Yesterday, the Prime Minister made a statement on the inquiry into the appalling events at Mid Staffordshire NHS Foundation Trust. The Inquiry — whose report may be found here — must be made to have profound consequences for the NHS, all who work in it and all of us who require it to care for ourselves and our loved ones.
I reproduce the statement in full below.
Today, Robert Francis has published the report of the public inquiry into the Mid Staffordshire NHS foundation Trust.
Mr Speaker, I have a deep affection for our national health service. I will never forget all the things that doctors and nurses have done for my family in times of pain and difficulty. I love our NHS. I think it is a fantastic institution and a great organisation that says a huge amount about our country and who we are, and I always want to think the best about it. I have huge admiration for the doctors, nurses and other health workers who dedicate their lives to caring for our loved ones. Nevertheless, we do them and the whole reputation of our NHS a grave disservice if we fail to speak out when things go wrong.
What happened at Mid Staffordshire NHS foundation Trust between 2005 and 2009 was not just wrong; it was truly dreadful. Hundreds of people suffered from the most appalling neglect and mistreatment. There were patients so desperate for water that they were drinking from dirty flower vases. Many were given the wrong medication, treated roughly or left to wet themselves and then lie in urine for days, and relatives were ignored or even reproached when they pointed out even the most basic things that could have saved their loved ones from horrific pain or even death. We can only begin to imagine the suffering endured by those whose trust in our health system was betrayed at their most vulnerable moment. That is why it is right to make this statement today.
An investigation by the Healthcare Commission in 2009, a first independent inquiry by Robert Francis in February 2010 and, long before that, the testimony of bereaved relatives, such as Julie Bailey, and the Cure the NHS campaign all laid bare the most despicable catalogue of clinical and management failures at the trust. Even after those reports, however, important questions remained unanswered. How were these appalling events allowed to happen and to continue for so long? Why were so many bereaved families and whistleblowers who spoke out ignored for so long? Could something like this ever happen again? These are basic questions about wider failures in the system, not just at the hospital, but right across the NHS, including its regulators and the Department of Health.
That is why the families called for this public inquiry and why the Government granted one. I am sure the whole House will want to join me in expressing our thanks to Robert Francis and his entire team for their work over the past three years. The inquiry finds that the appalling suffering at the Mid Staffordshire hospital was primarily caused by a “serious failure” on the part of the trust board, which failed to listen to patients and staff and failed to tackle what Robert Francis calls
“an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities.”
The inquiry finds, however, that the failure went far wider. The primary care trust assumed others were taking responsibility and so made little attempt to collect proper information on the quality of care. The strategic health authority was
“far too remote from the patients it was there to serve, and it failed to be sufficiently sensitive to signs that patients might be at risk.”
Regulators, including Monitor and the then Healthcare Commission, failed to protect patients from substandard care. Too many doctors “kept their heads down” instead of speaking out when things were wrong. The Royal College of Nursing was
“ineffective both as a professional representative organisation and as a trade union”
and the Department of Health was too remote from the reality of the services that it oversees.
The way Robert Francis chronicles the evidence of systemic failure means that we cannot say with confidence that failings of care are limited to one hospital, but let us also be clear about what the report does not say. Francis does not blame any specific policy, he does not blame the last Secretary of State for Health and he says that we should not seek scapegoats.
Looking beyond the specific failures that Francis catalogues so clearly, we can identify in the report three fundamental problems with the culture of our NHS. The first is a focus on finance and figures at the expense of patient care—he says that explicitly—underpinned by a preoccupation with a narrow set of top-down targets pursued, in the case of Mid Staffordshire, to the exclusion of patient safety or listening to what patients, relatives, and indeed many staff members, were saying. Secondly, there was an attitude that patient care was always someone else’s problem. In short, no one was accountable. Thirdly, he talks about defensiveness and complacency. He finds that, instead of facing up to and acting on data that should have implied cause for concern, all too often there is a culture of only explaining the positives rather than any critical analysis. Put simply, managers were suppressing inconvenient facts in favour of looking for comfort in positive information. This is one of the most disturbing findings. It is bad enough that terrible things happened at that hospital, but what the inquiry is telling us is that there was a manifest failure to act on the data that were available, not just at the hospital but more widely. As Francis says:
“In the end, the truth was uncovered…mainly because of the persistent complaints made by a…determined group of patients and those close to them.”
The anger of the families is completely understandable. Every hon. Member in this House would be angry—they would be furious—if their mother, father or loved ones were treated in this way, and rightly so.
The previous Government commissioned the first report from Robert Francis. When he saw that report, the former Secretary of State—now the shadow Health Secretary, the right hon. Member for Leigh (Andy Burnham)—was right to apologise for what went wrong. This public inquiry not only repeats earlier findings, but shows wider systemic failings, so I would like to go further as Prime Minister and apologise to the families of all those who have suffered for the way the system allowed this horrific abuse to go unchecked and unchallenged for so long. On behalf of the Government—and, indeed, our country—I am truly sorry.
Since the problems at the Mid Staffordshire hospital first came to light, a number of important steps have been taken. The previous Government set up the National Quality Board and the quality accounts system. This Government have put compassion ahead of process-driven bureaucratic targets and put quality of care on a par with quality of treatment. We have set this out explicitly in the mandate to the NHS Commissioning Board, together with a new vision for compassionate nursing. We have introduced a tough new programme for tracking and eliminating falls, pressure sores and hospital infections, and we have demanded nursing rounds, every hour, in every ward of every hospital, but it is clear that we need to do more. We will study every one of the 290 recommendations in today’s report and we will respond in detail next month, but the recommendations include three core areas—patient care, accountability and defeating complacency—on which I believe we should make more immediate progress. Let me say a word about each.
First, let me address how we put patient care ahead of finances. Today, when a hospital fails financially, its chair can be dismissed and the board can be suspended, but failures in care rarely carry such consequences. That is not right, so we will create a single failure regime, where the suspension of the board can be triggered by failures in care as well as failures in finance, and we will put the voice of patients and staff at the heart of the way in which hospitals go about their work. In Mid Staffordshire, as far back as 2006, there was a staff survey in which only around a quarter of staff said they would actually want one of their own relatives to use the hospital that they worked in. Over the following two years, bereaved relatives and campaigners produced case after dreadful case and campaign after chilling campaign, but these voices and these horrific cases were ignored. Indeed, the hospital was upgraded to foundation trust status during this period. We need the words of patients and front-line staff to ring through the boardrooms of our hospitals and, frankly, right beyond, to the regulators and the Department of Health itself.
So from this year, every patient, every carer and every member of staff will be given the opportunity to say whether they would recommend treatment in their hospital to their friends or family. This will be published and the board will be held to account for its response. Put simply, where a significant proportion of patients or staff raise serious concerns about what is happening in a hospital, immediate inspection will result and suspension of the hospital board may well follow. Quality of care means not accepting that bed sores and hospital infections are somehow occupational hazards—that a little bit of these things is somehow okay. It is not okay; they are unacceptable—full stop, end of story. That is what zero harm—the jargon for this—means. I have therefore asked Don Berwick, who has advised President Obama on this issue, to make zero harm a reality in our NHS.
Francis makes other recommendations. Today it is possible to give hands-on care in a hospital with no training at all. Francis says this is wrong and I agree. There are some simple but quite profound things that need to happen in our NHS and in our hospitals. Nurses should be hired and promoted on the basis of having compassion as a vocation, not just academic qualifications. We need a style of leadership from senior nurses that means that poor practice is not tolerated and is driven off the wards. Another issue is whether pay should be linked to quality of care rather than just to time served at a hospital. I favour this approach.
Secondly, on accountability and transparency, the first Francis report set out very clearly what happened within Stafford hospital, and it should have led to those responsible being brought to book by the board, by the regulators, by the professional bodies and by the courts. But that did not happen. Most people will want to know why on earth not. We expect hospitals to take disciplinary action against staff who abuse their patients. We expect the professional bodies—the professional regulators—to strike off doctors and nurses who seriously breach their professional codes. And, yes, we expect the justice system to prosecute those suspected of criminal acts, whether they take place in a hospital or anywhere else. But in Stafford those expectations were badly let down. The system failed, and that is one of the main reasons we badly needed this public inquiry.
Now that the recommendations about systemic failure are public, the regulatory bodies in particular are going to have some difficult questions to answer. The Nursing and Midwifery Council and the General Medical Council need to explain why, so far, no one has been struck off. The Secretary of State for Health has today invited them to explain what steps they will take to strengthen their systems of accountability in the light of this report, and we are going to ask the Law Commission to advise on sweeping away the Nursing and Midwifery Council’s outdated and inflexible decision-making processes.
The Health and Safety Executive also needs to explain its decisions not to prosecute in specific cases. Indeed, Robert Francis makes a strong argument that the Health and Safety Executive is too distant from hospitals and not the right organisation to be focusing on health care and criminal prosecutions in such cases. So we will look closely at his recommendation to transfer the right to conduct criminal prosecutions away from the HSE to the Care Quality Commission.
Thirdly, we must purge the culture of complacency that is undermining the quality of care in our country. This requires a clear view about what is acceptable and what is not. In our schools, we have a clear system of deciding whether a school has the right culture and whether it is succeeding or failing. It is a system based on the judgment of independent experts who walk the corridors of the school and analyse more than just the statistics. The public therefore know which schools near them are outstanding and which are failing. They have a right to know exactly the same about our hospitals.
We need a hospital inspections regime that does not just look at numerical targets but examines the quality of care and makes an open, public and explicit judgment. So I have asked the Care Quality Commission to create a new post, a chief inspector of hospitals to take personal responsibility for that task. I want the new inspections regime to start this autumn, and we will look at the law to ensure that the inspector’s judgment is about whether a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking. In the meantime, I have asked the NHS medical director, Professor Sir Bruce Keogh, to conduct an immediate investigation into the care at hospitals with the highest mortality rates and to check that urgent remedial action is being taken.
Complacency in the system has meant that, all too often, patient complaints have been ignored. So I am today asking the right hon. Member for Cynon Valley (Ann Clwyd) and the chief executive of South Tees Hospitals NHS Foundation Trust, Tricia Hart, specifically to advise on how NHS hospitals can handle complaints better in the future.
I have talked today about some of the systemic failures, but at the heart of any system are the people who work in it and the values they hold. It is worth quoting in full what Francis says, early in his report:
“Healthcare is not an activity short of systems intended to maintain and improve standards, regulate the conduct of staff, and report and scrutinise performance. Continuous efforts have been made to refine and improve the way these work. Yet none of them, from local groups to the national regulators, from local councillors to the Secretary of State, appreciated the scale of the deficiencies at Stafford and, therefore, over a period of years did anything effective to stop them.”
What makes our national health service special is the simple principle that the moment you are injured or fall ill, or the moment something happens to someone you love, you know that whoever you are, wherever you are from, whatever is wrong, and however much you have got in the bank, there is a place you can go where people will look after you and do everything they can to make things right again. The shocking truth is that that precious principle of British life was broken in Mid Staffordshire.
We would not be here today without the tireless campaigning of the families who suffered so terribly, and I am sure that the whole House will join me in paying tribute to their incredible courage and determination over those long and painful years. When I met Julie Bailey and the families again on Monday, she said to me that she wanted the legacy of their loved ones to be an NHS safe for everyone. That is the legacy that together we must secure, and I commend this statement to the House.