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Now that the next-stage review of the noble Lord, Lord Darzi, has ushered in a new era of performance assessment, will the Minister enlist the help of the National Quality Board to look critically at the range and impact of government-imposed targets and ask whether such targets any longer have a place in a system of performance management that should be focused on the overall quality of care delivered by an organisation and the quality of patient outcomes?
The Minister ended by saying that these failures should never happen again. Therefore, what steps will the Government take to avoid the distortion of clinical priorities that process-driven targets too often encourage?
Baroness Tonge: My Lords, the report made me feel sick and ashamed, because I once worked for the National Health Service, an organisation of which I have always been proud. As well as the House sending condolences to the relatives of patients who may have lost their lives as a result of incompetence at Stafford Hospital, I offer my condolences to the Minister, because it cannot be easy to deliver a Statement such as this. However, could she comment on a few points?
The reductions in expenditure that the hospital had to achieve in order to become a foundation trust must have led directly to underqualified staff being employed and corners being cut. Will the Minister comment fully on what the noble Earl, Lord Howe, said about the target culture in the National Health Service? Anyone who still works in the health service will say that this has corrupted the workings of the service. If there is no slack, people cannot work properly in a caring profession; they cannot give patients the time that they need. Targets have brought about this situation.
Will the Minister also tell us how the newly formed Care Quality Commission will function? The Healthcare Commission took a long time to pick up on what was going on at Stafford Hospital, and the new commission must also deal with mental health and social services. Finally, will she reassure the House that the chief executive of Stafford Hospital has not been given a golden handshake and moved off to an equally lucrative post somewhere else in the health service?
Baroness Thornton: My Lords, I agree very much with both the noble Earl and the noble Baroness about the shame that we all feel about this report. I thank the noble Baroness for her sympathy, but it is the people of Stafford who have been failed by this hospital and what has happened.
I will work my way through the points raised by the noble Earl. It is very legitimate to ask what the SHA and PCTs were doing during this period, and why they failed. We know that boards are accountable for ensuring that their PCTs and the regulator hold them to account. In this case, there are undoubtedly lessons to be learnt
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There is no doubt that there are lessons to be learnt about why the commissioning process did not adequately draw attention to the failures of care that was provided. That is why we have asked David Colin-Thomé to review the circumstances in Mid-Staffordshire prior to the Healthcare Commissions investigation, to learn the lessons about how the primary care trust failed to detect and prevent the failures. He has been asked to do this rapidly and he will publish his findings within a month. His recommendations will focus on what the commissioners in England should learn from this.
On a broader level, a substantial World Class Commissioning programme is under way to help commissioners to hold their acute providers to account for the outcomes that they deliver to their patients. The Healthcare Commission acknowledges that the SHA was not aware of the concerns about the quality of services provided by the trust before the Dr Foster Unit published its report in 2007. However, we know that as soon as the SHA became aware of the high HSMRs, it commissioned the University of Birmingham to undertake research into the findings on these in advance of the Healthcare Commissions investigation. At that stage, the trust was focusing more on the data issues than on the poor quality of care. There will undoubtedly be lessons for the PCTs performance managers to learn in ensuring that boards are held to account for monitoring the information needed to safeguard the quality of services provided to patients. That is part of the brief for David Colin-Thomés review.
The report asked a legitimate question about how the trust was awarded foundation status in the middle of this investigation. Perhaps I may explain the timeline. The Secretary of State supported Mid Staffordshire in proceeding to the Monitor assessment in June 2007, and it was authorised as a foundation trust by Monitor on 1 February 2008. Monitor examined the quality of safety, including the HSMR issues. The concerns at Mid Staffordshire were not known when the trust was authorised as a foundation trust, and Monitor based its judgment on the best information available at the time. I have already said that there had been a trigger in relation to those figures because they were being investigated as part of data collection, rather than as part of a failure of service to patients.
Monitor would not have authorised a trust in the midst of a Healthcare Commission investigation or if it had been aware of, or had serious concerns about, the quality of safety issues. The trust was authorised in the usual way. We have a clear process that works. Ministers approved this in the normal way. Again, we would never have supported an application had there been any indication that there were serious concerns or that a Healthcare Commission investigation was under way.
I repeat that the issues at Mid Staffordshire were not known when the trust was authorised as a foundation trust. Monitor based its judgments on the best available evidence. It would not have authorised foundation
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With regard to what is being done to improve the quality of safety, the noble Earl and the noble Baroness were right to point to the work of my noble friend Lord Darzi and his quality matrix review. Indeed, in the past few weeks we have spent quite some time discussing exactly how the setting of national standards will work at each level and how they will roll down to a local level. If we recall our previous discussions about how those quality standards would work at a local level, there is absolutely no doubt that they would catch this type of issue. They would take on board such things as complaints from patients. It is reprehensible that this trust did not discuss its patients complaints; that is disgraceful.
We do not see a trade-off between targets and quality. It is important to remember that the NHS had no targets in the 1980s and 1990s, and hundreds of thousands of people were on waiting lists. People were kept waiting in accident and emergency for 18 hours. But from the centre we have managed to turn that round by setting targets. We must remember that that has been achieved through the remarkable efforts of exceptional people who work on the front line within the NHS. The vast majority of healthcare establishments have met their targets and continue to do so day in and day out.
The next stage review High Quality Care for All, launched by my noble friend Lord Darzi, suggests that there will be no new targets. Until now, every NHS organisation across the country has had targets that have been achieved. We are now turning our attention, rightly, to ensure quality. This report has pointed out to us that there is a great deal more to do.
Baroness Wall of New Barnet: My Lords, as somebody who has been chair of two district general hospital trusts, I join in with the shame that has been expressed today. It is a shame which undermines and devalues all the good stuff that is going on in the health service. I have read the horrendous report and it is frightening and sickening, which is the word used by my noble friend on the Benches opposite.
I plead, as did my noble friend, that we do not confuse what has gone on in Staffordshire with what happens with targets. This incident is not about targets. I am chair of a big trust and value completely what patient care is about. Targets focus our minds on patients. It is not about having four hours because four hours is a good thing; it is about patients being seen much more quickly and being taken care of through the system. That happens every day in my trust and others. The benefit of all the trusts meeting the targets is that they have better healthcare. It is evident that
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Baroness Thornton: My Lords, I thank my noble friend for her remarks. She is quite right. The process for going for foundation status is rigorous, and we believe that the performance of foundation trusts has thus far been very good. In the previous Healthcare Commission annual health check, 38 out of the 42 organisations rated excellent for both service and financial performance were foundation trusts. I am pleased that my noble friends trust is going for foundation status, and I am sure that if her leadership has anything to do with it, it will almost certainly be approved.
Lord Walton of Detchant: My Lords, in the investigation that is to be conducted by my old friend Sir George Alberti, will account be taken of the patently serious failings of management? It is inconceivable that any hospital in this day and age could leave patients without food and fluid for periods as described in the report and that similar failings could possibly have occurred in any hospital in the National Health Service in which I have spent so much of my professional life. May I ask not only that the failings of management, the strategic health authority and local primary care trust be examined by Sir George Alberti, but what on earth was happening to the senior medical and nursing staff in this hospital, who must have been aware of the problems that led to this appalling report?
Baroness Thornton: My Lords, the noble Lord makes a fair point. From reading the report, my understanding is that members of the nursing and clinical staff were making complaints but they never reached the board. That is why the chief executive and the chair of the trust stood down on 3 March. On the good side, in terms of improving the performance of this hospital, this issue was undoubtedly due to a failure of management and understaffing. There is an action plan and increased investment in new staff. For example, there are now 12 matrons instead of three, the number of nurses has been increased significantly, the number of middle-grade doctors has been increased, as has the number of consultants, and 14 more housekeepers have been recruited. It is on the right trajectory, which is our major concern. Can we be confident that the people of Stafford can attend this hospital? I think we can now say that that is the case.
Lord Jopling:My Lords, is the Minister aware that the Secretary of States Statement and her answers to questions seem typical of the way the Government face crises of this sort, with parrot phrases such as Lessons to be learnt, Never again, Were going to set up a review and Were going to have an inquiry? Surely, the Government ought to have known about this. My noble friend on the Front Bench asked when the Secretary of State was first told about this crisis. We got no answer. That question is crucial because the Government surely should have known and should have had the facilities to find out.
Baroness Thornton: My Lords, the Government would have been alerted to the fact that the Healthcare Commission was investigating, when the investigation started and when it was proceeding, which was last year. I make the point that when the Healthcare Commission visited the accident and emergency department of Stafford Hospital in May last year, it did not wait to write its report but immediately went to the chief executive of that hospital to outline its concerns and start remedial action to improve services to patients. This is not something that we have sat on, nor have we waited around for improvements. Saying that one will learn lessons when things go wrong is exactly the right thing to do. We need to have a rigorous investigation, to be open about its results and to learn the lessons.
Baroness Thomas of Walliswood: My Lords, I am concerned about the apparent lack of a robust complaints system that could be used by patients and their relatives. Can the Minister tell us what has happened in the intervening period since the demise of the local health bodies that used to support patients? What has replaced that external support given to patients when this kind of crisis occurs?
Baroness Thornton: My Lords, as the noble Baroness will be aware, we discussed patients complaints at some length in the past year. The system is that a complaint is initially dealt with locally. If the complainer is not satisfied with the response he receives, the complaint then goes up the tree of the health service to be dealt with. That will work, by and large. The problem in this case was that the complaints being dealt with at local level were not being acknowledged and were not being taken as part of the planning process of clinical care within that hospital. That is part of the problem. I understand that the new leadership of the trust will look at the complaints that were made and how they were handled. It will ensure that the board is handling them in a correct manner in the way that we would wish.
Baroness Pitkeathley: My Lords, does my noble friend agree that as well as the major failures in management and clinical practice, about which we have all heard with shame, there were major failures of governance in this hospital? Can she reassure the House about the training that is available to people who sit on the governing boards of foundation hospitals, particularly in relation to listening to patients and the public? When a hospital applies for foundation status, part of the test of whether it should achieve that status should be its communication with patients and the public. If that is not the case, it ought to be.
Baroness Thornton: My Lords, my noble friend makes a very important point. Part of High Quality Care for All is a far greater transparency of the reporting and accountability of the board to its local population. This will be enshrined in the Health Bill which is now going through Parliament. At the moment, a number of trusts are working with Monitor to develop these quality accounts on a pilot basis. This is a part of the overall structures and accountabilities that we need to set up within SHAs to ensure that the boards and PCTs look to their local populations, and that board
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Lord Foster of Bishop Auckland: My Lords, does my noble friend agree that no one in the House should want to return to the micromanagement of the health service that we are all attempting to escape from? Does she further agree that, despite the criticism of targets, the four-hour target for A&E admissions was widely welcomed by patients and has resulted in a substantial reduction in waiting times? Will she explain what managers are for if it is not to live within budgets? Is not the attempt to blame the focus on budgets and targets the height of irresponsibility on the part of managements at all levels?
Baroness Thornton: My Lords, my noble friend puts his finger exactly on the point. This was a comprehensive failure of management to deal with both the targets and their financial administration. The targets we have set since 1997 have transformed the health service and have given the vast majority of people who use our healthcare enormous confidence in the way that they will be treated in a safe environment.
Baroness Masham of Ilton: My Lords, I received a letter from a worried member of the public about that hospital, where a relative had had a bad experience. I wonder how many local Members of Parliament received letters. Can failing hospitals lose foundation status?
Baroness Thornton: My Lords, there are six Members of Parliamentthree Conservative and three Labourin the area of the Mid-Staffordshire Hospital, quite a few of whom took part in the discussion in another place, to which I listened. They have all been concerned about patient care and from time to time have raised issues with the hospital and the department, all of which were dealt with. However, it was not clear until last spring that there was a systemic problem within the hospital that needed attention. I am sorry but I have forgotten the noble Baronesss second point.
Baroness Thornton: My Lords, failing hospitals can lose that status. I have a very long description of how that can happen, and I will happily put that in a letter to the noble Baroness, but it can happen.
Lord Campbell-Savours: My Lords, if all of those MPs knew, what was the board doing? Is not one of the lessons that we learn from this affair that we should stop putting nodding donkeys on boards of trusts if some of them are not competent enough to ask the awkward questions necessary to make sure that trusts function properly?
Baroness Thornton: My Lords, my noble friend is right that we need high quality people serving on our healthcare trusts and boards. By and large, I think that we do but, clearly, there was a problem with the board at North Staffordshire hospital and, as I have said, the chief executive and chairman have gone. The interim
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Baroness Thornton: My Lords, I beg the pardon of the House as I did not answer that question when it was addressed to me earlier. The chief executive remains suspended on full pay, in line with the standard disciplinary process. The trust is no longer paying the previous chairman and the future of the chief executive, who was suspended, will be determined by the outcome of an investigation.
Baroness Finlay of Llandaff: My Lords, it is clear in the report that, way back in 2003-04, the non-standardised in-hospital mortality rates were high. Has Monitor been asked to look at whether its procedures are assessing the right things? What is being done now to make sure that monitoring of all foundation trusts will be done according to a new set of criteria, given that the criteria clearly failed to pick up problems that were already evident?
Baroness Thornton: My Lords, Monitor considers safety quality, including HSMR, whose importance it recognises as one clinical performance indicator to be looked at when it reviews the clinical governance arrangements for trusts applying to become foundation trusts. To conclude on the clinical guidance governance on applications from trusts, it currently looks at a raft of other areas. Among those are: a discussion with the board, relevant clinical governance sub-committees, a review of the processes, a report of clinical problems, a clinical audit plan and a review of action plans to address issues. It reviews performance data, targets and standards, along with trends, press coverage and complaints covering trend analysis and reporting, including a review of the data from surveys of patient services and staff surveys.
When Monitor took the decision that allowed North Staffordshire to become a foundation trust, it had gone through that process and questions had, indeed, been raised with it on HSMR, but the trust and the board were then concentrating on it being about data collection and coding, not about patient care. I understand that both Monitor and the Healthcare Commission will be looking to make sure that they are more rigorous and that they communicate more obviously to ensure that these things happen in sequence. Better communication might have helped, although the evidence of the report will suggest that it would not necessarily have helped in this case.
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