§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Kemp.]1.24 pm
§ The Secretary of State for Health (Mr. Alan Milburn)
I hoped that we could have the debate earlier, in November, but, as some Members know, we had to consider emergency legislation dealing with human reproduction cloning at that time. Nevertheless, I trust that today's debate will give the House an opportunity to take a step back from the normal yah-boo politics of health—an opportunity for a more considered response to events at the Bristol royal infirmary that I believe people will come to see as a turning point for the national health service and a catalyst for change.
We are publishing today, to coincide with the debate, my Department's response to the report of the Kennedy inquiry. I should acknowledge at the outset that whatever is said here today, and indeed whatever was said in the report, will inevitably be of little comfort to the families of children who died or were damaged at Bristol. I have met the parents more than once, and I only hope that the action we are taking will help to assure them that we have all learned the lessons of what went wrong.
Sir Ian Kennedy and his team did an outstanding job, and I want to record my thanks to them for producing a report that I consider fundamentally important to the future development of the national health service.
The Kennedy inquiry into the care and management of children receiving complex heart treatment at the infirmary between 1984 and 1995 was established by my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson). Examining events at the infirmary between those dates, the report recognises that much has changed since then—not least at the infirmary itself, where, as I learned when I went there recently, cardiac care for both children and adults is now among the best in the country.
It is important to put the Kennedy report in context. Overwhelmingly, despite the real problems that undoubtedly exist in the NHS, patients receive good care and staff do a brilliant job. It is worth reminding people that the NHS is not full of bad doctors; it is full of good ones—people who are doing their best for patients, sometimes in difficult circumstances.
The report, however—in my view, at least—provides a searing analysis of the failings in organisation and culture that were prevalent not only in Bristol but throughout the NHS during those years. In brief, they were a failure to put patients at the centre of care, a failure of communication, a lack of leadership, paternalism, and what the report calls a "club culture", in which people got on in their careers by not rocking the boat. No standards were laid down against which performance in the NHS and quality of care could be measured. That was compounded by a decades-long underfunding of NHS services that is only now beginning to be put right.
Those broader organisational failings were most manifest in the specialist children's services. At the infirmary, and undoubtedly elsewhere in the NHS, children's services were last in line when it came to the allocation of resources. The report estimates that at Bristol all those factors—no single factor was responsible—conspired to bring about the unnecessary deaths of between 30 and 35 children.
449 As those who read the report may conclude, perhaps the greatest tragedy of all is that concerns were raised in and indeed outside the hospital about standards of care in paediatric cardiac surgery. Many people knew what was happening, but no one acted. The fact that it took a whistleblower, Dr. Stephen Bolsin, to bring the problems to the fore is perhaps the most serious indictment of the culture prevailing at that time.
The fault at Bristol, however, lay not with bad people, wrong though a few senior managers and senior clinicians were to act as they did. Underlying the whole Bristol tragedy was a much more profound structural and cultural problem—that of an NHS ultimately more geared to its own needs than to those of its patients, in which the question of accountability was confused in regard to services, professionals and patients.
I think most people would conclude today that a different relationship is needed between patients and services. When we published the NHS plan 18 months ago we tried to paint a different picture of the future of health care in our country, in which patients—and their safety—always come first; in which patients are in the driving seat and able to make informed choices about their care; in which there is a new culture of trust, not blame, in the NHS, with lines of accountability that are clear and a willingness to learn from mistakes; and in which the NHS is decentralised within a clear public service ethos, defined NHS principles and a framework of tough national standards which are regulated independently.
We endorse the Kennedy report's vision for the future of the NHS, but no one should underestimate the challenge involved in delivering it. As the report recognises, the NHS today is a very different health service. The report acknowledges that the underfunding that was such a feature of the NHS then is beginning to be addressed now. More significant for the longer term, 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 the quality of 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, wherever they occur in the NHS. The report welcomes annual appraisal and revalidation for doctors, and recognises that a new contract for hospital consultants is being negotiated and that joint training for health professionals is being introduced. Many of those changes, and other reforms contained in the NHS plan, are welcomed or endorsed by the Kennedy report.
As the report highlights, however, further action still is needed if we are to prevent another tragedy on the scale of Bristol. The Government's response to the Kennedy report that we have published today addresses the 198 recommendations he made. Many we have accepted either directly or in principle, and work is under way to implement them. In a minority of areas we have chosen to adopt a different solution to that proposed by the inquiry panel. In essence, our response to Kennedy falls 450 into two parts. The first includes the organisational and cultural changes needed to put the patient at the centre of the NHS. The second involves the changes needed to assure quality and secure improvements in services.
The reforms that are about putting patients centre stage involve giving patients more information, more power and more choice. The NHS at the time of the events in Bristol lived in the shadow of its own history: it was an organisation for which Government provided limited resources and in which doctors were left in charge of providing limited services, and patients—frankly speaking—were expected to be grateful for the limits of what they received. In today's world, most people would conclude that that will no longer do. People today expect services to respond to their needs—and rightly so. They want services that they can trust and that offer faster, higher-quality care. Increasingly, they want to make informed choices about how to be treated, where to be treated and by whom.
Those changes require a new culture of openness in the NHS. The days have gone when parts of the NHS could behave as if they were a secret society. In the end, the NHS does not belong to anyone other than the public and patients it serves. A service designed around the needs of patients has to give more power to its patients. As Kennedy said, the patients voice should beon the inside rather than on the outside.So reforms are being introduced to give patients a greater role and a stronger say in the NHS, with patients forums in every trust, patients electing patients onto trust boards, and the results of surveys of patients helping to determine the ratings and therefore the resources that trusts receive. The balance of power is shifting—decisively, I hope—in favour of the patient.
Kennedy describes the relationship between services and patients in the Bristol era asbased on a paternalistic approach to families and to the care and support they needed.Today's relationship between professionals and patients should be a partnership in which patients have a responsibility to keep healthy, treat professionals respectfully and use services wisely, but have a right to be involved in decisions about their care. That is why new procedures for informed consent are now coming into place, and they will need to be underpinned by a better patient focus in the education of future generations of clinicians. I hope that, increasingly, doctors, nurses, therapists and other clinicians will be trained together to learn the values of patient involvement and the need for better patient communication.
Professionals have the right to be valued by Government and patients and to exercise their skills and judgment for the benefit of patients. They have a responsibility to participate in audit and clinical governance, to work not on their own but as part of a team and to treat patients with respect and dignity.
The Kennedy report says:the culture in Bristol was not one which encouraged openness and honesty in the exchange of information between and amongst healthcare professionals and between them and families.Patients today have a right to know about their treatment and care. We are already publishing more information than has ever been published before about the NHS, whether that is local health service performance or specific data on mortality rates. We need to publish more, not less, information for the benefit of patients.
451 In the light of the Kennedy report, it is clear to me that such information should not be published by Government but should be published independently. That is why we have accepted the inquiry recommendation to establish the office for information on health care performance within the Commission for Health Improvement.
As the Kennedy report makes clear, there was no shortage of data about clinical outcomes at Bristol. The problem was that no one was responsible for analysing them or acting on them. The new office within the CHI will address that fundamental faultline.
There was another problem: parents and families did not have access to data at Bristol. The Kennedy report calls for that failure to be addressed through the publication of information on the performance of individual hospitals and consultant units. Open publication is the right thing to do. For data on surgical outcomes to be published, of course, they need to be robust, rigorous and risk-adjusted. They also need to command the confidence not just of patients, but of surgeons themselves.
The events at Bristol have, I believe, fundamentally changed the view of the medical profession about the publication of outcome data. There was a time when the very idea was regarded as unacceptable. Today, it is the profession itself that is leading the drive towards more open publication.
The cardiac surgeons are in the vanguard here. For example, the Society of Cardiothoracic Surgeons has published the results of coronary surgery for heart units in the UK and, within the last week, has extended this information to include the results of aortic valve operations over the last three years.
I am pleased to say that, following discussions, the society has agreed to go further still. We have now reached agreement that, from April 2004, 30-day mortality rates for every cardiac surgeon in England will be made public. This goes further than the Kennedy report recommendations. It means that, for the first time, patients themselves will be able to see the clinical outcomes that heart surgeons are achieving. We have of course to guard against defensive medicine. That is why the society itself will be involved in publishing this data, alongside the new office for information on health care performance, to ensure that the data systems are properly resourced and that the data themselves are credible and properly risk-adjusted and take rolling averages over a number of years.
This is just the first step to publishing more information on individual consultant outcomes over time.
§ Dr. Liam Fox (Woodspring)
Will the Secretary of State confirm that the data that are to be published will include paediatric cardiac surgery?
§ Mr. Milburn
We are in further discussions with the British Paediatric Association. By the summer, I expect that details on individual units will be published by the association in order to make that information more available. Over time, more data will be published about individual consultant outcomes, as I shall describe later.
§ Dr. Evan Harris (Oxford, West and Abingdon)
I warmly welcome the Secretary of State's emphasis that the data must be valid and must enjoy the confidence of 452 clinicians, and his stress on the consequential need to avoid defensive medicine. Does he accept that previous performance league tables lacked the data on patients' preoperative state produced, with the Department's co-operation, by Dr. Foster, and that they fell short of some of the welcome requirements that he has set out today?
§ Mr. Milburn
Yes, of course, but I want to make a couple of important caveats. First, I have told the House, and the Select Committee on Health when I have appeared before it, that we are never going to have perfect data. There is no such thing, and we should be clear about that. All the data that we publish, whenever we publish them, should come with the appropriate health warning.
Secondly, we will never get better data until we have the courage to publish. Only then will people begin to realise that the data have some significance. That is beginning to happen already with the organisational data that we are publishing on NHS trusts. Trusts are beginning to realise that the assessments that are made have consequences. That is as it should be, as organisations doing well differ from those doing consistently badly.
I do not mean to say that the same principles apply to individual surgeons, but in my time as a Health Minister I have witnessed the remarkable change that has taken place in the NHS and in the medical profession. There is a real recognition that the old order to which the Kennedy report in so many ways looks back has changed fundamentally. That change must continue, and we need to drive it forward.
§ Mr. Andrew Lansley (South Cambridgeshire)
The Secretary of State spoke of the publication of data on the NHS by the new office for information. However, will the office be responsible for acting on the data, or will that fall to the Commission for Health Improvement? Also, does the right hon. Gentleman agree that not only should action be taken on performance failure identified through the data, but that referral should be improved as a way of driving standards up? Does he agree with the report that paediatrics should be more widely available as a specialisation in general practice in order to ensure a greater awareness of good referral for children's services?
§ Mr. Milburn
The hon. Gentleman's second point is absolutely fundamental, and my speech will touch on the centrality of improving standards in children's services, in both primary and secondary care. Sometimes there is a debate about whether primary or secondary care is the more important, but we must improve the standards in all the services available for children and their families. We have some proposals for doing just that.
As for the relationship between analysis and action with regard to information, the beauty of Kennedy's recommendation that an office be established within the existing inspectorate which will have overall responsibility for overseeing standards of care is that that provides an opportunity to achieve precisely those linkages that were missing when the tragedies in Bristol took place.
People were analysing data at that time. Lots of people had access to data, but no individual or organisation had the responsibility for doing anything about what was found. Terrible tragedies occurred as a result.
453 It is important that we learn the lessons, and the office will have an important role to play in analysing the data and feeding information back to the service. The CHI will also have an important role, but I stress again that I believe we will secure lasting improvements in the NHS only if the analysis and dissemination of information is done in conjunction with the people who perform the operations.
I do not perform operations, and neither does the CHI. The people who do are among the most skilled in our country, and they should be among the most valued.
§ Rev. Martin Smyth (Belfast, South)
I share the emphasis that the right hon. Gentleman places on that issue. I have just two questions. First, he talked about data and defensive medicine. Is it not possible that some people involved may protect their reputations instead of giving the best service to their patient—in other words, if there is a risk, they will not take it? Medical science has been advanced by those who, using their skills, took risks and helped people. Secondly, are we training and encouraging enough paediatric specialists?
§ Mr. Milburn
On the second point, I hope that we are training a lot more but we have shortages, as the hon. Gentleman and I are painfully aware. I think that we can deal with that over time. It is worth remembering that the numbers coming through medical schools, training and so forth are a sign of optimism.
The hon. Gentleman's first point is very important. I have discussed that matter at length with Mr. Bruce Keogh from the Society of Cardiothoracic Surgeons. He put to me a sensible proposal, which we will need to discuss with the new office within the commission. We cannot have a situation in which open publication of data means that the surgeons who take on the highest-risk cases feel as if they will be penalised—that they will end up bottom of the league table in The Times. The proposal that we have discussed—obviously, we will need to refine it—is that we publish two sets of information: one to try to identify standard cases, so that we get some evenness and a benchmark; the other on the overall performance of the surgeon. Of course, that will be risk-adjusted and so on.
As the hon. Gentleman knows, there is a strong and credible science behind that. In parts of the United States of America—New York state and elsewhere—that sort of information has been published for many years. I think that we can do better than them, and the society does too. There are some safeguards that we can put in place, but I come back to the fundamental point, which is twofold. First, patients have a right to know. Secondly, surgeons and doctors have a right to be involved in the process of patients knowing. That is the way we intend to take it forward.
§ Mr. Milburn
May I move on for a moment?
As I said, we are working with the medical profession to extend the number and range of specialties where information on both the consultant's and the unit's comparative performance can be published. In each case 454 we will work closely with the royal colleges and other professional groups to build on national audit work already in train.
That is a courageous step on the part of heart surgeons and the society that represents them. I believe that it is the right step. It will tackle one of the deficiencies that lies at the centre of the Bristol tragedy—patients and parents were kept in the dark about the care and treatment that they were likely to receive. With the safeguards that I have described in place, open publication will not just make for a more open health service but will help to raise standards in all parts of the NHS.
It will certainly help to empower patients and help them to make informed choices about their care. As the House is aware, from July this year heart patients who have waited six months for their surgery will be able to choose between waiting longer locally or travelling further to be treated quickly in another hospital. As capacity expands, choice can grow. Choice will fundamentally change the balance of power in the health service. In the crudest of terms, hospitals will no longer choose patients—patients will choose hospitals. That is a fundamental change in accountabilities, whereby the patient is in the driving seat and the NHS looks outwards to patients rather than upwards to Government or even inwards to itself.
That brings me to the other element of our response to the Kennedy report—
§ Dr. Harris
May I quickly raise two points with the right hon. Gentleman? First, as regards the six-month limit, is he prepared to introduce safeguards so that hospitals do not try to rush people in within six months at the expense of more urgent cardiac cases where delays of between three weeks and six months have been experienced? I have raised that point with cardiac surgeons.
Secondly, I am so pleased to hear the right hon. Gentleman's qualifications about league tables. With hindsight, does he think that performance league tables for hospitals should be subject to caveats and quality controls similar to those he wants for surgeons' data?
§ Mr. Milburn
Sometimes I wonder why I bother to try, but let me try once again with the hon. Gentleman—just to test my patience.
I have told the hon. Gentleman on innumerable occasions that when we published the first set of what he calls "league tables" for NHS trusts I said—as I have said on every subsequent occasion—those data were far from perfect. They are far from perfect. However, we have to start somewhere. I hope that the hon. Gentleman is not saying on behalf of the Liberals that the Liberal party, of all parties, believes that the public do not have a right to know what is going on in their local health service. Of course they have a right to know, but caveats are attached to all such matters. However, we really must move to a very different relationship between public services and the public whom they serve.
I was about to say—
§ Mr. Milburn
I am grateful to the hon. Gentleman for that reminder. As regards the six-month limit, urgent or 455 emergency cases must always come first in the NHS. However, if capacity is going begging in other parts of the NHS, or even in the private sector, which could be used for the benefit of NHS patients who face a serious operation such as heart surgery, we should use it. No one will be dragooned into exercising choice. By definition, choice is a matter of individual volition. Individuals will be able to choose—and rightly so. If that means that we will be able to reduce waiting times for people who, as everyone agrees, are waiting too long for treatment at present, it is a sensible course.
The other element of our response to the Kennedy report is to address what it rightly identifies as the confused system of accountability that existed for standards, regulation and management in the NHS. The report sums that up well:We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was, in truth, no such system.
For all those reasons, we have established a clear national framework within which local NHS services can operate. When we came to office in 1997 there was an absence of national standards and no means of implementing them. There was no means of spreading good practice or of eliminating bad practice. There was no national evaluation of new treatments and certainly no independent external inspection of local services. As Kennedy rightly pointed out, that lack of clear standards and clear lines of accountability underpinned the whole Bristol tragedy.
It is easy to forget how far the national health service has come in only four and a half years. There are new national standards for services—for cancer, mental health, care of the elderly and coronary heart disease. There is greater transparency in local service performance. There is a new legal duty of quality and a new system of clinical governance to enshrine improvements throughout the NHS. The National Institute for Clinical Excellence evaluates new treatments. For the first time, the NHS has an independent inspectorate—the Commission for Health Improvement. With the NHS modernisation agency, there are now new systems for when things go wrong and more help to learn from what goes right.
Within that strong national framework, greater devolution to local NHS services can take place. However, Kennedy recommends that we go further still. There are five recommendations in particular that we will take forward.
First, we agree with the thinking behind the inquiry's recommendations on the separation of inspection functions from the overall management of the service. As devolution takes hold in the NHS, the Department of Health will move from a day-to-day management role to a more strategic one. It will set overall direction and ensure that there are proper arrangements for management, standard setting, inspection, improvement and accountability.
Secondly, inspection will be strengthened and made more independent. Through the National Health Service Reform and Health Care Professions Bill, the Commission for Health Improvement will have a new function of inspecting individual NHS trusts and other providers that offer NHS care against a set of agreed and published criteria. Where the commission finds evidence of unacceptably poor services, it will be able to recommend 456 that special measures are taken. The hon. Member for South Cambridgeshire (Mr. Lansley) asked about that a moment ago. In future, the commission will also make an annual report to Parliament on its overall findings on the quality of services provided to NHS patients—a further mark of its independence.
Thirdly, there will be greater co-ordination among those organisations responsible for assuring the quality of care in the NHS. That will necessitate closer working and, over time, organisational integration between the CHI, the social services inspectorate, the National Care Standards Commission and the Audit Commission, so that health and social care services are subject to a common set of standards, irrespective of whether they are provided by public, private or voluntary organisations. In the meantime, I confirm that we will establish a new non-statutory council for the quality of health care to bring those organisations together with other relevant organisations, such as the national patient safety agency, the National Clinical Assessment Authority and, of course, the National Institute for Clinical Excellence.
Fourthly, there will be reforms to professional self-regulation. Kennedy says that it should be organised in such a way that it provides adequate and transparent safeguards for the patient. Through the NHS Reform and Health Care Professions Bill, which is currently before Parliament, we are actioning the Kennedy recommendation that there should be a new body—a council for the regulation of health care professions—to ensure that the individual regulatory bodies, such as the General Medical Council and so on, act in a more consistent way. I can also tell the House today that in the spring we will publish the Government's proposals for the reform of the GMC alongside its own radical proposal for the revalidation of doctors. As a minimum, reform will need to secure a GMC that is smaller, with much greater public and patient involvement, with faster, more transparent procedures and with meaningful accountability to the public and the health service.
Fifthly, we will strengthen the system for reporting and analysing adverse clinical events and so-called near misses. The national patient safety agency that we have established is currently testing how such information can best be gathered and fed back to the NHS. The aim is to have a national system in place this year. Among other changes, we will establish a confidential telephone helpline, as recommended by Kennedy, to allow staff and patients to report problems and mistakes.
Those changes, alongside others in the Government's response today, will strengthen the national framework for standards within which NHS care should be provided, so that patients everywhere receive high-quality care. There is one important caveat to all this, however. No one can guarantee, even with the best standards system, that mistakes will not occur. Medicine is not a perfect science; it is a human science. Even the best doctors can make the worst mistakes. Our task therefore is not to pretend that we can somehow eradicate every error; our job is to ensure that systems are in place to detect errors, to minimise them and, perhaps most important, to learn from them.
§ Mr. Hugo Swire (East Devon)
In the spirit of the Kennedy report, and given that liability in most of those cases was agreed as long ago as 1998, what pressure—as a part of clearing up this appalling episode—will the right 457 hon. Gentleman now be prepared to apply to the NHS litigation authority to settle outstanding cases such as that of my constituents Jim and Bronwen Stewart's son, Ian, as soon as possible?
§ Mr. Milburn
I can tell the hon. Gentleman that pressure, as he describes it, has been applied. Indeed, when I met the Bristol heart children's action group, I told the chairman, Mr. Steve Parker, whom he will know, that I would try to facilitate a discussion between Mr. Parker and Mr. Stephen Walker, who leads the litigation authority. That meeting took place on 12 December. As the hon. Gentleman knows, a substantial number of cases have been settled and £1.8 million has been paid out thus far in damages. A small number of cases are still outstanding and the litigation authority will try to speed those through as quickly as it can. However, some cases are not in the hands of the litigation authority but in those of the claimants' lawyers. It is for those lawyers to try to be as speedy and co-operative as I believe the litigation authority is.
I was saying that, to minimise and learn from the errors, we need to develop a more open culture in the NHS and certainly move beyond any culture of blame. Anyone who has read the Kennedy report will find its tone, given the seriousness of the issues that it addresses, very refreshing.
I have asked the chief medical officer, Sir Liam Donaldson, to assess the feasibility of implementing a controversial Kennedy recommendation, but one that needs serious consideration. Staff who report an adverse incident promptly should be immune from disciplinary action other than, of course, if they have committed a criminal act. We shall assess the feasibility of being able to do that. That is also why we are considering reforms to the current system of clinical negligence that Kennedy saysinstitutionalises the notion of blame.As the House is aware, the chief medical officer is considering proposals for radical reform here with a view to publication of a White Paper on this subject later this year.
There is one final point. Lest we forget, the tragedy at Bristol was a failure in services for children. Too many children were failed by a system that was supposed to keep them well, make them well and keep them from harm. Improvements are now coming through. At a national level, they are being overseen by Professor Al Aynsley Green, the Nuffield professor of child health at Great Ormond Street hospital, who I have appointed as national clinical director for children. At a local level, each primary care trust and NHS trust will have a senior member of staff taking responsibility for improving children's health. By the end of this year, there will be new national standards for the care of children in hospital. Those standards will be in place for the first time.
Thankfully, few of us in the House have experienced the tragedy that the Bristol parents have faced. That said, I am sure that I speak for the whole House when I say that that does not diminish in any way the determination of us all to learn the lessons and change the system that let those families and children down so very badly.
Some of the reforms necessary to do that are already in place; some are being put in place through legislation at this time; and some, as I have outlined this afternoon, 458 will require further reforms in the future. Legislative change takes time and cultural change takes longer, but no one should be in any doubt that the reforms required to open up the NHS, to make it more accountable to its patients, to strengthen regulation and to raise standards are now under way.
There can be no greater loss for any parent than the tragedies that parents faced at Bristol. There can be no greater lasting legacy than that we learn the lessons, reform the structures and change the health service so that it is better able to ensure that what happened then is not repeated again.
§ 2.4 pm
§ Dr. Liam Fox (Woodspring)
For me, this is an issue not only of national concern but of great local importance. That goes for all those Members on both sides of the House who represent seats in and around Bristol. It is worth pointing out that all of them—Front and Back Benchers—are present for this debate.
The tragic events of recent weeks that we all witnessed on our televisions and read about in the newspapers will have brought home to those of us in the House in a very personal way the sadness and devastation involved in the loss of a child. So much worse it must be for parents who know or believe that it could have been avoided. It is with the greatest admiration that we look at the parents involved in the Bristol scandal and see not a driving emotion for revenge, but a determination to ensure that it cannot happen again.
It is also worth pointing out that life has not been easy for health professionals in Bristol recently. When I worked as a junior doctor in a bone marrow transplant unit, I learned early on that I did not have what it would take to work with sick young people, many of whom would die from the trauma involved. The people who do that show a special courage in their care for patients. The good recent results in Bristol, to which the Secretary of State alluded, should be a major boost for them.
Bristol has an excellent medical school that produces excellent doctors, and high-quality postgraduate education that produces top-quality medical personnel. I am sure that all hon. Members with constituents who work as health professionals in Bristol will want to pay tribute to those who overwhelmingly act with only one motive—to improve the care for all their patients.
Naturally, we welcome much of what is in the Government's response to the Kennedy report, and when we have time we will consider some of the issues in greater detail. We have been especially pleased with not only what the Secretary of State said today, but with what the Minister of State, the right hon. Member for Barrow and Furness (Mr. Hutton), said during the passage of the NHS Reform and Health Care Professions Bill about the Government's understanding of the need to move towards a single regulator for health care.
We very much welcome the strengthening of the Commission for Health Improvement. We always thought it ridiculous that when the Government negotiated the concordat with the private sector there was one body to investigate and regulate the private sector and one for the NHS. I think that it is nonsense to have two inspectorates when NHS patients can be treated in the two different systems. The assurances that the Minister of State gave 459 the other night were most welcome, and I hope that they will be transferred to proposals in legislation, which would certainly have Conservative support.
The Secretary of State will receive even more support if that single inspectorate is strengthened further and given a public health role. The improvements in mortality and morbidity have come about because of public health issues. It is worrying that we have falling immunisation rates and a rising incidence of infectious diseases and sexually transmitted diseases. We want a body that can take concerted action, across departments. If the attitude of the Minister of State in our debates in Committee and the House the other night is anything to go by, there is a good chance that we can get agreement on both sides of the House on a substantially improved and strengthened body. That would be to everyone's benefit.
There is no doubt that the Secretary of State was right when he said that information is the key to what Professor Kennedy wants. Those of us who have been involved in what happened in Bristol are all too aware that although there was an absence of information available publicly, a great deal was available to doctors in the know in the locality. It is interesting to see the referral patterns of those who were treated in Bristol. I hope that the publication of information will ensure that that problem does not happen again.
Questions arise from what the Government say in their response to the report. They state that more information will beprovided to patients on how local health services compare with othersand that there will begreater choice for patients over where they are treated".We need more details on exactly what information patients will get. Will it include aspects of primary care and issues that go beyond that into the community? How will it be made available? Where will it be available—in libraries, surgeries or on the internet? Who will decide what local information should be made available, and who will decide what information—if any—should be withheld? Exactly how will patient choice be rolled out in accordance with the information that will be available?
We are interested in some specific details. The Secretary of State talked about publishing information on 30-day mortality rates. As he said, that opens up a range of other issues. He is right to say that the medical profession itself has been leading the debate. Its openness and willingness to contemplate the publication and wider use of data differs from past attitudes. Even during my medical training, information was still regarded as something that the profession owned. There has been a huge cultural shift, for which we should all be very grateful.
I completely agree that information is, in itself, a good thing, and incomplete information is better than no information at all. Only fools and knaves fear information, and if it is incomplete, our job is to try to make it complete, not to try to withhold it. If information is to be meaningful, however, we must have certain assurances about what it will contain. It must be comprehensive and it must take into account the clinical background of those involved and the sort of units in which doctors will practise.
Recently, a case came to light concerning a hospital that was to have one of its stars withheld because its neonatal death rate was too high, until it was pointed out 460 to inspectors that the hospital is the regional centre to which difficult cases are sent. That demonstrates our need to have complete information in the appropriate context before we can decide on its usefulness.
Information must include the value-added data that make it much more useful to patients. Of course, patients must be able to understand it, and the majority of them are not statisticians. It is difficult to look at tables of information. It needs to be presented in a way that is accessible and, therefore, useful to patients. It is no use if it benefits only those who understand the complexities of statistics.
§ Dr. Evan Harris
I agree with what the hon. Gentleman just said, but before that he said that the publication of incomplete data was always better than a total absence of published information. However, in his example, which concerned a star rating based on inappropriate data, the information was misleading and its publication might have damaged morale and led people to avoid using the best unit for the most difficult cases. Would not that have been worse than having no data published?
§ Dr. Fox
I understand the hon. Gentleman's point, but to say that it is better to have no information is to move in completely the wrong direction. If information is incomplete, one must explain why it should be improved and point out how that could be done. That gives the professions a chance to respond. Of course, it is better to have full information, but withholding information because it is incomplete cannot be beneficial in a health care system where consumers are increasingly well informed and, indeed, desire to be better informed. I find it strange that a party that used to be liberal wants to withhold any data. It seems that it has been left behind in this debate.
We are interested in what the Government said in their response about consent. Fully engaging patients in consent is one of the most important ways in which information is usefully imparted to patients in the health care process. Perhaps when the Minister of State responds to the debate he will give us more details about how the Government intend to develop that. Will we have standardised consent forms so that patients everywhere and in every sector will receive the same information about the procedures that they may undergo, about what will happen to them after an operation and about any likely risk? If so, how will those forms be drawn up?
It is worth pointing out that the system has improved markedly in recent years, with far better information given to patients who have consented to medical and surgical procedures. I hope that the Government, in making improvements to the consent process, will welcome the big improvement in professional experience and, not least, the involvement of the royal colleges. We must, however, accept that there are limitations to what we can achieve. It is far easier to get fully informed consent for elective surgical and medical procedures than it ever will be for emergency procedures. We must not throw the baby out with the bath water.
We must also make sure that patients are fully informed about experimental procedures. I believe that patients understand the need for innovation and, very often, if they are given full information, they will agree to be involved 461 in experimental procedures. What they find completely unacceptable, as will the House, is being kept in the dark about the real reason for such procedures. We have to achieve a balance to ensure that we are not putting at a disadvantage those who are carrying out valuable clinical trials, because that might impede the development of quality medicine.
§ Dr. Howard Stoate (Dartford)
I agree with the hon. Gentleman that there have been improvements in the past few years. In my area and, I have heard, in other areas, consultants are now much more likely to write directly to patients, rather than to their GP, who will receive a copy, setting out the precise details of the proposed operation. The patient therefore has a written record from the consultant, which is surely to be welcomed.
§ Dr. Fox
Of course, that is to be welcomed. There is extremely good practice by some doctors in some areas. That is not the problem; it is that such procedures are not followed throughout the health care system. Any attempt to improve practice in both the private sector and the NHS is to be greatly welcomed.
Naturally, we have strong reservations about parts of the Government's approach, including the abolition of community health councils and the establishment of patients forums and patient advocacy liaison services. In recent days, our arguments on those matters have been well rehearsed. For example, we believe that the abolition of CHCs is ill thought out, expensive and vindictive. There is no reason for us to repeat those arguments today.
We are, however, concerned about one or two specific matters that I should like the Minister of State to address. The first relates to the National Institute for Clinical Excellence. The Government response refers toNHS bodies being directed to fund treatments recommended by NICE from January 2002"—which we already knew about—but goes on to say thatNICE guidance will no longer need the approval of the Secretary of State for Health before dissemination".Who will make the decisions about affordability, and where is the accountability in the system? That seems to go against the earlier assurances given by Ministers on that front. Urgent clarification by the Minister of State would be very welcome.
It is rather unclear what is meant by some of the statements in the Government's response on the future training of health professionals. For example, it says that the Government aresupporting people from non-traditional backgrounds to move into medicine.What does that mean? To whom is it intended to apply? What will it mean in practice? What does the response mean when it refers togreater public involvement in the selection of those entering training as health care professionals"?I am not entirely clear about what the Government intend by that. It would be useful if the Minister of State could clarify that.
462 I would also welcome clarification, which I thought the Secretary of State was going to give us, of the Government's plans for information. The Government response says that by summer 2002 there will beguidelines about sharing information with patients and parents of young children".Details on those points would help us all to avoid any unnecessary confusion in the debate.
We look forward to the Government's plans for the reform of the GMC. The Secretary of State was right to say that Bristol acted as a catalyst to that reform, but it was, in any case, well under way. I welcome Professor Kennedy's positive approach to the concept of the maintenance of professional self-regulation. He says:For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and discipline.He says that for doctors that body should be the GMC. I am glad that the Government have not listened to the voices of those who would have taken them in another direction.
I hope that when the plans are published there will be a clear separation of the disciplinary and investigatory aspects of the GMC. I suggest that it would be very useful if the Government included time limits for investigations, or at least for those conducted under normal procedures. There is a serious problem with lengthy investigations undermining professional self-confidence, removing staff unnecessarily from the NHS and costing a lot of money.
The Secretary of State alluded to the issue of clinical negligence. Professor Kennedy was bold in his assessment and suggested remedies. His report says that the clinical negligence systemshould be replaced by an alternative system for compensating those patients who suffer harm arising out of treatment from the NHS.He went on to suggest that an expert group be established to advise on the matter and that every effort be made to createan open and non-punitive environment in which it is safe to report and admit sentinel events.The National Audit Office report "Handling clinical negligence claims in England", published last May, estimated that on 31 March 2000 there were outstanding clinical negligence claims to the value of £2.6 billion. It estimated that a further £1.3 billion would be required to meet likely settlements for claims expected to arise from incidents that have occurred, making a total of almost £4 billion in outstanding claims. It showed that while 75 per cent. of publicly funded claims were unsuccessful, the total charge to the NHS for settling claims had risen sevenfold since 1995–96. In 1999–2000, 65 per cent. of settlements below £50,000 involved legal and other costs involved in settling claims that exceeded the damages awarded. Cerebral palsy and brain damage cases accounted for 80 per cent. of claims by value and 26 per cent. by number.
In 1999–2000, the average time from claim to payment of damages of £10,000 was five and a half years, which is not satisfactory. The debate has centred on medical practitioners and patients, and the effect on them of such a slow process. There is concern that the rise in litigation and its formal nature may adversely affect medical practitioners in their work and relationships. I have 463 first-hand knowledge of patients and doctors who have been devastated by the slowness of the process, and it has to be tackled.
The disproportionate amount of money spent on legal costs and the costs of settlement in smaller-value cases deprive the system of resources that could better be used to compensate patients or more widely deployed in the NHS. Many patients would like remedies other than compensation. The National Audit Office pointed out that a package of measures may be necessary to satisfy patients, perhaps including an apology, an explanation, access to remedial treatment, counselling, meetings with medical staff to explore what went wrong, an explanation of action taken to prevent it from happening again, and the provision of support. How many of those measures are missing in the sorry and tragic saga in Bristol?
We therefore welcome this debate and have issued our own consultation document, which has received a good welcome and thoughtful responses. I hope that the House can take a consensual view of what measures we need to introduce in this complicated area. We cannot allow the compensation culture or, even worse, the blame culture, to swamp our medical systems. Health spending is for health services, not lawyers.
We must still make a full remedy available to those who have been harmed in the health care system, which is why we find it hard to agree with Professor Kennedy's recommendation that we abolish the right to sue for medical negligence. We believe that that goes too far, but we are interested in conciliation, mediation and tribunal methods of achieving that goal. We are also worried about no-fault compensation, given the experiences of other countries, but we maintain an open mind on that.
Naturally, we agree with much of the Government's response and join them in thanking Professor Kennedy and his team for all their work. Many further issues have been raised and no doubt we shall consider them in detail in forthcoming legislation. There will be an inherent tension between inspection bodies and setting guidelines and standards on the one hand and what the Government describe in the report as the "freedom to innovate" on the other. All other countries suffer that tension, and we shall be no exception. Over time, we shall want to look in detail at the Government's responses and shall want to co-operate constructively, where we can, in the legislation that will flow from the report.
Finally, producing better and safer care is the best tribute that the House can pay to those who suffered so much in the Bristol tragedy.
§ Mr. Frank Dobson (Holborn and St. Pancras)
I very much welcome the Government's considered response to the Kennedy report and congratulate my right hon. Friend the Secretary of State on the progress that has already been made in implementing many of its important proposals.
Basically, the report spells out two things: what happened in Bristol and what needs to be done to prevent it from happening again anywhere else in this country. I congratulate all those involved in conducting the public inquiry, which has been extremely thorough and intellectually rigorous. That covers both aspects of the inquiry—the historic inquiry into what happened and the forward look at how best to avoid it in future.
464 I congratulate in particular Professor Ian Kennedy—now Sir Ian Kennedy—on the way in which he conducted the inquiry. When he was recommended to me, I knew that he was a great scholar and intellect. When I met him, I discovered that in addition he was questing and awkward, in the best sense of the word. I got the clear impression that he was extremely humane and understanding, so I was pleased to have the opportunity to ask him to chair the inquiry. My hopes and expectations, and those of everyone involved, were exceeded. He therefore deserves great congratulations on his contribution, not just to sorting out what happened in Bristol, but to future changes and improvements in people's treatment in the national health service.
After years of representations by concerned professionals and parents whose children had died or suffered brain damage, for a long time nothing was done—there was no response. It was 1997 before the General Medical Council finally started to investigate what had happened in Bristol, although concerns had been expressed in the mid-1980s.
In early May 1998, before the GMC concluded its inquiries, I met the Bristol heart children's action group, which represented parents whose children had died or suffered brain damage. I was deeply impressed, and deeply depressed, by the grief that the parents had suffered. I was deeply impressed and depressed by their dissatisfaction with the way in which they had been treated before, during and after what had happened to their children. I was deeply impressed and depressed by their disillusion with the personal, clinical, professional and management arrangements surrounding what had happened to their precious children: their children had been failed, and they had been failed. I explained that once the GMC had concluded its deliberations I would set up an inquiry.
The first time I met the group, we discussed the form that the inquiry should take, as there were various alternatives. I gave them a memorandum produced by Sir Cecil Clothier QC, the former ombudsman, which set out the merits, as he saw them, of a private inquiry with a public report, on the lines of the Nurse Allitt inquiry that he had carried out. I suggested that the parents should discuss the various alternatives with their colleagues and lawyers, and that they should then come back and meet me again.
I reflected on what the parents had said and its significance, and within minutes of their leaving my room I concluded that the only proper response was to establish a public inquiry with full statutory powers—that, in the circumstances, only that would suffice. Preparations started before I met the parents again and before the GMC came to its final conclusions.
Considerable pressure, one way or another, was brought to bear on me not to hold any inquiry at all, and certainly not a great big public inquiry, because of all the problems that it might cause. As a measure of the change that has occurred since then, I do not believe that any of those who tried to persuade me not to proceed would want to do that now. I am pleased that the culture in the NHS and the profession has changed and things have moved on.
By the time the General Medical Council announced its disciplinary decisions, in the middle of June 1998, I could announce the establishment of the public inquiry and the appointment of Professor Ian Kennedy to chair it. 465 The report confirms in detail what seemed fairly obvious in 1998 from a distance: there had been failures at every level—by individuals and of the system.
Surgeons had let down the children. The local NHS management had let down the children and their parents. The national health service advisory machinery on clinical standards, such as it was, had let down the children and the parents. NHS regional management had failed. NHS national management had let them down. Sadly, the professional bodies, including the royal colleges, had also failed to tackle this difficult problem.
It was not just a question of technical failure. There was an enormous failure of attitude, and a failure to take the right approach to patients and parents. They had been let down by the NHS and the professions, who were there only to serve them. It was not a question of failure against new, more rigorous and demanding criteria. It was a failure against Florence Nightingale's century-old immortal question, "Who is in charge here?" The answer was, "Nobody." Everybody was responsible, so nobody was responsible.
In terms of clinical standards, it must be recognised that at that time the NHS, as an organisation, was letting down patients and the professions. The professions were trying to set, monitor and raise clinical standards, but that was not working well, partly because of some of the professional attitudes spelled out in the inquiry report, and partly because within professional organisations and between professional organisations there was no clear definition of responsibility for identifying things when they went wrong, and for doing something about it.
Most of all, the NHS as an organisation made little or no contribution to the setting, monitoring and raising of standards of treatment and care. That had become blindingly obvious to me within a few weeks of becoming Secretary of State. That was why, even before the Bristol inquiry was established, we published a White Paper in December 1997 that was intended to assist the professions in what they were trying to do by way of improving standards. The National Institute for Clinical Excellence was established to set standards.
A duty of clinical governance was being imposed on the boards of NHS trusts. It is difficult to believe that for 50 years the NHS had operated a management system in which senior management had no responsibility for the clinical standards of the organisation that they were supposedly managing. All they had was a duty to break even at the end of the financial year—a duty that they frequently failed to discharge. They had no duty in relation to clinical standards, so they were given that duty. The Commission for Health Improvement was set up to make sure, through a process of inspection, checking and advice, that standards were met.
All doctors, we said, would be required to be subject to external clinical audit. National service frameworks were established to cover heart disease, cancer, the treatment of older people, mental health and diabetes. Patients and GPs, as my right hon. Friend the Secretary of State observed, were to be given information about the success rates of treatment in their local hospitals.
The medical profession was already moving to introduce the concept of revalidation, so that every effort could be made to ensure that doctors were up to date in 466 their knowledge and continually updated themselves. That was a difficult concept for the medical profession to take on, but members of the professions were doing that and continue to do so.
As my right hon. Friend pointed out, there have been further developments since the Bristol inquiry was established. One of the most important was the work by the then new chief medical officer, Sir Liam Donaldson, who started to consider how the NHS could learn from things that had gone wrong, and to apply to the NHS the approach of the aviation industry. The aviation industry has never sought to learn just from crashes; it has also always tried to learn from near-misses.
In the NHS there was hardly a process of learning from the crashes, and no process of gathering information and learning from the near-misses. Eventually, Professor Donaldson produced his report entitled "An Organisation with a Memory", and now my right hon. Friend has proceeded with the establishment of the national patient safety agency, which will help the professionals learn from things that have gone wrong, not just in their hospital or their unit, and not just from their own mistakes. They will be able to learn from the problems and mistakes of other professionals, and to identify procedures that appear to be intrinsically dangerous and should be avoided, or procedures that could be improved by minor changes.
Such developments have been endorsed by the report of the inquiry. In most cases the report recommends that the functions of the bodies that I and my right hon. Friend the Secretary of State have set up should be extended, their powers strengthened and their independence enhanced. I am sure that we all want that to happen. I am glad that there now seems to be a consensus in the House about the establishment of the Commission for Health Improvement and the National Institute for Clinical Excellence, as well as the introduction of other proposals that some people described at one stage as time and resource-consuming bureaucracy. All those changes were intended to help NHS professionals to make it easier to do their jobs as well as they would like. That is what they want and why they took up their professions in the first place. They are entitled to demand from us a system that helps them to carry out their professional tasks and does not hinder them.
A huge range of issues were raised in the report. I should like to concentrate on two of them. First, a major change in attitude is required in the medical profession. I think that it is already under way. Secondly—this may be more difficult—a change in public attitude and a major change in the law are required. First, as my right hon. Friend pointed out, there must be a much more open approach to patients and they must be more involved in decision making. Part of that openness concerns personal relations between professionals and patients, but another part of it is the publication of data, in relation to which there are dilemmas and difficulties. It is no use anyone pretending that there are simple, easy and quick solutions to the problem. Indeed, I do not think that anyone is suggesting that; at least, I have not heard anyone do so.
If one is a dedicated professional, the crucial issue is that the data should reflect the truth. The simplest truth is this: "When I did this operation, did the patient live or die?" That is a plain simple fact. Oddly enough, previously, and during the time in which I have been a Member of the House of Commons, NHS data did not 467 distinguish between deaths and discharges. It was only as a result of pressure exerted by me and others that that distinction began to be made. The difference between death and discharge is simple and straightforward, and involves no element of judgment. The minute that we start trying properly to make allowances for the advanced—or otherwise—nature of the condition being dealt with, or for the general health of the patient being operated on, some elements of judgment come into the data.
We will have to allow that to happen, but it is crucial that it is done fairly. If the process is unfair to the professional, it is bound to mislead patients; it cannot do otherwise. Unfair data would do no one any good. They would undermine confidence and give false impressions of the brilliance of some and the inadequacies of others. If an impression is false, it is worse than useless. None the less, we must try to make a start, and the profession, including cardiac surgeons, has gone far in that regard. The extent to which professional bodies have taken on the problem and are addressing the dilemma, however difficult it may be for their individual members—after all, those are the people whom they represent—is commendable. They have carried progress on the matter a long way and they need our encouragement. Provided that they are willing to publish the data, we are going down the right road.
Then we come to the question of the personal involvement of patients in decisions affecting their treatment or that of their children. There must be greater understanding in the profession, or at least in some of it, about how patients and parents feel. Some people at least are lagging behind and must make a greater effort to put themselves in the position of the confused and not especially well-informed patient. If the patient is a child, those in the profession must try to imagine themselves in the perturbing and deeply disturbing circumstances of the parent. There is a difference between our concern for our own health, however good or bad it is, and our anxiety about the health of our children. Many people are fairly cavalier about their health, but I know no one who is cavalier about the health of their child, so a different approach is needed when dealing with parents—a more concerned and understanding approach than in respect of adults.
That is part of the professional task, and the majority of people in the profession are now involving patients more and are doing their best. Some of the most distinguished and well-known surgeons and physicians in this country are well known not only because of their success rate, which can be demonstrated by any data, but because they involve the patients, who get to love them because of that involvement. That is good for patients. It makes them feel better, improves the success rate and gives everyone greater satisfaction.
Again, I point out that we must recognise the difficulties. It is difficult for professionals who hope that they know what they are talking about in a very difficult sphere to explain the complexities of what is happening to someone who does not have their long experience and medical education. It is difficult to try to talk about the risks and odds that are involved. We cannot expect people to do that task easily without it having been included in their medical and nursing education and training. We must ensure that it is included. Imagine the difficulty for the doctor or nurse who is trying, as an individual human being, to say to a parent, "The child that you have brought 468 into the world and who you dote on has a 60 per cent. chance of dying—even if my operation is a success." Imagine saying to a parent after an operation, "Although your child is still alive, I don't think that I've succeeded and I think that he will die", and then saying later, "I've failed; he died." We must recognise that that is not an easy task and provide all the encouragement, help and training that is necessary to give people the ability to cope with those huge stresses, on top of carrying out a complex, difficult, demanding and lengthy operation. It is not easy, and we must try to help.
On public attitudes and the law, I believe that everyone understands that the patient may die if a surgeon gets something wrong. Equally, everybody understands that, if a surgeon gets things right, a life may be saved. I regret to say that, in our blame culture, there is a tendency to lose sight of the fact that the patient can die even if the surgeon gets things right. In recent times, there has been a massive increase across the board in the number of people who look for somebody to blame when something goes wrong and assume that someone must be at fault. People were at fault in the Bristol case. That is clear beyond any doubt, but it is not always so. We must therefore encourage doctors, nurses and other professionals to draw attention voluntarily to the things that go wrong and not to be frightened about being sued or damaging their career because they tell the truth.
That must happen not only because, as the shadow Health Secretary pointed out, failure to do so is expensive but, more important, fear of telling the truth is bad for patients. The national patient safety agency will not work if people are frightened to report things that have gone wrong. The threat of litigation could put them off.
Nowadays, doctors are told to tell all, come clean and apologise, and that many people will be satisfied. That would be best for patients, and many would be satisfied. However, doctors who pick up their cars from the hospital car park, drive down the road and bump another car are told, "You shouldn't admit that it was your fault or your insurers and everyone else will be after you." We are asking people in the clinical professions to do something that is contrary to the culture outside the hospital. We must therefore tackle the culture not only in the hospital but outside it.
I had a slogan: keep doctors out of courts and lawyers out of hospitals. I once made the unseemly suggestion that the only place for a lawyer in a hospital was on the operating table. Apart from visiting, that still broadly applies. We must change the law and take seriously what happens outside the hospital if we are to improve what happens inside it. I strongly support the report's recommendation 119 to replace the current inadequate, slow, unsatisfactory, grotesquely expensive and lawyers' pocket and handbag-lining system of dealing with clinical negligence.
The system's main fault is that it is bad for patients' safety. My right hon. Friend the Secretary of State said that patients and their safety must come first in the NHS. They must also come first in our legal system. I welcome the chief medical officer's work in bringing people together to try to find a compensation system that is fair to those who have suffered but does not damage others who will be treated in future. When the Government present their proposals and we consider them, we should revert to the point that patients and their safety must be the top priority.
469 I have always felt strongly that we must resist the compensation culture that the United States would wish us to accept. Professor Kennedy also feels strongly about that. Unless we tackle the problem, it will undermine the impact of the inquiry's proposals, the changes that have already been made in the health service and the professions, and those that are in the pipeline.
I shall not attempt to cover other aspects of the report, but revert to what happened in Bristol. The performance of surgeons in operations on children's hearts in the Bristol royal infirmary was, to put it at its mildest, not as good as it should have been. Anxieties were expressed in the professions as early as 1984. In 1987, anxiety was expressed in the news media. From the time of his appointment in 1988, Dr. Stephen Bolsin, the consultant anaesthetist, expressed concern. Over the years, his anxieties grew, as did his efforts to get others to take them seriously.
For seven years, there was no outside investigation of the Bristol unit's performance. The representations that were made and the anxieties that were expressed at that time take up no fewer than 97 paragraphs in the inquiry report and are described as "confusion" and "muddle". Individuals and systems failed. Failings by individuals do not excuse system failures; system failures do not excuse those of individuals. The General Medical Council found individual doctors guilty of professional negligence. The inquiry found the system under which they worked equally if not more guilty.
Sir Ian Kennedy's foreword to the report summarises what happened in stark and simple terms, which I shall quote:There were failings both of organisations and of people. Some children and their parents were failed. Some parents suffered the loss of a child when it should not have happened. A tragedy took place. But it was a tragedy born of high hopes and ambitions, and peopled by dedicated, hard-working people. The hopes were too high; the ambitions too ambitious. Bristol simply overreached itself. Many patients, children and adults benefited; too many children did not. Too many children died.
We must all hope that the steps that have been taken to change the system, the changes that are already in the pipeline and the additional changes that the Secretary of State has endorsed today, all of which reflect the lessons from Bristol, will ensure that nothing as bad and on such a scale happens again. However, even the changes pose a dilemma. The new structures will produce many reports of minor failures that are observed early. The professions and the NHS may find their reputation undermined as a result of the publication of reports that are the product of the effort to improve clinical standards. All of us who want a better health service, including those in the news media, must bear that in mind. However, the improvements are the least that we owe the parents whose children suffered death or brain damage.
That brings me back to my first meeting with the representatives of the parents in early May 1998 when they made clear their wish for an inquiry that would put on record for them what had happened in Bristol. It was as important to them that the inquiry proposed ways in which to ensure that other children and parents did not suffer as they had suffered. That meeting took place 10 years after Dr. Stephen Bolsin first expressed anxiety about what was going on.
470 As the representatives of the Bristol parents got up to leave my office, one of the mothers asked, "Mr. Dobson, do you mind if I kiss you?" I replied, "Not at all. I like being kissed." She kissed me and I asked her whether she minded telling me why she wanted to do that. She replied that I was the first person in an official position to sit down and listen to what she and her fellow sufferers had to say. For 10 years, nobody had listened. That must never happen again.
§ Dr. Evan Harris (Oxford, West and Abingdon)
It is a privilege to follow the right hon. Member for Holborn and St. Pancras (Mr. Dobson), who started and ended his contribution in a suitable tone, while the middle was packed with suitable content. I agree with almost everything that he said. He should also be applauded for choosing Sir Ian Kennedy to run the inquiry and for giving the Kennedy committee the freedom of a wide-ranging inquiry. He had the option of establishing a narrow inquiry, which might have limited potential damage and only implicitly criticised the direction that Governments, including that of whom he was a member, had traditionally taken. He made a brave move that has been amply rewarded, both in terms of the subjects covered in the recommendations of the Kennedy report and of the acceptance by the Government of many of the recommendations.
I would like to read from the synopsis at the beginning of the Kennedy report, to set the context for some points that I shall make later about the culture of blame. Professor Kennedy states: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. There was a lack of leadership, and of teamwork.It is an account of healthcare professionals working in Bristol who were victims of a combination of circumstances which owed as much to general failings in the NHS at the time as to any individual failing. Despite their manifest good intentions and long hours of dedicated work, there were failures on occasion in the care provided to very sick children.It is an account of a service offering paediatric open-heart surgery which was split between two sites, and had no dedicated paediatric intensive care beds, no full-time paediatric cardiac surgeon and too few paediatrically trained nurses.It is an account of a time when there was no agreed means of assessing the quality of care. There were no standards for evaluating performance. There was confusion throughout the NHS as to who was responsible for monitoring the quality of care.It is an account of a hospital where there was a 'club culture'; an imbalance of power, with too much control in the hands of a few individuals.It is an account in which vulnerable children were not a priority, either in Bristol or throughout the NHS.And it is an account of a system of hospital care which was poorly organised. It was beset with uncertainty as to how to get things done, such that when concerns were raised, it took years for them to be taken seriously.The right hon. Member for Holborn and St. Pancras highlighted that last point, and many of the others, in his speech.
471 I am grateful to the Minister of State for the briefing that I received this morning on the Government's general approach, and for the opportunity to see this very lengthy report about an hour before the start of the debate. Making a statement, followed by questions, a few days after everyone had had the chance to read the wide-ranging proposals in the Government's report might have been a more appropriate way of dealing with this matter. Debating the matter now makes it difficult to give due credit to the Government for some of their proposals—although I shall try—or to give adequate scrutiny to some others.
Nevertheless, from what I understand of the Government's proposals, many of their responses to the recommendations are welcome. They will stand as a testimony to the people who campaigned for something to be done, including parents and Members of Parliament from the Bristol area who are here today, as well as my hon. Friend the Member for North Devon (Nick Harvey), who cannot be here today. He, too, pressed for an inquiry into this matter. If there is broad agreement on the Government's response, the children involved will not have died in vain, because steps will be taken to prevent—to the best of our ability—such things happening again.
The report is clear that there must be not only adequate resources but honesty about the amount of resources available, and about what can be delivered by means of those resources. Professor Kennedy sets out, in paragraph 29 of chapter 4, how one might imagine that a Government would be elected, and would put the resources in place, and that would be that. He states:On this reasoning, resource allocation in the public sector is the product of a compact between public and government.This approach would suggest that a service can never accurately be said to be underfunded since, within a relatively short timescale, its funding is regularly adjusted to reflect the prevailing political compact. On this approach also, it is idle to talk of a 'proper level of funding' or the 'necessary level of resources', since there is no absolute or proper level. There is only a political choice which, by reflecting the will of the electorate is, by that fact, the proper choice.He goes on to make this important point:To the extent that this describes the political reality of how resources are allocated to the NHS, it is an approach with a flaw at its centre. If the government of the day opts for X resources to fund a public service and then represents that service as being able to provide services which in fact cost X plus Y, then it immediately becomes possible to use the term 'underfunding'. And this has been the history of the NHS in the period in which we are interested and beyond.He says "and beyond", because this still applies.
The report continues:Governments of the day have made claims for the NHS which were not capable of being met on the resources made available. The public has been led to believe that the NHS could meet their legitimate needs, whereas it is patently clear that it could not. Healthcare professionals, doctors, nurses, managers, and others, have been caught between the growing disillusion of the public on the one hand and the tendency of governments to point to them as scapegoats for a failing service on the other.Of course, if governments had claimed that the service delivered by the NHS should be judged on the basis of a comparison with a moderately successful Second World country, no complaint could be raised. But the NHS was"—and I would say "is"—repeatedly represented as a comprehensive service which met all the needs of all the public. Patently it did not do so.
472 I would say that it patently still does not do so. That is why we must have an ordered debate on the priorities required. It is no good saying that the resources are in place, when clearly they are not sufficient to meet a particular need. I have said before that the resources that the Government started to put in, not when they came to power but in 2000, represent the sort of increases that we need. Indeed, the Kennedy report recognises that. In paragraph 36, on page 58, it states:In 2000. at last, the present government acknowledged this gap between claim and reality in the NHS. A significant boost in funding was announced.
We know that that will take years to come through in terms of increased numbers of staff, because of the time that it takes to train them, and questions must also be asked of the Government about those missing three years. Nevertheless, Kennedy does a valuable job in pointing out that the claims of politicians can sometimes create expectations that cannot be met. That can create a gap between the public estimation of the NHS and the reality, and the people working in the NHS often get clobbered as a result.
There is much in the Kennedy report about the culture of blame, and the Government often use such words in defence of their own policies. The right hon. Member for Holborn and St. Pancras was right to draw attention to the explicit terms in which the report talks about the culture of blame and the unwillingness to admit mistakes, both of which have arisen as a consequence partly of the club culture and partly of clinical negligence. The report states:Clinical negligence litigation, as a barrier to openness, should be abolished.It goes on to stress that the NHSmust promote openness and preparedness to acknowledge errors and learn lessons.It also states:clinical negligence is part of the culture of blame. It should be abolished.It recommends the introduction ofan alternative administrative system of compensating those who suffer harm arising from medical care.
That means no-fault compensation, a policy that my party endorses, although we recognise that there might be cost implications. The cost might be greater than the amount saved in legal fees, but it might be less. We are pleased to hear that the Government have not ruled the policy out. The chief medical officer still has to report on it, and we look forward to reading the White Paper.
The lobby representing people who make a living—not unreasonably, in their view—on the basis of clinical negligence is strong, and I hope that the Government will be strong enough to resist it. It has a point to make, but reporting errors and swift compensation for patients are important. I am not sure whether the Conservatives endorsed that system when they raised concerns about the matter. Perhaps that may be clarified from the Conservative Front Bench.
§ Mr. Oliver Heald (North-East Hertfordshire)
I am happy to let the hon. Gentleman see our consultation paper on the subject. I am a lawyer, but I do not do personal injury work and never have and I do not practise. I shall be fair to the world of the law, if I may. Does he acknowledge that Lord Woolf considered the clinical negligence claims procedures and proposed some good 473 reforms that are just beginning to bite and that are speeding up claims? Furthermore, Lord Justice Otton has made proposals, which I do not agree with, that are not hugely dissimilar to those of the Liberal Democrats, so it would be wrong to suggest that lawyers are not considering these subjects intelligently.
§ Dr. Harris
I am happy to accept that and do not seek to scapegoat lawyers for lobbying in their interests. However, I hope that the Government resist that lobby and look beyond it, although I am not convinced that they will.
There is more to dealing with a culture of blame than no-fault compensation. There is the problem of what awaits doctors who might report their own errors and shortcomings and, perhaps more relevantly, what might await the friends of doctors or other health care professionals if they report that clinician. Something must be done about the quintuple jeopardy facing health care professionals.
In the event of an error being made despite there being no hint of malice and no previous history of negligence, doctors may face, first, a criminal prosecution then, when that is concluded, possible prosecution and trial by the General Medical Council. They may then be dragged through the courts and, in parallel, face disciplinary proceedings from their employer. Many such proceedings are rightly conducted in public so that there is accountability. Nevertheless, it is unique that those four areas of jeopardy may be played out in the full glare of publicity. People might be tempted not to reveal their error or report on their friends and colleagues who may be subjected to a long drawn-out process.
The fifth jeopardy is trial by media. The accused are urged by their legal advisers to make no comment, but those making the accusations have the right to do so in the media. For legal reasons and reasons of professional confidentiality, which must still be respected by the doctor or health care professional accused, they cannot be rebutted. That major problem is nowhere more apparent than in the scenes outside the GMC when someone accused of malpractice, but in certain cases not found guilty of gross professional misconduct, must run the gauntlet of the press and media. Indeed, the accusers, sometimes encouraged by the media, may throw fruit and insults at such a person who leaves the GMC by the front entrance.
Such proceedings may be necessary, but we must recognise that they represent a huge disincentive for people to report their friends and colleagues. The accused cannot answer back. I hope that the Government will at least recognise that the problem exists, although they are not directly responsible for it. Perhaps some thought will be given to the matter. Of course, health care professionals must run the gauntlet of another jeopardy—the danger of politicians naming and shaming them while proceedings are still going on.
To a certain extent, a culture of blame is encouraged by the Government when they list hospitals as failing. I shall return to that when we discuss the quality of data on which judgments should be made. There is always a temptation for politicians, especially when they are held accountable for failings in the service, to shift 474 responsibility to a few who happen to be at the bottom of a league table. I understand that temptation, but if the league table is not based on adequate data that measure the right things in the right way, it will lead to unfairness and encourage a blame culture.
The Society of Clinical Psychologists has long campaigned for suspended doctors, the majority of whom are eventually reinstated. However, the long drawn-out nature of investigations of conduct means that they cost the NHS a huge amount. Indeed, the Secretary of State raised that as a matter of concern in opposition. Something must be done to restore such people to the NHS as soon as possible if they are deemed fit to practise and it should not be deprived of their work for too long.
The Government response recognises the need to merge the Commission for Health Improvement and the National Care Standards Commission. We welcome that. I do not criticise the Government for indecisiveness when they change their mind and we have requested that they do so. That would be unfair, so I commend them on their change of heart, although regrettably it is too late to include it in the National Health Service Reform and Health Care Professions Bill, which has just left the House. That deals with reform of the Commission for Health Improvement and it could have been used as a vehicle for making that change. However, there will have to be further legislation, which pleases me as little as it pleases Government business managers.
§ Dr. Harris
I understand that Members of this House may consider that unsatisfactory, as we could deal with those matters only when debating Lords amendments rather than during our two key scrutiny stages. Perhaps the Minister will clarify whether legislation has been drafted to deal with this welcome change of approach. All parties would like such timely legislation to be introduced, because the National Care Standards Commission is about to be abolished or involved in a merger even though it has just been established. That is not good for those who work for it or, indeed, work to it.
There is a significant question as to the independence of the new Commission for Health Improvement, which I raised on Report and in Committee with the same Minister who sits patiently on the Front Bench, and I raise it briefly again. It is not right that the Government talk in terms of completely independent scrutiny of the performance of hospitals and staff when they themselves lay down for the commission the criteria by which those hospitals will be judged.
The right hon. Member for Holborn and St. Pancras said that, if the data are poor or the criteria wrong, the performance indicators and tables may be unhelpful. I welcome those remarks. Indeed, as I believe and as he said, in those circumstances they may be worse than having no data at all, as they are poor for morale and they mislead patients.
The report refers to the National Institute for Clinical Excellence and the hon. Member for Woodspring (Dr. Fox) drew our attention to it. Paragraph 17 says:NICE guidance will no longer need the approval of the Secretary of State before dissemination".The Liberal Democrats have raised concerns about the fact that NICE is asked to judge affordability, which is no job for a group of pharmacological academics or> 475 clinicians because that wholly depends on the resources in the NHS. The scheme's one saving grace was that the Department of Health and Ministers would have had to approve publishing affordability advice to the NHS, although it appears that that is no longer the case. What may be seen as a move towards greater independence might be a move towards shedding responsibility for finance and resources issues, which lie fairly and squarely with the Government.
There is a further concern about NHS bodies being directed to fund treatments recommended by NICE from January 2002. That would be satisfactory if sufficient and extra funds were available and clearly identified for funding those treatments. I believe, however, that in many cases, because there is not enough money to fund such treatments, other areas will have to be de-funded and de-prioritised. I am not sure that we want the tyranny of the appraised, as it were, that such an approach involves. I ask the Government to reconsider.
The Kennedy report speaks of the danger of a wrong approach to priorities. I do not think that the Government have responded adequately to that either. Page 81, which refers to a discussion of the role of the Department of Health, quotes Professor Sir George Alberti, president of the Royal College of Physicians since 1997, as telling the inquiry that the Department's focus appeared at the timeto be more on throughput and waiting lists than on outcome or quality of careand that theguidance given in the area of audit was a reflection of this".The professor is quoted as saying:They were not interested in results; they were interested in as many people passing through the system as possible for as low a cost as possible … commercial considerations did seem to enter into it rather strongly.The report goes on to criticise initiatives such as those on waiting lists.
The present Government are falling into the same trap. I am thinking of their waiting-list initiative—which, thank goodness, they have abandoned—and their waiting-time initiative. If the Minister checks, he will find that I have never criticised the Government for the existence of a few "long waiters", extending beyond 15 or 18 months. I agree that that is an unacceptably long time for people to wait, but clinical priority should establish which patients are in most urgent need. The Government should tell hospitals that what is unacceptable is not a delay of a few weeks in treatment but the distortion of clinical priorities, which does not aid patient care, in respect of stable patients who have to wait longer than 15 months—a figure that is soon to be 12 months, then six months.
The Kennedy report describes prioritisation on the basis of numbers, rather than the clinical needs of patients, as being part of the culture in Bristol. I urge the Government to think again about the adoption of maximum waiting-time targets as the be-all and end-all of the waiting-time initiative. A better measure would be the average wait per patient, which would avoid the clinical distortions resulting from long waiters' becoming more clinically urgent than critical patients.
The Government have announced that hospitals will lose the funds following patients who choose to go elsewhere after waiting six months for a heart operation. That will put pressure on hospitals to treat people whose waiting time is approaching six months, so that they do 476 not lose the contract—the service agreement or the custom, as the new NHS has it. I fear that, as I believe has already happened, more urgent cases will be delayed within the six months so that cases due to be dealt with in seven months can be brought forward.
The Kennedy report talks a great deal about consent, and the Government should be applauded for their careful deliberation in that regard. They published model guidelines on consent in November, and have worked closely with the British Medical Association and other interested parties to ensure that they are implemented. I declare an interest as a member of the BMA's medical ethics committee, which has considered the issue regularly. Having done so, let me say that the BMA should also be applauded for its work on the consent guidelines toolkit.
Consent is not a simple matter. It is not a question of a signature on a piece of paper but an ongoing process, which continues throughout the management of a patient. The lack of informed consent at Bristol is one aspect of the problem, but similar aspects arose at Alder Hey. It will take a long time to change the culture—or, rather, two cultures. Some patients say "Whatever you tell me, doctor, I will be satisfied". Meanwhile, some doctors think that they know best. Nevertheless, I think that the change has already begun, and that the Government's deliberative approach will enable more progress to be made, not least in medical education. The importance of obtaining a valid consent rather than merely a signature is rightly being emphasised.
Before the hon. Member for Woodspring left the Chamber, I said that I wished to take up his—in my view—inappropriate response to my concern about the quality of data. He has not returned from the pressing media interview that called him away, and I am sorry that, once again, the Secretary of State cannot hear my response to his criticisms.
My point was that it was wrong to assume that all information put in the public domain entitled "Performance of hospitals" or "Performance tables" was desirable. Such data might be flawed; they might be incomplete to the extent that they were misleading, and would have negative effects on either the morale or the appropriate conduct of those being measured. I repeat that my party wants the public to be given more information, but that the information must be as complete as possible, although it will never be entirely complete. It must also be judged by means of peer review, rather than politically, for it to be of more help than harm.
I do not think that that has yet been established, which is why I was so pleased that the Secretary of State recognised the potential drawbacks of data. I pointed out to him that the Department of Health had co-operated with an earlier data set, which I think failed to take the difficulty of operations into account. It did take demography into account, and, through "Jarmanisation", specified the appropriate measures to adjust to the population that it served; but it had no data relating to the difficulty involved in some cases, and the complications affecting patients before operations.
§ Dr. Harris
I am merely saying that the data should be scrutinised. It would have to be decided whether they should be scrutinised by the medical profession alone or by an independent body—not a dependent body that would have to jump when the Government set criteria.
The Secretary of State acknowledged the drawbacks. That is why I was so pleased to learn of the basis on which the Society of Cardiothoracic Surgeons will work with the Department of Health to produce data. I believe that the medical profession—like the hon. Member for Woodspring, I do not speak for it—is willing to produce such data, as it does in journals all the time. But the idea that publishing data is the only way in which to establish whether they are any good flies in the face of a scientific approach.
The Government should say, as indeed they have, that they want to see performance data. They should agree with the responsible bodies—which I think should be the CHI and, in the case of medical data, the relevant royal college—the criteria, and the adjustments needed to ensure that they are valid. They should then establish a peer review system, which should involve not just the medical profession but data analysts and experts and, indeed, members of the public—who have been left out of the equation—before the publication of data that could be misleading.
The hon. Member for Woodspring made the point himself. He said that data had been published leading to the removal of staff from a hospital on the basis of a poor neonatal mortality rate, although the hospital was a regional centre taking the more difficult cases. The publication of such data certainly leads to more information in the public domain—hurray for that—but it damages the morale of people working hard with difficult cases, and makes the public tend to avoid the best units because they appear to have produced the worst results.
As I told the hon. Member for Woodspring before he left, I thought his response dishonourable when he said that expressing such legitimate concerns—he was echoed to an extent by the Secretary of State, who cannot resist making such glib party political points—
§ Madam Deputy Speaker (Sylvia Heal)
That is not really a point of order. The hon. Gentleman has, of course, raised it with the Member concerned.
§ Dr. Harris
Let me make it clear that I said that I thought it dishonourable—a dishonourable thing to do—to say, when legitimate concerns are being expressed about the quality of data, that the Liberal Democrats therefore do not want information to be published. I did not think that I had used the words referred to, but I am certainly happy to consider the hon. Member for Woodspring honourable. I am saying that to say such a thing is dishonourable, and wrong. I believe that people 478 will be more willing to co-operate with the publication of information if they have assurances of the sort given by the Secretary of State in his opening remarks about the need to ensure that it is appropriate.
§ Mr. Swire
I thank the hon. Gentleman for giving way on what is obviously a matter of great interest to the Liberal Democrats, as is evidenced by their presence in the Chamber. Does he think that the publication of data would have been helpful in cases such as the one before the General Medical Council today, concerning Dr. John Brennan and Dr. Graham Urquhart and the cancer tragedy in Devon?
§ Dr. Harris
I do not have the details of the case. Given what I have already said about the quintuple and even sextuple jeopardy that doctors face, I question whether it is right for a politician—whether or not he or she is in full command of the facts—to pass comment. We need to learn from cases in which people have been found negligent and in which suppression of data is involved, but I advise the hon. Gentleman to await the report on the case before urging the Government to act as quickly as possible.
§ Dr. Harris
In that case, we should await the ruling. It appears that we do not have long to wait.
The Government's response to the Kennedy report contains many recommendations that are welcome, but I ask the Minister to consider allowing us a further opportunity to discuss the issue when we have had a chance to digest the report and some of the other initiatives that daily issue forth from the Department of Health. My central concern is that it is no good for the Government to defend all their reforms by saying, as the Secretary of State appeared to do at one point, that we need to get rid of the old order. As with the slaughter of the first born, any crazy idea could be justified, given the nature of the Kennedy report and the serious concerns that it expresses about what happened.
The Government must justify every one of their proposals on its merits, and in many cases they have done so. However, getting rid of a culture of blame will not be achieved by just saying the words. It will mean ensuring that politicians from all parties do not seek to scapegoat—on the basis of inadequate information—those who work hard in a system that does not have the resources to deliver what politicians have been guilty of encouraging the public to believe can be delivered. With that caveat, I warmly welcome many of the recommendations in the Government's response.
§ Valerie Davey (Bristol, West)
Bristol—and especially the parents of those children who died or suffered brain damage during that difficult time—has waited a long time for good to come out of that tragedy. The Kennedy report was welcomed for both the quality and the quantity of its recommendations. After the Secretary of State's speech 479 today, and once we have had time to study the report in more detail, I am sure that the Government's response to it will also be warmly welcomed.
The Secretary of State widely endorsed the recommendations in the Kennedy report. The tenor of his speech was one of willingness to learn and to recognise the difficulties and the dangers of what had happened in the past. That is all part of moving forward and bringing some good out of the tragedy.
I am also sure that the parents would wish once again to thank my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson). I am sorry that he has had to leave the debate temporarily, but I want him to know that the parents have not forgotten their first meeting with him in May 1998. I met some of them after they had been to see him. They told me that at last they had some hope for the future. As he recorded, they were glad that for the first time someone in authority had listened and appeared to be willing to take them seriously and share their pain. I thank him for that and also for the thoughtful and thought-provoking speech that he made this afternoon.
I doubt whether even my right hon. Friend recognised, at the time when he set the report in motion, just how important it would be, not only for Bristol but for the whole of the NHS. Some of the parents, however, realised that something momentous had to happen—a change in the culture—to ensure that what had happened to them did not happen again. That is why they put so much tenacity, determination, love and thoughtfulness into their struggle. They acted with such dignity in all that they did that I wish to pay tribute to them.
I also wish to acknowledge the work of colleagues, some of whom I know regret that they are unable to be present in the Chamber for this debate. My hon. Friends the Members for Bristol, South (Dawn Primarolo) and for Bristol, East (Jean Corston), as well as the hon. Member for North Devon (Nick Harvey), tabled questions in the 1990s—and in one case in the late 1980s—and sought to represent their constituents involved in the issue.
The parents have also set up a new charity, Constructive Dialogue for Clinical Accountability—the CDCA—and I shall mention later some of the work that it has done. Its work corresponds closely with the Kennedy recommendations and the Government's proposals in seeking recognition for patients' contributions, alongside those of the professionals, to the future of the NHS.
I also wish to thank both medical and administrative staff of the Bristol royal infirmary who, since the tragedy, have worked to restore trust between patients and the medical staff. The staff have borne the brunt of much of the criticism, but the quality of treatment, especially in cardiac surgery, has now reached a very high level. That is due to their commitment and hard work.
In the Minister's response to the debate, I would be grateful if he could respond to a poor article in the Bristol Evening Post that concluded, from the faults at the BRI and the Secretary of State's comments earlier this week about the future for failing hospitals, that the hospital was to be taken over by private administrators. Those conclusions were simplistic in the extreme, and I would be grateful for the Minister's comments.
480 The Secretary of State, in his foreword to the Government's response, says that bringing about the changes that the Government seek in the NHS will require "time and commitment". I assure him of the commitment of the staff at the BRI and, in the time that has been available, they have done great things.
It is not appropriate this afternoon to deal in detail with the 198 recommendations and the Government's response to them. However, as other hon. Members have done, I wish to draw out some of the underlying themes that are so important but which involve more intangible aspects that are more difficult to monitor but essential if we are to achieve the change in culture. The need for openness and accountability is a thread that runs through the report and that ran, today, through the Secretary of State's speech. The summary of the report states:Openness and transparency are as crucial to the development of trust between healthcare professional and patient, as they are to the trust between the NHS and the public.We are now working at both levels, and we want greater openness between patients and professionals. In this case, there was a lack of openness—of which we have seen evidence—between the parent and the professional. We also need the wider trust between the NHS and the public to be re-established.
The fragmentation of the NHS and the establishment of competing trusts was not helpful in establishing the kind of trust that is essential—as opposed to the organisational kind of trust—to monitoring within the NHS. We need monitoring, and we need national standards for that monitoring of clinicians and managers. We have seen the disastrous consequences in Bristol where, as my right hon. Friend the Member for Holborn and St. Pancras said, there was a breakdown not only with systems but with individuals. When the two came together in Bristol, there was a culture of secrecy that is now being tackled.
Results in Bristol are now speaking for themselves. We have seen new data, although we have heard questions today about whether they are detailed enough. However, we have to start producing data, and those of the associate parliamentary health forum—as well as the work of Dr. Foster that was published recently in The Times— show that Bristol is doing remarkably well in cardiac performance. Bristol has the lowest standardised mortality ratio in the country, taking into account all forms of heart surgery.
The teams concerned need to be congratulated on publishing the data. They are the first cardiac unit to recognise the importance of publication, and they have done it of their own volition. That is something important to come out of events at Bristol. The beginning of a solution to the tragedy is for those clinicians in the cardiac unit to say, "This is what we have to do to raise standards. We have to work as a team."
I recognise that it is not just a question of the data. The data have been produced because the doctors and clinicians at Bristol have recognised their importance. They have worked together as a team, and have been willing to publish. They have seen the importance of that and they are now getting praise for it. It is not undermining their credibility, but enhancing it in Bristol, the country and this House. I want to applaud that, and it is recognised on both sides of the House.
Confidence is returning and a report by the Department of Health's review team on paediatric and congenital cardiac services is very encouraging. In summary, it states 481 that the Bristol unit can be "proud" of what it has achieved, that its "high quality clinical outcomes" were to be applauded, and that:The concept of close continued work with parents and families is obviously of vital importance to consolidate the improving confidence in the Unit.Following the anguish of Bristol, I trust that people will now look to Bristol and to the BRI for good practice that they can follow to improve their services, too.
I endorse the Government's work to establish national terms of reference. Many of us—certainly people of my generation—find it almost impossible to believe that those national standards were not in place when we took our families to hospital. We were vulnerable, and yet we put our trust—rightly, I am glad to say, in almost all cases—in clinicians without national monitoring. My constituents and I now seek such monitoring in terms of what we mean by a national health service.
The second important theme concerns the regulation of professionals. I congratulate the Government on proposing the Council for the Regulation of Health Care Professionals. That was directly recommended in the report and must be an important step in the right direction. Part of that body's responsibility is for education, as was mentioned by the hon. Member for Oxford, West and Abingdon (Dr. Harris). We look to that body to bring people into the medical profession from a far wider base.
At Bristol, we have recognised that, in some cases, medical schools have not drawn as widely as they should from the general public. We need people to bring wider experience to the medical profession; that would be useful. The report pointed that out, and I am sure that the medical department at Bristol university will be aware of that and will begin to tackle it.
I want to recognise the part played by Stephen Bolsin. It is perhaps not well known that he is in Australia now and has written about the benefits of a new electronic personal professional monitoring scheme that trainee anaesthetists are using. That scheme is bringing greater clarity and openness to the system, and it makes us realise that the impact of Bristol—which resulted, sadly, in the professor having to leave Bristol for Australia—is causing international ripples around the world.
Thirdly, the need for child-centred facilities has been mentioned. It is clear that the care of the child in most families is central and unquestioned. The fact that it was not central in the health service has raised eyebrows and caused deep concerns. With the establishment of the children's hospital in Bristol, we have far greater provision than anything available in the 1980s and early 1990s.
We need to scrutinise Kennedy carefully, as well as the Government's response. There is real dialogue in Bristol about whether we centre everything for children in the children's hospital—meaning that all other disciplines must be around that hospital—or whether we emphasise the in-depth departmental provision for, say, burns or neurosurgery. There is a genuine and open debate in cities such as Bristol as to where we locate children's services. There is no debate about the quality of those services and their prioritisation within the NHS in every city and district. How that is done is part of an ongoing debate. 482 No one should expect the Government's response today to be the final determining factor in the development of a quality NHS.
§ Mr. Lansley
On that point, the hon. Lady and her colleagues from Bristol have experience of the opening of the new children's hospital last year. On reflection, what is her view of this matter? The Kennedy report looked at the concentration of paediatric services in a children's hospital, co-located alongside other acute district general hospitals that could provide specialties that could not frequently be expected to be available in a children's hospital. The treatment of burns might be one sort of treatment that a children's hospital could not be expected to maintain full-time and would have to be co-located. Bristol has moved to that point; in Cambridge, we do not have such a service and we look to a children's hospital in London. What is her experience of that in Bristol? Would she prefer that, or would she prefer something different from the current system?
§ Valerie Davey
The hon. Gentleman asks questions to which I do not pretend to have the answers. I checked, and the Kennedy report speaks about operating such a service alongside a district general hospital. In Bristol, we have some regional capacity. Do we therefore take that phrase to refer to regional acute services? The debate continues. There is a lot of history to the location of the children's hospital in Bristol. The hospital is well served by the equivalent of district general hospital capacity, but what about the regional level of capacity?
I welcome the comments of other hon. Members today. I do not have the answer to the question, and we have not always received a unanimous response from clinicians and professionals on the matter. The question is a huge one. The Department needs to consider it carefully when it gives advice. I shall scrutinise its response to Kennedy very carefully.
I am sorry not to have an answer, but I do not apologise. It is beyond any hon. Member to offer a definitive response.
My final point has to do with focusing on the patient, and putting the patient at the centre of the health service. That strategy is informing the Government's approach to the NHS, and should also inform the public debate, as I said earlier.
That may sound strange, as one would expect the public to have understood the notion that patients are central to the health service already. However, as a matter of custom and practice, people have always deferred to the medical profession. The questioning by parents, especially in Bristol, has given us all a new approach, and set out a new agenda for the NHS that we need to follow.
The clear presentation of information by the cardiac surgeons in Bristol is a good beginning, but we must still listen to parents. The now established charity Constructive Dialogue for Clinical Accountability is made up of parents, the public and clinicians, and their aim is to ensure better dialogue. They want to make sure that communication between health care professionals and patients is developed. The charity believes that parental contribution and input to children's health care should be recognised as having a value equal to the contribution of professionals.
483 The charity issued a press release today that highlights the section of the Kennedy report that suggests that the NHS must work with people, and that it must celebrate its successes and make known its shortcomings.
It is invidious to name individual parents, but Maria Shortis and Trevor Jones have worked hard for many years to establish the CDCA. Although they are getting increasingly professional, they used lay terms to tell me that clinicians are not gods.
"Clinicians make mistakes," they said, "and we need to recognise that. It is no good them telling parents that all will be well, when it may not be." They told me that parents need to be treated as mature people. Obviously, they are concerned about their children, but they want the truth. Parents want to know what the probability is that an operation will succeed, but they understand about human error. That is their down-to-earth message. Thanks to some funding from the Department of Health, they have been holding training sessions around the country. They have taken on the GMC and the BMA, and have earned those organisations' reluctant respect.
Trevor Jones wants health funding money to go to doctors, not lawyers, as he put it. That blunt point has been echoed in the Chamber today. He does not want large sums to be diverted into medical negligence actions.
Interestingly, Trevor Jones made a link with the need for better provisions for informed consent. He said that truly informed consent requires better understanding. If clinicians took the time to talk in a mature fashion to parents about an operation's likely outcome, parents would have more trust, there would be far less litigation and money would be spent properly in the NHS.
I assure Ministers that the CDCA will not be entirely content with the response from the Government today. It will welcome what has been said, but its campaign continues. Its press release speaks about accountability and independent regulation, the adequate funding of quality services and active patient partnership. Then comes the sting in the tail: if the Department of Health is in charge, to whom is it accountable? Questions as pertinent and difficult as that will go on being asked.
I am convinced, from my experience with the Bristol cardiac unit, that lessons have been learned and acted on. However, the words of the Kennedy report still resonate with me, as they do with other hon. Members. We cannot guarantee that similar events are not happening elsewhere as we speak. I want to ensure that the lessons learned by the Bristol cardiac surgeons are learned by all similar departments in the rest of the country, and that professionals in every other discipline learn those lessons and act on them.
The culture of secrecy and of the patronising attitude to patients has begun to be dispelled in Bristol. I am sure, given what my right hon. Friend the Secretary of State said today, that the major task of ridding the whole NHS of that culture has been begun and is already, in part, in hand. All of us now must ensure that the process is taken forward nationally, throughout the NHS.
§ Mr. Andrew Lansley (South Cambridgeshire)
I am pleased to be able to contribute to the debate and to follow the hon. Member for Bristol, West (Valerie Davey). Clearly, she and other colleagues have put an enormous 484 amount of time, energy and effort into supporting the work of the parents who suffered the tragedies at Bristol royal infirmary over the years. They have tried to keep the issues to the fore and ensure that they have been followed up. It is to the credit of everyone involved, including the right hon. Member for Holborn and St. Pancras (Mr. Dobson), that we can debate these matters today with the benefit of a report that is both comprehensive and challenging.
In addition, I hope that hon. Members who have lived with these problems for many years will agree that we must today make sure that hon. Members who have only read about them in the Kennedy report think about the report's conclusions as they affect parts of the country other than Bristol. The lessons have to be learned by people in other parts of the country and they have to be acted on. In that way, the hope is that we can prevent the repetition elsewhere of the tragedies that took place in Bristol. We can do that by systemic change in the NHS and by promoting awareness and additional openness in the service. In that way, we can ensure that the accountability rightly described by the hon. Member for Bristol, West is being exercised by those who bear that responsibility. Members of Parliament to a large extent share in that responsibility. I am therefore pleased to have the opportunity to think about those issues from the other side of the country, as it were—from Cambridge. We are being challenged to think about how they will affect us and the configuration of our services for children.
Several hon. Members have said that it is challenging to try to deal with the range of issues as there are so many. There are 198 recommendations, which makes it challenging to try to respond to the report, and indeed to embrace the Government's response and to comment on it. I shall not attempt to do that across the board but focus on just one area.
When reading the report, one of the issues that sprang out at me was its criticism of the lack of priority that has been given to children's health services over many years. Today, rightly, the Secretary of State and others have focused on the lessons than can be learned for the NHS as a whole in terms of accountability, professional regulation, consent for treatment, inspection of the service and so on, but underlying all that is the fact that the tragedies occurred in respect of children's health services. It seems that one of the reasons why they occurred was because a relative lack of priority was given to children's health services, which were not integrated and managed in a way that would have inhibited the lack of performance. They were too often seen to be at the periphery of the professional practice of a hospital.
Chapter 29 of the Kennedy report sets the matter out clearly. It paints a stark picture:it is a remarkable feature of children's healthcare services that, over a period of 40 years, successive independent reports have made the same or similar recommendations.It mentions the Platt report of 1959 and the Court report of 1976. It does not go through them all in detail but elsewhere one can find references to the national confidential inquiry into peri-operative deaths in 1989, the 1991 guidance issued by the Department on children and young people in hospital care, the 1993 Audit Commission report, and a range of reports in the run-up to the 1997 general election, including one on hospital services by the Select Committee on Health and the Government's response to it.
485 Throughout that period, a series of reports often made similar remarks. They talked about the need for a child-centred approach to children's health care services; about recognising the difficulties for children of being treated away from their families; about a holistic view of the needs of children; about the given level of expertise required to deal with specialist factors associated with children; and about not treating children as a by-product of the professional expertise of treating adults—children are not simply a small version of adults when it comes to medical practice. The reports also talked about the need for minimal hospitalisation—it should happen only when absolutely necessary. There must therefore be a different approach to the relationship between hospital care and community care.
The Kennedy report says in chapter 29, paragraph 14:had the principles set out in the DoH's 1991 guidelines and the Audit Commission's report been implemented in Bristol, a good number of the shortcomings in care would have been addressed much earlier.What we learn from that is that it is not sufficient to publish reports. It is not sufficient even to publish Government responses to reports. They may be more comprehensive and compelling, but they must be turned into action. There must be delivery in response. There must be delivery in relation to children's health services and an increased priority for those services within the NHS if we are to avoid a new, but different form of tragedy occurring somewhere else because of a lack of specialist expertise and a lack of integration of health care services for children.
Several issues arise from that. Specific recommendations arising from the Kennedy report concern the future configuration of children's hospital and health care services. At the moment, it is difficult to see precisely how the Government will respond to those. There are relatively few instances where the Government's response rejects what the Kennedy report has said but there are some. The Secretary of State rightly focused on what he is accepting in the Kennedy report—the recommendations on introducing strengthened inspection procedures and the role of the Commission for Health Improvement—but he might have gone on to say that he is rejecting the Kennedy report's recommendations in relation to validation and revalidation of children's hospital services.
According to the Government's response, if I characterise it correctly, to accept those recommendations would run the risk of losing capacity in the NHS for the delivery of services for children because of the failure to validate or revalidate a particular service. I am uncertain about that line of argument.
It seems that there is an interesting difference in the mind of Ministers. They say that we should not have validation or revalidation of services because if the answer is that a service is not good enough, quality standards will not be met, the service will not be able to be offered and patients will suffer because of the lack of that service for the time being. Therefore, we must have an inspection system whereby the Commission for Health Improvement has strengthened powers to the point where it can call for special measures to be taken in order to remedy problems straight away.
486 What are those special measures and how swiftly can one act on the commission's findings? If it is not very swiftly, by implication services provided to children will not be of sufficient quality and will not meet the necessary level of validation.
§ The Minister of State, Department of Health (Mr. John Hutton)
I am reluctant to interrupt a good and thoughtful speech, but I take the opportunity to clear up any confusion in the hon. Gentleman's mind. Clearly, the Department will not turn a blind eye to services that we know are unsafe. We will not hesitate to take necessary action. If that means closing a particular service when the evidence is clear that it is not safe, of course we shall do that. We will not expose children to unsafe medical practice at any time it is drawn to our attention.
§ Mr. Lansley
I am grateful to the Minister. It would not have occurred to me that Ministers would turn a blind eye. Perhaps I should explain where my concern lies. It seems that one can take two attitudes in relation to services of that kind. One can say that services must meet a high standard before they can be offered. On the other hand, one can say that if services do not meet a minimum standard, they cannot be provided.
Often, inspection will find many quibbles. Inevitably, there is a large area that falls below a minimum standard, which means that the service cannot be offered. That service will have to show a path back towards a higher level comparatively, but there is a big gap between that and the point in a validation or revalidation system that demonstrates that one has met a certain measure of quality in order to provide a service in the first place.
The issue is brought into sharp focus in the validation of services that are not supranational or specialist. As the Minister will know, the Kennedy report sets out clearly the particular concern about hospitals across the country providing a specialist service when they did not have the necessary level of throughput. The issue then is whether validation is the better route. Is it better to say to non-specialist hospitals or those that do not have the necessary level of throughput of activity to deliver high clinical outcomes, "You cannot pursue that kind of service unless you meet quality standards"? That is a validation system rather than an inspection system.
The two are not mutually contradictory. Of course, having validated the provision of a service, one continues to inspect it to ensure that it is being provided to a satisfactory standard. However, it is not necessarily right to conclude that the validation and revalidation of children's services is complementary and desirable—perhaps especially as we want services with specified throughput rates in order to achieve safe clinical outcomes.
I raise that issue because I realise that to a certain extent Ministers are still thinking about it. Although on the face of it, the recommendations have been rejected, the configuration of services remains to be determined. National service frameworks must be completed this year because their shape will affect what flows from them.
As I said in an intervention on the hon. Member for Bristol, West, we need to consider the proper configuration of services because the lead times can be long. In Cambridge, Addenbrooke's hospital—one of the country's leading hospitals—is considering the shape of clinical 487 services at and around the site for 2020. For example, it is not currently the intention of the Addenbrooke's NHS trust board or the related health authorities to provide a children's hospital at Cambridge. That is because, although in every other respect Cambridge would be a satisfactory place in which to provide such a service, the catchment area comprises about 4 million people. I understand that the figure for Bristol is about 5 million. Cambridge is 56 miles from Great Ormond Street hospital, which is in the constituency of the right hon. Member for Holborn and St. Pancras, but Bristol is 119 miles from Great Ormond Street. Presumably, the distance to Birmingham is somewhat less.
One might conclude from the above that there are implied criteria for the continuation and strengthening of a children's service at Bristol that would not apply to Cambridge. There are criteria as regards the number and location of units throughout the country that provide children's services in a specialised children's hospital. However, I am not clear about those criteria; nor am I clear about how the Bristol royal children's hospital has responded to them or whether it has used different criteria from Cambridge.
Cambridge is precisely the right place for a children's hospital: it has a teaching hospital, it has nurse education, and it has not only a district general hospital but the regional capacities for many services. That relates to a point made by the hon. Member for Bristol, West. In the time frame under consideration—up to 2020—Papworth hospital may come alongside Addenbrooke's as an independent hospital NHS trust providing cardiothoracic services. The Rosie—a maternity hospital—is part of the Addenbrooke's trust, so we have expertise in neo-natal intensive care and the associated paediatric services.
One could easily conclude that Addenbrooke's was precisely the type of medical campus on which one would want to site a children's hospital. The development of children's services in the NHS would point to that conclusion. However, people at Addenbrooke's and in the NHS have not reached that conclusion and are not working towards that end. Why are they not doing so? Have implied criteria already been established for the configuration of services? If there are no such criteria, we need to draw them up soon—in the course of setting out the national service frameworks—to decide whether we need to make changes.
Otherwise, in a few years, hospitals such as Addenbrooke's will offer paediatric services in a range of specialities but those services will not be grouped together in a dedicated children's hospital. That would give rise to the problems that were mentioned earlier. The peripherality and fragmentation of children's hospital services may be continuing throughout the country because we have not thought quickly or clearly enough about the desirability of reconfiguring hospital services and of creating additional children's hospitals.
In the past, hospital services for children have—because of the relatively small number of children who have to undergo certain operations and procedures—been located in quite distant units. The Kennedy report made it clear that fewer centres result in greater competence and better clinical outcomes. The report points out that for certain conditions, such as congenital heart disease, there may be a case for having only two units in the country that provide those services.
488 By implication, therefore, children and their parents and families will have to attend hospitals at a great distance from their homes. That will result in considerable costs for those families and there will also be effects on the general health of the children. Many charities can offer help; for example, the Sick Children's Trust offers families long-term support when children spend a long period in a hospital that is some distance from their home.
The report made some recommendations about travel support for children and their families, but the broadening of such support was not accepted by the Government, although their response today seems to suggest that they are willing to consider further steps to improve such support in due course. Perhaps the Minister can comment on that in his response to the debate. One of the ways that children's health care services differ from adult services is the complete dependence of children on their families. There are consequences for their health when they are sent to distant hospitals and we need to recognise that.
I thank the Secretary of State for his introduction to the debate. One important point is that we should not only publish data but should recognise that they will show us the difference in performance and clinical outcomes between different hospitals.
The Secretary of State talked about cardiac surgery. I have previously raised with Ministers the need to assess clinical outcomes in tertiary hospitals. For example, the Papworth hospital, as a cardiothoracic institute, has extremely good clinical outcomes. The publication of additional data will show that there is every reason for such institutes not to be merged into district general hospitals. That might make sense in terms of co-location but the clinical excellence provided by a separate institute with a clear focus would be lost.
If hospitals such as Papworth and Addenbrooke's can live alongside one another as two hospitals on one site retaining their tertiary expertise, that will be to the overall advantage of the health service. However, we must recognise the better clinical outcomes in tertiary hospitals, so I welcome the publication of data that would enable us to do that.
Much rests on the effectiveness of the Commission for Health Improvement. I have no way of knowing how good the commission will be in undertaking its task. It has been examining paediatric services at Addenbrooke's and it is also visiting Papworth. I have every confidence in both hospitals and await the commission's findings. Ministers should consider how much rests on the CHI. As we have learned only too painfully from the events at Bristol, we have to discover where things are going wrong and rectify them. We must also keep an open mind as to whether there are new ways of ensuring that services are correctly configured and provided to a high standard.
§ Mr. Roger Berry (Kingswood)
The dominant emotion that I, like other hon. Members, felt, and still feel, in preparing for this debate and on re-reading the Kennedy report was one of deep sadness at the events that led to children unnecessarily dying or being damaged and deep sorrow for the parents who had to endure not only that experience with their children, but many years of trying to get to the bottom of the tragedy's causes.
Unlike in many debates in the Chamber, I feel desperately sad about the situation, and I am sure that that is true of every other Member. I also feel anger because, 489 as has been said already, concerns were being expressed about the situation at the Bristol royal infirmary as early as 1984. This debate is taking place 18 years after those initial concerns were expressed.
In case there was ever any doubt about the importance of reform in the NHS, or the importance of the Kennedy report and the Government's response to it, I refer to the fact that, almost unbelievably, 18 years after initial concerns were expressed, we are debating the issue today. That cannot be other than entirely unsatisfactory.
Alongside the sadness that I feel for the children affected and their parents, I would also express, as other hon. Members have, my admiration for the parents who have consistently pursued over the years their campaign for a full and proper public inquiry.
I should like to congratulate, first and foremost, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson). As he and other hon. Members intimated when we discussed the statement made in July, it was not as though establishing a full public inquiry was without its difficulties. Inevitably, some people will always wish to resist such a course of action. I should certainly like to express my great admiration for his decision to hold a proper, full public inquiry. It was the right decision to take; the tragedy is that it was not taken much earlier.
I join other hon. Members in thanking Sir Ian Kennedy and his colleagues for an extensive report, which took a fair amount of time to produce. Many hon. Members—my hon. Friend the Member for Bristol, West (Valerie Davey) was one—asked when we could have the report and see the outcome. I am sure that we would all agree that while the report took some time to produce, it is not only extensive in terms of the number of recommendations and pages; but a seminal document on the way in which we run our NHS, so it was well worth waiting for.
To complete my thanks, I thank my right hon. Friend the Secretary of State for Health for his statement this afternoon and for the Government's response to the Kennedy report. Inevitably, as the Government's response was available only a short time before this debate commenced, and although speed-reading courses are very effective these days, we need more time to digest some of the detail. However, the summary of the Government's response makes it clear that they are acting positively on virtually all the key recommendations. I thank my right hon. Friend and his colleagues in the Department of Health for the way in which they have dealt with this matter.
The Kennedy report is entitled "Learning from Bristol", and I want to take up a point made by the hon. Member for South Cambridgeshire (Mr. Lansley). I have resided in Bristol for a very long time and am aware of events at the Bristol royal infirmary, but a substantial part of the report deals with the lessons for the future—lessons for the whole NHS. The report could just as easily been on events in another hospital in the United Kingdom, so we should acknowledge that it is as much about general failings in the NHS at that time as it is about individual failings in Bristol.
I want to make four brief points, the first of which relates to the need for standards to evaluate performance and assess the quality of care. Again, like my hon. Friend 490 the Member for Bristol, West, I was surprised to discover when I was first elected to the House almost 10 years ago that there were no well laid down standards or procedures for assessing the quality of care.
I was born in the year that the NHS was set up—within a few days—and I owe a lot to the NHS, not least being here today, but it had never occurred to me that throughout the 1980s and early 1990s there was no regime to establish standards for evaluating performance or basic procedures for assessing the quality of care. As I picked up the picture as a Member, I found it astonishing that we did not have such a framework, and I was certainly reminded of that when I read Sir Ian Kennedy's report.
As all hon. Members know, the report reveals that, in the late 1980s and early 1990s, there were no national standards and monitoring was virtually non-existent. I was shocked by this comment in the Kennedy report:We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was in truth, no such system.I shall not quote the report extensively, but it went to say that that waswhen there was no agreed means of assessing the quality of care. There were no standards for evaluating performance. There was confusion throughout the NHS as to who was responsible for monitoring the quality of care.
Much progress has been made in recent years. The Kennedy report indicates areas where things can be improved, but we now have clinical guidelines, through NICE, national service frameworks, the CHI and much more. Kennedy states in his report that that gives rise for optimism and provides it as the basis for recommendations about improvements, but I simply make the point that I cannot have been the only citizen in Bristol, or elsewhere, who in the early 1990s and before did not realise that there was a problem of the kind that Kennedy analyses. That revelation will have come as a great shock to the vast majority of people. People need to know not only that such systems are in place, but what standards of clinical care patients are entitled to; indeed, they have a right to know that.
§ Dr. Andrew Murrison (Westbury)
The hon. Gentleman makes an important point about the changes to regulation, inspection and audit that have taken place in the NHS over the past 10, 15 or 20 years. Does he agree that those changes have been features of our national life in general and that institutions other than the NHS have changed in that way? Such change is not unique to the NHS.
§ Dr. Murrison
That is a good point. Of course, the NHS is crucial—I know, I have worked in it. Other areas of our national life are, arguably, just as important—in particular, health and safety, and there has been a great deal of improvement in the way in which health and safety issues pervade life in this country. Perhaps the hon. Gentleman might like to reflect on them, because they are also matters of life and death.
§ Mr. Berry
I am always delighted when Opposition Members support improved regulation for matters such as 491 health and safety. I entirely agree with the hon. Gentleman, but we are debating the Kennedy report and the point that I wish to stress is how welcome it is that we now expect in the NHS the use of national standards and monitoring in a way that did not occur at the time of Sir Ian Kennedy's report.
My second point is about the importance of open reporting. It may seem an obvious point, but let us not forget that the actions of Dr. Stephen Bolsin as a whistleblower led to the suspension of heart surgery at Bristol in 1995. We owe him an enormous debt of gratitude. It is not easy to speak out in such circumstances but, fortunately, I have never felt under the pressure that he must have been under. It is not easy to speak out and challenge authority, not least when one's job may be on the line. In his case, it clearly was.
Stephen Bolsin spoke out, made himself deeply unpopular and put his employment prospects at severe risk. We must give credit where it is due. As other Members have said, the Kennedy report refers to the time when there was a club culture andan imbalance of power, with too much control in the hands of a few individuals.It is important that the club culture and the situation in which Stephen Bolsin found himself never occur again. It is important to be reassured that, should anyone else find him or herself in that position, they will be protected by current arrangements in a way that Stephen Bolsin was not. I invite my right hon. Friend the Minister to assure the House that that will be the case.
The other issue is the way in which the clinical negligence system acts as a disincentive to open reporting. How does one reconcile increased openness in the NHS with the threat of legal action? Members have referred to recommendation 119, in which Kennedy recommended the abolition of the clinical negligence system and its replacement with an alternative system for compensating those patients who suffer harm as a result of NHS treatment.
I know that it is a controversial issue, but I urge the Government to consider the recommendation sympathetically, and I believe that they are doing so. Yes, litigation takes time, people may have to wait ages for an outcome and there are the costs that have been mentioned, but I am sure that most people would prefer money to go to the NHS rather than in legal fees. There is no guarantee, under a litigation system, that those who suffer harm as the result of NHS treatment will receive compensation. Many people decide not to pursue litigation because of the emotional stress and the costs involved.
The key point is that the current arrangements can discourage openness and, as my right hon. Friend the Member for Holborn and St. Pancras rightly said, that is probably bad for patients because they do not know what is going on. There are serious disadvantages with a litigation culture, so I welcome the Government's commitment—and their response today—to reforming the system of clinical negligence compensation. I look forward to the White Paper that will be produced in the near future.
My third point is about the need for a properly funded NHS. Kennedy, in his account of the situation at Bristol royal infirmary between 1984 and 1985, described it asa service offering paediatric open-heart surgery which was split between two sites, and had no dedicated paediatric intensive care beds, no full-time paediatric cardiac surgeon and too few paediatrically trained nurses.492 There is still the need for increased capacity at the Bristol royal infirmary and elsewhere in the NHS, and there is still a need for more doctors and nurses, notwithstanding the very welcome measures that the Government have taken in recent years, but the point about a properly funded NHS provides an important lesson that we need to learn: we cannot expect a top-class NHS unless we are willing to pay for it.
My final point is to echo comments that have been made about the BRI today. It must have been difficult in recent years for people at the BRI to work as effectively and as enthusiastically as they have done in the aftermath of these events. I cannot imagine the pressures that they faced in those circumstances. Therefore, I wish to pay tribute to the contribution of the staff at the BRI today. The nurses, doctors, managers and everyone else have had the onerous responsibility of achieving change since the tragic events took place.
Today's survival rates for children's heart surgery at Bristol are now among the best in the country. We need to recognise that that has been achieved in difficult circumstances, which is a tribute to the staff currently working at the BRI.
We must learn the lessons from Bristol, but the Kennedy report and the Government response are not just about the BRI; they are about the NHS as a whole.
§ Dr. Andrew Murrison (Westbury)
The Kennedy report is a magisterial tome, particularly the 530-page version. I prefer the slim volume but, like most hon. Members here today, I have ploughed my way through the big brother. It is to be thoroughly commended. I welcome it wholeheartedly.
It is a great shame that the Government did not produce their response earlier. However, those of us who sat on the Committee considering the National Health Service Reform and Health Care Professions Bill will recognise certain strands that have been reflected in the Bill.
It is good to see that so many people involved with the Bristol royal infirmary—Members for constituencies in Bristol and the surrounding area—are present. We must recognise that the BRI is a tertiary centre that draws from a wide area. Many Labour and Conservative Members—although, sadly, not many Liberal Democrats—have been involved in the debate.
I declare an interest in that I trained at Bristol. I have the highest regard for the BRI, which turns out first-rate doctors. This is a sensitive report that acknowledges that. It does not resort to the blame culture in which politicians of all persuasions at times indulge. It does not subscribe to the cult of the easy target. Where politicians have, on occasions, been insensitive, Kennedy has trodden warily.
The report begins by laying down what most of us who have dealings with the BRI know to be true—that it is full of dedicated staff doing the very best that they can under difficult circumstances. I expect that, like many here, I struggled with the volume on first reading but, for me, the thrust was given not in the report, but by Professor Kennedy's subsequent newspaper statement when he was reported as saying:The report does not make a virtue of the number of people criticized and is at least as scathing about institutional failings in the NHS as it is about the deficiencies of individuals.
493 I recognise much of what was written from my time at Bristol. The report hints at a blokeish club culture. Although it does not explicitly state it, it hints at an atmosphere of bravado—the sort of thing that sadly attracts people who lack empathy to those specialties that are associated with high mortality and risk. I remember full well the towering and almost overweening self-confidence and arrogance of many surgical specialists at that time. Equally, however, I am struck by a new generation of doctors who seem to be in all respects different in outlook from those of the past, including the not-so-distant past.
My perception is that medical schools have, somewhat belatedly, realised that society has changed and that we demand a more conciliatory style of practitioner, with far better communication skills. The trend in our medical schools and in subsequent professional development has been towards enduring skills at the expense of more ephemeral learning of facts. It is a welcome development that has been driven by the profession and not by Government. We should pay tribute to the hard work that has been put in. I submit that that hard work will bear far more fruit than the Government's attempts at reform, no matter how well meaning.
Despite my up-beat assessment, I counsel caution. In July, The Times asked Professor Kennedy:Could Bristol happen again? Could it be happening right now?",to which he replied, "Yes." In The Guardian in the same month, he basically said, "There but for the grace of God go any number of bits of the NHS." The problems that he found were not unique to Bristol; it just so happens that they manifested themselves first in Bristol.
Indeed, if we require proof of that we need only refer to the investigation by the Commission for Health Improvement into St. George's, Tooting that was published just four months ago. It concluded that the deaths of eight out of 11 heart transplant patients over a 10-month period at that hospital could not be explained away by chance. The report revealed that not only did surgeons and managers choose their patients inappropriately for transplant, but that the unit was infested with rats and cockroaches, which is disgusting.
I wish to dwell on communication because it is axiomatic that doctors have been bad at it, and this report is certainly witness to that fact. I think that all are agreed that we need to ensure that patients have more time with doctors. Indeed, that is an important aim of the current negotiations to develop the new contract for GPs and consultants. Five minutes for the patient is simply not good enough and I know very well that it is dangerous, both for patients and practitioners.
The British Medical Association's board of medical education is doing well in promoting communication and learning skills for doctors, but at the end of the day the key factor is time available for the patient. I fear that the Government must take a large portion of the blame for failing to recognise that for every bright idea, initiative or stipulation that they impose on practitioners, there is an opportunity cost—less time and poorer communication with patients.
On Tuesday, during the debate on the NHS Reform and Health Care Professions Bill, the Minister of State dismissed the second tracker survey because it covered 494 events in the last three months of 2000. He said that it was an historical document because it reflected a situation that was 12 months old. The events recorded in this report are at least six or seven years old and we must not suppose that what applied then applies now.
The report paints a grim picture of mismanagement and institutional failure at the BRI and extrapolates its assessment to the NHS as a whole, but we do countless professionals, whose dedication to patients puts many of us to shame, a grave disservice if we fail to register the improvements that have been made since 1995 and to recognise that many of the problems unearthed at Bristol originate much further back in the history of the NHS.
§ Dr. Doug Naysmith (Bristol, North-West)
Like other hon. Members, I want to thank a number of people who contributed to the report and the Government's worthwhile response: first, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), who described the circumstances in which he made the brave decision to establish a public inquiry to which we have the opportunity to respond; secondly, Sir Ian Kennedy, who chaired what must be one of the most thorough public inquiries ever, which presented sensible recommendations that are also clear, concise and easy to understand; thirdly, the parents of the children involved, who not only had their individual tragedies to contend with, but their individual grief to bear once more as the inquiry began and many of their stories came into the public domain again.
I rarely agree with my neighbouring Member of Parliament, the hon. Member for Woodspring (Dr. Fox), but I did today when he drew attention to the burden that has been placed on the staff at the United Bristol Healthcare NHS trust hospitals. There has been an unwarranted focus on them simply because they have been close to the eye of the storm. Similar comments apply to the current senior management and senior board members at the UBHT, who were not in post at the time of the tragedies and have coped admirably with their additional unwanted tasks.
Perhaps the most important result of the Kennedy report, and the Government's response to it, has been the recognition that the concerns of so many people in the national health service were ignored or pushed under the table for years. No appropriate action was taken on the very poor results of paediatric heart surgery for far too long. Although bits of information were available over a period of years, they were not acted on.
There are many disturbing comments in the report. It talks of a lack of leadership and teamwork, a hospital that was permeated by a "club culture" and the lack of open discussion. It was a place where review was difficult and, perhaps most tellingly of all,vulnerable children were not a priority".There was no means of assessing the outcomes of treatment. Indeed, there were no agreed standards to measure local results against. That surely contributed to parents being told the national success and failure rates for such operations, rather than being given the Bristol figures. Had those been available to parents, it is hard not to ask how many children might have been saved if their operations had been carried out elsewhere. Parents who wanted to do their best for their very sick children were let down by the very people they trusted to help them.
495 To make matters worse, the report criticises the way in which parents were given details of the operations to be performed on their children. For example, it mentions details that were written on scraps of paper and that when children died as a result of the operation, some of their parents were told of that in an unsympathetic manner, with little help or advice being offered. This rigorous inquiry was therefore welcome, however painful it must have been for those involved.
The Kennedy report made 198 recommendations, and I believe that the great majority have now been, or are beginning to be, addressed. Today the Secretary of State brought us up to date with the progress. The major point about the dreadful happenings at the BRI and the children's hospital is that they highlighted several areas of health care and clinical practice that were not uncommon at that time. Bristol was not the only place where systemic factors led to inadequate services remaining undetected for too long. It may be true that there was an uncommon conjunction of bad practice in one place at that particular time, but elements of the Bristol situation were certainly present elsewhere.
I know that as a result of the scandal being brought to light and the subsequent inquiry, the BRI and hospitals throughout the country have changed, or are beginning to change, auditing and assessment techniques and, at least as importantly, their approach to patients. The result in Bristol has been a dramatic improvement in the quality of cardiac care for both children and adults.
I want to quote from a recent report by a Department of Health review team, to which there has already been a reference today. The team is examining every children's heart service in Britain. On clinical excellence in Bristol it says:The Trust has strengthened the Clinical Team during the last 3 to 7 years by appointing additional Consultants in Medical Paediatric Cardiology and Intensive Care and the recruitment of two full time Paediatric Cardiac Surgeons. The Clinical outcomes for Cardiac Surgery are amongst the best in the UK. It has a strong Intensive Care Team and a well balanced service from ante-natal diagnosis to the care of adults with congenital heart disease.On clinical governance, it says:Audit practice and procedures appeared particularly strong and are coupled to the clinical governance system where it operates through the clinical directors on to Trust Board level. Again the principle of transparency was emphasised. The Cardiac Unit is the only unit in the United Kingdom which at present publishes its clinical outcomes on the internet.
That report clearly shows that much of what Kennedy recommended is not only sensible but achievable. That is why I welcome the Government's response to the Kennedy recommendations, including those that have been implemented and those on which announcements were made today.
§ Ross Cranston (Dudley, North)
My right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) began and ended his contribution with a moving tribute to the parents. My hon. Friends the Members for Bristol, West (Valerie Davey), for Kingswood (Mr. Berry) and for Bristol, North-West (Dr. Naysmith) have all spoken, as constituency Members, of their admiration for the parents. Of course nothing can replace their terrible loss or assuage their grief, but I should like to associate myself with my hon. Friends' remarks about them.
496 As the Secretary of State said in opening the debate, much has changed since these terrible events. More money has gone into the NHS and more doctors are in the process of training. There have been organisational responses. There has been work to ensure that patients' needs are taken into account; national standards have been established, and there are mechanisms both to monitor and improve those standards. In addition, more information is being published for patients.
In many ways, the report is an historic document, dealing with what happened, but also providing an important and challenging map, as the Government response puts it. The Secretary of State indicated what steps have been taken; what steps are being taken in the National Health Service Reform and Health Care Professions Bill, which is before the House; and what will be done in future by, for example, the Council for the Regulation of Health Care Professionals.
My hon. Friends and others have paid tribute to Sir Ian Kennedy, and I should like to associate myself with those remarks. I should declare an interest here, because I was dean of one of the law schools at the university of London when Professor Kennedy was the dean at King's college, London. I know his work. He effectively pioneered the study of medical law in this country and, in many ways, the report is a testament to his accumulated knowledge and wisdom on the subject.
I want to address one particular aspect of the report, which falls under the heading of "Openness". At the very outset, on page 3, the report says that although from the late 1980s there was enough information about mortality rates for questions to be asked at the Bristol royal infirmary, the mindset to do so did not exist. The information was not available to the parents or the public, and the information that was given to them was confusing, partial and unclear. In an important passage, the report states:Perhaps the most fundamental feature of a culture of safety is the need for the hospital to create an open and non-punitive environment in which it is safe for healthcare professionals to report adverse events, safe to admit error, safe to admit when things have almost gone wrong, and safe to explore the reasons why … Without a culture of safe reporting, it is impossible systematically to collect information about the incidence of adverse effects, especially errors.That open and non-punitive environment did not exist at the time at the Bristol royal infirmary or more generally in the NHS. As my hon. Friends have said, the anaesthetist Dr. Bolsin blew the whistle. As my right hon. Friend the Secretary of State said in his statement in July, and my hon. Friend the Member for Kingswood said this afternoon, we owe him a great deal.
The report recounts how Dr. Bolsin became concerned about outcomes of children's heart surgery in the late 1980s; how he raised his concerns with his colleagues and within the trust; and how open discussion was inhibited by the culture. We had first-hand testimony from the hon. Member for Westbury (Dr. Murrison), who described his experience of being trained at the Bristol royal infirmary. In particular, Dr. Bolsin was inhibited by the fact that his anxieties concerned Dr. Wisheart, one of the most senior and long-serving surgeons at Bristol. Wisheart's view was that the reason for the poor results at Bristol was the condition of the patients, rather than the care that was provided. The report summarises Dr. Bolsin's position:The difficulties he encountered reveal both the territorial loyalties and boundaries within the culture of medicine and of the NHS, and also the realities of power and influence.
497 To promote a climate of openness and dialogue throughout the NHS, my right hon. Friend the Secretary of State, when a Minister of State in the Department in 1997, issued a letter, "Freedom of Speech in the NHS", in which he called on chairs of NHS trusts and health authorities to adopt good practice, enabling NHS staff to raise concerns about health care responsibly without fear of victimisation. He noted that there was a private Member's Bill to provide legal protection for whistleblowers: he indicated that it had Government support, but said that it was necessary to act straight away in advance of the legislation. I commend his actions in September 1997 in which he was no doubt supported by my right hon. Friend the Member for Holborn and St. Pancras.
I must declare a second interest at this point, because before entering the House I succeeded Lord Borrie as the chair of trustees of the whistleblowers' charity Public Concern at Work, which promoted what became the Public Interest Disclosure Act 1998. That Act was ably steered through the House by the hon. Member for Aldridge-Brownhills (Mr. Shepherd) and, in brief, protects people who raise genuine concerns—in the context of the NHS, concerns about risks to patients or possibly financial malpractice—whether or not the information is confidential. It protects NHS workers who blow the whistle and have an honest and reasonable suspicion of malpractice. Disclosure is protected if made internally and to identified regulators if the whistleblower honestly and reasonably believes that the information is substantially true. In some cases, wider disclosures are protected.
As a result of the Public Interest Disclosure Act, the NHS executive issued circular No. 198 on 22 August 1999, reflecting the strong support of my right hon. Friend the Secretary of State for the Act's underlying policy. The circular noted that the NHS had had its share of incidents that could, and should, have been prevented, had staff felt able to raise their concerns about health care matters without being victimised. Clearly, what had happened at Bristol was one of the incidents contemplated by the circular, as the Kennedy inquiry had been established a year before by my right hon. Friend the Member for Holborn and St. Pancras.
The circular required every NHS trust and authority to have in place local policies and procedures complying with the provisions of the 1998 Act. I hope that in his reply, my right hon. Friend the Minister of State will lay out the steps taken to implement the circular. For completeness, I should say that the charity Public Concern at Work has done a great deal of work in the NHS to ensure that there are adequate whistleblowing procedures.
I return to the report, and in particular its consideration of the whistleblower, Dr. Bolsin, and of whistleblowing in general. I do not want my remarks to be misunderstood when I say that there is a flaw in the report. I am not criticising anyone for that flaw. It is inevitable in a task of such magnitude that not every issue will be given the same detailed consideration.
I look to my right hon. Friend the Minister of State, in his reply to the debate, to confirm my understanding of the correct position. It is important for the future of the NHS and even more so for other parts of the public 498 services, as so much has been done in the NHS since my right hon. Friend the present Secretary of State's letter in 1997. It is important that whistleblowers such as Dr. Bolsin feel able to take action in relation to serious concerns, without fear of victimisation.
What does the report say? At page 162 it states that Dr. Bolsin would not have been protected by the Public Interest Disclosure Act 1998 if that had been in force, despite the report's assessment that although his actions may not have been the wisest, his conduct was understandable and he was right to persist in raising his concerns. His good faith is not questioned in the report. Unfortunately, the report does not mention my right hon. Friend's 1997 letter or the 1999 circular.
The legal analysis underlying the report's conclusion about Dr. Bolsin is in annexe A. I apologise to the House if what I am about to say is unduly technical. All that the Act requires of whistleblowers such as Dr. Bolsin is that they reasonably believe—I emphasise those words—that the information tends to show—again, I emphasise those words—the concern, and that the disclosure is in good faith.
The report states at page 141 of annexe A, first, that it is not clear whether any of the disclosures would have been protected as reasonable, and secondly, that mixed motives, which it rightly says are easily attributable to whistleblowers, would deny protection under the good faith requirement.
With respect, both those points are wrong. The test that a person should reasonably believe that the information tends to show something is a very low threshold. To suggest that Dr. Bolsin would not have met it is surprising—I put it no higher than that. The report sets out his collection of data, which clearly must have led him reasonably to believe that his concerns were credible. There is no criticism of Dr. Bolsin in that regard. Although hindsight cannot be taken into account, it confirms his reasonable belief. Doctors have been struck off, and we have a massive report with more than 200 recommendations. Clearly, Dr. Bolsin reasonably believed that the information tended to establish his concerns about children's heart surgery.
As for the point about good faith, my right hon. Friend the Minister of State will no doubt remember from his own legal studies that in English law, the test of good faith is basic: it is honesty. By contrast, good faith in the civil law and in some aspects of United States law is more demanding. It requires fair dealing. To suggest that mixed motives, which whistleblowers typically have, obliterate good faith is to misunderstand the distinction. Of course, if the dominant—I repeat—dominant motive of a whistleblower is mischief making or if it is ideological, that good faith would come into question. However, the mere existence of mixed motives in no way means that there is an absence of good faith.
I believe that a third aspect of the report is in error, in relation to the wider disclosure that Dr. Bolsin made to Dr. Phil Hammond, the GP and media commentator. The report focuses on whether a particular gateway was satisfied. In my view, another gateway was clearly satisfied, as Dr. Bolsin had raised matters internally but had got nowhere and could therefore raise them outside.
I have detained the House for too long. I believe that it is very clear that Dr. Bolsin would have been protected by the Public Interest Disclosure Act 1998 if it had been 499 in force at the time. The Act and the measures to implement it in the NHS, and more generally, have ensured a fundamental shift in culture since these terrible events occurred. I was especially pleased to hear my right hon. Friend the Secretary of State announce acceptance of the report's recommendation on establishing a free confidential telephone line for the reporting of sentinel events. There is now a climate of greater openness and dialogue. Nothing in the report should dissuade people from expressing concerns because of a fear of victimisation. It is to the credit of Ministers that the culture has changed. The signal has now been given that speaking up about serious concerns is a safe alternative to silence.
§ 5.6 pm
§ Mr. Oliver Heald (North-East Hertfordshire)
The hon. and learned Member for Dudley, North (Ross Cranston) made a good point about the protection that those who want to give information to the authorities require under the Public Interest Disclosure Act 1998. I, too, will be interested to hear the Minister's response to that point. His contribution also shows that lawyers have their uses, as he gave us a fine technical legal analysis of the Act. Perhaps lawyers are not all bad. Have I made the declaration?
We welcome this debate, which has been a good one. My hon. Friend the Member for Woodspring (Dr. Fox), who opened for the Opposition, called for such a debate last year. We understood why it was not possible to hold it in November, but we welcome today's opportunity to consider the Government's response to the report. The debate has concentrated on the issues of information, openness and trust that are at the heart of what Professor Kennedy said in his report. I shall deal in a moment with some of those issues and the comments that have been made about them.
The debate has also been characterised by an understanding of the courage that has been shown by a number of people during the history of this dreadful situation. Of course, first among them are the parents, who have had to show great courage in tragic circumstances. It is hard to know how one would feel about losing a beloved child. There must be at least some comfort in the thought that something has come out of the tragedy. This is a very full, detailed report—I do not think that anybody could criticise it for not being fully comprehensive. The Government have listened and I pay tribute to them for that. The response that they have made today shows that they are taking the matter seriously, as they should. The courage of the doctors who deal with tiny babies and their surgery has been mentioned by a number of hon. Members, as has that of the former Secretary of State in initiating a public inquiry. So, the debate has brought out some of the good qualities in this dreadful situation as well as the bad ones, which we should not, of course, ignore.
My hon. Friend the Member for Woodspring paid tribute to the parents' courage from the perspective of a constituency Member of Parliament from the Bristol area. Several hon. Members spoke from that perspective and agreed with his comments about the parents and doctors who have brought about change at Bristol.
My hon. Friend spoke about the importance of informing the choice that parents make. He posed a question, which I hope the Minister will answer. 500 If comprehensive and balanced data show that a specific clinician in a specific hospital has a poor record, to what extent will it be possible for that to inform parents' choice? Will parents or patients be allowed to base choices about referrals on the data? If that cannot happen now, will it be possible in future?
My hon. Friend also mentioned consent and knowledge. He said that in some circumstances, informed consent was difficult to obtain—for example, in emergencies and when procedures are experimental. It would be helpful if the Minister could outline any proposals for handling emergencies and experimental procedures.
The Minister will be pleased to know that I shall not mention community health councils. However, if NICE produces guidance that has not been approved by the Minister, who makes the decision about affordability? It would be odd to leave it to NICE, given ministerial responsibility to the Treasury.
My hon. Friend the Member for Woodspring made two other points. First, he referred to people from non-traditional backgrounds entering medicine and its allied professions. Will the Minister explain more fully what the Government have in mind? What would be the benefits? Secondly, hon. Members from all parties paid tribute to the General Medical Council, which has proposed reform and been prepared to meet the challenge of change. Do the Government have any proposals for speeding up investigations? Although the GMC should not be too hasty, a proper sense of speed is necessary for discipline and accountability as well as for the courts and dealing with clinical negligence.
The right hon. Member for Holborn and St. Pancras (Mr. Dobson) made several important points. He was rightly given credit for choosing Professor Kennedy and for setting up a public inquiry. He said that there were failures at all levels and that one must always ask the Florence Nightingale question: "Who's in charge here?" He made important points about openness and the compensation culture. The extent to which the Government are prepared to move against the current arrangements on clinical negligence is not clear in the report. What is the Minister's thinking on recommendation 119?
The current system clearly has problems. As my hon. Friend the Member for Woodspring said, it takes a long time to reach a result, and the legal costs often outweigh the compensation. However, most of us believe that there should be some form of legal redress in clear cases of negligence. We have ideas about moving more towards mediation, perhaps, or having a tribunal-based system, and about bringing informality into the system and trying to speed it up, building on the Woolf reforms, and so on. Is the Minister able to give us his view on this? It is important to avoid a compensation culture. I think that the Americans, if they had a choice, would probably not have the system that has developed in their country. Let us make sure that we do not have a compensation culture. Achieving that will not, however, be entirely straightforward, and it would be interesting to hear what the Minister has to say on the matter.
The hon. Member for Oxford, West and Abingdon (Dr. Harris) felt strongly that we should not have a blame culture, and I agree with him. It was something of a non sequitur, however, for him then to say that the information that is published has to be strictly controlled by the medical profession. I accept that what the Society of 501 Cardiothoracic Surgeons has done is excellent and a good example of teamwork—that is obviously what we must aim for—but it would be wrong if the medical profession or anyone else had a veto on information being published. It is important that information should be placed in the public domain, even if it is not quite as complete as one might hope.
My hon. Friend the Member for Woodspring and the Secretary of State were right to say that to suppress information is never helpful. If incomplete information comes into the public domain, there are always opportunities for people to put it right. My hon. Friend gave an example of information from a regional centre, where one might expect the more difficult cases to be dealt with, not being clearly labelled as having come from there. His example showed what happens when information is put out that is not completely accurate. It was put right, because people are not prepared to accept false information. To suppress information is not the answer.
The hon. Member for Bristol, West (Valerie Davey) made an important speech about the doctors who have worked so hard to improve the situation at Bristol. She rightly concentrated, as did my hon. Friend the Member for South Cambridgeshire (Mr. Lansley), on the importance of child-centred provision. Although the hon. Lady did not claim to have all the answers—that was very honest of her, and something that we all ought to do more often—the points with which she was wrestling were important ones. There is no doubt that Professor Kennedy felt that this was an area of great weakness, in that suggestions for improving child-centred provision have been ignored for 40 years. It would be helpful if the Minister were able to give us some idea of why the validation and revalidation of children's hospitals is not to be pursued, and why he feels that relying on the Commission for Health Improvement is an adequate response to the recommendation.
Clearly, there are issues about structure involved here, which my hon. Friend the Member for South Cambridgeshire outlined. There are also issues about the quality of the provision. Having met nurses and others who deal with children in hospital, I know that they say, "It isn't good enough to have surgeons who normally treat adults treating children, because they do not really understand how to deal with a child." Very different kinds of clinical procedure are needed when dealing with a child. I understand, for example, that children recovering after an operation need particular care—more so than adults, although we also expect a high standard of care for adults. With children, there are different considerations, and it would be helpful if the Minister would amplify the extent to which that will be dealt with in terms of structures, standards and monitoring, as hon. Members have requested him to do.
My hon. Friend the Member for Woodspring asked a question that I remember asking the Minister in Committee not so long ago: what are the special measures? If the Commission for Health Improvement produces a report stating that a situation is unsatisfactory, the Secretary of State obviously has some powers of intervention. I believe, however, that the measures being suggested go beyond those simple powers. Will the Minister tell us today what they are? Will he also say why 502 the Government do not support the recommendation that travel costs and parental access should be more fully funded?
The hon. Member for Kingswood (Mr. Berry) made four points. He was surprised and shocked that there were no clear standards of care when the incidents occurred and that monitoring and an agreed means of evaluation were not in place. He also made an important point about the culture change that has occurred. My hon. Friend the Member for Westbury (Dr. Murrison) was trained at Bristol royal infirmary and he explained that years ago there was a hierarchical culture and arrogant attitudes among some surgeons, although he strongly made the point that that has changed.
Society's attitudes are changing and we are moving from a culture in which we accepted hierarchies and that the surgeon or consultant was not to be challenged or questioned to one in which we accept that patients have a voice and that they are entitled to information. We also accept that citizens are to be empowered, and I welcome that. It is not as surprising as the hon. Member for Kingswood suggested that things were as they were, but it would be surprising if they remained that way. It is a good thing that citizens are becoming more able to make choices and be informed.
The hon. Gentleman also made a point about whistleblowing and noted that health funding is important to standards. It is easy to ignore the basic funding position or the basic background against which a doctor works, but we should not do so. Inadequate equipment and buildings, which the report refers to, make it difficult for a doctor to perform and it is difficult for those in charge of monitoring performance and ensuring that it is achieved to set a world-class standard when world-class tools are not available for the job. We must all consider that issue and I am sure that we shall debate it further.
I do not want to speak at great length and there is much for the Minister to respond to. This has been a serious debate of the highest quality and, rightly, there was none of the usual party political knockabout. The report and this issue are so important that descending to that would not have been a good thing. I look forward to the Minister's remarks.
§ The Minister of State, Department of Health (Mr. John Hutton)
Anyone who heard the excellent speeches of right hon. and hon. Members will reach the same conclusion that I have reached: that this has been a thoughtful but sombre debate, which is entirely appropriate to the subject. It was genuinely illuminated by important insights into the tragedies at Bristol and the clear and obvious failures of individuals and the national health service. All Members rightly emphasised the need to learn the lessons from Bristol. I shall say more about that later, but, most positively, they rightly decided to look to the future—securing higher standards and better treatment and care, which we all want in the NHS.
The hon. Member for Woodspring (Dr. Fox) opened for the Opposition. I welcome his positive comments and his general support for the response that we are publishing today. He asked a number of specific questions. I shall try to deal with them, but in no particular order, as I have not arranged my notes in that way, although I may surprise him.
503 The hon. Gentleman began by asking what have become familiar questions about arrangements that we have established in statutes over the past two or three years relating to inspection arrangements for the NHS. He requested further and better particulars about how we intend to advance the commitment made today by my right hon. Friend the Secretary of State to secure more organisational integration between inspectorates. I thank the hon. Gentleman for welcoming what my right hon. Friend said, and I thank the hon. Member for Oxford, West and Abingdon (Dr. Harris) for doing the same.
The hon. Member for Woodspring was right to say that we must carefully consider these important issues. The changes in question would certainly require primary legislation. I agree with the hon. Member for Oxford, West and Abingdon that, given their importance, it would not be appropriate to try to make such amendments during the passage of the National Health Service Reform and Health Care Professions Bill in another place; that would deny Members of this place a proper opportunity to debate the Bill.
I am sure the hon. Member for Oxford, West and Abingdon understands, as I hope that the House does, that we are not in a position today to go into further detail about the proposed reforms, but, as I think I made clear on Tuesday, it is at the forefront of our mind that the NHS should have a set of arrangements for inspection of quality and performance monitoring that are as streamlined as we can make them, and the least bureaucratic possible. We want those arrangements to add value—not just to help the NHS to deliver high-quality services, but to inform the public better about the quality of those services. Those criteria will inform our thinking, and I am sure that Members will have many opportunities to debate them in more detail.
I was grateful to the hon. Gentleman for recognising the importance of greater public access to information that is comprehensible and adds value. I shall return to that shortly, because several Members asked about it.
The hon. Gentleman asked a specific question about consent, and how we were proceeding with proposals to standardise consent procedures. As he will know, the Department published a standardised consent form last November. Its use will become a requirement throughout the NHS in April. He asked about the standardisation of information. We shall need to develop the issues with the professions, and with patient groups, but the model consent policy will require trusts to make patient information available locally and in a form that people can use—as tapes or pictorial material, as well as written leaflets. Trusts are also required to provide information on local advocacy groups.
Information needs to be tailored to reflect the provision of local organisations and services, and the procedures that a patient is undergoing. We want as much standardisation as we can get, along with as much customisation as we can get. Perhaps that is an example of the hon. Gentleman's failure to understand what my right hon. Friend the Secretary of State said on Tuesday.
The hon. Gentleman asked an important question about the General Medical Council. He asked whether we were minded to seek ways of speeding the important process of investigating allegations relating to fitness to practise. The answer is that we are very much so minded: we will look sympathetically at proposals to speed the processes 504 of the GMC and its various disciplinary committees, and to make them simpler. As we are currently discussing those issues with the GMC, however, I do not think that I can deliver more than my statements of general intent.
The hon. Member for Woodspring asked for more information about how we intended to move people from non-traditional backgrounds into medical careers. He and the hon. Member for Westbury (Dr. Murrison) seemed surprised that we want to pursue that objective, although I may have misinterpreted what was said.
The hon. Member for Westbury implied that all the progress that had been made was down to the medical profession—that, anyway, is how I interpreted his remarks. I must tell him, with respect, that I think that the Government have played an important role in introducing change.
Hon. Members asked how we intend to proceed. In accepting Kennedy's recommendation 78, we have acted against a background of action that has already begun. In 1999 and 2000, and in subsequent years, higher education institutions were asked to bid for extra places, and to demonstrate an active commitment to recruiting students from a broad range of social ethnic backgrounds to reflect the patterns of populations served by the NHS. Most of the successful institutions addressed the issue of broadening the socio-economic background of the intake in a number of ways. Those included reviewing their selection processes, promoting outreach schemes and creating new—or increasing the numbers on—pre-medical courses designed to broaden intakes. That is an important policy objective if we are to address some of the concerns that Professor Kennedy expresses in his report and that right hon. and hon. Members have raised on several occasions in the House.
The hon. Member for Woodspring raised several other points and I shall return to his comments later. I calculated that I was asked 49 separate questions during the debate and I shall try my best to answer all of them, but I cannot guarantee to do so. I shall certainly write to hon. Members about those that I do not cover.
Like everyone else who has spoken in this debate, I wish to congratulate my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) on his decision to establish the inquiry. It was his decision to appoint Professor Kennedy, who did a superb job, and to make it a public inquiry, which was undoubtedly the right decision.
My right hon. Friend raised two important issues. He spoke about the need for medical professionals to adopt a more open approach to patients, and he was right to say that that approach creates its own dilemmas. We need to approach the issue carefully, in consultation with health professionals and patients. I agree that information must be fair and not give a false impression. We will need to work with the health professionals and others to ensure that that happens.
My right hon. Friend also spoke about the importance of the way in which patients are treated. As he said, when they or their family or loved ones are ill in hospital they are often under great stress and feel great anxiety. I agree that the training of doctors, nurses and other health professionals has a role to play, and that issue is being pursued. He is also right to say that progress is being made; we wish to maintain that progress, even though it can be extremely difficult.
505 Yesterday, I presented some prizes at a writing competition for doctors that was organised by the BMA. It was not, as someone at the event suggested, sponsored by the pharmacists to see who could interpret the doctors' handwriting. Perhaps I should not have said that. The competition was designed to get doctors to write about what brought them into the medical profession and what motivates them to stay in what we all acknowledge is a highly pressurised and stressful environment. The entrants wrote some fabulous pieces on what made them want to become doctors, but the majority centred on the relationship with their patients, their care for their patients and their desire to improve the health of their patients. The points that my right hon. Friend made about the essential relationship between the doctor and other health professionals and the patient lie at the heart of many of Professor Kennedy's recommendations, which the Government have endorsed. That relationship is the key to making the NHS a better service for patients.
My right hon. Friend the Member for Holborn and St. Pancras, the hon. Members for Oxford, West and Abingdon and for North-East Hertfordshire (Mr. Heald) and my hon. Friend the Member for Kingswood (Mr. Berry) all expressed concerns about the law on medical negligence and how a fear of being sued must not deter doctors from being honest about failures or being clear about when things have gone wrong. Other hon. Members talked about the disincentives of the present scheme of tort-based clinical medical negligence law suits. That is addressed in recommendation 119, which deals with replacing the present system with a no-fault compensation scheme.
All that I can say on the issue, which has obviously been the subject of serious concern, is that my right hon. Friend the Secretary of State said that we will publish a White Paper that will consider all the issues in some detail. The way forward will be informed by the work that the chief medical officer, Sir Liam Donaldson, has already begun of talking to the professions, lawyers, patient groups and others, and by what Professor Kennedy has to say on that immensely complicated matter, which also raises human rights issues.
§ Mr. Hutton
We will do it as quickly as we can and I hope that, in the not too distant future, we will have the White Paper. I cannot give a specific date—[Interruption.] That is what it says here, anyway. The hon. Member for Woodspring must understand that these are complicated issues. If we were to rush to produce an unsatisfactory White Paper, he would be the first to jump up and say that it was a rushed job. The seriousness of the issues raised today means that the most detailed consideration will be required before the White Paper is produced.
The hon. Member for Oxford, West and Abingdon made one of his usual speeches about the NHS and offered his prescription for what is wrong with it. He started where the Liberals always start—with resources. 506 [Interruption.] The hon. Gentleman is not here? Then this will not be nearly as much fun. [Laughter.] That is a great shame. I am sure that he will be listening through the monitors. If not, I shall send him a video of my remarks.
The hon. Member for Oxford, West and Abingdon spoke about resources, and made a perfectly fair criticism in that regard, but there are two points that I should make. First, Kennedy himself recognised and acknowledged the importance of the extra investment that the Government are making in the NHS. That is an important point to get on the record. Secondly, Professor Kennedy's report made it clear that the problems at Bristol were not caused by underfunding. He made it clear in paragraph 39 that that is not his view of the problems. That is not to say that there were not resource pressures at Bristol, but they were being experienced in every other hospital across the country at that time, and Bristol's performance was significantly poorer. The problems are clear and Professor Kennedy's analysis was specific.
I have dealt with the concerns expressed by the hon. Member for Oxford, West and Abingdon about recommendation 119, albeit perhaps not to his satisfaction. I welcome his support for the general direction in which we are travelling in relation to the reform of inspection, but I am disappointed, although I cannot say that I am surprised, by his comments on the CHI and the role of Ministers in setting priorities for the NHS. I have told him many times that that is a perfectly legitimate job for Ministers. It is Ministers' job to set priorities for the NHS—it is our responsibility to this House and the public at large.
I must take issue with the hon. Gentleman's view that there is any benefit or constitutional propriety in shuffling off that responsibility to the CHI, whose job is different—to inspect the NHS and to advise this House and Ministers about the quality of NHS care, not to supplant the proper role of Ministers in determining the overall priorities for the NHS.
We are making substantial extra resources available to support the introduction of the NICE guidelines. The hon. Gentleman took a rather cynical attitude to the issue of making more information available to patients—an issue to which we shall return in future. I was left in some doubt, however, about whether he was on the side of patients in this regard, and he needs to make up his mind about that.
My hon. Friend the Member for Bristol, West (Valerie Davey) made an impressive speech, and I echo and endorse her praise for those who not only campaigned on behalf of patients caught up in the tragedy but worked tirelessly to support their families. She mentioned Maria Shortis and Trevor Jones, and I echo her support. She was right to reflect the commitment and professionalism of staff at the BRI, who will continue to dedicate themselves to the needs and interests of their patients.
I agree with my hon. Friend about the benefits of publishing more health care information. Along with the hon. Member for South Cambridgeshire (Mr. Lansley), my hon. Friend raised the important issue of service reconfigurations affecting children in the NHS. The report makes a number of important recommendations in this regard. The hon. Gentleman referred to developments that are planned or under consideration in his constituency. He will know that we are committed to establishing a new national service framework for children's services across 507 the NHS. It will be an important step forward in improving services along the lines that Kennedy would like. Everyone in the House who is concerned about the welfare of children would like to see that as well. The work is being led by Professor David Hall, President of the Royal College of Paediatrics and Child Health, and Jo Williams, the director of social services in Cheshire, with the support of a number of leading professionals in the field.
That is about all that I can say today about how the reconfiguration will be addressed. It will form part of the work of the external reference group, and ultimately it will be reflected in the national service framework.
My hon. Friend the Member for Bristol, West said that, although the Kennedy report made it clear where the responsibilities lay, she had been asked to whom the Department of Health was accountable. I can tell her that the Department is responsible to the country, the public and hon. Members. Long may that remain so: we are fully accountable, in this House and outside it, for our decisions. The country will be the final judge of our performance.
The hon. Gentleman made a considered speech, as always. He was right to look at the report's implications for other parts of the country and of the NHS. He focused on children's services in the NHS. As I said, matters to do with reconfiguration will be dealt with as part of the work on the national service framework.
The hon. Gentleman was right to say that it will not be enough just to publish another report on improving those services. All of us know, from our experience in the House, in business or in government, that reports do not implement themselves. They need to be monitored and implemented. There will be a clear timetable for implementation of the national service framework, and that will form the benchmark for CHI inspections. We are under no illusions about the job that needs to be done, but I assure the House that this report will not gather dust on anyone's shelf.
I am grateful for the support that the hon. Member for South Cambridgeshire expressed for the families of sick children. He and other hon. Members asked about recommendation 142, which covers the hospital travel costs scheme. We have to make a difficult judgment on the matter. It is right that NHS resources are targeted on those whose need is greatest in regard to travel and support costs, but he will know that trusts use their general powers of discretion to provide a range of support facilities for patients and family members caught up in terrible events such as happened in Bristol.
Hon. Members will, like me, have visited hospitals where trusts make overnight accommodation available to parents and others and that provide a range of other services to support patients and families who have to travel with sick children. Again, long may that continue to happen, but we have to make a hard judgment about access to the travel costs scheme. We believe that help should be focused on those with the greatest need, but we will also do everything in our power to support the wider use of trusts' discretionary powers.
I agree with my hon. Friend the Member for Kingswood about the importance of the report. I welcome his support for the Government's response. He was right to emphasise the need for national standards. He and my hon. and learned Friend the Member for Dudley, North 508 (Ross Cranston) raised concerns about the extent and scope of the Public Interest Disclosure Act 1998 in relation to Dr. Stephen Bolsin.
We have corresponded with Public Concern at Work on the matter. In the light of Professor Kennedy's recommendations and conclusions in that regard, we have carefully looked again at the scope of the 1998 Act. We are completely satisfied that if the Act had been in force when Dr. Bolsin made his recommendations, it would have given him the necessary protection and cover, as it was designed to do.
My hon. and learned Friend the Member for Dudley, North made a scholarly and learned speech, in which he referred very politely to my legal training—although I do not think that my training was quite as good as his. I can confirm to him, as I have to Guy Dehn at Public Concern at Work, that the legal advice that we have received supports that organisation' s interpretation of the relevant sections of the 1998 Act. I am therefore satisfied that Dr. Bolsin would have been fully protected by the legislation. We will, of course, keep the matter under the closest scrutiny.
The hon. Member for Westbury rightly called the Kennedy report a magisterial tome, and welcomed both it and the Government's response. He described the report as sensitive and reflective, and he was right to do so. We certainly benefited from hearing his personal and professional observations about working at the Bristol royal infirmary. I welcome, too, his support for expanding recruitment to medical schools to a wider social range. That is the right thing to do.
My hon. Friend the Member for Bristol, North-West (Dr. Naysmith) described the recommendations as clear, concise and easy to understand. That is true. Like other Bristol Members, to whom I pay tribute, he emphasised the high quality of paediatric cardiac services at the BRI. Kennedy's recommendations were sensible and achievable. I agree with my hon. Friend in that regard.
I have referred already to the comments of my hon. and learned Friend the Member for Dudley, North, who rightly described the Kennedy report as an historic document. I am grateful for his support for the measures that we are taking.
Professor Kennedy's report on events at Bristol royal infirmary between 1984 and 1995 marks a seminal moment in the history of the NHS. It not only accurately identified the problems that existed at Bristol and across the NHS at that time—the lack of national standards, the absence of a proper system for monitoring and ensuring quality, the lack of information for patients, no effective role for the public in local health care services and inadequate regulation of both professions and services—but pointed the way forward in ensuring that the NHS learns from those events and improves its service to patients. We intend to make sure that that happens.
§ Mr. Lansley
I recognise that the Minister was asked to give answers to many questions and that he has not dealt with them all, but I draw his attention to the fact that I and my hon. Friend the Member for North-East Hertfordshire (Mr. Heald) referred to the Government's rejection of a package of 10 recommendations in the Kennedy report on validation and revalidation of trusts providing children's services to build quality into the provision of services, rather than to seek to inspect them 509 post hoc. The Minister may refer to that at the same time as he says that the Government are going in the right direction on inspection.
§ Mr. Hutton
I intend to refer to that, but the hon. Gentleman is wrong in his description of the difference between validation and inspection. It is wrong to say that the Government are concerned only about measuring quality, as it were, post hoc. We are building quality into services by, for example, establishing the new national standards contained in the national service frameworks and in a range of other measures, including NICE guidelines.
Under NHS Reform and Health Care Professions Bill, CHI will have new powers to advise Ministers about a range of special measures that could be taken. The hon. Member for Woodspring asked what those special measures would be. We have been through that issue on many occasions. He is aware of the range of special measures, which could range from visits from the modernisation agency and, looking at practice and how it can be improved to taking more serious measures: for example, to curtailing the provision of a service if it is unsafe and is placing patients' lives at risk. It is wrong to say that in rejecting the recommendations on validation we have compromised the pursuit of high-quality services across the NHS. It is just a different mechanism for securing those quality improvements.
In identifying the problems and recommending solutions, we warmly welcome the fact that Professor Sir Ian Kennedy has given a broad welcome and endorsement for the NHS plan and the general direction of health service reform and investment that the Government have initiated since taking office in 1997.
The events at Bristol were, in the view of Professor Kennedy, a tragedy. No one can dispute that assessment. As my right hon. Friend the Secretary of State made clear, the inquiry team estimated that between 1991 and 1995 alone, 30 to 35 more children under the age of one died after open-heart surgery at Bristol than might have been expected had the unit been typical of other paediatric cardiac surgery units in England at the time.
In five of the seven years between 1988 and 1994, the mortality rate at Bristol was roughly double that elsewhere in the NHS. As many hon. Members have observed, the warning signs were obvious but were neither acted on nor taken seriously enough. As Professor Kennedy makes clear, the failures were both structural and individual.
Too many children died as a result. In the view of the inquiry team, a third of all the children who underwent open-heart surgery at Bristol received less than adequate care. Those children and their families were let down by the very system that was supposed to protect and care for them. The emotional consequences of those failures are still being felt today by all the families involved, who have been devastated by the loss of those so young and vulnerable.
While acknowledging that grief and sense of loss, as we must do in the House today, it is important, as the 510 hon. Member for Oxford, West and Abingdon did, to record the view of the inquiry team: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.However, as the report noted:The system for delivering paediatric cardiac services in Bristol was frankly not up to the task".The failures in Bristol were both within the hospital—in its organisation, culture and leadership—and in the wider NHS.
The report clearly identified failures on the part of key individuals involved, but crucial failures were also recognised on the part of the NHS itself effectively to monitor and set standards for the quality of care provided at Bristol—or indeed anywhere else in the NHS at that time—and to give a high enough priority to the needs of sick children.
As Sir Ian put it:There were no agreed standards of care, and not only no external monitoring of clinical performance but no real mechanism for doing so.That is a shattering critique of the NHS at that time. All those deficiencies must be addressed if the NHS is to remain a high-trust organisation. Patients trust that doctors, nurses and other front-line staff will take the highest possible care over their treatment—and rightly so, because in the vast majority of cases that trust is fully deserved.
The NHS is full of excellent professionals who do their best for their patients and provide very high standards of care. Nothing in the report detracts from that; but that trust must always be earned—it can never be taken for granted.
The Government's responsibility—working with the medical, nursing and other health-care professions—is to do all that we can to maintain that vital relationship of trust and confidence between patients and the NHS. It is in that crucial area that Professor Kennedy's report is so important and where its recommendations will, I believe, make such a useful contribution.
Of course, as many hon. Members have said today, and as my right hon. Friend also made clear, things can and do sometimes go wrong. All of us know that even the very best doctors and nurses can make mistakes. As the report rightly stresses, heart surgery at any age is a risky enterprise. The trust that must lie at the centre of the relationship between patients and the NHS can, first and foremost, be enhanced by ensuring that NHS services are built around the needs of patients, with safety at the top of our list of priorities—not as an add-on.
We must be able to demonstrate that the NHS can respond effectively to concerns raised by patients and the public; that people working in the NHS are encouraged and feel able to speak out when necessary, safe in the knowledge that someone will listen and will take their concerns seriously; and that reliable and independent inspection and regulation, using national standards as a benchmark, will back up all those essential safeguards.
The relationship between doctors and their patients must depend absolutely on the principle of informed consent, where the right information is provided to the 511 patient, in the right way and at the right time to enable them and their family to come to the decision that is right for them.
Professor Kennedy makes a number of important recommendations in that area that we accept and fully endorse. The way in which patients and, in the case of young children, their parents, are treated by doctors and other key staff is of enormous importance in establishing and maintaining a relationship of trust and confidence. We are already taking action to improve the procedures for obtaining consent, and as our responses today make clear, they will fully reflect the principles outlined in the Kennedy report. There, as in other areas, important lessons have been learned from the events at Bristol.
In essence, the main features of the new NHS architecture suggested by Professor Kennedy in his report are: openness; clear standards; quality and safety built into every aspect of service delivery; a real partnership between patients and the health professions; and a service led by managers of the highest calibre who are provided with the right level of resources to do the job expected of them.
As my right hon. Friend made clear, we accept and share that broad analysis. That is why we have already begun the process of putting those new arrangements into effect. Significant progress has been made in that area since the terrible events at Bristol occurred.
Since 1997, we have taken action to establish new standard setting and inspection bodies: the Commission for Health Improvement and the National Institute for Clinical Excellence, both of which operate outside the Department of Health.
The new national patient safety agency and the National Clinical Assessment Authority will help to tackle the problem of poor performance wherever it is identified and help doctors to improve their clinical practice.
New national service frameworks—initially covering mental health, coronary heart disease, services for older people and diabetes—have laid out clear national standards for the first time. The frameworks will cover both long-term medical conditions and children's services in the near future. As I said earlier, the national service framework on children's services will help to address Professor Kennedy's specific concerns about further improvements in the standard of paediatric care in the NHS.
The modernisation agency is helping NHS organisations to improve their performance and to spread good practice across the NHS. There is more information available to the public than ever before about NHS performance both nationally and locally, backed up by a system of rewards for good performers and intervention when necessary where performance is not good enough.
My right hon. Friend the Secretary of State has outlined how we intend to make further and better information available to the public on the performance of individual consultants and surgical teams. Those important steps will help to maintain the vital trust between doctors and patients and increase public information about the standard of health care available. That will represent significant gains for both patients and the NHS alike.
As Professor Kennedy acknowledged, the reforms will require a new relationship not just between patients, the public and the NHS; the relationship between the Government and the NHS itself needs to change so that it 512 better reflects the society that we live in and the complexities of such a large and diverse organisation that now employs more than 1 million people and treats more than 20 million patients each year. The Government have already embarked on important changes in that regard, to which the Kennedy report adds further impetus.
My right hon. Friend has today set out the Government's view on the changing relationship between the NHS and the Department of Health. As the Government's response to the Kennedy report makes clear, the role of the Department is no longer to run the NHS as if it were a mid-20th century nationalised industry.
The proper balance needs to be struck between maximum operational responsibility for front-line service providers and the Department's responsibility to provide the accountability and the means—the resources and properly trained and supported staff—by which health care services of the highest possible quality and standard can be provided to patients.
As Kennedy makes clear and we have accepted in our response today, a key element will be to ensure that the highest priority is attached to improving the leadership and management of the NHS at every level. The new leadership centre, which we have established, together with the NHS university, which we are setting up, will play important roles in developing those vital skills. A new contractual framework for senior managers and a new national code of conduct will help to ensure that the highest standards are pursued at all times.
It is also the Department's responsibility to propose the overall framework of legislation and policy in which the service operates, and to do so in a way that reflects the need for flexibility, choice, quality and diversity in health care.
The Health Act 1999 and the Health and Social Care Act 2001 implemented important reforms. The NHS Reform and Health Care Professions Bill will also produce important further reforms, called for in the Kennedy Report, with the establishment of the new United Kingdom Council for the Regulation of Health Care Professionals and the office for health care information in the CHI, together with a stronger role for the public in decision making in the NHS.
We should not lose sight of the fact that those reforms are being implemented against the background of sustained and unprecedented public investment in the NHS, which will produce more doctors, nurses, therapists and other key staff, working in newer hospitals with better equipment and faster access to the latest technology.
In conclusion, it is our collective responsibility in the House to ensure that we learn the lessons of what happened at Bristol, and in the process see to it that we have an NHS fit for the new century. That will require the will to see through the necessary reforms and not to slow down the pace of change. It will need the necessary resources to be provided—yes, of course—to ensure that the improvements in quality, safety and capacity across the NHS take place. It will necessitate the active support of patients, public and NHS staff themselves.
I believe that all those key elements are in place. All of them will support the necessary change of culture in the NHS that Professor Kennedy rightly identified as being of fundamental importance. It is obviously true that none of us can turn back the clock. We cannot undo what was 513 done to those children and their families, but we can take action to put right the obvious failures identified in the Kennedy report.
The action that the Government have already taken, together with the further measures that my right hon. Friend has announced today, will make a significant contribution to realising that objective. I hope that all Members from both sides of the House will support those reforms in order to ensure, as far as we possibly can, that the trauma and suffering of those children and their families will not be repeated in the future.
§ Mr. Phil Woolas (Oldham, East and Saddleworth)
I beg to ask leave to withdraw the motion.
Motion, by leave, withdrawn.