strong correlation indeed. This is not an either/or, it is a both.

Q1065 Sandra Gidley: So are you saying they just did not look at the financial pressures in the round, they just took an easy step and cut the staff? Clearly the nursing levels were unacceptable. Again, are there no mechanisms anywhere for ensuring that there is an adequate level of staffing because what we have just heard - one nurse in charge of 80 patients - is clearly unacceptable and yet nobody anywhere seems to have picked this up? Do you not have the right mechanisms in place that would trigger concerns on this?

Mr Bradshaw: There are countless mechanisms in place and there are masses of guidance in place. The guidance was totally ignored by this hospital management and the mechanisms, such as they were, were not used or deployed.

Q1066 Sandra Gidley: Who should be able to pick up if the guidance is ignored?

Mr Bradshaw: That ultimately is the responsibility of the hospital board, for goodness' sake. The hospital board has a legal duty to comply with clinical guidance and they failed to do so.

Q1067 Sandra Gidley: Who picks up when the hospital board is ignoring it? There seems to be no management here by the strategic health authority. Should they not be overseeing this?

Mr Bradshaw: That is again not the case. The Healthcare Commission report was very explicitly not critical of the role performed by the strategic health authority, neither was David Colin-Thomé's report. I am sorry to have to say this to the honourable lady, but she, by her questioning, would be letting the management of that hospital off.

Q1068 Sandra Gidley: I am not letting anybody off.

Mr Bradshaw: Excellent.

Q1069 Sandra Gidley: If the report did not criticise the strategic health authority then who should have picked up the lack of adherence to the guidance? I am trying to get this clear; did the strategic health authority monitor it and pick it up or was it not their responsibility?

Mr Bradshaw: There are multiple roles here, are there not? I will go through them all but David and Bruce may want to elaborate in more detail. The prime responsibility for running a hospital is that of the hospital board. I think the honourable lady would accept that. This hospital board failed catastrophically to fulfil its legal and moral duty on all of these things. There is the professional responsibility - I think there was some questioning on this in the session before this one - of NHS staff who, if they feel that patient safety is being jeopardised, if they feel that the quality of care in their hospital or elsewhere is not up to scratch, they have a moral and professional duty to report that. There is the role of the royal colleges; where were the royal colleges? There is the role of the unions. We have already discussed the commissioning role of the primary care trust and the strategic health authority. There is also the regulator and in the end the regulator did its job in this case. Of course we did not used to have an independent regulator; we had a system where something like this would probably never have been uncovered before the life of independent regulation. We have a whole range of people performing a role here. I am afraid to say that the prime responsibility for what happened at Mid-Staffordshire - this is abundantly clear in the Healthcare Commission report which I think was an excellent report - lays with the management and board of the hospital.

Q1070 Sandra Gidley: I do not disagree with anything the Minister says, but he still has not answered my very, very simple question. It is important in case there is another Mid-Staffordshire waiting in the wings, although we all hope there is not. If the board is ignoring DH guidance, who is in a position to pick that up? Who should pick that up? Or does the buck stop with the board? Are you saying there is no mechanism to pick up a dysfunctional board?

Mr Bradshaw: If it is a foundation trust, then Monitor; if it is a non-foundation trust then ultimately the NHS has the power to remove the board.

Q1071 Sandra Gidley: So it is the failure of Monitor.

Mr Bradshaw: Monitor were only responsible for this hospital for the last year.

Mr Flory: I think the question you asked relates to the earlier question about the role of the service commissioner and the primary care trust. Whilst the responsibilities for delivering care safely and to the right standards is absolutely in the remit of the trust board and that is a buck that cannot be passed to anybody else (which is where the core of the problem was here) nonetheless the service commissioner has highlighted in David Colin-Thomé's report that the PCT could have been less reliant on other systems to detect problems. As David Colin-Thomé says in his report, there are lessons to be learned for primary care trusts about the way in which they hear, take note and involve patients and the public. There are issues for primary care trusts in the way that they receive, interpret and look at data which tells them the way in which the services they commission are performing. There are issues for the primary care trust in the way that their own medical leadership - not just the primary care trust board but through them into practice based commissioners, in the professional executives committees - get involved in an understanding of the way in which services are being delivered and the quality to which they are being delivered. In fact, the David Colin-Thomé report spells all this out very clearly. In fact most of the things that he recommends in there are in train, if you like, from the post-Mid-Staffordshire era both from Lord Darzi's report (Bruce might to say more about quality as the overriding principle) and also in world-class commissioning where in the past we tended to judge organisations (commissioners and strategic health authorities) on the aggregate performance of organisations that they relate with. What the big change in world-class commissioning is, is this explicit competencies that PCTs are required to have. It is all laid out along the lines that David Colin-Thomé re-emphasises in his report and it is by being competent in that way and meeting the requirements of the world-class commissioning framework that we would expect primary care trusts to be more proactive in their engagement and challenge when such as this happens.

Q1072 Sandra Gidley: World-class commissioning was not an issue then so that does not explain any of the failures. I think we need to move on. Minister, do you think the focus on reducing elective waiting times when it comes to Mid-Staffordshire jeopardised the safety of emergency admissions?

Mr Bradshaw: No. Again, apart from the fact that reducing elective waiting times to 18 weeks has been a very important achievement and is one of the public's main priorities when this government was elected given the dreadful legacy of long waits that we inherited, there has also been a massive improvement in capacity and performance in accident and emergency departments. We have more than doubled expenditure. There has been a huge increase in the number of A&E consultants. There is absolutely no reason why any hospital should have allowed its accident and emergency services to deteriorate because of its drive to reduce waiting times for elective treatment. As I said before, the vast majority of hospitals now meet the 18 week target and the vast majority also meet the A&E target.

Q1073 Sandra Gidley: As you are aware this is actually a larger inquiry on patient safety and throughout the inquiry we have heard from numerous witnesses about the importance of an open reporting culture. Clearly in this case it is just words. What can the department do to make sure that an open reporting culture is not just words and is actually something that is best practice?

Mr Bradshaw: The honourable lady is absolutely right to say that there was no open reporting culture in this case and in fact that is one of the real reasons and causes for some of the problems of different kinds that we have discussed. There was already guidance in place at the time that this board completely ignored on the importance of transparency, openness, reporting and so forth. That guidance has since been strengthened. There are the announcements that we made in some detail - very far reaching announcements - in response to the David Colin-Thomé and George Alberti reports on further improvements on openness, accountability, transparency and so forth. Bruce may like to say something a little bit more in relation to patient safety in general and the importance of an open reporting culture?

Professor Sir Bruce Keogh: I would like to say two things actually. One, if you do not mind, is about elective waiting time targets and the other is about where safety and reporting might come on the trust board agenda. I have had to deal in two trusts with elective waiting time targets. In March 2000, so nine years ago, a set of targets were imposed on my speciality which was cardiac surgery. I was working in Birmingham at the time and two people would come into a room to discuss surgery, one would usually be the man who requires it and the other would be his wife. We would go through the difficult and complex discussion about a life threatening operation and an operation which, if it was not performed in time, might also be life threatening. Eventually the man would agree to the operation and I would ask if there were any further questions. He would say "No" and his wife would say, "I have just one". I would say, "What is that?", knowing what was coming. She would say, "When?" and I would say "Eighteen months to two years". Her face would descend into a look of abject terror and her eyes would cloud over with tears. Believe me, we were functioning in a third world surgical service in a first world country. It was only through hard-nosed performance management coupled with targets that forced that through. We were sending for elective cases at half-past seven at night, often not getting out of theatre until eleven; we were operating on Saturdays and other days over the weekend. It was tough; it was hard. It brought us into conflict with the management but solutions had to be found. By the time I stopped practising cardiac surgery just over a year ago at UCLH another couple would come in, same discussion with the man, same question from the woman. This time I would say, "Well, what about next Wednesday or Thursday?" Again she would look aghast and say, "We thought waiting lists were longer; we were planning to go on holiday". So things have really changed. I think some of these targets, provided they are evidence based and clinically relevant, are very, very powerful. There are issues around targets which are about how the organisation as a whole handles these in a coherent way so that they do not compromise other services. I just felt that I would share that experience with you because I have heard a lot in the press that has implied that somehow or other targets are responsible for many of the problems. Furthermore, I have spent a lot of my working career in intensive care units, often sadly dealing with some pretty destructive wound infections, and if there had not been a hard-nosed target driven culture around MRSA we would not have seen the 50 per cent reduction that we have seen. Again it comes back to choosing very specific targets which are meaningful. That leads me into the next business about where safety and things should sit on the trust board agenda. I have already alluded to the fact that safety is one component of quality. I believe that quality and finance run hand in hand. A well-run hospital, as the Minister has said, is often one that provides the right substrate for good clinical services. On the trust board agenda I believe that quality should be number one and that there should be those three domains of quality: safety, clinical outcomes and patient experience as the sub-headings. I think if we address all of those we will avoid a huge number of the problems that have been alluded to during the course of the deliberations of this Committee.

Q1074 Dr Stoate: I just want to examine with the Minister the possible conflict of interest which can be levelled against foundation trusts that there is this risk that they are driven by commercial culture, they have to in a way suppress bad news and talk up their act. That could possible conflict with their role of providing top quality clinical services to patients in an open and accountable culture. Do you share that as a possibility and how do you think we could put that to rest?

Mr Bradshaw: Under payment by results and free choice all hospitals have to compete for business, not just foundation trusts. There is increasing evidence to show that patients are exercising their choice and hospitals will attract patients based on their reputation and the quality of care they provide. That is a vital part of the government's drive to not only give people and the patients more power over the care they receive but also drive up quality across the service. I would not make the distinction between foundation trusts and non-foundation trusts in that regard.

Q1075 Dr Stoate: Except the foundation trust culture is quite different. They are competing for a different level of financial income. They are putting money aside for future projects. They are managing their finances in a completely different way. They are far more commercially driven than merely effectively going out and winning contracts from PCTs. Surely that must be the case.

Mr Bradshaw: David may have something else to say about that but you are right that the financial structure of foundation trusts is different and its specific aim - the honourable member will know more about this than I do because he was around at the time and probably more engaged in the debate about foundation trust hospitals - was to reward high performing hospitals with more financial freedoms. I think the evidence, as I said earlier, would suggest that the two are not mutually incompatible. If you look objectively at the overall performance of foundation trusts and the rate of improved performance of those hospitals that have gained foundation trust status, it would seem to indicate that having those financial freedoms has helped them improve the quality and safety of their patient care.

Mr Flory: All I would add to that is that choice and competition are hand in hand in that regard. For people to be able to choose where to go to for their care then there is that element of different providers and the competition that creates. What is really important to remember is that part of that competition is not competition on price; the price is fixed through the payment by result system so there is no competitive advantage for a trust in cutting its costs absolutely to the bone to be able to beat the competition by providing at a lower price. That is a very important part of the way the system works, that the price is fixed through the tariff mechanism.

Q1076 Dr Stoate: That is helpful but to go right back, Minister, to what you said right at the very beginning, you said yourself that some of the indicators were "fair" and then they went to "weak" at one point. How was it that the department recommended that this be put forward to Monitor for consideration for foundation trust status if you already had indicators that were showing "fair" or possibly even "weak" in some of their clinical performance?

Mr Bradshaw: I would have to remind myself of the exact chronology, but it was in the June of 2007 that the approval was given by the previous ministerial team for the hospital to go forward to Monitor for consideration. At that time there were no concerns that ministers were aware of that would have justified them refusing that going forward for consideration by Monitor. I cannot recall the exact healthcare check at that time; it would have been the 2007/08 one but it would not have come out until later and it would have been the one that we referred to earlier which the Healthcare Commission said was provisional. That was once the Healthcare Commission was already beginning to ask questions of the trust.

Q1077 Dr Stoate: Yet it was still allowed to go forward and become a foundation trust without too much trouble.

Mr Bradshaw: I do not think it was without too much trouble. There is a process that all trusts have to go through and that process is more rigorous now than it was then but it has become more rigorous irrespective of the experience of Mid-Staffordshire. The decision by Monitor's board to grant foundation trust status again happened in 2008 before the Healthcare Commission launched its investigation.

Q1078 Dr Stoate: Monitor's investigation cannot have been that rigorous if they failed to spot anything wrong.

Mr Bradshaw: That is a question you need to put to Monitor. Monitor have explained how they made the decision and they have defended that decision.

Q1079 Dr Stoate: Is it reasonable to keep effectively two regulators? We still have Monitor and now we have CQC. Would it not be better to roll them into one and say that the CQC should just do the whole thing?

Mr Bradshaw: The CQC do do the whole thing in terms of -----

Q1080 Dr Stoate: Then why do we need Monitor?

Mr Bradshaw: Their roles are slightly different. Monitor also what I would describe as a performance management role which we discussed earlier; Monitor has the power ultimately to deal with personnel issues, deal with boards for failing, failed management and so forth. The independent regulator - I think this is a very important distinction not least in terms of public confidence - has to be completely independent from the performance management and from the financial management role that Monitor has in order for the public to have confidence that it is totally independent and its role is across the health and social care sectors. Of course the new one under the CQC not only has more powers but it is integrated across all of those sectors and it has powers that the Healthcare Commission did not have to intervene in hospitals including in foundation trusts.

Q1081 Dr Stoate: I understand that, but you still do not see a case for amalgamating like the three bodies you have turned into the CQC; you do not see a case for putting Monitor into the same umbrella.

Mr Bradshaw: Then who would be responsible for performance managing foundation trusts?

Q1082 Dr Stoate: That is what I am asking you; you still see a role for it.

Mr Bradshaw: Yes.

Q1083 Jim Dowd: I accept the principal point you make about the responsibility ultimately and originally being with the management and the quality of the management at Mid-Staffordshire, but do you not feel that the granting of foundation trust status to it exacerbated the problems which clearly were existing at the time?

Mr Bradshaw: David may have something to say about this. If you look at the timeline of what happened, the granting of foundation trust status was only just before the Healthcare Commission formal investigation began. As the Healthcare Commission made clear in its report and in the subsequent statements that it has given, as soon as it went in, in March 2008, it demanded immediate improvements to the quality of service at that hospital and some, if not all, of those improvements were rapidly forthcoming. To say that the actual granting of foundation trust status made things worse at the hospital is not actually borne out by the objective evidence because the Healthcare Commission itself said that the quality began to improve as soon as its investigation began, which was a matter of a month or so after the formal approval of foundation trust status.

Q1084 Jim Dowd: Does this case not exemplify a lot of the criticisms that critics of foundation trust status have that once the institution obtains the foundation trust status it becomes more secretive and disengages from a wider consideration other than the best interests of the institution?

Mr Bradshaw: No, I do not accept that. At the risk of repeating myself for a third time, if the Committee looks objectively at the performance of foundation trust hospitals it will find that not only do foundation trust hospitals outperform on quality, on safety, on patient satisfaction than non-foundation trust hospitals but the rate of improvement among foundation trust hospitals is overwhelmingly faster than it is among non-foundation trust hospitals. I simply do not believe that that is borne out by the evidence.

Mr Flory: One of the regular pieces of feedback we receive from organisations who have been through the process and become foundation trusts is that it is very, very challenging for the whole board, not just the executive membership. Quite often we look to learn from applications that have gone forward and been considered by Monitor's board but have been deferred or sent back to do more work. Quite often there are concerns expressed in that, from Monitor's point of view, about the capability of the board to govern that organisation to the standards that they require and that we would expect. I think the challenge for the board in getting to foundation trust status is very demanding on them. Of course that does not guarantee that things will not subsequently need to change and in this instance - and in one or two other instances that we have seen - Monitor have used their powers to intervene to change key individuals, chair or chief executive at the top of these organisations when things go wrong.

Q1085 Jim Dowd: Do you think that the lack of provision in the legislation for the removal or the loss of foundation trust status was, with hindsight, a mistake?

Mr Bradshaw: That is something that certainly will be part of the deliberations that I indicated to this Committee are currently under way within the department at the highest level to consider what legislative changes may be required to address some of the concerns that have arisen out of this case.

Q1086 Dr Taylor: I want to try to explore why patients and families were systematically ignored. We have a detailed submission from Cure the NHS and they make it quite clear that they addressed the Council of Governors meeting and the Council of Governors listened but did nothing and actually the comments were not even minuted. They then went to the Overview and Scrutiny Committee and the result of that was that they received a letter from a solicitor telling them not to contact them with individual concerns. There was no official patient and public body to support these people. They go on and say further that it was the government which twice closed down channels for patient and public involvement (meaning community health councils and forums). Then they say, "The short history of the Local Involvement NetworKs in Staffordshire is little short of farcical". The huge problem is that this group of very dissatisfied patients and families had no body, because of the lack of an effective LINK, to actually put their case forward so they were totally disregarded. How can you make LINKS more much effective and much more rapid or is there any other way of opening the door to these sorts of groups? CHCs, where they were effective, did it exactly, which is possibly why they were abolished. Patient forums were beginning to be effective and could have done this. We have now gone to this third group but from the comments we hear from many places they really are not being effective in any way. What can you do to drive the LINKS forward to make them work?

Mr Bradshaw: There is a lot in that, Dr Taylor. I could turn your question around and say what you said about Community Health Councils that a lot were not effective which -----

Q1087 Dr Taylor: Yes, there were good and bad ones.

Mr Bradshaw: I do not think there is any doubt - this is abundantly clear in both the Healthcare Commission report and David Colin-Thomé's report which is very explicit about this - that one of the greatest failings at this hospital was that patients and the public were not listened to. It is all there in the report as to why that was the case and why this happened. I think the point you make is also interesting: where were the overview and scrutiny committees? Who is the democratic regulator of local healthcare? We have already discussed where were the royal colleges and where were the unions. You will also have noticed from the Healthcare Commission report that there was a PPI but it was divided and there was trouble (I think there was a resignation, there was disagreement between members as to how serious the problems were). I am very well aware of the specific concerns that you raise about the Staffordshire LINK because they have been raised with me by David Kidney, a Stafford MP, who came to see me specifically about this. There are concerns that I have taken up. A senior official from our department has gone to Stafford to look into the problems that LINK is encountering. However, from all of the advice I have been given by my officials who are experts in patient representation and complaint systems, they do not think it would be accurate to describe the problems that have been faced by Staffordshire LINKS as typically of LINKS around the country. They are specific and they are about the structure, they are about the competence and those things are being addressed.

Q1088 Dr Taylor: The All Party Parliamentary Group of Patient and Public Involvement is having great difficulty in getting a minister to come and discuss this issue. Could we ask you to put some pressure so that we could get a minister to come to a meeting to discuss this issue?

Mr Bradshaw: I will certainly have a word with my ministerial colleague who has responsibility in this area.

Q1089 Dr Taylor: Thank you very much. Moving on from there to the complaints system, I think many of us are very worried by the changes to the complaints system and the fact that we are losing the automatic independent review stage. We are told that 32 out of 43 complaints about Mid-Staffordshire were upheld by the Healthcare Commission (which was the independent bit of the complaints process). By losing that, are we not losing one of the alarm bells that might alert us to something going wrong elsewhere?

Mr Bradshaw: No, we are not losing it. The previous system was that there was the internal complaints system; there was then the Healthcare Commission as a first call for independent complaints if somebody was not satisfied with the way that the NHS locally dealt with that complaint. If one was not then satisfied with the Healthcare Commission there was the ultimate complaint option to the ombudsman. We think the new system is much simpler because it will put more pressure on providers to resolve complaints at a local level. The ombudsman will have exactly the same role as the Healthcare Commission used to have in terms of taking up complaints that are not resolved locally. The other systems that we have put in place will require hospitals to publish the number of complaints they receive, the number that are resolved locally, what lessons have been learned and implemented as a result of those complaints, the number that have not been resolved locally and have been referred to the ombudsman and the number of those that have been upheld. All of that is now in the public domain so I think that will make a huge difference both in terms of acting as an incentive for hospitals to deal better and properly with complaints and their performance will be measured on that as well in terms of the annual health check. There are a number of measurements in place, I think, that will ensure that the complaints system is already much better and much stronger than it was in the past.

Q1090 Dr Taylor: Will you be putting pressure on providers to make it easy for complainants to have an independent review?

Mr Bradshaw: The ideal is for that provider to deal satisfactorily with the complaint.

Q1091 Dr Taylor: What if it does not?

Mr Bradshaw: If it does not, absolutely. One of the first things I did as a minister was insist that all primary care trusts in their annual prospectus which they issue to every household in their areas put the fact that you can complain and there is a system of complaints right up there in a very prominent place with details of how you complain. The vast majority of good hospitals do this themselves. Not only are we doing that, but through the NHS Choices website we are doing what we can to encourage people to complain. Whenever members of this Committee and other MPs write to me with constituents' letters saying they were not satisfied with the treatment they have had at a hospital or by a GP but they are reluctant to complain, I say, "Please complain because if you do not complain nothing is every going to change. Hospitals and GPs in the future will be measured on both the level of complaints and how well they handle them and implement the lessons they learn from them."

Q1092 Dr Naysmith: Minister, in your earlier remarks you drew attention to the fact which puzzles us all, the whole mystery about why there was not much in the way of complaints - or noise, as we have called it - until the Healthcare Commission really began to get involved and call for evidence and so on. That is a mystery. The other mystery, given that the secretary of state has assured us that whistleblowers in the NHS are guaranteed full protection backed up by the law, is why nobody blew the whistle at Mid-Staffordshire at all. Do you have any comments?

Mr Bradshaw: No, I agree with that statement. I think it is extraordinary. There were, as I understand it, two whistleblowers between 2005 and 2008 but they were not related to issues that were contained in the Healthcare Commission report. It is astonishing given what we have discussed earlier about the professional duty of people to raise concerns. If professionals in the NHS do not feel that their concerns are being taken seriously by management they have the unions and the royal colleges as an avenue. If, after that, they are still not satisfied they have total legal protection now under the law passed by this government if they blow the whistle. Not only that, they have recourse to the independent charity Public Concern at Work that will give them free, independent and confidential advice. I have to say, the evidence around the country is very encouraging on this. If you look at the latest staff surveys, if you look at the latest surveys done by one of the nursing magazines there has been a dramatic and constant increase in the number and proportion of NHS staff who say they know how to blow the whistle, that they have done so and it has led to change, and that they would do so again. There has been a year on year improvement in that. You may find it fruitful to ask Public Concern at Work about their experience of the whistleblowing system because they will also say that there has been a huge improvement from the culture of the past. It is a mystery to me why there were not more whistleblowers.

Q1093 Dr Naysmith: It must have had something to do with the culture that was operating at Mid-Staffordshire I suspect. It sounds from what you have just said that you are confident that staff are aware now about what they can do and the protection that is available to them if they do blow the whistle.

Mr Bradshaw: Certainly from the independent surveys - not our surveys - that have been undertaken of NHS staff, that is the case; the vast majority of NHS staff are aware of their whistleblowing rights, that local trusts have an obligation to have clear whistleblowing policies in place and to ensure their staff are aware of them. You are right, Dr Naysmith, there were a whole host of problems in this hospital, one of them was a culture of being a closed institution that clearly did not mitigate in favour of people feeling that they could raise concerns. However, it still does surprise me that, particularly some of the professionals involved, did not go further than they did in terms of raising concerns.

Q1094 Sandra Gidley: I want to probe a bit into this. We heard in the earlier session from Dr Daggett that Mid-Staffordshire does have a whistleblowing charter. He read some of it out to us and it seemed to be quite clear that the staff were allowed to escalate a complaint to a number of agencies which were specified (the Audit Commission and the Environment Agency were mentioned) but there was no mention of a regulator in that. Any member of staff looking at the trust's whistleblowing charter would not have felt empowered in any way to go to the RCN or the Healthcare Commission. Is there not a case for reviewing those charters? What you have just said is very good but clearly that is not penetrating to the staff on the ground.

Mr Bradshaw: I hope I made clear what I said earlier that I obviously think there has to be a hierarchy of actions. The honourable lady will know more about this being a healthcare professional herself, that you raise it first of all with your manager and then there is a succession of steps you go through. It is right to expect people to go through those steps rather than going immediately either to the local media or to the independent regulator. Any hospital should make quite clear that the independent regulator is there specifically for these sorts of issues. To be fair to the Healthcare Commission it was in the end only as a result of the complaints that were brought to its attention that it become involved and engaged in this hospital. So it did happen, even in the case of Mid-Staffordshire. I would expect any good whistleblowing policy to make quite clear what avenues are available to people and that is certainly what we make clear from the centre.

Q1095 Sandra Gidley: Do trusts have to lodge their whistleblowing policies with anybody so that it can be clear that it is adequate? Clearly the policy there was less than adequate.

Mr Bradshaw: Yes.

Q1096 Sandra Gidley: Who do they have to lodge them with?

Mr Bradshaw: They have to have them and they have to make clear to their staff that they have them.

Q1097 Sandra Gidley: Who actually looks at them to make sure they are worth the paper they are written on? Is this back to the board?

Mr Flory: It does come back to the board. Expectation and good practice would be that that policy, like all policies, would be available on the trust's website.

Mr Bradshaw: If there is a feeling by anyone that a whistleblowing policy in a trust is not satisfactory, then bring it to our attention.

Q1098 Charlotte Atkins: You have been very clear that the buck really is with the hospital management and the chief executive in terms of whether they are delivering good patient care and patient safety. You have also said in the House that there should be no rewards for failure in the NHS. Despite all that we now have a former chief executive of Mid-Staffordshire being allowed to resign without any disciplinary proceedings and also receiving £110,000 since stepping down. I cannot see how this can be justified given that we have a very clear policy that there should be no rewards for failure.

Mr Bradshaw: I share your surprise at the way that has been handled and these are questions you might like to put to the interim chief executive when he appears before you in a moment.

Q1099 Charlotte Atkins: I think we certainly will be doing that because it seems to me that the chief executive presided over massive failures and clearly he should not be allowed to get away with it. You also made it very clear in the House that you expected the report and investigations of the former chief executive to be made public. I wonder when that is going to happen.

Mr Bradshaw: Again that is a question you might want to put to him.

Q1100 Charlotte Atkins: It is not in your power to do that.

Mr Bradshaw: It is not in our power to force it to happen but the secretary of state has written to the board requesting that they publish it.

Q1101 Charlotte Atkins: Talk me through the procedure because clearly this is a matter of huge public concern not just in Stafford but Staffordshire as a whole but clearly right the way through the NHS because we must learn the lessons for the whole of the NHS from the failures of Mid-Staffordshire.

Mr Bradshaw: I think the secretary of state has made it abundantly clear since he has been in office that there should be no rewards for failure. If you look at the action we took in regard to Rose Gibb, the former Chief Executive of Maidstone and Tonbridge Wells, where, against legal advice we stopped that payment being made; she took us to court and we won. I think that shows that the secretary of state is absolutely determined to ensure that there is no reward for failure in the NHS. The public will not tolerate rewards being paid to managers who have been responsible for such abject failure. In the case of foundation trusts, as I have already indicated earlier in answer to some other questions, our powers of intervention are limited and that is something that we are considering in the context of what further powers we may need to consider taking in order to ensure that such a situation cannot be repeated.

Q1102 Charlotte Atkins: So the £110,000 was actually awarded by the hospital board, was it?

Mr Bradshaw: These are really questions you need to ask the interim chief executive, both about how the process happened - it is their responsibility - and about the amounts and what the amounts represent.

Charlotte Atkins: Thank you, we will do that.

Q1103 Sandra Gidley: There have been lots of calls for an independent inquiry into Mid-Staffordshire; what is the problem with having one?

Mr Bradshaw: I think the secretary of state has summed this up rather well by saying that we have not ruled out a further inquiry but we would need to be convinced that it would add real value. We feel that the reference that is often made to the Bristol heart babies inquiry of course refers to a time before we had an independent regulator. One of the very purposes for setting up independent regulation in the health service which we have only had since 2000 was to obviate the need for full, lengthy, very expensive public inquiries into things that went wrong in the NHS. I also think - and I hope that the Committee shares my view - that the Healthcare Commission did a very good job. I am not aware that its report has been criticised for missing or not putting its finger on what went wrong in this hospital. We have had two subsequent investigations which I think, given the timescale in which they were carried out, have been very thorough and had led to significant action on behalf of the NHS and the Department in its response. If there are issues that people feel have not been addressed and not been properly looked at we have made it quite clear that we are always prepared to consider those. The secretary of state and I also had a meeting with Staffordshire MPs this week on this issue at which representations were made again to the secretary of state and he undertook to reflect further on them. If one looks at the comments of Sir Ian Kennedy who, after all, chaired the Bristol inquiry and was the chair of the Healthcare Commission, his view was very clear. He did not think that a full public inquiry would be sensible or necessary in these circumstances given the independent inquiries that have already been taken. However, we are open to persuasion.

Q1104 Sandra Gidley: Do you think that the independent inquiries fully related with some of the patients and patients' representatives? That seems to be where the call is coming from. There seems to be a feeling that there have been a lot of reviews, some of these have covered the same grounds but I think it comes back to a lack of engagement with the people who use the hospital and their relatives. Is there something that could be done there to give more confidence?

Mr Bradshaw: Again I am not here to defend the Healthcare Commission or the work they did, but I think it is unfair to say that the Healthcare Commission did not engage with patients. If one looks at what happened once the Healthcare Commission announced it was having its investigation it was deluged with evidence, submissions and requests to give evidence and talk to it. It was on the basis of a lot of that evidence that its report was written. Since then I know that the chair of the Care Quality Commission, Barbara Young, has been up to Stafford and has spoken to people. I know that David Colin-Thomé and George Alberti did so as part of their reports and they have also agreed I think to go and to a public meeting in the very near future to discuss their reports in more detail and allow whoever wants to to question them. It is also very important not to ignore the fact that every single patient or family of a patient who feels they may have been the victim of poor or dangerous treatment at that hospital has been offered a completely independent clinical review of their case notes. I am not sure and I do not think the secretary of state is sure what extra value a long and expensive public inquiry may bring. I hope that everybody's priority now needs to be to ensure that that hospital improves and continues to improve. The danger which I think was articulated very well by one of the other Stafford MPs in the debate, Tony Wright, is that there is a danger that one of the repercussions of a long and expensive public inquiry could be that it actually diverts attention, resources and commitment from the hospital in its immediate job of improving care.

Q1105 Sandra Gidley: You mentioned the independent case note review and the submission we have had from the Cure the NHS organisation makes it clear that they do not feel it is independent because it is set up by the hospital and the hospital's own board is managing it. Is there any way, at the very least, that some reassurance could be given that there will not be further cover-ups or problems ignored?

Mr Bradshaw: Yes, and those were concerns that were raised personally with me after one of the adjournment debates we have had on this issue recently. I think I am right in saying that it is no longer the case that the hospital is managing the system; it is being managed by the PCT, but David may want to confirm that.

Q1106 Sandra Gidley: Are there some things we do not know yet, such as the reasons behind the number of avoidable deaths at the trust?

Mr Bradshaw: Yes, but as was made clear in the Healthcare Commission report itself and the very careful statement that was made by Ian Kennedy afterwards, it is not possible - as some people did, including I am afraid, a lot of the media - to extrapolate a number of avoidable deaths from the HMSR figures. We have gone over that in some detail before and in fact it is very misleading to do so. The only way that we will know and that families will know how many avoidable deaths there were is as a result of the individual case note reviews and that is a process that is now underway.

Q1107 Mr Syms: Since 1997, since the Labour Party has been in office, you have had an inquiry into the events of Bloody Sunday in the 1970s in Northern Ireland; you have had an inquiry into BSE under the previous Conservative Government. This is a fairly recent thing. If this was a rail crash involving hundreds of people there would be a public inquiry; I am sure there would be. I understand what the Minister says, but I just think there ought to be some way of allowing the families to actually give evidence and to get to the bottom of things for their peace of mind. I think the government really ought to reconsider this.

Mr Bradshaw: As I have already said, we have not ruled out a further inquiry. I think Mr Syms does not take into account in his question the fact that we have an independent regulator whose job it is to have these investigations. I am not aware that he has any criticisms of the job that is done but, for the reasons I have already articulated, on balance we think at this stage it would be unhelpful not to government but actually to this hospital and to the local health community. That is a balanced judgment.

Q1108 Dr Taylor: The last question, Minister, could take several hours so I am going to abbreviate it. It is a question about the European Working Time Directive. We have heard very strident calls from some of the colleges but now other colleges are coming on board with the College of Surgeons and really feeling that we are going to be in big trouble on the first of August. There is a recent work from the College of Physicians looking at what is happening in the USA where they have agreed that they will keep it at 80 hours with certain restrictions. All I am asking is will you look at the recent work as well as from the College of Surgeons and the arguments in favour of a speciality opt-out for some specialities and certainly 56 hours rather than 48 hours. It is merely just to raise the question and ask you to bear in mind that it is not only the surgeons who are jumping up and down now, it is the other colleges who have realised how difficult it is going to be.

Mr Bradshaw: Let me say something in general about this then I think Bruce, who is one of the world's leading experts on this issue, will want to say something I am sure. First of all, people have had ten years to plan for this and the vast majority of hospitals have done so and they have implemented it without any problems. I am afraid to say there is no excuse for not being prepared. I hope the Committee would also agree that tired doctors are not only dangerous for patients but they are dangerous for doctors. I was at a Royal College of General Practitioners dinner last night where one of their officials was telling me of two recent cases of doctors who had died driving home from hospital after very long shifts, having fallen asleep at the wheel. I think there is a very serious issue here and there are details that still need to be worked out, but I am confident that the health service would be in a position to implement this. It will require the re-organisation of services in some hospitals and I think it is not fair to say that George Alberti says that this was a problem or will be a problem at Mid-Staffordshire; I think he said it had the potential to be a problem at lots of places if they did not address some of these organisational issues and work out very clearly whether they needed to be doing X and whether they could share Y with another provider and so forth. Bruce may want to say more about that.

Professor Sir Bruce Keogh: It is a perplexing question. I do not agree that the first of August will be a disaster but I do think that it is going to be very challenging for organisations both managerially and clinically particularly around the areas of training, workforce and perceptions about the impact on safety. I have personal experience of this because my colleagues and I introduced the 48-hour limit at the Heart Hospital in April 2007, so two and a half years ahead of the deadline, as it were. What is absolutely clear in this is that it requires a very significant cultural change. I think that cultural change, if I can be so bold, is perhaps more difficult for senior clinicians who find the concept difficult. I put myself in that category because we have been brought up in a different way. We have been brought up in a way where we have trained for long hours, we have used that to get exposure to rarer and more complex things and you will be very familiar with that argument. What has gone through my mind are a couple of things. Firstly, why does it take six years to train a cardiac surgeon in the UK and only three years in the US? That has to pose a spark, if you like. The second is that we are seeing a big generational difference across the board not just in medicine in the way the younger generation look at their work life balance. Thirdly, you will be aware that there is a report coming out from the Royal College of Physicians today about feminisation of the workforce. In relatively short order we are going to have more women doctors than male doctors and the social demands on women are different to those on men. I think what may at the moment appear to be quite a threat may actually be the stimulus we need to innovate in the way we train people so that we are adopting a completely new approach and not just a modified approach. If psychologically you adopt the attitude that you are just going to modify what you do now, then this is a very difficult problem. If you disassemble what you are doing now and ask how can reconstruct it in a different way and how can we completely review the way we train doctors and the way we handle handovers at the end of shifts, then I think that puts us in a different place in terms of our attitudes to the European Working Time Directive. The Directive actually applies to individuals; it does not apply to rotas. To get it to apply to rotas is more tricky than getting it to apply to individuals. One of the things I did a few months ago was establish a working group to look at this which has representation from everyone ranging from the royal colleges to the Department of Health and the BMA. I think we are making pretty good progress and out of that has come a working group on derogation. In this country there are about 6800 rotas. We have applications that are being considered at a meeting tomorrow for derogation of 220 of those. Of those most are pretty legitimate requests for derogation because they are around physical reorganisation of plant or services and some are related to difficulties of recruitment into some specific specialities (neuro-surgery would be an example). Following the derogation meeting tomorrow a report will be sent to David Nicholson, then to the secretary of state and should come to the House before recess so that you will have an opportunity to deliberate on that. In the meantime the secretary of state has also asked Sir Christopher Edwards, the new Chairman of Medical Education England, to commission Postgraduate Medical Education and Training Board (PMETB) to look at the potential impact of the European Working Time Directive on training. I think a lot of this is about whether we are just trying to do more of the same or whether we are actually looking to innovate, to improve the training and to improve the life for those who deliver the service. I have worked a one in two as some other people in this room will have; I know what it is liked to be called multiple times during the night and sometimes feel physically sick because you are so tired and then still have to work the next day. We cannot go back to those days. It is not right. It is not right for the staff; it is not right for the patients. One of the other claims that is being made is that somehow or other they do things differently in Germany. We have looked at this quite closely. The Directive is quite clear; it does not allow for a sectoral or speciality opt-out. We have had our lawyers look at this very, very closely. There are different ways of applying the Directive and it has been applied differently in Germany to here. Here it is enforced by legislation and in Germany it is done through collective agreement. Therein lies the difference. However, in both the individual has to opt out of the European Working Time Directive. The reason why we are very cautious about recommending a mass opt-out, if you like, is that in terms of delivering a clinical service you need to have a good, coherent rota and to do that you need to know exactly who is going to be on which day of the week and what times. We are just worried about people being bullied or harassed into opting out when they really do not want to. That introduces a whole new level of complexity into the rota which itself will pose safety problems. Some of these issues are detailed in a letter to the president of the Royal College of Surgeons on 27 April of this year. Those are some headline views, but when the deadline comes we have to be vigilant because it is difficult and it takes time for the culture to settle in. What I have noticed at the Heart Hospital was that whilst it was difficult initially soon people started to find ways of really making it work for the benefit of both the staff and patients.

Dr Taylor: Thank you. You crammed a vast amount into a short time for which I am very grateful.

Q1109 Jim Dowd: I agree with you very strongly about the length of time it takes to train clinicians in this country compared to elsewhere. In passing I would mention the role of the royal colleges as gatekeepers in all this. I think the concern, certainly that has arisen recently over the impact of the European Working Time Directive, is not so much on the cover issue (I understand what Ben said, that organisations have had a lot of time to prepare for this and should be ready), I think it is the more subtle and nebulous views that are now being expressed about the impact on training and seeing a mix of cases. If that is the case, the time it takes to train clinicians is surely going to increase rather than decrease.

Professor Sir Bruce Keogh: I think in some areas that is true, but I still come back to my question: why in heart surgery does it take three years in the US versus six years here? The answer is: a different culture, a different approach and different methodologies for training. That is the direction we need to go in. It may be that in order to get exposure to rare conditions you need to prolong training and the colleges I am sure will look at that, but there are also other issues. If one feels that this has an impact on training then we need to look at the relationship between senior consultants and newly appointed consultants. That has been an issue in the speciality in which I worked and almost all units now have a good mentoring system and good team work. Again a lot of this comes back to team work and how senior, more experienced clinicians support less experienced clinicians, their younger colleagues who are the future of the NHS.

Q1110 Chairman: Professor Keogh, could you share with us the letter you sent to the Royal College of Surgeons recently on this particular matter?

Professor Sir Bruce Keogh: Yes, I can. It was from the secretary of state.

Q1111 Chairman: Thank you. Minister, you mentioned that you could possibly get us some information about the number of letters from MPs and patients that were sent to the trust that we have been discussing and probably a comparator, presumably one the same size that does about the same type of work that the trust does. We would appreciate it if you could get that for us as well.

Mr Bradshaw: Yes.

Q1112 Chairman: Could I thank you very much indeed for coming along and helping us with this evidence session.

Mr Bradshaw: Thank you.

Witness: Mr Eric Morton, Interim Chief Executive, Mid-Staffordshire NHS Foundation trust, gave evidence.

Q1113 Chairman: Good morning and can I welcome you to this evidence session. Could you give us your name and the current position you hold for the record please?

Mr Morton: My name is Eric Morton. The substantive post is Chief Executive of Chesterfield Royal Hospital NHS Foundation Trust and I was appointed by Monitor as Interim Chief Executive at Mid-Staffordshire on 9 March.

Q1114 Chairman: You are doing both jobs presumably.

Mr Morton: Yes.

Q1115 Chairman: Double salary?

Mr Morton: I wish!

Q1116 Chairman: Have you been able to form an impression as to why the trust was in such a state when you actually got there?

Mr Morton: I cannot be analytical but I can give you some impressions. Certainly it strikes me as an organisation which has lost its way for a period of time. I do not think it is sudden and if you track back through the history there were clearly concerns about the performance of the trust back in 2001 which tended to go below the water line and then reappear again. I think it potentially suffers from a condition which can affect many district general hospitals around the country. It is very easy, I think, as a DGH to become isolated. I think it is really important that you have linkages with other DGHs and other teaching centres so that you refresh the knowledge and have an awareness when you work in an organisation like Stafford Hospital of what happens in other organisations, how the world moves there. There has certainly not been a strong history of that in this area, unlike the home patch where there are very strong clinical linkages and have been for many years. I do not think it is something you can fix quickly. I think also there is an issue with the staff. They do feel they have been battered and bruised for a long period of time. That means that when you are in that sort of environment very often you accept the status quo as being perceived as the norm and that can potentially dull senses over a long period of time.

Q1117 Chairman: The question was posed that, given the extent of the problems in there, why have there not been more changes at senior and middle management levels.

Mr Morton: In terms of the board there has been quite a dramatic turnover in the last few months, since February. There remains only one non-executive director on the board who has been in post for about 16 to 18 months who has now taken over chairmanship of the audit committee. You are aware that the chief executive moved on. The new medical director joined us on 19 April.

Q1118 Chairman: What is your top priority at the hospital now?

Mr Morton: I think we have quite a number of priorities that we are trying to move forward. There is an issue about public confidence; the public in the area have a right to have confidence in their local hospital. For many of us who work in DGHs they tend to be the pride of the local community; it is probably the most precious asset that you have in a local town and it is one that all the public want to succeed, they want to have confidence in it and they want to know that when they need it it is there and it will provide them with not just good clinical care but good general care; it will look after them. We have clearly got a lot of work to do to restore that pride and trust back in the hospital. We have also got to do a lot of work internally. I do think that the staff are pretty battered and bruised over the last two years. They feel that they need some light at the end of the tunnel; I hope we are trying to give them that now. We need to be ambitious as an organisation; we need to put right what we got wrong. We need to have much more clinical engagement than we have ever had before. The organisation has to be open; it is has to take the lid off and shine the light in. Good organisations which open themselves up to the public, which listen to what the staff tell them and, importantly, take action on the back of that - even if that action is to say, "We hear what you say, but ..." - then that is the only way an organisation can go forward. It has to change culture and that is not going to be a quick fix, I have to say.

Q1119 Chairman: You may have heard the exchanges earlier in that there has been a debate about whether or not there should be a public inquiry in relation to what happened at the trust. Do you have a view about that?

Mr Morton: From a personal perspective, in the eight weeks I have been there, we seem to have been perpetually under the microscope. From my point of view I want to see the organisation start to look forward. I think the staff need to look to the future. I think it could have a disabling effect looking over their shoulders again for the next inquiry to come. The report that we received from the Healthcare Commission and the subsequent reports, particularly from Professor Alberti, were pretty analytical and they certainly went very public.

Q1120 Chairman: In our first evidence session on patient safety - which is several months ago now - I do recall one of the witnesses saying in part that when things come out as something that has happened inside part of the National Health Service and it becomes public it is very demoralising not just for that department but overall within that institution. Would you say that would be the case?

Mr Morton: I think that is true. I think there is a lot of pride from NHS staff in the organisation within which they work. There is a lot of pride in being part of the NHS. When we get it wrong it hurts because the only way we can improve is to learn from mistakes, to put things right and hopefully ensure that that mistake does not occur again.

Q1121 Dr Naysmith: Could I ask you first of all, Mr Morton, why do you think you got the job of taking over what many would call a failing trust? Was it something you applied for or were you headhunted for the job?

Mr Morton: I received a phone call from Monitor asking me to go in.

Q1122 Dr Naysmith: Was that based on your reputation?

Mr Morton: I have no idea.

Q1123 Dr Naysmith: It just came out of the blue.

Mr Morton: Yes.

Q1124 Dr Naysmith: Good luck to you.

Mr Morton: Thank you.

Q1125 Dr Naysmith: Are you satisfied now that the trust is providing a safe service?

Mr Morton: I do not think we can ever be satisfied that we are providing the safest possible service in any hospital in the country or in any GP practice so it is going to be about constantly learning. I think what we have to have - and we are beginning to get to - is a real awareness that where we make mistakes, where we have potentially a near miss which does not cause damage but where a mistake could have occurred, that we learn from that. One of the things the chairman and I are particularly trying to push over the last six to eight weeks is much more of an open culture, much more of an internal reporting culture, the ability to raise concerns with us as quickly as possible. All members of staff at the trust with their May payslip received a letter from me reminding them of their responsibilities to raise concerns with us, to report incidents, that the organisation would take a non-disciplinary approach to incidents that were reported and the only time we would look potentially less favourably on that would be if it contravened professional regulations, if it involved a police inquiry, if it was not the first time that that error had occurred and we would also, if I am honest, take a fairly dim view of incidents occurring that are not reported.

Q1126 Dr Naysmith: So you are confident that it is safer now than it was.

Mr Morton: I do think it is safer now. I do not think that that is a quick fix since I have been there; I think the culture has started to shift from the day the Healthcare Commission came in. I think that was a very sobering experience; the whole process of the report was an incredibly sobering experience and that has helped us to raise standards and I think it will go beyond the walls of Mid-Staffordshire.

Q1127 Dr Naysmith: Why do you think the Cure the NHS group - I am sure you are aware of them - are still finding so many examples of unsatisfactory care in the trust?

Mr Morton: I think we have a much better reporting culture within Mid-Staffordshire and I may go so far as to say it is probably a more honest reporting culture than we might find in many of the hospitals at the moment because it is very much in the public domain. There are incidents still occurring; there are incidents that are occurring in my local hospital in Chesterfield. There will always be incidents where we have a public service delivered by people to people; we will make errors of judgment, we will make mistakes. The important thing is that we learn from those and we have a structure to minimise the impact of mistakes like that. There is certainly an attraction from the Cure the NHS for people reporting their concerns which I actually welcome and I am keen that they not only report them to Cure the NHS but they report them to me as well.

Q1128 Charlotte Atkins: You are the Interim Chief Executive; are you full time?

Mr Morton: I am sharing my time between Chesterfield and Mid-Staffordshire at the moment.

Q1129 Charlotte Atkins: So you spend 50 per cent of your time -----

Mr Morton: A little bit more than 50 per cent in Stafford; it is about three days a week, sometimes four.

Q1130 Charlotte Atkins: What worries me is that you have a hospital in crisis and you have effectively what is a part time chief executive on a temporary basis. Do you think that is the right way forward for a hospital which has suffered so much in the last few years?

Mr Morton: It is difficult for me to answer that because Monitor made the call. There is absolutely not doubt that I think it needed a different pair of eyes in there. It does need to recruit and in fact the date has now closed for applications for the substantive post. The interviews for that I understand are due to be held at the end of June or beginning of July so that a substantive appointment can be made. I would absolutely agree that what the hospital needs is a full time chief executive who has a long term future with the organisation and who will bring it forward and provide the appropriate leadership.

Q1131 Charlotte Atkins: When does your contract end?

Mr Morton: I do not have a fixed term contract until the decision is taken that I go.

Q1132 Charlotte Atkins: So until you have a replacement you will continue.

Mr Morton: It is a flexible contract; I have no idea when it will terminate.

Q1133 Charlotte Atkins: Can you tell us why the former chief executive received £110,000 since he stepped down?

Mr Morton: It is not possible for me to answer because I do not deal with the contractual position of the chief executive; that is dealt with by the chairman and by the non-executive directors. What I do know, as accountable officer, had to reassure myself about was that the payment that was made was no more than the contractual entitlement.

Q1134 Charlotte Atkins: Do you think we could get the detail of that information?

Mr Morton: I would have to refer to the chairman on that.

Q1135 Charlotte Atkins: You could approach the chairman and you will let us know what the chairman says.

Mr Morton: I can ask the chairman on your behalf, yes.

Q1136 Chairman: So that we can have that information for our report. Will you make the report of the investigation into the former chief executive public?

Mr Morton: I am afraid I cannot answer that one either; the report was to the chairman, it was not to me. Again I can only pass that back to the chairman.

Q1137 Charlotte Atkins: Are you saying you know nothing about this? We have had this culture in the past of buck passing and we seem to be having more buck passing going on now because we are not getting from the chief executive important information that people want to know about in Staffordshire - particularly in Stafford - as to whether there are going to be rewards for failure within the NHS.

Mr Morton: It would have been quite inappropriate for me to have any involvement in the process around the substantive chief executive as interim. It has to be led by the chairman. The chairmen of hospital boards are responsible for the hiring and dismissal, resignation or whatever of chief executives. It is not a role that I can perform; it has to be the chairman of the non-executives.

Q1138 Charlotte Atkins: The Minister of State, Ben Bradshaw, invited us to ask you on the basis that we might get answers from you.

Mr Morton: I cannot comment on what the Minister said. All I can do is refer you to the fact that the report went to the chairman of the board and not to me.

Q1139 Charlotte Atkins: On the basis of the fact that you cannot answer those questions, do you think that the minister of state and in fact the secretary of state should be looking very carefully at the rules under which foundation trust hospitals run and that we should amend those to ensure that there is more openness and transparency?

Mr Morton: I think you need to look at NHS foundation trusts not as a global entity but individually. You have a particular issue in Mid-Staffordshire. There is no doubt that it was a very close culture and I absolutely accept that. When I arrived and the chairman arrived at the end of March they had no board focus on clinical measures, clinical outcomes, clinical indicators or complaints. I absolutely accept that and we have moved to try to put that right. I think we also need to look at how other NHS foundation trusts have worked who have a very open structure with regular meetings of councils of governors where absolutely the same papers that go to the board of directors also go in public session to the council of governors and where the public can come along, ask questions and challenge.

Q1140 Charlotte Atkins: Should we then legislate to make sure that the good practice is the normal practice in all foundation trusts?

Mr Morton: I do not have a view on that.

Q1141 Charlotte Atkins: In your own hospital trust presumably you have this openness and your board meets in public.

Mr Morton: The board in Chesterfield does not meet in public. It has the council of governors which meets in public which take the same reports.

Q1142 Charlotte Atkins: So your board does not meet in public.

Mr Morton: It meets in public annually, not more regularly.

Q1143 Charlotte Atkins: Again the minister in the previous session made it very clear that the secretary of state and himself would regard openness as being vital and for the hospital board to meet in public except for the odd occasions where there might have to be some sort of confidentiality due to contractual reasons.

Mr Morton: Yes and all foundation trusts received a letter to that extent from the minister and all boards are considering it. I can tell you what the position is in Chesterfield now; I am not anticipating what the position might be in the future.

Q1144 Charlotte Atkins: Why did you decide in your trust that you should meet in secret?

Mr Morton: I would not describe it as meeting in secret. The public meeting is the council of governors; that was to give them the prominence with the general public to receive exactly the same reports so that the elected representatives - the majority on the council of governors, as you know, are publicly elected from the membership so that it has a democratic majority within it - receive exactly the same reports, particularly on clinical performance, clinical governance, clinical outcomes, financial reports, service performance. That is, if you like, to all intents and purposes a public meeting in our view.

Q1145 Charlotte Atkins: It may be but the issue is - and we heard it from the minister of state - that the buck stops with the hospital management board. Why, therefore, does the hospital management board not meet in public?

Mr Morton: Are we talking about Chesterfield?

Q1146 Charlotte Atkins: Yes.

Mr Morton: The position in Chesterfield is that the board, when it was established, decided to promote the council of governors as the public meeting. Board members attend that - non-executive directors as well as executive directors - with the council of governors in the same room and with the public there. As I say, it takes exactly the same reports. It was a conscious view to elevate the prominence and the role of the council of governors and to give it real power and real teeth.

Q1147 Charlotte Atkins: It seems to me that a change in the law is necessary. Moving onto to other issues, what arrangements are there now in Mid-Staffordshire to allow clinical and other staff and patients to raise their concerns either through LINKS or through the PCT? Clearly what we have established from the reports that have been produced and from our interview with the minister of state, there has not been a reporting culture and a lot of the concerns only really came into prominence about the time when the Healthcare Commission investigation started in March/February 2008. What arrangements are there now to ensure that those channels are fully open?

Mr Morton: We have put in place a number of things. First of all, I mentioned that I have written to all members of staff personally along with their May payslip to encourage them and require them to report concerns that we will investigate and we will go back to the individuals with the outcome of those investigations. I have been very public locally in offering to meet personally any patients or any families and relatives of patients who have had a poor experience to understand their concerns. I have met with quite a number of families and relatives and at the conclusion of the meeting we have invited them (because clearly they are very interested and very enthusiastic about speaking to us) to join our patient councils and we have had about a 75 per cent take up of that which I think is really, really promising. We have committees linking into each of the divisions where patients can exercise a voice. I attended a medical staff committee recently; I think I was told it was the biggest turnout for some time. The medical director is now a full member of the medical staff committee so I hope that we will be able to better engage with the medical staff which has clearly been an area that was weak in the past.

Q1148 Charlotte Atkins: Have you met with Cure the NHS?

Mr Morton: The chairman has met with them on several occasions; I have met with them once. I have offered to meet with them, but they declined.

Q1149 Charlotte Atkins: Why did they decline?

Mr Morton: I have no idea.

Q1150 Charlotte Atkins: Did you use the law firm Carter-Ruck to send a letter to a newspaper than planned to publish information supplied by one of your consultants about unsafe services?

Mr Morton: Yes we did.

Q1151 Charlotte Atkins: Why did you do that?

Mr Morton: Because the report that we had seen a draft of was factually incorrect.

Q1152 Charlotte Atkins: Presumably they went ahead and published.

Mr Morton: They did not publish, no.

Q1153 Charlotte Atkins: Why did you not just ask for a right of reply?

Mr Morton: The damage, I think, would have been in running a report which was factually incorrect. We felt it was better for the report not to be produced in the first place. We did exercise our right to bring that to the attention of the newspaper and on the basis of the information we gave they decided not to print the story.

Q1154 Charlotte Atkins: So the information supplied by the consultants, was that inaccurate? Or was the report that was going to be produced by the newspaper inaccurate?

Mr Morton: I only saw a draft of what they were intending to print. It was one consultant.

Q1155 Charlotte Atkins: What about the information from the consultant? What has happened to that?

Mr Morton: I have not seen the information from the consultant.

Q1156 Charlotte Atkins: Who would see it?

Mr Morton: As far as I understand he spoke to a reporter.

Q1157 Charlotte Atkins: I am assuming it is a he; am I right?

Mr Morton: Yes you are.

Q1158 Charlotte Atkins: Has he raised these issues within the hospital trust?

Mr Morton: He has had discussions with a medical director. We asked a medical director to speak to him to understand his concerns and hopefully he is being reassured about his concerns. There is a particular issue around nurses on ward rounds, as you know.

Q1159 Charlotte Atkins: So he is not being suppressed.

Mr Morton: He is not being suppressed at all, no. What I would say is that the previous medical director excluded him from the premises; when the new medical director arrived we reversed that.

Q1160 Charlotte Atkins: Why was he excluded from the premises originally?

Mr Morton: That was to allow an investigation to take place. It was not necessary to exclude him so we restored him to work.

Q1161 Charlotte Atkins: Why would you exclude him because an investigation is happening? I do not understand. Was it an investigation into him personally?

Mr Morton: There was a separate investigation running into his conduct, yes.

Q1162 Charlotte Atkins: How much did it cost to involve this law firm, Carter-Ruck?

Mr Morton: I cannot remember.

Q1163 Charlotte Atkins: Can you let us know?

Mr Morton: I can let you know, yes.

Charlotte Atkins: Thank you.

Q1164 Jim Dowd: Mr Morton, I realise you are in an unusual position, pro tem at least. You say you do three days at Mid-Staffordshire and two at Chesterfield. I would be interested to know who runs Mid-Staffordshire on the two days you are not there and what is happening at Chesterfield on the three days you are not there.

Mr Morton: It is a bit more flexible than three and two - I was at Mid-Staffordshire four days last week - but I take the point you are making. The executive team at Chesterfield is fairly long established; it has a very experienced non-exec; it has a very strong board. It is not facing any severe challenges; its performance is good in all respects clinically and performance-wise. That might be one of the reasons why Monitor suggested that I might want to spend some time in Mid-Staffordshire. In terms of the time in Mid-Staffordshire, between three and four days, it is not unusual in any hospital for the chief executive to have external duties for one to two days a week. What I have had to do is cut cloth accordingly so on the days I have been in Mid-Staffordshire I have concentrated on Mid-Staffordshire and therefore not found the time to be able to engage more widely with the West Midlands health community which you would normally do, and I have had to pull out of some events in the East Midlands to try to spare the time. It has been very much focussing on the time on where I hope it will have the most positive impact.

Q1165 Jim Dowd: Would I be incorrect to adduce from that that the role of a chief executive of a foundation trust is actually just a part-time job?

Mr Bradshaw: I do not think it is a part-time job, no.

Q1166 Jim Dowd: So I would be wrong.

Mr Morton: I think you would be wrong, yes.

Q1167 Jim Dowd: The model of management that you had discussions with Charlotte about previously, you say the board meets privately but the governors meet in public once a year.

Mr Morton: Is this Mid-Staffordshire we are talking about?

Q1168 Jim Dowd: No, Chesterfield, where you have your well-established organisation that runs itself. The directors are at the AGM as well along with the governors. One of the criticisms of foundation trusts is that they look a lot like commercial organisations. If you ask me, that is the way a plc runs.

Mr Morton: I will just make a couple of corrections, if I may. The council of governors at Chesterfield meets every six weeks in public, not annually. The non-executive directors and the executive directors are invited to attend - most of them do attend - every six weeks. They take exactly the same papers that have been to the meeting of the board which would have taken place a week or two earlier and the main reports they look at are the clinical governance and clinical performance reports and the hospital performance reports.

Q1169 Jim Dowd: That is not now the case in Mid-Staffordshire, is that right? The board does meet in public.

Mr Morton: The board in Mid-Staffordshire met in public last month. At the moment it was planning to meet on a quarterly basis; we have since received a letter from the department and so I am sure that Mid-Staffordshire, along with all other boards, will be reviewing the frequency of its public meetings. The council of governors at Mid-Staffordshire meets about six times a year, so not as regularly as Chesterfield, and that does meet in public.

Q1170 Jim Dowd: If the board is meeting in public now at Mid-Staffordshire and you described Chesterfield where this does not happen as a well-run organisation with no particular threats, how is Mid-Staffordshire disadvantaged by having to do this?

Mr Morton: I do not think it is disadvantaged. I think it has a far less mature public face in terms of its council of governors than Chesterfield and many others. Chesterfield has been a foundation trust for five years so it has had the ability to build its public face within the council of governors and to elevate the role of the governors so that they are providing real scrutiny in public session with the board of directors. Mid-Staffordshire has only been a foundation trust for just over a year. I think frankly it never really got the chance to become a foundation trust because within a month the Healthcare Commission were in. Consequently I do not think it had the ability to reach out into its local community as it should do to try to engage with the wider local population. Certainly those foundation trusts that have been around for a couple of years have built very strong links into local authorities, voluntary groups, partnership agencies, local area agreement fora. Speaking locally for Chesterfield, the hospital is now much more engaged with the local community than it ever was and is seen as a key local partner, as a major employer, a major training agency, a major purchaser of goods and services locally.

Q1171 Jim Dowd: You say there is a clinical director who was there before the trouble started.

Mr Morton: One of the non-executive directors - there is only one remaining - and he has been on the board for about 16 months.

Q1172 Jim Dowd: Most others have come on board since the Healthcare Commission report. Throughout the organisation at Mid-Staffordshire there must be a number of people who were there during the difficult times. Have you detected any sense of recognition of failure amongst them or is it just an embattled minority that the world does not understand?

Mr Morton: I think the staff generally feel a heavy degree of responsibility for the care they have delivered and I would be disappointed if they did not.

Q1173 Jim Dowd: Do they recognise the need to change?

Mr Morton: I think we do recognise the need to change and I think the change started well before I got there and certainly pretty much as soon as the Healthcare Commission arrived. There were major changes made in 2008 to A&E in particular when the Healthcare Commission voiced their concerns about that. They returned in February of this year, unannounced, reviewed the A&E services and gave them a pretty clean bill of health. It was actually quite reassuring to be asked last week to host a visit from a foundation trust in the south of England that was struggling to deliver A&E services and they were pointed in the direction of the A&E department at Mid-Staffordshire to look at how it can be done. We can come out of the position we are in at Mid-Staffordshire and I think when you get into a position that we have been in where we were not providing good care - - I am not making any excuses; we did not provide good care for a period of time, we let the local population down - that is something we can come out of, we can build on it and people can come and look at Mid-Staffordshire in the future and hopefully learn lessons.

Q1174 Jim Dowd: Finally, what changes have been put in place or are being considered by the board to ensure there are adequate checks and balances and scrutiny of the way the trust is run overall?

Mr Morton: We have put a number of measures in already. Myself and the chairman were quite surprised when we arrived at Mid-Staffordshire that there was not a focus on clinical governance and clinical performance so we established from the first of April a health governors committee which I guess many other hospitals have had for some years, which is a board level committee, its co-membership is the medical director, director of nursing and the non-executive directors. The non-executive director that is chairing that is Sir Stephen Moss who had a long career as a very senior director of nursing in a major teaching hospital in the East Midlands. That meets monthly. It has with it clinical representation from the hospital and we have also invited a representative from the primary care trust to sit in. As a major commissioner of services they need to understand the care level and the quality of service that we are delivering. That will meet on a monthly basis; it will report to the board, it will develop (and we are hoping to see the first cut of this next month) a clinical performance report which will look at all sorts of issues ranging from mortality performance split between emergency and elective (because the two are very different and we need to concentrate on the individuals and not look at the bottom right hand). It will look at the reported level of incidents; it will review serious and untoward incidents; it will review inquests and reports to the coroner; it will look at complaints and trend complaints; it will understand lessons to be learned from complaints and it will also look at pretty obvious clinical indicators like lengths of stay, infection rates and so on. What we are going to try to do is build up a portfolio of clinical performance which many other hospitals have done, I have to say, which stands at least equal rank to the harder edge performance of waiting times, financial performance and so on. That will go to the health governors committee and our anticipation is that we will share that publicly with the council of governors and it will also go to public meetings of the board. We have to be more open about clinical performance.

Q1175 Dr Naysmith: I would like to clear up something you said. You said the board meets in confidence and then you meet again later with the governors in public. You said they see the same reports so they have all the information, but the difference is that the main board takes decisions on these reports; these reports will be considered at this wider meeting later, but the decision has already been taken. That seems to be the wrong way round. Would it not be better to meet in public before and then the decisions can be taken with the views of the governors taken into account?

Mr Morton: Are we referring to Chesterfield here?

Q1176 Dr Naysmith: Yes.

Mr Morton: The council of governors meets on a six weekly cycle and the board meets every month so in fact sometimes the council of governors will receive the report before the board, it depends on the sequencing of the papers. What I am absolutely clear about is that it is exactly the same report; we do not do a re-run.

Q1177 Dr Naysmith: I am talking about decisions.

Mr Morton: I absolutely understand that.

Q1178 Dr Naysmith: You cannot do that if the decision has already been taken by the board beforehand. But you were saying that sometimes -----

Mr Morton: It depends on how the cycle falls but there can be a very open debate in the council of governors - and there is and we do have members of the public arrive - and the governors feel incredibly engaged because they are seeing exactly the same reports and therefore they can feed their views in for the board to take into consideration, representing their wider membership but, as you say, it is the board that takes decisions which is what the board is there to do.

Q1179 Chairman: Could I thank you very much indeed for coming along and helping us. Good luck with the two jobs.

Mr Morton: Thank you.