Mid Staffordshire NHS Foundation Trust

Oral Answers to Questions — Prime Minister – in the House of Commons at 12:32 pm on 18 March 2009.

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Photo of Alan Johnson Alan Johnson The Secretary of State for Health 12:32, 18 March 2009

With permission, Mr. Speaker, I wish to make a statement about Stafford hospital, following the Healthcare Commission's investigation published yesterday.

The report details astonishing failures at every level, and shows that for patients admitted for emergency care at Stafford, there were deficiencies at every stage. The Healthcare Commission found disorganisation, delays in assessment and pain relief, poor recording of important information, symptoms and requests for help ignored, poor communication with families and patients, and severe failings in the way the trust board conducted its business. While the management was obsessed with achieving foundation trust status, the wards were understaffed and patient care seriously compromised.

The report cites incidents of patients left without food or drink for days because operations were delayed, of nurses who had not been properly trained to use basic, lifesaving equipment, and of patients admitted to A and E being triaged by receptionists. It notes that there was a dangerous lack of experienced staff, observation and monitoring of patients was poor, essential equipment often was not working, and there were no systems in place to spot where things were going wrong in order to make improvements. In short, it is a catalogue of individual and systemic failings that have no place in any NHS hospital, but which were allowed to happen by a board that steadfastly refused to acknowledge the serious concerns about the poor standard of care raised by patients and staff.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I apologise on behalf of the Government and the NHS for the pain and anguish caused to so many patients and their families by the appalling standards of care at Stafford hospital, and for the failures highlighted in the report.

In the course of my statement I will set out the actions that we will take in response to the report, but I want to begin by summarising the events that led to the Healthcare Commission's investigation. The Commission became aware of high mortality rates for specific conditions or operations at the trust during the summer of 2007 through its routine analysis and a statistic known as hospital standardised mortality ratios, more commonly called SMRs, produced by the Dr. Foster research unit, based at Imperial college.

Whenever the Healthcare Commission is alerted to unusually high mortality rates, it initially asks the trust to provide further information to explain such anomalies. High standardised mortality ratios are not necessarily an indicator of poor clinical performance and nor do they signify that there have been avoidable deaths, but they do act as a screening tool to identify the need for investigation. Further analysis showed that there were consistently high mortality rates for patients admitted as emergencies going back over several years.

The trust repeatedly dismissed the significance of these statistics, saying that they could be explained by the problem it was having with the recording of data. The accuracy of information coding—that is, the system for cataloguing types of surgical and other interventions—had historically been poor in the trust, and the internal group that the trust itself had set up to consider high mortality rates assumed that they could be explained by coding errors.

The Healthcare Commission refused to accept this explanation and launched a full-scale investigation in March 2008. In May of that year, following its first visit, the commission asked to see the chief executive and set out its immediate concerns about the poor patient care and inadequate staffing levels that it had observed. Since then, there has been gradual improvement. The Healthcare Commission states in its report that

"the Trust deserves credit for progress on infection control and for responding positively to the concerns of the Commission."

On an unannounced visit in February to the accident and emergency department, the Healthcare Commission noted significant improvements. Its visit raised no immediate concerns about the safety of patients admitted to the accident and emergency department.

However, the failures are stark and they occurred over a substantial period of time. Patients will want to be absolutely certain that the quality of care at Stafford hospital has been radically transformed and, in particular, that the urgent and emergency care is administered safely. I have today, jointly with Monitor, asked Professor George Alberti, the eminent physician and national clinical director for urgent and emergency care, to lead an independent review of the trust's procedures for emergency admissions and treatment and its progress against the recommendations in the report. He will report in five weeks' time and his findings will be published to the House.

The Healthcare Commission has told me that it is confident that Stafford hospital is an isolated case, and that having looked at other trusts with similarly high standardised mortality ratios, it is reassured that a similar succession of serious lapses in care has not occurred elsewhere.

The National Quality Board has been set up to look at how organisations work effectively together in patients' best interests. It is composed of representatives of the royal colleges, patient groups, regulatory bodies and clinical experts. I have asked the board to look at how we can ensure that any early signs that something is going wrong are picked up immediately, that the right organisations are alerted and that action is taken quickly.

The public and the House will want to know how the problems at Mid Staffordshire could have remained undetected for so long. One of the reasons the Healthcare Commission began its investigation was that after having been initially alerted to the problem in the trust, it became clear that there had been serious failings for some time. The Healthcare Commission's report raises serious concerns about why the primary care trusts and the strategic health authority either failed to spot the problems at the trust or, having spotted them, failed to act.

I have asked Dr David Colin-Thomé, the national clinical director for primary care, to review the circumstances surrounding the Mid Staffordshire NHS Foundation Trust prior to the Healthcare Commission's investigation to learn lessons about how the primary care trusts and the strategic health authority, within the commissioning and performance management systems that they operate, failed to expose what was happening in this hospital. His recommendations will focus on what commissioners across England—GPs and PCTs—can learn from this case to be sure they are advocating effectively on patients' behalf.

Our principal concern today must be to reassure the families and friends of patients who have died at Stafford hospital that they will be able to ascertain whether any of the failings detailed in the Healthcare Commission's report contributed in any way to the death of their loved ones. As the Healthcare Commission has said, it is not possible to determine conclusively from any set of statistics whether there were any avoidable deaths owing to poor standards of care—that can be done only through a case notes review. I can confirm that the new leadership of the trust will respond to every request from those relatives and carry out an independent review of case notes to determine whether or not the care that they or their loved ones received was appropriate.

The failings at Stafford hospital are inexcusable. I hope that we can close this chapter in the hospital's history by acknowledging and addressing past failings and by ensuring that lessons are learned by government and the NHS at all levels to make sure that these terrible failures are never allowed to happen again.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

The House will be grateful to the Secretary of State for his statement and will share with him the apology that he expressed on behalf of the Government and the NHS to all the families and patients adversely affected by the events at Stafford hospital.

We were all shocked and appalled at the failings in patient care at the hospital. There was a systematic failure in respect of patients receiving emergency care. Triage was done by unqualified receptionists; treatment was carried out by too few, too poorly trained doctors and nurses; there was inadequate staffing in the emergency department and on wards; nurses were poorly trained; patients were pushed out to the wrong wards, where the care that they needed was not available; patients were left in pain; patients were left without food and drink; basic hygiene needs were not met; nil by mouth patients were left for days waiting for operations; cardiac monitors were switched off because the nurses were not trained to use them; there were too few critical care beds; and there was a failure to prevent blood clots that went on to kill patients.

A number of things were lacking in the Secretary of State's statement. I say first that it would have been better for him to have acknowledged the role played by Julie Bailey and the Cure the NHS campaign in Staffordshire in calling attention to what had happened at Stafford hospital. As the Healthcare Commission said in its report, when it launched its investigation there was an unprecedented level of response from patients and relatives who wanted to tell its representatives what was happening. That, frankly, is illustrative of the abject failure of the NHS to listen to what patients and relatives were telling it about what was happening at the hospital.

We do not know how many patients died needlessly, but we do know that the board of the trust did not listen to complaints from patients and their families, or even to the doctors and nurses on the front line at the hospital. The board did not devote its efforts to the quality of care for patients but was obsessed with financial results, organisational change and targets—not with the care and safety of patients.

Our job is to find out not just what happened, but why it happened—and, by doing so, to ensure that it does not happen again. Clearly, the board of the trust was appointed to this task, but it should not have been simply left to get on with it. What was the primary care trust, which was responsible for commissioning services from the hospital, doing about the situation? The Healthcare Commission report says:

"Staff from the PCT involved in commissioning told us that they inherited a chaotic situation"— following the merger of primary care trusts—

"with no detailed handover from the previous PCTs...The minutes of the PCT's performance...committee did not reveal any evidence that the PCT was aware of any problems in the quality of service being provided by the acute trust".

The PCT was concerned with cost and volume, not with quality. I urge the Secretary of State to ensure that a powerful lesson is learned about how commissioning is undertaken across the country.

The strategic health authority was, until February 2008, responsible for the performance management of the trust. It saw the mortality data at the same time as the Healthcare Commission, asked what was happening, sent the university of Birmingham to do an academic inquiry and came away, apparently reassured, that it was a matter of coding. Why did it not get to the truth of what was happening? Why was it that a year ago, the chief executive of the trust, who was responsible for what was going on, said:

"We worked with the Strategic Health Authority and investigated this apparently high mortality rate and concluded that it was due to problems in the way we were recording and coding information about patients. We have, over the last year, employed more clinical coding experts"?

He employed not doctors or nurses, but clinical coding experts. Why did the strategic health authority have the wool pulled over its eyes? Given that the then chief executive of that SHA, Cynthia Bower, has since been appointed by the Secretary of State to be chief executive of the Care Quality Commission, which will take over the Healthcare Commission's responsibilities in two weeks' time, is the Secretary of State confident that the CQC will intervene where necessary in future, and that it will be effective when it does so?

When the Secretary of State passed to Monitor the application for this trust to be a foundation trust in the summer of 2007, one of his jobs was to assure himself that there was a good quality of care. Did he simply tick a box called "They've met the four-hour target in A and E" or was there any additional evidence? It should have been his job to know that the Healthcare Commission had initiated an investigation into the trust. Even if the Healthcare Commission did not tell Monitor, it was his job to do so, and there is an admission in the Department of Health documents that that should be part of the process.

When the Healthcare Commission carried out its investigation, and wrote on 23 May 2008 requiring urgent action by the chief executive at the Stafford hospital, what did the Secretary of State and Monitor do about it? Why did they not intervene at that moment to remove the board and put in new management? It has taken us 10 months to arrive at that point. It was not simply the case that the events in question were historical, and that everything had been solved by then. The report of the Healthcare Commission says:

"As late as September 2008, we found unacceptable examples of assessment and management of patients."

The problems persisted and the board carried on. It is still in denial, and when Mr. Martin Yeates, the chief executive resigned, he said, among other things:

"I am very proud of what we have achieved so far."

The public in Staffordshire had a right to know what was going on, and the chief executive of their trust never told them what was happening.

After Maidstone and Tunbridge Wells, the Secretary of State came to the House on 15 October 2007 and said:

"we should be spotting these issues much earlier and getting rid of incompetent chief executives or chairpersons who, fortunately, are in the minority, rather than waiting for a report such as this, by which time, frankly, most of the damage has been done."—[ Hansard, 15 October 2007; Vol. 464, c. 571.]

Where is there any evidence of early and effective intervention by the Secretary of State, his Department, the strategic health authority, which acts on his behalf, or the primary care trust, which also acts on his behalf? Why did that not happen?

Will the Secretary of State acknowledge that constant organisational change, loss of financial control and an obsession with narrow process targets also contributed to the failure of this hospital, as they have in so many other places before, such as Maidstone and Tunbridge Wells and Stoke Mandeville? There is a systematic problem here. Will he ask the National Quality Board to look at the structure of targets so that it delivers on performance management and continuous improvement without the distortion of clinical priorities and clinical decision making, which has followed on from the application of the four-hour A and E target?

Moving from targets to outcomes, devolving decisions to the front line, giving real information and choice to patients, listening to patients, and holding hospitals to account for their performance through competition are not just the policy changes needed; they are the essence of an NHS that does not just respond to tick-box, top-down targets, but responds to the real need of patients. Learning from what has gone wrong is the essence of understanding how to improve it in the future. When will the Government learn that lesson?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Gentleman makes a number of valid points, and one that I do not consider valid, which I will come on to.

The hon. Gentleman's point about Julie Bailey and the Cure the NHS campaign was absolutely right. Indeed, I said in my statement that patients and staff raised concerns over a long period, and we can look at the number of complaints that went through the process. Let us remember that before the early part of this century, there was no independent regulator and no proper complaints procedure. A complaint would only have ended up in the trust—there was nowhere for it to go after that, and there were no statistics. Accident and emergency was a data-free zone. We can go back only about as far as 2001 to get any real indication of what happened.

What we know is that in the three years 2005-06 to 2008-09, there were 43 complaints by patients at the hospital. That is not unusual, incidentally. What is unusual is that 32 of those complaints were upheld at the level of the Healthcare Commission, which is where complaints now go beyond the local trust. [Interruption.] Mr. O'Brien says that we have just stopped that. We can debate those issues, but it is very important to talk about what happened at Stafford. Mr. Lansley said that we have to know how this happened. He made a valid point about patient organisations, including Cure the NHS.

As for why it happened, the hon. Gentleman made a valid point about the primary care trust. Actually, we have to put that in the plural—it was primary care trusts at the beginning. I believe that there were two or three before the reorganisation. Now there is one, but previously there were a number. The reason I am asking David Colin-Thomé to look at that as far back as 2002 is precisely that we need to know what the primary care trusts were doing. We need to know why the strategic health authority, too, was not picking up on the problem on behalf of its patients. That is a central feature of what the SHA and PCTs are meant to do as commissioners.

All that we know—the hon. Gentleman will have seen this in the Healthcare Commission's report—is that there is a turgid argument about coding errors. It was pointed out by the Commission for Health Improvement in 2002, when it examined Stafford as part of a rolling programme of looking at every hospital in the country, that the system of collecting data was poor. That then seems to have become the major reason no one would examine what was actually happening to patients and patient care. The SHA commissioned Birmingham university to produce a report, which once again seemed to suggest that the problem was all about coding errors. We should pay tribute to the Healthcare Commission, which, having listened to that over and over again, refused to accept it and actually went in to see what was happening in the hospital.

I do have confidence in the Care Quality Commission, not least because this House has given it greater powers than the Healthcare Commission has. Looking at what happened at Stafford, although no one knew it when we were debating the matter, there is no better argument for why those registration and other powers are so important.

The hon. Gentleman asked when the information was passed to Ministers, and he made a point about how the Healthcare Commission could have tackled the problem much earlier. This was approved in the Department before I arrived— [Interruption.] Well, he asked me when I approved it, so I am just answering that I did not approve it; it happened before.

The simple fact is that the approval was for a system that looked to the future. The consideration was whether the board had a strategy for the future—the hospital had a three-star rating from the Commission for Health Improvement—and whether it was capable of carrying it out. At that time, in June 2007, there was no indication of a Healthcare Commission inquiry. Indeed, the commission itself was alerted by the Dr. Foster figures in the summer and autumn of 2007.

As far as the question about what the commission did is concerned, when it went in in May 2008 it had the ability, which Parliament had given it, to put that hospital into special measures immediately. That is the commission's decision, not ours. It is an independent regulator's decision to do that. What the commission did—I think it was the right thing to do—was not wait for 18 months until it had produced a report but immediately call the chief executive to a meeting and say, "There are serious concerns." Obviously it had to produce a report with recommendations, but it said that those concerns had to be tackled immediately. It states in its report that the trust did start to tackle those issues, although the hon. Gentleman is absolutely right to say that we have to be confident that there is not still a state of denial in the trust. I am still not confident about that, for some of the reasons that he gave. That is why I have asked George Alberti to go immediately and produce a report in five weeks.

Where I take issue with the hon. Gentleman—I hope that Members of all parties will not use this turgid argument—is the idea that somehow this is to do with targets.

Photo of Evan Harris Evan Harris Shadow Science Minister

That is what is in here.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Gentleman says from a sedentary position that that is in the report. No, the report says that staff—

Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Chair, Speaker's Committee on the Electoral Commission

Order. The hon. Gentleman should not be saying anything from a sedentary position. A Minister is answering a case that has been put by the Opposition Front-Bench spokesman, and other hon. Members should listen.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

Thank you, Mr. Speaker. This is an important point. Staff said in the Healthcare Commission report that their managers were pushing them on this issue, on the basis that they had to meet the target. However, I have just explained that A and E was a data-free zone. Horrendous things were going on there, including 12-hour trolley waits, that needed to be tackled. The argument made by the College of Emergency Medicine and the Royal College of Nursing is not that we should do away with targets. Indeed, the hon. Member for South Cambridgeshire himself said yesterday, in a very measured statement, that he has no problem with time limits—he did not use the word "targets"—but that they must never be used as an excuse to damage patient care.

We must not let the management of Stafford off the hook through some suggestion that patients cannot be treated reasonably and quickly unless we do away with standards for patient care. There is no excuse for getting untrained receptionists to triage nurse, and there is no excuse, least of all targets, for leaving someone with a broken thigh bleeding in A and E for six hours without any attention. There is no excuse for the chronic understaffing that took place at Stafford. I therefore believe that although there may be an attempt to score a few political points here, to the people of Stafford targets are not responsible for what happened in that hospital. The problem was poor management and inadequate staffing.

Photo of David Kidney David Kidney Labour, Stafford

The report makes it very clear that the care failings ran deep and wide. It is less clear why that performance attracted the highest, three-star rating and foundation trust status just last year. I put it to the Secretary of State that the big challenge now is to get that hospital performing to the right standard every day for every patient while totally reconstituting the trust. May I ask him to lead from the front and come to Stafford to meet people in the hospital and talk to the patients groups that he praised in his statement? Will he explain to us how he is going to stay involved as we make those changes?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend has written on several occasions about the situation at Stafford, as have other hon. Members of all parties over the years. I will be very pleased to come and meet the patients and the representative patients groups at Stafford, and I am keen to go through with them the various measures that I have set out today so that I can be assured that there is nothing else that we can do to put their minds at rest.

Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health, Liberal Democrat Spokesperson (Health)

I thank the Secretary of State for early sight of the statement.

We all recognise the full horror of what has been uncovered in the report—the gross neglect of patients and many dreadful and inhumane examples of poor treatment. Conditions were described by one relative as being reminiscent of the workhouse, which is a shocking comparison to make. There has clearly been an absolute dereliction of the duty of care, which should shock us all. Stafford is not a private hospital, for which we can all blame uncaring shareholders. This is the NHS, and that is what makes it so utterly shocking.

I, too, pay tribute to the relatives who refused to be fobbed off and kept battling away, trying to get justice for their loved ones. It is the Government's absolute responsibility to ensure that we eradicate that sort of experience from the NHS. It must never happen again. In saying that, I am conscious that it was not that long ago that we considered the abject neglect that was found in Maidstone hospital. There are therefore repeated examples of those concerns.

I hope that the Secretary of State will not only focus—rightly—on the culpability of those at the hospital, but face up to the possible wider causes and failures that led to the shocking scandal. So far, we have received an apology from him and the Government only for the failure of others. It is a strictly limited apology and further investigation is required.

The Secretary of State has announced several specific steps that he wants to take, but will he agree to relatives' demands for a full, independent public inquiry into all the possible causes of the scandal and the vital lessons to be learned? Such an inquiry should consider the following matters. First, it should examine the need for justice for patients and relatives who have suffered so much. Secondly, it should consider the rigid operation of the four-hour target and the bullying that too often surrounds it—when one goes to hospitals and talks to emergency care practitioners, one hears that that plays a part. Doctors are told to divert from important care to treat people who are close to the four-hour target, and nurses have been threatened with the sack if the four-hour target is breached. It is extraordinary that the statement did not mention the four-hour target, given that the report refers to it.

It beggars belief that the hospital was a three-star hospital, which secured foundation trust status despite all that we have heard was going on. Is that not reminiscent of Haringey council, with its three-star status as the baby P tragedy unfolded? Surely we need a review of the way in which hospitals are assessed in the light of the events. Although managers are rightly in the firing line, what about the clinicians working in emergency care? Clearly, there was appalling understaffing, but did anyone speak out? Should any clinicians be held accountable for what happened? Has anyone left the trust? Has anyone gone through internal procedures? Those questions need answers.

We should also consider the role of the coroner, who failed to provide information about inquests, which would have been helpful. Surely that obstructed the investigation. What about the crucial role of the primary care trust and the strategic health authority? How on earth did matters go on for so long? The high mortality rate dates back to 2003—five full years—before anything was investigated.

What of the role of Cynthia Bower? She was chief executive of the strategic health authority and she is becoming head of the Care Quality Commission. What about her predecessor, who is now chief executive of the NHS? Is there a conflict of interest—

Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Chair, Speaker's Committee on the Electoral Commission

Order. Obviously, Front-Bench spokesmen get an allocation, but the hon. Gentleman has spoken for four minutes and I must consider Back Benchers and the fact that there is an Opposition day debate today. If the hon. Gentleman is about to wind up, that is fine, but he is taking liberties at the moment.

Photo of Norman Lamb Norman Lamb Shadow Secretary of State for Health, Liberal Democrat Spokesperson (Health)

I am grateful for that guidance and I will wind up my remarks.

The chair of the Healthcare Commission has talked of appalling standards of care and chaotic systems, which are intolerable. Will the Secretary of State instigate a public inquiry? Will he apologise if the conclusion of an independent inquiry shows that the culture of top-down bullying in enforcing rigid targets has played a part in the scandal?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I think that the hon. Gentleman is wrong to call for a public inquiry. We have a very good Healthcare Commission report, which underlines the difference between what has happened and the Bristol royal infirmary inquiry, which considered the position between 1984 and 1995, when there was no commissioner or independent regulator. There was no one to go in and examine the matter and no information. Now, the Healthcare Commission has provided an excellent report. We need to do more—that is why I said that events from 2002 to 2005 need to be examined. We need to be reassured that things are happening now. There needs to be an independent review of case notes and the National Quality Board needs to examine the alerts.

The next stage review, which Lord Ara Darzi leads, appears esoteric in many ways, because it refers to each board having to produce a quality account as well as a financial account and it mentions quality metrics. It is not the stuff that gets people excited, but it is right. When we consider what happened at Stafford, we must move even further. Bruce Keogh, the medical director of the NHS and an eminent cardio-thoracic surgeon, said that there is a

"moral, professional and social responsibility" on everyone in the NHS to know

"what they are doing and how well they are doing it".

That did not exist previously. The hon. Gentleman spoke about Maidstone, but there was no ability to have such reports previously. The Healthcare Commission's approach has done us proud, and I therefore do not believe that there is a need for a public inquiry.

On what is happening in the trust and whether there is an issue about people on the board or clinicians, I stress that the board, which is now led by a new chair and a new chief executive and has a new clinical director, received the report officially only today. They must now go through due process. I want people to be treated fairly, with due process. The board will consider the report today and decide whether it needs to use internal procedures in the way the hon. Gentleman suggests.

Photo of Brian Jenkins Brian Jenkins Labour, Tamworth

I thank my right hon. Friend for his apology on behalf of himself and the Government for what can be seen only as a tragic let-down for patients in the trust. The report often states that the trust board could—and did—ignore individual concerns. What will my right hon. Friend do about creating a mechanism that forces the board to answer individual concerns? Not only that, the concerns should be printed locally—that would reinforce the resolve of people who may want to formalise a complaint—so that we can see the scale of problem and bring pressure to bear locally. When can we, as individual citizens and patients, exert pressure on the trust boards?


British people have been let down badly by the majority of our regulatory bodies for far to long.

Many of our local & national complaint procedures are now merely an instrument for burying genuine complaints of mismanagement and governance.

All members of parliament should show some integrity and follow the lead Mr Brian Jenkins MP has, that is, represent the concerns of THEIR electorate.

Submitted by alan handley

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend is right. The Healthcare Commission makes recommendations about what the trust must do, especially about the extraordinary fact that the board, when it met, dealt with only high-level stuff. It never received any complaints. To revert to an earlier point, the staff complained regularly. There was only one consultant in A and E when there should have been around four. There were three matrons in a hospital that now has 12 and should have had that number all along. Patients and staff made those complaints regularly, but they never reached the board.

Of course, some high-level stuff needs to be examined, but the Healthcare Commission has also made some basic "how you manage a hospital properly" recommendations, which must be implemented. I am confident that the new management will do that.

Photo of Bill Cash Bill Cash Conservative, Stone

The Secretary of State was good enough to have a word with me yesterday about the appalling situation, which many hon. Members and the national press have thoroughly described. However, I revert to the question that I put to the Prime Minister about an inadequacy in the way in which the Government are handling the matter. I am surprised and appalled by it. So far, I have counted five separate reviews that they propose: a review of case notes—of course, that is important to establish culpability; the Alberti review, which deals only with A and E; the Care Quality Commission review, which raises questions about a conflict of interest, in that its inquiry will include an analysis of the role of the strategic health authority, in which the person who is now in charge of the CQC was involved; the PCT review; and that of the SHA.

As the Secretary of State knows, I wrote to the Healthcare Commission many months ago. I pay tribute to Julia Bailey, Debbie Heseldine and Ken Lownds, who worked on the report—

Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Chair, Speaker's Committee on the Electoral Commission

Order. The hon. Gentleman must ask a question. I have given him a bit of leeway; I got him in at Prime Minister's questions—he has done well today—but he cannot make a speech.

Photo of Bill Cash Bill Cash Conservative, Stone

I understand that, Mr. Speaker, but these are hugely important questions. Bringing all those matters together in one public inquiry, as we did in different circumstances back in 1984, with legionnaires' disease in the same hospital, should be very carefully considered. I strongly urge that we do that; otherwise we may miss the wood for the trees. May I say finally that—

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The hon. Gentleman has vociferously and persistently raised the case of concerned constituents. Indeed, he represented Stafford until 1997, so I listen with more than usual respect to what he says. The point about the case notes review is that no public inquiry or anything else can determine whether a patient died unnecessarily other than by having clinicians go through the case notes, so offering that to the loved ones of people who have died is absolutely right.

The hon. Gentleman said that Alberti would deal only with A and E, but A and E is the problem. The Healthcare Commission has made the point that the issue was to do with one third of the patients coming into A and E and the emergency assessment unit. With the greatest respect, I do not think that a public inquiry will take us any further forward. Yes, there was a public inquiry into legionnaires' disease at the same hospital in '84, but there was no independent Healthcare Commission at that time. The Healthcare Commission has provided the report. To have a public inquiry on top of that would just delay moving forward on the issue, so with the greatest respect, I disagree with the hon. Gentleman.

Photo of Kevin Barron Kevin Barron Chair, Health and Social Care Committee, Chair, Health and Social Care Committee

Does the Secretary of State agree that having no reconfiguration of primary care, no change in the status of a hospital and no targets would take away the responsibilities that health professionals have to patients? Would he also be prepared to allow the findings of the case notes review to be reported to the regulatory bodies, if that is applicable?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I agree with my right hon. Friend on all those points. One reason standards have improved so dramatically is that we have proper measuring and independent regulation and we have set standards. The targets become standards as soon as they are achieved, and they have indeed been achieved. I also agree with the point about drawing to the attention of the regulator any information that emerges from the case notes review.

Photo of Michael Fabricant Michael Fabricant Opposition Whip (Commons)

These issues precede 2002. It is to my great regret that I was told by Staffordshire paramedics in 1999 that people would be far better off going to Burton than to Stafford. When I made inquiries about that, I was just fobbed off. What can the Secretary of State do now to reassure my constituents that Burton, Good Hope and other hospitals, as well as Stafford, are safe places to go to?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

People have to look at what the Healthcare Commission says. The Healthcare Commission has looked at all the so-called outliers—hospitals that had a very high standardised mortality ratio—and it is assured that the problems are not the same as at Stafford. The Healthcare Commission has its own alert system, leaving aside the Dr. Foster system, in which five red lights, as it were, went off about care at Stafford hospital. That has not happened in Burton or other hospitals around the country.

I find it inconceivable that what happened could have happened over such a long period, and the hon. Gentleman is absolutely right: it probably went on for much longer. Mr. Cash made the same point to me yesterday. However, we now have the procedures in place and we have the Healthcare Commission, and people can rest assured. Hon. Members in all parts of the House have to ensure that there is no hiding place for poor patient care.

Photo of Charlotte Atkins Charlotte Atkins Labour, Staffordshire Moorlands

Last week Bill Moyes of Monitor told me in the Select Committee on Health that the Mid Staffordshire NHS Foundation Trust met its criteria

"in February 2008, after...a lengthy assessment."

Does that not undermine the credibility of the foundation trust assessment process? Could the Secretary of State also give me an assurance that the proper patient care priorities of other hospitals, including the University hospital of North Staffordshire, will not be compromised by its determination to secure foundation trust status?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend raises an important point, which is central to the issue that we are discussing. I do not think that Bill Moyes or Monitor could have made any other decision. Let us not forget that the decision on Stafford was made before the Healthcare Commission decided that it needed to investigate. Yes, there were issues to do with the high standardised mortality ratio, but there are such issues in many hospitals. Once the Healthcare Commission decided formally to investigate on 18 March 2008, the hospital already had foundation trust status. Why did Monitor do that? It did so because the system looks at whether there is a proper strategy to implement.

There are lessons for everyone to learn, but I will tell the House what Bill Moyes said last night:

"we have certainly learned since our assessment of Mid Staffordshire that we need to look wider than we did at the time. At the time we tended to rely on other bodies to bring us information, whereas now we look at a whole range of issues about quality, including things like complaints".

Apparently that was not previously in the system. We all need to learn from what has happened. I am not saying that Monitor or anyone else—and certainly not the Government—does not have lessons to learn, but the 115 foundation trust hospitals that have managed to achieve that status, to which many others aspire, are a world away from the awful events that were happening in Stafford.

Photo of Michael Howard Michael Howard Conservative, Folkestone and Hythe

May I offer the Secretary of State a simple and constructive suggestion? Will he ask the chairman of every hospital's trust how much time its board has spent in the last year considering each of the following three topics: meeting Government targets; the status of the trust; and improving patient care? Would the answers to that question not help the Secretary of State as he tries to ensure that nothing similar ever happens again?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

They would not, in the sense that the primary duty is to concentrate on patient care. That is the primary duty of all clinicians. [ Interruption. ] Well, look, the worst mistake that we could make in this House would be to besmirch the whole of the NHS with what happened at Stafford, which was an absolute exception. I hope that the right hon. and learned Gentleman accepts that, because that is what the Healthcare Commission says. Anyone who has seen any NHS worker anywhere in the country who looks at what happened would be appalled. The chief executive of the NHS has today written to every trust board, drawing their attention to what happened at Stafford and asking them urgently to review the situation to ensure that they are doing the things that the Healthcare Commission has recommended Mid Staffordshire trust must do, which includes ensuring that patient complaints reach the board.

Photo of Tony Wright Tony Wright Labour, Cannock Chase

This is a shocking and shaming report, as my right hon. Friend has said, but it is not a surprising one. My files are full of cases describing a lack of basic care at the trust. That is why I wrote to the Healthcare Commission asking it to look at the pattern of complaints and saying that I thought that they "highlighted systemic care issues". Now we know from this extraordinary sentence in the report that

"the board did not routinely discuss the quality of care".

We are talking about a trust that had sky-high mortality rates and sky-high levels of upheld complaints that did not even routinely discuss the quality of care at board level. That is beyond belief. The Government have now rightly put the quality of care at the top of the NHS agenda, but how can we be sure that that really happens everywhere in the country?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend's constituency covers Stafford hospital—he will shake his head if I am wrong—and once again I pay tribute to the work that he has done. The National Quality Board, among other things, will ensure that quality is central to everything that happens in the NHS—again, that came from the Darzi review. The process will involve presidents of royal societies and, crucially, patient representatives, as well as the regulators. They will be focused completely on ensuring the introduction across the country of quality metrics, CQUIN—commissioning for quality and innovation—and all the other terminology that is important to clinicians, so that quality becomes the organising principle of the NHS. It is their job to ensure that that takes place everywhere across the country. With that drive and commitment by clinicians, who were paramount in shaping Darzi's review, my hon. Friend can be assured that quality will indeed be the guiding principle and that, as I said earlier, there will be no hiding place for poor patient care.

Photo of Richard Taylor Richard Taylor Independent, Wyre Forest

During the years of deficit, strict vacancy freezes were put in place in all trusts. Will the Secretary of State reassure us that the vacancy freezes in Mid Staffordshire were not followed by a permanent reduction in nursing posts?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I can reassure the hon. Gentleman that there are no vacancy freezes. The Healthcare Commission has said that the hospital was drastically understaffed, and had been so for years. He is absolutely right to say that it had to move from deficit to surplus; it is quite right that extra money going into the NHS must be matched by trusts handling their finances properly, but that must never, ever be at the expense of patient care. It is obvious that this hospital was understaffed for many years, particularly in A and E.

Photo of Gordon Prentice Gordon Prentice Labour, Pendle

Doctors and nurses are in the first line of whistleblowers. I want to hear my friend say loud and clear that clinicians have a professional obligation to speak out loudly when things go wrong, and to take any concerns to their professional bodies. Why on earth did that not happen in this case?


Yes; thank you Mr Prentice. Does this raise questions about the alleged poor practice and standard of care at Blackburn?

Submitted by Peter Catterall

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend is absolutely right. It is one of the great mysteries of Stafford that, as far as we are aware, that did not happen. The Healthcare Commission has said that clinicians and staff gave up registering complaints at the hospital because they felt that they were wasting their time, but I cannot answer the question of why those complaints did not come up through a different route. My hon. Friend is right to raise it, but there is no answer to it in the Healthcare Commission's report. Perhaps one will emerge from the other reviews.

Photo of Jacqui Lait Jacqui Lait Conservative, Beckenham

I apologise to the Secretary of State for interrupting him earlier. I put it down to the fact that I was horrified by the tale that he was telling us. Will he tell us who was responsible for the appointment of the non-executive directors of the trust, who was responsible for the system of appointment for the non-executive directors, and what qualifications the non-executive directors had that gave them the skills to be non-executive directors?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

It was the chair and chief executive of the trust, before it became a foundation trust, and now it is the governors of the trust who are responsible for appointing the board and for ensuring that the people whom they appoint as non-executive directors have the skills to do the job.

Photo of Clive Efford Clive Efford Labour, Eltham

Although I accept that the Government should always keep targets under review, does my right hon. Friend agree that it is utter nonsense to suggest that targets were at the heart of this problem, and that that is a reason for health professionals to neglect people who are in urgent clinical need? Does he think that replacing the word "targets" with the word "outcomes" would somehow alter the fact that we were measuring the performance in our NHS hospitals? Is it not right that we need to learn—

Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Chair, Speaker's Committee on the Electoral Commission

Order. Hon. Members are supposed to ask only one supplementary question. There were three in there somewhere.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend is absolutely right—[Hon. Members: "Page 49."] Members are saying, "Page 49". I have read every page of the report that the Healthcare Commission has conducted and written. It says that targets cannot be used as an excuse for basic failures in management. Hospitals all over the country are getting waiting times down—the Conservatives had a target of 18 months in their patients charter—and it would be bizarre and perverse to say that, because this one hospital, Stafford, has been so appallingly managed and so understaffed, we will now take away the assurance that patients across the country have that they will be seen by a specialist within two weeks if they are suspected of having cancer, that they will wait no longer than 18 weeks for their operation, and that they will wait no longer than four hours in A and E. That would be ridiculous. It is a bizarre argument and I do not understand it. On the point about outcomes, I suggest that my hon. Friend read the leader in The Times on Monday, which made the same point as eloquently as he did.

Photo of Douglas Hogg Douglas Hogg Conservative, Sleaford and North Hykeham

Does the Secretary of State agree that there has clearly been gross incompetence by management and staff in this case? That raises the question of what happens in the public sector when gross incompetence occurs. Surely he will agree that it is important that disciplinary procedures should be commenced as rapidly as possible, that due process must be observed, and that those responsible should be disciplined—and, if necessary, sacked—and paid the minimum that the law requires.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

The right hon. and learned Gentleman is absolutely right, but, as he said, this must be done through due process. I would expect that due process to be speedy and to come to a conclusion quickly, and neither I nor anyone else in the House wants to see any rewards for failure.

Photo of Rob Marris Rob Marris Labour, Wolverhampton South West

The NHS overall does a great job. Stafford hospital is just a few miles from my constituency, and I am outraged at what has happened. The Secretary of State said in his statement today that "the management were obsessed with achieving foundation trust status". There have been far too many reorganisations of the NHS, both under this Government and under previous Governments. We have too many non-executive directors who are accountants, we have trust boards that are unbalanced, and we have too many senior managers in the NHS who are incompetent and not being fired. Will my right hon. Friend assure me that he and his Department will abandon the distraction of foundation trust status, which Wolverhampton is about to go through, and that he will try to ensure a better balance on trust boards so that we have fewer—

Photo of Michael Martin Michael Martin Chair, Speaker's Committee on the Electoral Commission, Speaker of the House of Commons, Chair, Speaker's Committee on the Electoral Commission

Order. I must remind hon. Members of the practice of putting only one supplementary question to the House.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

My hon. Friend has strong views about foundation hospitals, which I do not agree with. He was right, however, in his first comment. The NHS, which deals with 1 million people every 36 hours, does a terrific job up and down the country. He is falling into the trap of equating Stafford with everywhere else. There are 115 foundation trust hospitals that do a terrific job and whose standards are very high. They are part of the NHS, but it is quite right that they should have that extra freedom if they prove worthy of it. The important thing is that it should not only be financial competence that determines whether they are worthy of that status; it should also be their very important focus on patient care.

Photo of Evan Harris Evan Harris Shadow Science Minister

Seven years ago I warned the Secretary of State's predecessors and Dr. Fox that these political targets would result in clinical distortions. Does the right hon. Gentleman accept that this hospital was a three-star trust and a foundation hospital under his Government's target metrics? Surely he cannot simply blame the managers, when they were told that they would lose their jobs unless they met the Government's priorities. According to the managers, these were P45 targets, and the Secretary of State cannot simply blame them for what has happened.

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

What the hon. Gentleman says about targets is stuff and nonsense. There is a debate about this issue. The Royal College of Emergency Medicine and the Royal College of Nursing think that targets are right. They think that the tolerance levels involved should be 95 or 96 per cent., rather than 98 per cent, but to turn Stafford into a technical argument about three percentage points is perverse, and it is unworthy of the report that the Healthcare Commission has produced.

Photo of David Drew David Drew Labour, Stroud

I am a foundation trust governor in my acute hospital trust—

Photo of David Drew David Drew Labour, Stroud

There you go: there's an admission! If the model is used properly, and if governors are empowered, it offers by far the best method of accountability, despite political differences. Is it not about time that we had faith in this model and empowered the governors, so that we can prevent the Staffords of this world from happening again?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I believe that my hon. Friend might have shared the view of my hon. Friend Rob Marris at the time when we were having the debate about foundation trusts. However, he now speaks very eloquently from his experience of the trusts, and I think that he is absolutely right.

Photo of Anne McIntosh Anne McIntosh Shadow Minister (Environment, Food and Rural Affairs)

Will the Secretary of State take this opportunity to assure the House that there are no systemic failures in the NHS system, and that his Department's regulations are not taking every ounce of initiative and flexibility away from the health professionals? For instance, if a patient is not eating at meal times, families are not allowed to visit in order to feed the patient. Is not that nonsensical? Can we not reintroduce a degree of flexibility into the arrangements, and trust the health professionals to allow what is best for the patients in their care?

Photo of Alan Johnson Alan Johnson The Secretary of State for Health

I think that the hon. Lady has a particular incident that she wishes to speak to me about, and I would be very pleased to talk to her about it. I can reassure her that there is no systemic failure in the NHS, on any model. Of course, we now judge this independently; we have independent statistics. We have the Dr. Foster statistics, which are used only in this country, Canada and the United States. They are not hard and fast—there is a debate in the British Medical Journal this morning about them—but they are a very good indicator of when there is a problem in a hospital. These things never occurred before. Anyone who reads the report of what was happening at Bristol royal infirmary—in a data-free zone and without resort to independent regulation—will see that we have moved on a great deal since those dark days.