Health Committee - Minutes of EvidenceHC 657

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Oral Evidence

Taken before the Health Committee

on Tuesday 23 April 2013

Members present:

Mr Stephen Dorrell (Chair)

Andrew George

Barbara Keeley

Grahame M. Morris

Andrew Percy

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Rt Hon Jeremy Hunt MP, Secretary of State for Health, and Una O’Brien CB, Permanent Secretary, Department of Health, gave evidence.

Q471 Chair: Good afternoon, Secretary of State and Permanent Secretary. You are both very welcome to the Committee. As you know, this is a hearing following on the hearings we have had about the Francis report and the Government’s own preliminary response to the Francis report. It would be helpful to the Committee if we can simply begin. I should say at the beginning of this session that we want to cover a lot of ground, so-if I may appeal to my colleagues-if we can keep both questions and answers, in the words of the Speaker, short, we will cover more ground more efficiently.

I would like to begin by asking you to set the scene, Secretary of State, about how the Government intend to take forward their further response to 290 recommendations from this point. You made it clear when you made a statement to the House that this was your initial response and there was further work still to do.

Mr Hunt: Yes. First of all, thank you to the Committee for this opportunity to discuss what I think is, as far as the public are concerned, the single most important issue that they would like to see addressed in the NHS-but there are other broader issues which we may come on to as well. I would describe it as my substantive response. We will go through all 290 recommendations later this year, and essentially we intend to accept the spirit of all of them. We agree with what Robert Francis was basically saying. There may be recommendations where we can achieve the same thing as he wanted in a slightly different way. What we have announced so far covers around 100 of them, but I think there is enough there for people to see the heart of how we intend to give the public confidence that, where there is poor care, it will be rooted out and dealt with more quickly than happened at Mid Staffordshire.

Q472 Chair: May I ask you to be a bit clearer about the thought process that led to the work that Don Berwick is doing? On the face of it, it is odd, Robert Francis having spent four years looking into the background as to what happened in Stafford, now to have another report from Don Berwick. What is the added value in that?

Mr Hunt: Basically what he is doing is giving us information about how to fix the problem that Robert Francis identified, so it is an implementation thing. It will be a quick process. He is going to report in July. The main way that we will implement what he says is through the new inspection regime that the chief inspector of hospitals will be implementing from the end of this year. That will start, as I say, before the end of this year. So it is really about how you get largescale culture change across the organisation. What is the test of whether we are getting that organisational change? The latest figures I saw show that inside the NHS in a year there were 70 wrongsite operations, which is pretty shocking. How do you create a culture where that kind of thing doesn’t happen? Don says it is a fouryear process. I want to make sure we start off in the right direction.

Q473 Chair: The title of the advisory group is Safety of Patients in England, and the terms of reference appear to focus the attention of Don Berwick’s work very much on safety, as opposed to the other two principal parameters of quality as it is these days defined.

Mr Hunt: Yes. This is only one part of our response to Francis, but I think it is an important part, because in some of the meetings that I had with the Mid Staffs families, Cure the NHS and people like that, they said that what was missing was what they call a zeroharm culture, in which harm to patients is as rare, or as big a deal, as fatalities in the airline industry, for example. They said they thought that was a very profound cultural change. It is interesting that that has happened in some parts of the NHS already. If you look at the work at Salford Royal, for example, it has an outstandingly good record on safety. The Don Berwick review is going to help us to understand how one rolls that culture out more widely.

Q474 Chair: It is odd, isn’t it, to be doing work focused on patient safety so soon after the Government announced the abolition of the National Patient Safety Agency as a separate focus of attention in the monitoring of quality? And perhaps the need for it is illustrated by the recent saga in Leeds as well.

Mr Hunt: We have never wavered in our commitment to safety. The question is how you-to use that horrible phrase-mainstream a commitment to safety throughout the whole NHS. I am very confident that safety will be one of the domains that the chief inspector of hospitals looks at when he or she goes round every hospital in the country. It will be a critical part of the definition of success for a hospital-and also, indeed, beyond the hospital sector.

Q475 Andrew Percy: You have picked up on Leeds, and we have heard the phrase "patient safety" used a lot. As you can imagine, in my constituency and across Yorkshire and northern Lincolnshire we have had the word "safety" bandied about in March regarding the Leeds unit, and it has caused considerable concern to my constituents. So first of all, Secretary of State, could you give us your opinion on the events of March with regard to the Leeds unit, which we now know happened a day or two after a High Court case was lost; we had the use of dodgy data and the unit was blamed. All sorts of allegations were thrown up about whistleblowers, when in fact those whistleblowers happened to come from units that just the day before had lost a case in the courts. Could you give us your views on what, frankly, to me as a local MP and to people who use the unit, has been a pretty despicable process?

Mr Hunt: I would not use those words, but let me say straight up that I completely understand the widespread concern in Leeds and neighbouring areas about the future of the heart surgery unit. I understand and appreciate why this is something that people feel extremely strongly about and, indeed, the distress that this kind of issue causes. But I do think we need to have a different approach to safety issues in the NHS. What happened at Bristol and at Mid Staffs was that there was disturbing data, and then there was a big argument about whether the data was any good, and nothing was done in the period where the data existed. The result was that patients continued to be harmed and 30 to 35 children lost their lives, arguably unnecessarily, in Bristol.

I would never want-and I do not think any of us would want-to be in an NHS where we put patient safety at risk. If there is a potential problem, the responsible thing-the only thing-that Bruce Keogh could have done, faced with the information he had, was to say, "We’re going to get to the bottom of this data. We’re going to find out if it’s right or not-but we’re going to suspend heart surgery while we do that." That was absolutely the right decision. I was as delighted as he was, and the people of Leeds were, that, on further investigation, it was found that it was safe to continue. It is also important to say that part of the reason for what you describe as the "dodgy data" was that the hospital themselves did not supply correct and complete data. Also, they have made changes that have persuaded everyone in the system that it is safe to continue. They are not continuing in exactly the way that they were operating previously.

Q476 Andrew Percy: Is it not the case, though, that the situation with Mid Staffordshire was incredibly different, because we had five years of data? This is information that was only a few hours old. Indeed, Dr Cunningham, who is one of the senior strategists at NICOR, has clearly said that the conversation on this data was only the first pass, so it was incomplete data and Sir Bruce Keogh should have known, as the person who established this unit, that this was data that did not really stand the test. I cannot believe that we are hearing that this is a process that can be defended, or indeed a model or a process that we would want to see another unit go through. That does seem strange to those of us in Leeds, particularly when we look at how Bristol was treated in October 2012 when the CQC had ruled that the trust was failing to meet essential standards on quality. There was no heavyhanded approach and suspension there. In November 2012, a coroner found 10 failures over the death of a little girl at Birmingham in 2009. Those units were dealt with differently.

This was dodgy data, and to throw it back at the unit is not acceptable, because this was, as was said by the senior strategist from NICOR, the first pass of the data. I would seek from you, Secretary of State, an assurance that the way Leeds has been treated-which has done huge reputational damage to the unit, not only in the region but nationally, and has caused a huge amount of concern to patients-is not the model that we are going to see used elsewhere in the country. That would then be defended by saying, "Look at Mid Staffs." But the difference with Mid Staffs was that we had five years of data that should have been picked up on. Here we had data that was only a few hours old, which analysts who are used to dealing with this, including Bruce Keogh, should have known was incomplete information. I want to express to you the concern that this has caused, and seek an assurance that we are not going to see this as a model to be used elsewhere in the country.

Mr Hunt: Perhaps I could ask you how you would do it differently. If a hospital supplies incorrect data and the result is that it shows that their mortality rates are two and threequarters higher than what might be expected to be the national average, are you really saying that you think the NHS should not take immediate action?

Q477 Andrew Percy: What I would probably say is that we should follow the Healthcare Quality Improvement Partnership steps, which they clearly set out in their process, whereby they would notify the audit team and have additional scrutiny of the data. Statistical analysis would then be undertaken and the "Lead Clinician…within the provider organisation should be contacted about the potential outlier performance," and asked "to either validate the results, or identify any data errors". Those are the exact steps that are set out by the Healthcare Quality Improvement Partnership, and they do not appear to have been followed here. We had this strange situation where people just appeared with data that was only a few hours old. The unit was not able to test that robustly, and we then had this heavyhanded approach, which was proven to be unnecessary but which has done huge reputational damage-coming, as well, just a day or two after the High Court decision. I would have thought there would have been a conversation with the unit first, to establish whether or not the data was correct.

Mr Hunt: We have to do all those investigations into the data immediately. The question is whether heart surgery should continue while investigations are being carried out into data that indicates that mortality rates may be two and threequarter times higher than they should be. Also, let us be clear that this was not the only concern about what was going on there. There were also concerns about the staffing rota. There were concerns about the referral of more complex cases. There was-as I think Sir Bruce Keogh described it-a constellation of concerns. The only responsible thing to do in that situation is to suspend surgery. I accept that it is more messy to do it that way, but I would ask you whether you would be able to look in the eye the family of someone who was then operated on unsuccessfully, perhaps with fatal consequences, and say that allowing that surgery to continue was the right thing to do while we investigated whether there was a real problem in the data.

I want to say this: I think that is something that I do want to change throughout the NHS. I want people to take patient safety much more seriously than it has been taken in the past, and I do not want operations to continue where there is a serious concern about safety and risks to patients. That is part of the change that we need to see, and that the public want, in response to what happened at Mid Staffs.

Q478 Chair: Is there not a learning experience coming out of Mid Staffs, Leeds, and indeed out of other examples in the health service, that what is required is a realtime process that does identify data that should give rise to patient safety concerns, but also sifts it as part of an ongoing routine-with, of course, the ability to act and intervene quickly if new data becomes available, but to intervene following proper testing of the data?

Mr Hunt: I agree with you, and I think one of the big changes that we are making at the moment is to make surgery survival rates much more transparent. We are rolling them out now to 10 specialties. It has been incredibly successful for adult heart surgery. It is much harder for children’s heart surgery because the actual number of operations is so small. We all need, and the public need, to understand that, where you suspend surgery because there is a concern, it does not mean that there is a problem; it just means you are doing an investigation. We need to understand that the right thing to do, where there may be a problem, is not potentially to put anyone’s life at risk by proceeding.

That is a big cultural change, and I fully accept that we need to learn from what happened on this occasion. Indeed, the other thing we need to recognise is that the rate at which that data becomes available is going to be a gradual process over the next few years as more information reaches the public domain and we get the risk adjustment right. So it is going to be a transition for everyone.

Q479 Andrew Percy: I do not really like the attempt to paint those of us who have criticised this process as if we were in some way prepared to be lax and put patients at risk. In Yorkshire, constituents of mine-indeed, from my area-were put at risk because they were moved to other units while this was going on. This is really the point that the Chairman just made-that we are all happy to support a tough decision if it is backed up by evidence and data. The "constellation" point that is referred to has been thrown out there on a number of occasions, but of course the whistleblowing complaints that formed part of that constellation came from another unit, which had just two days before been a defeated party in court. I don’t want us to be painted as in some way merely supporting our unit-we are all aware of our responsibilities, especially now after Francis-but this came down to a situation where data was used that it should have been clear from the very beginning was obviously dodgy. I still cannot get into my head the reason why Leeds was treated so differently from Bristol and Birmingham, which had had similar complaints. There were other units that had outliers in their data, and Leeds was treated differently. That was my final comment, or question.

Mr Hunt: I need to say that we want to treat concerns about mortality data differently everywhere from now on. This is the lesson from Mid Staffs. I do not think you and I are in any disagreement that, where there is a first cut of data, the most important thing is to get to the bottom of whether or not there is a real problem. Where we may disagree is whether, while you are doing that, you take a decision to suspend the surgery that is happening at a particular place. That needs to be an operational decision based on what the actual risks are to patients.

Andrew Percy: We just don’t want the Leeds model.

Chair: We cannot have a competition for the last word.

Q480 Valerie Vaz: May I stick with Leeds, because it is important to learn the lessons from that? You know that Stafford hospital is very close to my constituency and certain things have happened there that I do want to ask you about, perhaps a bit later. What I would like to find out now is this: when did Sir Bruce Keogh have this information and when did he tell you about it?

Mr Hunt: I found out about the information on 28 March, the day before it went into the public domain. I was informed; it was not my decision, because this is an operational decision. I was following the advice I had from the NHS medical director as to what was the most appropriate course of action with respect to patient safety in Leeds, but I knew the day before it went into the public domain, and on the day it went into the public domain I spoke to three local MPs.

Q481 Valerie Vaz: When did Sir Bruce Keogh have this information?

Mr Hunt: I believe it was-I think he had the information on the Tuesday of that week. I will write to you if it is different information. I think I was told about it on the Thursday.

Q482 Valerie Vaz: So he had the information while the court case was going on.

Mr Hunt: I think the court case is completely irrelevant to this. Professor Keogh has a responsibility-

Q483 Valerie Vaz: I am just asking: did he have the information when the court case was going on?

Mr Hunt: I don’t know the exact dates when the court case was going on.

Q484 Valerie Vaz: Okay, but he had it before he went in and suspended operations at Leeds.

Mr Hunt: There was a short period-

Q485 Valerie Vaz: He had it a while before, did he?

Mr Hunt: I don’t know. I will write to you with the exact date that he had it.

Q486 Valerie Vaz: I think that you should know, because you are the Secretary of State and this was a huge issue which made the front pages of lots of newspapers. It is the kind of thing that people feel they have to do-publicise-and then people feel defeated. They don’t want to do that. The good thing is that the Leeds clinicians fought back; they were on television, but they looked really tired, and they fought back. My key point is: did Sir Bruce Keogh have the information before, and should he not have published that and told people about it?

Mr Hunt: As I say, I will find out and let you know the exact date he got it, but he took a pretty rapid decision based on his operational belief as to what was the prudent thing to do on the basis that there might be a risk to patient safety. I think he took exactly the right decision.

Q487 Valerie Vaz: That, as well, may be. So he has this data and goes in. When did he verify it with the hospital?

Mr Hunt: He had immediate discussions with the hospital, but the question that caused the controversy was what happened-

Q488 Valerie Vaz: Was it on the day that he suspended it?

Mr Hunt: The decision was taken to get to the bottom of what had happened with the data, and he informed me at the time that this was going to be a matter of weeks, not months. But the difficult decision was whether to carry on with surgery in the meantime. I think he rightly decided that, where there was a possibility of danger to patients, the prudent thing to do was to suspend surgery in the meantime.

Q489 Valerie Vaz: So he did not discuss his version of his data with the hospital. He did not ask them for their data.

Mr Hunt: It was not his-

Q490 Valerie Vaz: Did he say, "My data’s correct; your data’s wrong. Have you got any data?" This is quite key, isn’t it? As you say-and we all agree, and I totally understand, what you are trying to do with transparency-the point about transparency is, "Is all this data publishable?" The plea to come out from here is to make this publishable so that people know what they are talking about. He may have correct data, but did he check it with the appropriate people, and was it the correct data? I thought that was the argument, wasn’t it, because they did not have the same data?

Mr Hunt: Let us first of all be clear. It is not "his set of data" and "their set of data".

Q491 Valerie Vaz: It is his decision. He is making the decision, isn’t he?

Mr Hunt: The data that we are talking about is the data that was supplied by the hospital, and that was deficient.

Q492 Valerie Vaz: To him?

Mr Hunt: To the system, not specifically to him. That data was deficient in some pretty important details, such as the weight of the children who had operations. That is an important part of the risk adjustment process that you do to decide what excess mortality is. When he was informed about this data it was a first cut of data, so it was right that that kind of data should not be published until you have properly drilled down and got to the bottom of it. Then I agree with you entirely that we do want to have a system where that data is made available to the public much more quickly. That is what we are working towards, and there is a big transparency revolution.

Just as an aside, one of the problems with Mid Staffs was that there were issues that bits of the system knew about but the public did not. That is what we want to avoid. So, yes, we do want that data to be made publicly available as soon as possible.

Q493 Dr Wollaston: Secretary of State, isn’t there a wider issue that has been missed here, which goes back to the Bristol heart scandal-the fact that all paediatric cardiac patients are going to be safer if we have a smaller number of larger units? Are we going to be able to get away from this idea about which unit has different mortalities, grasp the nettle and say we need to have a smaller number of units and not have a system where everybody is fighting for their own personal unit? How are you going to drive that forward so as to put the safety of all patients across the whole NHS at the top of the agenda?

Mr Hunt: Trust you to get to the nub of the issue, and that is the substantive issue. I would be delighted to discuss that with you in great detail on another occasion, but because that is what "Safe and Sustainable" is, and "Safe and Sustainable" is subject to legal proceedings at the moment and I have to make a final decision on this, based on what the independent reconfiguration panel says, I will not comment on that with respect to children’s heart surgery, if you don’t mind. But I can say to you that I accept the clinical case that in a number of areas-I think the best example is what has happened to stroke care in London; London is now the safest place in the country to have a stroke, because they reduced the number of hospitals looking after people with strokes, I think from 32 to 8, and halved the stroke mortality rate in the process-there is a very big body of clinical evidence about that.

Q494 Dr Wollaston: So do we need to change the procedures so that these things can happen more efficiently, and people can understand and be very clear that that is the way we prioritise patient safety?

Mr Hunt: That is one of the reasons why we need to have much more transparency about that data. I think the public do understand that certain, more complex, needs need to be treated in fewer places, where specialist expertise can be developed and they can get the best possible treatment as a result. So I think there is that understanding. There is something else, though. Even when you have the right number of places-for example, cancer treatment, rightly, is given in many hospitals across the country-publishing mortality rate variations can be very helpful in identifying outlying practice and where the right procedures are not being followed. We have seen some extraordinary improvements in heart surgery performance after the pioneering work by Ben Bridgewater and Bruce Keogh in publishing heart surgery survival rates. There is a benefit, even if you are not thinking about it in terms of potential consolidation of where surgery happens.

David Tredinnick: I would like to move on to talk about duty of candour.

Q495 Valerie Vaz: Before you move on, Secretary of State, I want to ask you, if it is possible-I know there is lots of different information coming out, but it would be very helpful if you could do this-for the public generally, either to write to the Committee or put on your website a timeline of who knew what and when in terms of Leeds? That would help us to move forward, and help with how to handle future situations.

Mr Hunt: I am more than happy to do so.

Valerie Vaz: Thank you.

Q496 David Tredinnick: You have accepted the Francis recommendation for a statutory duty of candour to apply in cases where hospital errors have led to the death or serious injury of a patient. As I understand it, this duty is to sit alongside an existing contractual duty of candour in standard contracts between commissioners and providers to be "open and honest with patients when things go wrong". What penalties are there for providers if they breach the contractual duty of candour they have with commissioners?

Mr Hunt: That is something that we will be coming to in due course, but it depends on whether the responsibility lies with an individual or an organisation. The point is that we think that providers should have a duty in law to be transparent with people when they have done harm, and we accept that. What we have said that we are going to wait to decide is whether individuals should have criminal responsibility for breaching that statutory duty of candour. That is one of the things that Robert Francis has asked us to consider. The reason why we are not announcing our decision on that at this stage is because we want to wait for the Don Berwick safety review.

The most important thing in all of this is to create a culture of openness, in which where there are mistakes they are admitted, and patients and families know as quickly as possible. We want to make sure that there are not any negative consequences in terms of the worry people have, because you might in fact end up with a culture of fear where, if someone has done the wrong thing and a colleague talks about it, there is the potential for a criminal investigation. We gave our initial response very quickly because we wanted to get cracking, but that was an area where we did not want to rush in and to make a wrong decision.

Q497 David Tredinnick: It is work in progress. There is work to be done on this.

Mr Hunt: Correct.

Q498 Barbara Keeley: May I ask an additional question on the definitions around where hospital errors have led to death or serious injury to a patient? It strikes me that there is also the issue of where a relative, as a patient, has died in very bad circumstances. So the care didn’t lead to harm in the sense of a death or injury-maybe the person was going to die at some point anyway-but it comes through clearly from the Francis report how many families were distressed because of the way that their relative died. As we are concerned about palliative care, that is an important thing too. If they feel guilty about the way that their mother, father or sibling died, that is a harm that people, in my experience, do not get over.

Mr Hunt: I completely agree with that. Let me be clear that just because someone might have died within a few weeks or months anyway, it does not mean that a hospital would not, under the statutory duty of candour, have an obligation to tell family if they thought they were responsible, because of poor care, for that death happening earlier than it might have happened. There is no getout in that respect at all.

I also want to make the point that we want there to be openness and candour where there is any type of harm. So it is not just about where there is serious injury or death. But when you are talking about statutory duties backed by laws passed in this place, you do have to be careful. As I say, what we are trying to do is to get this tricky balance right so that we do not overlegislate and make the overriding concern in hospitals one about people protecting their legal backsides. We want people to feel that where there is harm, where things go wrong, the normal and right course of action is to be open with everyone about it.

Q499 David Tredinnick: Following on from Barbara’s question, do you accept that relatives should have a remedy where hospitals have breached a statutory duty of candour?

Mr Hunt: They will. That is what a statutory duty of candour is. They will have recourse under the law. The hospital will have broken the law.

Q500 David Tredinnick: What form should that remedy take, over and above compliance with the duty?

Mr Hunt: We have said we accept that there will be legal recourse-that it will be against the law-but precisely what the penalties will be is something we are looking into at the moment.

Q501 David Tredinnick: Finally on this, it seems that you are proposing two duties of candour. On the one hand you have a contractual one, and then you have a statutory one as well. Doesn’t this risk causing a lot of confusion among providers and the public?

Mr Hunt: No. Contractual duty of candour applies to everything; it is a standard part of all NHS contracts. What it is saying to people working inside the NHS is, "It is your contractual responsibility as part of working at this hospital"-or in this NHS establishment- "that if you are responsible for patient harm, or if you see patient harm, you tell someone about it." That is part of people’s contracts. What we are saying is that there will be a statutory duty on organisations to make sure that people who are harmed, or their families, are told, where this has led to serious harm or death. It is a higher grade, if you like, for the organisation. We have also said that there will be criminal liability on organisations if they deliberately supply misleading information about things like mortality rates. We are raising the bar in terms of the potential sanctions at organisation level, but we are going to wait until Don Berwick completes his review before we decide whether that should apply to people at an individual level as well.

Q502 Chair: If there is already a contractual duty of candour and there is somebody, in the form of a commissioner, who has a duty to enforce the contractual duty of candour, why do you think it would be any more effective to have what would effectively be a duty at large to be candid?

Mr Hunt: Because we have had the contractual duty of candour for some time, and we are trying to send a signal that this really matters, that this is a board-level responsibility on providers. We want it to be absolutely clear to them that this is a legal responsibility.

Q503 Chair: Who enforces it?

Mr Hunt: The board will be legally liable. Families-

Q504 Chair: If the board has failed?

Mr Hunt: If the board failed, the family could take-

Q505 Chair: But how do the families find out if someone has not been candid?

Mr Hunt: That is what we are trying to change. We are trying to make it much easier for them to find out. We are trying to change the culture when it comes to whistleblowing, for example, so that it is not possible for whistleblowers to be suppressed as has happened in the past. If I may say so, Chairman, that is precisely the reason why we are hesitating before introducing criminal responsibility at every level of an organisation. We do not want largescale coverups. We want a culture where NHS employees do come forward if they know something has gone wrong.

Q506 Barbara Keeley: I would like to move on to staffing levels, because resources are a key issue in the Francis report, particularly the issue of adequate staffing levels, and publication of those. I have raised with you here in this place issues about that, and there are polls and surveys which seem to indicate concern. Nurse managers, for instance, in a recent poll expressed concern about unsafe staffing levels on three quarters of hospital wards, and one third report staffing levels that are unsafe on a weekly basis. Some say that that can be the case on every single shift. As a member of this Committee, I get people who tweet me. A nurse in the NHS was telling me, via Twitter, that the ratio she was having to work with was 2:29. It is very disturbing if that is happening, and she persists in telling me that that goes on at her hospital; I don’t know which hospital it is.

Francis recommendation 93 says, "The NHS Litigation Authority should introduce relation to staffing levels". Francis also recommends that "The procedures and metrics produced by NICE should include evidencebased tools for establishing the staffing needs of each service." You mentioned-I am sure they will be delighted-that Salford Royal as a very safe hospital. I know that they pay very great attention to this issue and they think it is very important that there is transparency. Why can we not have a recommendation to say both that these levels have to be established and that they have to be known? If nurses are very concerned about this-nurse managers are very concerned about it and people are tweeting members of this Committee telling us that it is 2:29 in their hospital-and yet we have very good safe hospitals like Salford that take it as read that all this information should be in the public domain, why not just recommend that the information should be put out there in the public domain by every hospital every day? Let the public decide if they think 2:29 is adequate-and of course they will not think it is adequate.

Mr Hunt: First of all, we are accepting that recommendation by Robert Francis. What we are not doing is saying that we are going to mandate from the centre. Indeed, I think Robert Francis told this Committee that he did not think it would be right for a Secretary of State or Minister to mandate staffing levels.

Q507 Barbara Keeley: But he did say, "The procedures and metrics produced by NICE should include evidencebased tools for establishing the staffing needs of each service." That is what good hospitals do.

Mr Hunt: I agree. That is what we agree with, and I accept that recommendation. What is interesting at Salford Royal is that they have a tool that changes on a daily basis. If an additional three frail elderly patients are admitted to a ward, that changes the requirement that day on a particular ward and they are able to react, whereas other hospitals do not check their staffing levels except periodically, maybe even only every few months. That very much is best practice, and that is what we want to see happening. The way that we will make sure that it happens is by having every hospital in the country inspected against that standard. So we will look at whether they have adequate staffing.

Q508 Barbara Keeley: But will it not fall off in between? Inspections cannot be every week, can they? You are saying that this is not checked enough-that it is not checked in the way that Salford check it, every day, or changed according to patient needs. I do not know how often inspections will take place, but one hospital could let it drift miles away from where it should be, and then we could be in a situation with two nurses to 29 patients, which is not acceptable.

Mr Hunt: That is why we will have the inspections, but we will also have a lot of data that is available much more frequently than just when an inspection happens, on things like mortality rates. Also there will be lots of other data on a hospitalbyhospital basis, as we have now, but much greater than the current level. I will certainly look into whether staffing levels are one of the things that should be included in what is published.

Q509 Barbara Keeley: There is no better way than just having each hospital publish it.

Una O’Brien: I completely agree with the Secretary of State. The essence of this is timely transparent data. We need to make sure that the tools are fit for purpose. There needs to be more work on the quality of evidence behind the tools. The second stage is to ensure that they are systematically adopted and, thirdly, that there is adjustment and management on a daily basis. I know from my own experience of working in a hospital just how things can change within a shift. That is a really tough thing to get right systematically across every ward, across every hospital, but it is an ambition that we must have. The critical thing we need is the Salford Royal example, where data is visible on a daily basis to patients and visitors-and that must be the goal that we set ourselves.

Q510 Barbara Keeley: If they can do it, everyone can do it.

Una O’Brien: That is exactly the point.

Q511 Andrew George: Following on from there, Secretary of State, if you are saying that you agree with Robert Francis that these levels should not be mandated from the centre, can we perhaps go down one notch, as it were, and say, "Look, let’s not go for mandatory; let’s go for guidance levels on hospital wards"? If we are to have these tools and the transparency available and, let us say, the information is published, how are we to then judge and assess? Would you not agree that if you are going to have these tools-all this data is being published but no one actually has any kind of guidance or benchmark against which they are then going to judge it-it should be no to mandatory but yes to guidance levels of registered nurses on hospital wards?

Mr Hunt: When I say no to mandatory I am saying no to me mandating it. The problem is that if it is done by a Minister, it is a very blunt tool: "This is the number of patients you have. This is the mandatory ratio of nurses to patients and healthcare assistants to patients." Also there is a danger, I think, if you do that, that a hospital could think that that is the end of the story as long as they are meeting what the Minister says about the number of nurses. Numbers matter, but nurse training also matters, as does the attitude of the people in the hospital. The investment in technology matters, too, because that will have a big impact on whether nurses spend a lot of time filling out paperwork or whether they can spend time with patients. So there are a lot of other factors. What that Robert Francis recommendation says is that every hospital should have a proper tool that is able to guide it accurately as to the number of staff needed. That is what we are talking to NICE about at the moment. Then we will be inspecting them against the use of that tool. As Barbara said, that happens on a daily basis in our best hospitals and that is the kind of practice that we would like to see spread out.

I have one final point. I think that the measure of this-and it is very important, if hospitals are going to succeed, that we do not start telling them how to run their internal processes-is how well patients are looked after. One of the key things that the chief inspector will be looking at is the patient experience-things like whether people say they would want their friends or family to be treated there, how the complaints procedure works, patient safety, all those kinds of things, and whether staff would want to treat their own family in their own hospital. Those are very good early-warning systems if people are getting their staffing levels wrong.

Q512 Andrew George: That is helpful. The message that we have had from your chief nursing officer and from others-the mantra coming from the Department, if you do not mind me using that expression-is that it is not about staffing levels; it is about culture and leadership. If I were to give you a single transferrable vote option and to offer you staffing levels, leadership and culture, which order would you place them in?

Valerie Vaz: It’s a Lib Dem proposal.

Andrew George: Joking aside.

Mr Hunt: My predecessor would shoot me if he thought that any mantras were coming from the Department of Health after the Health and Social Care Act.

Andrew George: Put that word aside, then.

Mr Hunt: Let me answer your question-and this is going to sound like a terrible fudge but it really is not. If you read the Francis report and what went wrong at Mid Staffs, it is clear that it is all of those things. It is clear that they skimped on staff-and that was a terrible thing to do-and that they cut corners. They were trying to get rid of their deficit in order to get foundation trust status. It is clear that the leadership was utterly appalling. What was your third one?

Q513 Andrew George: Culture.

Mr Hunt: It is clear that the culture was completely wrong. That is why when we designed the new inspection regime I was very keen that it should not just look at a single measure. What people are concerned about at the moment is patient care, compassionate care and patient experience, but it is important that this new regime looks at what a hospital needs to do holistically. So it looks at all these different things-culture, leadership, numbers, safety, clinical outcomes-and comes to a holistic view of what a hospital is there to do. In that way we can avoid what I think happened before: there was a big national focus-much needed-on bringing down waiting times, but in some hospitals, particularly where there was weak or bad leadership, that happened to the exclusion of other important things. As a result, you got a very warped outcome.

Q514 Andrew George: Yes, I do think it was a fudge, but nevertheless I respect the response. You are saying that mandatory staffing levels are not a route down which you would be prepared to go. Given that in fact there are mandatory levels in paediatrics and intensive care, do you think that is something that should be done away with?

Mr Hunt: We should follow clinical evidence on these things. If clinical best practice says we need to have a certain staffing level, that is what we should have. What I am nervous about is Ministers dictating that, because very often these things change on a daily basis, certainly in terms of the pressures on something like an ICU.

Q515 Andrew George: I do not think anyone is suggesting that it should be politically rather than clinically inspired.

Mr Hunt: That is a great relief, I am sure, to the 3 million people who use the NHS every week.

Q516 Andrew George: Moving on to your statement to the House on 26 March, and the announcement that you would make it a prerequisite for NHS-funded student nurses to spend up to a year working on the front line as healthcare support workers, you went on to say, "That will ensure that people who become nurses have the right values and understand their role." Is it only nurses that you need to ensure have the right values, or is it doctors, managers, Secretaries of State and others? Are there others who we can ensure have the right values only by making them work as healthcare support workers first, before they are allowed to perform their professional function?

Mr Hunt: If you are suggesting that everyone who wants to be Secretary of State for Health should work as a healthcare assistant, actually I do think that everyone involved in health policy should get experience on the front line. I have been trying to go out on the front line every week over the last month. and I have learned a huge amount from doing it. That is not just the royal visit of the Health Secretary arriving in the hospital, but actually rolling up your sleeves and getting involved in frontline work. I think it is an incredibly important thing to do. Una is putting in place a plan for all Department of Health civil servants to do the same. It is very important, and I would say that it absolutely applies to every part of the health service, including managers.

With regard to nursing, it is very important to say that the vast majority of nurses do an absolutely brilliant job, but we do need to make sure that people go into nursing with the right values. What Health Education England says is that there is a big dropoff, which costs the NHS a lot of money, when people start to do practical experience in the wards as part of their nursing degree. It therefore thinks it would be much better if people had this experience first and could then really see whether they were right for nursing before being accepted for a place on a nursing degree-a place that someone else could have taken-when in fact it was not right for them.

Q517 Andrew George: So this is a mandatory stipulation coming from the centre. I just wanted to be clear that, if you are going to do this, you are in effect saying that nurses are uniquely, if you like, guilty of not coming to their role with the right values, because it appears to me that you have picked on that profession.

Mr Hunt: Not at all. If you look at that response, you will see that we propose different measures for all the people who are involved in different parts of the NHS. There was a widespread view that there are some issues with nursing that came out in the Francis report that need to be sorted out, but we have also proposed some pretty important changes for healthcare assistants, for managers, for civil servants and for politicians.

Q518 Barbara Keeley: Why did you change the period from three months to a year, though? That seems to be a key point.

Mr Hunt: I don’t think it is that big a change. He said "at least three months" and we have said "up to a year".

Q519 Barbara Keeley: But nurses seem to think it is a year. You have had quite a kickback against it, haven’t you?

Mr Hunt: From some nursing leaders. There is also a great deal of support for it in parts of the nursing profession, particularly among some older nurses, who recognise this as being quite similar to how nurse training used to be.

Q520 Andrew George: It is nurse preceptorships, which were, if you like, a casualty of Project 2000. In a sense, being a nurse preceptor is quite a different role, though, isn’t it, to working as a healthcare assistant? Is that not the reintroduction of nurse preceptorships for students? Indeed, for postgraduates, provided they were properly paid, that might be an option that you would be prepared to support, particularly if they were supernumerary.

Una O’Brien: We certainly need to look at the practicalities of this, which is why we have been very clear with Health Education England that the first step is to pilot it, because there are different perspectives that need to be tested in order to make it work. The one point that I think is perhaps worth drawing and adding to what the Secretary of State has just said is this. While it is true that we have to recruit for values across the piece for all professions, in the end it is the nurses who coach, train and line manage healthcare assistants on the ward. So they are in a unique relationship to that part of the work force. That provides a linkage between what the aspirant trainee nurse does and the actual outcome of how good they are in that supervisory role at the end of it. One of the lessons from the Francis report is the sense of a disconnect between the role of the healthcare assistant and the role of the qualified nurse; that was never intended by policy but it actually turned out to be the case in practice. What we want to see now is a much broader continuum drawn between those two very important professional roles.

Q521 Andrew George: We do not have time to move on to the practicalities of who employs, who pays and so on-perhaps we might later-because I am being urged to move on, which I will. Perhaps we might seek a written note on that, if I may be so bold as to ask.

Coming on to the issue of whistleblowing-certainly the welcome indication that the Government will be responding to the Francis proposals, particularly to enhance the protection for whistleblowers-and moving on from the last set of questions in a sense, if you are whistleblowing to the public or the press you then perhaps get the protective blanket of enhanced protection. In fact what we need to ensure is a culture of proper reporting of inadequate staffing levels-a very strong theme that clearly comes through the Mid Staffs report-and that members of staff are protected and their concerns are respected, and not dismissed in the way that the Mid Staffs example showed. This is prewhistleblowing in a sense. What can you say will protect members of staff who raise these issues so that they will not have their professionalism undermined as a result of doing so?

Mr Hunt: You are absolutely right. In a way, if you have whistleblowing, the system has failed, because you have reached a point where something has gone seriously wrong and someone thinks their only option is to tell the press or write to someone outside the organisation. We are trying to create a culture where when things go wrong-things go wrong in all large organisations, indeed in all organisations-they are dealt with immediately. The best example of where we would like to see real change is in the way that hospital complaints procedures work. That is a living, breathing way of hospitals finding out how things may not be going the way that they should.

The real change we need there is to make sure that all hospitals do what many hospitals do already, and use the complaints procedure as a way to drive change in behaviour. That is why the work that Ann Clwyd and Tricia Hart are doing is so important. Most of the time, the people who are complaining want just one thing: they want to know that the NHS has learned from the mistake that they experienced. So it is about that cultural change. That is why one of the things that the chief inspector will be looking at when he or she goes round hospitals is the culture in hospitals. One of the questions that all staff are asked in NHS hospitals is whether they feel able to speak out if they see things going wrong with respect to patient care. There is a metric there, but we have to be careful not to overemphasise metrics. We also have to allow inspectors to smell the atmosphere in a hospital and actually decide whether they feel the culture is right. It is a big change. I think we can get there, though.

Q522 Chair: Do you agree with the proposition that it is one thing to go and ask a member of staff whether they feel able to raise concerns, but that a rather more tangible version of the same question is for an inspector on a visit to a hospital to ask to be shown the evidence of when concerns have been raised? If you have a hospital department where no concern has been raised about an untoward event for a whole 12month period, that probably tells you something about the culture in the department, doesn’t it?

Mr Hunt: I would go even further, Mr Chairman, and say that the inspector should ask for evidence as to what has changed in the hospital’s procedures and behaviour as a result of complaints from the public. That is the real evidence that there is a listening, open culture.

Q523 Grahame M. Morris: My question is on the same theme, Secretary of State, regarding this culture of openness and candour. You said that, if we are talking about whistleblowers, the system has failed. You reminded us that you had written to all the NHS trusts to tell them about their obligations about public interest disclosures and to ensure that any confidentiality clauses in agreements with former employees embraced the spirit of the guidance that you had issued. Does that guidance negate the need for gagging clauses now? I am rather alarmed, when colleagues are raising issues about staffing levels, that you say, "I'm the Secretary of State now. That’s devolved, and I can only give guidance." Most people would think that it is not rocket science, in the care of the elderly, to come up with a number for the staffing ratio and then staff can judge, "This is an issue and we should be raising it as a concern." I am wondering whether it applies here in relation to gagging clauses as well.

Mr Hunt: The Secretary of State has the ability to issue fiats, commands-and mantras even, Mr George-in any range of areas, but the question is where it is appropriate to do so. When it comes to something like staffing numbers, which can change on a daytoday and a wardby ward basis, what is much more important than the Secretary of State deciding what those staffing numbers should be is to have a standard based on a proper tool. That is what we are working on with NICE, to see how that could be developed so that staffing numbers properly reflect the pressures on a ward at any particular hour. That is the critical thing. There are some things that happen NHSwide. One of them is some of the contracts that are used, and one of the clauses that has typically been in some of the compromise agreements when NHS staff have left the employment of the NHS has been a clause that prevents them from speaking out. If agreements are over a certain value, they have to be approved centrally-not by the Department of Health, but by the Treasury-and we have made it clear that we will not approve any of those contracts unless they explicitly say that people will be free to continue to speak out on matters of patient safety.

Q524 Grahame M. Morris: Does that mean, Secretary of State, if I could press you on that, that there really should not be any need for gagging clauses, and that any contracts that have already been signed with gagging clauses simply do not apply, so you would encourage people who had concerns as whistleblowers-or whatever we wish to call them-to speak out?

Mr Hunt: Yes.

Q525 Grahame M. Morris: That is very definite and I appreciate that. May I ask you another question on the same kind of subject in relation to fairness and transparency? Do you think that freedom of information requests should also apply to private sector health companies who are providers within the NHS?

Mr Hunt: I think private sector health companies should operate on a level playing field with public sector providers in the system. Certainly, when it comes to transparency, that should apply as well. My particular concern would be things like survival rates, mortality rates and the success rates of different surgical operations. But my basic principle in this would be a level playing field.

Q526 Grahame M. Morris: It is possible for private sector companies who are bidding for public sector work in the health service in particular to disaggregate a contract in terms of FOIs. One of the big elements, of course, is staffing levels, and it is not possible to do that with a private sector provider. Would you agree that that should be addressed and do you intend to do it?

Mr Hunt: Clinical commissioning groups have a responsibility to commission in the best interests of patients, so I would expect them in their commissioning to make sure that any contracts they signed were with organisations that had the right staffing levels. That is an absolutely fundamental point. Clinical commissioning groups are led by GPs, so they would not want it any different.

Una O’Brien: Perhaps it is worth adding that, of course, any organisation-whether third sector or private sector-that is providing health services has to be registered with the CQC and is subject to the CQC inspection regime. The combination of inspection and contract are the two critical levers to drive transparency in nonNHS providers.

Q527 Grahame M. Morris: There is a better way to do it. There is an instruction that could be given by the Secretary of State to say it would apply. Is it correct that Monitor is recommending that? May I take issue with the Secretary of State’s answer that clinical commissioning groups would not compromise numbers? Perhaps there is a potential that they might if they have a financial interest in so doing, if they derived a greater return. You are suggesting that is inconceivable. I think it is conceivable.

Mr Hunt: If I may come in here, what the Permanent Secretary is saying is that you have a double lock on private sector providers, not only in terms of the way they are commissioned-CCGs will be commissioning in patients’ interests-but also because they will be subject to the same inspection regime. With regard to conflicts, let us be absolutely clear. The CCGs have to publish-we have put this in primary legislation, which was not the case before-any potential conflicts of interest to make sure that there are no doctors who are making decisions in areas that could benefit them financially. Again, that transparency is going to work in terms of making sure that CCGs do act in the interests of the people that they are commissioning care for, and not in their personal financial interests.

Chair: Predictably, this is arousing some interest.

Q528 Barbara Keeley: May I take you back to what you said about gagging clauses, Secretary of State? You talked about the checking being related to the process of Treasury signoff. But when we talked about this in the case of the United Lincolnshire Hospitals Trust, which we did a few weeks ago, David Nicholson told us-he had told us previously-that there was no Treasury signoff. That is one of the most shocking things about that really quite large amount of money. There was no Treasury signoff because there is a loophole if the arrangement relates to an employment tribunal, as it did in that case. You would have no mechanism at ministerial level if there were another such case. It does seem, particularly in the case of that one, which was quite large, that we should not have loopholes like that, should we?

Una O’Brien: Very simply, we have closed the loophole.

Q529 Barbara Keeley: How have you done that?

Una O’Brien: The Treasury guidance has been changed since this came to light.

Q530 Barbara Keeley: Whatever the status, judicial or otherwise.

Una O’Brien: Yes. It has to have the same level of approval.

Q531 Dr Wollaston: Does this indicate that it is sometimes difficult to hold private providers to account for sticking to their contract if you cannot see the full details of the contract and the financial background to it, particularly where halfway through, perhaps, it is found not to be viable and the terms are changed? Do you think it is reasonable for the public to be able to see and hold these companies to account properly by seeing all the details?

Mr Hunt: They should absolutely be held to account. As I say, we should have a level playing field in that respect. We also want to encourage innovation, but I do not think private companies should have anything to fear from transparency in what they do.

Q532 Dr Wollaston: Would you say that they should be subject to FOIs-that they should have to put in all the details? As I say, it is about having transparency and having that army of armchair accountants looking at what is happening and holding them to account. What would be the argument against publishing?

Mr Hunt: We have to have a fair playing field. That is the crucial thing. As for what actually happens, this is something that, as you know, Monitor has been looking at in quite a lot of detail, and there are some things that are easier for private companies and independent sector organisations, and some that are easier for NHS organisations, across a whole range of things. But when it comes to transparency in a way that impacts on patient safety, it needs to apply across the board. When it comes to inspection regimes and CQC licensing, those are issues that override that and need to apply to everyone.

Q533 Andrew George: I have a brief question going back to gagging clauses. Last year we produced a report on the CQC in which we raised, among a number of issues, the treatment of Kay Sheldon. Given that reappointments are in the process of being determined, in relation to that and to ensuring that an organisation internally follows the practice that you are advising, will you be taking an overview on ensuring that those who have blown the whistle on an organisation, like Kay Sheldon within the CQC, will not have their reappointment compromised as a result of any internal ill feeling which may still exist?

Mr Hunt: I do want to make sure that people’s own future is not compromised if they whistleblow about something that they are concerned about. In this particular case there is a longrunning history of acrimony between Kay Sheldon and the CQC board. I am going to be meeting her, so I will withhold any judgment about the individual case until I have had that meeting. What I would say is that I think the CQC itself has changed very dramatically in the last few months since the appointment of David Prior and David Behan and there is a real determination to embrace a new role-to be, if you like, the nation’s whistleblower-in-chief, and to root out failure without fear or favour. I think they are really rising to that challenge. So, when I read things in the press about CQC failure, I think it is important to put it in the context of an organisation that is going through very significant improvement.

Q534 Mr Sharma: My question is regarding patient feedback. The report indicates that there was a very low response, or patients were not responding or giving feedback, but that whatever feedback was given was late; data was not collected in time. Now there is a further response from the Government about improving the performance and getting more response, about whether it could be friends and families responding, and how we get it. My question is: how good will the "friends and family" test be as a genuine measure of patient feedback?

Mr Hunt: The answer is that it is an important measure. I think it is already making a difference. It is being rolled out across the NHS from this month for in-patients and A and E, and from September for maternity. It is an important thing to do, but it is also important to say that it is only one measure. It is really important that we do not hang our hat on absolutely everything to do with patient experience being about friends and family. It is very significant that we are asking the question. The staff "friends and family" test is even more significant, asking staff whether they would want their own friends or family to be treated in their own hospital. It is pretty shocking that there are five hospitals where a quarter or more of staff would not want their own friends or family to be treated in their hospital. But I think it is important that these are judgments made in the round, which is why one of the key areas that the new chief inspector of hospitals will be looking at will be the patient experience. They will look at "friends and family" and the complaints procedure. They will talk to people and make an overall judgment about patient experience. I think it is important in that context.

Q535 Mr Sharma: Do you say that action will be taken against providers who have low ratings on the test? What action would be appropriate?

Mr Hunt: There are two types of low ratings. There are low ratings in the context of a breach of what Robert Francis called "fundamental standards", such as patients not being fed or washed properly, not being given water or not being given the right medicines. In that situation the new system is designed to create a failure regime which makes it impossible for the system not to sort out the problem. There will be a timelimited period within which any of those breaches have to be sorted out, and if they are not, the hospital will go into administration. So there is that type of event. Then there is another situation where a hospital gets a low score but is not in breach of fundamental standards, and it needs to improve. That would be very similar to schools that get a disappointing Ofsted report. What you hope is that publishing the fact that things are not well creates pressure on the board to improve. That is one of the exciting changes that have happened in the state education system-that most schools do see themselves on a journey where they are trying to raise standards. Whatever they got from Ofsted, they are trying to do better next time. I hope that is what will happen with the majority of NHS hospitals.

Q536 Valerie Vaz: Have you ever been into a school where they got a low Ofsted and seen the morale of the teachers and students? Sometimes it is not very helpful, is it?

Mr Hunt: Actually, I would disagree with that. I think where you have a poor-

Q537 Valerie Vaz: You have not been a teacher, though, have you, so-

Mr Hunt: I have been into schools that have had disappointing Ofsteds, yes.

Q538 Valerie Vaz: You haven’t been a teacher, though, or a pupil who-

Mr Hunt: Yes, but I am perfectly aware that morale is low in schools that are given a bad Ofsted, but the question is: do you want to expose that problem, deal with it and address it, or do you try and pretend that problem is not there? I think the right thing to do is to address that problem-[Interruption]-as other problems are being addressed as we speak.

Valerie Vaz: Are you trying to escape?

Q539 Grahame M. Morris: Very quickly, I wonder if I could ask you the "family and friends" question, Secretary of State-not that you are either family or friend-but just in terms of not only whether you would recommend the service but whether you and your family actually use it. I am intrigued to know.

Mr Hunt: Are you talking about the NHS?

Q540 Grahame M. Morris: Yes.

Mr Hunt: Yes. Both my children were born on the NHS and I had an operation on the NHS last year, so yes, absolutely. Indeed, I would recommend the service that I received warmly. I thought it was absolutely excellent.

Q541 Dr Wollaston: Moving on to the response to complaints, one of the issues that we found in our inquiry was that many complainants felt they were treated as the problem rather than the issue that they were complaining about. This has been talked about in the NHS for a long time. What do you see as the real change that would make that culture change happen?

Mr Hunt: This was brought alive to me in a conversation I had with Professor Don Berwick, who is doing the safety review. He talked about the performance of hospitals with regard to safety as being on a classic bell curve, where there are some outstanding performers and some terrible performers, with the majority being somewhere in the middle. He said that the most important thing when it came to patient safety was for there to be a learning atmosphere, so that wherever you came on that curve you felt you were on some kind of journey. This is a slightly oblique answer, but we need a system that treats differently organisations where, although they may be in a bad place on the curve, there is a dynamic management determined to address those problems, and places where that management is not in place and they need some root-and-branch changes. For me, that is where a complaints system is so important. Wellrun organisations, not just in the NHS but anywhere, really value their complaints procedure because that is a way of finding out what they are doing well and what they are not doing well. It is the impact it has on your daily operations-how much you use it to learn-that is the key thing.

Q542 Dr Wollaston: So that is what you will be using as the marker-how much they are using it to learn-and different institutions will be at a different place and need more intensive change.

Mr Hunt: Yes. I want to be careful, because we will be going out over the summer for proper public consultation about how the inspection regime will work, and that is one of the things that we will be asking people about. But, if you ask me what I have concluded about how complaints procedures need to work, it is that.

Q543 Chair: One of the things that came out of the Francis report was his concept of fundamental standards. This reflects a debate we had with the previous management of CQC-whether CQC is there to regulate to a basic level or to facilitate improvement to the aspirational level. Out of that discussion came a difficulty with focusing on fundamental standards as Robert Francis appears to see them. How do you see that debate? Are you confident that it is possible to deliver a definition of a fundamental standard that does not sound minimalist and tolerant of poor quality?

Mr Hunt: It is a very important question, and I would say that is probably the big change that the Government’s response to the Francis report heralds. We do believe that the CQC needs to be there to drive improvement across the system and not just to monitor breaches in fundamental standards. When I read Francis and reflected on my own experience in the last few months it was clear that there is a huge amount of regulatory complexity, and with the system as it currently stands, it is very hard to work out precisely which organisation is responsible for what. That was one of the big problems with Mid Staffs as well. So we concluded, after a lot of discussions, that it was very important that across the system you have one definition of success for what a hospital should be, that one organisation should be responsible for making that judgment, and that that organisation therefore needs to be responsible, first for checking whether there have been breaches of fundamental standards, but also where on that bell curve a hospital sits in terms of overall performance.

That is why we decided to adopt the model that we have with the CQC. It also means, incidentally, removing from the CQC a very important responsibility-the responsibility it currently has to be part of the solution. We have removed the ability for the CQC to issue enforcement powers. That will be going to Monitor, because we do not want the CQC to be conflicted where there is a problem. We want the CQC to be the people who say, "Yes, this hospital does meet its fundamental standards," or, "No, it does not." Then it is other people’s responsibility-NHS England, Monitor and so on-to put the problem right.

Q544 Chair: Its role is described as that of a regulator, but it is more of a measuring device.

Mr Hunt: I think the CQC are the people who will drive higher standards throughout the NHS and also be the-

Q545 Chair: That rather leaves open the question: what is the role of the Commissioning Board?

Mr Hunt: They are the independent judge. The Commissioning Board has a huge role in driving up those standards through its oversight of the CCGs, through the contractual commissioning arrangements. But in the end you need a referee, an independent judge, as to whether those standards have been reached or not. That will be the job of the chief inspector of hospitals.

Una O’Brien: I think it is fair to say that we would accept the Francis recommendations on the distinction between the fundamental standards, on the one hand, and, on the other, the standards to push at the boundary of excellence, which NICE will continue to set. We have now established a very clear programme for those standards working through individual specialties. The way that we now envisage the system working will include the ratings system. The basis on which those ratings are achieved will involve NHS England, the CQC and NICE, so that there is one version of what good looks like, not four or five different versions. So it is very important that the standards are really clear.

One of the great lessons that we have learned is that the generic way in which the essential standards were crafted in the 2008 legislation was not fit for what we wanted to achieve. Particularly listening to Robert Francis when he gave evidence to your Committee, I thought that the way he described what fundamental standards should be like, and said that they should be meaningful and visible to the patient or the visitor on a ward, was very compelling. It is going to be a challenge to get it right, but I think there is a huge commitment now to do that work over the summer, to consult on it. We need lots of participation from patient groups and third sector and other organisations to help us develop standards that are meaningful, measurable and comprehensible to people on a daily basis on the wards, not some vague generality. That is what’s got to change.

Q546 Valerie Vaz: May I turn now to the chief inspector? We want to drill down into that, because you don’t seem to like the Health Committee, or Robert Francis, very much, because neither of us suggested having a chief inspector. Might I first ask you where the idea came from?

Mr Hunt: I certainly wouldn’t say that I don’t like the Health Committee; it is always a pleasure. I think that what we did-I have discussed this idea at great length-was follow Robert Francis’s recommendations to their logical conclusion. He said that there was regulatory complexity and there needed to be regulatory responsibility instead, so that within the system everyone knew precisely who was responsible for what. I concluded on that basis that there needed to be one organisation that was responsible for making a judgment about how well a hospital was performing, and that should be the CQC, with a new chief inspector of hospitals-and then that the responsibility for fixing problems when they are identified should lie elsewhere, so that there would be no conflict of interest whereby the person who made the judgment that there was a problem was then wrapped into saying, "We do think progress has been made," because they had been part of the team implementing a solution. It was in order to get that regulatory simplicity and accountability in the system that I decided this would work.

I will be open with you; you may have a different view, judging by your earlier comments, but I do think that the Ofsted model in schools has transformed state education. Over the last 20 years there has been a real improvement in standards in state schools because parents know how good their local school is. It is much harder to get that information about your local hospital.

Q547 Valerie Vaz: Let us go back to the chief inspector. I think I asked you in the Chamber, when you first made the announcement, who they would be accountable to. It will not be yourself or the Commissioning Board; is that right? They are just accountable to-

Mr Hunt: The chief inspector of hospitals is accountable to the public.

Q548 Valerie Vaz: Yes, but how? There should be a link. I am just asking. I do not know. This is your idea.

Mr Hunt: Yes, I know.

Q549 Valerie Vaz: I am just asking you to help us. Help me.

Mr Hunt: The chief inspector of schools-

Q550 Valerie Vaz: Don’t use the analogy: just tell us how it is going to work.

Mr Hunt: I am about to tell you, if you would be kind enough to let me answer your questions. The chief inspector of schools is accountable to the board of Ofsted, but actually their responsibility is to the wider public because their job is to tell the public about the quality of state schools. I want the chief inspector of hospitals to be accountable in the same way.

Q551 Valerie Vaz: So they lie within the CQC; that much we know.

Mr Hunt: Correct.

Q552 Valerie Vaz: It would be the CQC that, presumably, in its accountability to Parliament, comes before us, and presumably we can question the chief inspector. Is that right?

Mr Hunt: Yes.

Q553 Valerie Vaz: Will the chief inspector have power to shut down a hospital if they want to?

Mr Hunt: They will have the power to trigger administration, yes. If they identify failures and breaches of fundamental standards, if they categorise a hospital as failing, there will be a maximum period within which those problems have to be addressed. If the hospital fails to address those problems within that period, they will be able to trigger administration for the hospital, yes.

Q554 Valerie Vaz: That is separately to, say, Monitor or the CQC itself. It is the chief inspector that has that power.

Mr Hunt: Yes.

Q555 Valerie Vaz: Solely.

Mr Hunt: Not solely, because Monitor also has power in different ways, but the chief inspector will have the power. The crucial change is that they will be able to make that decision on the basis of the quality of service offered to patients and not just on financial grounds, which has tended to be where the centre of gravity has been to date when it comes to administration regimes.

Q556 Valerie Vaz: So there is one inspector, but do they have subinspectors? Surely you are not expecting the one person to go round all the hospitals.

Mr Hunt: No, just as the chief inspector of schools doesn’t go round every school.

Q557 Valerie Vaz: You are going to have subinspectors.

Mr Hunt: Yes. The chief inspector would have a team.

Q558 Valerie Vaz: Does that come out of the CQC budget?

Mr Hunt: Yes.

Q559 Valerie Vaz: Are they going to get extra money for this?

Mr Hunt: Yes.

Q560 Valerie Vaz: How much?

Mr Hunt: We are in discussions with them, but they will have as much money as they need in order to do this job properly.

Q561 Valerie Vaz: I don’t know what "as much money as they need" means.

Mr Hunt: They will have the money they need to do this job properly. When those figures have been bottomed out, of course we will make them available to Parliament.

Q562 Valerie Vaz: Do you know roughly what the time scale for that would be?

Mr Hunt: The chief inspector is going to be starting his or her work before the end of the year so you will have the information long before that.

Q563 Valerie Vaz: What kind of salary level will they be at?

Mr Hunt: It will be whatever salary is necessary to get the right quality of person to do this job, but it will be a peerreview process. The important change from the way the CQC operates at the moment is that the people inspecting hospitals will be people who know how to run a good hospital, and what to look out for. It will be people who are more experienced, and indeed more expensive salarywise, than the current CQC inspectors.

Q564 Valerie Vaz: With the greatest respect, it was this Committee that decided that the CQC needed slightly reforming, and then David Behan was put in place and then David Prior, so we should be taking some credit for that. What we found was that this was an organisation in transition. I am just hoping-and asking-that you will think carefully about whether foisting something like this on it is a good thing to do at this point. You have decided on it without consultation, and you have decided this is the right thing even though the Select Committee and Robert Francis have said it was not really part of the whole makeup on patient safety and what happened at Mid Staffordshire. This is just a request that you think through carefully what they are going to do, because I do not want to envisage a kind of Bruce Keogh situation, where someone who is not really accountable to you, and not really accountable to Parliament, just goes and closes down a hospital on maybe a different kind of evidence, or evidence that is not out in the public domain.

I said I would bring up Stafford hospital, and we have seen the same thing again. There is very much an attitude of, "As soon as something goes wrong, let’s shut it down," and I do not think people see the consequences of that. Can I have assurances from you that that is not going to happen under this regime?

Mr Hunt: I would not characterise the regime in that way at all. This regime is making sure that, where there are problems, they are addressed a great deal more quickly than happened in Mid Staffs. The idea of having a rigorous independent peerreview inspection system for hospitals is to make sure that we root out problems much more quickly and that all hospitals see themselves as on a stairway of excellence progressing in the right direction. That is the intention of the new system.

Far from this being foisted on the CQC, the CQC are embracing this with great enthusiasm because they think that this is an inspection model that will work. They recognise that this will deconflict them, because they will not be responsible for putting problems right. Their job will be to identify where there are issues and also to encourage all hospitals to strive for excellence. That is a very simple, clear role-a role that they are embracing with great enthusiasm.

Q565 Valerie Vaz: Yes, and I think we all want that outcome, but we certainly heard from them that they were making inroads into having specialist inspectors in specialist places. We will wait to see, but I just say that as a plea.

May I take you to something else that you have suggested? Will hospitals that are rated as outstanding have an incentive of greater freedom from regulation? That is what you have kind of said, isn’t it? In which case, if you have a hospital that is rated outstanding, how long are they rated as outstanding, and when are they just left alone and have less regulation?

Mr Hunt: We will be consulting on this over the course of the summer. The thinking is that where we have confidence in the leadership of the hospital, and that they are outstanding in their performance, less burden will be put on them in terms of the normal CQC regulation. However, there will be constant monitoring of things like mortality rates and surgery success rates, so there will be lots of indicators that could prompt an unwarned inspection by the CQC. It is not that we will not be keeping an eye on how those hospitals are performing; indeed, we want that information to be in the public domain. But where we have confidence, we think it is right that they should have-I think a former leader of yours used this phrase-earned autonomy. I think that works in the context of good, wellperforming hospitals.

Q566 Dr Wollaston: Secretary of State, you have rejected the recommendation to have regulation of healthcare assistants, who are delivering most of the care in our hospitals-and, of course, in the wider community. Could you tell us why you have rejected it and gone for a vetting and barring scheme instead?

Mr Hunt: I absolutely accept the spirit of what I think Robert Francis is trying to achieve in that recommendation, which is that the public should know that all the healthcare assistants working in NHS hospitals have proper training, and that if they are found to have committed a breach of care they should not be able to get a job in another part of the NHS or the health and social care system. I was concerned that introducing a regulatory superstructure for hundreds of thousands of healthcare assistants might end up being a tickbox computer exercise. So what we have decided to do is to achieve that through a vetting and barring system. We will set up a system whereby people who are found responsible for a breach of fundamental standards would not be able to get a job elsewhere, and also introduce minimum training standards. I think we are achieving the same thing in a different way.

Q567 Dr Wollaston: Did you talk to health visitors themselves about what they felt the right way forward would be?

Mr Hunt: Not personally, but we are consulting on all these changes and I think that, hopefully, if they have some good feedback we can incorporate that into how we implement those two schemes.

Q568 Dr Wollaston: Are you happy, however, that having a vetting and barring scheme will address the underlying issue, which is how we give healthcare assistants greater continuing professional development and bring in aspects of appraisal? It does not have to be a tickbox scheme. There are other things about regulation, aren’t there, such as a sense of the job being more recognised?

Mr Hunt: I agree, and Camilla Cavendish is doing a review for us at the moment. By the way, I am trying to get all these reviews to report before the summer break, because it is kind of "review city" at the moment. I want them all to report quickly because I want to implement their findings. Camilla Cavendish is looking at the whole professional recognition of healthcare assistants, and you are absolutely right about that. Incidentally, one of the changes in nurse training that we are trying to achieve is to create a much easier pathway for healthcare assistants into nursing. So we absolutely do want to improve that professional recognition.

Q569 Dr Wollaston: On that wider note, I am sure you would be very welcome in Torbay, to roll up your sleeves and come and do some work.

Mr Hunt: Maybe I could go to the Wollaston surgery.

Dr Wollaston: I hope you will apply for the job.

Q570 Barbara Keeley: Robert Francis recommended the introduction of a new status of registered older people’s nurse, to recognise the special requirements of caring for the elderly. It would seem, as there is such a large population of older people in hospital now, that that would be an important recommendation. I think it would be an important step forward, but you do not seem to agree, Secretary of State. Could you tell us why?

Mr Hunt: Una might have some comments on that because she has thought about the issue a great deal. I do think that improving skills around geriatric care is very important. We did think, and are still thinking, about that recommendation very carefully. We just did not want people inside the nursing profession to think that older people’s care was the job of specialist other people, when actually this is something that is central to everything that all nurses have to do in the modern NHS. It was about working out the right balance.

Q571 Barbara Keeley: But recognising expertise might show that it now has an importance which it previously did not have.

Una O’Brien: We have thought about this very seriously, and we still continue to want to hear people’s views on it, although our instinct is that there is a risk of putting older people’s nursing into a silo, which is the opposite of what we want. Going round any hospital today you will find older people on pretty much every ward, except the children’s wards. There will be people in the cancer wards, people in as day cases, and people on longstay wards. So there are issues to do with care and support for elderly people in pretty much every place in a hospital.

The question that we are now wrestling with is: is the curriculum sufficient? We are going to be working with Health Education England to really look at the nature of the primary nurse education that we are commissioning, because the state does pay for pretty much all of that and we have a very big influence over that curriculum. It is really about looking at the place where we can have the biggest impact, as well as taking the full spirit of what is in the recommendation. It is not that we disagree with the underlying intent, but-quite the opposite-it is trying to find a way that will have the biggest impact.

Q572 Barbara Keeley: Perhaps a thing to take on board, if you are still thinking about it, is that local councils have done a good job in terms of having older people’s champions.

Una O’Brien: Yes.

Barbara Keeley: Of course the Opposition, the Labour party, has a shadow Minister for Care and Older People. Increasingly that is well supported, in that people think it is a good idea to recognise that there are some special things about that expertise and specialisation that should be recognised. So I would go for it, but that is my view.

Chair: One of the things the Committee comes under pressure about is the exciting subject of death certification reforms. David volunteered to ask about this.

Q573 David Tredinnick: Certainly. I was waiting for your lead, Chair. Do you commit yourself, Secretary of State, to introducing the death certification reforms enacted in the Health and Social Care Act 2012 by the announced date of April 2014?

Mr Hunt: I have to apologise to the Committee because I think the dates may slip from the dates that I wrote in the letter that I sent to you, Chairman, last December. There are some implementation issues. We are absolutely committed to the reform. There have been some implementation issues with regard to the charging regime and the cooperation with local authorities, who are going to have a pivotal role in this. I do not know whether you want to add to that.

Una O’Brien: This is something that we feel very strongly about-ensuring that it is safely implemented. It is the biggest reform of death certification in 50 years, as I know the Committee understands: the medical certificate of the cause of death and then the introduction of the role of the medical examiner. What we are working with at the moment are the draft regulations which we want to put out to consultation. That is where there has been a delay because-

Q574 David Tredinnick: When is the consultation going to take place?

Una O’Brien: I am very much wanting and expecting that consultation to take place imminently. We want a whole Government consultation that captures the issues for the Home Office as well as for the MOJ, and we are just in the process of resolving those issues between the three departments. But there is no letup in the commitment to making this happen.

Q575 David Tredinnick: Right. Are you going to accept all the Francis report recommendations on improvements to the system?

Una O’Brien: As far as I can tell, they are consistent with what is proposed, but we have not addressed the specificity of those recommendations in this initial response. I have gone back and double-checked those recommendations, and they look to me to be broadly consistent-but, as I say, we are going to have a further response in the autumn that will go through each and every recommendation and clarify the position on this.

Q576 David Tredinnick: I used to chair the Joint Committee on Statutory Instruments, and I see from a letter that you wrote, Secretary of State, that you were hoping to submit statutory instruments-four of them-to the JCSI in June this year. Has that slipped? Presumably it has.

Mr Hunt: It has, I am afraid, and that is why I wanted to express my apology to the Committee. It is one thing that is taking a bit longer than we anticipated.

David Tredinnick: Yes. The laying of draft fees regulations and the debating of the same later in the year will presumably slip a bit.

Q577 Chair: May I suggest, Secretary of State, that it might be helpful if you wrote to the Committee with a revised timetable for the implementation of what is in the Act, and also any reflections on what Francis recommends ought to be added to the provisions of the Act?

Mr Hunt: I will do that.

Chair: Thank you.

Q578 David Tredinnick: Chair, with your indulgence, may I ask this? There are 14 hospitals now under investigation by Sir Bruce Keogh and his team on the grounds that they are persistent outliers on at least one national mortality indicator. Given that there have been longstanding concerns about the reliability of death certification in hospitals, can you be confident that their mortality data are reliable?

Mr Hunt: Shall I start on that? The answer is that mortality data is an incomplete indicator. There may be reasons why those hospitals are perfectly safe but, as we discussed earlier in the case of Leeds, the data is not correct. Because mortality rates were one of the lead indicators in the case of Mid Staffs that were not taken seriously quickly enough, we thought it was appropriate to do this research into those hospitals and to make sure that where there appeared to be issues they were being addressed. This is a kind of bridging process while we set up the much more thorough inspections that are going to be done by the chief inspector of hospitals.

Q579 David Tredinnick: Can you, or we, trust any NHS death certification and mortality figures at the moment?

Mr Hunt: I think the answer is yes, but they have to be treated with caution, because excess mortality is excess against a mean. It does not mean that every example of excess mortality is an avoidable death, but it does mean you should investigate-and that is what is happening.

Q580 Valerie Vaz: Are you satisfied that those 14 hospitals are the right ones?

Mr Hunt: They are the outliers in terms of mortality statistics.

Q581 Valerie Vaz: Are you satisfied?

Mr Hunt: We should definitely investigate mortality outliers, yes.

Q582 Chair: When we asked Professor Nick Black what conclusions he drew out of excess standardised mortality, he told us that, if you look behind the data of the outliers, you find that avoidable deaths are actually a constant proportion of deaths reported by hospitals wherever they are on the statistical analysis of standardised mortality. In other words, standardised mortality is not a reliable indicator of avoidable deaths. Is that an observation you either contest or take into account in your policy making?

Mr Hunt: It is one that we are neutral about, because we recognise that they are not a complete indicator of performance. This is an evolving science, but we think it is right to investigate where we think there are outliers. That is what we have decided to do. It is one of the things that I am sure will exercise the new chief inspector of hospitals a great deal, because they will have to make a decision as to where they want to do snap inspections if they think things are going wrong. They may look at that and at other things that prove to be quite reliable indicators of problems, such as high rates of staff saying that they would not want their own family to be treated in a hospital. So I think there are a number of indicators that you would keep under review, but just while we are setting the system up we thought this was the right thing to do.

Q583 Chair: It was quite striking in your answer to David Tredinnick that you said you were focusing on standardised mortality because it happened to be a lead indicator where problems were proven to exist in Stafford. Actually, if you analyse the use of SMRs round the system, the evidence appears to suggest that it is not a reliable indicator of avoidable death.

Mr Hunt: I understand that debate. The truth is that people will need to look into this kind of issue in a great deal more detail as part of our new hospital inspections regime. I thought it was prudent to take immediate action because it was a lead indicator for avoidable death at Mid Staffs. That is why we decided to take the action we did.

Q584 Barbara Keeley: Moving on now, we have the spending review in a few months’ time, and we still have the Joint Committee’s report on the Draft Care and Support Bill, on which three members of this Committee did an excellent job for four months, so we support it. Could you tell us when you intend to respond to that Joint Committee report, and whether there will be an opportunity, for instance on piloting, to propose how you would implement the cap on care costs and other issues before the Bill is formally brought in? We wanted, as a Committee, to look at guidance and detail, and we were not able to do that because of the timing of the Committee and the out date we had. For instance, there are fears in local government about the impact on them. So will there be piloting? When can we see a response, and will there be piloting of how it will work?

Una O’Brien: There is going to be a reference to the Bill in the Queen’s Speech. The impact assessment, which will give a lot more detail on the points you are raising, will be published shortly after that, with the Bill in its form to come forward for first reading.

Q585 Barbara Keeley: We know already that the Government’s proposal is that the cap and other measures will have effect from April 2016, the date having originally been set as April 2017. Do you think-I do not know, Secretary of State or Una, whoever wants to answer it-that that could be brought forward? Or could there be some interim measures? For instance, evidence was put forward that changing things like the means test threshold levels could be done without a Bill. That could be done as soon as you wanted it to be. So is there any prospect that that will be coming forward, and are these things that might be laid out in the spending review?

Mr Hunt: We would love to do them as soon as possible, but I am afraid these things are all subject to public finance. I was delighted when it was brought forward from 2017 to 2016, but it is just a question of what the other pressures are on public finance.

Q586 Barbara Keeley: Okay. When you last gave evidence to this Committee in November you said that you would be looking at resuming crossparty talks. There are still some elements of this that it is important to get crossparty support for, and a debate out there among the public about these measures so that the public are ready for a solution when it goes ahead. Is that something you intend to take forward?

Mr Hunt: I am very happy to have crossparty talks if my opposite number would like to do that.

Q587 Barbara Keeley: I think he has indicated again and again that he would.

Mr Hunt: All I would say is that I am not aware of any great issue of contention on those particular proposals, but I am very happy to engage with him-

Valerie Vaz: You are going to our team.

Mr Hunt: -by all means.

Q588 Dr Wollaston: Both this Committee and the Joint Committee on the draft Care and Support Bill made recommendations that we should make it far easier to bring forward integration of health and social care budgets. Can you perhaps update us and tell us how that is going to move forward?

Mr Hunt: Yes. I completely agree with that, and the next big strategic challenge that I need to focus on, following on from the Francis report and Mid Staffs, is the integration agenda. It is a big job. Part of it will be potentially through things in the Care and Support Bill, but there are lots of other things that will not necessarily need primary legislation where there are barriers-things like what we can do to encourage pooling of budgets, the way primary care operates, the technology agenda, which is very linked to that, the way payment by results works, and the systemwide disincentives to the pooling of budgets. So there is a very big piece of work that we need to proceed with apace.

Q589 Dr Wollaston: I am glad to hear that. There is one area where integration is already at an advanced stage in Torbay, but they are finding that there are barriers being put in the way of proceeding with integration. In fact, if anything, their whole system is under threat. Very specifically, the issues are that they are being forced to use their foundation trust pipeline for their care trust where the care trust is not financially viable enough to survive on its own. There are also issues around the involvement of the Office of Fair Trading. There is a single sole bidder for the care trust, and that is the local foundation trust. Our understanding, as a Committee, was that Monitor would be able to make a judgment as to whether that was anticompetitive or whether it should go ahead. But in many areas I know-such as Bournemouth-these kinds of decisions are being held up very significantly by another raft coming in with the OFT. Is there any encouragement that you can give organisations like Torbay that this can all be streamlined, because it could completely disintegrate?

Mr Hunt: It is immensely frustrating when you hear stories like that. The only thing I can say, which is as encouraging as politicians’ words can ever be, is that we really do want to address those issues. In the next few months we want to look at what the systemwide barriers are. Some of them are matters of European law, which is very difficult to change. There are a lot of things that we can do which do not involve changing European law that could make a very big difference.

It is absolutely essential that we do this. The people who most need better care and treatment than they currently get are frail elderly people with longterm conditions. Those are the people who need a properly joinedup service-whichever part of the system they are in-which knows what other parts of the system have been doing, where there is clear responsibility for their care, and where there is a clear determination to make sure they have a joinedup care plan. That is absolutely essential. It is the next big bullet the NHS has to bite. It is completely understandable that our focus has been on hospital care in the wake of the Francis report, but it is very important that we put as searching a spotlight as possible on the quality of care for the frail elderly outside hospital and the systemwide barriers to making that care of the standard that we would all want.

Q590 Dr Wollaston: I would just like to reflect on the fact that this Committee visited Denmark and Sweden, and when we were in Copenhagen they showed us slides of the Torbay model. So it is not just recognised nationally; it is recognised internationally. If the Torbay model, which is internationally recognised, were to disintegrate because of barriers being thrown in its path, it would be an absolute tragedy. Can you assure the Committee that you will look closely at the specific issues that it and some other trusts are facing?

Mr Hunt: Yes, I can.

Q591 Chair: Can I enlarge on that a little? As these expressions of concern about integration have come forward, they have tended to focus on the proposition that either Monitor, or sometimes the OFT, are interesting themselves in a commissioner’s interest in commissioning-not providing-integrated pathways of care. My understanding is that it has always been the Government’s position that there is no basis on which a commissioner’s desire to commission an integrated pathway of care can be challenged on competition grounds. If that is correct, would your door be open to any commissioner who feels that their desire to commission an integrated pathway of care is being challenged by the competition authorities?

Mr Hunt: How you have described the Government’s position is exactly how I want it to be, but the work that I need to do in response to what Sarah and other people have said is to look at precisely where any legal barriers might be. Sometimes these legal barriers are imagined and sometimes they are things that are real. But I am clear that this is a very important piece of work, and perhaps something on which, if the Committee were interested, we could have a whole session on what we can do to deal with those issues.

Chair: It will undoubtedly come up in the inquiry that the Committee has already announced into the implementation of the Health and Social Care Act, because it is one of the understandings the Government made clear during the passage of the Act.

Andrew does want to come back to the question of healthcare assistants.

Q592 Andrew George: I will come back, because it seems that we have been very efficient with our time. I want to ask about the regulation of healthcare assistants, home care workers or those care support workers that exist. We have just been talking about integrated care, so this is something that really applies across all sectors if we are to have an effective health and social care service. All the management regimes that exist seem to be increasingly putting on pressure through cost-centre management on the lowest-cost suppliers of service, who are the healthcare assistants and healthcare workers. You have rejected the proposal that those people be regulated. Why is that? What would be necessary in order for you to change your mind in that respect?

Mr Hunt: I am not going to implement a measure unless I can see that the measure we are talking about is going to make a measurable difference in improving standards of care. In fact, when you talk to Julie Bailey and some of the families from Mid Staffs, they say that some of the best care they found in Mid Staffs was from healthcare assistants. The concern that people are trying to address is about where there is inadequate training, or where the wrong person has been able to get the job. I think that we can address those in another way. What I am worried about is creating a national bureaucracy that does not address those issues but allows people in hospitals and other parts of the system-care homes-to say, "It’s all right, because we’ve complied with the statutory regulations. Therefore everything is fine," when what matters is the way people are managed, whether they get proper training, whether we have a robust way of making sure that people who have been convicted or found guilty of abuses of care in other parts of the system are unable to get jobs elsewhere. Those are the main issues that we need to address. We can address those more effectively by doing other things.

Q593 Andrew George: You must acknowledge that, although Julie Bailey may well be satisfied, in many other areas there have been failings in that particular sector itself, and that has been found not just in hospitals but indeed in the home care sector and elsewhere. Given that there are also concerns about nurses who depend increasingly on healthcare assistants to perform their functions, there is a missing element, if you like, of being able to identify clinical symptoms because you do not have a trained professional undertaking personal care of that patient. Given that-as you have even mentioned yourself-there is a need for training for healthcare assistants to perform a wide range of the functions that we are increasingly expecting them to perform, I cannot see why you have rejected the proposal to introduce regulation. Surely you must accept that this would enhance their professional status, which can only do one thing, and that is to enhance the quality of care.

Mr Hunt: I do not believe that would happen, and I am worried that it would end up being a bureaucratic process. I do not want to repeat myself, but I think we can address the concerns.

Let me make a broader point, though. Of course there are some bad apples in any profession-I am sure members of the public would say there are some bad apples in Parliament as well-but it is a mistake to respond to Francis by saying that the main thing we need to do is to be better at rooting out bad apples. You talked about home care, and one of the most frequent complaints we hear, which worries me greatly, is the concept of a 15minute slot when someone goes in to look after someone needing care and has time either to give them a meal or to wash them, but not both. When that happens it is not the responsibility of the healthcare assistant; it is the responsibility of the system that is only giving people those 15minute slots. People who become healthcare assistants and nurses do so from the best of motives. It is about sorting out those systemwide problems that, as I think Professor Pearson said, can drum the compassion out of people, because they are pressured into behaving in ways in which they do not want to behave. It is important that we address those underlying issues rather than just thinking that this is about striking off more nurses from the NMC, or statutory regulation of healthcare assistants.

Q594 Dr Wollaston: On measles, may I ask you about the national epidemic? I received a very moving email from the parent of a child who has leukaemia whose immune system is suppressed, and he rightly makes the point that this could be an unfolding tragedy not just for his own family if his son contracts measles but also more widely across the country, with many children who are too young or too unwell to be vaccinated. There are parts of my constituency in particular-I raised this with you recently-where 30% of children have not been vaccinated against MMR. The point that the father who has written to me wants me to raise with you-I also share his concern-is whether it is now time for us to have a national campaign, a catchup campaign, to help protect these families. Is it not time that we stopped using this term "herd immunity" and talked about "community immunity", because when you immunise your child you are protecting children like his son, who are in very grave danger if they contract measles?

Barbara Keeley: May I amplify what Sarah is saying? We have had a significant rise recently in Salford, but just in certain parts of the city, mainly among children and young adults who were not immunised in the 1990s. We have gone from having very low numbers to, at the end of last week, having nine cases confirmed, and a very much larger number of cases suspected and confirmed this year. So it is not just Wales. There is a perception that it is just Wales. The reason we need a national campaign is that it is in other cities too, and we now have this concern in Salford.

Mr Hunt: I completely agree with that. The concept of community immunity is a very good one and we certainly must not think of this as something that is happening only in Wales. I am receiving regular updates from the chief medical officer. We have comprehensive plans in place, and we need to use this as a moment to slay the myth about MMR. I do detect a turning point in terms of the public’s attitudes towards this, but there is still that critical 11 to 15yearold age group that may not have been vaccinated because they were toddlers at precisely the time when the MMR scare was so appallingly whipped up. But I agree with your concerns. I want to reassure you that we are taking this extremely seriously inside the Department of Health and we absolutely do want to make sure that we do everything we can to protect people like the person whose father contacted you.

Q595 Dr Wollaston: Will that involve a national campaign now to bring it home to people that they do need to act-a national media campaign?

Mr Hunt: If you are talking about a national plan, yes. As to the precise role of publicity in that, which is what people normally mean by a campaign, I would be guided by the chief medical officer as to the moment she thought that was appropriate. In terms of making sure that we have sufficient numbers of vaccines, making sure that we are talking in a targeted way to communities and schools, that is something that absolutely is going on.

Q596 Barbara Keeley: I do not think we are yet seeing the mass turnout that we need to have of those families that need the vaccination for their teenagers in Salford. The message did get out in Wales but it has not got out in places like Salford. So we are seeing pleas and things in the local paper and online, but it requires more than that because people need to be convinced that they have to do it.

Mr Hunt: I will relay those concerns to the chief medical officer. My understanding is that she feels that we have good plans in place, but I will relay those concerns and make sure that I am satisfied, on the basis of what you have said to me today.

Q597 Valerie Vaz: I have just a few more questions. I touched on Stafford hospital earlier, and I wonder if you are aware of the strength of feeling about what has happened at Stafford hospital, and if there is anything that you are doing about it to consult with local people, or even the MPs.

Mr Hunt: There is a process that has been set in train. I have to respect that process because it is set down in regulations. I am very aware of the concerns of the people of Stafford, but I hope you understand that, because in the end that decision will arrive on my desk, I cannot make a comment on that particular case at this stage.

Q598 Valerie Vaz: It seems to me that we are here because of Stafford-that is what we are discussing-and that takes me back to the Francis report. He did indicate there was a problem between Monitor and the CQC, and that does not seem to have been resolved in your response.

Mr Hunt: I very much hope that is not the case. One of the most substantive parts of our response is to clarify the respective roles of Monitor and the CQC so that there is absolute clarity about who is responsible for what. Those are the changes we have been discussing today concerning the chief inspectorate of hospitals. Monitor has a very important role there. Its job, as the regulator for the FT sector, is to sort out problems as and when they are identified. That is a big responsibility, but that is what it has to do. We need a system where it is not possible to duck problems, because it is always difficult to address those problems. It is particularly difficult-it is worth saying-for politicians to address these problems, because we all know about the unpopularity of reconfigurations. But, where patient safety is at risk, it is incredibly important that these issues are addressed.

Q599 Valerie Vaz: I understand that, but there is an independent reconfiguration panel, and it goes to the heart of what happened at Leeds and at Glenfield. There is a process, and that does not seem to be being applied. The same goes for A and E. I do not think you quite realise that, sometimes when A and Es are closed down, it has an impact on other hospitals.

Mr Hunt: I most certainly do realise that. I would strongly refute your suggestion that the process is not being followed. In this case it is being followed. It is very important that it should be followed, and when it comes to reconfigurations involving A and E we have made it very clear. We have done something that was not done before: we have introduced the four tests which we have said must be met before any reconfiguration happens, precisely because we are aware of the concerns of the public.

We are also doing broader work about how A and E works generally, because we have pressures on A and E at the moment, which are significant, but also because there has been a failure of the system to persuade the public that there is anything credible in between a GP surgery and an A and E. All the kinds of things you can have in the middle-urgent care centres, or whatever-have not succeeded in giving the public confidence in what they do. That is another reason why Bruce Keogh is doing his review of what our overall strategy should be. Bruce Keogh seems to be doing quite a lot of reviews these days, but this is an equally important piece of work that we will hear back on, which will help to inform all of us as to the right way forward.

Q600 Valerie Vaz: I think that is because people were not expecting this reorganisation from the Health and Social Care Act. That is why. I am sure we could all work together.

May I move on finally to the section 75 regulations? I am sure you are aware that there are still some concerns about them, particularly among the royal colleges, and I wondered if you were going to withdraw them and redraft them again.

Mr Hunt: We have withdrawn and redrafted them.

Q601 Valerie Vaz: But there are concerns about the redraft.

Mr Hunt: I think we have addressed the concerns of people in the House of Lords. For the record, you should understand-as I am sure you are aware-that what we are putting in are the same procurement regulations that applied to the previous PCTs. They reflect the guidance that the last Labour Government put out to PCTs, which they said they must follow if they were to comply with European procurement regulations. That is what those section 75 regulations do. There has been a lot of mischief about the purpose of those regulations. Let us be clear that the purpose of the Health and Social Care Act was to insert clinical leadership and local decision making into procurement decisions. It was not to create a competition freeforall, and that will not be the impact of these regulations.

Q602 Valerie Vaz: But people do feel that that is the case. Are you saying that you are not going to redraft them?

Mr Hunt: I look forward to you very generously going out and informing people of the reality of those section 75 regulations so that they don’t feel that is the case.

Q603 Valerie Vaz: Are you saying you are not going to redraft them?

Mr Hunt: I have already said that. By the way, I also do not think that what is happening in Stafford hospital is about the Health and Social Care Act; it is about making sure that when there are serious problems in the system we do find a sensible way of addressing them.

Q604 Valerie Vaz: I was not suggesting that, but anyway. May I ask you about one thing in the Government’s response which I do not understand? Perhaps you could clarify what it means. One of the points was that you have said that pay will be linked to quality of care delivered rather than simply time served. Could you expand on that, and say how you would measure it, and who will be measuring the quality of care to enable people to get, what-performancerelated pay?

Mr Hunt: We will have, as a result of the new structures that we are putting in place, much better ways of measuring the quality of care delivered in hospitals. The rolling out of the "friends and family" test will be one of the measures, but the judgments made by independent inspectors about the quality of care will also be explored, and we would like to see more link between the quality of service delivered and pay. On the other hand, I would not want to create a structure where people felt that you had to be paid to deliver a high quality of care, because I think this is core to what people in the NHS do.

Q605 Valerie Vaz: So that does not say that, then.

Mr Hunt: No, it does not. I do not think that compassionate care is something you buy; it is something that you create, a culture that you can nurture. We are working through how to get that balance exactly right.

Valerie Vaz: Thank you.

Q606 Grahame M. Morris: I have a question about the section 75 regulations. The implication of the Secretary of State’s answer was that there are just one or two politicians who say that this is going to open up the service to privatisation. In fact, there is a recognised body of opinion-consisting of the British Medical Association and a whole raft of organisations-that has warned that that is precisely the consequence. I firmly believe it was the intent as well. The suggestion is, "Oh well, this is only a minor change." It is not. It is fundamental, and it will open up the national health service to wholesale privatisation. I wish you would just be clear about that.

Mr Hunt: It will not. I am not sure this is something that we can resolve now. All I would say is that, as it is completely consistent with the procurement regulations that your own Government put in for the PCTs, you have to show what is different if you are going to justify the assertion that this is about enforced privatisation-which it most certainly is not.

Chair: This is a story that will run, and probably not achieve consensus.

Grahame M. Morris: Yes, and we won’t have a health service in 2016.

Chair: Thank you very much for your time, Secretary of State. We have covered a lot of ground and we shall have a report in the next few weeks. Thank you very much.

Prepared 17th September 2013