Health and Social Care (Safety and Quality) Bill

Debate between William Cash and Jeremy Lefroy

Friday 9th January 2015 Commons Chamber

[Jeremy Lefroy]

I would like to speak to new clauses 2 and 3 together. The new clauses tabled by my hon. Friend the Member for Stone (Sir William Cash) seek to embed safety as the central component of the CQC’s inspection regime. My hon. Friend is not only a supporter of the Bill but a major inspiration behind it. His determination in this place to establish what went wrong in the care of his constituents and mine, and to ensure that our NHS was improved as a result, is a major reason for us being here today.

I agree entirely with the principles contained in the new clauses. New clause 2 would place a duty on the CQC to include safety in its annual performance assessment and ratings, while new clause 3 would require the CQC to consider safety in its annual state of care report. I believe that clause 1 of my Bill would already ensure that the CQC has a duty to do all that is contained in new clauses 2 and 3. I will try to explain why.

Clause 1 states that the requirements for registration with the CQC will always cover safety by securing that registered providers of health and social care “cause no avoidable harm”. The CQC will therefore be under a duty both to consider safety in its inspections and ratings and to cover this area in its state of care report. Indeed, it already does so, and here I pay tribute to the previous Government for introducing this annual state of health and social care report through the 2008 Act.

The foreword to this year’s report, to which my hon. Friend the Member for Stone has already referred, is hard hitting about safety and indeed quality. It states:

“The variation in the quality and safety of care in England is too wide and unacceptable. The public is being failed by numerous hospitals, care homes and GP practices that are unable to meet the standards that their peers achieve and exceed.”

I welcome this candour. This is what we expect from the CQC—to hold the NHS and indeed the Government to account, and to ensure that action is taken.

Let me mention an article that appeared in The Times yesterday, showing the huge variability of standards within the NHS and praised some outstanding trusts, specifically mentioning one in Birmingham and a couple of others. What we want to see is those standards being uniform across the NHS. I know that all those working within the NHS and social care want to see that. Nobody goes into work wanting to fail; they want to succeed for their patients to whom they have a duty of care. For our part, it is our responsibility to ensure that they have the environment in which that can happen. That is a small part of what this Bill is designed to bring about.

[Sir William Cash]

I recall the extraordinary experience of discovering that in order for the original trust in Mid Staffordshire to achieve trust status, an interview was necessary. In that interview, I believe 48 questions were put, 35 or so of which were about finance—not about care and safety. That demonstrated why everything went wrong. Now, however, under these arrangements, the whole situation is completely reversed, which is a thoroughly good idea.

[Jeremy Lefroy]

I entirely agree. There were moves towards that when the Healthcare Commission, which was responsible at that stage and manifestly failed in the case of Mid Staffordshire, was replaced by the Care Quality Commission—an understanding by the previous Government that progress needed to be made in ensuring the quality and safety of care. That progress has been maintained and accelerated under the present Government.

I was referring to the 2013-14 report. One of my hon. Friend’s new clauses specifically provides that safety should be a part of such reports. Indeed, the report goes into detail over the way in which the CQC has inspected for safety. On page 12, for instance, it gives an example of a wide variation in the ratings on safety and four other measures—effective, caring, responsive and well led—for each department in a particular hospital. The ratings for safety range from inadequate to good, which shows that even within a trust or a hospital, there is a wide range of safety performance. The CQC is therefore already fulfilling what my hon. Friend is seeking in these two new clauses.

Of course, the same might be argued for clause 1 itself: why is it necessary when the CQC is now implementing the Secretary of State’s requirement to ensure that providers “cause no avoidable harm”? The reason is that, without clause 1, a Secretary of State would not have that obligation. While I cannot imagine a Secretary of State who would not consider safety and “no avoidable harm” as top priorities, experience and indeed the CQC’s own report from which I have quoted show that some of the organisations for which the CQC has the responsibility for regulation have not, and might still not, take safety seriously enough.

[Sir William Cash]

I distinctly remember insisting over and over again during the debates on the whole question of Mid Staffordshire that were taking place until the last general election that it was the Secretary of State who had to take the final responsibility for these matters, and that the duties imposed on him and the functions that he had to perform had ultimately to be his and must not be transferred to some other agency, however worthy it might be and however hard it might work to achieve objectives which, as we now know, were not being complied with satisfactorily, but which are being complied with satisfactorily now, under the Care Quality Commission. The argument that my hon. Friend is advancing comes straight from the history of the experience of Mid Staffordshire, and there is no one better to put the case than him.

[Jeremy Lefroy]

I thank my hon. Friend for what he has said. I entirely agree that this is an extremely important matter. Clause 1 will ensure that there is no slippage in the future, because the Secretary of State cannot get out of her or his responsibility, and the Care Quality Commission’s annual state of care report will be part of the process of holding the Secretary of State to account. I encourage, indeed challenge, this or any future Government to hold a proper annual debate on the report, because it is a vital report. Indeed, I should welcome a debate on the 2013-14 report, uncomfortable thought it might be for certain people.

I believe that new clauses 2 and 3 are unnecessary, because what they prescribe flows from clause 1. However, I am most grateful to my hon. Friend the Member for Stone for tabling them.

--- Later in debate ---

[Sir William Cash]

I see him nodding and I am glad that I managed to pass that test. I am always grateful to my hon. Friend, who ensures that we all keep up to the mark.

On this occasion, I think we would have the capacity to make the change in the first place, but, if not, perhaps we can take a belt-and-braces approach in the House of Lords and use the notwithstanding formula. We shall see.

[Jeremy Lefroy]

Again, I am most grateful to my hon. Friend the Member for Stone (Sir William Cash) for tabling this new clause, which covers an important subject—the language skills of doctors—although of course the language skills of all involved in clinical care are vital.

Clear and understandable communication is essential to safety and the quality of care of patients. Language skills are a necessary condition for good communication, but not a sufficient condition. They must be accompanied by good communication skills, with which not all of us are automatically blessed, however good our language skills. Communication skills teaching is now an essential part of training in medical and nursing schools and it is to the credit of the previous Government that they ensured that it was embedded in the curriculum of new medical schools and was taken forward in existing schools. I welcome the Government’s support for that important approach.

I understand that regulations have been in place for a short while to ensure that all doctors, whether from within or from outside the European Union, have appropriate language skills before being granted a licence to practise. I want to hear from the Minister what the effect of those important regulations has been and whether he believes that new clause 4 is necessary. I would also like him to consider whether the assessment of language skills should include communication skills within that language.

[Jacob Rees-Mogg]

I want to speak in support of my hon. Friend the Member for Stone (Sir William Cash). This is an important new clause on a matter that it would be wise to have clearly set forth in primary legislation.

The heart of the matter is, unfortunately, the European Union and the mutual recognition of qualifications within the EU, and there are good reasons for that. The only way to open up service industries generally is if mutual recognition of qualifications takes place, so if we are to have a single market in services that is an important basis for it. However, above and beyond that there must be a fundamental principle of patient safety, which is embodied in this excellent Bill, and a lack of good language skills and of understanding of a language is a danger in both directions. It is a danger for the doctor who is listening to the patient explain his or her symptoms and it is also a danger when the doctor explains to the patient what steps the patient needs to take for better health. If there is confusion, it can have a seriously deleterious effect on the patient’s health.

We must be clear that this is not about restrictive practice or protecting the market for British doctors but about ensuring that there can never be such confusion. As my hon. Friend the Member for Stone says, if this provision runs into trouble with the European Union, we need to state clearly that it is of such fundamental importance that it must override international treaty obligations. It was Disraeli who said in his speech in the Manchester free trade hall in 1872, “Sanitas sanitatum, omnia sanitas”—that the first duty of Minister is the health of his people. That statement has underlined and guided Conservative policy for nearly a century and a half.

Francis Report

Debate between William Cash and Jeremy Lefroy

Wednesday 5th March 2014 Commons Chamber

[Jeremy Lefroy]

I agree. The treatment of whistleblowers has been a disgrace, not just at Mid Staffs but in many other places. I have seen consultant contracts from way back that have prevented their raising issues even with their Members of Parliament, and I am glad to say that sort of thing is coming to an end. I want to try to focus as much as possible on the Francis report, however, as I believe there are many important lessons that all of us, including me, have to learn.

As the Health Committee has said, as a consequence of the issues I have outlined,

“a healthcare system established for public benefit and funded from public funds risks the undermining of its guarantees of safety and quality.”

It is my sincere hope that we never have the need for another inquiry of this nature. This should mark a watershed in the NHS—a time when patient safety and high-quality compassionate care is the rule, delivered through a positive and caring culture, underpinned by safety and quality management systems through our health service and backed by openness and accountability, which I am sure many Members will speak about later. It is thus that we can respect the memory of those who suffered at Stafford, but also in many other places across the UK, as the work of the right hon. Member for Cynon Valley (Ann Clwyd) has shown.

The Francis reports, and particularly the accounts of patients’ experiences, should be required reading for all medical and nursing students. I ask the Secretary of State to confirm that he will pursue that with Health Education England.

Robert Francis, for whom I have the greatest respect for the calm and understanding way in which he conducted the inquiry, made 290 recommendations, but I shall concentrate on his essential aims. He writes of fostering a common culture of putting the patient first. It is sad that he must write that, but it is necessary. However, before we rush to find fault with a service which has lost its way, let us just consider the society in which it operates, starting with ourselves. Can we honestly say that we always put our constituents’ interests first? What about others in the professional and business worlds? When self-interest and personal fulfilment are so often lauded, why is it that we expect the NHS to be so very different? Saying that is neither to excuse nor to lower the bar, but to understand how difficult it is in some circumstances to maintain that highest of standards. Ensuring that patients come first when dealing with several very ill and distressed folk, perhaps at 2 o’clock in the morning, takes more than just compassion. I am not downplaying compassion in any way—it is essential—but the underpinning of quality and safety systems carried through as second nature is also required. It means ensuring that the leadership is on call to provide extra help as soon as it is needed. It demands the strength to speak out for what is not acceptable and an openness to admit when there are problems. Without the systems and standards, the supportive leadership, the strength and the openness, not even an angel can always put patients first, much as they would wish to.

There has been much debate about staffing levels, and rightly so. Although the problems at Stafford went far beyond numbers, there is no doubt that cuts contributed to them. When I was first selected as parliamentary candidate in 2006, the trust had a £10 million deficit. It wanted to achieve foundation trust status and needed to balance its books, and part of its solution was to reduce the number of nurses. I should have questioned that, as should others, but we accepted the trust’s assurances that it would not harm patient care. I say to all right hon. and hon. Members that one thing that must come out of this report is that each of us must be emboldened to challenge our local trusts when they make statements such as, “This won’t harm patient care”, despite their cutting 100 or more nurses. The approach to staffing management and data publication used at Salford Royal NHS Foundation Trust has been held up as an example of good practice in staffing by the Health Committee and the Secretary of State, so let us act and adopt it everywhere.

I recall that when I was first elected to this House, I was shocked at the tone and content of some of the responses by the NHS to complaints. Not only did they take several months to arrive, but they were sometimes complacent, and they certainly lacked compassion and understanding. That has, for the most part, changed considerably for the better—it certainly has in Stafford. The overwhelming message I receive from my constituents who need to complain is that they are not interested in compensation, but they are interested in a better NHS for everybody. So let us approach the complaints system from their premise, not that of lawyers. That is the responsibility of the chief executive, who should review all complaints, and personally read and sign all response letters. The Secretary of State responds to several complaints each week personally and in this, as in many other ways, he sets the example.

Although I am encouraged by the progress made in treating complaints, I am less confident about accountability.

[Mr Cash]

Does my hon. Friend accept that it is clearly stated in the prime ministerial guidelines of 2005 that when somebody writes to a Minister who has responsibility, including the Secretary of State, the relevant Member of Parliament is entitled to receive a personal letter that comprehensively and efficiently deals with the question at issue? Does my hon. Friend also agree that, regrettably, that did not happen in all instances when matters were raised with regard to Stafford hospital?

[Jeremy Lefroy]

I thank my hon. Friend for that intervention and for all the work he has done on this issue. It is salutary for all of us to remember that when we get such a letter it often represents probably another 10 people who did not write to complain because they do not want to affect the NHS. We should treat each letter of complaint as being of immense importance.

I said that I am less confident about accountability, so let me say why. This is not just a question of the resignation of executives within a trust or the NHS when things go badly wrong, although it remains astonishing to me that no one has had the courage to do this given that the failings in Stafford were so clearly systemic; it also concerns the approach of the professional bodies representing nursing and clinical staff. The Francis inquiry saw evidence of poor co-operation with the General Medical Council from other organisations, including royal colleges, even though serious matters of fitness to practise and patient safety were involved; they almost put the practitioners above the patients. Those representing the medical and nursing professions are accountable to the public first and foremost. The best way of maintaining public confidence in their professions is to ensure that they treat their members who are not fit to practise in a firm, fair and swift way; cases of doctors or others being suspended for months or even years are too frequent.

Before I discuss Stafford specifically, may I just make a few remarks about hospital standardised mortality ratios? The Francis report states that Professor Jarman

“made it clear that it is not possible to calculate the exact number of deaths that would have been avoidable, nor to identify avoidable incidents…The statistics can only be signposts to areas for further inquiry.”

I urge all those who handle HSMRs to do so with care. They are extremely important as guidelines, and it was absolutely right that they were the first statistics that showed up the need for the Healthcare Commission inquiry, but to extrapolate numbers from them can be difficult and the evidence does not necessarily bear it. We have seen examples of that happen.

Mid Staffordshire NHS Foundation Trust

Debate between William Cash and Jeremy Lefroy

Tuesday 7th January 2014 Westminster Hall

[Jeremy Lefroy]

I am most grateful to my hon. Friend. I will come to that important point.

I pay tribute to the work of Support Stafford Hospital, because the impact of its campaign has shown just how much the community values the services at Stafford and Cannock. I also pay tribute to the working group, which I set up, and all those who have worked with me on that to provide us with the detail on alternative proposals, some of which I shall outline.

There is no doubt that the administrators listened carefully to what was said in the consultation and made a number of changes in their final proposals. However, the proposals as they stand are insufficient. What I am setting out requires not a re-doing of all the work of the trust special administrator—given what I have said about the urgency of the situation, that would not be sensible—but a modification of the detail.

I do not believe that such a modification would necessarily require more money than is currently proposed, although that remains to be seen, but it would be of huge benefit to many thousands of my constituents, and those of hon. Friends and other hon. Members. It will also ensure that both Monitor and the Secretary of State can fully comply with their legal obligations under the Health and Social Care Act 2012, in respect of health inequalities, as I will show later.

My proposal is that rather than cutting three areas of service in Stafford, those continue in a more cost-effective form, at least for two or three years. I, and the clinicians at Mid Staffs, consider that it will be quite possible to show how these services can be run across the two sites in Stoke and Stafford on a networked basis. The areas concerned are paediatrics, obstetrics and maternity and critical care.

First, the report proposes a reduction of the critical care unit to four beds. It says that the possibility of the highest level of critical care—level 3—should be maintained, but it is not clear how this will be possible without a rota for specialists in critical care. The critical care department at Stafford made its own submission to the consultation, which suggested a reduction in beds and a networked specialist rota. That seemed eminently sensible. Given that the CCU at Stafford is a net contributor and supports several other activities, I urge Monitor and the Secretary of State to determine that this model is tried for a period, during which it will, hopefully, be proven to operate well, clinically, operationally and financially.

The TSA’s final report also proposes, as my hon. Friend the Member for South Staffordshire (Gavin Williamson) mentioned, removing the consultant-led obstetrics and maternity service and replacing it with a midwife-led unit dealing with approximately 350 to 400 births a year. That is a step forward from the draft report, which proposed no childbirth at all at Stafford. However, my constituents and I do not believe that it is sufficient.

Currently, Stafford sees more than 2,000 births a year and that is likely to rise, with extensive house building, various new business parks being built and the doubling of the size of MOD Stafford, to mention but some developments, resulting, in the coming years—even with a MLU—probably in some 2,000-plus babies being born in other maternity units, mainly at Stoke and Wolverhampton. UHNS in Stoke already sees some 6,000 a year and its population is also growing. With at least 1,000 births, and probably more from Stafford, UHNS will probably approach 8,000, which is the number currently born at the largest unit in the country, in Liverpool.

The NHS rightly promotes choice for women about where to have their babies and the Prime Minister has spoken out against the trend towards ever larger units. Yet that is precisely what is being proposed here for women who are unable to use a MLU, due to the possibility of complications in childbirth. There would also be an impact on those who currently use UHNS and the Royal Wolverhampton, as their local units will become even busier—probably including Walsall as well—taking in women from a much wider area.

My proposal, and that of clinicians at Stafford, is to continue with the current service, fully networked with UHNS, while the impact of the current rise in both the population and birth rate is assessed. That would also enable the special care baby unit at Stafford to continue to support the regional intensive care network for babies, as it currently does. An added benefit would be that women will continue to have a local obstetric and gynaecology service, which I am sure the Minister will appreciate as he comes from that specialty. Again, that would relieve pressure on the larger University hospital of North Staffordshire and the Royal Wolverhampton hospital.

Thirdly, the TSAs propose to reduce the paediatric assessment unit to 14 hours a day from 24 hours a day and to do away with in-patient paediatric beds. There will be no paediatric rota, although A and E doctors will receive extra paediatric training and paediatric out-patient services will continue. The principal reason given by the TSAs is the national standards of the Royal College of Paediatrics and Child Health, which state that such services should be provided by a full consultant rota, which is usually between eight and 10 consultants, whereas at Stafford it is between five and six.

Let me be clear about the consequences: if the proposal is allowed to happen, the clear logic is that dozens of other paediatric units across the country that have similar numbers of consultants, or indeed fewer consultants, must be closed or have their activities drastically curtailed. Monitor cannot use the argument that that must happen at Stafford but not at other foundation or NHS trusts for which Monitor or the NHS Trust Development Authority are responsible, and neither can the Government.

The argument that all in-patient paediatric care should take place in the largest hospitals is not accepted by the general public. They fully understand why very sick children should go to specialist units; they do not understand why their local general hospital cannot receive sick children at night or for short stays, and neither do I. If experts at the Royal College insist on making that argument, however, let it be open, let it be consistent across the land and let it be agreed by all political parties. The proposal should not be implemented by stealth through a trust special administration that in no way arose because of the performance of the paediatrics department at Stafford.

I have one final point.

[Mr William Cash (Stone) (Con)]

I have been waiting for my hon. Friend to reach his conclusion so that I can say how much I support him in his endeavours on Stafford hospital, which affects my constituency of Stone. I had to fight so hard to get the public inquiry that has led to many of the changes, and I simply offer him many congratulations. I support pretty much everything that he says, and I believe that he has done an enormous service to his constituents through his work over the past few years.

[Jeremy Lefroy]

I am most grateful to my hon. Friend, and I return his compliments. He has likewise tremendously supported the trust and the work that has been done.

My final point is that the children and families who will be most affected by the paediatrics proposal are those on the lowest incomes. Such families are the least likely to have access to private transport to take their children nearly 20 miles to the nearest hospital at night. For them public transport in the daytime is often poor, and a taxi fare is beyond their means—certainly if they have to visit a sick child several times. I believe that those on low incomes should have fair access to health care, which both Monitor and the Secretary of State have a responsibility to ensure.

The paediatrics department at Stafford made an alternative proposal in its response to the consultation. That alternative was measured and understood the need to cut costs. The alternative proposal included a reduction in the number of in-patient paediatric beds, and consultants would have worked in a network across both of the new trust’s sites.

A pattern can be seen: critical care, maternity and paediatrics. There are sensible alternative proposals.

Dairy Industry

Debate between William Cash and Jeremy Lefroy

Thursday 13th September 2012 Westminster Hall

[Jeremy Lefroy (Stafford) (Con)]

I congratulate the hon. Member for Dunfermline and West Fife (Thomas Docherty) on securing this debate.

Staffordshire is one of the UK’s leading dairy counties. Dairy farming is important to my constituency; let us not forget how important it is to so many others. Some 70 trades and suppliers, possibly more, are estimated to depend on each 400-acre dairy farm.

Another almost unique feature is that Staffordshire has kept its county farms, which were set up after the first world war. Half of Staffordshire’s county farms, some 50 of them, are in my constituency of Stafford. Those farms provide a route into dairy farming for young people, which is essential because the average age of farmers is between 55 and 65, depending on who we listen to.

Last Friday, I attended a meeting at Church farm, Coppenhall, at the invitation of the Madders family, with many dairy farmers and the National Farmers Union. We discussed the problems they face. As time is brief, I will highlight three or four areas.

Clearly, the first area is milk prices and fair treatment. The common refrain was, “Give us the highs in prices and we’ll take the lows.” It is often said that the processors and supermarkets are quick to put down the prices paid to farmers but are slow to raise them when the market goes up, and the market will surely go up because dairy production figures across Europe in August 2012 show that in Germany production was 0.3% down, in France production was 1.7% down and in the UK production was 3.7% down. Those figures reflect a combination of the weather and low milk prices. So there will surely be price rises, which must be passed on to farmers.

The second vital area is marketing. Many of my constituents are already taking up the challenge of adding value—Bertelin Farmhouse Cheese in Ellenhall, for example, which was previously in the constituency of my hon. Friend the Member for Stone (Mr Cash), who will no doubt know the farm—but there is much more potential. I have recently had to start buying lactose-free milk, for which there is a huge market in the UK, yet the milk I buy is made in Denmark by Arla.

[Mr Cash]

Does my hon. Friend agree that there are also enormous export opportunities for dairy farmers? I have just come back from India, from where people will shortly be coming to see Staffordshire dairy farmers precisely to try to develop joint ventures. Is that not a great opportunity?

[Jeremy Lefroy]

As so often, my hon. Friend is a prophet. I was just about to say that.

The previous Minister, my right hon. Friend the Member for South East Cambridgeshire (Mr Paice), who has rightly been applauded, was in China on a trade mission and saw no British dairy products, despite there being many from the Netherlands, Germany, Denmark and so on. We must do more, and the industry must do better.

Supermarkets, too, can do more. On a holiday in the Republic of Ireland a few years ago, I entered a Tesco that was festooned with Irish tricolours promoting products processed or produced in the Republic of Ireland. I welcome that great idea. I want to see far more Union flags in UK supermarkets promoting British foods.

The UK Government, too, can do more, but, first, a word of praise from the farmers. They say to me, and I do not know whether hon. Members agree, that the Rural Payments Agency has improved considerably in the past two or three years, and due credit should go to the RPA and the ministerial team.

As the hon. Member for Carmarthen East and Dinefwr (Jonathan Edwards) said, the current EU negotiations are vital. I am concerned to hear that British representation is not as strong as sometimes it should be. In a debate last year, I stressed the continued importance of single farm payments, particularly to the small farmers who continue to be the backbone of the UK dairy industry. The UK and Portugal are currently the only countries applying voluntary modulation from pillar one to pillar two. The concentration on environmental measures has clear benefits, but we should not go any further in that modulation if it puts us at a competitive disadvantage to our European neighbours.

I want to allow time for others to speak, so I will conclude by saying that I welcome this debate. The time is right for fair prices. I worked for many years in the coffee industry, in which I saw the impact of fair trade and fair prices. I would like to see a similar approach in the dairy industry, based on the voluntary code of practice, with supermarkets, processors and farmers working together.

Finally, I pay great tribute to those dairy farmers who work day in, day out, week in, week out, rising before dawn and going to bed late at night, to put those products on our tables.