HC Deb 18 July 2001 vol 372 cc289-304 3.31 pm
The Secretary of State for Health (Mr. Alan Milburn)

With permission, Mr. Speaker, I wish to make a statement about the Bristol Royal infirmary inquiry.

The report of the inquiry into the care and management of children receiving complex heart treatment between 1984 and 1995 is being published today. It is now available in the Vote Office. I am grateful, Mr. Speaker, for your agreement that the parents and their representatives should also have advance access to copies of the report.

The inquiry was established in 1998 by my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson). I want to express my thanks to Professor Ian Kennedy and his panel members, Professor Sir Brian Jarman, Mrs. Rebecca Howard and Mrs. Mavis Maclean, for doing a quite outstanding job in delivering a well considered and far-reaching report.

Words in a report can never be enough for those families whose children died or were damaged. When I met representatives of some of the parents earlier this week I think that I was speaking for the whole House when I expressed my profound sorrow for the pain and loss the families have endured. I hope that the report at least provides an explanation, and that those families are able to take some small comfort from it.

The report and its annexes run to some 12,000 pages. We will study the findings and the 198 recommendations with care. Today, I can outline the thrust of the inquiry's findings and some of the Government's initial responses. Our substantive response will be made in the autumn. It is right that this House and the public should have the opportunity to study the report in detail. It will be available from this afternoon on both the inquiry's website and through the Department of Health's website. I would welcome views from the public and those working in the NHS to inform our full response.

In examining events at the Bristol Royal infirmary between 1984 and 1995, the report recognises that a great deal has changed since then. It also, quite rightly, commends NHS staff in Bristol and throughout the country for their dedication and commitment in providing care and treatment to hundreds of thousands of patients every day.

I hope that today, above all other days, all of us—across the House, in the media and among the public—remember one simple truth: the NHS is full of good doctors, not bad ones, and of good people who are doing their best for patients, sometimes in difficult circumstances. The report rightly reminds its readers that between 1984 and 1995 staff at Bristol carried out heart surgery on 1.827 children. The great majority of those children are alive today because of the efforts of those NHS staff. As the report puts it:

Many patients, children and adults benefited; too many children did not. Too many children died. In discovering what happened at Bristol, the report describes a tragedy born of high hopes and ambitions". The senior NHS staff concerned got things wrong, not least because they assumed that in time they were bound to come right. As we now know, they never did. Between 1991 and 1995, the report makes it clear that between 30 and 35 more children aged under one year died after open-heart surgery in Bristol than was typical of similar heart units elsewhere in England. The report says that that was not due to differences in the severity of the cases. While mortality rates fell throughout the rest of the country as time went on, this did not happen in Bristol.

The report paints a picture of a hospital short of resources and short of specialist staff. Cardiac care was split between two sites; children's services played second fiddle to adult services. Power was concentrated in too few hands. The hospital was a closed world. The report describes a "club culture" in which problems were neither identified nor resolved. Paternalism towards patients sat side by side with rivalries between professions.

Concerns about paediatric open-heart surgery at Bristol were first raised as early as 1986—first inside the hospital, then outside, then with the Department of Health and Social Security, as it was at the time. Concerns continued to be raised but no one acted effectively to protect the welfare of the children who were patients there.

There was a tragic combination of key clinicians failing to reflect on their own performance, senior management failing to grasp the seriousness of what was going wrong, and people in various official capacities—including in the Department of Health—failing to act. Uncertainty about who was responsible for sorting out problems meant that they were never sorted out. In the meantime children were dying who should not have died. It was left to a whistleblower, an anaesthetist in the hospital, Dr. Stephen Bolsin, to trigger the chain of events which led eventually, in 1995, to the suspension of children's heart surgery. As the report says, Dr. Bolsin is owed a debt of gratitude for what he did.

The report is directly critical of certain individuals, including the senior doctors concerned. As the House is aware, Dr. Roylance, Mr. Wisheart and Mr. Dhasmana have already been the subject of action by the General Medical Council, but the inquiry panel made clear its determination to avoid simply pointing the finger of blame at a few individuals. I commend this approach, because, the Bristol tragedy was born of deeper causes than the actions of a handful of senior clinicians and managers, wrong though they were to act as they did. The children who died and who were damaged were failed by a few people in senior positions in the hospital but, even more so, they were failed by the very system that was supposed to make them well and keep them from harm.

If the NHS is to learn from when things go wrong, it must move beyond a culture of blame. The tenor of the Bristol inquiry report is, in my view, a significant step towards a more open and honest health service. Medicine is not a perfect science. Even the best people can make the worst mistakes. Putting right what can sometimes go wrong relies on the NHS being able to acknowledge error and having systems in place to minimise error. The absence of such an approach at Bristol, and in the wider NHS at the time, contributed directly to the tragedy that cost dozens of children their lives.

Bristol was designated a specialist regional centre for children's heart surgery. It probably never should have been. It never performed sufficient operations to ensure safe outcomes for patients. Monitoring was virtually non-existent. Accountability was confused. There were no national standards in place. The inquiry report puts the position starkly: we cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was, in truth, no such system. That was the norm for the NHS then. The events at Bristol have been a major catalyst for change since. As the report repeatedly acknowledges, since those years the NHS has moved on. Earlier this year the new Bristol Royal Children's hospital opened. The United Bristol Healthcare trust has a new, strong management team with extra cardiac staff.

As elsewhere in the NHS, problems remain—of course they do—but it is worth noting that today's survival rates for children's heart surgery at Bristol are among the best in the country. The energy and commitment that the staff, the managers and the trust board have shown in turning the service around deserve recognition and praise. I hope that the whole House will join me in doing so today.

The NHS today is a very different health service, too. As the report acknowledges, the under-resourcing that was such a feature of the NHS then is beginning to be addressed now. The events at Bristol have spurred the Government and the medical profession to work together to put in place new standards and structures to improve quality in care. As the Kennedy report says, Recent developments give cause for optimism. These include statutory responsibility for the quality of health care, the development of clinical guidelines through the National Institute for Clinical Excellence, and the monitoring of performance through the Commission for Health Improvement. The report welcomes the establishment of the National Patient Safety Agency to run a single reporting system for all adverse health events. The report welcomes annual appraisal and revalidation for doctors; it recognises that a new contract for hospital consultants is being negotiated and that joint training for health professionals is being introduced. The clinical negligence system, which the report rightly criticises, will be the subject of a White Paper to be published early next year. Many of these changes, and other reforms contained in the NHS plan, are welcomed or endorsed by the report.

As the report highlights, however, further action still is needed if we are to prevent another tragedy on the scale of Bristol's. Between now and the autumn, the Government will give the report's recommendations careful consideration. Today I can tell the House that I am taking the following steps immediately in response to the Bristol report.

First, the report laments the lack of priority given to children's services in the NHS. It calls for the appointment of a national director of children's health care services. I have therefore appointed Professor A1 Aynsley-Green, Nuffield professor of child health at Great Ormond Street hospital, to take up the post with immediate effect. His priority will be to spearhead the faster development of the first ever national standards for children's health services. Standards for children in hospital, including children with congenital heart disease, will be ready next year.

Secondly, the report calls for patients and parents to have a greater say in the NHS and in their own care. Informed consent must be a cornerstone of a modern health service. Today we are publishing information for patients and specifically for parents about the questions that they should ask before consenting to treatment for themselves or their children. Next month we will invite views on our proposals for increased public involvement in the NHS. By April next year, every trust will have a specialist patient advocacy and liaison service in place to help patients who are experiencing problems with treatment, as part of a wider programme to inform and empower patients within the NHS.

Thirdly, the report identifies a failure to act on concerns about services, not through a lack of data, because Bristol was awash with data. There was however, no single point where data were brought together for analysis, evaluation, dissemination, and, most important, follow-up action. For data on surgical outcomes to be published, of course, they need to be robust, rigorous and risk-adjusted. That will inevitably take time. The report does, however, recommend publication to give both NHS staff and the public accurate information. It recommends the establishment of a new independent office for information on health care performance within the Commission for Health Improvement to co-ordinate the collection and publication of data. We will action those two recommendations. In so doing, we will ensure that the new office works in tandem with the medical organisations that have been pioneering improvements on data collection about clinical outcomes.

Fourthly, the report criticises confusion in regulation and accountability in the NHS. It recommends the establishment of an overarching body—the council for the regulation of health care professions—to ensure that the individual professional regulatory bodies act in a more consistent manner. That is in line with a similar commitment that we made last year in the NHS plan. We will action that recommendation, following consultation, alongside our proposals to reform the General Medical Council in the NHS reform and decentralisation Bill later this year.

Fifthly, the concern is expressed in the report that NHS managers should also have responsibility for maintaining standards and protecting patients. It recommends the establishment of a new regulatory body for NHS managers. We will consider that proposal, but in the meantime, we will seek to develop a new code of professional conduct for NHS managers in conjunction with their professional associations. I will announce the further steps that we will take to strengthen safeguards for patients when we publish our full response in the autumn.

Professor Kennedy and his panel have provided us with a report that builds on what is now being achieved, but the ambition is bigger still: to build a new culture of trust, not blame, in the NHS—an NHS where there is greater partnership between patients and professionals; where lines of accountability are clear; where there is openness about mistakes; where services are designed from the patients' point of view; and where safety for patients always comes first.

None of that can ever make good the loss experienced by the Bristol parents. Throughout the inquiry, they have acted with great dignity and purpose. Their determination has been, as ours must now be, to see some good come out of the events at the Bristol Royal infirmary. As one parent put it to me earlier this week, "There are no winners from Bristol. We are all losers. I just hope that future generations can be the winners." I hope that through this report the families will gain at least some consolation from the knowledge that, over time, the lessons learned from what went wrong for their children will help us to prevent it from happening again to any other children.

In framing its recommendations, the inquiry panel said that its aim was to build a bridge between the lessons of the past and the NHS of the future [so] Bristol will be remembered not merely as a synonym for tragedy but also as a turning point for the NHS". It is for us—all of us—to ensure that is indeed the case. I commend the report to the House.

Dr. Liam Fox (Woodspring)

I thank the Secretary of State for his statement today and for making a copy of it available to the Opposition in advance. I also thank the inquiry team for making the report available to us in advance and for all its hard work in producing such an excellent report. It would be verging on insulting its great effort to try to make any pretence of a definitive response this afternoon, yet very major issues are involved, and parents and professionals will rightly want them to be fully explored in Parliament. So I begin by asking the Secretary of State whether he will give an undertaking now that, having had time to reflect on those issues during the summer, the Government will make time available soon after the recess to debate them fully in the House in Government time.

The report says that learning from error, rather than seeking someone to blame, must be the priority to improve safety and quality. That is a much easier concept for hon. Members to accept than it is for many of the parents who have lost their children so tragically; but however understandable a part of human nature wanting to attach blame may be, it is our job to ensure that we minimise the risk of such events being repeated elsewhere. We need to determine which errors came from individuals, which came from specific systems and conditions in Bristol and which were endemic in the culture of the NHS. Of course, it very easy for us to do that with the benefit of hindsight.

The report says: At the time while the paediatric cardiac service was less than adequate, it would have taken a different mindset from the one that prevailed on the part of the clinicians at the centre of the service and senior management to come to that view. It would have required abandoning the principles which then prevailed, of optimism, of 'learning curves' and of gradual improvements over time. It would have required them to adopt a more cautious approach rather than muddling through. That this did not occur to them is one of the tragedies of Bristol. We must not be too hasty in our judgment of them, or judge them by the massive advances in medical culture that have occurred in the past decade.

Clearly, however, some problems could and should have been recognised. Effective teamwork did not always exist at the BRI. The report says: All the professionals involved in the PCS service were responsible for this shortcoming. Those in positions of clinical leadership must bear the responsibility for this failure. We also had the problem of the split site, which meant that cardiologists, as opposed to cardiac surgeons, could not be effectively involved in intensive care. It is worth pointing out to the House that the cardiologists in Bristol were extremely well regarded by their fellow professionals and by parents throughout the south-west.

As the Secretary of State pointed out, it was not simply the outcomes in Bristol which should have raised the alarm, but the growing gap between Bristol and other centres. Between 1988 and 1994 the mortality rate at Bristol was roughly double that elsewhere in the UK for five out of seven years. That mortality rate failed to follow the downward trend in other centres. The Secretary of State mentioned statistics relating to children under one; the excess death rate was even higher for children under 30 days. It is clear from the evidence that there was no excuse for that on a case-mix basis. Around 35 more children died than might have been expected, and each individual was a tragic and irredeemable loss.

We will reflect on the responses that the Secretary of State has made today. Will he publish the job specification for the national director of children's health care services, so that we can all see exactly what is expected of him?

Will the Secretary of State think again about his proposals on consent and information, and go further? The report says that the sense is gained that informing patients and gaining their consent was regarded as something of a chore by surgeons. I believe that that has changed dramatically in recent years, but surely in an ever more protocol-driven medical world, there is a strong case for introducing standardised consent forms at least for non-emergency procedures so that all patients and their parents will know in advance what to expect from surgery, what to expect after the operation, what the complications may be and what the likely outcomes are. As individual users of the health service, surely we have a right to know what to expect of it.

Will the Secretary of State consider going even further with his plans for a health care performance office? This country requires a truly independent academic institute able to develop a standardised methodology of determining outcome. If we cannot properly measure outcomes, we cannot make rational choices in health care in this country as in any other western country.

We will need more time to consider some of the more contentious recommendations: the abolition of clinical negligence litigation and the common terms of employment for doctors, nurses and managers, to name but two. It is worth the House bearing in mind the fact that, in the words of the report, The story of the paediatric cardiac surgical service in Bristol is not an account of bad people. Nor is it an account of people who did not care, nor of people who wilfully harmed patients. It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work together effectively for the interests of their patients. Finally, in paying tribute to the courage and steadfastness of the parents of those patients—some in my constituency and many nearby—the greatest service that we can do them is to take Professor Kennedy's report away and reflect on it not in anger, but with the determination to make sure that those precious and irredeemable losses are not repeated elsewhere.

Mr. Milburn

I thank the hon. Member for Woodspring (Dr. Fox) for the content and tone of his response. He is correct to say that the report is large. As he knows, the body of the report runs to some 500 pages and the annexes are much longer still. There are 198 recommendations. Some are small recommendations; some are fundamental and far reaching. They require proper scrutiny, and time is needed to enable us to study them as we should.

On the possibility of a debate, I welcome the hon. Gentleman's comments. I have no objection, but it is a matter for the business managers. If we can arrange a debate, clearly we should.

The hon. Gentleman makes an important point about looking back with the benefit of hindsight. Professor Kennedy and his panel reflect much on that in their report. With the benefit of hindsight, it is clear that the norms and behaviour that were accepted then are at variance with the current position. It is also true that mistakes were made even within the norms prevailing then. As we discuss these issues, it is important to recognise how far things have moved on in just a short time. I welcome the attitude of individual doctors and the medical profession, and the recognition that the culture of the past can no longer pertain in the NHS of today.

With regard to cardiologists, the situation was even worse than the hon. Gentleman describes. At the time, no single paediatric cardiac surgeon specialising in that discipline was available. That may explain some of the difficulties that many of the parents subsequently encountered.

On the job specification for the national director, I am happy to write to the hon. Gentleman and let him know the details. On consent forms, we have already developed a model consent form which has been out for consultation. By 1 October this year we expect to have a finalised version in place. That is needed not just in some hospitals in the NHS, but across the entire NHS.

Mr. Frank Dobson (Holborn and St. Pancras)

I join my right hon. Friend and the shadow Secretary of State in expressing my sorrow about what happened to the children, my concern for the parents, and my admiration for the steadfastness of the parents who struggled long and hard for the inquiry. I hope that they will find the outcome in some way satisfactory.

As both previous speakers have said, what happened was not the product of bad people. It involved good and caring people. That is a measure of just how awful the arrangements in the NHS were at the time for setting and monitoring standards of performance. There was no setting of standards nationally, locally, managerially or professionally, nor was there any monitoring of standards. That is largely why those events occurred. My right hon. Friend is no doubt as pleased as I am that the report states that there is cause for optimism because of changes that have subsequently been made to start establishing and monitoring standards.

My right hon. Friend rightly gave great prominence to the problem of the blame culture. The report makes it clear that if improvements are to be made, all the professionals and managers must be open and willing to report when things go disastrously wrong or when near-misses occur. They must accept that they may have been at fault, and they must apologise for what has happened and publish outcomes. All that will be necessary, but I am convinced, as the inquiry was clearly convinced, that it will not happen while the possibility of litigation for clinical negligence continues to exist.

I hope that when the Government have completed their consideration of the report, they will agree with the inquiry recommendations and rid the national health service of the threat of clinical negligence litigation, which does much harm and encourages the blame culture.

Mr. Milburn

I am extremely grateful to my right hon. Friend for his contribution. I should like to place on record my thanks, as well as those of the whole House and people in Bristol, to him for his courage in establishing the public inquiry. Let us remember that the decision was extremely controversial when it was made, but it has proved, with the benefit of hindsight, to be absolutely right.

My right hon. Friend was right about the setting of standards. In the report, Kennedy was extremely critical of a hands-off approach in the national health service. In fact, there were two lines of accountability in the NHS—clinical and managerial. As my right hon. Friend knows, because the two lines never met, problems relating to clinical outcomes and surgical mistakes were never gripped as one hopes that they would be nowadays.

My right hon. Friend was right about publishing outcomes, but he knows as well as I do that the science of ensuring that the data that we publish are rigorous is pretty rudimentary. There is an awfully long way to go to ensure that they command confidence not only in the professions, but—in a sense, this is more important—among patients. It is pointless to publish information that is inaccurate and gives a misleading impression.

Only yesterday, I had the pleasure of meeting the cardiac surgeons committee. I spoke to Mr. Ash Pawade from Bristol, who, as my right hon. Friend knows, is a surgeon who specialises in children's heart surgery and has a reputation that is not only national but international. Like the committee, I am convinced that great progress is being made in respect of the ability to publish rigorous data that will properly inform patients and professionals, and in which we can all have confidence.

On my right hon. Friend's final point, it now seems right to review the issue of clinical negligence and its operation. I have some sympathy with his comments. I am sympathetic to the position of ordinary doctors and of surgeons in particular. Day in, day out, while we talk so easily about getting rid of the blame culture, they face the threat of being dragged through the courts as part of a clinical negligence claim. In the end, it seems difficult to reconcile the idea of openness in the national health service with the threat of legal action. We must consider the matter and keep it under review. Indeed, I have asked the chief medical officer to chair a committee of experts to examine it. We will introduce a White Paper in the new year that will, I hope, make recommendations for radical reform.

Dr. Evan Harris (Oxford, West and Abingdon)

I want to place on record my sympathy with the situation of the families from Bristol, and pay tribute to them and their action group for their persistence in setting up the inquiry and in continually contributing to it, thereby enhancing its status. I join the Secretary of State in commending his predecessor, the right hon. Member for Holborn and St. Pancras (Mr. Dobson), for his foresight in setting up an inquiry which was not narrow but which had a very wide remit. I want also to pay tribute to my hon. Friend the Member for North Devon (Nick Harvey) for his assiduous work in asking questions both locally and in this place.

I thank the Secretary of State and the inquiry for their courtesy not only in allowing me the opportunity to be shut in a room with the Conservative spokesman for an hour to read and digest a 500-page report with 11,000 pages of annexes, but for the extensive nature of the report and the wide-ranging recommendations that it makes.

We believe that credit is due to the Government for already having implemented some quality control mechanisms—and the Commission for Health Improvement and clinical governance. We welcome the steps that they have taken so far. However, my fear, which is reflected in the view of the inquiry team, is that the case is not isolated and that similar circumstances are arising elsewhere. As the Secretary of State so rightly said, it is a system problem. Does the right hon. Gentleman accept the figures suggesting that while 30 to 35 babies died unnecessarily in Bristol, as many as 25,000 avoidable deaths nationwide may have been caused by errors in medical care? Does the right hon. Gentleman therefore accept that a culture change is needed to tackle the macho style of medicine, which is based on individualism rather than team work? Does he also accept that protection for the whistleblower remains inadequate in a system where, for example, junior doctors rely on the patronage of senior doctors to get promotion?

I was pleased to hear the Secretary of State's response to the right hon. Member for Holborn and St. Pancras, but will he go further? The report is clear about the impact of the recommendations on the tort system of medical negligence. It states: Clinical negligence litigation, as a barrier to openness, should be abolished. It stresses that the NHS must promote openness and preparedness to acknowledge errors and learn lessons. It also states that clinical negligence is part of the culture of blame. It should be abolished. It recommends the introduction of an alternative administrative system of compensating those who suffer harm arising from medical care. That is no-fault compensation. I hope that the Secretary of State will clarify that the expert panel's scope will include the ability to implement the recommendation for a switch to no-fault compensation for which my hon. Friends have previously called.

Does the Secretary of State accept the need for not only patient bodies but the public to be embedded in the structures of the NHS and for that culture to permeate all aspects of healthcare"? Will he assure us that he will be able to deliver that after the abolition of community health councils and health authorities?

Providing misleading performance data in the absence of clarification is unhelpful. Does the Secretary of State acknowledge the role of referring clinicians and commissioners, who failed in the case that we are discussing to deal with patients' questions and check outcomes? How does he expect those roles to be tackled when local public health advisory functions are dissolved?

Does the Secretary of State accept the inquiry team's emphasis on public service ethos? Does he welcome the report's recommendation that continued extra funding is required because quality costs, especially consultant expansion? If that is understood, the children will not have died in vain.

Mr. Milburn

I am grateful for the hon. Gentleman's comments. On his last point, the report rightly acknowledges the contrast between previous under-resourcing and current investment. Professor Kennedy rightly calls for the investment to be sustained. That is music to my ears. I agree that it is the right thing to do, and I hope that we can achieve it.

Let me consider some of the hon. Gentleman's other substantive points. He mentioned a macho style and the merits of whistleblowing. Dr. Bolsin did people an enormous favour. However, the need for whistleblowers is a sign not of success but of failure. We want a national health service that can blow its own whistle if necessary, and be honest with people.

We, too, should be honest. It is easy for Members of Parliament to criticise. Professor Kennedy makes the important point when he reminds the report's readers that these heart operations are incredibly complex. When a baby's heart is operated on, it is the size of a walnut. Such an operation requires dexterity, expertise and skills at which most of us can only wonder. We must therefore be cautious when apportioning blame, although we must acknowledge that mistakes were made and that big cultural changes must be effected in the NHS. I hope and pray for a time when we do not need whistleblowers in the NHS because it publishes validated, rigorous information that commands confidence with the public and professionals. The report goes some way towards achieving that.

The chief medical officer's committee will consider the merits and disbenefits of no-fault compensation, which is not as straightforward as the hon. Gentleman suggests.

Professor Kennedy is right about embedding the patient's and, indeed, the public's voice in the NHS. He explicitly makes the point that if patients are to be better informed, their voices need to be heard inside the NHS, not outside it.

Valerie Davey (Bristol. West)

I thank my right hon. Friend for his important statement and welcome the report's in-depth study of complex circumstances. However, before we look to the future, I ask the House to join me and all hon. Members whose constituents have suffered in the tragedy in extending sympathy to the parents and families of those who died or were seriously disabled.

I ask my right hon. Friend to ensure that, as he continues with the Department to improve the NHS further, the experience of those families is never forgotten.

Mr. Milburn

I join my hon. Friend in extending the sympathy of the Government—indeed, of the whole House—to the families concerned. I also thank her for all her work, which has been widely taken into consideration during the past few years in dealing with some of these issues. Yes, it is important that we do not lose sight of the families' expertise. We owe them a great debt of gratitude. It would have been easy for them simply to pursue a case against the national health service in court but, instead, they have quite legitimately raised concerns about the operation of the NHS.

When I met representatives of the families earlier this week, I was powerfully struck by the fact that, in the end, they wanted some fairly simple things: an understanding and an explanation of what had happened to their families and, most important of all, an assurance that it would not happen to other families. That selflessness is something that we can only commend.

Mr. Graham Brady (Altrincham and Sale, West)

Does the Secretary of State agree that, in reducing mortality rates for children's cardiac surgery, it is essential to have not only the best possible performance in the United Kingdom but the best performance that can be achieved? Will he tell the House how this country compares to other developed countries, whether we are near the top of the league, and whether there is anything that we can learn from overseas?

Mr. Milburn

There are, as always, lessons to be learned from elsewhere in the world. As I said earlier, we have some of the most world-renowned paediatric cardiac surgeons in this country. That is something that we should trumpet loud and clear. In many ways, we provide children's heart surgery that is up there with the best, and we must make sure that it continues to be so. That is why we must keep providing new investment, and ensuring that we take advantage of the way in which technology and treatments are moving forward. As I have said many times in the House, one of my personal top priorities is to ensure that heart disease services for children and adults improve. That requires not only more investment but certain changes to the way in which health care is being delivered, and we will continue relentlessly to pursue that in the years to come.

Jean Corston (Bristol, East)

I thank my right hon. Friend for his statement and for the prompt way in which he has responded to some of the recommendations made by Professor Kennedy and his inquiry team. I also reiterate the thanks to my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) for setting up the inquiry and, most of all, for making it a public inquiry, because that did so much to restore the confidence in the process that we were putting in place of the parents whose children so tragically died. I would also like to thank my right hon. Friend the Secretary of State for confirming that the events surrounding this tragedy were entirely atypical of what goes on in the NHS in Bristol every day of the year.

Will my right hon. Friend pay particular attention to the role of the chief executive of a health care trust, and confirm that the chief executive should be the court of last resort for members of staff who want to raise concerns? They should be able to raise those concerns in an atmosphere free of stigma, and the final result should not end up involving shooting the messenger, as it did, sadly, in Bristol.

Mr. Milburn

I agree with my hon. Friend about the public inquiry. Public inquiries are not easy, as Professor Kennedy and his panel found, but they have conducted this one with great aplomb. They have written a report that is not only an easy read but extremely well considered, and I pay tribute to them once again.

It is absolutely right that the chief executive should be the court of last appeal, and the chief executive of the trust in Bristol, Mr. Hugh Ross, has introduced a new system for the reporting of concerns. There is a whistleblowing system in place, and a means of raising concerns at various levels in the managerial hierarchy. However, Mr. Ross has quite rightly retained the prerogative for individual members of staff who are concerned about raising an issue with their direct line manager to raise it with him personally. That is a good idea, and it speaks for the real progress that has been made in Bristol over the past few years.

Nick Harvey (North Devon)

I commend the Secretary of State on his statement and the steps that he announced in it and echo the appreciation of the right hon. Member for Holborn and St. Pancras (Mr. Dobson), who set up the inquiry. As one of those who campaigned for and gave evidence to it, I welcome its report, which I believe is of sufficiently broad scope to help those parents who feel that light needs to be shed on events at Bristol to enable them to understand and come to terms with what happened.

The Secretary of State drew a distinction between clinical and management accountability. He said, "The children were failed by the very system that was supposed to make them well," and that accountability was confused. On management accountability, will the right hon. Gentleman give further thought to how management at all levels of the NHS can be persuaded to understand that it must be open and accountable? When Members of Parliament such as the hon. Members for Bristol, East (Jean Corston) and for Bristol, West (Valerie Davey), myself and others started to ask questions on the affair, the shutters were pulled down and we were given misleading answers. Perversely, that caused me to take a far greater interest than I would otherwise have taken.

All areas of the NHS must be open for legitimate scrutiny from Members of Parliament, the media and elsewhere, or mistakes will turn into tragedies and tragedies will turn into scandals.

Mr. Milburn

I agree with some of those sentiments and I pay tribute to the hon. Gentleman for his role in handling the consequences of the Bristol tragedy.

The hon. Gentleman is in many ways right about the way that managers behave. They have a pretty difficult job. They have to be accountable to me and, therefore, accountable to the House. That must be right in a public service. They are also accountable to their local communities and to representatives of local communities. That must be right too.

This is a two-way street. We sometimes talk pretty glibly about partnerships between patients and professionals and so on and so forth, as if rights and responsibilities flow only one way. They do not. If patients and professionals are to work more in partnership, that places a greater onus and a greater responsibility on the patient. If informed consent has been given, the patient has signed a contract with the professional. That changes some of the relationships. That is true, too, in terms of the relationship between Members of Parliament, public representatives and the NHS, but, in broad measure, I agree with what the hon. Gentleman had to say.

Mr. Win Griffiths (Bridgend)

Like other Members, I congratulate my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) on instituting the public inquiry. I also congratulate my right hon. Friend the Secretary of State on making his statement to the House and responding so positively and quickly on crucial points.

My interest arose out of a tragedy that struck two families in my constituency and, listening to what has been said, I was reminded of the replies that I got from the trust, which amounted to saying, "Things are very difficult and great skills are involved, but, fundamentally, there are no problems." We know from the report that there were serious problems in Bristol.

I appreciate what has been said about paediatric services, but from my own experience and from what other Members have told me, I think that there is still a wider problem in the health service with accepting that there must be an entirely new approach to those problems. I hope that my right hon. Friend will undertake to bring together health service clinicians and those who are involved with these matters to talk through what is needed and ensure that such tragedies cannot occur—not just in paediatric and cardiac services, but right across the health service.

Mr. Milburn

I agree with my hon. Friend's comments, but he should not underestimate the extent to which there has been movement over the past few years. I met the Society of Cardiothoracic Surgeons yesterday and it is about to publish its latest outcome data, which are retrieved from its member surgeons. The society told me about a survey of its members on whether they support the open publication of outcome data so that those data are seen not just by the profession but by patients. Eighty per cent. of the cardiac surgeons surveyed supported open publication. That is a huge movement from where we were just four or five years ago. It expresses a recognition in the medical profession and among individual doctors that the closed world that epitomised Bristol during those tragic years will not do nowadays. Things have moved on. The important thing to realise is that it is not just the Government who have moved it on, but the profession.

Andrew George (St. Ives)

I echo the appreciation of right hon. and hon. Members for the inquiry and the manner in which it was undertaken. I agree that the primary emphasis should now be on looking forward, learning lessons and taking action. I seek the Secretary of State's advice about the relevant cases that fall outside the reference period of the inquiry, such as that of Mr. and Mrs. Barnes in my constituency, whose son William died in 1983 following an operation by Mr. Wisheart. Like many others, they are anxious to find out more about what happened before the reference period. They seek the support of the Secretary of State and his officials to find out what happened outside that period. I should be grateful if the Secretary of State would advise on that.

Mr. Milburn

The hon. Gentleman makes a good point. If it is helpful, I will contact the inquiry secretariat to see what information they have gathered during the inquiry, which has been going on for three years, and whether it is relevant to his constituents. I shall write to the hon. Gentleman and let him know, and if he is unhappy with that, we can think about how best to raise the matter.

Mr. David Hinchliffe (Wakefield)

Are there not some important parallels between what happened in Bristol and the clinical problems that have occurred elsewhere? I am thinking in particular of the case of the surgeon Christopher Ingolby in my area. I know that my right hon. Friend is familiar with the case. Clinicians and managers were aware of serious problems for some time, but they were not made public. Patients and their families were kept in the dark. The Secretary of State has rightly mentioned key reforms, which have overtaken events and will markedly improve things, but one piece of the jigsaw is perhaps missing. Public involvement in and scrutiny of the health service could pick up some of the concerns that are known among professions, nursing staff and managers, but never see the light of day elsewhere. Could my right hon. Friend say a little more about public involvement?

Mr. Milburn

I agree with my hon. Friend. There are common factors in many of these horrendous cases, not just in Bristol but elsewhere. Usually, the common factor is that people in the hospital and the NHS environment around the hospital have known that there has been a problem, but the patients and their families have not known. We must change that.

I have heard people say that the problem in Bristol was that there were no data, so no one knew what was going on and there were no measures to assess how well a surgeon was doing against the national average. That is not true. Data were available, and had been developed by surgeons themselves. We must publish information more openly, so that the public, local GPs and the primary care trusts, as well as the doctors in the hospitals, know what is going on.

Two years ago, we published for the first time clinical indicators of death rates following surgery. The data are raw and rudimentary, but none the less are a significant step in the right direction and will make patients more aware of what is going on in their local health service. We must do more of that in the future, but we can only do so in conjunction with the medical profession.

On the issue of public scrutiny, Kennedy is pretty clear and explicit that that is where we must make changes. We must not just open up the national health service to make information more available, but get the public in at the heart of the service.

Kennedy comments on the existing structure of community health councils and on our proposals in the last Parliament for patient forums. We shall return to that shortly, but I think there is an important lesson to be learned from all this: if we are genuinely to have a national health service that is focused on the needs of patients, we must have more power for patients.

Ms Gisela Stuart (Birmingham, Edgbaston)

My right hon. Friend rightly points out that we need to learn for the future from inquiries such as this, so that such mistakes are not made again. He also draws attention to the availability of data, and the way in which they were analysed.

I understand that the report reaches strong conclusions about the number of operations that have been performed in a safe environment. Before too long my right hon. Friend will have to make a decision about the future of heart transplant centres, and part of those data will no doubt influence it. May I urge him not just to look at the number of individual operations performed by an individual surgeon, but to pay due attention to the needs of the team work involved and the collective activity that provides the necessary expertise? Will he treat the data holistically, rather than in a mechanistic way?

Mr. Milburn

My hon. Friend has raised an extremely important point, which I know is of great concern to her constituents and those of many other Members—not just in Birmingham but, as she will know, in Sheffield and Manchester.

Real dilemmas are involved. There is, for instance, the dilemma of having to choose between maintaining a local service—to which Kennedy refers explicitly—and ensuring that patient safety comes first. My accountability to the House means that I must ultimately be accountable for patient safety, and patient safety must come first in the reaching of these difficult decisions.

My hon. Friend is aware of the state of play. I assure her and others that no final decisions have been made, and that before any are made there will be open and full consultation.

Dr. Howard Stoate (Dartford)

My right hon. Friend has pointed out that it was not so much a lack of data as a lack of monitoring that led to the tragic events in Bristol. That extends well beyond surgical outcomes. Dr. Harold Shipman managed to kill many of his patients; data must have been available, but no one had monitored the fact that many more patients were dying in his surgery than in any other surgery in the land, because it is extremely rare for a patient to die in a doctor's surgery.

Has my right hon. Friend given any thought to how monitoring might be extended well beyond surgical outcomes, across the whole range of primary care services? Has he given any thought to what sort of data might be published and how they could be made accountable and meaningful, so that patients could judge the whole range of NHS services rather than just surgical outcomes?

Mr. Milburn

My hon. Friend makes an extremely good point. There is a huge amount of data around; the problem is that those data are often pretty rudimentary, and are not integrated.

The hospital episode statistics data that we collect identify deaths in hospital, particularly deaths following surgery. What we do not have in the NHS is a means of collecting data relating to deaths outside hospital, so we give a rather false impression when we publish some of the statistics. However, some of the information is available through the Office for National Statistics, and we are engaged in a project to establish how we can best integrate ONS and HES data to give a rather more rounded picture of mortality rates.

I support the Kennedy recommendation for all the responsibility to be put "offshore" from the Department of Health and, in a sense, from the medical profession, but for work to be done in conjunction with the profession through the new office in the Commission for Health Improvement. That will co-ordinate collection and publication of information.

Julie Morgan (Cardiff, North)

I welcome the report and the recommendations, but will my right hon. Friend confirm that the responsibilities of the new national director of children's health services cover England alone? If that is so, can he ensure that the director liaises with the National Assembly for Wales? I am sure my right hon. Friend is aware that children in Wales who need heart surgery must travel to centres in England—in many cases, to the one in Bristol—whereas the cardiological investigation will take place in Wales. It is important that there be no loophole. Can my right hon. Friend ensure that the new national director liaises closely with the National Assembly for Wales?

Mr. Milburn

I can certainly give that undertaking. My hon. Friend is right that the new national director applies to the NHS in England. There are other arrangements for Wales but given the flow of patients from Wales to England it is important that there be contact between the two organisations.

Mr. Stephen McCabe (Birmingham, Hall Green)

I welcome the Secretary of State's statement on this sad affair. Given that the report by the National Specialist Commissioning Advisory Group predates the findings of the inquiry by quite a considerable time, will he give an assurance that he will not make any decision on the findings of the NSCAG report until the full implications of the inquiry have been properly considered? Will he make the NSCAG and inquiry reports available to hon. Members, so that we can consider the findings in tandem before crucial consultations and decisions are arrived at?

Mr. Milburn

On NSCAG, I have nothing much to add to what I said to my hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart): clearly, we will need to ensure that the implications of Kennedy are understood before we make any decision. That must be right. All I can say is that final decisions on the matter are some way off.

On the report from NSCAG, I will write to my hon. Friend.