Westminster Hall
Wednesday 1 December 2010
[Mr James Gray in the Chair]
Candour in Health Care
Motion made, and Question proposed, That the sitting be now adjourned.-(Jeremy Wright.)
9.30 am
Mr Robert Syms (Poole) (Con): It is a pleasure to serve under your chairmanship, Mr Gray. I start with an apology: I cannot possibly do justice in this debate to all those who have suffered as a result of mistakes made by the national health service. I know that a lot of people are paying attention to this debate, and I will do my best to make the case for a duty of candour in health care, particularly a statutory duty. That would be progress.
In the House, if an hon. Member makes a mistake, however outrageous, everybody thinks that it is fair enough as long as they apologise quickly. I want to put forward the arguments for why honesty is the best policy and why it is best to acknowledge that mistakes are made in medicine and in the health service. That is part of the medical process. If people inform relatives, put their hands up and say, "We made a mistake," that is a far better way to proceed than what seems to have happened in the past.
I would like to thank Peter Walsh from Action against Medical Accidents for assisting me as I prepared for this debate. Over the next few weeks, Ministers are due to decide on their preferred option for honouring a commitment to require openness when things go wrong in health care. During the 2010 general election, the Liberal Democrat manifesto stated:
"We will: require hospitals to be open about mistakes, and always tell patients if something has gone wrong."
I do not often quote from the Liberal Democrat manifesto, but it is probably important to do so under current circumstances and the coalition. That pledge was also included in the coalition programme for government:
"We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong."
That has clearly been lifted from the Liberal Democrat manifesto. The White Paper, "Liberating the NHS", stated:
"We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong."
That shows consistency running from the original Liberal Democrat manifesto to the coalition programme for government and the White Paper produced by the Department of Health.
Those commitments have been widely interpreted and welcomed as going some way towards the introduction of a statutory duty of candour in health care. Such a move has been advocated for many years by patient groups and others, including the ex-chief medical officer, Sir Liam Donaldson. Recently, Ministers have made it
clear that as well as the possible introduction of an explicit statutory duty of candour, they are also considering not altering or adding to the statutory regulations, but merely issuing new or refreshed guidance to existing regulations contained in the Care Quality Commission (Registration) Regulations 2009.
It is implied that that is more likely to be the favoured option because there is an extreme reluctance to add or alter statutory regulation. I will speak about those two options, with a view to encouraging support for the introduction of a statutory duty of candour. Action against Medical Accidents has campaigned on that matter for a number of years, and representatives from that charity met with a Health Minister to try to put forward their case about the right way to proceed.
Put simply, the situation is unacceptable. It comes as a shock to most people, particularly patients and members of the public, to know that health care organisations are in breach of no rules and will face no sanctions if they cover something up or decide not to inform a patient-or, in the case of a fatality, their relatives-that something went wrong during an operation or health care.
Probably more by accident than design, the current system tolerates cover-ups and denials. People ask how that can happen in a modern, ethical health service, and the vast majority of people would agree that honesty with patients and their relatives is a moral and ethical requirement. There is an abundance of guidance on the issue, and best practice dictates that honesty, or being open, is the only course of action.
We know that there are a million incidents in the national health service each year, about half of which cause some harm. Within those cases, there are many serious incidents, so it is a large problem. When something goes wrong, most people want someone to explain what happened to their relative, mother, father or daughter. In part, such behaviour is part of the professional code for individual doctors and nurses, and is recognised as a central component of an open and fair patient safety culture. However, the failure to be open and honest when things go wrong is not uncommon.
Although many trusts or PCTs do act openly, a significant minority tell patients nothing. Something must be done to provide parents and relatives with a flow of information and an honest approach. Patients and their families are unfairly denied crucial information about what happened during their health care procedure, and they may never learn the truth. If they do, they are often deeply traumatised by the initial dishonest response to something going wrong. It is not unusual to find people who have spent decades campaigning under difficult circumstances to find out what happened to one of their relatives.
If patients suspect that something has gone wrong but have to fight to get the truth, they lose all confidence in the health care system and are more likely to take legal and disciplinary action. The NHS and health care organisations have failed to develop a learning culture and the ability to learn from errors and make things safer. Instead, they have developed a culture of defence or denial; they do not want to see themselves in the newspapers.
The situation in England became even worse when the previous Government introduced the Care Quality Commission (Registration) Regulations 2009, which came
into force in April 2010. That introduced a statutory requirement on health care organisations to report anonymously incidents that caused harm to the national incident reporting system. However, it did not include an equal requirement on the organisation to inform the patient or their relatives.
Therefore, an organisation is not currently in breach of the regulations if it covers up an incident from patients or relatives. It may be bad practice, but there is no real sanction as long as it sends an anonymous report to the system. An organisation will be ticked off if it does not send a report for the purposes of national measurement, but it will not be ticked off it fails to be open and honest with a patient or their relatives. Let me draw the Chamber's attention to a document produced by Action against Medical Accidents entitled "The need for a statutory duty of candour in healthcare." It is a good article for those who want to look at the more detailed requirements involved.
I pay tribute to my constituents, Derek and Joan Bye. As MPs, we deal with many constituents, but Mr and Mrs Bye have had to put up with a horror story following the death of their daughter, Helenor Bye, who died on 27 April 1978 in south Wales. There was a catalogue of medical errors. The parents were lied to, records were altered and their MP, John Morris, then the right hon. Member for Aberavon, held a debate in the House of Commons on 27 November 1979, volume 974, columns 1253-64. He called for a public inquiry, although that was turned down.
The situation was compounded by the fact that body parts were taken from Helenor Bye, some of which have been returned over the years. The last time body parts were received by the parents was in 2005. They have been through the most horrific period because of what happened to their daughter, what happened subsequently and, more importantly, because all along the line they felt that they were being lied to and that people were not being open and honest. Mr and Mrs Bye have become doughty campaigners for a more honest and honourable system of health care. They have also campaigned on their concerns about the drug Epilim. I cannot do justice to that campaign today, but if any journalist wants to know what can go wrong, I advise them to look at the case of Mr and Mrs Bye. They have had a very rough time.
Action against Medical Accidents calls for a change in the law and the introduction of a statutory duty of candour. It is called "Robbie's law" because of the case of Robert Powell, who died on 17 April 1990, aged 10. His parents have campaigned for over 20 years to try and get justice. Similar things happened to them, such as changed medical records, and there was a catalogue of events, but they still do not feel that they have justice. Their campaign has continued under several Secretaries of State. The case is currently with the Welsh Assembly, and Mr and Mrs Powell are waiting to hear whether there will be a public inquiry into what happened to Robbie. Will Powell, who feels passionately about putting right what happened to his son and getting to the truth, has been a doughty campaigner for a long time. I pay tribute to him.
All the people whom we are talking about are, in their own way, fighting for the truth, not only to find out what happened to their loved ones, but so that such
things do not happen again to someone else. This debate is about setting out a context and a better way of doing things, so that we have a much more honest and honourable system and families do not have to spend 10, 20 or 30 years going through absolute hell. Mr Bye told me that the start of the healing process is learning the truth and knowing what has happened to one's relative. That is a very important point.
The Government have two options to consider. They can go for an explicit duty or for more guidance. Ministers often go down the guidance route. When the NHS constitution was being debated in the previous Parliament, the then hon. Member for Wyre Forest, Dr Richard Taylor, who served with me on the Health Committee, raised the issue of openness and whether we could go further down that route. He was informed by the then Minister of State, Mike O'Brien, "No, we can do it all through guidance," yet guidance so far has not produced the results that we need.
Department of Health officials met representatives of Action against Medical Accidents and other stakeholders on 16 November 2010, when the two options were discussed in some detail. I shall go through the pros and cons of both. Option 1 is no new statutory duty but refreshed guidance in respect of the existing CQC regulations. The pros of that are that it would require no new legislation or change in the regulations.
Dr John Pugh (Southport) (LD): Is not the difficulty with guidance the fact that guidance is already in place and any other guidance would simply reiterate what it says? Clearly, guidance by itself is not doing the trick in this case.
Mr Syms: The hon. Gentleman makes a very important point, because we have to change the whole culture of the national health service and I am not sure whether guidance will do that.
An argument can be made that the existing CQC regulations, backed up by clearer guidance, could be interpreted as making it a requirement to be open. For example, regulation 17 has been cited. It says that service users should be provided with adequate information and support in relation to their care or treatment. The guidance could clarify that that includes telling them if something has gone wrong. However, one of the cons is that, as the hon. Member for Southport (Dr Pugh) said, that would be in effect no different from the current situation. Such guidance and the existing regulations already existed when the policy to introduce a requirement was agreed. They were clearly not seen as sufficient then.
Given that the Department of Health was of the firm opinion previously that the existing regulations, even with the guidance alongside them, did not constitute a statutory duty to be open with patients when things go wrong-because at that stage they were not supporting a statutory duty-it is hard to see how that could be credible now.
Such a measure would be unlikely to be enforceable. Lawyers would no doubt have a field day if, given the above, the CQC tried to impose sanctions on a trust based on such a tortuous and dubious interpretation when the opportunity to be clear and specific had not been taken. Even if such a measure were enforceable, the CQC would be unlikely to give it a high priority,
given the number of clear statutory obligations already spelt out in the regulations themselves, rather than developed by supporting guidance.
Option 1 would not have anything like the same impact as introducing a specific statutory duty, if it had any impact at all. The Department of Health would be trying to say, "This has always been the case, but we didn't realise it and didn't think it was important enough to make it clear." That option would fail to deliver positive opportunities for sending a clear, unequivocal message about the importance of being open and would fail to support a major culture change. It would not deal with the bizarre situation whereby there has already been, since April 2010, a statutory obligation to report anonymously to the national incident reporting system patient safety incidents that cause harm, but there is no equal requirement to tell the patient or a relative. It would send the message that being open with patients is not important enough to justify a minor amendment to the regulations.
Option 2, which I prefer and think should be given serious consideration by the Government, is to introduce a specific statutory duty by amending the existing CQC registration regulations. That would send a clear, unequivocal message about the importance of being open, which would support and underpin other initiatives to develop a more open and fair culture. It would be enforceable. The CQC has confirmed that it would be practical for it to enforce such a measure. Of course, it would be a condition of registration with the CQC. It would have real impact: boards and management could not escape noticing the change or recognising the need to comply. At the moment, even when doctors or nurses want to be open with patients, sometimes the management of PCTs or of hospitals are less keen. We must send a clear message so that the whole organisation undergoes a major culture change in how it deals with patients.
Option 2 would balance out the existing statutory regulation where it is a statutory obligation to report anonymously patient safety incidents that cause harm but there is no equal requirement to tell the patient or a relative. It would not add to the regulatory burden on health care organisations, and I think that it would enjoy public confidence, which is a very important thing to have in this area. That option would be relatively easy to achieve. The con is that it would require a change in the regulations, so there would possibly be some legislation.
In my opinion, option 2 is the best way to go. It is not something that is supported only by a few oddbods; such a change has the support of many people, including many senior people in the medical profession. I know that there are concerns about compensation and litigation, but the evidence from the United States, where many insurers now do insist on a more honest system, is that when people receive an apology, they are less likely to sue. When they find out what happened to their relative, they accept that mistakes are sometimes made and they are less likely to pursue lengthy and costly legal action.
People are sometimes pushed into legal action by the sense of injustice that they feel when their relative has undergone harm or perhaps died in the course of treatment. They feel a sense of injustice and are then driven to take that action. Of course, many of the costs to the NHS are from the legal fees, not necessarily the money paid out in compensation.
I shall go through a list of some of those who would support a statutory duty of candour. I have already mentioned Sir Liam Donaldson, the ex-chief medical officer, who formally recommended a statutory duty in 2003. Harry Cayton, chair of the Council for Healthcare Regulatory Excellence, has also supported such a duty. The late Claire Rayner, who was a doughty campaigner on behalf of patients, and a former nurse, supported it. Professor Aidan Halligan, the former deputy chief medical officer for England, who is currently chief of safety at Brighton and Sussex University Hospitals NHS Trust, is completely supportive of the proposal. There is also Sir Graeme Catto, the immediate past president of the General Medical Council; Sir Donald Irvine, a past president of the GMC; Sally Taber, director of Independent Healthcare Advisory Services; Cure the NHS; Patient Concern; and Sufferers of Iatrogenic Neglect. There is broad support in the LINks-local involvement networks-organisation for the view that what has been described is an important thing to do.
In recent years, we have become aware of a major disaster at Stafford hospital. It has affected not one or two people, but hundreds of them. Of course, it has been the subject of much debate, many statements in the House and a lot of real concern, but had there been a statutory duty of candour, the management of Stafford hospital would not have been able to get away with the poor standards of treatment and nursing and the fact that many hundreds of people lost their lives. Such a duty is a very important and practical measure, and if the NHS is to mean anything to the people of this country, being open and honest with those who have suffered as a result of what are sometimes unavoidable accidents is the best way to proceed.
There are clear benefits to introducing a statutory duty, and there is an historic opportunity in that regard. I listened to my right hon. Friend the Secretary of State talking over the weekend about more transparency. Introducing such a duty would be a brave step, because all the advice from people in the Department of Health would be, "Careful, Minister. Don't do anything that might have long-term costs."
However, in the modern age-an age of freedom of information, when thousands of documents appear on the internet-it is not unreasonable that a cornerstone of the NHS in this century should be that people are up-front and honest, and tell the truth when something goes wrong. Things inevitably do go wrong-not necessarily deliberately, but simply because that is the way of the world and medical science. People can then understand what has happened to their relatives.
As my constituent Mr Bye said, "The start of the healing process after the loss of a loved one is to know the truth of what happened." It is a very poor thing if Governments cannot tell the truth. One has to acknowledge that truth has not always been the essential component of the NHS that it should be. I propose that the Government give serious consideration to a statutory duty of candour, because that is the best protection for those who use the health service and for higher standards. The best protection is that all of us believe in honesty in public life.
9.50 am
Tom Brake (Carshalton and Wallington) (LD):
It is a pleasure to serve under your chairmanship this morning, Mr Gray. I congratulate my hon. Friend the Member
for Poole (Mr Syms) on securing the debate and on lucidly and concisely setting out precisely why the Government should look carefully at a statutory duty of candour. I have not heard any effective arguments against it, but I will come on to some arguments from opponents. My hon. Friend set out why the duty would boost public confidence and he rightly pointed out that an apology-as we have probably all experienced-often, first, helps to secure closure for a family if a loved one has been involved in a tragic accident, and, secondly, can defuse a difficult situation that could end up in the courts for years afterwards. He has rightly set out the reasons why a duty of candour is a necessity.
My hon. Friend started by quoting from the Liberal Democrat manifesto, and I would expect nothing less in the coalition, so there is no need for me, as a Liberal Democrat, to do so. He also mentioned that the proposal has been carried through to the coalition agreement and, subsequently, into the NHS White Paper, which-although it perhaps does not contain a proposal as specific as a duty of candour-certainly makes it clear that hospitals need to be open about mistakes and always tell patients if something has gone wrong. One development to which he did not refer was the fact that legal aid will no longer be available in cases of clinical negligence, which I hope the Minister will pick up on in her response. I wonder whether that will have an impact and whether that strengthens the case for a duty of candour.
As I said in my opening remarks, there are opponents of a duty of candour. A briefing has been sent to Members by the Medical Protection Society, which is a
"leading provider of comprehensive professional indemnity and expert advice to...health professionals around the world."
The briefing states that the society is committed to promoting openness in health care and supports the principle in the NHS White Paper that hospitals should be open about mistakes and always tell patients if something has gone wrong. However, it goes on to say that the MPS strongly believes that a change in culture would be more effective than a statutory duty. However, I agree with Action against Medical Accidents, which also briefed me for the debate. It said that perhaps the MPS is missing the point: it is not a question of a duty of candour or a change in culture, as it is perfectly possible to have both. Indeed, the duty of candour is one way of supporting and underpinning a change of culture, so that health care organisations are always open and honest with patients when things go wrong. The MPS says that it has been advocating that change in culture, and it is true that a number of organisations have been advocating it for the past 50 years or so, but the desired change has not happened. I am not sure how much longer one can wait for it.
There is an issue about guidance and about how seriously organisations take guidance when they are statutorily required to do other things. There is always a risk that guidance gets left aside while organisations focus on statutory duties. As the MPS said, it is correct that there is a professional duty for doctors and nurses to be open with patients in the event of a mistake, but there is a wider issue about there being no statutory duty on all health care organisations to promote and support that practice in their organisations. As my hon.
Friend the Member for Poole said, the medical professionals may want to be open but, unfortunately, they are being advised by managers, who are not subject to the same professional codes and perhaps believe that less openness is the best course of action. My hon. Friend referred to the Stafford case, and, as I understand it, it was a legal officer who sought to suppress the doctor's report in that case. When the General Medical Council was asked to confirm how many cases it had brought against a doctor specifically for a breach of this part of its code, it confirmed that it has not brought a case against a single one.
My hon. Friend also referred to the very sad case of Robbie Powell and the sterling efforts that the family have made. I am pleased to see that Mr Powell has joined us here today.
Mr James Gray (in the Chair): Order.
Tom Brake: I am sure that Mr Powell will be listening carefully to what is said and reading the remarks in Hansard later. That family have played a major role in bringing this issue to our attention and are working with AvMA to promote what they hope will become Robbie's law.
The MPS has provided information that I think works against its case. Its research shows that, at the moment, a third of doctors are not prepared to be open and honest when an accident occurs. If so many doctors feel constrained from or concerned about being open when an accident has occurred, it supports the case for a culture of candour. The MPS also refers to states in the United States where there is a duty of candour and where it perceives that there may be a difficulty in enforcing the duty. In his remarks, my hon. Friend the Member for Poole made it clear that the Care Quality Commission has confirmed that it could and would enforce a statutory duty, and would be in a position to do so, if that were part of its regulations.
Another issue that the MPS raised, which we need to respond to, is that the proposed duty would not include near misses. It is arguing against the duty of candour, but at the same time saying that it would be a problem if near misses were not included. I understand that there is a general agreement that, although it might the norm for near misses to be reported to the patient, there would be discretion in cases in which reporting a near miss might cause unnecessary harm. There is recognition that the near miss issue needs to be addressed carefully.
One important fact is that, whether it is a duty or a requirement, it must apply to all health care organisations. If there was one thing in the coalition agreement that was slightly remiss, it was the fact that it referred only to hospitals, but there is a wider health body that we need to include. I am sure that the Minister will clarify in her response that the duty of candour, or the requirement, would need to apply not only to the patient but, sadly, if the patient has died as a result of the accident, more widely to include family members. It should not be strictly restricted to the person who had the misfortune of suffering the accident.
Dr Pugh: My hon. Friend mentions hospitals, but does he not accept that there are severe diagnostic failures at primary care level? Failures to refer can seriously imperil life, so they, too, need to be encompassed in the duty of candour.
Tom Brake: I thank my hon. Friend for his intervention, and I entirely agree. A duty of candour must not be restricted simply to hospitals, because, as he rightly says, GPs in primary care and other health care providers regrettably also make mistakes. A duty would need to encompass more than simply hospitals, as was initially proposed in the coalition agreement.
I entirely support the points that my hon. Friend the Member for Poole made in opening the debate. There is strong, overwhelming evidence in support of a duty of candour. Guidance has not done the job, and a duty of candour really would open up the system and make sure that families and those who have suffered are, and know they are, entitled to receive information about an accident. That would make it much easier for them to arrive at closure. Regrettably, under the current system, people must all too often use great energy and perseverance to extract with great difficulty information that they should be entitled to from the outset.
10 am
Dr John Pugh (Southport) (LD): I thank the hon. Member for Poole (Mr Syms) for introducing this important and timely debate and for putting the Government's dilemma so succinctly and accurately. I also pay tribute to my hon. Friend the Member for Carshalton and Wallington (Tom Brake), who has done as much as anybody in this place to raise the issues of a duty of candour and patient rights.
I do not know whether anybody caught Ian Hislop's programme about do-gooders on the BBC this week, but in it he described the creation of the journal The Lancet. It was set up by a young doctor, who, among other things, wished to expose some of the deficiencies in the appalling surgical practices at that time. He was greeted with wholesale acrimony from much of the medical profession and he was successfully sued. That shows that there is resistance in most businesses and professions to acknowledging error.
In an excellent book published some time ago, the sociologist Erving Goffman suggested that people in all organisations-whether in health, business, teaching or policing-have a vested interest in supporting their colleagues, playing as part of a team and working together to minimise the reputational loss that their organisation can suffer. He analysed in particular detail how that can happen in health services right across the world, although it must be said that such things do not always happen for bad reasons. People have duties of loyalty to colleagues and a genuine concern for the organisation to which they belong-for its reputation and, where admitting to errors might seriously imperil it, for its very survival.
People inside organisations often recognise that mistakes will happen in their organisations. I have worked in the teaching profession all my life, and I have not always been very overt about my colleagues' deficiencies, even when that sometimes has involved people suffering from alcoholic intoxication when they should not. There are therefore circumstances in which people cover up. There is also probably a belief in many organisations that the internal resolution of problems is the best way to proceed.
However, there is a huge downside; confidence is eroded by simply taking such a path. Worse still, false confidence persists; in other words, there are palpable
and demonstrable errors in organisations, but nobody finds out about them until it is too late. Errors remain uncorrected, and poor performance is undeterred or, in some cases, it worsens.
That is where the duty of candour fits in, because it will, on a voluntary or simply a request basis, lessen the problems. There is an enormous amount of evidence not only that patients want the NHS to be candid with them, but that the NHS finds it hard to be candid. The Department of Health itself spoke of a culture of denial in the NHS-denial about error and, more seriously, about negligence.
No one believes that things will necessarily improve if nothing is done. No willing provider entering the frame will find it easier to be more candid than NHS organisations; in fact, they might have other motives for covering up. They might be answerable to others apart from members of the public, such as shareholders and the like. There is therefore a genuine concern to get things right.
Every Member of the House of Commons has probably come across a case, or several cases, where they feel that things have gone badly wrong. In my intervention on my hon. Friend the Member for Carshalton and Wallington, I mentioned primary care. A young man in my constituency-he was a relative of a friend of my daughter's-went to his GP five times to complain of listlessness, a lack of energy and so on. He was brushed off with suggestions that he needed more rest and less stress. He was told that he perhaps had glandular fever, but no blood test was done. Eventually, when one was done, it was discovered that he had late-stage leukaemia. My children attended his funeral. That clearly was a failing.
I am also familiar with the ongoing case in my constituency of a TV soap star with a disabling condition that was brought on by receiving the wrong diagnosis and the wrong treatment. Similarly, I had the long-running case of a lorry driver with severe hypertension who was prescribed Viagra for other complaints, even though Viagra increases blood pressure. The thought of a lorry driver being prescribed a drug that can imperil not only him but members of the public is quite disturbing.
A woman in my constituency was falsely diagnosed with cancer and treated for it until, on the spur of the moment, she decided to request a check of the X-rays. Staff then found that the X-rays that they had been using, and which they had assumed were correct, were those of another person. That woman had spent a year in absolutely harrowing circumstances. More disturbingly, we do not know whose X-rays were assigned to her. Presumably, that person was not given the treatment that this woman was wrongly given.
Each of those cases leads to a prolonged complaints procedure, involving the ombudsman and the Care Quality Commission. In other cases, as other Members have indicated, there have been accusations that records have been altered. The whole process is inordinately cumbersome and difficult. To some extent, it exists because there is no candour where candour would probably be the solution.
On top of that, there are the systemic failures-the Mid Staffordshires, the Bristol heart babies and so on. To be fair, the Government recognise that this all comes with the territory of running the modern health service, and they are, to some extent, endeavouring to deal with
the problems. Lots of things are going on, and we all want to applaud and support what the Government are doing on quite a few issues. We also applaud the previous Government for having initiated some of these things.
Incident reporting has got better, which is wholly desirable. Complaints are monitored, which is good and a move wholly in the right direction. There is more intensive recommending of procedures. The NHS is more of a learning body than it ever used to be; good practice is disseminated, while bad practice is identified and controlled. There is a general beefing-up across the piece of NHS guidance-particularly to the secondary care sector-about things not to do, things that will help and things that will avoid mishap.
Right across the profession, there is a constant stressing of professional ethics, as spelt out by the General Medical Council or whoever. In the past few days, we have had the phenomenon of publicising outcomes, with efforts by Dr Foster and, presumably, the Department of Health to see that outcomes are properly tracked.
Mr Syms: It is interesting that it is sometimes non-NHS organisations such as Dr Foster, rather than the NHS itself, that put their finger on the things that go wrong. The NHS is a wonderful organisation generally, but most of my constituents would be surprised that there is not a duty of candour already. One reason why we have not got one is that we find out that we do not only when we actually have a problem.
Dr Pugh: Dr Foster is probably doing what the Government will eventually get around to doing, and it will presumably prompt the Government to do that more expeditiously.
In some cases, private organisations may find it slightly easier than the Department of Health to progress such matters, but a lot of internal consultations and procedures will need to take place. Such organisations do not need to be answerable for how they treat the bodies within the NHS. A recent key development is the Government's willingness to ensure immunity for whistleblowers, and to encourage whistleblowing when appropriate. That is a good thing, but there is evidence that whistleblowers still take genuine risks. For instance, they may not be sacked or redeployed, but they may experience difficulties getting employment elsewhere in the health service. I know of cases in which genuine whistleblowers have regretted the professional outcome that has resulted.
Such Government measures are self-evidently to the good, but they are not the same, equivalent to or a substitute for a duty of candour. Frankly, not all errors will be reported and not all complaints will get bottomed out. As others have said, guidance is ignored, professional ethics can be flexibly interpreted, and outcomes, whether published by Dr Foster or others, often come too late or are too general for individual cases. As I pointed out, although whistleblowers may have temporary immunity, that may not last. The Department of Health spoke of a culture of denial; but if such a culture exists, it needs to deal with it.
The argument against a statutory duty of candour-that, in a sense, the simple duty to be open with patients or relatives when requested is otiose or redundant-is not sustainable. It cannot be used as a genuine reason for
Government reticence or hesitation. I therefore ask why the Government are hesitating when they are going ahead with so much else. A duty of candour is a disincentive to cover up, and it takes away the risk for whistleblowers.
Statutory duties are important. I give a parallel example. Local authority reporting officers, usually directors of finance, have the job of identifying when a council is spending money in a reckless and improvident way. They have always been in that position, but prior to there being a statutory duty to show the council the red card they were often bullied by the political establishment. As a result, they unwillingly had to consent to the deployment of council resources in ways that were reckless. Without a statutory duty, the same sort of thing can happen in health institutions. People can be put under a lot of pressure, and unless they can say, "But I have the statutory duty to report this," they will find themselves in appreciable difficulties.
If we all believe in transparency-and we do at the moment-the duty of candour must be part of it. It keeps patients informed of their genuine situation. It is entirely in line with what the Secretary of State says again and again-it is a good quote, which I paraphrase, about no action being done to me without my consent. That is the gist of what he says. Why, then, do we hesitate, given the coalition agreement? The Liberal Democrats are clearly on board, and many Conservative Members genuinely support it. Indeed, the coalition agreement is emphatic.
I have the perception that somewhere in the background in the Department of Health the voice of Sir Humphrey can be heard. Just as the Minister is about to initiate a statutory instrument on the subject, someone in the civil service-I do not accuse the permanent secretary-says, "That is a very brave decision, Minister." The Minister is thus persuaded that his decision may not be as positive as appeared at first sight.
If one thinks about it, a candid admission of error or, worse still, of negligence is intrinsically damaging and potentially expensive. I have seen stats suggesting that the potential damage to the NHS, if every person who had a complaint pursued it legally to the nth degree, might be a bill of something like £10 billion. That is half of the internal savings that the NHS needs to make.
However, the stats also show that litigation costs against the NHS are far less than that. The unnerving feeling inside the Department of Health is that if it goes for a statutory duty-I believe that it should-that picture might change dramatically, as the number of complaints that end up in successful and expensive litigation mushrooms.
Tom Brake: Does my hon. Friend agree that, because the information is now in the public domain, another consequence might be that the number of accidents will reduce because people will take the necessary action to ensure that such things do not happen?
Dr Pugh:
One sincerely hopes so. I was a member of the Committee that considered the NHS Redress Act 2006, which I believe is not yet in force. The sort of thinking suggested by my hon. Friend was behind that Act, but the same forces that are delaying the duty of candour are probably responsible for delaying its implementation. I cannot recall there being much dissent
among the parties as to the merits of that legislation. The idea was that complaint costs would reduce if we had an open policy of admitting errors, patients surrendering none of their legal rights but simply being given the apology and the explanation that they wanted.
As the hon. Member for Poole said, people who wish to pursue a complaint against the NHS if they believe that their treatment has gone wrong are not looking for money. They are looking not only for an explanation and an apology; they are looking for an assurance that whatever happened to them or their relative will not happen to others.
Prior to the NHS Redress Act 2006, we looked hard at the costs of litigation in the NHS. Yes, it cost the NHS a lot of money; and, yes, something could have been done to reduce it. The really depressing thing, however, was that the bulk of the money went into the lawyers' pockets on either side. The NHS is not about helping to boost lawyers' profits.
The 2006 Act seemed to offer an alternative to litigation, which everyone would support, but the nagging fear in the Department of Health was that it would become a platform for litigation-that if someone admitted a fault it might be a sound basis for taking legal action. Are those fears well grounded? I believe that we do not precisely know, but we all have our own feelings on the subject. People cite the Michigan case in the United States, where they went outright for a duty of candour, and litigation costs to the health service have declined.
The duty of candour is not something that can be piloted, and once it has been done one cannot withdraw it. To go ahead with it is almost an act of faith. I am very keen on the concept of evidence-led policy, but I see evidence-led policy debates taking place in the Department of Health. If we go ahead with a statutory duty of candour-and I firmly believe that we should-it will be a statement about what sort of NHS we want.
I conclude by quoting Sir Liam Donaldson, the former chief medical officer for England. He said,
"To err is human, to cover up is unforgivable".
Regardless of the risks, I doubt whether the Government want to do what is unforgivable.
10.19 am
Liz Kendall (Leicester West) (Lab): It is a pleasure to serve under your chairmanship, Mr Gray. Every 36 hours, NHS services are used by some 1 million people, the vast majority of whom receive safe and effective care. None the less, as in every other health care system in the world, not all care in the NHS is as safe as it could be, and too many patients are harmed by it, sometimes seriously and even fatally.
Modern health services are delivered in a highly complex, often pressurised, environment, and involve the care of many vulnerable and seriously ill patients. More than any other environment in which risks occur, health care is reliant on people taking difficult decisions that rely on judgments that are not always straightforward or clear cut. In such circumstances, things can and do go wrong. Sometimes, as I know from my own experience, the consequences can be very serious for the patient, their family and their carers.
Patients and their families have a right to know if something has gone wrong, to get an explanation of what has happened and to receive an apology and,
if appropriate, compensation. As hon. Members have mentioned, it is also vital that professionals and NHS organisations learn lessons from mistakes to improve care for patients and, wherever possible, to save taxpayers' money by reducing the cost to the NHS from clinical negligence claims.
During the past decade, important progress has been made on improving patient safety in the NHS. Last year, the Health Committee's report on patient safety acknowledged that the previous Government became one of the first in the world to make it a priority to address patient safety across the whole health care system. A unified system for reporting incidents and learning from them was introduced, and it was centred on the national reporting and learning system and the National Patient Safety Agency. The creation of this system was, in a large part, down to the pioneering work of Sir Liam Donaldson, and I should like to pay tribute to him for his work on this vital issue.
Since the establishment of the data reporting system, the number of reported incidents has increased significantly, which is a good thing. At the last count, more than 3 million incidents had been reported, ranging from very minor incidents to the more serious ones. The NPSA has worked hard to improve patient safety, both nationally and within individual NHS trusts. I personally experienced such work when I was director of the Ambulance Service Network at the NHS Confederation. We set up a programme of work, with patient safety leads in ambulance service trusts, front-line paramedics, PCT commissioners of ambulance services and the NPSA to identify the particular areas of care where mistakes were being made-it is often in the handover period-and to share best practice to prevent such mistakes.
I question some of the comments that have been made this morning about managers wanting to cover up problems. In my experience, both managers and professionals have difficulties in blowing the whistle on their colleagues. I just want to put it on the record that the ones that I have worked with have wanted to be open and to learn the lessons.
My experience has shown me that the NHS needs to do more to improve patient safety. As identified by the Health Committee's report and Ara Darzi's next stage review, there is still huge under-reporting across the system, because, as hon. Members have said, there is too often a "blame culture" in the NHS.
I agree with the hon. Member for Carshalton and Wallington (Tom Brake) that this is not just an issue about hospitals. Primary care, which accounts for 95% of patient contacts with the NHS, accounts for only 0.25% of reported incidents. Although substantial progress has been made, patient safety is still not always a top priority for NHS boards. Most importantly, patients still too often feel that the NHS is not genuinely open and honest with them when a mistake is made.
In 2005, the National Audit Office's 2005 report, "A safer place for patients" found that only 25% of NHS trusts routinely inform patients when an incident has taken place, and an astonishing 6% admit to never informing patients. Like other hon. Members, I have seen such practice in my own constituency. Patients feel that mistakes are not promptly or openly admitted to and they have to battle the system to-in the words of
the hon. Member for Poole (Mr Syms)-"get at the truth", which, so often, is the start of the healing process.
Last week, I went to a meeting at the University Hospitals Leicester NHS Trust with two of my constituents, Mr and Mrs Harkisan-Hall, who lost their son in the hospital's neo-natal unit. It was only at the coroner's inquiry that they found out that the two qualified nurses on the unit were both on a break at the same time, leaving a nursery nurse in charge of very vulnerable children. They felt that they had to battle to get that information, and they still have not seen the full reports of what the staff said. Like them, I believe that that is unacceptable.
Mr Syms: The hon. Lady makes a good point. One point that I meant to make was that if people do not hear what has happened, coroners can find it difficult to determine how someone has died. If people are not honest about what has happened to a particular individual, coroners do not have the full information.
Liz Kendall: In this particular case, interviews were conducted with the two qualified nurses. The trust did not read both transcripts together and did not see that both nurses were on a break at the same time. People are astonished that such simple things happen, and it is vital that we learn from this process.
Before I go on to talk about the duty of candour, I want to discuss two concerns about the Government's policy in relation to patient safety. It is important that hon. Members do not look just at the duty of candour in isolation from what is going on in the rest of the NHS, including on patient safety. My first concern is the Department of Health's decision to abolish the National Patient Safety Agency and to move responsibility for this issue to the new national NHS Commissioning Board. There are real concerns about whether the board will have the necessary skills, experience and time to focus on such a vital issue when it will also be responsible for setting NHS outcomes, assessing whether GP consortiums are delivering on those outcomes, commissioning a whole range of specialist services and managing contracts for all primary medical services. That is a huge agenda for any board, even without adding responsibility for patient safety.
Will the Minister tell us what resources and how many staff from the NPSA will be transferred to the NHS Commissioning Board? Which NPSA activities will the board take on? For example, will NPSA continue to publish patient safety alerts and bulletins and other guidance to identify key problems and help spread best practice? Will it also run workshops with leads for patient safety in individual providers, such as those I was involved with in the Ambulance Service Network? Will the national Patient Safety First Campaign, which was launched last year, and the annual patient safety week, which was held early this month, have the staff and resources to continue?
My second concern relates to the Government's reorganisation of the NHS and fact that the service needs to make efficiency savings worth some £20 billion over the next three years, as the NHS chief executive said. The first report on adverse incidents in the NHS
was drawn up by Sir Liam Donaldson in 2000. Its key recommendation was that the NHS must be open and honest and learn from its experiences. To do that, the NHS must become, as the report's title suggests, "An organisation with a memory". But the Government plan to abolish many of the very organisations that have worked hard to build this memory and understanding of how to improve patient safety.
If the NHS has to make efficiency savings worth some £20 billion, there will inevitably be job losses and posts frozen, some of which could include those staff who have worked hard to learn lessons from the mistakes that have been made in the NHS. How will the Minister ensure that the NHS retains its "memory" on patient safety when PCTs and strategic health authorities are being abolished, new GP consortiums are being established, community services are being transferred to different providers and staff posts are being frozen and reduced? In particular, what steps has she taken to ensure that managers and front-line staff who have knowledge and expertise in patient safety are retained in the NHS at a time when the Government want to cut management costs by 45% and make efficiency savings of £20 billion?
Finally, I want to talk about the duty of candour. As hon. Members have said, the introduction of a statutory duty of candour was first recommended by Sir Liam Donaldson in his 2003 report, "Making Amends". I agree with hon. Members that there is a strong case to look again at this issue, as a Health Committee report recommended in 2009.
I think that it was the hon. Member for Carshalton and Wallington who said that too often the debate is split between those who want a statutory duty of candour and those who think the NHS should instead focus on creating a culture of candour. Of course, changing the practice of individual staff and organisations does not require legislation, but I think that we can see from existing laws, such as those that helped to reduce drink-driving, those that introduced the smoking ban and others, that legislation often plays a vital role in changing culture and behaviour.
Some professional bodies are concerned that a duty of candour would make it less likely that incidents would be reported. I am not convinced that that would be the case, particularly if the duty is combined with an
"exemption from disciplinary action for those reporting adverse events or medical errors-except where there is a criminal offence or where it would not be safe for the professional to continue to treat patients".
That was the recommendation of Sir Liam Donaldson back in 2003.
Others question whether a statutory duty could be imposed when it might be difficult to specify or enforce sanctions. That concern has not prevented other parts of the world from introducing legal duties, including some US states, Sweden, France and Denmark. It is also worth noting that the Equality Act 2010, which was introduced by the last Government, imposes a number of legal duties on public bodies to consider the impact of their policies and decisions on different groups, without specifying what the sanctions will be if those duties are not complied with.
The final argument against a statutory duty of candour is that patients might end up trusting professionals less, because they have to report a mistake rather than
because they want to. I think that the far greater risk for doctor-patient trust is the perception, and too often the reality, that professionals do not tell patients when things go wrong. I know that if a mistake was made in my own care, or in the care of one of my family or friends, I would want to know-and indeed I believe that I have the right to know.
To conclude, I think that the NHS has made important progress on improving patient safety and it has started to try to change its culture, to become more open and honest. However, the evidence shows and hon. Members have clearly demonstrated in this debate that the NHS is still not as open as it should be, not only with its own staff, but-crucially-with patients. The abolition of the NPSA, the huge reorganisation that the NHS is about to undergo and the future cuts in numbers of staff actually make a stronger case for having a duty of candour in place.
The White Paper, "Liberating the NHS", says that the Government will
"require hospitals to be open about mistakes and always tell the patient when something has gone wrong".
It also says that that requirement will be implemented by summer 2011. So I just want to ask the Minister to clarify whether the Government are therefore proposing a statutory duty of candour? Also, will she now agree to bring together patient groups, professional bodies, experts on the duty of candour in this country and abroad, as well as those who represent NHS trusts-such as the NHS Confederation-to discuss how we can all best move forward on this vital issue?
10.34 am
The Parliamentary Under-Secretary of State for Health (Anne Milton): It is a pleasure to serve under your chairmanship for the first time Mr Gray congratulate my hon. Friend the Member for Poole (Mr Syms) on securing this debate. As Chairman of the Regulatory Reform Committee, he is no doubt acutely aware of some of the issues that exist around regulation, not least those that exist around the duty of candour. His humility and recognition of the impossible task that we face here today-to truly reflect the pain and suffering of those who have suffered as a result of medical harm-does him considerable credit.
We take candour and openness in the NHS extremely seriously. Everybody does, because it is a vital issue. As anyone who has ever been treated knows, a health care system is not just about how quickly someone is seen or how quickly their stitches come out; it is also about trust. Trust is fundamental-between patients, the patient's family and health care professionals-and we must do everything we can to ensure that that trust is upheld.
As my hon. Friend may be aware, one of the early references to a statutory "duty of candour" was included in "Making Amends", a 2003 report, which I know hon. Members have referred to. It was a consultation paper from the then chief medical officer, Liam Donaldson, and it set out proposals for reforming the approach to clinical negligence in the NHS, suggesting
"a duty of candour requiring clinicians and health service managers to inform patients about actions which have resulted in harm".
The paper also proposed to foster an environment of openness and honesty among all NHS staff; it encouraged "integrity", which is a word that we perhaps do not use often enough, and it proposed exempting those who
report adverse events or medical errors from disciplinary action, unless there are serious extenuating circumstances. It is a key belief of the coalition, and I would hope all Members of the House, that the focus should be on the performance of the organisation rather than on penalising individuals who bring matters of concern out into the open. The hon. Member for Southport (Dr Pugh) has already mentioned whistleblowing. I think that the point is that this debate is not necessarily about the protection of whistleblowers or a right to whistleblow; it is perhaps about a duty to whistleblow.
It is important to note the good work that is currently being done to promote candour. The previous Government should be congratulated for providing staff with advice and support to help them to communicate with patients, their families and carers following harmful incidents. The Health Act 2009 requires all NHS organisations to be aware of the NHS constitution, which places a duty on NHS staff to acknowledge mistakes, apologise for them, explain what happened and put things right. The professional codes of practice for doctors and nurses contain a similar duty.
As somebody who trained as a nurse and worked in the NHS for 25 years, I think that professional codes of practice and professional standards are not talked about often enough. We look for someone to blame: we look for the organisation to blame; we look for the board to blame, and we look for the chief executive to blame. What we do not talk about is individual professional standards and I feel particularly strongly that we need to do everything that we can to raise those standards right up.
The National Patient Safety Agency has been running its own campaign to promote candour in the NHS, as the hon. Member for Leicester West (Liz Kendall) said. That campaign, entitled "Being Open", is a long-term process rather than a short-term push. It encourages the provision of verbal and written apologies to patients, their families and carers; it promotes continual communication with those involved in incidents, and it requires thorough record-keeping of all "Being Open" discussions and documents.
However, we all know that still more needs to be done, as hon. Members have said and as I know myself from my own constituency casework; I have a number of people who have continually fought to try to get the truth about what happened to their relatives. The recent White Paper, "Liberating the NHS", states that
"we will require hospitals to be open about mistakes, and always tell patients if something has gone wrong".
It is quite simple: we expect the NHS to admit to errors; apologise to those affected, and ensure that lessons are learned to prevent errors from being repeated.
In one year, the NPSA receives notification of more than one million incidents. Most of those incidents result in no harm and we welcome the high level of reporting. However, the incidents that result in harm obviously cause distress and anguish for the patients and families involved. In those cases, it is even more important that the lessons are learned and that organisations are open with those who have been affected.
Dr Pugh:
I want to ask about the future of the NPSA. If it is going to be brought within the national commissioning body, will a Chinese wall be established
between the NPSA and the other operations of that body? It crosses my mind that risks can allegedly be increased or decreased by commissioning decisions themselves.
Under those circumstances, the NPSA has got to be free to impute itself, as it were, if the national commissioning body is going to be part and parcel of the same organisation. So, can the Minister assure me that there will be no conflict of interest when the NPSA is placed within the national commissioning body, which may itself-through its commissioning procedures-be one of the risk factors?
Anne Milton: The hon. Gentleman is absolutely right. That is terribly important. It is not only important to have Chinese walls and be seen to be separate; it is important to be separate. I will come to that point in detail in a minute.
Measuring openness is not as straightforward as measuring reporting. We welcome high levels of reporting, as they are an indicator of an open and supportive culture of patient safety, but there are still reasons why people within the NHS and organisations shy away from openness. Without a doubt, professionals who strive for excellence are reluctant to admit errors. The higher up the tree one is, the harder it is to say, "I've made a mistake." All of us face that issue in our professional lives.
People may have unfounded concerns about possible admissions of liability, even though apologising when something has gone wrong is not in any way an admission of liability. The fine line between the two sometimes prevents people from saying what relatives want to hear: "I am so sorry this happened." That is not necessarily saying, "I have made a mistake." It is such a shame when professionals resort to a defensive stance, often encouraged by myths about where liability lies. Also, at times, they may fear reprisal, blame and even bullying.
We are considering options for introducing a requirement for openness and will make a decision in due course. The hon. Member for Southport felt that we were hesitating, and was concerned about possible evidence of Sir Humphreys in the Department. We are considering, not hesitating. It is important to get it right. Members have discussed the three options, but I will run through them quickly and mention a few relevant issues.
The first option is using what is in the existing Care Quality Commission registration requirement regulations. It is already mandatory for NHS trusts to report all serious patient safety incidents. We could also require organisations to demonstrate that they have met the openness requirement, which would not require new legislation. It makes sense to use existing means to detect and investigate trusts that are not as open as they should be. The counterargument is that that approach is not specific enough, and that the wording of the guidance would need to be made more explicit. We have seen many cases in which guidance has failed.
The second option involves introducing a new legal, statutory duty of openness explicit within the CQC regulations. That would send a clear signal about the importance of openness and provide patients and campaigners with a single clear duty that they could use to demand full disclosure. However, the Government
want to create new legislation only when absolutely necessary, although when necessary, it should be done. We would need to ensure that any new legislation or new approach was not counter-productive. We want to make it easier for staff to come forward; we do not want new legislation to have unintended consequences.
The third option involves incorporating an openness requirement into the new NHS contractual, performance and commissioning processes, to which the hon. Members for Leicester West and for Southport referred. It certainly appears possible to pursue openness through the new commissioning arrangements. For instance, it could be written into standard NHS commissioning board requirements that providers commit to being open. The hon. Member for Leicester West asked whether the NHS commissioning board would have time to take a role on patient safety. In many ways, safety underpins all commissioning decisions. Any decision on any service commissioned should have safety wrapped around it. That is fundamental.
As with any complex matter, each of the options has its pros and cons. It is imperative that a decision on the issue is not rushed. I reassure the hon. Lady that campaigners and organisations have good access to officials within the Department, and I am sure that all their views will have been taken into account when a decision is made, because we are aware of the importance of getting it right. It is terrible to think that the first duty of the NHS is to do no harm. Safety wraps around everything that we do.
The hon. Lady also mentioned the decision to abolish strategic health authorities. I understand that SHAs are the performance managers of trusts, yet that did not help in Staffordshire. In many ways, bringing commissioning decisions closer to the patient within general practice will mean that decisions about care and its consequences rest where they should.
Liz Kendall: The Minister raises the important issue of Stafford and the lessons to be learned there, and says that the SHA did not take action. Obviously, we will wait for the outcome of the independent inquiry, but as responsibility will move to GP commissioning consortiums, can she tell us whether any of the GPs in the area raised concerns about Stafford, or whether any of them have submitted evidence to the inquiry? I am not aware that they have.
Anne Milton: I did not point a finger at the SHA; I pointed out that SHAs were performance managers. Where performance fails, one must ask oneself what was happening in the management of that performance that it could fail so abysmally. The hon. Lady must not forget that the GP consortiums will involve a much wider range of professionals in commissioning decisions than just GPs, including a lot of people involved in care. They will not necessarily consist only of NHS professionals. Voluntary bodies and other organisations that provide care will also have input.
The sad truth is that when things go wrong, relatives want to know what happened, as my hon. Friend the Member for Poole pointed out, but they do not always find out. They want the truth and honesty, but we often see precisely the opposite. Doors close, the shutters go down and NHS organisations resort to a defensive stance, sometimes quite aggressively. My hon. Friend
mentioned his constituents the Byes and the Powells, who have campaigned endlessly for the truth and continue to campaign. I pay tribute to all the people, some of whom we do not know about, who use their own tragic circumstances to ensure that the same thing does not happen to others. Their efforts should never be underestimated.
Tom Brake: The Minister said that the NHS sometimes adopts an aggressive stance. I remind her of my question to her about the possible impact of withdrawing legal aid in clinical negligence cases. Often, families use such cases as a way of trying to secure an apology because one has not been forthcoming. If that option is not available to them, it reinforces the need for a duty of candour.
Anne Milton: The hon. Gentleman pre-empts me by a second; I was about to come to legal aid. My experience is that even with legal aid, the courts are rarely an option for most people. Allowing discretion on the reporting of near misses would, I fear, open another minefield beyond which people could hide, as he also mentioned.
I have certainly brokered meetings between NHS organisations and my constituents to try to bring them together and make the NHS organisations stop feeling so defensive. I have been an advocate for people in my constituency just so they could hear what happened. I should think that many hon. Members rely on personal relationships, particularly within hospital trusts, for such purposes. Maybe they know a supportive medical director to whom they can say, "Look, this family, this couple or these relatives just want to know what happened; this isn't going to go anywhere." That is a leap of faith. The NHS organisation has to say, "Fair enough." When that happens, closure can follow.
The hon. Member for Southport rightly pointed out that accidents occur across the NHS and mentioned, in particular, the failure to diagnose in general practice. That is an ongoing, rumbling issue that I hear about not only as a constituency MP, but as a Minister. I thank him for recognising that the solution to getting to a situation where we have effective measures in place to ensure candour is a dilemma. It is not an easy decision. He is also right to point out that the NHS is not alone in protecting itself. My goodness me, we know a lot of professions that close their doors when one of their members is under attack-the legal profession is one. People just want the truth, but sadly the shutters go down and the doors close, and closure cannot be achieved.
Mr Syms: I am pleased with the way the Minister is responding to the debate and recognise that a statutory duty of candour is one of a range of measures that the Government are considering. However, if they decide not to take that route initially, it is important that they do not rule it out, because the culture change that is needed might not come about as a result of what they are doing, but we will still need to get there at some point. I still think that a statutory duty of candour would be the biggest and most successful leap towards that goal-the hon. Member for Carshalton and Wallington made a good point on that-but even if the Government choose not to go there, they should not rule it out, because I think that ultimately that is where we will end up.
Anne Milton: I thank my hon. Friend for his intervention and am sure that the report of this debate will aid people in making their decisions on the matter.
On the point raised by the hon. Member for Carshalton and Wallington on legal aid, I understand that the Ministry of Justice proposal on restructuring and refocusing the scope of legal aid is currently out for consultation. There will still be an exceptional funding route for those not eligible for legal aid, but he might want to raise that specific point with the MOJ because it is important. The hon. Member for Southport rightly picked up on the fact that we included in the White Paper the principle of "No decision about me, without me", and that probably needs to be extended to situations where harm happens.
A few Members mentioned international precedents, but we must be slightly careful, because what happens abroad cannot necessarily be transported to this country. Those precedents tell us that there can be problems in adopting a statutory duty of candour. It can be difficult to measure success and, therefore, find any evidence of where success or failure has occurred. We must also be mindful of the differing health care and legislative environments that exist around the world when looking at international examples. In Pennsylvania, for example, we have been told that a complicated set of requirements makes enforcing its version of a statutory duty particularly problematic.
In conclusion, there are complex issues at play in relation to a statutory duty of candour, and views are held on both sides of the argument for and against such a duty. What we can say, as has been documented in the White Paper, is that we are absolutely set on achieving that change in culture to achieve openness and candour in the NHS and all organisations that provide care. We are exploring those complex issues carefully. The culture of secrecy and denial is a disease that needs to be cured, but to do so we need to understand and treat its causes at their source, rather than simply treating the symptoms with an ineffective plaster.
As my hon. Friend the Member for Poole stated, the start of the healing process is about learning the truth. The Government will need to decide how we can provide the environment, with or without legislation, in which the truth can come out immediately-in a timely fashion-and openly. We need inspirational leadership and highly developed management skills in our NHS leaders to create that change in culture to create an open atmosphere among staff, not the closed culture that we have seen. We need a culture that replaces the fear of the consequences of openness with the courage to recognise that openness, honesty and truth will, ultimately, not only give families what they need to heal their wounds and achieve closure, but allow staff to learn from their mistakes, raise their standards and raise the bar on their professional standards.
The Government will consider all that when making the decision, but Members should rest assured that everything that has been said today and all the effort to highlight the issue will be taken in account to ensure that we get the right system in place to give people what works.
10.55 am
PACE (Stop and Search)
11 am
Richard Fuller (Bedford) (Con): I appreciate the opportunity to have this debate. The shorthand definition of the code of practice that I wish to consider is "stop and search", but it also includes "stop and account". The draft guidelines recently issued by the Government state:
"The primary purpose of stop and search powers is to enable officers to allay or confirm suspicions about individuals without exercising their power of arrest."
We would all recognise that that is an important part of policing powers, but some issues arise from it and I have some questions to which I should appreciate a response from the Minister. My interest arises partly from my membership of the all-party parliamentary group on race and community and from conversations that I have had with the Runnymede Trust and the StopWatch coalition, both of which have alerted me to issues of the context in which the proposed changes and guidelines are being made. The most significant issue is disproportionality between people of different ethnic origins.
A black person is at least six times as likely as a white person to be stopped and searched by the police. It is twice as likely to happen to an Asian. That is grossly disproportionate and those ratios have remained stubbornly constant in the past five years. The report "Stop and think", which was produced earlier this year by the Equality and Human Rights Commission, included research findings that
"black and ethnic minority youths were over-represented in the criminal justice system. This over-representation started at the point of entry into the system, and largely continued as young suspects and defendants passed through it."
If the very first part of a person's interaction with the criminal justice system is disproportionate, there may be consequential effects at other stages in that system.
The black population of England and Wales is approximately 2.6%, but black people represent 14.8% of incidents of stop and search, 7.6% of arrests and 14.4% of the prison population. I think that anyone would find those statistics chilling. It is a rare thing for me to say I agree with Bernie Grant, the former Member of Parliament for Tottenham, but in 1997 he said:
"Nothing has been more damaging to the relationship between the police and the black community than the ill judged use of stop and search powers. For young black men in particular, the humiliating experience of being repeatedly stopped and searched is a fact of life".
Of course society has moved on in 13 years, but, as the statistics have shown, disproportionality is still significant.
Stop and search is not a power that is used occasionally. Last year, there were more than 2 million instances of stop and account by police and more than 1 million of stop and search. That amounts to more than 10,000 a day, which is not only disproportionate, but shows widespread and pervasive use in our society.
I accept-and this is probably much of the intent behind Government moves-that the recording of information accounts for considerable police time. It is estimated by the Daily Mail that the proposed changes will save 450,000 hours of police time by eliminating the stop-and-account element and 350,000 hours of police
time by reducing stop-and-search forms. Those are welcome savings in police time, to enable our police to spend more time in their jobs on the beat, and in helping citizens by combating crime.
However, against a backdrop of considerable community concerns, and severely disproportionate impacts, perhaps the Minister could assist with the answer to some questions. The first is about the removal of the requirement to record stop and account. As I have said, that represents 2 million actions by the police each year, so it is certainly clear that removing the requirement to record stop and account will save considerable police time. However, as we have not yet ended disproportionality, is the Minister concerned that we would lose an important source of information on fairness?
I understand that it would be possible for chief constables to re-institute stop-and-account searches if local concerns were expressed. That is a very welcome part of the proposals, but how will the local pressure be voiced? What would constitute a valid local concern and how would it be differentiated from concerns thought to be invalid?
I would also appreciate the Minister's views on the decision by Suffolk police to de-fund the stop-and-search reference group. What message does that send to people who have concerns about disproportionality and the reliance on the raising of concerns by local voices? On the same point, what role does the Minister see for the Equality and Human Rights Commission? Are steps such as the enforcement action warning that it issued this week to Thames Valley police and other forces seen as part of the community response to disproportionality in stop and account and stop and search?
The Government have-and I welcome this-removed parts of the justification for section 60 stop and search on the grounds of race. The National Black Police Association said the original draft proposal
"opens the door to racial targeting that could be based on gossip, malice and outright racial prejudice."
Perhaps I might use this opportunity to thank the Minister for, and congratulate him on, the changes, and for his statement:
"Previous guidance did not place any restrictions on use but now it will make clear than an individual characteristic such as ethnicity should never be the sole basis for any search."
That shows the direction of travel of the Government. They will look at areas where there is disproportionality and seek to eliminate that. They will look at areas where ethnicity is misused in policing, and ensure that that no longer happens. I would welcome the Minister's comments on the background to the draft guidelines and the change.
Section 60 stop and search is a very significant power that we provide to the police. It enables the police to stop and search an individual where there are no grounds for suspicion of the particular individual, in a designated area, for a period of 24 hours. Nationally the black population of the country, as I said earlier, is about 2.6%, but they represent 32% of stops and searches under section 60. Therefore, under the police power to stop and search with no grounds for suspicion of the individual concerned, a black person is 26 times more likely than a white person to be stopped. That is a shocking statistic and everyone, including members of the police force, will want that ratio to be changed.
The usage of this blanket power, which does not rely on individual assessment or suspicion, has grown over the past few years. In 2004-05, there were 45,600 incidences of section 60 stop and search being used. Just three years later, in 2008-09, the figure had more than trebled to 149,955. This is a specialised, exceptional power akin to those available under section 44 of the Terrorism Act 2000. Does the Minister believe that there should be specialist oversight of the authorisations that chief constables are using to invoke this power? I am not aware of any areas where there is currently national oversight over particular actions by chief constables, but given that the use of these authorisations is growing and disproportionate, and given that these very powerful measures are targeted on an area, not an individual, I would greatly appreciate it if the Minister could tell us what oversight, if any, there could be over them.
Other issues are related to the information collected on the stop-and-search form. Again, I think that the proposals are being introduced with the good intention of reducing the amount of police time that is spent on form filling. The Minister may, in an offhanded way, have called it box ticking, but I am sure that he accepts that some of this information is valuable. I want to alert him, therefore, to some reasons why some of the information that will be lost from these forms might be valuable, and he might want to consider how such concerns could be addressed.
The first piece of information that will be lost from the stop-and-search form is the name of the person who has been stopped and searched. How will it be possible to identify and measure repeat stops and searches that might amount to harassment? If an individual is stopped and searched routinely by the police, that will be evident from the current form because the individual's name will have been collected, but it will not be evident under the proposed change. How might we deal with concerns about harassment if that information is lost?
Secondly, as a result of the targeting of individuals in a community, there might be community concerns. How will the community have the information that it needs to identify and measure whether particular individuals are being targeted? There is, therefore, not only the individual concern; there will also be a community concern if four or five individuals are routinely stopped and searched and people feel that their community is being unfairly targeted.
The second piece of information that will be lost is whether injury or damage was caused as a result of the search. If that information is not collected, my concern is that we might leave the police open to allegations that some injury or damage was caused. How will it be possible to identify and account for incidents of the misuse of force? The corollary of that is the issue of how the police will be guaranteed protection against allegations that an injury did occur.
The third piece of information that will be lost relates to whether anything was found as a consequence of the search. One of the concerns about the use of stop and search relates to how effective it is in tackling crime. With so few stops and searches resulting in an arrest, how will we know how effective stop and search is likely to be if we have no information about whether anything is found as a consequence of a search? Overall, stops and searches have resulted in an arrest rate of about 10% to 13%, which means that nine out of 10 stops and
searches-3 million in total-do not result in an arrest. Three million is a widespread trawl through our communities, and that can have counter-productive effects by separating the police from the communities that they serve.
Over the past few years, since the quote from Mr Grant, progress has been made. Our police have done an enormously good job of reaching out to communities. We need to do more of that, but stop and search is not necessarily one of the main ways to do it. We need look only at the effectiveness of one of the important powers in section 60 in tackling knife crime. A review of statistics from 11 London boroughs with a high incidence of knife crime showed a broad correlation between the incidence of knife crime and the number of stops and searches-when there are a large number of knife crimes, the police carry out more stops and searches. However, there is no correlation between the number of stops and searches and a reduction in knife crime.
Let me give an example. In 2008-09, Tower Hamlets and Islington both experienced approximately 305 knife crimes. The police in Tower Hamlets responded with a stop-and-search rate that was two and a half times that of Islington. Although knife crime fell by 11% in Tower Hamlets, it fell by nearly 25% in Islington where such a large number of stops and searches were not carried out.
People in those communities want knife crime dealt with. However, stop and search does not appear to be a tool that helps and we must look at alternatives. In his response, perhaps the Minister will talk about initiatives other than stop and search that can be used to reduce the disproportionality of the statistics on ethnicity in our criminal justice system.
For example, the practice-oriented package initiative that was introduced in Stoke-on-Trent reduced the disproportionality ratio from six times the national average to just 1.5 times that average. In Cleveland, the number of stop and searches was reduced by 80%. That reduced the disproportionality in stop and search and also reduced the crime rate. Will the Minister also endorse police innovations in tackling drugs without the use of stop and search, which has been done to good intent?
I understand, appreciate and support the Government's efforts to reduce the waste of police time spent collecting information that is not helpful in tackling crime. I believe and understand that the Minister shares my concerns about disproportionality and wishes to ensure that police powers are used correctly. I welcome the change to the draft guidelines that have stopped ethnic profiling from being written into our legislation. That move is welcome, but considerations and concerns remain about the continuation of stop and account without the recording of information, and about the reduction of information in the stop-and-search forms. I look forward to hearing the Minister's response.
11.17 am
The Minister for Policing and Criminal Justice (Nick Herbert): First, may I congratulate my hon. Friend the Member for Bedford (Richard Fuller) on securing the debate and on raising the issues in such a forceful way? Such matters continue to generate a significant amount of public interest and highlight some of the concerns about front-line policing that we are keen to address.
We are keen to ensure that officers strike the right balance between necessary bureaucracy for the sake of accountability-which is important-and irrelevant form filling that wastes the time of the police and the public, and impacts unduly on citizens going about their business by asking unnecessary questions.
It is important to understand how policing, and the bureaucracy that surrounds it, impacts on community relations. Procedures such as stop and account and stop and search are most effective when local communities understand them and support their use. There is a difference between stop and account and stop and search, and we must be mindful of ensuring that the processes associated with them are not confused. Stop and account is where an individual is asked to account for their presence, actions and so on, but they are not searched. It can be one step on from the general conversations that officers have with members of the public every day. Stop and search clearly goes further than that. It is an intrusive procedure and therefore a cause of more concern among local communities.
Many of the proposed changes to the Police and Criminal Evidence Act 1984 code of practice A are necessary to reverse the increase in paperwork generated by the last Government. In our judgment, that paperwork hampers police operations and leads to encounters with the public that are ineffective, bureaucratised and poorly understood. We need officers on the street to record only information that is of value, and it may differ from situation to situation and from force to force. I do not want to see in place measures that discourage proper interaction between police officers and members of the public.
Let me explain the rationale behind our stop-and-account proposals. The abolition of the national recording requirement for stop and account will potentially free up around 450,000 hours of police time, allowing officers to increase the quality-and shorten the duration-of these brief encounters, and enabling forces to be more responsive to the communities that they serve.
I share my hon. Friend's concerns about the level of disproportionality in the use of police powers. However, when the statistics for stop and account are examined more closely, it appears that it is not used in a disproportionate manner across England and Wales. It is also fair to say that there is less concern about the operation of stop and account than there is about stop and search. That is why we are removing fully the national requirement for recording stops and accounts, leaving local recording to a local decision where a local need is identified.
Individual police forces know their own communities better than Whitehall does. Increasingly, they will be answerable to their local communities, as we have set out today with the introduction of the Police Reform and Social Responsibility Bill. Those forces should know the extent to which the operation of stop and account is a matter of particular local concern. They are best placed to analyse their own statistics and understand how they use the tactic and how it impacts on ethnic minority groups locally, and they should be held to account by their elected police and crime commissioners, with the scrutiny of new police and crime panels to ensure the proper use of such procedures.
The Government understand that stop and search is a very different tool and is far more intrusive. It is right that its monitoring and use should continue, both nationally and at a local level. We are reducing the number of pieces of data to be completed on a stop-and-search record from 12 to seven, saving more than 300,000 hours of officers' time every year as well as reducing the duration of these encounters for those stopped and searched.
My hon. Friend expressed concern about some of the pieces of data that will be removed. However, key information about each encounter will still be recorded, including the self-defined ethnicity of the person stopped, which is obviously the critical information, and we have made minor amendments to code A to encourage the further use of mobile technology to reduce even further the time taken to record each stop and search. The 12 recording requirements used during a stop-and-search encounter will be reduced to seven: ethnicity, the object of the search, the grounds for the search, the identity of the officer carrying out the stop and search, the date, the time and the place. Such requirements do not prevent police officers from recording information that they feel would be useful intelligence, but it is not necessary as a Government requirement for such information to be held in a stop-and-search record.
Our amendments to the guidance on the use of section 44 stop-and-search powers follow the Home Secretary's announcement on 8 July, which curtailed the use of this power in the light of the judgment of the European Court of Human Rights in the case of Gillan and Quinton v. United Kingdom. My hon. Friend also raised issues around section 60 stop-and-search powers, both in terms of the guidance supporting officers' use of this power, and the disproportionality figures that have been reported in the press recently.
Let me assure my hon. Friend and all hon. Members that there was never any intention on the part of the Government to encourage the use of ethnic profiling or unlawful discrimination in the use of this power-far from it. The original draft of the guidance contained wording that had been introduced in code A by the previous Government in 2003 in relation to the police's use of section 44 powers. The original draft explained that all authorisations had to be supported by clear intelligence and that, on occasion, intelligence could suggest a possible suspect description that included characteristics such as race, age, sex and so on. However, it also stipulated that race should never be the sole reason for stopping someone under section 60.
The guidance was evidently not clear enough and was misconstrued. We therefore considered the responses to the statutory consultation and have redrafted the relevant paragraphs to include all protected characteristics under the Equality Act 2010. We have stated clearly that unlawful discrimination will not be tolerated.
I must, however, warn against judging the use of a key tool such as section 60 purely on a national statistic. The figures cited in the press about black people being 26 times more likely than white people to be stopped and searched under section 60 are potentially misleading if they are not examined a little more closely. In 2008-09, 76% of all section 60 stops and searches were conducted by the Metropolitan Police Service in London. Therefore, to assess the use of that power against the national population's ethnicity breakdown is deceptive. We need
to compare that 76% with the ethnicity of the population of London and the remaining 24% with the rest of the country. When we do that, we find that the use is not so disproportionate.
The power is used to tackle specific issues relating to serious violence and, in particular, knife crime. The Under-Secretary of State for the Home Department, my hon. Friend the Member for Old Bexley and Sidcup (James Brokenshire), who is responsible for crime prevention, recently responded to a debate in this Chamber on youth violence and was very clear about how we need to protect our communities against violent crimes.
The use of section 60 as one of the many tools that the Metropolitan police use as part of their continuing action against knife crime receives significant support from communities in London. The Metropolitan police have gone to great lengths since the start of Operation Blunt 2-their programme of action against knife crime-to increase community engagement. An example of that is the young Londoners engagement programme, which explains why the powers are so important and the dangers of carrying knives. The Metropolitan police are in the process of reviewing their operational use of the power, and all boroughs have been reminded that they must be proportionate in their use of section 60.
Neighbourhood policing-such a rare thing at the time of the Macpherson inquiry in the late 1990s-is now embedded throughout the country in such a way as to give the public far greater confidence in the way in which their police service operates. The Government are determined to do everything that they can to ensure that neighbourhood policing is protected, despite the budgetary challenges that confront forces. We are also determined that the British tradition of policing by consent should flourish, and that can happen only if the public understand why the police do what they do and, just as importantly, if the police understand how their actions are perceived by the public.
My hon. Friend the Member for Bedford referred to the role of the Equality and Human Rights Commission. The commission has praised the "Next Steps" process developed by the National Policing Improvement Agency, which is being used by the police in, for example, Merseyside and Dorset, as well as Lewisham in London. It helps the police to understand the way in which they use stop and search and how the population of an area and the apparent levels of disproportionality might in some circumstances not present a true picture. The early feedback on "Next Steps" is positive, and we hope to be able to expand it to other areas shortly.
I have been impressed by the way in which my hon. Friend has raised these issues. Since the general election, there has not been a great deal of debate in the House about these issues or the changes that we propose to make. There may be debate in relation to the orders that we have laid to change the PACE codes, but I would welcome the opportunity for further discussion with my hon. Friend and other hon. Members. I would be happy to convene a meeting with key representatives of the police, including the deputy commissioner of the police in London if he would be willing, in order to talk about their use of stop and search, why they believe that it is such an important tool in their fight against knife crime, why they believe that it has public consent and how they are alive to the important issues of disproportionality that can be raised.
In summary, stop and search is a vital tool. The challenge for the Government and the police is to ensure that the powers are used fairly and with the support of the community, and it is a challenge that I am confident we will meet.
11.30 am
HIV
2.30 pm
Mr Edward Leigh (in the Chair): The sitting is resumed.
David Cairns (Inverclyde) (Lab): That might be the best cheer I get all day. I welcome you to the Chair, Mr Leigh. It is a pleasure to serve under your chairmanship in this important debate. I also thank Mr Speaker for allowing this debate on HIV services in the UK to take place on world AIDS day. I have been in Parliament for nine years, but I am still ignorant about how debates are selected-whether there is a lottery or whether Mr Speaker has a say in the matter. If he does, I thank him; if it was a lottery, I thank the Fates for timetabling this debate on 1 December.
I begin with a point of clarification. This is not for the benefit of hon. Members present in the Chamber, as they are well aware of the procedures of this place, but for those who are watching the debate on television or the internet, and those who will read the account of the debate in days to come. This debate will focus mainly on HIV in the UK, but that is not because we think that HIV outside the UK is not a problem, or because we are unaware of the scale of HIV in the developing world.
Africa has 10% of the world's population but 72% of the deaths from AIDS, and we are aware of that. However, parliamentary procedure means that different Departments respond to the debates on different days, and today it is the turn of the Department of Health, not the Department for International Development. Therefore, although an enormous number of points could be raised about the global AIDS epidemic, I will in the main restrict my comments to HIV in the UK. With your indulgence, Mr Leigh, I might also sneak in a few comments about the international scene; I alerted the Minister about that in advance.
If colleagues are anxious to hear about the international aspects of the HIV epidemic, I should say that a world AIDS day reception will be held this evening at 7 pm in the Commonwealth Parliamentary Association Room. You are invited, Mr Leigh, as are all hon. Members, friends and colleagues.
Mr Gareth Thomas (Harrow West) (Lab/Co-op): My hon. Friend is performing a service by raising the issue of HIV/AIDS in the UK. Does he also recognise that many people, both inside and outside the country, want to know what the UK Government intend to do about the future funding of the Global Fund to Fight AIDS, Tuberculosis and Malaria? That body has an excellent record in getting drugs to people with TB, malaria and particularly AIDS, many of whom are still in desperate need.
David Cairns: I am grateful to my hon. Friend, who was a distinguished and long-serving Minister at DFID. In a sense, it is a false dichotomy to say that there is an AIDS epidemic in the UK and an AIDS epidemic in Africa and never the twain shall meet. One of the largest at-risk populations in the UK is the African community--people who come from Africa and are HIV positive, or those who contract the disease in the UK within the African community. I will speak about that in a moment.
My hon. Friend is correct to highlight the need to address the problem of the AIDS epidemic in Africa. Over the past few years, one of the most effective ways of doing that has been through the Global Fund to Fight AIDS, Tuberculosis and Malaria. The last Government had a good record in ensuring that the global fund was initiated, then adequately resourced. During the most recent meeting of the fund in October, high, medium and low targets were set for the level of replenishment. Unfortunately, the global community failed to hit the low target, let alone the medium or high targets.
I understand why the Government do not come forward and state the exact figures for the replenishment of the fund. Through DFID, they are conducting a multilateral aid review, and until they decide their priorities, they cannot say how much will be made available for the global fund. Until we can provide a figure, I encourage Ministers to let the world know, at least with rhetoric, that we remain committed to the global fund.
Much of the world looks to the UK for an international lead in tackling AIDS, and other countries will be looking to our figures for the replenishment of the global fund before making their commitments. The Government have an excellent opportunity to set a global lead. I was going to make those points about the international community at the end of my speech, but I have made them now.
Let me return to matters for which the Minister is responsible-she will be pleased to hear that-rather than the rest of the world. I will make three points about how we should respond to the ongoing HIV epidemic in the UK and our public policy; priorities. First, I will speak a little about prevention, secondly I will discuss testing and treatment; and thirdly, I will say something about care and support. Those three things do not exist in isolation; they are not, to use fabled management-speak, in "silos." One point leads into another, but for the purposes of the debate I will say a little about each issue in turn.
The backdrop to this debate is not only the ongoing financial constraints under which all Governments around the world are operating, but the NHS reconstruction and reconfiguration that the Government have embarked on, as well as the messages contained in the public health White Paper, launched yesterday by the Secretary of State. Because the national health service is undergoing a process of change and transition, there is some uncertainty. Until we get answers to some of the questions that we raise, that uncertainty will continue.
As I pointed out in the main Chamber this afternoon, although the Minister's responsibility on such matters is constrained to the NHS in England, the HIV virus does not respect geographical borders. It is incredibly important for the Government to work closely with the devolved Administrations in Edinburgh, Cardiff and Belfast to ensure a coherent, joined-up approach. That is the only way to tackle the virus in a way that will see a reduction in the number of people affected and reverse the rate of increase in new cases of the disease. Therefore, although I am addressing the NHS in England, the message must be heard by those who configure the NHS in the devolved Administrations. I was pleased to hear that the Secretary of State for Scotland will meet the Minister responsible for health in Scotland tomorrow, and will put that important issue on the agenda.
The first issue that I mentioned was prevention. In the early days of the epidemic, not much was known about the virus. There were no drugs and no effective treatment. Messaging was, by necessity, extensive and untargeted. Those of us old enough will remember the adverts with the collapsing tombstones and the gravelly voice telling us about the new virus-AIDS-and how dangerous it was. We remember the posters and the radio adverts, which were essentially blanket advertising for the whole UK. People debate the relative impact of those messages, but we remember that campaign many years after it happened, so it did have some impact.
The situation of those who have HIV in the UK today means that that type of mass media advertising is not perhaps the best way of getting a message to those most at risk. That point was made in the foreword to the "Halve It" document, by Lord Fowler, about which I will speak shortly. Lord Fowler was a distinguished former Secretary of State for Health and Social Security, and he is remembered very fondly by people who work on behalf of and alongside those with HIV and AIDS for the forward-looking approach that he took. As he acknowledges, such mass communication messages are no longer relevant, and the campaign must be more targeted.
Will the Minister tell us whether the Government's strategies on sexual health and HIV propose to target messages on specific, at-risk communities, and particularly but not exclusively on younger gay men, for whom some of the safe sex messages may have been lost in time, and the African community? Those communities are not mutually exclusive, of course, but the messaging to each will have to be different. Particularly now that more heterosexual people are contracting the virus, many of whom are in the African community, there is a pressing need to develop messaging that speaks to that community and to its values and structures, whether through Church or faith networks or whatever, so that we can overcome some of the ignorance and stigma in the black African community in this country. I would be grateful for the Minister's comments on what she proposes to do about that.
Pauline Latham (Mid Derbyshire) (Con) rose-
David Cairns: I am happy to give way to a vice-chair of the all-party group on HIV and AIDS.
Pauline Latham: Does the hon. Gentleman accept that, in addition, white heterosexual people who perhaps have got divorced recently, after having had a monogamous relationship for many years, are now going out into the world of single dating and getting into a mess because they do not realise that HIV/AIDS is out there in the heterosexual community? Is that not an expanding area that we should also be targeting?
David Cairns: The hon. Lady is right. I was saying that the messaging should not go exclusively to gay men and to people in the African community. There must be a message for everyone, but the messaging needs to be differentiated. There will need to be different messages to different people, within relative constraints. I hope that the Minister will deal with her point.
There is concern. I am of the generation that came to maturity at the time when the AIDS epidemic-well, I might not have come to maturity yet; it is probably up for debate whether I have reached maturity.
Mr Thomas: Don't do yourself down.
David Cairns: Yes, I am doing myself down here. I am of the generation that came to adulthood when the virus was making its first big impact, so those messages really stayed with me. I wonder whether that is the same today, particularly, although not exclusively, for young gay men of 17, 18 or 19. We cannot be squeamish about this issue. We must speak a language that they hear and will listen and respond to. I do not expect the Minister necessarily to go into that in detail today, but I want an assurance from her in that regard. I know, particularly given her former career, that she is not squeamish about these things, and we cannot be squeamish when people's lives are at stake.
Of course, one way to prevent the spread of the virus is to ensure that everyone who is HIV-positive knows that they are HIV-positive-knows their status-and is receiving the correct drug treatment. It is not widely appreciated that when someone who is HIV-positive is on the correct level of antiretroviral drug treatment, they become significantly less infectious. I had not appreciated that-I must confess that that was ignorance on my part-until fairly recently. It means that treatment for one person is prevention for another.
When an individual is on ARVs and is less infectious, that helps to constrain the spread of the epidemic and when people know their HIV status, it alters their sexual practices. Most of the evidence and studies show that. The more people we can test and the more HIV-positive people who know their status and are receiving the right treatment, the more we will do to prevent the spread of the virus.
Jenny Willott (Cardiff Central) (LD) rose-
David Cairns: I am happy to give way to another vice-chair of the all-party group.
Jenny Willott: I have just had a baby and I was tested automatically for HIV during my pregnancy. Does the hon. Gentleman agree that extending such automatic testing could play a valuable role in identifying cases very early, so that people can receive the treatment that, as he said, will not only help them with their own medical needs, but prevent them from spreading the condition?
David Cairns: The hon. Lady makes an excellent point. I think that it was my right hon. Friend the Member for Holborn and St Pancras (Frank Dobson), when he was Secretary of State for Health, who introduced automatic testing in pregnancy. If we look at the graph, we see that the tail-off is quite astonishing: once opt-out testing was introduced for pregnant women, the numbers of babies being born HIV-positive plummeted.
Of course, the issue is not just about babies. Quite often when we are talking about the prevention of mother-to-child transmission, we focus on the baby, but a woman is involved as well. As the hon. Lady rightly says, if a woman's own HIV-positive status has been diagnosed at the beginning of pregnancy, she can be put on the correct course of ARVs. That is why, in the northern world, mother-to-child transmission has been, if not completely eliminated, massively reduced- because not only ARVs but the correct education about
breastfeeding are making an enormous difference. However, almost 500,000 babies born in Africa every year are HIV-positive. That is completely preventable-entirely avoidable. If pregnant women are tested and put on ARVs, they do not need to pass on the virus. It is one of the great scandals of our age that something that is solvable-we have solved it here-could be solved throughout the world with the correct financial support and the political will, but it has not been.
Mr Thomas: Is not one of the conclusions that can be drawn from the comments made by the hon. Member for Cardiff Central (Jenny Willott), as well as from my hon. Friend's point about mother-to-child transmission, that we need to ensure that the Department of Health and DFID work closely together, so that the lessons of success in dealing with HIV in this country can be properly worked into our development policy abroad? Is it not therefore a concern that DFID's HIV/AIDS team seems to have shrunk very small-if indeed any cadre of skills in this area is left in the Department at all?
David Cairns: I am grateful to my hon. Friend. He has far greater knowledge of these matters from within DFID than I have. If what he says is true, clearly it is a very worrying development. I was fortunate enough to meet some members of the HIV/AIDS team in DFID a few weeks ago. Whether or not the team is smaller than it used to be, it is certainly very committed. I also met some DFID workers when I was in Kenya a few months ago, and they are doing a tremendous job.
It is to the credit of the Government that they have protected the international development budget, but of course there will be reprioritising within that budget. Part of what we are doing as an all-party group is ensuring that these issues are not lost in the reprioritisation. This is what people find very frustrating about the international dimension of this issue. Enormous progress has been made and the tide is beginning to turn. If we withdrew funding or support or lost the political will at this stage, it would be a disaster and a tragedy, not least because in five years' time we would have to return to the matter, because we could not let the number of deaths and new infections let rip, as we saw happen in the 1980s and 1990s.
Mr Thomas: Will the all-party group, as part of its thinking about the Government's multilateral aid review, also consider funding for the new UN women's agency? I ask that in the context of the comments from a previous UN Secretary-General, who said that AIDS in many parts of the developing world has an increasingly female face and that we need to ensure that we continue to champion efforts to tackle issues relating to gender equality-for many reasons, of course, but in particular to help with the fight against AIDS.
David Cairns: My hon. Friend makes an excellent point. The new agency has real potential to make a difference. We are all relieved that some of the world's appalling, oppressive, anti-women regimes that were muscling in have been set to one side, which will allow the agency to focus on the issues that he mentioned.
A saying that we hear over and again now in Africa is that the face of the epidemic is female. That is not just because of mother-to-child transmissions, but because of the disempowerment of women and the limiting of women's ability to make choices about their own sexual and reproductive health. Of course, that is not the case solely in Africa; it is the case elsewhere in the world as well. However, it is a particularly pressing problem in Africa and one that we must not lose sight of.
I was talking about the need to ensure that people who are HIV-positive know that they are HIV-positive. That is why the all-party group is pleased to support the Halve It campaign, which is composed of many agencies, clinicians and groups advocating on behalf of people with HIV. It is campaigning to halve the number of late diagnoses by 2015. That is an ambitious target, but the document sets out steps that can be taken to meet it, and I would be grateful for the Minister's comments on them.
Yesterday, I was pleased that when I urged the Secretary of State for Health, while he was making his statement on the public health White Paper in the House, to look at the Halve It campaign, he gave an undertaking to do so and see whether it could form part of the HIV and sexual health strategy. I would be grateful if the Minister confirmed that she will look at the campaign's document, particularly at the steps that can be taken to halve the numbers of late diagnoses and of those living with undiagnosed HIV by 2015.
I shall press on because I know other hon. Members are keen to take part and I want to hear the Minister's reply. Once a person is diagnosed--I shall speak about some of the hurdles in a moment--the virus changes from being in its potentially lethal undiagnosed state, which poses a wide public health risk due to how it can be transmitted, to being a more normal-I use that word advisedly-long-term managed condition. That brings different challenges with it.
One thing that we are looking for in the detail of the NHS restructuring plan is how people will access services in the long-term managed phase of the condition. Who will commission those services, particularly in low-prevalence areas? Until those questions are answered, there will be uncertainty in the community. I want the Minister to answer specifically the question of who will commission HIV services in the new restructured NHS. Will it always be the GP? Is the GP the best placed person to do so? Do GPs have the time and the expertise, particularly in low-prevalence areas? I am sure that GPs in much of London, Brighton, Manchester or Glasgow have the necessary expertise because they have the caseload, but in other areas that might not be the case. Is a one-size-fits-all approach across the NHS the right solution or is something a little more granulated necessary to deal with the full complexity of the issue?
We have to face up to the fact that a lot of people who are HIV-positive simply do not want to access services through their local GP. Whether it is wise or unwise, it is understandable in some areas, particularly in smaller towns or villages, where everyone knows everyone else, and you know who works in your GP's surgery and they know everybody and everything about you. Under those circumstances and given that the stigma prevails, and the myths, misunderstandings and prejudice that people with HIV face, it is understandable that there are those who will not want their status to be known in their own
community. In evidence put forward yesterday by the National AIDS Trust, we saw how many people face discrimination in the workplace due to their HIV status.
AIDS is a complex condition. It affects people physically, emotionally and psychologically. In that complex mix, it is important that the NHS is responsive to that and allows people pathways to treatment that might not always be the same in every place. I would be grateful for the Minister's views on that.
Mr Russell Brown (Dumfries and Galloway) (Lab): I congratulate my hon. Friend on securing the debate. Because stigma is still attached to this condition, people in rural localities, such as mine, will seek advice and help from further afield, thereby distorting the figures on the prevalence of the condition in certain parts of the country.
David Cairns: My hon. Friend is absolutely right. He represents an area that is not only largely rural but on the borders of Scotland and England, which brings me to the point that I mentioned at the very beginning. I imagine that many of his constituents will be accessing HIV services in Carlisle, for all sorts of reasons, but partly due to the stigma still associated with the condition. They do not want to access services in small villages and towns. Ultimately, we have to get to a situation in which there is no stigma, prejudice or discrimination and people can happily access GP services for a long-term managed condition, as people with diabetes, asthma and other long-term managed conditions can. Until such a time, we have to be sensitive to these issues.
Another reason why people are wary about always accessing services through GPs is the lack of awareness and understanding that many GPs demonstrate. Part of the reason why we have so many late diagnoses is that GPs do not pick up the telltale signs often enough. An alarming number of people had seen their GP on many occasions during the 12 months before they were eventually diagnosed as HIV-positive, and it was not picked up that they might have been HIV-positive. An astonishing number of people had been in-patients in the 12 months preceding their diagnosis; they were almost certainly HIV-positive while they were in hospital, but it was not picked up.
A lady recently got in touch with the all-party group-a middle-aged, professional, white lady-who had suffered serious recurrent health problems for two years and had seen numerous clinicians, including a GP on many occasions, before anyone thought to offer her an HIV test, which brings me back to the point that the hon. Member for Cardiff Central made. That lady was a textbook case: she had every symptom and yet her GP never thought to offer her an HIV test. That is clearly happening across the country, which explains why we have 22,000 people who are HIV-positive, but do not know it. It is not the case that none of them ever visits their doctor-they regularly visit their GPs, perhaps they even go into hospital as in-patients, and yet their status is not picked up. That is a public health disaster because the ability of those people to infect others is much greater than it would be if they were receiving the correct course of ARVs.
We need assurance that, within the restructuring, GPs will get very good guidelines and necessary training, and be encouraged to offer people an HIV test in the routine manner suggested earlier, to tackle undiagnosed HIV.
Jenny Willott: Will the hon. Gentleman also suggest that we need to tackle the stereotypes about the kind of person who might have HIV? That is one issue for people who do not go to their doctor, or who do go but whose GP does not pick up on it. As the hon. Member for Mid Derbyshire (Pauline Latham) mentioned earlier, GPs may not think that a middle-aged, heterosexual white woman is likely to be HIV-positive. We need to tackle those stereotypes.
David Cairns: The hon. Lady is correct. Part of the education of GPs must be about looking at the symptoms, not only what the GP imagines a typical at-risk person would be. Having said that, we need to show that those within high-risk groups of people are being tested as well.
The tremendous progress that has been made in testing in the past few years is truly astonishing. Someone can be tested and have the result in less than a minute. I hope that he will not mind me mentioning it, but the hon. Member for Brighton, Kemptown (Simon Kirby) saw this first-hand last night when he received a test through the services provided by the Terrence Higgins Trust in the House, and he had the result in less than a minute. Testing is not the long drawn-out process that it was years ago, but can be done much more quickly.
Finally, on care and support, people are living longer with the virus, which is a very good thing, but it brings with it challenges and complications-physical, emotional and mental. It is very important that we understand the need to have a strategy for people living longer with HIV. The AIDS support grant is no longer ring-fenced, and I am not arguing that it should be re-ring-fenced, but I am arguing strongly for it to stay within the grants that go to local government as a specified budget line.
In that way, local people can hold their local authority to account in exactly the way that the Secretary of State outlined yesterday. It is his belief that local people should be able to see the services being provided for them, and argue for services. If the AIDS support grant disappears as a title altogether and is subsumed into the general pot of money that local government gets, local people will not be empowered to come forward and demand the kind of services for which money is being made available.
In conclusion, I hope that the Minister will address some of the concerns about the AIDS support grant and the Government's vision for it. I hope too that she will be able to calm some of the fears and uncertainties out there on how HIV services are to be commissioned, how they will be accessed, and how they will be supported under the new NHS that the Government have in mind.
Mr Edward Leigh (in the Chair): Order. Five Back Benchers have intimated that they wish to take part. I intend to call the wind-ups at about 3.30 pm. Hon. Members can do the maths, so I ask for brief speeches from now on.
3 pm
Mike Weatherley (Hove) (Con): I congratulate the hon. Member for Inverclyde (David Cairns) on securing this important debate, whether by skill or fortune.
The Hove and Brighton area has one the highest rates of HIV in the UK. Many of my constituents live with the virus, and others have friends and colleagues that do so. It is a great privilege to speak up for them on any day, but especially on world AIDS day.
I wish to make two clear points. First, HIV does not always conform to stereotypes. HIV does not affect only young men on the gay scene, or people in or from Africa. As we heard earlier, it also affects white, middle-aged and older straight men and women. Until politicians, policy makers, doctors and the general public take that fact on board, dealing with HIV will continue to be hard work. Secondly, 26% of all who live with HIV in the United Kingdom are undiagnosed. Tackling this must be a priority.
In Brighton and Hove City primary care trust, about 450 people are HIV positive without knowing it. The Government and local services must do everything that they can to bring the number down, and I am determined to do what I can to support the NHS at the local level in this task.
My two earlier points are linked, because it is precisely those who are not in what are known as high-risk groups who get diagnosed the latest. Heterosexual men have the worst rates of late diagnosis, at 65%. That is possibly because they are less likely to consider themselves at risk, as we heard earlier, and unlike women they will never be tested in ante-natal settings. It could also be because clinicians may not consider them to be at risk. Heterosexual men over 50 years old have the worst rates of diagnosis; 73% of those not diagnosed until over the age of 50 are diagnosed late.
HIV comes in many shapes and sizes. At 54%, more than half of new diagnoses in 2009 were among heterosexuals, something that surprised me when researching for the debate. At 51%, more than half of HIV-diagnosed individuals accessing HIV care in 2009 were infected through heterosexual sex. The proportion of heterosexual diagnoses in which people are believed to have been infected in the UK has risen year on year throughout the epidemic. From 2003 to 2007, it doubled from 12% to 24%, and it continues to rise. It is now about 32%. The over-50s represent one in five of all adults seen for HIV care in 2009. That is due to an ageing cohort of people diagnosed previously, as well as an increase in new diagnoses among older people.
I dwell for a moment on the growing cohort of people of more than 50 years of age that live with HIV. This cohort will be bringing new needs to the NHS, and it should be ready for them. As people get older, they see more of their GPs. Many older people living with HIV suffer side effects from treatment; overall, they report twice as many other long-term non-HIV conditions as their non-HIV positive peers. As a consequence, they need to spend more time in health care, including primary health-care settings, than their peers. That makes their relationship with non-HIV specialist doctors almost as important as their relationship with HIV doctors.
The Terrence Higgins Trust surveyed about 400 people aged over 50. It found that
"respondents repeatedly told stories of discrimination, ignorance and poor clinical treatment in generalist healthcare, particularly in primary settings."
The survey concluded that there was important work to be done to address HIV discrimination in primary care settings, as doctors there may not be so familiar with people who have the virus.
In Hove and in Brighton, we have some of the most HIV-aware clinicians in the country, and our specialists
are among the best in the world. However, we must not be complacent, as parts of the NHS in our area will be less HIV-aware, as we heard earlier. I urge the Minister to work with her colleagues, the all-party group on HIV and AIDS and charities such as the Terrence Higgins Trust to tackle the problem. Training for GPs and surgery staff could be one way to do so.
Medical care is not the only service needed by older people. In the same Terrence Higgins survey, fewer than one in 12 older people with HIV said that they would approach a mainstream organisation for older people for support. Age UK and the Terrence Higgins Trust are working to change attitudes and to improve understanding of HIV in mainstream social care and social networks for older people. Again, I hope that the Minister will listen to the views of people living with HIV. as her Department moves to create a social care system fit for the 21st century.
I turn next to late and undiagnosed HIV. Of all adults diagnosed with HIV in 2009, 52% were diagnosed late, when their CD4 count dropped below 350. People with the worst rates of late diagnosis are over the 50s. Recent research suggests that the majority of those people will have had previous contact with their doctors. Late diagnosis, whatever the age, is a problem; if treatment is not started promptly, it can do serious damage to the body and severely cut life expectancy.
HIV treatment is excellent, and if diagnosed promptly, one can live to an old age. It is not right that some of my constituents will not have this opportunity by being diagnosed too late to benefit from it. It even makes financial sense to treat people early; it is much cheaper to have people someone stable on HIV treatment than it is to treat them for the endlessly recurring serious conditions that can result from undiagnosed HIV. HIV treatment also reduces viral load; as a result, those who are diagnosed and on treatment are less likely to pass on the virus.
Now is the time, while we are focusing on public health and while we are worrying about public finances, to take action to tackle late diagnosis and undiagnosed HIV. I am proud to say that people in Brighton and Hove are not sitting back waiting for someone to come up with a solution but are already working hard to tackle the problem. There have been two pilot studies in our area looking into ways of reducing undiagnosed HIV, using clinicians in the area. Of 596 people tested, only two positives were found. However, even more people were identified through an anonymous survey done by the university of Brighton. I urge as many people as possible to be tested, because of the 3,872 anonymous tests 54 were positive.
My constituency is proof that HIV can affect anybody, whatever their background, age or sexuality. As more people with HIV grow to old age, we must ensure that they receive services of which we can be proud. Such services should include prompt diagnosis.
3.6 pm
Ian Austin (Dudley North) (Lab):
I am delighted to take part in this debate. First, it gives me the opportunity to congratulate my hon. Friend the Member for Inverclyde (David Cairns) not only on securing the debate but on the important work that he does in chairing the all-party group on HIV and AIDS. Secondly, it gives me the
opportunity to recommend to the Minister the work of Summit House Support. It is a fantastic charity, led by its chair Claire Pennell and its chief executive Suzanne Callen; for the last 18 years, the organisation has provided phenomenal services and support for people with HIV and AIDS in Dudley and Sandwell.
Thirdly, it gives me the opportunity to thank the Minister and her Department for the support that Summit House receives from the Department of Health through the Dudley and Sandwell primary care trusts. Finally, it gives me the opportunity to raise a number of points that I know are of interest to the staff at Summit House Support and those who work in the field.
I am delighted that the Secretary of State for Communities and Local Government has written to local authorities promising to increase spending on AIDS support over the next 10 years-I understand by £10.5 million. Is the Minister able to tell us how organisations in the HIV sector such as Summit House Support can safeguard the way in which local authorities decide to spend their grants? Will there be criteria for allocation, a needs assessment or some sort of ring-fencing process that considers the real needs of those with HIV? We have heard that is often a hidden group, so it needs to be done through specialist agencies, and it is fair to say that some of those working in the field are extremely concerned that money could be sidelined for other uses by local authorities if things are not monitored correctly.
As my hon. Friend the Member for Inverclyde said, people living with HIV are worried about the GP commissioning proposals now being considered. HIV is clearly a specialist area, and GPs historically have not had much interaction with those who have to live with it. In some cases, there is not the relationship of trust that should exist. Many people living with HIV are genuinely frightened or concerned about the proposals.
The current sexual health strategy will end shortly. What plans do the Government have to write a new strategy, given that the sexual health agenda has changed since 2004? Has the Minister also considered the extent to which NHS employees are routinely trained in HIV routes of transmission? I understand from the service users I met at Summit house that staff who have received such training and who understand the facts about transmission and infection are likely to be able to deal with people infected with HIV more effectively than those who have not had such training. Does the Minister think that training in HIV routes of transmission should be incorporated into employees' standard training if is not already part of it?
Finally, would the Minister be prepared to visit Dudley to see first hand the fantastic work done at Summit house? If her diary does not allow her to do that, would she be prepared to let me bring people from Summit house to meet her in London?
3.10 pm
Stuart Andrew (Pudsey) (Con): May I say what a pleasure it is to serve under your chairmanship, Mr Leigh? I congratulate the hon. Member for Inverclyde (David Cairns). I am rather reassured that, after seven years, he does not know how these debates are chosen, because I certainly do not have a clue after seven months.
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