NHS: Keogh Review

Earl Howe Excerpts

Tuesday 16th July 2013 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, with the leave of the House I shall now repeat a Statement made in another place earlier today by my right honourable friend the Secretary of State for Health on the Sir Bruce Keogh review. The Statement is as follows.

“Mr Speaker, I would like to make a Statement about Professor Sir Bruce Keogh’s review of hospitals with high mortality rates, which is being published today.

Let me start by saying that in the health service’s 65th year, this Government are deeply proud of our NHS. We salute the doctors, nurses and other professionals who have never worked harder to look after each and every one of us at our most vulnerable. We recognise that the problems identified today are not typical of the whole NHS, nor of the care given by many wonderful NHS staff; but those staff are the ones who are most betrayed when we ignore or pass over poor care. The last Government left the NHS with a system that covered up weak hospital leadership and failed to prioritise compassionate care. The system’s reputation mattered more than individual patients; targets mattered more than people.

We owe it to the 3 million people who use the NHS every week to tackle and confront abuse, incompetence and weak leadership head-on. Following the Francis report into the tragedy at Mid Staffs, the Prime Minister asked Professor Sir Bruce Keogh, the NHS medical director, to conduct a series of ‘deep-dive’ reviews into other hospitals with worrying mortality rates. No statistics are perfect, but mortality rates suggest that since 2005 thousands more people may have died than would normally be expected at the 14 trusts reviewed by Sir Bruce.

Worryingly, in half of those trusts, the CQC—the regulator specifically responsible for patient safety and care—failed to spot any real cause for concern, rating them as ‘compliant’ with basic standards. Each of the trusts has seen substantial changes to its management since 2010, including a new chief executive or chair at nine of the 14. However, while some have improved, failure or mediocrity is so deeply entrenched at others that they have continued to decline, making the additional measures I announce today necessary.

This time, the process was thorough, expert-led and consisted of planned, unannounced and out-of-hours visits, placing particular weight on the views of staff and patients. Where failures were found that presented an immediate risk to patients, they were confronted straight away rather than waiting until the report was finished. We will be publishing all those reports today, alongside unedited video footage of the review panel’s conclusions, all of which I am placing in the Library. I shall also today set out the actions the Government are taking to deal with the issues raised. I would also like to record my sincere thanks to Sir Bruce and his team for doing an extremely difficult job very thoroughly and rapidly.

Sir Bruce judged that none of the 14 hospitals is providing consistently high-quality care to patients, with some very concerning examples of poor practice. He identified patterns across many of them, including professional and geographic isolation; failure to act on data or information that showed cause for concern; the absence of a culture of openness; a lack of willingness to learn from mistakes; a lack of ambition; and ineffectual governance and assurance processes. In some cases, trust boards were shockingly unaware of problems discovered by the review teams. So today I can announce that 11 of the 14 hospitals will be placed into special measures for fundamental breaches of care. In addition, the NHS Trust Development Authority and Monitor have today placed all 14 trusts on notice to fulfil all the recommendations made by the review. All will be inspected again within the next 12 months by the new Chief Inspector of Hospitals, Professor Sir Mike Richards, who starts work today.

The hospitals in special measures are as follows: Tameside Hospital NHS Foundation Trust, where patients spoke of being left on unmonitored trolleys for excessive periods and where the panel found a general culture of ‘accepting sub-optimal care’; North Cumbria University Hospitals NHS Trust, where the panel found evidence of poor maintenance in two operating theatres, which were immediately closed; Burton Hospitals NHS Foundation Trust, where the panel found evidence of staff working for 12 days in a row without a break; North Lincolnshire and Goole NHS Foundation Trust, where the panel identified serious concerns in relation to out-of-hours stroke services at Diana, Princess of Wales hospital. The panel also witnessed a patient who was inappropriately exposed where there were both male and female patients present.

The list continues: United Lincolnshire Hospitals NHS Trust, where there were a staggering 12 ‘never events’ in just three years, and the panel had serious concerns about the way ‘Do not attempt resuscitation’ forms were being completed; Sherwood Forest Hospitals NHS Foundation Trust, where patients told of being unaware of who was caring for them, of buzzers going unanswered and poor attention being paid to oral hygiene; East Lancashire NHS Trust, where the panel highlighted issues of poor governance, inadequate staffing levels and high mortality rates at weekends. Patients and their families complained of a lack of compassion and being talked down to by medical staff whenever they expressed concerns.

The list continues: Basildon and Thurrock University Hospitals NHS Foundation Trust, where there were seven ‘never events’ in three years and concerns over infection control and overnight staffing levels; George Eliot Hospital NHS Trust, where the panel identified low levels of clinical cover, especially out of hours, a growing incidence of bed sores and too many unnecessary shifting of patients between wards; Medway NHS Foundation Trust, where a public consultation heard stories of poor communication with patients, poor management of deteriorating patients, inappropriate referrals and medical interventions, delayed discharges and long A&E waiting times; and Buckinghamshire Healthcare NHS Trust, where the panel found significant shortcomings in the quality of nursing care relating to patient medication, nutrition and observations, and heard complaints from families about the way patients with dementia were treated.

For these 11 trusts, special measures will mean that each hospital will be required to implement the recommendations of the Keogh review, with external teams sent in to help them do this. Their progress will be tracked and made public. The TDA or Monitor will assess the quality of leadership at each hospital, requiring the removal of any senior managers unable to lead the improvements required. Each hospital will be partnered with high-performing NHS organisations to provide mentorship and guidance in improving the quality and safety of care.

Three of the 14 hospitals are not going into special measures. They are Colchester Hospital University NHS Foundation Trust, the Dudley Group NHS Foundation Trust and Blackpool Teaching Hospitals NHS Foundation Trust. While there were still concerns about the quality of care provided, Monitor has confidence that the leadership teams in place can deliver the recommendations of the Keogh review and will hold them to account for doing so.

This is a proportionate response in line with the findings of the review. Inevitably, there will be widespread public concern not just about these hospitals but about any NHS hospital, and some have chosen to criticise me for pointing out where there are failures in care, but the best way to restore trust in our NHS is transparency and honesty about problems, followed by decisiveness in sorting them out. The public need to know that we will stop at nothing to give patients the high-quality care they deserve for themselves and their loved ones. Today’s review and the rigorous actions that we are taking demonstrate the progress that this Government are making in response to the Francis report. I shall update the House in the autumn on all of the wide-ranging measures that we are implementing, when the House will be given a chance to debate this in government time.

The NHS exists to provide patients with safe, compassionate and effective care. In the vast majority of places it does just this—and we should remember that there continues to be much good care, even in the hospitals reviewed today. Just as we cannot tolerate mediocre or weak leadership, we must not tolerate any attempts to cover up such failings. It is never acceptable for government Ministers to put pressure on the NHS to suppress bad news, because in doing so, they make it less likely that poor care will be tackled.

We have today begun a journey to change this culture. These 14 failing hospital trusts are not the end of the story. Where there are other examples of unacceptable care, we will find them and we will root them out. Under the new rigorous inspection regime led by the Chief Inspector of Hospitals, if a hospital is not performing as it should, the public will be told. If a hospital is failing, it will be put into special measures with a limited time period to sort out its problems. There will be accountability, too: failure in the NHS should never be a consequence-free zone, so we will stop unjustified pay-offs and ensure it will no longer be possible for failed managers to get new positions elsewhere in the system.

Hand in hand with greater accountability will be greater support. Drawing inspiration from education, where super-heads have helped to turn around failing schools, I have asked the NHS Leadership Academy to develop a programme that will identify, support and train outstanding leaders. We have many extraordinary managers such as David Dalton in Salford Royal and Dame Julie Moore of University Hospital Birmingham, but we need many more to provide the leadership required in our weaker hospitals.

At all times the Government will stand up for hard-working NHS staff and patients, who know poor care and weak leadership have no place in our NHS. It was set up 65 years ago with a pledge to provide us all with the best available care, and I am determined that the NHS will stand by that pledge. We owe its patients nothing less. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I am disappointed that the noble Lord should have chosen to turn this occasion into a rather poorly directed political tirade. I can assure him that I am perfectly capable of trading party political debating points with him; I have a great deal of material in my brief which I will not hesitate to use if he pushes me. However, I choose not to because I think this is an occasion for reflecting in a mature and considered way, as befits this House, on a very important report. Therefore I begin with a welcome—I am glad that the noble Lord and his party accept the veracity of the report. It is a fine piece of work. It was done very thoroughly and very rapidly and we are grateful to Sir Bruce.

The noble Lord said a lot about mortality data with which I agree. At a national level, mortality has improved; however, the 14 trusts selected for these deep-dives had long-standing performance issues on mortality rates, some going back to 2005 or even earlier. Therefore, it is only partially true to say that this is a problem that happened on our watch. We want to make sure that we are lifting the lid on any failures of care that need to be tackled and we are not afraid of doing that. Again, the noble Lord was right to say that while higher mortality rates do not always point to deaths that could have been avoided, they indicate that there could be issues with the quality of care. That is why we decided to ask Sir Bruce Keogh to carry out these inspections and to give us his findings.

The rationale for the review was that the 14 trusts were outliers for at least two consecutive years on one or other measure of mortality. I agree with the noble Lord that it is pointless to bandy figures around, and I am not going to do that. He rightly quoted Bruce Keogh saying that it is clinically meaningless and academically reckless to use mortality formulae to quantify actual numbers of avoidable deaths. That reflects Robert Francis’s view, but we now have clear evidence that those mortality data were indicative of more deep-seated problems. That has been the value of this exercise, I suggest. I cannot comment on the letter written by the noble Baroness, Lady Young; I have not seen it. However I am sure the House will agree that the report by Sir Bruce has challenged us all to look again at why poor care persists in some hospitals.

As regards staffing levels, the number of front-line staff has gone up since May 2010. There are 6,000 more doctors and 1,000 more midwives, for example. On staffing, one can be too simplistic. It is not simply about the crude numbers. It is not simply about nurses. The number of staff on the wards will vary according to skill mix, clinical practice and local factors. It is right that nurse leaders have the freedom to agree their own staff profiles. That gives flexibility to respond dynamically to changes in patient demand and workforce supply. I do not in the least dismiss the potential concern that staff may in some instances have been stretched, but I do not think we can make generalisations of the kind that the noble Lord was suggesting that we did.

On A&E, as the noble Lord knows, urgent care boards have been working flat out since May with local A&E departments to develop individual plans in order to improve A&E performance in all areas where targets have not been met, and that includes the 14 trusts considered by the Keogh review. However, this is not only about A&E; it is about how the NHS works as a whole, how it works with other areas, such as social care, and how it deals with an ageing population and more people with long-term conditions. Dealing with these pressures means looking at the underlying causes. That is why, together with NHS England, we are putting together a strategy that focuses on the people who are the heaviest users of the NHS: vulnerable older people and those with multiple long-term conditions.

There is no doubt that people are right to focus on the funding of social care. That is exactly why we in the Department of Health have allocated significant additional funding to local authorities, including a transfer from the NHS that is worth £1.1 billion a year by 2014-15. We have also announced as part of the spending round that has just concluded a local integration fund of £3.8 billion across health and social care in 2015-16. Pooling budgets in that way will help drive down the costs to the acute sector by tackling the acute and expensive pressure points in the system, such as A&E, by improving prevention, reducing unplanned hospital admissions and allowing people to stay in their own homes and live independently.

I agree with the noble Lord that many of the messages in Sir Bruce’s report—in fact, all of them—are urgent. As he knows, in the Care Bill, we are looking at the whole question of openness and candour in a number of respects. Although the duty of candour is not one that we plan to build into the Care Bill, it is very relevant to it. It will be introduced by secondary legislation. The key challenge is a change in behaviour rather than the law. That is why the legislative changes arising out of Francis are targeted and carefully designed to support a culture of openness.

I hope that I have answered most of the noble Lord’s questions; those that I have not answered, I will write to him about.

[Lord Warner]

My Lords, I want to ask the Minister about the Government’s future intent. Are he and his colleagues now satisfied that Sir Bruce has found an indicator or indicators which require constant attention, year on year? Can we expect to see, either by Sir Bruce or by the new Chief Inspector of Hospitals, an annual look at the outliers on mortality rates and a regular report to Parliament about the findings of the exercise? Is this going to be institutionalised as part of the performance management of the NHS?

[Earl Howe]

We will see the Chief Inspector of Hospitals picking up the baton, as it were, from Sir Bruce Keogh, whose way of working in this exercise has been very instructive. His judgments were based on talking, not just to a few people in the trust, but to patients, a wide range of staff and, in some instances, people outside the trust. I am sure that Sir Mike Richards, the new chief inspector, will want to learn from that. It will be up to the CQC to decide whether this will be institutionalised. Its methodology is evolving. The hospital aggregate rating system will have a role to play in systematising the evaluation of performance and in any future instances of very poor care we will no doubt see a level of transparency from the CQC which we have, perhaps, not had before. However, I would not want to commit the CQC to reporting annually to Parliament in a particular way. It will report annually to Parliament but it is largely up to it how it does it.

[Baroness Jolly]

My Lords, we welcome the drive to improve quality in these trusts and across the NHS, based on the eight ambitions for improvement held in the report. In the Statement read by the Minister, the Secretary of State said:

“In some cases, trust boards were shockingly unaware of problems discovered by the review teams”.

Surely the boards were in receipt of data on quality. If not, why not? If so, why was action not taken? What attention is being paid to issues of trust board governance and its support and development?

[Earl Howe]

We will now see follow-up action by the CQC, not least in the area of trust governance where the quality of that governance has been called into question by Sir Bruce. That will be done rapidly. It is by no means the case that governance is defective in every trust, but question marks have been placed on some and it is important that assessments are made, not just by the CQC, but by the Trust Development Authority and Monitor as the two bodies responsible for overseeing the provider section. It may be that the CQC will be asked to carry out further work, but we are looking, for the time being, to the TDA and Monitor to do that.

[Baroness Emerton]

My Lords, how did Bruce Keogh’s team determine whether staffing levels were short, inadequate or low, as was mentioned in the Statement, when we have not actually got a base against which to measure staffing levels? We raised this all the way through the passage of the Health and Social Care Bill and we have been raising it during the passage of the Care Bill. What was the evidence for low staffing?

[Earl Howe]

I know that this is a concern of the noble Baroness and I understand that. She will know that work is going on to try to frame better rules of thumb and guidance on staffing numbers. When Sir Bruce looked at this area he had very closely in mind the precept that Robert Francis gave in his report when he said:

“To lay down in a regulation, ‘Thou shalt have N number of nurses per patient’ is not the answer. The answer is, ‘How many patients do I need today in this ward to treat these patients?’ You need to start, frankly, from the patient, as you do with everything”.

That was the basis of Sir Bruce’s assessment on that issue.

[Baroness Armstrong of Hill Top]

My Lords, will the Minister acknowledge that Sir Bruce Keogh made it absolutely clear that over the past decade there has been significant improvement in mortality rates across the National Health Service? He said that, because of the increasing complexity of the patient, that improvement is probably greater than the 30% that is measurable. Will he therefore congratulate those hospitals—the vast majority—that have led the improvement? At the same time, of course, we must tackle poor performance and make it clear that that is unacceptable. However, in doing so we have also to acknowledge the significant improvement that has happened over the past decade.

[Earl Howe]

I applaud that and we should all celebrate the success of outstanding hospitals—there are many in the health service—which have led the way in improving mortality rates over the past few years. The noble Baroness is quite right. Indeed, Sir Bruce suggests that those hospitals should now be asked to partner with some of the hospitals that are struggling in certain respects to show the way, whether that is on governance, on systems in A&E, on quality of surgical outcomes or whatever it happens to be. That is an appropriate idea, and we should undoubtedly ensure that it is taken forward. However, as the Statement itself reflects, the 14 hospitals that are under the microscope at the moment are not representative of the quality of care that the NHS delivers day in and day out, which is of a very high standard by any benchmark.

[Lord Cormack]

My Lords, I accept what my noble friend has just said, but he will understand that there will be concern throughout the country at this very disturbing indictment—because that is what the report is. Will he talk to the new chief inspector to consider whether we can have a form of assessment of hospitals—the noble Lord, Lord Warner, effectively referred to this—so that patients throughout the country know whether their local hospital is graded as being excellent or not? Will he also ensure that there is a debate on the Floor of this House, as there will be on the Floor of the other House?

[Earl Howe]

I can certainly use my best endeavours through the usual channels with regard to my noble friend’s latter question. On his first point, he is absolutely right. That is what led us to believe that aggregate hospital ratings, provided that they are produced in a sophisticated and careful way, will be very informative to the general public and to patients in a local area, and to professional staff within the health service. The Healthcare Commission, of old, used to produce aggregate ratings. They fell into disuse and, I have to say, into some disrepute, because they were so broad brush as to be meaningless. When we asked the Nuffield Trust to look at this area, it told us very clearly that, as long as we adopted a nuanced and sophisticated approach so that what was assessed was not just a hospital trust or an individual hospital within that trust but rather the performance of individual medical teams and units within a hospital, we would provide useful information to the public. However, that information needs to be accessible.

[Baroness Masham of Ilton]

If the chief inspector, when visiting failing hospitals, finds a lack of senior sisters on the wards and a shortage of doctors working in emergency medicine, what is he going to do about it? Does the Minister realise that there is a serious shortage of emergency medicine doctors?

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[Earl Howe]

The noble Baroness is right. There is a serious shortage in certain specialties, and emergency medicine is one of them. Work is currently going on in Health Education England to ensure that we boost the numbers in that specialty. As for what the CQC can do, there are a range of actions available to the chief inspector. In most such instances he would draw the attention of the chief executive and the hospital board to whatever problem he had found, and it would then be incumbent on the trust to put its own house in order within a reasonable space of time. That would be the norm. We should not forget that commissioners of care, too, will be encouraged to join in that conversation, to ensure that providers are properly held to account through the NHS contract. There are a range of actions that could be appropriate, and only in the most extreme cases will warning letters have to be issued or more drastic action taken.

[Baroness Smith of Basildon]

Despite the rather alarmist —and, as it turns out, inaccurate—briefing over the weekend, this is, as we have heard, not a historical report; it is about what is happening here and now in 14 hospitals in the NHS. I was sorry that the Minister skirted round the problems of staffing in the NHS. My local hospital, in Basildon and Thurrock University Hospitals NHS Foundation Trust, is named in the report as one of the 14 hospitals. Yet since the general election it has lost 345 nursing staff. The report found,

“inadequate numbers of nursing staff … compounded by an over-reliance on unregistered support staff and temporary staff”.

The noble Earl himself referred to this when repeating Jeremy Hunt’s Statement. May I tell him that that hospital is now recruiting 200 staff this week? That is welcome, but it can be no coincidence that, after the report, it is recruiting the staff that it needs. Does he now really believe that the £3 billion spent on reorganising the NHS was the best value for money, when staffing levels are so low?

[Earl Howe]

It was not £3 billion that was spent on reorganising the health service. As the noble Baroness knows, it was probably less than half that figure. The important point is that the saving in this Parliament will be at least £5.5 billion, with a £1.5 billion saving every year thereafter. I therefore suggest to her that it is meaningless to bandy that figure around. I am very glad that Basildon hospital is taking the action that it is. It has recently undergone significant leadership changes. A transformation programme is under way, and that is part of it.

[Lord Elystan-Morgan]

The Statement repeated by the noble Earl makes the point that the story does not end with the 14 failed trusts. Does he agree that there is clear evidence of the acceptance of standards that are not worthy of our community or of the National Health Service, and that, very probably, such a situation is not unassociated with the lack of a hierarchy of discipline in nursing? Will the Government therefore give an undertaking that, by way of an agonising reappraisal of the situation, they will concentrate on establishing whether the institution of the hospital matron could be considered again, as a post that was effective and seemed to operate well? Many people the length and breadth of this land believe that to some extent we should revert to that system, rather than worshipping at the altars of accountancy and management.

[Earl Howe]

The noble Lord makes an extremely important point. Those hospitals that I have visited where the standard of care is manifestly excellent have all had nurse leaders at board level whose responsibility it is to make the quality of nursing care absolutely centre stage at every board meeting and to transmit to every nurse in that hospital what good quality care looks like. Whether we call that person a matron or not is perhaps a matter that we can discuss at leisure—but the point that the noble Lord makes is extremely valid.

[Lord Black of Brentwood]

My Lords, I agree with my noble friend very strongly that failure should never be a consequence-free zone. But would he agree that, for far too long, the bitter truth is that it was a consequence-free zone? My late mother was treated in the Basildon and Thurrock University Hospitals NHS Foundation Trust in 2008 and 2009, on two occasions. On the first occasion, she sustained an injury after being left on the toilet for 40 minutes, from which she never recovered. On the second occasion, having been admitted suffering from a heart attack, she was shifted between wards three times in 24 hours. I wrote to the chief executive and he wrote back to me with 11 separate apologies. I wrote back to him saying that apologies were no good unless something happened.

I agree with the noble Baroness, Lady Jolly, that boards must have responsibility. Would my noble friend agree that they must have responsibility for scrutinising data and, above all, looking at complaints, otherwise nothing will ever change?

[Earl Howe]

My Lords, the historical culture of that particular trust has been focused on financial targets, and the tone from the top now needs to focus on improving quality and long-term sustainability. There is a string of issues identified in Sir Bruce’s review, all of them urgent. The good news is that I know that the current management is addressing those issues. I am naturally sorry to hear of the personal experiences of my noble friend’s family.

[Baroness Jay of Paddington]

My Lords, I wonder whether I can assist the noble Earl, and indeed the House, by quoting directly from the letter from the noble Baroness, Lady Young of Old Scone. The noble Earl referred to it earlier and said that he was not aware of the details. This is a letter to the Prime Minister from the noble Baroness, dated yesterday, in which she says that he has been “misled” in the response that he gave in Prime Minister’s Questions. She says that the CQC, of which she is a former chair,

“was not pressurised by the previous Government to tone down its regulatory judgments or to hide quality failures”.

She goes on to say:

“So I am afraid neither my evidence to the Francis Inquiry nor my current recollection … can be interpreted to support the view that, in the words of your answer at PMQs ‘there was a culture under the previous Government of not revealing problems in the NHS’”.

She finishes the letter by asking:

“How can this misapprehension best be corrected for the record?”.

Perhaps the noble Earl can suggest that.

[Earl Howe]

I am rather sorry that the noble Baroness should have raised that, as I was rather keen to protect the noble Baroness, Lady Young, from any embarrassment, because I think that the whole House respects her. All I can say is that the substance of the letter to which the noble Baroness refers is diametrically opposite in content to the evidence that the noble Baroness, Lady Young, gave to the Mid Staffs public inquiry.

[Lord Cotter]

In the report there are, quite rightly, robust words about poor management. However, I refer the Minister to a point that I and others have raised in the past. There is a great concern in the health service about untrained, or poorly trained, healthcare assistants. Nurses have said to me that they are held responsible for the work done, often by untrained or inadequately trained people. I have raised this before. Can I ask the Minister to look at it again as a very serious issue?

[Earl Howe]

We are indeed looking at it very urgently at the moment in the light of the review published a few days ago by Camilla Cavendish, which focuses on exactly that issue.

[Lord Sutherland of Houndwood]

My Lords, one thing that is very positive in the Minister’s Statement, and in the way in which he responds to questions, is that he clearly understands that this is a multifaceted problem and that there is no single way in which to deal with the whole set of issues. That being said, there is, of course, a “but”. The “but” is that one element of the government response—already referred to at least twice—is the role of the future Chief Inspector of Hospitals. The view taken, and reiterated again today, is that the inspector should be within the umbrella of the CQC. For some of us, at the moment, the CQC is part of the problem. It has not solved all our problems. I share the hopes of the Government that the CQC will remove itself from its current difficulties. However, in the mean time at least—or, in my view, in the longer term—a chief inspector should have both the responsibility and the authority of reporting directly to Parliament, as does the Chief Inspector of Schools. That would be a helpful element of transparency.

[Earl Howe]

I would have agreed with the noble Lord had he made those comments 18 months or two years ago. However, the CQC has turned a very important corner. It has new leadership and has articulated new ways of working. The leadership of the CQC commands high levels of confidence in every quarter of Parliament. I am encouraged by that. However, the point that the noble Lord makes about transparency is vital. The CQC is very clear that it is not its function to gloss over poor care when it is found, nor indeed to fail to celebrate good care when that is found.