“it is absolutely clear that all the ingenuity and skill that we have brought to cushioning vulnerable people as far as possible from the effects of the economic circumstances cannot be stretched any further, and that some of the people we have responsibilities for may be affected by serious reductions in service—with more in the pipeline over the next two years.”

Unfortunately, excellent though our local hospital is, we are facing a situation where 1,000 people will lose their care packages this year, and I am very concerned about that.

Jim Shannon: The Francis report makes some recommendations on mental health, which is in the social care category. One of those suggestions was the training of family members to look after those with mental health conditions better at home, so as to improve their quality of life and help rehabilitate them. I do not see much of that in the report. Would the hon. Lady like there to be more emphasis on family members who are under pressure and are helping others with mental health conditions at home?

Barbara Keeley: Indeed, and our most recent inquiries in the Health Committee are about mental health issues. There is a series of issues that need to be looked at. It is rare in a health debate for me not to mention carers. We need to be realistic about the fact that we are now putting a huge amount of pressure on those carers. Removing social care packages will affect our local hospital, but it will also affect those family members, because in the end who is the person who cares? It is the family member to whom the role falls.

To conclude the point about staffing issues in A and E, we found in our earlier inquiry that fewer than one in five emergency departments were able to provide consultant cover for 16 hours a day during the working week, and the figure is lower at weekends. The whole issue of mortality rates is very much linked to that, and we cannot ignore it. We must keep focusing on the problem with recruitment and the lack of consultant cover.

My right hon. Friend the shadow Health Secretary referred to the warnings by the president of the College of Emergency Medicine. During the time when the college was warning about these issues, Ministers were tied up in knots by the challenges of reorganisation. That is key. Ministers have insisted that they are acting now, but it is clear that those warnings from the CEM in 2010 did not get enough attention until recently. The staffing situation can hardly improve when so few higher trainee posts in emergency medicine are being filled. In the latest recruitment round, 156 out of 193 higher trainee emergency medicine posts went unfilled.

My final point is about the difficulties caused by the cost of the NHS reorganisation reforms. In the past few months the spotlight has fallen on unnecessary spending

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and waste. We all should be concerned about that. We know that emergency departments are spending £120 million a year on locums, and this could be getting worse. The Health Committee has also recently focused on redundancy costs, which have absorbed £1.4 billion of NHS funding since 2010, with £435 million attributed just to restructuring costs. The scandal of the scale of redundancy payments to NHS staff was made worse when we found out that such a revolving door was in operation. The Health Committee was told that of 19,100 people made redundant by the NHS, 3,200 were subsequently rehired by the NHS, including 2,500 rehired within a year and more than 400 rehired within 28 days. There were reports of payments of £605,000 made to an NHS executive whose husband also received a £345,000 pay-off, with both reported to have been subsequently rehired elsewhere in the NHS. That is a scandal. I know that the Minister said it would not happen again, but that is £1 million that could have been spent on patient care.

The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter): Will the hon. Lady give way?

Barbara Keeley: I would prefer not to. That money could and should have been spent on improving staffing, particularly nursing staffing. Those patients and family members who have been let down by NHS failures, of which we have heard innumerable examples, deserve to know that everything possible is being done to avoid such failures in future.

Of all the things I have talked about, safe staffing is crucial, as is transparency and staffing ratios. We increasingly have to take on board the fact that there is a funding gap in both the NHS and social care. Indeed, the chair of the British Medical Association said in his new year statement that the funding gap in the NHS is so bad that if the NHS was a country, it would not have even have a credit rating. That is what we are facing.

Alun Cairns: Will the hon. Lady give way?

Barbara Keeley: No, I do not have time.

Given that situation, we have to learn that precious NHS resources cannot be wasted on reorganisation and redundancies any more, particularly where staff are being rehired. The NHS will reach its 70th birthday in 2018, so let us hope that all the measures we are talking about today, and the implementation of whole-person care under a Labour Government, will help it be in better shape.

4.21 pm

Alun Cairns (Vale of Glamorgan) (Con): Thank you for calling me to contribute to this debate, Mr Speaker. I am sorry that the shadow Health Secretary is not in his place. After repeatedly refusing to take any interventions from me during his lengthy speech, he said that I would have time to make my contribution later, and I wish he was here to hear it, because I will be referring to him and seeking his help and support.

I approach this debate with mixed emotions. I am extremely sorry about the need for the Francis report in the first instance and believe that there remain serious questions about why there was such a long delay before a thorough investigation took place into the lack of care and the misconduct at Mid Staffs. I pay particular

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tribute to my hon. Friend the Member for Stafford (Jeremy Lefroy) for his contribution earlier and for the role he has played in pursuing this matter right through to the end, and to my hon. Friend the Member for Stone (Mr Cash) for his contribution and for raising this matter from the outset. My heart goes out to those who suffered needlessly and to their families who campaigned for so long. It is also worth remembering that for every one person who went public and put their head above the parapet, there are probably tens who stayed quiet and are probably still silent on issues that will have affronted them.

On a positive note, I am pleased about the progress made over the past 12 months. I am also pleased about the strong action has been taken by the previous Health Secretary and by this one, and about the leadership and determination that the Prime Minister showed at the outset in 2010 in seeking to root out the issues. The present Health Secretary has taken direct action to ensure: that nursing numbers are published; that there is data transparency; that details on surgery outcomes by consultant will be available for inspection; and that named consultants will be available for older patients. Those positive interventions will make a significant difference and will go a long way to preventing any recurrence.

Ultimately, the staff involved deserve the credit for the change, but the Health Secretary has been key to being the patients’ champion. A culture has developed where we can rightly champion the NHS and can even question it. We have now come to a point where we can criticise the NHS without being seen as undermining it. All of the best organisations welcome feedback, particularly negative feedback, because it gives the best chance of putting problems right to prevent any recurrence.However, my mixed emotions are far more complex than that. As I see changes and improvements taking place in England, I remain concerned about what is happening to the national health service in Wales and the impact that that is having on my constituents. It is quite obvious from this debate that the concerns that have been raised are shared by Members on both sides of the House, which is something that we should view positively. However, I am not so sure that those concerns are shared in all quarters, especially by Members on the Labour Front Bench. Again, I must pay tribute to the right hon. Member for Cynon Valley (Ann Clwyd) for her determination and persistence in rooting out these issues wherever they occur—be it in Wales, Scotland, Northern Ireland or England.

It is fair to say that political points can be made about the cuts to the NHS budget in Wales, but I fear that the situation is even more serious and dangerous than that. Any criticism of the NHS in Wales is now dismissed as party political or politically motivated. It is the identical culture that existed at the time of the Mid Staffordshire crisis.

Only two weeks ago, my hon. Friend the Member for Bristol North West (Charlotte Leslie) discovered that Professor Sir Bruce Keogh, the NHS medical director in England, had last November written to his counterpart in Wales, Dr Chris Jones, raising concerns about the mortality rates at some Welsh hospitals—at six in particular. It has now come to light that that action was prompted by the right hon. Member for Cynon Valley. In the e-mail, Professor Keogh, who had investigated 14 hospitals in England for the same reason, offered his assistance. I

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have a copy of his letter here. It was not a criticism; it merely questioned the data and offered help should there be any need for further investigation.

There was no response from Dr Jones, which is worrying in itself. Most alarming, however, was the response from the Welsh Health Minister when the matter became public. Mark Drakeford rightly pointed out that simple comparisons cannot be made because of the different ways in which data are collected. However, in response to calls for an inquiry, he said that he was “coldly furious” and that it was

“a concerted political attempt by the Conservative Party to drag the Welsh NHS through the mud.”

He even had the audacity to accuse the NHS in England of being in crisis. He clearly felt that attack was the best form of defence. What worries me most is the blatant rebuttal without wider consideration. The politics appear to be more important than the patients. This was a letter from one clinician to another, yet it was a politician using every political tactic possible to undermine its contents.

A pragmatic approach would have been to point out the differences in the collection of the data and to have reassured patients. I suspect that the reality was that the Welsh Health Minister was responding in the full knowledge of all the other statistics on the NHS in Wales, such as those on waiting times and diagnostic delays, which could well contribute to higher mortality rates. Again, a pragmatic approach would have been to announce an investigation, or at least to seek out the root causes of the apparent high mortality rate according to the way in which the data were collected.

It is ironic that the Welsh Health Minister has today announced a change in the way the data are collected. Obviously, that is some shift, but I note that it has come out only after the political games had taken place. It is two weeks since my constituents were alarmed by the accusations that I had dragged the Welsh NHS through the mud.

In researching for this debate, I looked at recent cases that have become public in the NHS in Wales. There are troubling similarities with those that led to the Francis report. Lilian Hopkins received treatment from a local health board that treats patients from my constituency. For several days, a sign was left above her bed that said “Nil by mouth”. That left Mrs Hopkins too weak to lift a glass of water. Her prosthetic limb was not removed for two weeks, when she was left in bed for that time. Screams of pain at night were treated with sedation. At an earlier date, her family had asked for an investigation. It was promised, but not conducted. Three nurses have been arrested for falsifying records.

This is the same local health board where the police are investigating the circumstances surrounding a man who waited four hours in an ambulance outside the hospital, only to die at the same A and E department some hours later. The right hon. Member for Cynon Valley has listed several examples that I could refer to, but these are examples that I have picked up in the past couple of weeks.

The Royal College of Surgeons published a report last July that claimed that 152 patients have died over the past five years while waiting for cardiac surgery across two local health boards alone in Wales. The royal college also stated in its report that 2,000 cardiac operations were either cancelled or not scheduled between January

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and March last year. The report says that south Wales is the only part of the UK where patients are regularly dying on cardiac surgery waiting lists. It says that the provision of urgent and emergency surgery is simply inadequate.

I should like to be able to report that the situation has improved since the publication of that report last July, but it has not. Some patients are now being sent across the border to England to be treated in the independent sector, which strikes me as emergency action; instead, attempts should be made to identify the culture and issues that potentially parallel the Mid Staffordshire crisis.

I could point to lots of data, but I shall pick up just a few of the differences between Wales and England. Urgent cancer waiting times have not been met in Wales for the past five years. On average response times, in Wales 58% of patients are seen within eight minutes in category A calls. In England, the figure is 72%. One of the most worrying statistics, which Professor Sir Bruce Keogh particularly identified, relates to diagnostic services. In his e-mail, he pointed to the statistic that in Wales 26,000 patients are waiting more than eight weeks for diagnostic services. In England, 9,000 patients are waiting longer than six weeks. We need to bear in mind the difference between the populations: 3 million people in Wales and 50 million in England, yet 26,000 people are waiting for diagnostic services in Wales and 9,000 waiting in England. The statistics speak for themselves.

Peter Watkin Jones, a lawyer involved with the Mid Staffs inquiry, has said that a culture change is needed in the NHS in Wales. Having heard the shadow Health Secretary’s contribution, I do not think he recognises that. Again, I was sorry he felt that attack was the best form of defence. The right hon. Member for Cynon Valley has said that high mortality rates are a smoke signal indicating that something is wrong. The Royal College of Nursing has said that its members do not always have time for training and staff development in Welsh hospitals.

If the right hon. Member for Leigh (Andy Burnham) genuinely wants the lessons of Mid Staffs to be learned, if he wants to ensure that patients in Wales do not have to suffer the same indignity and if he wants to play a positive role in informing health care across the UK, I ask him to agree to make every effort to influence his colleagues in Wales to respond positively to the questions that are being asked, to put party politics aside and to introduce an effective inquiry for the sake of my constituents and those across the whole of Wales; otherwise, everything that he has said today will simply be hollow.

4.35 pm

Kevin Barron (Rother Valley) (Lab): I reread the executive summary of the Francis report yesterday when I was on a train journey, and I decided that in today’s debate I would like to look at one of the most crucial aspects of his findings in respect of what happened at Mid Staffs.

On page 62, at paragraph 1.102, the summary states:

“The senior officials in the DH have accepted it has responsibility for the stewardship of the NHS and in that sense that it bears some responsibility for the failure of the healthcare system to detect and prevent the deficiencies at Mid Staffordshire sooner

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than it did. There is no doubt about the authenticity of their expressions of shock at the appalling story that has emerged from Mid Staffordshire. However, it is not possible to avoid the impression that it lacks a sufficient unifying theme and direction, with regard to patient safety, to move forward from this point in spite of the recent reforms put in place by the current Government.”

It goes on to say:

“Where there are perceived deficiencies, it is tempting to change the system rather than to analyse what needs to change, whether it be leadership, personnel, a definition of standards or, most importantly, culture. System or structural change is not only destabilising but it can be counterproductive in giving the appearance of addressing concerns rapidly while in fact doing nothing about the really difficult issues which will require long-term consistent management. While the DH asserted the importance of quality of care and patient safety in its documentation and its policies, it failed to recognise that the structural reorganisations imposed upon trusts, PCTs and SHAs implementing such policy have on occasion made such a focus very difficult in practice.”

It is my contention that we could probably say that of every reorganisation of the NHS, certainly in my three decades in politics.

The summary goes on to discuss the lessons learned and related key recommendations:

“The negative aspects of culture in the system were identified as including: a lack of openness to criticism; a lack of consideration for patients; defensiveness; looking inwards not outwards; secrecy; misplaced assumptions about the judgements and actions of others; an acceptance of poor standards; a failure to put the patient first in everything that is done.”

It goes on:

“It cannot be suggested that all these characteristics are present everywhere in the system all of the time, far from it, but their existence anywhere means that there is an insufficiently shared positive culture.”

Again, it is my contention that that sums up not just the past 30 years but perhaps the past 60 years of our national health service.

The summary goes on to say that achieving change

“does not require radical reorganisation but re-emphasis of what is truly important”.

All parties in the House should recognise that it is not the reorganisation but the re-emphasis of what is important that is significant. Paragraph 1.119 lists how that can be achieved:

“Emphasis on and commitment to common values throughout the system by all within it; readily accessible fundamental standards and means of compliance; no tolerance of non compliance and the rigorous policing of fundamental standards; openness, transparency and candour in all the system’s business; strong leadership in nursing and other professional values; strong support for leadership roles; a level playing field for accountability; information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation.”

I was not surprised by any of that.

The right hon. Member for Sutton and Cheam (Paul Burstow) was a member of the Select Committee on Health in the previous Parliament between 2005 and 2010, and I had the privilege of chairing that Committee. In 2009 the Committee looked at patient safety in the NHS. We visited one of only four hospitals that were part of a patient safety project on how to look after patients inside hospitals, never mind outside. We looked at some of the major issues at the time, such as how different parts of the NHS interacted and their failure to communicate with one another properly. Much of the time they were working with different regulations, and occasionally the inspectorate was not sure what it

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was responsible for inspecting. This whole restructuring has been going on for a very long time, and it has been more confusing to people working inside.

I am pleased with how the Government have reacted to some of the Francis report’s main recommendations, but I take issue with them on one point. If we are to change the culture inside the NHS, we really need to look at the duty of candour. The Government have accepted the report’s recommendation on a duty of candour for organisations, but they have rejected the recommendation to extend that duty to individuals. I think that is fundamentally wrong.

I spent nine years as a lay member of the General Medical Council, which regulates doctors, and for the first few years I would sit on fitness-to-practise committees. I think that the only way we shall get change is if individuals have responsibility for the duty of candour, not just organisations. I believe that the Government have got that fundamentally wrong. If they really want to tackle the issues that led to the awful situation at Mid Staffs, they need that duty of candour to extend to individuals.

On the Government’s decision on the duty of candour, the Patients Association has stated:

“We question that if individuals are not already motivated by their own professional code, how will a duty on their employer encourage them to come forward?”

That is absolutely right. It continued:

“Without this fundamental change within the NHS, the Duty will just be providing lip service to the issue of patient safety and patients will struggle to see any real improvements.”

That is a big assumption, but on balance I agree. It is something that the Government, no matter who is in Richmond House, need to tackle throughout the NHS.

I have in my hand a copy of the Health Committee’s report on patient safety, which was published in July 2009. We looked at patient safety across the health care system and compared it with what was happening abroad. We visited New Zealand, which has a comparable health system—I accept that the country has only 4 million occupants, compared with our 60-odd million. We looked at why the culture here is the way it is, why people are not open and why they do not learn from mistakes that other health professionals have made. Often those mistakes are not reported because people fear they will get into trouble. We took evidence from the British Airline Pilots Association and learned that any mistake a pilot makes in an aeroplane is whizzed around the world so that other pilots understand it and learn the lessons immediately. That is not the case in our health service.

I want to mention two of the Committee’s findings from New Zealand. The first relates to investigating complaints. I do not think that leaving the duty of candour to organisations, as the Government suggest, will work well. New Zealand has a statutory body—I have mentioned it before in the House—called the Health and Disability Commissioner, which resolves complaints. People can go to the commissioner to request investigations, and they can do so anonymously if they do not want their colleagues to know about it. It is completely independent of the health care system. It works, and it has been working for many decades.

Another area we looked at in New Zealand—again, I accept that it is a very small country—was compensation and redress. I know from my experience of 30 years in Parliament that when people complain about something

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that happened to them in their local hospital that they are unhappy about, they are treated as if they are going to get into litigation and that it will cost a lot of money; immediately the barriers come up. That culture is not good for our health service, it is costing massive amounts of money for us as taxpayers, and it is certainly not good for the individual concerned. I do not know how many times I have been told that all the patient wanted was an admission that the hospital got it wrong and an apology; they did not necessarily want money. New Zealand has a redress system that some might call a no-fault liability system. Here, it would mean getting rid of lots of lawyers who make massive amounts of money and careers from public money for NHS litigation. Just those two areas hold back changing what is wrong in our system.

Barbara Keeley: I wonder whether my right hon. Friend has had similar cases to a difficult one that I had for months involving someone whose wife died in terrible circumstances at home. He was badly let down by the care she received and he wanted redress. He found that people were happy to have meetings with him and to talk to him, and were sympathetic and supportive, but whenever something was put in writing, it was absolutely dreadful. He was very offended and horrified by everything that was in writing, and that is the chilling effect of lawyers because they checked everything. It ruins the support that can be given after a difficult bereavement and when someone has a real case. Things can be said, but they cannot be written down.

Kevin Barron: I agree entirely. The system is defensive and people do not get a satisfactory response, but the lessons are not learned. Issues are not reported for fear of the consequences. The Minister is a doctor. He will know that if as a junior doctor he had seen a senior doctor doing something wrong and had gone public about it, it might have affected his career. Some young doctors’ careers have been affected. That is not good for the system, and it is certainly not good for patients.

I am a wholehearted supporter of the national health service and the way it is funded. There is none better in the world, and we can use it without question. It may be different in different parts of the country, but access to health care in this country is second to none in the world for the whole population as opposed to just those with money. Could it better? Yes, and what the Francis report said was a lesson for all of us, and for the national health service. We should change the culture, but we will not do that with reorganisation or by blaming one another in the Chamber for what is right or wrong. That just feeds the politics of the national health service. We must change the culture by putting the patient first, and after 60-odd years it is about time we did.

4.47 pm

Sir Tony Baldry (Banbury) (Con): It is a great pleasure to follow the right hon. Member for Rother Valley (Kevin Barron) who has chaired the Select Committee on Health and who made some extremely important points about accountability. This has been an interesting debate, much of which has focused—understandably, given its title—on what is happening in Staffordshire a year on from the Francis report into Mid Staffs trust. It is also understandable that considerable cross-party

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concerns have been raised about the NHS in Wales. The Francis report applied to the whole of England, and I want to make some observations as a non-Staffordshire Member of Parliament who has benefited from it.

Much has happened during the last year—for example, the appointment of Stuart Rose, former head of Marks & Spencer, to advise the Government on leadership. His brief is to explore how the 14 NHS trusts placed in special measures can be helped to tackle concerns about their performance. David Dalton, chief executive of the Salford Royal NHS Foundation Trust, is exploring how NHS providers can collaborate in networks or chains, effectively building on an initiative last autumn in which high-performing NHS hospitals were invited by the Secretary of State to provide support for hospitals placed in special measures.

I suspect that much remains to be done to tackle relational aspects of care, including ensuring that patients are treated with dignity and respect and are able to communicate effectively with doctors and other staff. Indeed, the NHS as a whole, including GPs, will probably need to do a lot more in future to support patients to manage their own health and well-being and involve them as partners in care. Sir David Nicholson, the head of NHS England, who retires shortly, has described this concept as “the empowered patient”—in essence, the need for us all to get better at managing our own health problems to reduce the burden on hospitals.

Everyone has had to learn lessons as a consequence of the Francis inquiry, but it is not appropriate or, indeed, fair, continually to castigate those working in the NHS, whether they be nursing staff or managers. On the contrary, we need to ensure that NHS staff are supported to do the job for which they have been trained. Not unreasonably, as in other aspects of life, there will be a close correlation between staff experience and patient experience. Patients receive better care when it is given by staff working in teams that are well led and where staff consider that they have the time and resources to care to the best of their abilities. One reason ward sisters have always been so highly valued is that they are an extremely good example of team leaders, as experienced nurses who have developed, and are able to pass on, a culture in which patients are treated with dignity and respect, and who motivate their colleagues to do the same.

If we are to have an NHS fit for the 21st century, we need continually to attract talent into it. We will not do that if people consider that those working in the NHS are all too often set up to fail. We also need to improve efforts to attract clinicians into leadership roles, as advocated by Roy Griffiths way back in 1983. As a senior and much-respected clinician and physician, Sir Jonathan Michael has been able to achieve as chief executive of Oxford University Hospitals NHS Trust much that I suspect could not have been achieved by a chief executive who was not a clinician. We should value the role of managers in the NHS instead of constantly criticising them. Successful leadership in the NHS needs to be collective and distributed rather than residing in just a few people at the top of NHS organisations. The involvement of doctors, nurses and other clinicians in leadership roles is essential.

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The NHS is an organisation that is constantly evolving. The NHS of today is very different from the NHS of 30 years ago, when my father retired as a consultant physician, and the NHS of 30 years ago was very different from the NHS on the day that it began. Both my parents worked in the hospital service on day one of the NHS, my father as a young registrar and my mother as a theatre sister. There is a danger that our perceptions of the NHS, and of what hospitals should look like, become frozen in time, with James Robertson Justice as a snapshot of hospital care. The type and nature of illnesses that hospitals are having to treat changes over the years; so too, therefore, does the hospital layout. I recollect that my father had four Nightingale wards, two male, two female, with 15 beds along each wall and 30 beds to a ward, filled almost entirely with patients dying from lung cancer. Lung cancer is still a killer, but not in anything like the numbers then. We need to recognise that hospitals are changing. In that regard, I very much welcome the work of the Royal College of Physicians through its future hospital commission—an initiative that has not received anything like the publicity and debate that it merits.

The current pattern of acute care is based on the model of district general hospitals providing comprehensive emergency and elective services for relatively small populations—a model developed back in the 1970s. A whole number of factors are changing that model. For example, advances in medical technology mean that it is now possible to treat many patients much more speedily and less invasively. Hysterectomies that might previously have involved a woman patient remaining in hospital for up to 10 days can now be performed through keyhole surgery involving a much shorter stay. There is clear evidence from the Royal College of Surgeons that specialisation can achieve better outcomes. Indeed, the concept of the general surgeon, or surgeon specialising in general medicine, is now pretty much obsolete. Almost all surgeons practising in the NHS today specialise, to the benefit of their patients, in surgery on a particular part of the anatomy.

On the other side of the equation, there are significant demographic changes, resulting in increasing numbers of elderly people. The elderly population is set to expand exponentially as we post-war babies, with much longer average life expectancies than our grandparents, start to reach our 70s and 80s. Many more frail elderly people have long-term medical conditions and an increasing number of people have multiple long-term conditions and—that terrible word—comorbidities.

I therefore very much support the 11 core principles of the Royal College of Physicians’ “Future hospital” report. We need to ensure that NHS patients are at the centre of care—what Robert Francis described as a “patient-centred culture”. We need to ensure that the NHS provides a seven-day-a-week service and that hospital trusts have a 24/7 approach. It is clearly unacceptable that mortality rates are significantly higher for patients admitted into hospitals at the weekend. GP out-of-hours services need to be improved and co-located, and hospital emergency departments need to integrate the urgent care pathway.

At the Horton general hospital in my constituency, an emergency medical unit is being developed to help strengthen the A and E unit and its rapid medical assessment capabilities and to try to ensure that people

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go to A and E only if they really need to. The links between generalist and specialist pathways are being strengthened, but I suspect that the 24/7 approach will lead to some reconfiguration of services, although that should not necessarily mean that they will become more remote. For example, Horton hospital now has a daily fracture clinic throughout the week and a renal dialysis unit, because it makes more sense for those services to be delivered there. However, emergency abdominal surgery is now carried out at the John Radcliffe hospital in Oxford.

In all of this, we need to remember that whoever is in government, and whichever political party or combination of parties is running the country, we need collectively to face the Nicholson challenge of saving significant amounts of money in the running of the NHS. If we cannot manage the Nicholson challenge, the NHS simply will face a black hole in funding and will fall, more or less, into managed decline.

Indeed, in a recent press report, Sir David Nicholson is reported as predicting that, if the NHS does not pursue a number of reforms, including enhanced primary care, more GPs and more specialisms, it faces

“a £30 billion hole in funding by 2021”,

which is certainly within the political life expectancy of many of us in this House. He also observed, rightly, that

“the NHS is not frozen in aspic for us to worship as some great thing—it will decline and it will die if we don’t recognise the choices that are available to us now”.

Over the past year, following the publication of the Francis report, there has been considerable progress, including towards greater openness and transparency in the health service, including the implementation of a new statutory duty of candour. England now leads the world in transparency and openness about surgeons’ clinical outcomes, so patients can access their surgeons’ outcomes for particular procedures or operations, such as hip replacement. There has been considerable improvement in the Care Quality Commission’s inspection model, the Government have ensured that a named consultant is in charge of someone’s care throughout a hospital stay, and there is clear recognition that the NHS needs to provide a seven-day-a-week service.

We need to move forward with a health service that puts patients at the centre of care. A number of years ago, nursing was made increasingly a graduate profession, but whether one is a graduate doctor or a graduate nurse, patients still need tender loving care. I do not think that my mother, when she was a ward sister, was ever too proud—or considered it not to be part of her role, if necessary—to ensure that patients were comfortable in bed, to give them a bed bath, to make sure that they were eating properly or, if they should die, to ensure that they were laid out with dignity and care.

There have been concerns about health care support workers and we should welcome the recent review by Camilla Cavendish, which has made a number of recommendations on the training of and support given to health care assistants and how that can be improved. Health care assistants do extremely valuable work in hospital. They should be valued and properly regulated.

Last Friday I attended an open day for care workers, which was organised by Oxfordshire county council because, given the ageing population, we are going to need many more health care workers in hospitals and nursing homes and to give domiciliary support.

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We have yet to see the full benefits of commissioning and the extent to which commissioners can help improve and monitor the quality of NHS care. One thing that has interested me in this debate is the issue about who actually runs the NHS, because I assumed that once we had commissioning bodies, they would drive where the money was spent. We have also yet to see the full benefits of the new governance arrangements in the NHS, and of ensuring more joined-up working between the NHS and other providers, such as through health and wellbeing boards. Healthwatch Oxfordshire is certainly still getting into its stride as an organisation.

I hope that the House will have an opportunity, in a Back-Bench business or Westminster Hall debate, to discuss the Royal College of Physicians report on the future hospital programme. It is in the process of establishing development sites, which will implement and further develop the recommendations made in its report. I certainly hope that it will consider the Horton general hospital as one of those development sites, not only as one of the smaller general hospitals in the country, but as a hospital that serves a large geographical catchment area.

As Chris Ham, the chief executive of the King’s Fund has observed, high-performing health care organisations

“benefit from continuity of leadership, organisational stability, and consistency of purpose”.

I suspect that, having learned the lessons of Mid Staffordshire, we now need to concentrate on ensuring that there is continuity of leadership, organisational stability and consistency of purpose in the NHS.

5.1 pm

Mike Kane (Wythenshawe and Sale East) (Lab): Aneurin Bevan’s father died in his arms from coal dust disease, and that drove his passion to establish the NHS when he came into government in 1948. We could put a major fault line down the middle of the Chamber between the two sides in this debate, but we could take away one win if we agreed on one thing underlying the Francis report—the development of a common patient-centred culture.

The Prime Minister mentioned Aneurin Bevan in Prime Minister’s questions today, trying to assume his mantle as the guardian of the national health service, but I assure the House that the right hon. Member for Witney (Mr Cameron) is no Nye Bevan.

Bevan’s “In Place of Fear” clearly set out the principle on which the NHS was founded. It is sometimes worth going back to such principles, as well as looking at its vision for the future. The principle was that

“no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means.”

People died in Mid Staffordshire because of lack of means. I compliment the hon. Member for Stafford (Jeremy Lefroy) on an absolutely excellent speech, and on the care and compassion he has shown his constituents during the past few years.

I agree with the Secretary of State that much of the debate is about leadership. I welcome the fact that we will develop more leaders, because leadership in hospitals is a key way forward. I worked in education for many years and I know that, like schools, hospitals reflect the nature and ethos of their leaders. The more leaders we can create, the better the health service we can create.

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However, I also agree with my right hon. Friend the shadow Health Secretary. Bevan’s principle in “In Place of Fear” was that no person would be denied medical aid by lack of means in a civilised society, but because of the top-down reorganisation that we currently face, we are in fear. It is no coincidence that several Greater Manchester MPs are in the Chamber for today’s debate, because we are worried about the strategic leadership of Healthier Together, the organisation overseeing the changes in health care across Greater Manchester. Such top-down reorganisation is creating fear. It has sucked £3 billion out of NHS front-line services and in my opinion—I am not talking about winter pressures—it is putting patient care at risk, which is ultimately what the Francis report is all about.

That is no more apparent than in my constituency of Wythenshawe and Sale East. We knocked on 17,000 doors during the short space of a few weeks last month, and the single biggest issue raised was health care, particularly health care at Wythenshawe hospital. First, I want to praise the staff at the hospital, from top to bottom, and the service that they provide. I was born there and I had a minor medical procedure on my toe there recently. The staff were excellent, from top to bottom.

As my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) said, the reorganisation downgraded the accident and emergency facility at Trafford. That decision might have been right or wrong, but because of the rushed nature of the reorganisation and the fact that it was top-down, not bottom-up, it led to a lack of capacity at the neighbouring hospital at Wythenshawe. My right hon. Friend the Member for Leigh opened the Wythenshawe walk-in centre a year or two ago. That has been shut and the services have been transferred to Wythenshawe hospital.

What is happening to Trafford general hospital really grates on me, even though it is not in my constituency, because it was the first NHS hospital. It was opened by Bevan on 5 July 1948. He handed over the keys to the hospital.

The reorganisation has led to Wythenshawe hospital having to take the strain. It is failing the Government’s guideline of treating 90% of A and E patients within four hours. The chief executive of the University Hospital of South Manchester NHS Foundation Trust, which runs the hospital, said that the increased day-to-day admissions meant that 22 extra beds were required. That is a whole ward. To add to the organisational chaos that the top-down reorganisation has created, the hospital is now being investigated by Monitor, the Government regulator. It is almost a self-fulfilling prophesy.

To provide the extra accident and emergency space that is needed, surgical wards are being used. That has led to the cancellation of dozens of operations. At the last count, about 80 operations had been cancelled. The situation has led to nearly 1,000 ambulances having to queue down Southmoor road, which is just outside Wythenshawe hospital, this winter.

In the short week and a half that I have attended this Chamber, I have seen that debates can turn into statistical conventions. However, Members on both sides of the Chamber know—this was made clear by the stories from Mid Staffs—that there are real people in those ambulances and that it is 80 real people who have had

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their operations cancelled at Wythenshawe. It is not only those people who are affected; their families are affected too. Can we legitimately call ourselves civilised, to use Bevan’s words, when sick people are being denied medical aid today? I do not think that we can.

I am grateful for the Secretary of State for agreeing to meet me to discuss Wythenshawe hospital and the A and E emergency. My litmus test will be Bevan’s test. I hope that that will form the basis of my conversation with the Secretary of State. I will press him on that when I meet him.

5.8 pm

Mr Bernard Jenkin (Harwich and North Essex) (Con): I believe that the Francis report is becoming a major turning point in the life of our national health service, which is one of our great institutions and is probably treasured above every other institution that the British people hold dear. The Francis report has moved the NHS from being a rather impenetrable bureaucracy into something that is much more fallible, human and compassionate.

The Francis report highlighted the failings at Mid Staffordshire NHS Foundation Trust and stated that they were very much the result of a failure of leadership. As Francis said:

“The patient voice was not heard or listened to, either by the Trust Board or local organisations which were meant to represent their interests. Complaints were made but often nothing effective was done about them.”

Damningly, he found:

“There is no evidence that the substance of any complaint was ever raised with the Board.”

I shall come back to that point later. He also said:

“Such an approach completely ignored the value of complaints in informing the Board of what was going wrong, and what, if anything, was being done to put it right.”

As Members have been saying, this reflected a culture of denial about failings and complaints not just at Mid Staffs, but across much of the NHS. We know that the problems were wider than this one trust. In a report last year the parliamentary and health service ombudsman, whose office is the responsibility of the Committee that I chair, the Public Administration Select Committee, carried out a survey of 94 trusts from across England and found that only 20% of boards were reviewing learning from complaints and taking resulting action to improve services; less than half were measuring patient satisfaction with the way complaints were handled; and less than two thirds were using a consistent approach to reviewing complaints data. One other finding, from memory, was that only 2% of trusts were considering complaint handling as a strategic issue to consider during a trust board awayday.

Jeremy Lefroy: Will my hon. Friend share his reaction to the news that the parliamentary and health service ombudsman is taking far more seriously complaints brought to her and instigating far more investigations than two or three years ago?

Mr Jenkin: Yes, I welcome that. My Committee works closely with the PHSO, Dame Julie Mellor. I paid a visit to the PHSO’s office in London last week and listened to some of the complaints coming in by telephone. We have a lot to learn from the way she is changing things, but there is a lot we need to do to bring the institution

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of the ombudsman into the 21st century. My Committee is working on a report to be published shortly, which will make recommendations on that.

The role of boards in the leadership of NHS trusts has not been given sufficient attention. Many boards are changing their practices and improving, but the research that we have been given suggests that the chairman of the board of a trust is the most important person in setting the tone of the organisation. We inherited a system where executives took all the decisions and the role of boards was to oversee. No. In the private sector, the chairman of a company, even the non-executive chairman of a company, is the most crucial person for setting the tone, the values and the atmosphere in the organisation. We need to lay much more emphasis on the leadership of trust boards.

The Francis report prompted the NHS, Government and Parliament to question the prevalent management culture in the NHS, and it is the main reason why we are looking not just at the ombudsman, but doing an inquiry into how complaints are handled not just by the NHS, but by Government Departments and across public services. As part of our inquiry we took evidence from Sir David Nicholson, the chief executive of NHS England, and Chris Bostock, head of NHS complaints at the Department of Health.

The ombudsman told us that she found what she called a “toxic cocktail” within some NHS hospitals which combines a reluctance by patients, carers and families to complain, with a defensiveness on the part of hospitals and senior staff to hear and address those concerns. In oral evidence to our inquiry, Sir David accepted that when he said:

“I do think there is a real issue about defensiveness and a lack of transparency in the way that we work”,

and he accepted that complaints are important for learning and improving.

A great deal has been said in this debate about processes, procedures, legal sanctions, rules and accountability, but those are for when things go wrong. What we want in our health service is a culture of listening, understanding, caring, learning and supporting. I shall say a little more about that. Sir David said that the need for openness is not always recognised in the NHS. He went on to say that

“we are publishing lots of data and information and people can connect together through social media and all the rest of it, things are opening out, but the leadership of the NHS…is having difficulty coming to terms with that and”—

a rather nice little understatement—

“is slightly behind it.”

He accepted that that came down to leadership and culture. In a powerful admission from somebody who has been at the heart of the NHS for so long, he said:

“Undoubtedly, in broad terms, the NHS leadership is not equipped to handle some of the big issues that are coming forward, so we need to tackle that leadership. We need to work really hard on the culture of the system overall, because as you are going through that transition the importance of setting the right tone from top to bottom of the organisation is increasingly important…You need to make sure that you are learning the lessons and getting innovation from the system as a whole.”

I am bound to add that, at the end of the session, I asked him about his own leadership. It is a credit to him that he explained that the diagnostic process that NHS leaders go through had been applied to him. He said:

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“What it said about me was that first of all I was strong on the pace-setting. Give me a target and I will make it happen…Secondly, the feedback was that I was good at setting out a vision of what the future might look like. My weaknesses were around facilitating and coaching, and actually they are the issues that in a modern NHS will be much more highly prized than perhaps the last one.”

I know that Sir David Nicholson has come in for an awful lot of stick and criticism, but there was a degree of self-knowledge there, and he expressed much regret in front of our Committee for what he had missed.

Francis recommended changes to the law, and the Government are implementing those recommendations. However, I agree with the Select Committee on Health that enshrining duties and standards of care in statute is simply not enough. In fact, statutory changes are almost irrelevant to the day-to-day life of people working in the NHS. The word we hear often is “culture”, and that is what needs to change and is changing. The key change needs to be to attitudes and behaviour within the NHS, particularly among those in leadership positions, who set the tone of the organisation that they lead. Leadership is central to that—not just the leadership of trusts, but leadership across the organisation at all levels.

The Secretary of State is right to emphasise the importance of compassion in the NHS and the need to support those who are required to show compassion every day. Management need to feel and respect that compassion and reflect it in how they treat their staff, otherwise, as one colleague said to me, patients become objects, not people. The way health care staff feel about their work has a direct impact on the quality of patient care as well as on an organisation’s efficiency and financial performance. If those in the upper tiers of management are not also involved in feeling compassion for the patient, they place too great a burden of compassion on front-line staff. The people on the front line need support from those up the management chain, and compassion has to come from the top.

High-quality, patient-centred care depends on managing staff well, involving them in decisions, listening to what they have to say, developing them and paying attention to the physical and emotional consequences of caring for patients. Funnily enough, that point was made by a commercial witness to the Public Administration Committee’s inquiry into complaint handling, Mark Mullen, the chief executive of First Direct. He told us that

“there is a relationship between how you treat your people and how you ask or expect or want your people to treat their customers…it is virtually impossible to create a positive outcome with customers unless you have created a positive relationship with your own employees.”

I wish to leave the House with that serious thought—how NHS staff feel about their work has a direct impact on the quality of patient care, as well as on efficiency and financial performance. That is what this is about.

I am taking a close interest in the NHS leadership academy, which the Secretary of State referred to. It clearly has a clear role to play, although it is very small at the moment. It deals only with potential trust chief executives—senior leadership in challenging roles. It is early days, and we need to involve the academy with trust boards, trust chairs, the leadership of NHS England and even the Department of Health. The academy must give priority to the values of compassion, openness and transparency, listening to and learning from complaints

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and accepting and learning from failure. It is not about people going off to Harvard, learning how to develop fantastic strategies and coming back with a personal vision that they impose on their organisation. That is not the kind of leadership the NHS needs, and indeed, such leadership does not work in business either. That is true not just for a few leaders, but for every leader of every team in every trust and GP practice in NHS England and the Department of Health. It is a much bigger agenda for the NHS leadership academy than currently envisaged, but we need that ambition if there is to be speedy and permanent change in the culture of the NHS, the attitudes of the people in it, and the way they behave.

There is a great deal of excellent practice in the NHS, as in most large organisations, but it does not seem to be gathered in any systematic way so that learning can be shared. One consequence of that is that there does not seem to be a shared understanding of the kind of leadership that makes excellent practice more likely. Despite the scale and complexity of the health service, there is a common commitment to compassionate, safe, sustainable care among clinicians, managers, trusts, chairs and regulators, which could be the foundation for building a shared understanding of good leadership and practice. None of this will be a quick fix, but many building blocks of good practice are already in place. Gathering that learning together would strengthen and hearten leadership across the NHS. I believe that that is the real role of the NHS leadership academy as it builds its capacity, and I look forward to its developing in the future.

5.21 pm

Sarah Champion (Rotherham) (Lab): I welcome this debate because it has given us an opportunity to reflect, to learn and, hopefully, to not make some of the same mistakes again. I pay tribute to hon. Members who were directly involved with the events surrounding Mid Staffs. Their persistence in protecting their constituents and changing the culture has been remarkable and something we should all learn from. I particularly pay tribute to the hon. Member for Stafford (Jeremy Lefroy) for telling us how the staff at Stafford hospital have learned and are working as hard as they can to make changes, so that they can deliver an excellent service to all their patients.

The Francis report, published a year ago, made stark reading. It exposed the dreadful practices that no one should ever have to endure, with shocking stories of patients left in their own excrement, unfed, and pleading for water. My heart genuinely goes out to patients and their families who suffered such poor treatment at the hands of an NHS that was seemingly driven by apathy, not by quality of care.

One year on, have we learned the lessons that were so hard won? Robert Francis made many recommendations about how the NHS should put patients at the centre of care. He spoke of a structure of fundamental standards and measures of compliance. He discussed openness, transparency and candour throughout the system, all underpinned by statute. He also raised the need to improve support for compassionate, caring and committed nursing. A recent report by the Nuffield Trust reviewed

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the progress made, and there is some good news. Nursing is receiving a significant degree of attention, especially in ensuring fundamental standards of care, and the handling of patient complaints locally has been given renewed attention by the chairs of local clinical commissioning groups.

I think that complaints and compliments are key to improving practice, and like many Members, I use the Sheffield-based social enterprise website, Patient Opinion, which to date has shared 65,000 patient experiences of care and received millions of hits from the NHS, MPs, commissioners and the general public. There is clearly a desire for patients to share their experiences, and an NHS that wants to listen and learn. Is it not worrying, however, that an independent organisation is fulfilling that role? Although I am a huge advocate of Patient Opinion and fully support its work, the voice of patients and accountability should also come from within the NHS, not just outside it. In practice, under this Government patients still have little say in how their health care is commissioned or provided. As my right hon. Friend the Member for Leigh (Andy Burnham) stated, more than £10 million of the £43.5 million allocated to Healthwatch branches is still unaccounted for, so how can Healthwatch fulfil its role?

The Nuffield Trust also identified bad practice. I am saddened to hear that some national bodies have persisted in the behaviours towards hospitals that contributed to the problems identified by the Francis report. That suggests that there is still a fundamental lack of co-ordination between different NHS bodies, and elements of the system-based culture that led to the failings in the Mid Staffordshire trust, but while this is saddening, perhaps it should not be surprising.

For the changes Francis recommended to be implemented, they need to be fully adopted by the Government. Instead, the Government have spent £3 billion on a top-down reorganisation that nobody wanted and nobody voted for. Almost 1 million patients have waited more than four hours in A and E in the last 12 months and, as has already been pointed out, hundreds of mental health beds have been lost in the last two years. Last year, a third of people referred for counselling gave up because the waits were too long. Patients are still suffering at the hands of the Government.

If we do not urgently change the culture of the NHS to become more patient-centric, patients will continue to suffer. There needs to be a fundamental culture shift in the NHS that has not yet been achieved, and will not be achieved while the Prime Minister continues to put profits ahead of patients. The recent proposals to sell off our medical records are a perfect example of how “supposedly” patient-centred the Government are. Data collection and monitoring are essential, so it is a shame that the Government are stopping the collection of some datasets, such as health inequalities.

Staffing cuts are preventing patients from being at the centre of care. How can we provide patient-centred care when the Government are side-stepping the need for adequate levels of staffing, in terms of both volume and skills mix? How can we expect nurses to put into place systems, such as having a named nurse, when their numbers have been cut by around 7,000 since 2010? The Royal College of Nursing has said that it wants to deliver patient-centred care, but without the right skills mix in place, it is difficult for it to do so.

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Continued “efficiency savings”, driven by a Prime Minister who promised not to cut the NHS, make it virtually impossible for patients to receive a service suited to their needs. A continual focus on savings suggests to me that the Government have not learned from the Francis report. Patients are not always seen as individuals with individual needs and wishes. Our changing society means changing patients, and changing patients have changing needs. Today, nearly two thirds of people admitted to hospital are over 65, and an increasing number are frail or have dementia. Too often, hospital buildings and staff are not equipped to deal with people who have multiple complex needs.

One of my concerns is that patient experience is still variable. We need to understand why experience differs and how we can make it consistently excellent for all. Will the Government commit to identifying and tackling the causes of inequalities in patient experience? Do they have the conviction to look at the needs of the patient and how they can be best met, rather than looking at existing provision and how patients can be shoehorned into it?

The problem is not necessarily what has been addressed by the Government, but what has not. The blame culture fostered by the Government leads to fear and finger pointing, rather than improved patient care. The Government need to commit to re-introduce a culture of learning, support, and quality patient care in the NHS. A blame culture will not get us anywhere: listening to patients, and taking their needs seriously, will.

5.28 pm

Grahame M. Morris (Easington) (Lab): I am honoured to be able to participate in this debate, and it is champion to follow my hon. Friend the Member for Rotherham (Sarah Champion) in the debate—

Bob Stewart (Beckenham) (Con): Champion!

Grahame M. Morris: Thank you very much, Bob.

I want to make three points. First, I want to consider the context of the Francis report. I have the honour of serving on the Health Committee; we have held several inquiries and had the opportunity to meet and question Robert Francis on several occasions, so I am pleased to participate in this debate to consider where we are, one year on.

I also want to touch on mental health. As often happens when one speaks at the tail end of the debate, that has been raised by other hon. Members, but the issue is close to my heart. The third issue I want to discuss is the impact on social care. Although the Secretary of State kept implying that Francis is about acute hospitals, in fact his recommendations extend across the spectrum. The ideas and proposals in the 290 recommendations are just as valid for mental health and social care as they are for acute hospitals.

Clearly, the failings at Mid Staffs were absolutely shocking. I am sure that Members on both sides of the House who believe in the values of the NHS will, like me, have been appalled by those terrible events, but it is important not to conflate those terrible events with a wider diagnosis of the state of the NHS. We should think of the tremendous dedication and effort put in by the hundreds of thousands of NHS staff—I think the NHS is the biggest employer in Europe outside of the

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red army; it is a substantial employer—who make it such a national treasure that is ingrained in our psyche. I want to place on record the thanks of Labour Members, and, I think, the whole House, for their efforts.

Bob Stewart: I’ll intervene on that point.

Grahame M. Morris: Well, that’s very kind of the hon. Gentleman.

Mr Deputy Speaker (Mr Lindsay Hoyle): Order. The hon. Member for Beckenham has only just come in. He perhaps ought to hear a little bit more of the debate to get the flavour of it before he intervenes. That would help his good self.

Grahame M. Morris: We should remember that most hospitals provide very high standards of care, and have dedicated and compassionate staff. I am not just talking about doctors and nurses, but ancillary workers, cleaners and support staff. I worked in a pathology department as a medical scientific officer for a number of years. We should remember that the NHS is an integrated service that relies on all of its elements to perform at a high level and deliver a high-quality service.

Clearly, what happened in Mid Staffs was alarming. There were unacceptable practices, including, as other Members have said, professional failings. The hon. Member for Stafford (Jeremy Lefroy), in a terrific speech that was considered, thoughtful and non-partisan, alluded to those professional failings. My right hon. Friend the Member for Rother Valley (Kevin Barron), a former Chair of the Health Committee, made the point strongly that many Labour Members feel there should be a duty of candour on individuals. That is one of the recommendations of the Francis report that was rejected by the Government but could well make a difference. There were clear signs that changes needed to be made and we need to ensure that failures are never repeated elsewhere.

When care failures are uncovered, the priority above all else is to make a candid assessment of what went wrong and what needs to be done to fix it. Francis was clear on the need for cultural change. That is exactly what happened in the wake of the Mid Staffs scandal. Despite attempts by some Government Members to undermine Labour’s commitment to the NHS, for the record we should be aware that it was the then Secretary of State, my right hon. Friend the Member for Leigh (Andy Burnham), who is now in his place, who called in Robert Francis to lead the initial review into what had happened so that we could find out what went wrong and learn lessons for the future.

I accept the point made by the hon. Member for Stafford that we should not hark back to previous Administrations, but my recollection, as a relatively new Member from 2010, is that that was not something we engaged in. It was a huge issue for Labour, and for me personally, that people were dying due not to lack of care in a hospital setting, but to the length of waiting lists—people were dying on waiting lists. After 1997, the NHS was transformed. Spending had tripled to £104 billion when Labour left office. Under Labour, 100 new hospitals were constructed, and the Labour Government employed 89,000 more nurses and 44,000 more doctors than had been employed in 1997. The transformation of the

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NHS under the last Government was reflected in public satisfaction with the service, which rose from record lows before 1997 to record highs.

There was a bit of contention during Prime Minister’s Question Time, and subsequently during the opening speeches in the debate. The Secretary of State suggested that the number of nurses had risen, but my information from the Royal College of Nursing and FactCheck indicates that that is not the case. I hope that the record can be corrected, because staff numbers are a key issue. A number of Members have referred to it today, and Robert Francis cited staffing as a causative factor.

It would, I think, be irresponsible to assume that a combination of implementing the Francis recommendations—even all of them—and talking down the last Government will be sufficient to ensure the provision of high-quality care throughout the NHS. The truth is that the combination of cuts in alternative services—I am not just talking about the replacement of NHS Direct with the 111 service, the reduction in the number of walk-in treatment centres, the difficulties in gaining access to GP services and, indeed, the cost and disruption caused by the top-down reorganisation—is more likely to contribute to failures in care. It will certainly increase the pressure on accident and emergency departments.

The Francis report made it clear that the “overwhelmingly prevalent factors” in the failures at Mid Staffordshire

“were a lack of staff, both in terms of absolute numbers and appropriate skills”.

It was made clear that ensuring that our hospitals are adequately staffed is key to ensuring that standards of care are high. That point was made by the hon. Member for St Ives (Andrew George), who I know has been campaigning on the issue for some time. A year on from the Francis report, a survey found that 39% of nurses believed that the staffing position had become worse rather than better, and 57% said that their wards remained dangerously understaffed. I hope that the Minister has noted that, because it must be cause for concern.

The hon. Member for Stafford told us that when he was first elected the NHS trust was running a deficit of £10 million, and the focus of the hospital management was on reducing the deficit in order to secure foundation trust status. What went through my mind then were figures given to the Select Committee, according to which nearly a third of NHS trusts are predicting deficits towards the end of the current financial year, and the possibility that similar pressures will be applied as a result. We are now seeing the spectre of clause 119 of the Care Bill, which we are to debate next week on Report and Third Reading. If it paves the way for rapid hospital closures—Labour Members fear that predatory private health care interests may seize the opportunity—that will be very dangerous. We must examine that issue very seriously.

According to evidence from the survey conducted, I think, by the RCN, not only are hospital wards increasingly understaffed, but nurses are being burdened with work that is preventing them from doing their jobs. I am sorry to fire statistics at the House, but, according to that evidence, 86% agreed that the amount of non-essential paperwork had increased in the last two years. There

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has thus been an historic recent increase in administrative duties. That has been keeping nurses in their offices or at their nurse stations, standing in front of computers or photocopying machines, instead of being available on the wards providing the TLC—that direct health care—that patients require.

Just this week the president of the Royal College of Psychiatrists warned the Government that the mental health sector is heading towards its own Mid Staffs-type scandal. I am very concerned about that. The figures for that field were given earlier, but the fact that the budget for mental health services is reducing in real terms should be a cause for concern. This Government gave a commitment to parity of esteem as between physical and mental health. That was promised and loudly trumpeted as a significant step forward, but in truth it has failed to materialise. There is a clear funding imbalance between acute providers and non-acute trusts, which will disproportionately impact on mental health services in the wake of the Francis report.

I also want to touch on the tariff reduction. In 2014-15 there will be an overall reduction in the tariff price—essentially, the price that hospitals are paid for procedures and operations they perform—of 1.5% for acute providers and 1.8% for non-acute trusts. A third of NHS trusts are predicting they will be in deficit at the end of the financial year, and this tariff reduction will only compound that problem. This means the efficiency target for mental health and community trusts is in practice a fifth higher than for acute trusts, so perhaps it is no wonder that we have a chronic bed shortage, highlighted by various newspapers and the BBC, with children and adolescents travelling long distances to access appropriate care and sometimes temporarily being put in police cells. This is not acceptable, and there are real concerns that programmes introduced by the last Labour Government to make talking therapies available to people with mental health conditions are not getting the priority they deserve. Last year half of all patients referred for counselling did not see a specialist, with a third giving up entirely because the waits were so long.

As I mentioned in an earlier intervention, 1,700 mental health beds have been lost over the last two years, and services are under such pressure that people with mental illnesses are ending up either in police cells or presenting at accident and emergency departments, as the right hon. Member for Sutton and Cheam (Paul Burstow) said. Those are completely inappropriate locations.

I want to mention the cuts to social care since 2009 and the impact they are having on the ability of the service to deliver quality care in the light of our review of the Francis recommendations. We should not forget that since 2009-10 some £1.8 billion has been cut from local authority budgets for adult social care. The cumulative spending power of my own local authority, Durham county council, is being reduced by 17.3% under this Government.

Areas such as mine with a legacy of coal mining or industry have higher care needs. These are the areas that are being hardest hit by cuts to local government. It is simply not possible to make cuts of this significance to local government without it having an impact on standards of care. Some 76% of community nurses agree that social care cuts have resulted in increased work pressures, with just 15% thinking that patients are receiving adequate support from social care services. Cuts mean that an

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increasing number of those with care needs are going without any support—the figure I have seen is about 800,000—and those receiving support are not even having basic needs met. We know about the 15-minute visits, and councils are now having to introduce or increase charges for services that may well have been free before or might be free in other parts of the country.

Care in the home and in the community is declining, and people are turning to their local hospitals—this is the point I am trying to make—as the default option. That means that those who should be taken care of at home are staying unnecessarily in hospital beds. Accident and emergency is the coal face—the pressure point—and any failures in the system show up there, putting even more pressure on an already burdened system. In “The Francis Report: one year on”, Robert Francis said that there needs to be

“a frank discussion about what needs to be provided within the available resources…It is unacceptable to pretend that all can be provided to an acceptable standard when that is not true.”

I agree with him. It is no good telling people that care standards will be improved or maintained while removing the support that is required to provide high standards of care, particularly social care. In conclusion, I agree with the Health Committee that legislation and regulatory bodies can only do so much to ensure that care standards are met if the necessary staff and resources are not available.

Mr Deputy Speaker (Mr Lindsay Hoyle): I now have to announce the result of Divisions deferred from a previous day.

On the motion relating to the draft Marriage (Same Sex Couples) (Jurisdiction and Recognition of Judgments) Regulations 2014, the Ayes were 360 and the Noes were 104, so the Question was agreed to.

On the motion relating to the draft Marriage of Same Sex Couples (Registration of Shared Buildings) Regulations 2014, the Ayes were 363 and the Noes were 100, so the Question was agreed to.

On the motion relating to the draft Marriage of Same Sex Couples (Use of Armed Forces’ Chapels) Regulations 2014, the Ayes were 366 and the Noes were 103, so the Question was agreed to.

On the motion relating to the draft Consular Marriages and Marriages under Foreign Law Order 2014, the Ayes were 367 and the Noes were 100, so the Question was agreed to.

On the motion relating to the draft Marriage (Same Sex Couples) Act 2013 (Consequential and Contrary Provisions and Scotland) Order 2014, the Ayes were 365 and the Noes were 103, so the Question was agreed to.

On the motion relating to the draft Overseas Marriage (Armed Forces) Order 2014, the Ayes were 368 and the Noes were 98, so the Question was agreed to.

I now call Alex Cunningham.

5.48 pm

Alex Cunningham (Stockton North) (Lab): Thank you, Mr Deputy Speaker. It is an especial pleasure to follow my near neighbour in the north-east of England, my hon. Friend the Member for Easington (Grahame M. Morris), and I agree with everything he said. I was particularly interested in his reference to the reduction

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in tariff costs, which made me think about the new hospital we were planning to replace the Hartlepool and North Tees hospitals. That is yet to be delivered, despite its being crucial to health care in the area we both represent. I am hoping that we may soon hear from the Government that they are going to approve the assistance we need to deliver it, which will help us cope in that part of the world with the reduction in the actual tariffs.

Our national health service is for millions one of the world’s success stories of the second half of the 20th century, with teams of dedicated people—from porters and reception staff to nurses and consultants—who have risen to the challenge of change and innovated to do the best for our people. As a result, the NHS has survived and largely prospered despite the often unnecessary burden and restrictions placed on it by Government.

I am pleased to have learnt this afternoon that the future of the health service is in good hands: during this debate, I heard from my great niece, Meghan Quarne, who has just managed to secure a place at the Edinburgh medical school, so I am one very proud great-uncle this afternoon.

Yes, the NHS has been a success story, but there have been many failings that have devastated families, health professionals and politicians. We must never minimise the impact of failures that have occurred under different Governments at, for example, Bristol, Alder Hey and Mid Staffs. We must take action to ensure that we improve what we do in the NHS.

I also recognise that a number of trusts have been placed in so-called special measures. That is good not because of the things that are going wrong, but something is being done about the problems so I look forward to seeing the improvements that we all desire.

Of course it does no one any credit to play the political blame game. Members from current and previous Governments must recognise that things do go wrong, sometimes badly, and that everyone should work co-operatively to drive the improvements that we all want. That said, we must also recognise that the NHS is still a success story. It is treating more people with more complex conditions as well as the routine ones. However, the Francis report exposed an organisational subculture within parts of the NHS that was guilty of persistently compromising patient safety, jeopardising the quality of care and tarnishing the experience of the NHS as a first-class health care system.

In the most extreme examples, the failings identified in the Francis report have resulted in patients dying needlessly owing to dehydration and exposure—yes, severe neglect. It is unquestionable that such deficiencies resulted in suffering being needlessly caused to large numbers of patients. The report highlighted a wide-ranging and complex mix of failings, which included a board that was more focused on finance than on the quality of care received by patients; chronic understaffing that impacted on the ability to provide the care required; and a culture of poor practice and neglect that many staff felt powerless to challenge.

There can be no doubt that the situation was utterly abhorrent and should never have been allowed to arise, let alone be repeated. The NHS Confederation was candid, but accurate, in describing the failings at Mid Staffordshire as

“a nadir for the health service.”

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In short, there are lessons to be learned from the ordeal—lessons that need to be learned quickly and thoroughly. The recommendations made by the Francis report some 13 months ago were therefore squarely aimed at addressing and improving that frame of mind within trusts through increased levels of transparency and by placing greater focus on the quality of care being delivered.

Although it is important that we recognise that genuine culture change is a slow and evolutionary process that could take time, particularly when some of the changes in question are centred on sensitive issues such as the ability to raise concerns, it cannot be an excuse for risking further neglecting patients by failing fully to address each of the core concerns that were identified.

It is therefore disappointing that the Government have taken an inconsistent, scattergun approach to the report’s findings, ploughing ahead with a damaging top-down reorganisation of the NHS, cutting thousands of nurses and delivering a crisis in A and E. That course of action is destined to weaken and destabilise the NHS, not remedy the problems that have already been diagnosed. It must be a matter of concern that the recommendations that Francis made appear to be some considerable way off becoming a reality.

With the health service’s resources being limited in the face of rising demand for health care, coupled with an increasingly complex system of commissioning services that can involve many layers of bureaucracy and administration, it is more important than ever that the Government acknowledge the limitations that exist to transforming the culture of the NHS through legislation alone.

Although the Government accepted the report’s recommendation to introduce a duty of candour to organisations, they rejected the recommendation to extend that duty to individuals. My hon. Friend the Member for Easington mentioned that earlier. However, those individuals—the leaders and professionals in the NHS—are central to transforming care.

All parts of the NHS—from the ward to the board—have a role to play in creating a more open and honest health service. Every member of staff, regardless of role or seniority, should therefore see providing dignified, compassionate care to all patients as central to their duty. The vast majority of them do so, but I am still apprehensive because an organisational duty alone will not help individuals challenge an organisation with a dysfunctional culture. A simple duty on an employer will not encourage employees to come forward if they are not already motivated to do so by a professional code of conduct.

It is worth noting that an inherent tension remains between prioritising the quality of care delivered to patients and pushing the importance of financial performance. This is particularly true if increasing front-line staff numbers is viewed as the main route to improving safety and quality at the expense of an unnecessary and complicated reconfiguration of care pathways and services.

The Francis report identified one of the root causes of the terrible failures at Mid Staffordshire as a fundamental lack of staff, and many people have talked about that. Although some of the failings were the result of unprofessional behaviour on the part of individuals,

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the factor overwhelmingly responsible for many of the failings was a lack of staff. Yet, despite this finding, there are now thousands fewer nurses and front-line staff in the NHS than in 2010, with 7,000 front-line staff being made redundant between 2010 and 2013.

Achieving the excellent results and care that patients demand and deserve is dependent on a number of factors, and adequate staffing is certainly central to achieving that goal. However, excellent care requires not only the appropriate number of staff but, importantly, staff with the correct mix of skills. Those skills include a range of factors, including leadership, staff engagement and appraisal.

Although I appreciate the attraction of nationally set minimum ratios of nurses to patients, it is important that we recognise that this is an over-simplification that does not necessarily represent the safest way forward. Not only would a minimum staffing level remove the flexibility required to meet the changing needs of patients, but a nationally set minimum would run the risk of being seen to constitute a ceiling rather than a floor. Instead, appropriate staffing and the best mix of skills are perhaps best determined locally, based on robust evidence and local circumstances.

I well remember that, when I was a non-executive director of the North Tees and Hartlepool NHS Foundation Trust, we had a fantastic chief nurse—her name was Smith—who led a tremendous team. She inspected the wards. She took a team of people on to the wards. They talked to the patients. They looked under the beds. They dragged their hands across the top of the wardrobe units to test their cleanliness. They did a full and thorough check. They talked to the staff. They put nurses at the centre of patient care—something that is absolutely critical today.

Although there has been a small increase in the number of hospital-based nurses in the past year, a paper from the NHS regulator, Monitor, analysing foundation trusts’ plans for 2013 to 2016, shows how temporary increases in nurse numbers this year, 2013-14, will be outweighed by larger cuts to nurse numbers over the next two years. Indeed, the paper suggests that hospitals are planning to “significantly reduce nurses” from next April and that the temporary rise this year is just

“a short term fix for operational pressures”.

Specifically, the analysis shows that, although trusts are planning to increase nurse numbers by 2% this year—around 3,400—that will be followed by 4% cuts in 2014-15 and around 6,900 will go the year after.

There has never been any excuse for neglect by nursing staff. There has never been any excuse for what happened at Mid Staffs. But if, as Francis said, a lack of staff was fundamental to the Mid Staffs failure, that is surely the central lesson for us all, including the Government, to learn.

5.59 pm

Sir Peter Bottomley (Worthing West) (Con): It is 10 years after the trust lost its three-star rating and went down to zero. It is nine years after most people monitoring hospital performance knew what the problems were. Whistleblowing began in 2007—the Royal College of Nursing knew that, but others did not.

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I should like to focus on recommendation 11 of the report that came out three and a half years ago. It deals with the candour required of staff, and it says that clinicians and their views should be represented at all levels of the hospital and the trust. A contrast to what happened at Mid Staffs is provided by a hospital in Seattle—the Virginia Mason medical centre—that decided, first, that if it made mistakes it would admit it and, secondly, that any member of staff could stop the process if there was a significant problem. I recommend a book by Charles Kenney called “Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience”, which should be read—or a summary should be made available—by virtually everyone concerned with organised health care in this country.

Some of the lessons are simple but rarely put into practice. Let me make an analogy. My brother-in-law, Christopher Garnett, ran the London to Edinburgh line for the Great North Eastern Railway, and members of staff would say that he was the only manager who got on the train and asked everyone what he could do to help make their job more effective; they were used to managers telling staff what they could do to make the manager’s job more effective.

The Virginia Mason medical centre looked at what it was doing, and it discovered that nurses spent a third of their time with patients. After changing how they worked, nurses spent 90% of their time with patients. Dr Gordon Caldwell of Worthing hospital in my constituency said that people should be in hospital only if it is doing them some good. They should have a named doctor and a named nurse, but he discovered that, probably throughout the health service—partly but not entirely because of the European working time directive—a patient’s doctor and nurse probably did not speak to each other about the patient more than once a week. That is not good enough.

There is a series of issues, but the key one is empowering front-line staff. Dr Kim Holt, a clinician and leader of Patients First, with whom I am involved, warned in advance that Haringey children’s services were no longer staffed by the right number of qualified senior clinicians. She made it plain that the baby Peter case was not just about a failure to bring together the child’s records from the different parts of the health service to which the family had taken him. She said that the locum, who ended up with all the blame, could not possibly have done the job that she was asked to do. Kim Holt suffered under her employer—the trust. She stood up to it, and would not be bought off and silenced. I pay tribute to her for that.

I could speak at length about this, but I should like to end with a request both to the people at the top of the health service in England and to Ministers. I suggest that Ministers and NHS England meet the group of clinicians that Kim Holt can bring together with Roger Kline at Patients First, listen to their stories and ask where in the process of NHS management, each complaint or disciplinary case has got to. That involves managers, nurses, midwives, doctors and others. The Department of Health should make sure that that happens, but not necessarily in public. It should ask each of the managers involved what they have done all the way through each case and whether they would like to revise what they are doing. There are still too many whistleblowers being bullied, bribed, bought off or sacked 10 years after the Mid Staffs events told us what could go on.

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6.4 pm

Liz Kendall (Leicester West) (Lab): It is a pleasure to speak in this important debate. Members on both sides of the House have shown that we are determined to learn the true lessons from the appalling failings at Mid Staffordshire and to understand what needs to change to prevent them from happening again.

We have heard many serious and thoughtful contributions, but I want to start by paying tribute to the hon. Member for Stafford (Jeremy Lefroy), whose calm, considered, thoughtful and dignified approach to the issue and the work he has done on behalf of his constituents is a lesson to us all. My right hon. Friend the Member for Cynon Valley (Ann Clwyd) hit the nail on the head when she said that there is nothing to be gained by politicising these issues, but everything to be gained by understanding the lessons and being open about the problems so that they can be tackled properly.

My hon. Friend the Member for Stalybridge and Hyde (Jonathan Reynolds) and my right hon. Friend the Member for Rother Valley (Kevin Barron), along with many other hon. Members, emphasises the importance of openness. As a constituency MP, I have seen how the NHS too often tries to sweep patient complaints and mistakes under the carpet, ignoring them and pushing patients away. Being open early on, admitting mistakes and learning the lessons is a much better way forward.

A number of hon. Members spoke specifically about the process that Mid Staffordshire hospital is currently going through. My hon. Friend the Member for Stoke-on-Trent North (Joan Walley) and the hon. Member for Stafford rightly said that there is a lack of clarity about the process and the timetable. I hope that the Minister, when he responds, will give those hon. Members and their constituents much greater clarity on what will happen.

My hon. Friends the Members for Rotherham (Sarah Champion) and for Wythenshawe and Sale East (Mike Kane) raised important points about making the system more accountable and how that is much harder since the NHS reorganisation, with all the different bodies—a point I will return to in a minute. My hon. Friends the Members for Worsley and Eccles South (Barbara Keeley), for Easington (Grahame M. Morris) and for Stockton North (Alex Cunningham) rightly talked about staff shortages and the serious impact they can have on patient care. If we are to get to the root of the problem, simply publishing data every month is not good enough. I was really pleased that the right hon. Member for Sutton and Cheam (Paul Burstow) talked about mental health. We have been talking mostly about physical health, but he was right to raise those concerns.

In the time available I cannot do justice to all the points raised today, or to the Francis report’s 290 recommendations, so I will focus my comments on the two most fundamental challenges we now face: first, ensuring that the views of patients, their families and the public are heard and acted on, at every level and at all times; and, secondly, ensuring that there is clear leadership to make the service changes we need to improve safety and quality at a time of unprecedented pressures on the NHS. Unless we do that, there is a risk of the failings in Mid Staffordshire happening again.

Alun Cairns: Will the hon. Lady give way?

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Liz Kendall: I will give way to the hon. Gentleman this one time.

Alun Cairns: I am grateful to the hon. Lady for giving way, unlike her colleague earlier. In the spirit with which she has opened her contribution, and in relation to the comments made by the right hon. Member for Cynon Valley (Ann Clwyd), the comments of the Royal College of Surgeons and the example I highlighted of worrying cases in the NHS in Wales, will she make every effort to influence her colleagues in the Welsh Government, and indeed the Welsh Health Minister, to conduct a Keogh-type inquiry into the NHS in Wales?

Liz Kendall: Wherever there is evidence of poor care, it must be looked into. The hon. Gentleman did not mention that the Welsh Assembly has ordered a specific independent inquiry by experts outside Wales into aspects of care at the Princess of Wales and Neath Port Talbot hospitals, which I welcome.

Of all the lessons to be learned from Mid Staffordshire, the most important one is that the primary cause of the failures was the hospital and the trust board not listening to patients and their families, and not putting their needs and concerns first. Sir Robert Francis rightly says that there must be fundamental changes to ensure the real involvement of patients and the public in all that is done and to secure a common patient-centred culture throughout the NHS.

National Voices, a coalition of more than 130 patient, user and carer organisations, says that a concerted drive to listen to patients and carers must be a top priority for all trust boards and care organisations. It emphasises that over and above regulation, which it says has

“an important but limited role in ensuring quality and safety.”

Ministers have rightly spoken about the need for effective regulation and have taken some welcome steps, but the Care Quality Commission and the new chief inspectors will not be the main way of preventing the sort of failings we saw at Mid Staffordshire. Regulation identifies problems when they have begun, rather than preventing them from happening in the first place. Regulators cannot be everywhere all the time, but patients and their families are, which is why their views must be heard from the bedside to the boardroom, and at the heart of Whitehall.

The Labour Government made important progress. They published, for the first time, data on stroke and cardiac care. That helped to improve standards for patients and was a powerful incentive for staff to make changes. The next step is to provide systematic and comprehensive patient feedback. That must move from being the exception to being the norm.

The Government’s friend and families test is welcome as far as it goes but, as National Voices says,

“it is a crude measure on which the NHS would be unwise to place too much reliance.”

It asks only whether patients would recommend an NHS service to others, but not why, and it does not provide the detailed, real-time feedback that patients want and staff need to improve the quality of care. Developments such as the patient opinion and care opinion websites offer a powerful way forward. They enable people to tell the story of their NHS or care experience online, in writing or on the phone. That gives

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patients a voice, allows other people to see what is being said about a service, and in a simple and cost-effective way provides staff with a direct incentive to improve.

The Secretary of State said we must all be champions for change, and hon. Members may remember that I wrote to everyone saying that as a Member of Parliament they should sign up because it is a great way for us to understand what is really going on. I have asked my hospital trust and other services to do the same. That will be a powerful way of making change happen.

We must also look at how staff are trained to ensure that they always put patients first. Places such as Worcester university are leading the way: patients and families help to interview people who are applying to be nurses and health care assistants; they help to develop the content of courses so that they include what really matters to patients; and they take part in teaching students. Ministers should have spent the last three years championing such initiatives instead of reorganising the training structures as a result of the Health and Social Care Act 2012.

Individual patient voices are not the only ones that must be heard. We need a strong collective voice for users. The Francis report recommended investing in patient leaders to speak out on behalf of the public, to help to design services locally, and to hold them properly to account. Ministers claimed that that is what Healthwatch would do, but their rhetoric is simply not matched by the reality: national Healthwatch has nowhere near the same power, authority or levers to change services as NHS England, the Care Quality Commission or Monitor.

Local Healthwatch bodies are also weak. They were late out of the starting blocks and are woefully understaffed. Last week, we heard that £10 million of the £40 million budget that was promised for local Healthwatch has gone missing, despite the explicit recommendation in the Francis report that

“Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch”.

If Ministers are serious about giving patients a strong voice locally, they must look again at the support that Healthwatch is getting on the ground.

A strong patient voice is more essential than ever before because of the huge pressures on local services. Across the country, the NHS is struggling to cope with the increasing number of frail elderly people ending up in hospitals that were designed for a different age. Twenty per cent. of hospital beds have older people in them who need not be there if they had the right support in the community or at home. Half a million fewer people are receiving basic help to get up, washed, dressed and fed as council care budgets are cut to the bone. Mental health services, especially for children, are under intolerable strain as money for vital community services is being diverted to cope with pressures elsewhere in the system. This is not good for patients and families, it puts staff under pressure, and it ends up costing the taxpayer far more as people end up in more expensive hospital care or, in the case of mental health patients, being transported hundreds of miles around the country.

The NHS needs radical change, not to its back-room structures but to its front-line services and support. Improving safety and quality means that some services must be concentrated in specialist centres and others must be shifted out of hospitals into the community

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and towards prevention, fully integrated with social care. Under the previous Government, plans had been drawn up to reorganise services in every English region through Lord Darzi’s next stage review, but rather than pushing forward with those plans and making the changes that patients want and need, Ministers scrapped them simply because they were developed under the previous Labour Government. Instead, they embarked on a huge back-room NHS reorganisation, wasting precious time, effort and resources.

As several hon. Members have said, the new NHS structures are utterly confusing, with no clear lines of accountability or responsibility. There are now 211 clinical commissioning groups, 152 health and wellbeing boards, 27 NHS England local area teams, four NHS England regional teams—I am not sure what they are doing—23 commissioning support units, and 10 specialist commissioning units, alongside Monitor, the Care Quality Commission and NHS England. Can you make sense of that, Mr Deputy Speaker? Who is providing the leadership? Who is to be held to account? Across the country, people are doing their contract negotiations for next year, trying to make changes to services, and they say to me that there is no clear leadership in the system. That must change.

We have heard a lot about changing the culture in the NHS. That culture is about behaviour and the millions of personal interactions that happen every single day in the NHS. Getting those right will not happen through regulation alone but by giving patients and the public a powerful voice in every part of the system. This issue has had too little attention since the Francis report was published. Crucially, the culture is about leadership, and leadership comes from the top.

I warn Ministers not to be complacent about saying that the bullying culture has gone. On Friday, I met the chief executive of a trust who showed me an e-mail from the NHS Trust Development Authority, which is quite close to Ministers’ doors. I will not be able to say exactly what it said because it contained swear words, but it said, in effect: “Open the beep beds; just beep do it.” That was in an e-mail to a chief executive. The bullying culture is still going on. Ministers need to get a grip, particularly on what is happening at the NHS Trust Development Authority, which is causing real problems in the system.

Grahame M. Morris: This is more pervasive than something that happens at the highest level. When members of my trade union, Unite, from the Yorkshire ambulance service raised legitimate concerns about the impact on the service of privatisation and de-skilling, the reaction of management was to de-recognise the trade union. That is outrageous.

Liz Kendall: This is not leadership; this is not what we want in our health service.

Real leadership is about setting a vision and working with staff and patients to make it happen. Yesterday Sir John Oldham published the report of his independent commission on whole-person care, which was drawn up with people who have worked in the system and sets out the reforms that we need to ensure that our NHS and care services are fit for the future. Across the NHS, patients and staff are crying out for clear leadership. Until we get this right, we will not really have learned the lessons from the failings of Mid-Staffs.

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6.19 pm

The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter): The publication of the Francis report was an incredibly humbling day for our national health service. It was humbling not just for those of us in this place who care about our NHS, but for the many staff who work tirelessly to look after patients and for everybody involved in looking after people as part of our health and care system.

The central plank of the report highlighted the fact that a culture had developed at Mid Staffordshire that was not in the best interests of patients. Targets and bureaucracy had got in the way of delivering high-quality care, and far too often the management of the trust did not listen to the concerns of patients or to the sometimes valid concerns of front-line members of staff.

Robert Francis made a number of recommendations in his report. The Government accepted the principles of the report and we have made great progress in implementing many of the proposals, which I will come on to later.

It is important that all parts of our health and care system learn lessons from things that have gone wrong in our health service. Front-line staff need to learn lessons where appropriate and managers need to learn to listen and respond to the concerns of front-line staff. We need to create a culture that is open and learn how to put things right in the future in order to improve patient care. That is what good health care is about, whether someone works on the front line of the service or whether they are involved as a commissioner, a manager or a Minister.

There have been many good contributions to the debate and I will do my best to touch on as many of them as I can in the time available. In particular, there has been strong advocacy for the local NHS. I pay particular tribute to my hon. Friend the Member for Stafford (Jeremy Lefroy) for his work and tireless advocacy over many years—including before he became an MP and certainly during his time in this place—on behalf of his local patients and the local hospital and staff who look after them in Mid Staffordshire. Without his long-standing efforts and those of my hon. Friend the Member for Stone (Mr Cash), we would not be where we are today and that part of the world would be less better represented. Importantly, they are the people who have asked consistently the difficult questions and allowed us to get to our current position of not just tackling poor care at Mid Staffordshire and putting right the challenges that that has thrown up, but looking at how we can improve pockets of bad care elsewhere in our health and care system.

Most hon. Members have focused on two particular themes, the first of which is the need to learn lessons from the Francis inquiry into what happened at Mid Staffs, for the benefit of the wider health and care system. We heard some very good speeches, particularly from the right hon. Member for Rother Valley (Kevin Barron), my right hon. Friend the Member for Banbury (Sir Tony Baldry) and my hon. Friend the Member for Worthing West (Sir Peter Bottomley). They discussed the broader lessons that can be learned and the importance of an open culture, of supporting clinical leadership and of recognising that perhaps staff are the best advocates of what good-quality patient care looks like in our health system.

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In his constructive contribution, my hon. Friend the Member for Cannock Chase (Mr Burley) noted that the challenges and difficulties faced in Mid Staffordshire arose because the management in particular were blinded by targets, financial incentives and drivers, and lost sight completely of what matters most in a hospital at all times, which is delivering high-quality, good patient care. The biggest lesson we can learn, as my hon. Friend made clear, is that we need always to make sure that the delivery of high-quality care is the first and only driver of what happens on the ward. It should never be about meeting a financial target. Of course, the two are not always mutually exclusive, but in this case it is very clear that things went very badly wrong at that trust.

As was pointed out by the shadow Minister, the hon. Member for Leicester West (Liz Kendall), a significant speech was made by my right hon. Friend the Member for Sutton and Cheam (Paul Burstow), who talked about the importance of parity of esteem between mental health and physical health. He did a lot in his time in government, and he has always been a keen advocate of that. I know that he is very proud, as the Government are, that the 2012 Act has for the first time enshrined in law genuine parity of esteem between physical health and mental health. That was touched on by the Francis report, and the Government can be proud of doing that. As he will know, we have also invested £450 million in improving access to treatment in mental health services. I know that he took that forward in government, and he can be very proud of that record.

Paul Burstow: Through the Minister, may I pose a question to my hon. Friend the Minister of State who has responsibility for care services? He told us that Sir David Nicholson had issued a clarification about area teams not doing enough to deliver parity of esteem, but that has not materially changed how the finances are arranged, with money being taken away from mental health to pay for Francis delivery in acute care. Will that be addressed?

Dr Poulter: My right hon. Friend is absolutely right to say that the first step in addressing financial disincentives for mental health, which have been in the system for many years—in fact, for decades—was to establish parity of esteem in law. He helped to achieve what for the first time has been done under this Government. The next step is of course to make sure that other measures are in place to encourage and incentivise the system to spend money appropriately. Members on both sides of the House agree that we should take pressure off acute services, and nowhere is that more important than in mental health. It is important to invest in improving access to psychological therapies and talking therapies to support people, and to put in place early intervention for those with mental health problems. That is quite important, so the Government are investing money in it.

It is also important to collect proper data on mental health for the first time. For many years, data have not been collected effectively to ensure that we know what good mental services look like, but the Government will make sure that we can deliver that.

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Andy Burnham: I thoroughly agree with the Minister about collecting data on mental health so that we can make proper judgments about the quality of services, but why has the Department of Health scrapped the annual survey of expenditure on adult mental health services?

Dr Poulter: It is very difficult for me to stand at the Dispatch Box and take any lessons from the right hon. Gentleman and the previous Government on mental health issues. Only this Government have taken serious steps to improve parity of esteem and enshrine it in law, and only this Government are investing in mental health on the ground, with £450 million that is particularly focused on talking therapies. If the previous Government had any interest in mental health, they had 13 years to make investments and to improve data collection to drive better commissioning, but they took no steps towards doing that, and I am afraid that their record on mental health was abysmal and very poor. Unfortunately, patients paid the price for that.

We are very proud of our record on mental health, but it will take several years to turn around the fact that there was no parity of esteem in the past. Investment is now going in on the ground and things are being put in better order. My right hon. Friend the Member for Sutton and Cheam played his part in that, and the 2012 Act was a huge step forward in delivering those improvements.

I will try not to get drawn away from the topic of the Francis inquiry, Mr Deputy Speaker—we are talking about the broader health and care service—but I mentioned mental health, which we can be proud of, because it was mentioned by Francis in his report.

It is also important to talk about some of the wider lessons that can be drawn from the Francis inquiry. The right hon. Member for Cynon Valley (Ann Clwyd) and my hon. Friend the Member for Vale of Glamorgan (Alun Cairns) spoke particularly about the need, apolitically, to make sure that the whole of the United Kingdom draws such lessons. I have had very productive meetings with counterparts in Scotland, and Wales can also learn lessons about the importance of transparency and openness, and about recognising potential areas of poor care.

I hope that shadow Ministers will take up those matters with their counterparts in Wales, because such a situation can only be to the detriment of patients there. That is not a political point, but one about good care. It is important for us to deliver that in the system at the moment. It is also important because English patients are treated in Welsh hospitals. My right hon. Friend the Secretary of State is very excited about that point, which is why he is a very strong advocate of the needs of English patients and why he takes a particular and important interest in what happens in Wales, quite rightly drawing comparisons between the two systems.

Robert Francis found, as we have discussed, that individuals and organisations at every level of our health service let down the patients and families whom they were there to care for and protect. That was a systemic failure on the part of everyone concerned and cultural change was needed throughout the system. To prevent the same thing from ever happening again, the Government are changing the culture by requiring transparency and openness, by empowering staff and supporting strong leadership, and by embedding the patient voice and listening when something goes wrong.

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Joan Walley: I have listened carefully to the Minister’s response to the various contributions that have been made throughout the debate since 1.15 pm. I hope that he will respond to the points that I made about the current situation in Mid Staffordshire and north Staffordshire before he goes on to the generalities of the Francis report. Does he accept that it was a bombshell when we heard last Wednesday that the recommendations of the trust special administrator had not been accepted in full? We are in a state of limbo. Will he tell the House what is the state of play of arrangements in north Staffordshire and Stafford? We need to know that and cannot deal with the uncertainty.

Dr Poulter: Again, I will not deviate from the general theme of the debate and try your patience, Mr Deputy Speaker. The recommendation of the trust special administrator was that consultant-led services were to be transferred away from Stafford and that there would be a midwife-led unit for Stafford. I am sure that Members on both sides of the House are great proponents of midwife-led units and of increasing the choice that is available. The Secretary of State has made it clear that he accepts the TSA recommendations in full and that local commissioners will have to do a health economy review to assess whether capacity is available elsewhere, before services are moved in the way that was envisaged by the TSA. The Secretary of State has asked NHS England to work with local commissioners to identify whether consultant-led obstetrics could be safely sustained at Stafford hospital. That only happened last week. We will update the House in due course and perhaps statements will be made by NHS England.

Joan Walley rose

Dr Poulter: I have given a very helpful reply to the hon. Lady, but I will give way once more.

Joan Walley: I say to the Minister and the Secretary of State that the use of the phrase “in due course” causes great concern. The new arrangements need to be in place in September 2014. Any delay to the acceptance in full of the recommendations in the TSA report will cause great uncertainty. The Government need to show that they are doing what the Francis report recommended and leading by example. Will they do that in the case of north Staffordshire and Mid-Staffordshire?

Dr Poulter: We are leading by example. As I outlined, the Secretary of State has accepted the TSA recommendation in full. A process is now under way involving NHS England and local commissioners. That was initiated last week. It is important that those conversations happen and that an update is brought forward in a timely manner. That is the right thing to do. It is not appropriate to rush decisions and processes because of a political agenda, rather than an agenda of benefiting the local patients and women concerned. I am concerned as a doctor and as a Minister that we must do the best thing by patients. Rushed decisions are not always the best thing for patients, because conversations need to happen between local commissioners and NHS England. I hope that the hon. Lady will be a little patient, because I am sure that the right decision will be made in due course.

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There are three key areas in which the Government have taken forward the recommendations of the Francis inquiry: encouraging a culture of transparency and openness in the health care system; empowering front-line staff and encouraging good leadership in the NHS; and putting the patient at the heart of everything that the NHS does. As we have discussed, the patient was not at the heart of everything that was done at Mid Staffordshire for a period. That is why we have to learn the lessons and ensure, as best we can, that that cannot happen again.

On transparency and openness, it is important to highlight how we have already delivered on the recommendations of Robert Francis’s report. The CQC has appointed three chief inspectors for hospitals, social care and general practice who will ensure not only that the organisation is complying with the law, but that the culture of the organisation promotes the benefits of openness and transparency. Importantly, we now have clinically led inspections for the first time, which means that people who really understand what good care looks like will be in charge of the inspection process. That clinical leadership in the inspection process and at the heart of what the CQC does has to be of benefit to patients, and the Government are proud that we have delivered that.

We have also introduced a new statutory duty of candour on providers, which will come into force this year. It will ensure that patients are given the truth when things go wrong and that honesty and transparency are the norm in every organisation.

Kevin Barron rose

Dr Poulter: The right hon. Gentleman might wish to intervene in a moment, but first I will respond to his good points on the importance of the duty of candour. There is some disagreement between us, because he said that there should be a duty on individuals. He will be aware from his time at the General Medical Council that there is already a duty on professionals to act in the best interests of patients and raise any concerns about the quality of care. As a body, the GMC has learned lessons from Mid Staffordshire and reviewed its processes, but it is important to recognise that many front-line professionals at Mid Staffordshire tried to raise concerns. The culture at the trust was such that those in management positions did not always listen to them. If we want to support whistleblowers and people’s ability to speak out freely for the benefit of patients, that has to be done at organisational level. Health care professionals are already under a duty through their professional obligations, which I hope reassures the right hon. Gentleman.

The right hon. Gentleman has been in the House for many years and will remember that problems of people not being able to speak out freely in their organisations date back to the Bristol heart inquiry. Professor Kennedy, who oversaw that inquiry, noted that it was the cultural problem in that hospital provider that prevented people from speaking out. The problem was not that people were not prepared to speak out—they recognised their professional obligations; it was that there was a wish at a senior level not to recognise problems. That is what we need to tackle. We are now almost 15 years on from the Kennedy inquiry into Bristol—I was a law student at Bristol university at the time—and the NHS has perhaps

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not learned the lessons that it needs to. I am sure that putting a duty of candour on to NHS organisations will begin to get us where we need to be.

Kevin Barron: Will the Minister consider what I said about how an independent statutory commissioner could examine complaints about patients’ care, as happens in New Zealand? Will he get back to me about whether he thinks that is a good idea? The people who work in the institutions that he is talking about have no faith that anything can be changed.

Dr Poulter: I will talk about complaints a little later, but the right hon. Gentleman has made some important points. When we consider how to improve the delivery of care in our health service, it is important that we examine international comparisons. The system in New Zealand includes a different form of compensation, and perhaps that is partly why it has a more open culture—there could be many other factors. It is acknowledged much earlier in the process that something has gone wrong, and there is a genuine attempt to explain the situation to the family and say sorry. That is what good health care is all about.

No matter how good, well trained and dedicated staff are, things will sometimes go wrong in a health service. When they do, it is important that we are open and honest with patients and that we do our best to put things right if we can, or explain and apologise if we cannot. That is why we believe that the duty of candour needs to exist at organisational level. Of course, I am happy to write to the right hon. Gentleman, or meet him if he would like to talk through some of the issues that he raised today. He makes good points, and I know that he does so on a completely apolitical basis because he has the best interests of the health service at heart. We might disagree on other issues, but on this one it is worth having a meeting to discuss his views further.

Subject to the passage of the Care Bill, a new criminal offence will be introduced to penalise providers who give false or misleading information where that information is required to comply with statutory or other legal obligations. It means that those directors or other senior individuals, including managers, who consent to, connive in, or are negligent regarding an offence committed by the provider could be subject on conviction to unlimited fines or even custodial sentences. We must ensure that managers and those running the health and care service in a health care provider provide information in an honest and transparent way that is always in the best interests of patients.

Importantly, we are introducing through the Care Bill a single failure regime to ensure that failure is not only about the financial sustainability of the trust, but about whether a health care provider is providing good care, and the quality of that care. One problem in the past with the trust special administration regime has been that it is rarely used. When it is used, however, it is important to ensure that it is there to protect patients. Often in the past it was used only in a way that focused on financial failure. One important lesson to learn from Mid Staffs is that there should be a failure regime that also considers quality of care. Hospitals are not just about good accounts; they are primarily about delivering good care, which is why we need a single failure regime.

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My right hon. Friend the Secretary of State has been a tremendous advocate for the importance of quality of care in trust, and he should be commended for that. Thanks to him, we are now ensuring that we improve the TSA regime in that way.

Mr Jenkin: The Minister is outlining the legislative and regulatory changes that arise from the Francis report, but does he agree with the Health Committee, which attaches far more importance to the leadership academy mentioned by my right hon. Friend the Secretary of State? Is not the quality of leadership much more important to the day-to-day care that is delivered throughout the health service, and will the Minister say a bit more about that?

Dr Poulter: I am not sure whether my hon. Friend has seen my brief, but that was exactly the point I was coming to. He is absolutely right and he highlighted the issue earlier in a strong contribution to the debate. It is important to empower front-line staff to be advocates for patient care and to take leadership roles in hospitals. Clinical leadership is at the core of everything that needs to be done, and we must promote strong leadership throughout a health care organisation, and throughout the sector.

We amended the Enterprise and Regulatory Reform Act 2013 so that a person has the right to expect their employer to take reasonable steps to prevent them from suffering detriment from a co-worker as a result of blowing the whistle. That has supported clinical workers and front-line staff in raising concerns and as whistleblowers. We established the NHS Leadership Academy in 2012 as the national hub for leadership development and talent management. Since it launched its NHS fast-track executive programme in January, there have been more than 1,600 applicants. We are also introducing a new fit and proper person test for directors of registered health care providers, which will allow the CQC to insist on the removal of directors who are responsible for poor care. Those strong steps are in place, and there are others, which I would be happy to discuss another time with my hon. Friend, to embed not just clinical leadership but good leadership throughout our health and care services.

Importantly, in delivering high-quality care and embedding good leadership, we must focus much more on outcomes rather than targets. That goes to the centre of what Robert Francis said, and is led by good clinical leadership. What matters in the health service is that we deliver high-quality care based on good outcomes of care for patients, and we must listen to patients about what good care looks like. The Government are delivering those things, which are at the centre of what Robert Francis recommended as lessons to be learned from Mid Staffs.

Finally, I mention the important issue of embedding the patient voice and listening when things go wrong. As the shadow Minister outlined, the Government have introduced the friends and family test, through which nearly 1.6 million patients have already given instant, real-time, feedback to the NHS about their care. Patients are saying what their experience of care is like. It is not about ticking a box or meeting a target; patients are feeding back information and saying, “Yes my care was good” or “No, my care was not as good as it could have

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been, and this is how it could be improved.” Good care is about ensuring that we deliver clinical excellence through clinical leadership, listening to patients, and ensuring that we feed back their experiences into delivering better services and a better experience of care. Those are things the Government are doing.

Through the chief inspectors of hospitals, social care and general practice, we are putting proper clinical leadership into the inspection process. We are also ensuring that all feedback from patients, whether concerns voiced on the ward or complaints made once they are back at home, makes a difference. I pay tribute in particular to the work done by the right hon. Member for Cynon Valley on the complaints process, on which there were valuable lessons to be learnt. I thank her for her efforts, which have made a big difference. We are still working on further measures we can put in place to ensure that complaints are listened to. This is all about listening to patients, learning lessons and delivering better care.

We are proud of our record in government in listening to patients and ensuring that we develop proper clinical leadership. We are also proud that, as a result of the Francis report and the measures put in place by my right hon. Friend the Secretary of State, we are beginning to deliver much greater transparency in our health service. It is also important that we have that transparency in the back office. I disagree with what the shadow Minister said about not needing to reorganise the back room. We have to deliver more transparency, better procurement and improvements in how we run the hospital estate. If we do that properly, there will be more money to deliver high-quality patient care.

The coalition Government—I know the Minister of State, Department of Health, my hon. Friend the Member for North Norfolk (Norman Lamb), agrees with me strongly on this—want to see a more productive NHS that is patient-centred and does not waste money in the back office that should be spent on patient care. I make no apologies for organisational steps such as the removal of many of the bureaucratic processes in place under the previous Government, thus saving £1.5 billion a year already. That is good, because it means that more money goes to the front line to deliver high-quality patient care.

The 65th year of the NHS was perhaps its most challenging—certainly in recent memory. The Francis inquiry threw up many challenges for our health and care system, but I believe we are meeting those challenges. Our Government are ensuring that our NHS remains a health service of which we can all be proud, not just today but for many years to come.

Question put and agreed to.


That this House has considered the matter of the Francis Report: One year on.