To be published as HC 229 iii

House of COMMONS



Public Administration Committee

Complaints: Do they make a difference?

TUESDAY 25 June 2013

Mark Mullen, Simon Roberts, Lynne Wood and Abi Gray

Sir David Nicholson and Chris Bostock

Evidence heard in Public Questions 168 303



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Oral Evidence

Taken before the Public Administration Committee

on Tuesday 25 June 2013

Members present:

Mr Bernard Jenkin (Chair)

Charlie Elphicke

Kelvin Hopkins

Greg Mulholland

Mr Steve Reed

Lindsay Roy


Examination of Witnesses

Witnesses: Mark Mullen, Chief Executive Officer, First Direct Bank, Simon Roberts, Chief Operating Officer, Boots UK, Lynne Wood, Senior Manager, Customer Experience, and Abi Gray, Customer Experience Manager, John Lewis, gave evidence.

Q168 Chair: Can I welcome you all to this panel about complaint handling? We have two panels this morning. We are very pushed for time. We are going to do our best to ask very short questions. It would be very helpful if you could give us crisp, concise answers; it would help us get through as quickly as possible. I appreciate that John Lewis is well represented, but I am anxious to make sure the three organisations in front of us get equal time. Could you each identify yourselves for the record, please?

Simon Roberts: Hello, good morning. I am Simon Roberts, the Chief Operating Officer for Boots UK.

Mark Mullen: Good morning. I am Mark Mullen, the Chief Executive Officer for First Direct.

Lynne Wood: Good morning. I am Lynne Wood, Senior Manager, Customer Experience for John Lewis.

Abi Gray: Hello. Abi Gray, Customer Experience Manager at John Lewis.

Q169 Mr Reed: Good morning. I will start off with a relatively general one, if I may: why is good complaints handling so important to your different organisations?

Abi Gray: Fundamentally, it is important to protect our reputation with our customers. We strive to ensure that they are loyal; we want them to come back. If anybody has a complaint, it is crucial that it is heard. We can discuss what action is taken later on, but in the first instance it is just crucially important to make sure that we acknowledge what that person is voicing and pay serious attention to it.

Mark Mullen: Our strategy is to lead our category in customer service. To do that, you have to be pretty hot, for want of a better word, when it comes to both managing complaints and resolving them.

Q170 Chair: Why is it your strategy?

Mark Mullen: It is differentiated. It is not a category generally identified with excellence when it comes to customer service and First Direct is singular in that regard.

Simon Roberts: In our industry, the whole aspect of customer care, as we call it, is fundamental to our strategy and our brand. Every contact we have from a customer, whether it be an observation, a compliment or a complaint, we see as an opportunity to learn about how we can be even better for customers, so it is at the very core of everything we are interested in learning from customers.

Q171 Mr Reed: How do you ensure that you do the learning?

Simon Roberts: The first thing is about having a way of listening to customers day in, day out, week in, week out, month in, month out. We have a number of ways that we have feedback from customers. We have feedback from all our stores across time of day and week. That is the fundamental basis of learning to really be, I would go as far as to say, obsessed about what our customers say. We then take the individual and broader themes from that and use it in our leadership and management processes to make sure we learn quickly and then adopt the lessons into the way we run our business.

Q172 Mr Reed: Are there any different views on that question or is that what everyone is feeling?

Mark Mullen: Slightly differently, I handle my own complaints. There is a systematic way of learning in an organisation that you have to engineer into your processes, but there is also an individual way, which is to get your hands dirty, investigate your own complaints, find out what has gone wrong and resolve them and answer them yourself.

Q173 Mr Reed: To what extent do you use complaints to drive strategic objectives, like expanding market share and improving your offer compared to your competitors?

Simon Roberts: In the area of complaints and customer contact it is a very rich source of helping you understand what customers would like to see us do more of or differently. As my colleague described before, that may be at a store level-so in a local store even knowing what the customers in that store would like to be different or better-or at a national level. It applies at many different levels, so it is absolutely crucial to see what customers say, whether it be positive or needs improvement as the fundamental sources for differentiation and improvement.

Q174 Mr Reed: Abi and Lynne perhaps, John Lewis is used quite often by senior Ministers as something that the public sector should emulate, particularly in terms of customer services. Do you think it is fair to make a comparison between an organisation like yours in the private sector and how public sector organisations operate and might use complaints?

Abi Gray: There are clear differences. The organisational structure that we have is different, but there are some similarities in terms of the way the business is run, the way the accountability is assigned through the organisation, how we monitor complaints and ensure the data are moving through the organisation to drive improvement. I think that could be the same.

Q175 Mr Reed: That could be the same. Do you believe that you can replicate the way in which the private sector operates and uses complaints in the public sector?

Mark Mullen: No.

Mr Reed: Could you expand on that?

Mark Mullen: I think the motives of public and private sector are very different-obviously, one commercial and one not. Therefore, to the point I made at the outset, which is reinvestment in a particular area of a business to serve your strategy, for us it is easy. It is easy for us to invest in complaint management and in, if you like, complaint avoidance, because that is the whole purpose of the strategy. I am not sure that is the whole purpose of the strategy when it comes to the public sector. Complaints, or the avoidance of them, are a consequence of it, but they are not necessarily one of the, if you like, core objectives of it.

Simon Roberts: I would say that the relative priority of understanding what is important to customers or stakeholders has a lot of similarities. I see it as a cultural issue to what extent feedback from customers, complaints from customers are prioritised in the leadership system and I see lots of similarities between the two from that perspective.

Q176 Mr Reed: Why would that cultural difference exist?

Simon Roberts: It is clear from our organisation’s perspective that if we prioritise what our customers say as the first decision point in designing our future strategy, it helps us understand more quickly and we can respond. It is about a speed of response to rapidly changing markets.

Q177 Mr Reed: Culturally, why would that not be the same in the public sector or why should it not be the same?

Simon Roberts: I can only speak from my own experience in a retail and pharmacy organisation. One of the things from my own experience is the priority that we place on what customers say is something that is very important in the core of how we do business. Culturally, that is therefore a really strong part of the way we run our business. Clearly, that has to be a prerequisite for the views of customers to come to the fore.

Q178 Mr Reed: Finally, can I ask Mark what do you think the public sector is prioritising instead of that?

Mark Mullen: To this point, I can absolutely understand why the culture of the Health Service would be different from the culture of central Government, would be different from the culture of transport-all sorts of different parts of the public sector. For it to have one cohesive culture I think is unlikely and therefore to say public sector versus, I do not know, private sector is just a huge comparison to make and I do not believe that comparison is fair.

Q179 Charlie Elphicke: Does this not go to the heart of the matter? If you provide a rubbish service you will lose customers, you will stop making profits, your pay will be cut and shops will close and, in the public sector, the same incentives do not exist. How can we then build those incentives into the public sector that make them want to think in a similar way to the way you guys do?

Mark Mullen: You paint a bleak picture and I think it is a fair one, which is why I do not think that the comparisons are, bluntly, valid. The reason it is a very bleak picture you are painting is because it is not the only motivation to satisfy customers. It is a downside argument that you are making, which is very fair. I do not think everyone in every industry is in it because of the fear that their customers will leave or the fear that they will earn less or the fear that they will lose their jobs. I think there is a joy in getting it right in serving customers and solving their complaint in and of itself. So my suspicion is that you have to play on the carrot side, if you like, or the incentive side of it if you move to public sector, much more so than necessarily is the case on the private side.

Q180 Chair: Reward and recognition of good customer service.

Mark Mullen: I am a much bigger fan of a carrot, incentivised approach to behaviour, performance, call it what you will, outcomes than punishment, so yes.

Q181 Charlie Elphicke: What does that look like? Give me some ideas on what the politicians could do to make the public servants really excited about doing a great job.

Simon Roberts: From our experience, I agree with the point that has just been made. Very much focusing on when colleagues in our stores or our support office do really good things for customers is something that we have really emphasised in the way that we lead. It is really important to look for the times we get it right as well as the times we do not get it right. We have launched a performance leadership system in our business for all of our 65,000 colleagues where everybody is reviewed and their performance assessed based on how good they are with customers. We have a measurement system, as I mentioned before, week by week that specifically focuses on individual care of customers. It can be very valuable to understand both the individual and the national picture. We very much focus on individual ownership, individual reward, individual recognition of instances of getting it right for customers. When we do not get it right for customers, we use that as a positive learning experience to work out what we could have done better.

Q182 Charlie Elphicke: So you build it into the appraisal process.

Simon Roberts: Yes.

Q183 Charlie Elphicke: You would say to Sir Humphrey, "The way you have dealt with the complaint is really, really good. You will get another point of career advancement" or however it is measured. Then that person will know, "If I do a really great job, I am going to do better myself and I will get more pay and more seniority".

Simon Roberts: Clearly, we run a lot of stores, pharmacies and opticians across the UK. We tend to find that teams are very interested in how, together, they can deliver good customer care and service. The individual elements are important, but I would also emphasise the team elements as well within a specific store or department. We find our teams respond really positively when the overall performance of that part of the business does well, so I think it is both, not just an individual issue.

Chair: Moving on, Mr Hopkins. Sorry, I think John Lewis wanted to come in. I apologise.

Abi Gray: Within our organisation, we spend a lot of time focusing on the values of the organisation. It is my belief that by doing that we generate a good deal of pride in the people who work there. Therefore, when they are handling a complaint they are not thinking in that moment about the longterm prosperity of the business. They are thinking about wanting that customer in front of them to be happy, so that their reputation is preserved. That is fundamentally what it is about, certainly for us.

Lynne Wood: Just building on that, because our strategy is around delivering the best service, our partners want to improve that continually. So we do not just wait for the complaint, because often that is right at the end. Any feedback, as you said, is taken as "how can we improve that?" It is about doing the right thing, which sounds very clichéd, but it is about doing the right thing, taking accountability and respecting that piece of feedback wherever it comes from and doing something with it. That is what differentiates particularly what John Lewis does.

Q184 Chair: I am very glad we let you in at that point, because in fact, if I may just summarise, what you are saying is the strategic motivation for looking at complaints may well be a commercial one, but by the time you get down to the process of dealing with complaints and listening to customers it just has to be ingrained into the culture and values of the organisation. The motive for management wanting to do that is really of secondary importance, because the reason you want to deal with complaints effectively is because you want the satisfaction of sending away happy customers rather than making extra profit for your business. Does that not rather suggest that there is quite a big parallel between the private and public sectors, because if there was strategic leadership from the top in, say, the Health Service that really drove a positive complaints culture, because most people want to do the right thing in the Health Service, they would deliver a better complaints culture? Agreed?

Lynne Wood: I would have thought that is where the similarities are, because I would not have thought that people want to wake up and do the wrong thing. It is about doing the right thing but knowing that they can, are empowered to do the right thing and know where to go if they cannot fulfil that. We find it starts from a leadership perspective in the partners, but all the way down to any partner, any channel, any touch point, so it is intrinsic within an individual to want to do that.

Simon Roberts: I think that is a really important point. The objectives of the organisation have to be able to show up for every individual colleague to be able to do what is right locally for their customers or patients or stakeholders. I would really agree with the point made that creating a culture where people feel free to be able to do the right thing for customers in the moment is very important in our organisation, because at the end of the day, a dispersed leadership culture is enabling people to show up at the very best for customers. We get the best customer feedback when we empower our people to be themselves for customers and to really care for customers in the way that they think best at that moment in time.

Q185 Kelvin Hopkins: Is there not a fundamental difference between the public services and the retail sector? Public services, particularly health, have legal and, indeed, I think, moral obligation to serve the whole population. The retail sector is serving people’s desires and wants and does a generally very good job. You are working in a situation of oversupply; if they do not buy from you, they buy from somebody else. The Health Service is in tight, short supply and you have to depend upon your local services and I may say that my own experience of the Health Service is universally superb.

Chair: Is that a question?

Kelvin Hopkins: Yes and I got a nod, so that is an answer: yes.

Abi Gray: I can respond to that. I guess I would just say that our goal day to day is, yes, customers have a choice as to where they shop, but everything we do is intended to invite them to shop with us and we hope that they will.

Chair: Moving on to your next section.

Q186 Kelvin Hopkins: Yes, about the practicalities of handling complaints, the retail sector often has face-to-face desks in your stores, very approachable and easy for customers, with a friendly face. The public services often have written and not face-to-face arrangements; there is often a delay and slow reaction times. Do you think that there could be a more approachable way of dealing with complaints in the public services? Could they learn something from you?

Simon Roberts: One of the significant trends we are noticing is that customers make contact with us in many different ways now: clearly, in our stores, in our face-to-face operations, as you have described, but also to our contact centre, also online and via Facebook. The lesson that we have learned over the last period of time is to try to open up as many channels as possible, recognising the face-to-face one will always be the prevalent channel given the nature of the industry that we are in. But we are finding more and more in the way our customers want to have contact with us that we have to really open the accessibility in many different ways. We have found particularly some of the social media channels are becoming increasingly important and our ability to be able to respond in the same way, in a very personalised way as we would in a face-to-face environment, is what creates a differentiated level of care. So, to your question, it would be about the breadth of accessibility beyond the written form and the ability to be able to flex resource or investment in resources to be able to respond in a timely way that the customers, patients or stakeholders want to get a response to their question.

Q187 Kelvin Hopkins: You are talking about the high end of competence. 20% of our population are functionally illiterate. They cannot deal probably even with telephones. They need to be able to speak to somebody. The face-to-face experience is fundamental.

Simon Roberts: Absolutely. Face-to-face is clearly fundamental. I guess what I am trying to describe is that in addition to that the other channels are very important and then we leave customers the choice as which one is going to work best for them.

Q188 Kelvin Hopkins: What should the Government do to improve things?

Mark Mullen: I have one observation on the face-to-face experience, which is I run a direct bank with no face-to-face experience and yet it has industryleading satisfaction in empathy, care levels. It outperforms everyone in those regards, so I am not certain that you need-

Q189 Chair: There is not much in writing.

Mark Mullen: There is not much in writing. It is all done by phone or online. The point is that the going-in position from the people who deal with us is that we will listen to them and we will care about what they tell us. I am not sure that you need to physically be sitting in front of somebody in order to build that sort of trust. I take your point about literacy and accessibility and, absolutely, it is not for everyone.

Q190 Chair: Even if you are talking to somebody different every time you contact the organisation.

Mark Mullen: Yes. The only reason it works is that the level of competence and training from one person to the other creates continuity, so you build a relationship with the brand, not with the individual.

Q191 Kelvin Hopkins: Yes, but again you are dealing with competent customers.

Mark Mullen: You are.

Q192 Kelvin Hopkins: Rather than incompetent patients.

Mark Mullen: Yes, but we are dealing with people for whom banking is a necessity, not necessarily a joy or a pleasure, so their intention is to get in and get out and get done what they want to get done quite quickly. They are not experts on banking or finance or in any other of those areas.

Q193 Chair: How do you deal with hearing or sight impaired people?

Mark Mullen: We have hearing loop technology. We have-I cannot remember what the technical term is-essentially keyboard conversations via the phone. We have different resolutions on the website. We outperform our competitors when it comes to hearing and sight impaired customers too. I am not anti face-to-face by any stretch of the imagination, but I would hate for people to think that face-to-face was a necessity in order to create an empathetic relationship with an individual, because our experience is that it is not.

Q194 Chair: What about John Lewis?

Abi Gray: I guess I would say the customers are different in any organisation and their needs and wants are going to vary as well. So I would ask them what sort of environment they want to have when they have that conversation and design it to suit.

Q195 Kelvin Hopkins: I did ask the question what you think the Government should do in the public services to make them more responsive to patients, passengers, pupils and students as well.

Chair: Any answers to that?

Simon Roberts: Maybe the other lesson that we have learned is that continually listening to customers about how best for them to make contact with us has helped us develop some of the channels that I described earlier. One of the big pieces of learning that came from the responses we get is customers tell us all the time how we would like to be able to interact with you more, learn more at a local and national level. Our learning has been to continually understand what are the channels that customers may want that we may not have developed fully and use that as a way of prioritising decisions.

Q196 Chair: Can I move on? Everybody agrees that the culture is critical-and I can quote each of your organisations saying that in one way or another-and implementing training schemes so people have the right skills. But how do you compare the culture of the public sector with the private sector? How would you ingrain the same kind of culture into the public sector as you do the private sector?

Mark Mullen: I can offer a thought, which is that there is a relationship between how you treat your people and how you ask or expect or want your people to treat their customers. In my experience, in the service sector it is virtually impossible to create a positive outcome with customers unless you have created a positive relationship with your own employees. So culture begins within and you have to treat people with the same degree of care and respect irrespective of whether they work for you or whether they are your customers. The danger is a lot of people focus on the customer and think, "The customer is king, we must do everything to serve them", but you cannot make that happen if you treat your people as in any way of lesser importance. They have to be the same.

Lynne Wood: In John Lewis, because we have a very good balance between partner and customer, I agree with what Mark said. It has to start with the partner first as well, to enable them to imagine how a customer is feeling at a certain point going through their complaint journey with us. So it is not doing to the customer, it is with partners and employees. Picking up your point again, it is how employees can understand what that customer is going through as well and how we can best deliver a better service for them. That is something culturally, rather than doing to customers through employees, making sure that employees understand what the customer impact is. Clearly they do, but it is understanding from a customer’s perspective.

Q197 Chair: On this point about employees, what happens when there is unhappiness from an employee or a group of employees? How do you think that differs in your organisation from public sector organisations that seem to embody this culture of denial? Perhaps a caricature, but it seems to exist. What do you think the difference in the organisations is?

Abi Gray: I do not know that I know enough about the other organisations. I can tell you how it works for us. As Lynne was saying, the ultimate purpose of our organisation is the happiness of its members through worthwhile and satisfying employment. So, if there is unhappiness or dissatisfaction, managers are accountable for the happiness of their teams, which is measured through an employee satisfaction survey, and that unhappiness is taken seriously.

Q198 Chair: So if you see a bad employee satisfaction survey, what does it tell you about the business?

Simon Roberts: Maybe building on the points that have been made, I wholly agree with the first point, which is that the leadership culture in each individual part of the business has to be really interested in what is not going well as well as what is going well. In the same way that you have just described, every year we would look at the employee satisfaction of an individual part of the business and link it to the customer satisfaction. To the point that Mark just made, we see a very strong correlation between the type of leadership that is focused on customers, the colleague satisfaction, the customer satisfaction and the business performance. We see a very clear correlation between each and all four of those elements. In our business, we have found that as we have deployed more of a focus on the leadership locally, very focused on customers, employee engagement has improved, customer satisfaction has improved, as has local performance. So that system of those four elements working together has been our experience.

Q199 Chair: That brings us on to the question of leadership. How does leadership ensure that complaints from employees as well as customers are properly analysed, processed and dealt with? What is the key component?

Simon Roberts: The key component I would describe as a way of leading in each part of the business that is very open and encourages colleagues to speak up about things that could be better as well as the things that go well. That is both in a day-to-day sense as well as in a more formalised listening and recognition sense and I think both are really important.

Q200 Chair: So do you ask your employees to tell you about their failures as well as their successes?

Simon Roberts: Learnings-what have we learnt about how we are with customers as well as what we have done well, absolutely.

Mark Mullen: Their individual or personal failings?

Q201 Chair: They might be individual or personal; they might be collective.

Mark Mullen: Definitely collective. I do not recall asking an employee to tell me about their personal failings, to be honest with you, but I can tell you that if you want to demonstrate that you are interested in what somebody has to say, whether it is about you or your organisation, you have to be prepared to do it publicly. It is not enough to create an open line to you saying "You know what? You can call me any time you want. You can send me an email and I will definitely respond to it." It is not demonstrating leadership. It is leading, but I think you have to be prepared to be more open than that and you have to be prepared to show people, not just the individual but their colleagues, that you are prepared to acknowledge a failure directly.

Q202 Chair: The public sector is notorious for the blame culture and we are seeing that right now with the naming and shaming of officials in the CQC, for example. How do you prevent that blame culture coming into the discussion about what things go wrong in your business?

Mark Mullen: Well, we sink or swim together, to be honest with you, and there is a sense of proportionality. I deal with customers every week, some of whom demand heads on sticks, frankly; who have had an experience that upset them and they believe that there is an individual in the organisation who is culpable. When we investigate, we will often find that it is an emotionally charged conversation and that really there is a sense of disproportion to the customer’s reaction, which is understandable, but we do not punish people simply because a customer is not happy. It is just not what we do.

Q203 Chair: Even if something has gone wrong.

Mark Mullen: Yes, even if something has gone wrong.

Q204 Chair: Or an employee or a group of employees have done something that is not in accordance with procedures or they have failed to spot something. A lot of people in the public sector think accountability is about being able to blame someone when something goes wrong. Are you saying that accountability is something different in the private sector?

Mark Mullen: I think the Health Service and banking have this in common, which is that there are some decisions that can go wrong that are materially detrimental to the customer: not inconveniencing, not distracting, but genuinely detrimental. You cannot ignore that and you cannot allow that to pass unnoticed, but ultimately we are both working, I suspect, in pretty complicated sectors. You made the point at the outset that people are trying to do a good job. The going-in position is that most of our people, in fact the overwhelming majority, come to work to do a good job. They are not trying to fail and so if you encounter failure it is generally not because of indolence or lack of effort or lack of engagement. There is a whole bunch of factors that can play into it. You have to make a judgment and be measured. There is no policy rule that I can refer to about making an individual judgment about whether somebody has been negligent as opposed to where somebody has made a mistake. There is a big difference between the two.

Q205 Chair: But then how do you prevent the organisation going into denial and saying, "Well, it is not our fault. Everyone was trying their best." That is very common in the public sector: "We are all trying our best. We have limited resources. There is a limited amount we can do."

Mark Mullen: Sorry to interrupt you. The difference is it is our fault, but everyone was trying our best. There are times when everyone tries their best but fails, but it is our fault.

Q206 Chair: Okay. John Lewis seems to create this sense of collective responsibility for failures and then collective responsibility for better outcomes. How does management generate that sense of collective responsibility as opposed to people blaming each other?

Lynne Wood: There is a combination of collective and individual responsibility and what I find in John Lewis is that the role modelling from leadership is there. So it is not who has done the wrong thing. It is leadership want to understand what we can do better to improve that with partners. It is very much taking that collective responsibility, but also individually making decisions to make it right. I am not saying there is no blame culture. It is how can we learn from this? It is the difference between having a big policy decision and a major issue, but there is a continual view about how we can improve things and take responsibility for it, because that is what we are here to do. It is role modelling that I see very much in John Lewis from the top down, as Mark said, taking individual responsibility to deal with complaints. I do not know how many other organisation would do that.

Q207 Greg Mulholland: Does this not show, do you think, that there is a real limitation in comparing the private sector and the public sector? There might be a clear and helpful overlap sometimes; for example, if people are not getting their bins emptied on time and there is a pattern that is then being followed and then improvements are made, then that is positive complaint handling. But if you take the example of the NHS, where someone has had poor care that perhaps has led to the quality of life of someone being ruined or, indeed, someone having died, then frankly some of the things you are saying do not apply. So do you think we have to be careful about the analogy and being clear where it applies and where it does not apply?

Mark Mullen: I make a distinction between the controls, the audits, the various different checks, balances and lines of defence any organisation has, whether it is public or private, to try to prevent the wrong thing from happening, as opposed to somebody making a mistake within a process. Because at the end of the day, all of the systems, all of the rules, all of the regulations, all of the procedures we have reduce the risk of failure but they do not eliminate it and I suspect they never will. I get a sense of a growing sense that if anything goes wrong somebody is to blame and therefore we will find the culprit one way or another. I do not necessarily think that is within organisations. I get a sense of a public sentiment that somebody must be accountable for anything that goes wrong. At some level that is true, but it is not intentional. It is not even negligent. It is because all systems are, to a greater or lesser extent, human systems and there is risk in them

Q208 Greg Mulholland: That might be fine for First Direct, but that is clearly not fine for the NHS. The only parallel perhaps is if there was severe maladministration, indeed potentially corruption in the senior echelons of a bank. That is the only time that you could say there was anything in terms of a parallel of accountability. But if something has gone seriously wrong within the NHS, then people are accountable all the way up to the Prime Minister. That is a fundamental principle of our democracy and there is no parallel in your organisation. Therefore, do you accept that to some extent the analogy you are talking about is helpful, but to some extent it can be quite false, because accountability in the public sector absolutely does and should mean that people need to be held to account for their actions? In the end, sometimes that is what people want.

Mark Mullen: I am honestly not disputing that. I do struggle with the idea that the NHS is ever going to find itself in a position where it will not make mistakes. I think it is inevitable, I really do.

Q209 Greg Mulholland: We are going to come on to the section about covering up mistakes, but we are talking about accountability and what I am saying to you is that there is not the same need for accountability, certainly not democratic accountability, in your organisation as there is in the public sector, particularly the NHS.

Mark Mullen: That is absolutely true.

Q210 Kelvin Hopkins: Just to reinforce the point, selling somebody the wrong vacuum cleaner is quite a different matter from somebody dying. You do not have people dying because they have the wrong vacuum cleaner.

Lynne Wood: No and, as Mark said, I do not think you can compare the two. We are not established to ensure that mistakes are not made or policies and processes are not broken, it is how you recover from that and I think you are right, we cannot compare exactly the accountability for someone’s death and buying the wrong vacuum cleaner. It is how they are handled or how they are recovered from that and the learnings from that. That is probably the difference, from our perspective.

Simon Roberts: There is one other point I would make, which has been a distinct learning for us obviously working in both healthcare and in retail. In our ability to improve what we do, one of the big things that we have looked at is to the whole point of day in, day out, week in, week out to what extent is the leadership of the business right in the heart of the business learning, seeing, feeling, understanding what is really going on? As Mark described, day in, day out I would see complaints, I would see compliments, I would spend time in the contact centre, in stores, in our dispensaries with our pharmacists. The key point I would make is the degree to which the learning about what we can improve happens through visible, in the heart of the business, fast response. That has been something that we have been really working on, so the spirit of sharing. That has been a significant shift in the leadership focus in our organisation, which has enabled us to respond and learn more quickly.

Q211 Chair: Can I just ask Mr Hopkins’ question the other way round: how important would you think it is to have an effective complaints and customer feedback system in a life and death organisation like the NHS rather than in just, say, a consumer products or consumer services organisation?

Mark Mullen: More important.

Chair: It would be more important.

Mark Mullen: Yes. It does not mean that you are necessarily going to have a weaker complaints management process in the private sector, but all things being equal, yes. You would expect the feedback loop and the way that you reengineered failures or learnings from failures in life and death businesses-aircraft travel is another one-to be of an order of magnitude where the tolerance for failure was significantly lower. Therefore, the early warning signs that tell you that something might be going wrong would be significantly lower. To give you a practical example, we might set an average speed of answer on our telephone calls to say we want to answer all our calls within 20 seconds, because we know that as long as we do that we will hit our satisfaction threshold. In other businesses, I can absolutely understand why tolerance thresholds for failure would be much, much narrower.

Q212 Chair: If you were dealing in a business with much narrower tolerance thresholds where it was about life and death, what effect should that have on the leadership of that organisation to ensure that things are run better?

Simon Roberts: Clearly, in our business we have a responsibility to deliver medicines and drugs to millions of people every day within the UK. As you will imagine, we have a huge focus on our consistency, our training, our delivery, our follow up and a focus on accuracy in that regard. It is a core element of everything we do in our leadership to make sure that we continually learn and improve.

Q213 Chair: When you get complaints and customer feedback for things gone wrong in that part of the business, how do you deal with it? Supposing somebody gets the wrong medication and they die. You are part of the Health Service in that respect. Is the leadership required to address that any different from the leadership that would be required to address the same kind of problem in the Health Service?

Simon Roberts: Fundamentally, clearly we take very seriously our responsibility to make sure that we get all of those systems and processes right. Clearly, we have regulatory responsibilities in terms of how we do that, but the parallels across the organisation I think are similar. Fundamentally, we want to care for our customers and patients. We want to give them the very best level of care and we prioritise the way we do that at the very core our leadership system. So the principles are the same across the organisation. The requirements governing the healthcare part of our business are different, but they follow the same principles.

Q214 Chair: The point I am trying to get to is: what is the difference between the way you process information and data about those kinds of complaints and the way you process information and data about how quickly people answer the telephones or other things? Are the systems and processes fundamentally similar?

Simon Roberts: They are very similar because, as I say, at its core it is about our care for the customer and patient.

Q215 Chair: Thank you very much. Is there anything else that anybody wants to add? Are there any questions that occur to any of you about what you would ask the Chief Executive of the Health Service, who is one of our next witnesses, about how complaints and customer feedback is handled in the Health Service, with your perspective? Give us some thoughts.

Mark Mullen: I am struck by the importance of demonstrating that you have listened to complaints for the people who work in an organisation. So if you have a community of employees or customers who are telling you that something is wrong and have been telling you that something is wrong, whether it be about resource levels or about prioritisation, for some time and you do not do anything about it, then it becomes demoralising to your people if, frankly, they know the problem. They have known the problem forever because they talk to customers all the time and they are not seeing a visible demonstration of anyone investing or doing something different. I think that is corrosive, because then there is a gap: "We want you to do the best job you can, we want you to listen to customers, resolve complaints quickly, but we are really not prepared to invest to help you". I am not sure that I see the visible connection between the intent, which is to create a customeroriented culture in public service matched with "Well, okay, how are we following that up with specific and meaningful investment in change on the ground?" I do understand it is a fairly difficult balance to get in the current economic climate.

Q216 Chair: Would anybody else like to have a go at my question?

Simon Roberts: As we have described all the way through, the key to this, whether it be in the NHS or in other organisations, is about the extent to which local leadership can both listen to customers and colleagues and also feel empowered to make the right decisions within the scope of their local responsibilities. That is as relevant, I would have thought, in the NHS as it is in a private sector organisation. Our big learning, as I have described, is about developing that local leadership to be able to take on those responsibilities and to feel confident in doing so. "Confidence" is a really important word, because if people feel confident locally they are more likely to move more quickly to respond to the needs of customers and patients.

Q217 Chair: But that confidence and empowerment depends upon the national leadership.

Simon Roberts: For sure, for sure, but there is also a mutual dependency both ways, because confidence can work up and down the system.

Q218 Chair: The last word to John Lewis.

Abi Gray: My question would be how visible the complaint data is up the organisation, because if it is visible it becomes easier to make the decisions.

Chair: Thank you all very much indeed. We have finished absolutely bang on time. I am most grateful to you. Excellent session. Thank you.

Examination of Witnesses

Witnesses: Sir David Nicholson, Chief Executive, NHS England, and Chris Bostock, NHS Complaints, Department of Health, gave evidence.

Q219 Chair: Could I ask each of our next two witnesses to identify themselves for the record, please?

Sir David Nicholson: Yes. I am David Nicholson. I am the Chief Executive of NHS England.

Chris Bostock: Chris Bostock. I am the official at the Department of Health with lead responsibility for NHS complaints policy.

Q220 Chair: I think we are going to need to move the microphones slightly more in front of you, because I cannot quite hear you or if you can just speak up a little bit that will be fine. Thank you very much. Thank you both very much for being with us. I know, Sir David, that you have a rather gruelling schedule of Select Committees and we are very grateful for you accommodating us on a different day from everybody else. Thank you very much indeed. This inquiry really does arise as much from the Francis Inquiry into Mid Staffs as anything else, but we are particularly anxious to know what the system is learning from this. You both listened to the last session. Do you have a reaction to the previous session, the previous witnesses, what they said?

Sir David Nicholson: I was not surprised by what they said. I have spent time with not those individuals but other individuals in other industries to think about how all these issues work and what we can learn, as the NHS, from it. They are pretty standard things that have been set out. They are good things that work in practice, things that the NHS can learn from. The difference, for me, is that, first of all, the NHS is not an organisation in the sense of the organisations that you had there. The NHS is a healthcare system based on over 400 statutory organisations with their own accountabilities, their own boards, their own responsibilities. There has been a policy over the last 20 years to delegate more responsibility and accountability to those individual organisations and I guess many of the organisational lessons need to be learned by those organisations. That is not to say that the centre does not have a responsibility to set the tone and to do all of that, but there are some areas where the centre can make a real contribution and some where it cannot. If you take, for example, things like appraisal systems, they are vitally important for organisations. It would be wrong for us to set up an appraisal system from the centre that applied to every single organisation, every context in the NHS. Each organisation has to take its own judgment about what suits it and its base.

Chris Bostock: In terms of general complaints system principles, which are the provision of remedy to the individual making the complaint, but also ensuring that lessons are learned to improve future delivery, I think they came out very well. But what struck me most was the fact about tackling a concern or a comment early on in order to prevent it developing into a complaint, so tackle on the front line to prevent that escalation.

Q221 Chair: The Francis Inquiry exposed an organisation where complaints were clearly not being heard and not being heard over a long period and those complaints did go up the system, but they were not heard up the system either. Now, it sounds to me, Sir David, as though you are saying, "Well, it was not the system further up’s responsibility to hear those complaints and the system was right to push them back to the organisation that was not listening the complaints".

Sir David Nicholson: Sorry, I certainly did not mean to give that impression. If you look at the Mid Staffordshire experience and, as you can imagine, I have looked at it quite a lot, there are three or four things about complaints and that that come out of it. The first one-and this was shown when Francis did his original inquiry in 2009-is there were elements of information and knowledge that had come out of some complaints, which were lodged in different parts of the system and at no time did the system bring it all together into one place so it could make an assessment about how serious that was. So there were complaints going from MPs to the Department of Health, there were complaints going to the organisation itself, they were going to general practitioners and nowhere in the system did all of that information come together so that people could make a judgment about the scale of it. I think that is a really important lesson for the NHS and we can talk about what you might do about that, but that was one thing. So, absolutely right, the system has a responsibility to make sure that that happened.

Q222 Chair: I am listening to what you are saying and I appreciate that you could give us a very long answer. The evidence we have been taking on public services and the Civil Service in general is that when an organisation is failing, most people in that organisation know that organisation is failing, but, exactly as you described, nobody wants to hear or to accumulate the information and confront the truth that the organisation is failing. Now, that was quite clear in Mid Staffs, but a lot of people believe and there is evidence to suggest that that failure to hear, which you are just describing now, went much further up the system. How much do you recognise that as a failing of the NHS as a whole?

Sir David Nicholson: Robert Francis, in his report, says that it was a failure of the system to support and help those patients and those individuals in those circumstances.

Q223 Chair: Okay. That is a good answer. I appreciate your honesty. So how has Francis’ recommendations on complaints changed the thinking further up the system about complaints handling?

Sir David Nicholson: The first thing is that, for us in the NHS anyway, the 2009 report by Francis was the first time that we saw all of this brought together and we sat down nationally across all the bodies responsible and worked out how we could make sure that those sorts of things were surfaced right up the system in the future. Under the auspices of something called the National Quality Board, which is where all the regulators and organisations come together nationally to think about these things, we put together a document that set out a set of processes and systems to enable us to do that. So, for example, if any of the various organisations involved with a particular organisation has a worry about the way that is working, any of those organisations can call together a risk summit. So we can bring everyone together, pool all of the information that we have available to enable us to make judgments on that. So there is a mechanism, in a sense, for doing that.

Q224 Chair: Would that be greeted as a bad thing to have to do or would that be greeted as a good thing to do? Do you see the difference? I mean, how do you see complaints, as a positive thing or as a negative thing, because if there was more welcome for complaints they might be listened to more readily?

Sir David Nicholson: You ask a broader question about the way in which the NHS deals with the feedback that it gets from its patients, from its staff and all the rest of it, and there has been a tradition and a culture in the NHS for some time that has been counter to that. That is not a tradition and culture that has been brought about from people wanting to do bad things or anything of that nature. If I think about my own experience, many years ago I was a complaints manager in a trust. There is a very strong medicallegal litigation culture in organisations and, at that time, the answer to any complaint was to deny, because of the potential litigation responsibilities. So you have a culture of that in the NHS that I think we have to understand. We have to tackle it.

Q225 Chair: When did you first become aware of this culture?

Sir David Nicholson: When I was a complaints manager in a trust. At that time, individual organisations did not take responsibility for the liability of the clinicians who worked within it. They had to do that individually themselves, so it was quite a strong, systematic way, a professional culture, in a sense, about litigation.

The other one is the reputational management bit, which I think we can see and we saw it in Mid Staffordshire as well, where on the one hand there is a concern, inevitably, in the circumstances-if you are the chief executive of an organisation or whatever, you want people to think the best of it and all the rest of it-but also, there is also quite a lot of pressure on you as an individual, particularly from your staff, to represent and support your organisation publicly.

They are quite powerful things to combat. My argument is that they absolutely have to be combated-

Q226 Chair: What are the strategic steps that the NHS England and Wales leadership is taking in order to put the right culture around these issues?

Sir David Nicholson: At the heart of it, there is the issue of transparency and openness. It is absolutely central to all of this happening. That is why, as far as NHS England is concerned, we publish all the data that we do. Later this week, we are going to be publishing a whole lot of data about surgical outcomes across 10 specialties. We are publishing data around outcomes generally. There is a whole lot of stuff that we are putting out into the public domain. We meet in public. We live stream our meetings. We are trying, from a national perspective, in a sense to role model the way in which we think the system should operate.

Q227 Chair: Can I just press you a little bit on that? I am sorry; I keep interrupting you when you are being very helpful. In the previous session, we heard about how important it is to have that openness within the organisation, which might not necessarily be public data, but it is about generating an acceptance and an enthusiasm for hearing within the organisation. Mid Staffs would never have happened if that culture had existed and it is a prerequisite for openness outside.

Sir David Nicholson: Yes, it is, absolutely.

Q228 Chair: How are you generating that culture in the NHS, because that would be a big change, in my experience?

Sir David Nicholson: Sorry, in terms of our own organisation?

Chair: Yes, because it was your organisation, bluntly, that did not hear the truth about Mid Staffs for quite some time.

Sir David Nicholson: Sorry, I was talking about NHS England. If you are talking about the Department of Health-

Q229 Chair: The Department of Health and NHS England. Everyone is in it. We are all in this. It is a collective failure, is it not, and we have to accept that there were collective failures?

Sir David Nicholson: NHS England did not exist at that time. That is the only point I am trying to make. This is a new organisation that we are creating to enable us to take that forward.

Q230 Chair: Well, the NHS, as far as the public are concerned.

Sir David Nicholson: It is being absolutely clear and open in the way in which complaints data goes around the system, so the commissioners get access to complaints data from individual providers; the way in which we analyse that data; the way we can look at the really rich amount of information we get from the patient survey, the biggest patient survey in the world, the biggest staff survey in the world; the way in which NHS England has set out strategically, in terms of the way it is approaching things, the two main measures for the way in which the service is going to go forward. The way we are going to measure our own success is the satisfaction of our patients and our staff. They are the two main measures that we are going to use.

Q231 Chair: And that is going to be done at local level and national level.

Sir David Nicholson: That is completely throughout NHS England, yes.

Q232 Chair: In the end, is there clarity about who has ultimate responsibility for making sure that complaints throughout the system are being properly handled?

Sir David Nicholson: Each individual organisation is responsible for making sure its own complaints arrangements are in place and NHS England and the other bodies nationally are responsible for making sure the system, as a whole, works and that we get a position where we are responsive to our patients.

Q233 Chair: Thank you very much. Anything you want to add, Mr Bostock?

Chris Bostock: Not at this point.

Q234 Greg Mulholland: Good morning, Chris, and good morning, Sir David. Sir David, some of the phrases that keep cropping up in the written evidence that we have about NHS complaint handling are also some of the same themes and phrases in the Francis report in the appalling course of events in Morecambe Bay. They are things like "withholding key information", "a lack of openness", "a culture of defensiveness", "a lack of proper process", "a tendency to evade responsibility and accountability". Is the sad truth that there is a culture of secrecy and cover up in the NHS?

Sir David Nicholson: I do not believe that there is in the way that you just described it. I do think there is a real issue about defensiveness and a lack of transparency in the way that we work. This is not a new issue for us; we originally named it as that, in that sense, in 2007/2008 when Ara Darzi did the work on the NHS as a whole. I think what you are seeing is a healthcare system going through a really significant transition at the other end of it to create a much more conducive, open and transparent healthcare system and that is very painful.

Q235 Chair: Are you talking about the transformation on complaints or about the whole reform process?

Sir David Nicholson: I am talking particularly about the relationship between the NHS, the public and patients, of which the complaints system is an important part, but it is one part. That relationship is going through a dramatic and significant change. So, on the one hand, we are publishing lots of data and information and people can connect together through social media and all the rest of it, things are opening out, but the leadership of the NHS, not everywhere but in some places, is having difficulty coming to terms with that and is slightly behind it. That is my analysis of where I think we are at the moment. What we are seeing are the problems and issues that the system is trying to deal with as it goes through that big change.

Q236 Greg Mulholland: A lot of this come down to leadership, all the way to yours. Do you think in your tenure, in your role, that you will be able to say that you have dealt with this? I am afraid another thing that is consistent in many of these, both at a local and national level, including things like NHS Specialised Services and indeed in NHS England itself, is allowing senior staff who are not independent to be the judge of their own actions. Do you not accept that there is an issue with everyone all the way up to you, and that without the leadership there-and many would question whether that leadership is there-we are not going to see that at the lowest level?

Sir David Nicholson: That big change that is going on inside and outside the NHS around the relationships with its patients and the public: we are in that at the moment. There are important parts to making that change happen. Part of that is the leadership of the NHS. I can talk to you about the analysis that we have done about the nature and type of leadership we have in the NHS, and what we are trying to do to change it. Undoubtedly, in broad terms, the NHS leadership is not equipped to handle some of the big issues that are coming forward, so we need to tackle that leadership. We need to work really hard on the culture of the system overall, because as you are going through that transition the importance of setting the right tone from top to bottom of the organisation is increasingly important; that is what we are trying to do. You need to make sure that you are learning the lessons and getting innovation from the system as a whole.

All those things are happening at the moment, and it is part of the journey, in a sense, that this healthcare system is going through, as most healthcare systems in the world are at the moment, as you can see. You said the thing about people were not independent in the way that they were operating. One of the things that was really important in 2008 when we thought about all of this was getting more clinicians into leadership positions in the NHS overall. It is a particular issue for NHS England. Looking at the way in which our organisation has been set up, you can see an enormous influx of clinical people who can help and make the right kinds of decisions for the NHS going forward.

Q237 Greg Mulholland: Is that not precisely part of the problem? These people are now judging their own actions and there seems to be no accountability above them. The Safe and Sustainable Review into children’s heart surgery has proved a fiasco. I accept that a lot of the decision making, but not all, happened before NHS England. Nevertheless, clearly lessons have not been learned. There were 14 secret meetings, and even bodies that have a statutory duty of accountability have been refused key documentation throughout the process of that. It took a costly judicial review to prove that the process had been done unlawfully. Of course, that has then been backed up by the Independent Reconfiguration Panel, who showed that senior people in the JCPCT, and following through in the NHS Specialised Services, have not been open or transparent and have carried out a process in an unacceptable, flawed way. Yet what accountability is there to deal with that?

Sir David Nicholson: Well, we are going to put it right.

Q238 Greg Mulholland: In what way? Investigate those people?

Chair: Sir David, please answer the question.

Sir David Nicholson: We are currently working with hospitals and patient organisations to think about what kind of process we would need in order to get the right decision making and the right transparent way of working. Not everyone will ever sign up to all the decisions we make in this regard, but I absolutely take the point that going forward we need to be completely transparent around all of that.

Q239 Greg Mulholland: What about going back? Never mind going forward. Of course that is important; that is getting the decision right next time so that another £6 million will not be wasted. What about the question I am asking you, which is retrospectively, who is going to hold those people to account? Are we going to have a proper investigation into the individuals who made that flawed decision? In the end, that decision was made by individuals who did it in an incorrect, unacceptable and actually unlawful way. Or are we going to carry on this culture of secrecy where we brush that under the carpet and simply carry on and say, "We will get it right next time"?

Sir David Nicholson: I certainly do not want to brush anything under the carpet. I guess what I am going to say to you now will not satisfy the point that you made.

Greg Mulholland: Will it answer it?

Chair: Hang on, let him answer the question.

Sir David Nicholson: The JCPCT was set up with 151 primary care trusts, all of which have been abolished. Most of the people that led that process have now left the service. We could spend a lot of time and effort as NHS England going back through all of that, but we think our time and effort is best spent on looking forward.

Q240 Chair: Can I just ask a supplementary on this? It does sound a sorry saga. What do you think are the key lessons the NHS needs to learn from that episode?

Sir David Nicholson: There are two that I particularly identify. One of them is it is very, very difficult to make decisions about national services in the current regulatory arrangements. You had 151 different statutory organisations, for all of which you had to make a judgment about what the right thing to do or not to do was in those circumstances.

Q241 Chair: So the openness and transparency gets lost in the process.

Sir David Nicholson: It completely got lost in that particular process. It all became about how to hold together 151 different organisations, all with different interests and different values during that process. My guess is that some of the ways in which things were not transparent were because of the kinds of arrangements that had to be put into place to make that happen. That is not the issue with NHS England; there is now one organisation responsible for making the decisions, not 150 odd.

Q242 Chair: So that has already been remedied.

Sir David Nicholson: It is only remedied if we do act in an open way, which is the second one: being open and transparent and making sure that all the information, knowledge and difficult judgments that people make are out there for people to see and make their comments on as we go along.

Q243 Greg Mulholland: Just to pursue the point of individuals, in the end it is individuals who make decisions. Committees make them collectively and have the responsibility collectively, but also as individuals as part of that Committee. You cannot seriously be saying that it is perfectly acceptable just because NHS structures have changed for people to then leave some of them off to collect their fairly sizeable pensions and not have their decision-making looked at-decision-making that has been deemed to be flawed and unlawful. Otherwise surely we cannot possibly learn the lesson.

Sir David Nicholson: We had the Independent Review Panel, and we have had the legal investigations into it. We have all that information available to us.

Q244 Greg Mulholland: But will those people be held to account?

Sir David Nicholson: I can’t sack them because they don’t work for us anymore.

Q245 Greg Mulholland: But will they be criticised at least?

Sir David Nicholson: They have been.

Q13 Greg Mulholland: Not individually. We have simply been told that the decision was made in an unacceptable way. Are we going to learn from that by looking at people who made that decision, their motivation and the way they did that?

Sir David Nicholson: We do not plan to spend our time doing that. So, in the way that you have described it, we will not be doing that, no.

Q246 Chair: This is a very interesting stand-off, because this is a very certain type of accountability that a colleague on this Committee is demanding, and you are not able to give it. The press do this, Select Committees do this, Members of Parliament do this, members of the public do this, try to find individuals and blame them for what has gone wrong. What do you feel about this kind of accountability? How do you think the Health Service can best operate while satisfying that desire for personal transparency about managers and individuals in the system and holding the whole thing together at the same time? Tell us what you feel about that.

Sir David Nicholson: I completely understand it. It is a completely reasonable thing to expect to happen. However, the healthcare system is slightly more complex than thinking about one individual organisation, which tends to be people’s frames of reference. That is the frustration, in a sense. At a national level, it is perfectly reasonable to be held accountable for how the system operates, but it is quite difficult over and above a particular individual organisation when you want to deal with specifics in that way.

Q247 Chair: The CQC situation is very relevant in this particular case because, as an organisation, they want to hold accountable and discipline people who may have done the wrong thing. We are not passing any judgment on that; I think the jury is out. When it all goes public and people are named in public and consequences flow from that-I mean, this is the political world we live in-the Health Services does not seem capable of operating in this environment. What do we need to do to make the system of trust and openness between different agencies and organisations in the Health Service operate amidst this incredible glare of blame and publicity?

Sir David Nicholson: I think it is quite hard. I have not got an answer to you in that way.

Q248 Chair: Do you think it infects the management culture so that that blame culture gets into the management culture as well?

Sir David Nicholson: It can do. I can perfectly understand how it does, but it is not the right thing to do. In a sense, part of being a public service leader is having a set of values about focusing on the interests and importance of patients and all the rest of it, so to work counter to that is not the right thing. I think it is perfectly legitimate for people to try to-

Q249 Chair: What are the steps you are taking to change this defensive culture so that this openness, which my colleague here is saying you failed to deliver in Leeds, becomes natural and expected? How are you changing that?

Sir David Nicholson: There are a whole series of ways. One of them is the way in which we are tackling the whole issue about leadership development and selecting leaders, how we do it and the kinds of things that they do. I can talk to you about that if you want because it is a really important intervention that we have been making now for the last two or three years to get us into a place where our leaders are much more equipped to work in an environment that you have just described. Secondly, it is literally publishing and getting all of this information out into the public domain so that people can see it for their themselves and ask the questions that they think are the right ones.

Q250 Greg Mulholland: Just to pick up the point that you made, Chair, we have had it proven that this decision was made unlawfully and that it was flawed, by the High Court and the Independent Reconfiguration Panel. The point is those individuals who were responsible for making that unlawful, flawed decision are not in any way being held accountable. I will ask you one very simple question. This is an open question and I hope you will give a positive answer. To enable that to happen, can you please look personally, as the Chief Executive of NHS England, the man at the top who reports to the Secretary of State for Health, and can you ensure that the appalling refusal by the National Specialised Commissioning Team and the JCPCT, whilst it was in existence, to supply all necessary documentation to the Yorkshire Health Overview and Scrutiny Committee will now be overturned? Can you ensure that that democratic body is able to properly scrutinise this decision? Could you personally see that that can happen?

Sir David Nicholson: Yes, of course.

Greg Mulholland: Thank you very much.

Q251 Kelvin Hopkins: If we go back to Francis and Mid Staffs, he said very bluntly there was a "lack of care, compassion and humanity". There have been widespread comments that the reason for this was they were more concerned with foundation trust status, their financial performance, and to be seen to be a good performer in Government eyes than they were with patients. Isn’t that fundamentally a problem?

Sir David Nicholson: Absolutely. It is a problem in that individual organisation. It was a very, very big problem.

Q252 Kelvin Hopkins: I must say, I am a Labour Member of Parliament; I voted against foundation trusts. I still believe they were profoundly wrong, and I voted against trust status 20 years ago. Nevertheless, Government wanted to prepare the ground to move more into a commercial form of operation in the health sector rather than a public service sector arrangement. Isn’t that drive underlying all these problems?

Sir David Nicholson: I genuinely do not believe that is the case. Some of our most entrepreneurial and innovative foundation trusts are quite capable of running a service that shows care and compassion to individual patients. I do not think there is a connection between those two.

Q253 Kelvin Hopkins: I know one chair some time ago who chose not to continue in office as chair of the trust because the trust was becoming more of a business than a public service.

Sir David Nicholson: My experience of foundation trusts and people who leave them is not in that. They are as much part of the sign-up to the NHS values and principles as set out in the constitution as any groups that I see. I do not see that distinction.

Q254 Kelvin Hopkins: But when individuals working in the Health Service, as was the case at Mid Staffs, were overloaded because they were understaffed, compassion even from the best of human beings starts to suffer.

Sir David Nicholson: Care and compassion is part of what we are there for; it is what the public and patients expect from us and it is what we all expect throughout the system. There is no excuse in those circumstances for what happened at Mid Staffordshire.

Q255 Kelvin Hopkins: Previous Governments-and I am a Labour Member of Parliament and I opposed what they were doing-went to great lengths to abolish community health councils. There was a strong implication at the time that the reason for this was because the private sector companies that were going to come in did not want community health councils because they were a nuisance and made it too easy for patients to complain. Is that fair? What do you know about community health councils?

Sir David Nicholson: I worked with community health councils for many years as a trust chief executive, and I got on extremely well with the community health councils. They provided a valuable service and resource to the local population.

Q256 Kelvin Hopkins: They were deeply unpopular with our local trust. On the radio last week, there was a debate about CQC, and they had a former chair of a trust, and he said the only body that he worried about and that really made his life difficult was the community health council because there was a face-to-face opportunity for patients to complain. That is what he did not like, and that is why this Government wanted a light touch regulation and to drive things into the market. Wasn’t that the truth?

Sir David Nicholson: There is no short-cut, though. I do get worried when leaders of organisations say, "The only organisation I am worried about is," when in fact what they should be worried about is the services that their patients are getting, and what their organisation is doing. That should be the focus.

Q257 Chair: Without community health councils-I presume we are not planning to bring them back-

Sir David Nicholson: Not as far as I know.

Chair: -what does a positive complaints handling culture look like, from the NHS?

Sir David Nicholson: When you look at international comparisons of the NHS with other healthcare systems, in most of them we perform pretty well, and in some of them we do very well. The one we do not do so well on is responsiveness. If you look internationally, we are not a very responsive healthcare system broadly across the board.

Chair: So that is what we’re not.

Sir David Nicholson: So complaints are an important part of creating that responsiveness as an NHS healthcare system going forward. Complaints are really important from that perspective, but it is on a continuum from, on the one hand, listening to what your customers are saying on an individual, day-to-day basis right the way through to someone taking up a complaint. It is critically important.

Q258 Chair: What role will service commissioners have-and you are the lead commissioner-in the new NHS in relation to complaints handling, and what will be in the commissioning contracts about complaints and complaints handling in order to promote the right culture?

Sir David Nicholson: Of course, we are quite a big complaints handler ourselves now anyway because of our commissioning of primary care. As you know, lots of people when dealing with primary care would much prefer to deal with the commissioner rather than the service provider, so we are responsible for making sure that our own complaints handling is absolutely top rate. We plan to do that by doing all of the kinds of things that you would expect from the way in which we handle our complaints at the front line, through to the way in which we analyse how successfully we have dealt with them, right through to the way in which we as a board consider them. In the next two or three months we will have published a patient insight dashboard that will give lots and lots of data to our board and publicly about what patients are saying about the kinds of services that we directly commission

Q259 Chair: But there are a very large number of different bodies that people can complain to in the NHS. Is that confusion not itself a barrier to people complaining? Should there not be a single point of contact? How are you going to address the complexity of complaining in the NHS?

Sir David Nicholson: Do you want to deal with that?

Chris Bostock: Certainly, there has been a view-in fact it first arose in response to Shipman in the Fifth Report-that having a central point for the receipt of complaints about the NHS system-wide would be advantageous in some respects because they could then be directed to the appropriate bodies and they could be dealt with and so on. Certainly, the Ombudsman in the past, Julie Mellor, has asked for that to be investigated. I think this could be argued in two ways. My concern about it is the evidence suggests that someone making a complaint about the NHS, in the first instance, is looking for a response at local level from the organisation that created the situation in the first place, and an appropriate remedy offered at local level. If we are to put patients at the forefront of the NHS, then that is the system we should stay with. Once we start to depersonalise it, if you will, and put it into a central bureaucratic point, it increases the bureaucracy and moves it directly away from the local contact. It could be argued both ways. I would tend to side with the fact that the majority of people want local resolution in the first instance, but were that not to be satisfactory they want an independent stage in order to address that.

Q260 Chair: But you accept that complaining in the NHS is very complicated at the moment.

Chris Bostock: I accept that the system itself is complicated. We have professional regulators, providers and the commissioners, and there is no doubt that that in itself is complicated. The majority of complaints tend to be about service provision. Whilst we may not have got the messages out and we may need to do more around information, I am not quite sure that if someone has a problem with service provision it is that complicated.

Q261 Chair: What is the Health Service going to do to address that complexity so that a patient who wants to complain knows how to complain?

Chris Bostock: Firstly, we cannot lose sight of the fact that the Prime Minister has asked the Right Honourable Ann Clwyd and Professor Tricia Hart to review NHS complaints handling, in terms of both transparency and good practice and so on. I would not wish to move into areas to prejudge those recommendations. I do not think there is any doubt that we as a Department need to work with regulators, the Ombudsman’s office and so on in order to ensure not only that the system is clarified and the information is shared, but also, picking up a point that was raised earlier, that the data and information from complaints handling is shared more widely across the system.

Q262 Chair: So whatever new system is put in place, perhaps more a question to Sir David, how will you, as Chief Executive, measure the success or failure of the new system?

Sir David Nicholson: In terms of complaints?

Chair: In terms of how the system is measuring the commissioning process and the complaints handling process as one process.

Sir David Nicholson: The first thing is the relative satisfaction or otherwise of our patients, the way they were dealt with, how they felt about the way their complaint was handled and what happened around all of that. That is one important mechanism by which we will do it. We are also adding into the contract that commissions should have sight of the way in which their individual providers are analysing their complaints, and what actions they are taking to put them right.

Q263 Chair: How will the commissioning process actually embed measurement of the success of the complaints system so that it is reflected and embedded in the commissioning process? The commissioning is the main thing you are going to be doing, and yet the complaints handling is one of the most important things you want your providers to be operating. How are commissioning and the monitoring of complaints integrated? Maybe it is a challenge you have not given much thought to yet.

Sir David Nicholson: No, we have given some thought to it, but only at a contractual level. We would write into the national contract going forward the standards that we would expect of appropriate complaints handling, and how they would measure it.

Q264 Chair: How will commissioners monitor the performance against these criteria?

Sir David Nicholson: In a sense, one of the helpful ways in which these Select Committees operate is to focus your attention on it at a moment in time. Having looked at it over the last week or so, it is clear to me that the data definitions of what is required are not sufficiently clear or helpful to providers at the moment to make proper benchmarking and sharing of information available.

Q265 Chair: So you think I am asking the right question.

Sir David Nicholson: I think you are asking absolutely the right question.

Q266 Chair: The message we get from the private sector is strategic leadership and the access to comprehensive and indeed complex data about the complexity of the whole organisation is essential in order to be able to understand whether complaints systems are working or not.

Sir David Nicholson: Absolutely. There is no shortage of data, but it is not collected in a way that is either systematic or helpful enough in the decision making that you make. Nor is it, at the moment, consistently applied across the NHS in a way which could enable people to make the right kind of decisions.

Q267 Greg Mulholland: I just have a question very specifically on the structure, Chair, following on from your questions. This may have been a decision that you took yourself, Sir David, but the decision was taken to effectively amalgamate the complaints manager function with the patient advice and liaison service at a local level. We all understand, and I think your description, Chris, of what people want from a local complaint is one that we would broadly share. I think, Sir David, you will be aware that the decision to effectively amalgamate those functions, in some people’s eyes-and I am sure this was not by design-has led locally to a deliberate attempt to deflect or block complaints. Of course, one of the problems is that the NHS complaints manager is a statutory function.

Chair: Sorry, you must ask a shorter question.

Greg Mulholland: It is an important point though. The patient advice and liaison service is not, and if people are being pointed only to the PALS, as it is called, are they not being denied their access to the proper statutory complaints process?

Chris Bostock: Firstly, let me be clear. The decision as to whether or not to amalgamate PALS with the complaints function rests with an individual trust. There are advantages in doing so; arguably there are disadvantages in doing so. The big advantage, I would argue, is the fact that we have talked about, and Sir David has mentioned it, the spectrum of people raising comments and concerns right the way through to complaints. We do instinctively tend to focus on complaints because it is statutory, but a significant number of people, through choice, prefer not to make a complaint, whether they fear it impacting upon future healthcare and so on. They may just make a comment to someone on the frontline. They may wish to go to PALS rather than lodge a formal complaint. If you amalgamate, all that is picked up as a whole.

On PALS itself, I agree. There is absolutely no justification for insisting that someone go through an advice/comment route if they wish to make a complaint. The policy position is clear. The decision as to whether or not to raise a concern, make a comment or make a complaint rests with the individual patient, their carer or their representative, and they ought not to be funnelled through simply for the sake of manipulating complaint statistics.

Q268 Greg Mulholland: If I can just say, there seems to be some cases in certain trusts where, precisely, people are only being directed toward PALS, and therefore they do feel that is stopping them from getting to make a formal complaint, or indeed not telling them how they should do that properly.

Chris Bostock: We did clarify this with an entry in the week, which as you may know was the previous mechanism to go out to Chief Executives. From memory it was around January 2010, but I can give you the precise one. Perhaps there is an argument for reiterating that message, so thank you.

Q269 Lindsay Roy: Apologies for the late arrival. In a nutshell, Sir David, can you tell us what quality assurance arrangements you plan to put in place?

Sir David Nicholson: For complaints, or generally?

Lindsay Roy: Your overview of the complaints handling procedure.

Sir David Nicholson: The first thing is that the organisation NHS England is responsible for complaints, particularly around those services that we commission; so around primary care, dental care, optometry-specialised services. We have set up a system, a mechanism not unlike the Ombudsman, in terms of how we operate when complaints are made. We have a whole series of metrics around what the outcome of that is from the numbers of complaints that we have, through the amount of time it takes to deal with them, through to the patient or relative satisfaction with the way that they are dealt with. That is the first bit.

The second bit is what do we do with that data and information and how can we make changes to services. That is why we have constructed a patient insight dashboard, which will give us all of that data, by organisation and practice if we need it. It will also give us data that is around on social media about the various organisations and practices that we operate, so that we can look at that data and make interventions when required, when things are not going well.

Q270 Lindsay Roy: In your view how robust is the system so far?

Sir David Nicholson: We are learning as we go forward. It could be a lot better.

Q271 Lindsay Roy: How much better?

Sir David Nicholson: A lot better. We have been running it now from 1 April, and we have received over 3,000 complaints since then. We need to be better at almost all of the levels that I have just described.

Q272 Lindsay Roy: What are you actively doing to make it better?

Sir David Nicholson: First, we are thinking very carefully about the additional training for people who are involved in the various elements of that process. We have also judged that the capacity that we have needs to increase significantly. We are identifying people in the area teams across NHS England to give us more capacity to enable us to have a much more personal service in relation to that. We are piloting and trialling mechanisms for different ways of getting better feedback quicker about people’s experiences after the complaints system.

Q273 Mr Reed: I would like to ask about sharing learning to improve delivery of services. We heard from the previous panel about the importance of engaging frontline staff, listening to them in order to improve services. How do you listen to your frontline staff in the NHS to achieve that outcome?

Sir David Nicholson: There are two big ways in which we are measuring success across the NHS over the next period, as an organisation. They are staff satisfaction and patient satisfaction. In terms of patients, predominantly to begin with we are using the friends and family test to enable us to do that. The first set of data will be published in July, as you know. We have been using this in the Midlands for the last 18 months or so, and it has now rolled out across the whole country. Organisations, for their own benefit, and for us nationally, will be able to look by ward and department, get direct feedback from patients both in quantitative terms but also in terms of free text, so we will have that information nationally, and the organisations will have it locally by individual ward.

We are just about to launch a similar process for staff. Each organisation has its own mechanisms for talking to its staff, engaging and involving them. That is not our job nationally, other than to encourage them. There will be the equivalent of regular either monthly or quarterly data that will be produced. We have started our own organisation now, NHS England, so there will be direct feedback that people can make that goes right up the organisation, and will be published, which will set out where people feel that they are.

The other thing I would say, as part of the way in which we are trying to attack the issue of getting leadership ready for the future, is we are investing a huge amount of resource at the moment in making training and development opportunities available for frontline nurse leaders. There are literally hundreds, and there will be thousands, of ward sisters going through a whole series of developmental events to enable them both to manage better their own ward, but also to engage properly in the way their organisation operates.

Q274 Mr Reed: If your friends and family test reveals a level of concern in a particular organisation or ward, how do you then make sure that you act on what they are telling you?

Sir David Nicholson: There is an escalation process that would operate in these circumstances. Clearly it is a matter for the individual organisation to take action and do whatever they think is appropriate. If that does not happen, it is the commissioner’s responsibility to ensure that action is taken. If any of the individual organisations involved with that organisation feels it needs to be escalated, they can call a risk summit or whatever, as required. We will be looking at a national level at the real outliers for friends and family, in the same way we look at the outliers for mortality.

Q275 Mr Reed: You said earlier on, in your previous comments, that you were looking to involve, or have been involving, clinicians at more senior levels within the Health Service. Clinicians will have fantastic expertise and experience in their areas of professionalism, but the way that they work tends to mean that they are telling people what will happen to them because it is best for them. Are they going to create a more open culture if that is the experience you are bringing into more senior management levels in the Health Service?

Sir David Nicholson: That is a really important point that you make. In 2008, we identified the top 1,000 leaders in the NHS; people who ran the big organisations and were responsible for leading the NHS. We put them all through a diagnostic process where we identified what their strengths and weaknesses were, and what the development needs were, and a whole series of really interesting things came out of that. About 70% of our top leaders are clinicians, though predominantly nurses and physiotherapists. It is not doctors; we have a shortage of doctors involved in all of that. The sorts of things that you describe are part of their professional culture, and part of our interventions is to change that.

I do not want to bore you with all of this, but if you look at leadership generally, leadership is very often contextual in the sense that a particular way of leading can be really good in one context but not in another. Really great leaders can use more than one of these aspects of leadership. One of the things we found in the NHS was that there is a particular type of leadership, which in the jargon is described as "pace-setting". It is about getting stuff done, setting targets, hitting them and then getting the next one and driving the organisation forward. If you look at NHS management, it is predominantly pace-setting, when in fact, to deal with the world that we are talking about in the future, being responsive to patients, engaging with local populations and creating services around individual patients, there are different styles that you need. We have got a major task to shift NHS leadership from the predominantly pace-setting to something else. That is a really important precondition for making this happen, and we have set up a leadership academy to enable us to do that. That is what we are trying to do at the moment; it is a really important part.

Q276 Mr Reed: To what extent is the leadership of the Health Service regularly diverted into crisis management rather than stable leadership?

Sir David Nicholson: Well, if you run an acute hospital, apart from it being a fantastic job, if you think about them, they are treating literally hundreds of thousands of people every quarter or every month. There are literally millions of individual connections between clinicians and patients. In that environment, they are organisations which are operationally very difficult to manage. From time to time, things happen. There are problems or crises: your beds are full, the A&E department is full, all of those sorts of things. You need people in those circumstances who are capable of responding to those sorts of issues. There is some of it, inevitably, as part of your job that you have to do. From an NHS management perspective, my view on all of this is that the NHS needs consistency of purpose. That is one of the problems that we have constantly been dealing with, because we get directed to do particular things at particular times, which may or may not be the right things to do. That is more of an issue for us than crisis management, because in lots of ways we are geared up to deal with some of that.

Q277 Mr Reed: You have talked quite a lot about the autonomous nature of the range of organisations in the Health Service. I am presuming that that must make it more difficult to share learning from complaints. Let’s take an example. There have been a number of cases of people dying or being injured in mental health settings because of the use of policing, but there is no national strategy on the use of policing within mental healthcare settings. Why has learning not been shared across an area as significant as that?

Sir David Nicholson: I cannot comment on the particular issue that you talk about, but the old system did not do this very well either. It is not that, before we had foundation trusts and all this, we were great at learning across the system as a whole; we have not been. There is a whole variety of reasons for that. Some of them are very much the same as those that relate to the culture around complaints. Openness and transparency is a very important part of that. We have been trying to bring organisations together in clusters and networks to enable them to make that learning. We have developed a number of academic health science networks across the country whose prime responsibility is the sharing of good practice. We are clustering providers together and putting an infrastructure in to enable them to share good practice across those organisations. That is one concrete way that we are trying to create a mechanism by which people can do that. Similarly, those 14 academic health science centres work together nationally to make sure that we can get networks of learning across the system.

I would say that the mental health people, generally speaking, are very well networked, and with a bit of support and help we can make arrangements to share the kinds of things that you have described across it.

Q278 Mr Reed: Lastly, if I may, I want to ask about the patient voice within CCGs, where the new model that we have of GP-led boards and groups means, if you are a patient dissatisfied with the service you get at your local GP surgery, you no longer have an independent PCT to complain to; you have to complain to a board of GPs. Has the user voice been left out of this?

Sir David Nicholson: No. In this particular case that you described, they can complain to NHS England, so the organisation I am responsible for takes the place of the PCT in that regard. We are responsible for investigating those complaints, and are doing so.

Q279 Mr Reed: Are you satisfied that the patient voice has been robustly built into the structure of CCGs?

Sir David Nicholson: As part of being authorised as a clinical commissioning group, they had to demonstrate ways in which patients were engaged and involved in the decision making that they had. The vast majority of them were able to do that to the satisfaction of that authorisation process, so I would say that they have reached a set of minimum standards. Some are doing enormous amounts and some are doing less. We have to make sure everyone learns from that, but it is never enough.

Q280 Mr Reed: How do you make sure of that? A lot of your answers have been predicated on the idea of autonomy in organisations, and trying to cluster organisations together in the hope that they will come up with solutions to these problems. Do you need a little bit more command from the centre to make some of these outcomes happen?

Sir David Nicholson: I have never been criticised for that. I genuinely think that is a better way of doing it. If you have the data, then you can benchmark yourself in a much more effective way than me at the centre saying, "This is what you all should do." I am not saying there is nothing that should ever be done from the centre, but sharing good practice and making sure that people are engaged in all of that is much better done in a network where you have open data on which people benchmark themselves, rather than being told what to do from the centre. That is my experience.

Q281 Chair: Just picking up on that point, I have to confess, Sir David, I have heard quite a lot of what you said about this demarcation of responsibility, which does not sound like the right kind of sharing relationship that exists in the organisations we took evidence from earlier. Obviously, the NHS is a vast organisation, and it is much more difficult to have that sharing relationship across such a large organisation. Isn’t that sense of shared responsibility for the right outcomes what is lacking in the Health Service? If it had not been lacking, maybe Mid Staffs would not have happened in the way that it did.

Sir David Nicholson: The point you make is really important, and there is a dilemma for us around it. If you take something like the four-hour target for accident and emergency, which came out of a whole set of work done by a previous Government around what patients valued in terms of accident and emergency, they valued not having to wait. They thought that, once you got into the service it was okay, but getting into it was the problem. We therefore invented this target of four hours, but to deliver it you need the whole system to work together to make it happen.

Q282 Chair: Targets are not management, are they?

Sir David Nicholson: No, but the point I am making is that, in order to deliver it, the whole system has to work together. You need that shared ownership across the system to enable it to happen. In most places, that is exactly what does happen, but in some it doesn’t. I think there is a shared understanding and a shared knowledge. It is not enough, I take that completely, but I do not think it is completely separate.

Q283 Greg Mulholland: I have a few quick final questions to bring some of those themes together. On data sharing, we all agree that that is incredibly important. What therefore are you going to do, Sir David, about the real problem that NHS data and local authority data do not talk to each other and they cannot work together on that data considering their joint responsibility for health and social care?

Sir David Nicholson: Yes, it is a really important thing. A precondition to all of that will be the use of a unique identifier for individuals across health and social care. At the moment, we have had real problems in getting a unique identifier across the NHS. We are now starting to work with the Local Government Association and local government generally to see whether we can have a unique identifier for an individual, the NHS number as it happens, between health and social care. As we move into the post Spending Review world, where integration between health and social care will be even more important than it is now, the impetus behind that is going to be the single most important thing that we can do.

Q284 Greg Mulholland: Can I just ask you about the January 2010 checklist for reporting, managing and investigating information governance of serious untoward incidents? It is very topical with all the things that we have discussed today. A layperson reading that would get the impression very strongly that the response to serious untoward incidents is governed largely by what the media impact would be, and what the damage to reputations of senior officials in the NHS might be. Is that not an example of us not looking at a patientcentric NHS, but an attempt to deal with the media and reputations?

Sir David Nicholson: I had not read it in the way that you have just described it. If that is the way you think it reads then it needs to change, because you are absolutely right. The prime responsibility in a serious untoward incident is the interest of that patient and that family, to make sure that what happened is being addressed directly, but also any lessons are learned are shared. If that does not say that, then we need to look at it. I will absolutely take that away.

Q285 Greg Mulholland: My final related question is, as you know because it was very high profile, your deputy, the Medical Director of NHS England, Sir Bruce Keogh, marched in and closed down Leeds children’s heart surgery at the Leeds General Infirmary. We now know that the basis on which he did it was flawed data-talking about data sharing. Can I ask you, therefore, now that we know that it was flawed data, why you, as the Chief Executive of NHS England, have not conducted an investigation into that? Is this the Old Pals’ Act?

Sir David Nicholson: No, not at all. Bruce Keogh, Medical Director of the NHS, an eminent and experienced heart surgeon himself, had information brought to his attention that he felt was right to take action on. I think he was right to take the action that he did. In these circumstances, it seems that the potential harm to patients overrode the detailed analysis of that information at that particular time, so I think he was absolutely right to do it.

Q286 Greg Mulholland: But I have to say, Sir David, that is precisely the kind of cover-up that we are talking about.

Sir David Nicholson: I don’t think it was a cover-up. It was the opposite of a cover up.

Q287 Greg Mulholland: Well, I am afraid it wasn’t. I have got an exchange of emails supplied to me from the Daily Star, who got it through freedom of information. It shows that as it emerged that the data and the reasons for suspending the surgery were flawed, it was indeed brushed under the carpet. I ask you again why you have not investigated. The simple reality is that a safe surgical unit was closed down. If you are going to close down surgical units the way you do in Leeds, you would need to do it all over the country, with very similar parameters, so why are we not having a proper investigation into the data being flawed and the information being suspect?

Sir David Nicholson: First of all, there are ongoing investigations into Leeds as we speak.

Q288 Greg Mulholland: I am not talking about that. I am talking about the specific decision.

Sir David Nicholson: The story in relation to Leeds has not ended. When we come to the conclusion of all that, we will make an assessment about how successful or otherwise our intervention was. At this moment in time, Bruce Keogh made the judgments that he did based on the best information that he had available, and I think he did the right thing.

Q289 Greg Mulholland: But it made children less safe. If you close a safe surgical unit, you have made children less safe.

Chair: I think we’ve got the point.

Sir David Nicholson: I don’t accept that that was the outcome.

Greg Mulholland: It is true.

Q290 Chair: That is the law of unintended consequences, isn’t it? If you close a safe facility and it drives people to take other risks, it might result in harm to patients if the wrong decision has been made.

Sir David Nicholson: These judgments are very finely made. He made that judgment based on the information that he had.

Q291 Chair: I want to finish in five minutes. I think you have been very open with us, and I am very grateful for that. We have spent a lot of time talking about leadership and the importance of leadership throughout the organisation, and what needs to change in the style of leadership in the NHS. You even made a little joke about your own style of leadership, which I thought was very open of you. I attended a seminar chaired by the Ombudsman, in which the findings of a survey of NHS trust boards showed that, when they go on away-days, only 2% of them reported that they consider complaints as part of their strategic planning. Isn’t that the kind of thing that you want to change?

Sir David Nicholson: It is vitally important that those things change. In 2007, when we did our analysis of the NHS, what was happening to it and the way it had been, which was no longer sustainable, one of the things we said was that-while it is rather a trite thing, it is quite important-boards should look out, not up: out to their communities and their patients, and not up to the centre.

Chair: That rings very true with me, I must say.

Sir David Nicholson: One of the things I say to many chief executives is if you spent less time trying to manage me, and more time trying to manage your business, we would all be better off.

Q292 Chair: What have you learnt? You have grown up with it.

Sir David Nicholson: The thing I have learnt in all of this is that you have to be very sparing about what you expect from the centre, you have to have four or five things that you consistently want to do, and people need to be able to plan and organise themselves knowing that there is that consistency of purpose in the system, and that it will not swing about from year to year and month to month. Getting that right is a really important thing.

Q293 Chair: To what extent has it changed your view and your style of management? Leadership is a matter of leading by example. Do you think you have had to change as a result of this experience as well?

Sir David Nicholson: Absolutely. I went through the same diagnostic process that everybody else did

Q294 Chair: What have you changed?

Sir David Nicholson: What it said about me was that first of all I was strong on the pace-setting. Give me a target and I will make it happen, which is not always bad, just in case people thought that. Secondly, the feedback was that I was good at setting out a vision of what the future might look like. My weaknesses were around facilitating and coaching, and actually they are the issues that in a modern NHS will be much more highly prized than perhaps the last one.

Q295 Chair: When you look back at your period as the Chief Executive of the Strategic Health Authority, which included Mid Staffs, what things do you think you should have done differently?

Sir David Nicholson: It is quite hard for me to answer that question.

Chair: It is hard. I appreciate I am asking you a very hard question.

Sir David Nicholson: That is not because I haven’t thought about it quite a lot, as you can imagine.

Q296 Chair: With some regret?

Sir David Nicholson: I do what I do; I do not focus on regret. I think my analysis of what was happening in the NHS at that time is broadly the analysis that Robert Francis made in his report. Indeed, one of the reasons I applied for this job was to tackle some of those issues. That, for me, is an important reflection on that. It makes me more determined to make things happen and improve services for patients. Over the period that I have been the Chief Executive, there have been dramatic improvements in healthcare in this country.

In terms of my time at that particular SHA, if I do regret, what I regret is that I had the opportunity to meet the patient groups at some stage, and I didn’t take it. If I am absolutely honest, that is the thing that I regret. This thing about when you are a senior leader at whatever level, having direct contact with patients and their relatives and customers, and all the rest of it, is the crucial learning from all of that.

Q297 Chair: Is that something you feel apologetic about?

Sir David Nicholson: I have apologised for what happened at Mid Staffordshire. It was terrible. For those individual patients, it was shocking. As you know, not only did they get really poor care from the NHS, but also when they raised it as an issue they were told they did not really have poor care from the NHS, which is just the most awful thing. Of course, I feel apologetic about the system. Could I have done differently? I have thought about it a lot. I can’t see what it could have been that I could have done. Nevertheless, of course I feel all of that.

Q298 Chair: There was data that either crossed your desk and you saw, but you didn’t quite see, or the data just didn’t cross your desk. Which do you think it was?

Sir David Nicholson: The data didn’t cross my desk.

Q299 Chair: What has changed so that the data would cross the desk of your equivalent in the new structure, and there would be a new safeguard in place?

Sir David Nicholson: You mean in terms of this job, the Chief Executive of NHS England?

Chair: Or your regional equivalent.

Sir David Nicholson: First of all, part of the issue is that there is just a plethora of data, so it is identifying which are the ones that need to pass your desk and which do not. We are much clearer now about the kinds of data that absolutely must cross a leader’s desk: for example, that piece of data around whether the staff would recommend their organisation as somewhere where they would work. That kind of data does now pass my desk, and passes the equivalents’ desks in a way that it never did before; similarly with mortality data.

Q300 Chair: On the looking up instead of looking out, do you think the openness to news about things going wrong, about failure, would allow management to tell you, in that position now, in a way that they obviously did not tell you before? There were plenty of people who knew about Mid Staffordshire. They must have known in the structure of the NHS about Mid Staffordshire, but somehow they did not feel able to tell you. Do you accept that?

Sir David Nicholson: If you are asking whether there were people who knew what was happening at Mid Staffordshire in the management system who were not saying it, then I don’t think there is any evidence that anyone said that at the time.

Q301 Chair: But most people in Mid Staffordshire Hospital knew it was a disaster. There was even one account of a visiting clinician who got back in his car and said, "Just get me out of here". There were patient groups that the system didn’t hear. That is the point, isn’t it? It is not just about data and processes. It is about the values of an organisation that wants to hear. Is that changing?

Sir David Nicholson: I think it is completely changing. In a sense, what you are seeing now is the struggle that leaders and organisations are going through as that begins to happen more and more.

Q302 Chair: How much has it changed you?

Sir David Nicholson: Inevitably, in any circumstances, it would change you. When the NHS has gone wrong in the past it has been when people in senior positions have lost sight of what it is there for, and that complete focus on what it is there for. I have to say that the NHS Constitution is not a well-known document, but is a really, really important statement of values and principles of the NHS. I think the whole of the Mid Staffordshire thing was a big wake-up call for the leadership of the NHS in that regard.

Q303 Chair: Including you?

Sir David Nicholson: All of us.

Chair: Thank you very much for your candour today, Sir David. Thank you very much for the evidence you have given us; it has been extremely helpful.

Prepared 1st July 2013