NEW: NHS chief executive Sir David Nicholson has revealed his thinking on issues including the independence of foundation trusts, regulation and the reforms during his second day of evidence to the Mid Staffordshire Public Inquiry.
Wednesday 28 September
NHS chief executive Sir David Nicholson has revealed his thinking on issues including the independence of foundation trusts, regulation and the reforms during his second day of evidence to the Mid Staffordshire Public Inquiry.
Regulation of managers
Sir David told the inquiry the current situation was “not sustainable” and it was an “anomaly” that chief executives headed up a board with a nurse, a doctor and an accountant who could all be struck off by their respective professional bodies, while the chief executive could not.
He said the Council for Healthcare Regulation Excellence was looking at plans for a voluntary system but it could “in time” become more formal.
Asked whether it had been right for NHS deputy chief executive David Flory to consider moving former Mid Staffs chief exec Martin Yeats to another “post in the system” said it had been wrong in that case but there was an argument for giving failing chief executives another chance.
He said: “The most obvious thing that goes wrong for a chief executive is that they fall out with their doctors. That does happen and it’s not because they’re bad chief executives; they may in retrospect not have been ready for the job.
“I think it’s a good use of resources and value for money to try and place these people into other [jobs in the NHS] so they can rehabilitate.”
Sir David said it was a big risk to try and regulate such a huge workforce whose roles ranged from “housekeeping to the direct care of patients”.
“I think it’s the complexity of that has stopped people doing it. I’m not convinced spending huge amounts of time and effort on training and education maybe the best way forward.”
Asked to respond to comments from Royal College e of Nursing chief executive Peter Carter and Nursing and Midwifery Council boss Dickon Weir-Hughes that HCAs should be regulated, Sir David said “the nursing profession would say that wouldn’t they”.
He said: “I think it’s an issue. Whether it’s of the importance in terms of all the other things that we are trying to do at the moment I wouldn’t like to second guess.”
Asked by chairman Robert Francis QC how much time he thought should be given to ensure that the people generally “charged with feeding and providing basic care to our most vulnerable patients are fit and proper people to do that?”
Sir David said it was important HCAs had proper professional supervision but was unable to think of anything specific the department was doing nationally to improve the situation.
Asked about the extent of foundation trusts’ independence from central control Sir David said it was possible for them to be independent but not completely autonomous as they had to work with the rest of the system.
“To advocate this idea of autonomy seems to me to potentially give the wrong message to the system,” he said.
The inquiry was shown a letter from former executive chair of the foundation trust regulatory Monitor Bill Moyes to Sir David from 2007. In it Dr Moyes complains that the NHS chief executive had acted out of turn in writing to foundation trust chief executives to remind them of their responsibilities around hospital acquired infections in the wake of the scandal at Maidstone and Tunbridge Wells Trust.
Sir David defended his decision, although admitted he should have written to private sector providers as well, something he later did.
He added: “Monitor is the regulator of foundation trusts; it’s not the defender or the head office… [In the letter] I’m setting out what the expectations of their customers, their patients and the organisation that funds them are for the future of the service.”
Asked if the 2016 deadline for trusts to become FTs could be extended, Sir David said it would be driven by “our ability” to make all trusts financially and clinically sustainable.
Sir David told the inquiry the NHS Commissioning Board, of which he is chief executive designate, would meet in public and he would like the meetings to be broadcast over the internet.
He said all organisations receiving money from the NHS should meet in public and should also publish data on number and type of complaints in their annual reports, with the best organisations including patient stories as well.
In order to give patients “more clout” they should be given budgets “to use as they see fit” in their local health community.
Sir David told the inquiry he did not have a view on whether the economic and quality regulator should be combined, saying it was an issue for another day.
Asked about the Care Quality Commission’s quality risk profiles, which are supposed to bring together information about health and social care providers from a range of sources and be made publicly available.
Sir David admitted they were “not there yet” but said they had the potential to be “powerful”.
Sir David was asked about how the NHS would operate following the implementation of the Health Bill currently going through parliament.
He said the establishment of clinical commissioning groups was being handled in a “significantly different way” to the creation of primary care trusts which took on the “totality of their commissioning responsibilities” from day one.
“In this environment we can either partially or wholly authorise CCGs or not authorise them as all. It’s perfectly possible not to authorise a CCG at all.
“That’s not our intention,” he added.
He told the inquiry that when primary care trusts are abolished in 2013, local organisations would remain “on the same footprint” with “predominantly the same people” to do any commissioning the CCGs aren’t ready to do.
Asked by inquiry counsel whether these organisations would just be PCTs “under a different name” Sir David said they wouldn’t be statutory bodies.
He added: “It’s a transitional arrangement which personally I think is the safest way of moving from the system we have to the new system.”
Sir David was also asked about the NHS Trust Development Authority which will have responsibility for non foundation trusts when strategic health authorities are abolished.
He said it would be based outside London, although it had not been decided where yet, and whether or not it had regional arms would depend very much on how many organisations still had to achieve foundation trust status.
He confirmed the four SHA clusters would form the basis for the regional arms of the NHS Commissioning Board and said agreement had been reached with the Care Quality Commission and the ? NHS Trust Development Authority that they would organise themselves along similar lines as a way of “getting communication going at that level as fast as possible”
Inquiry chairman Robert Francis QC asked why the government had to legislate to make changes to the NHS and why, for example, if it wanted to increase clinician involvement in commissioning it could not have just replaced PCT boards with GPs.
Sir David said although they had considered other options, health secretary Andrew Lansley had had a “pretty strong view about the way he wanted to do it”.
However, he said the legislation would make it more difficult for the health secretary to reorganise the NHS in future.
“The NHS is essentially what the health secretary says it is and the powers of the health secretary are very significant… [with] reorganisations in the past there was the view that if we get it slightly wrong the health secretary would have the power to put it right. These set of changes are not like that,” he said.
Tuesday 27 September: afternoon
NHS chief executive David Nicholson has told the Mid Staffordshire Foundation Trust public inquiry he would like to see the government have power to bring failing foundation trusts back under state control.
During the first day f his evidence on Tuesday Sir David accepted this views put him at odds with the policy of the government, which earlier this month amended the bill to remove the ability to deauthorise foundation trusts.
He said: “The ability to renationalise a foundation trust in this situation [Mid Staffs] should be a possibility,” Sir David said. “[The government] wants all organisations to be foundation trusts but I believe that from time to time it may be necessary for the state to take direct management of an organisation.”
He said the new NHS Trust Development Authority should be given the powers to remove foundation status.
The inquiry was shown a letter sent to the trust from Sir David following the foundation trust diagnostic board to board in which he said he anticipated it would be two years before the trust would be in a realistic position to apply for foundation trust status.
However, just four months later, a month after Sir David left to become chief executive of NHS London, NHS West Midlands had given its backing to the trust’s foundation status bid.
He accepted he had not expected it to enter the pipeline so soon but said there was nothing “intrinsically” wrong with the trust which would prevent it from becoming a foundation trust.
Asked what he blamed the failure of the system to pick up problems at the trust Sir David said he had thought he had put in place the people and processes to make sure nothing like that happened but “it simply wasn’t enough” and the SHA did not have the capacity to closely monitor all organisations.
“The basic reason why the SHA divided its time [the way it did] was more [determined] by the financial deficit of that organisation than any other part of it. It wasn’t that the individuals involved and the people working in the system weren’t committed to quality and patient care or anything of that nature but it genuinely was I think at that time quality was not the organising principle of the NHS. It wasn’t the thing that was driving us during that period.
“I wish it was different… Indeed it was one of the reasons that I decided to apply for the job of the chief executive if the NHS,” he said.
Sir David accepted his “share of responsibility” as chief executive of the SHA, however he said the focus on finance had achieved results in terms of the sustainability of organisations.
Asked about former trust chief executive Martin Yeates, whom he was on the appointment panel for, Sir David said he had been the wrong appointment as although he had the operational capability he had not been strategically minded enough.
However, he said Staffordshire was a part of the country where it was often difficult to recruit senior managers.
Sir David told the inquiry the DH had begun a lot of work on leadership, including the top leaders programme, to make sure there was a good pool of potential candidates in the system.
Asked how this impacted on recruitment from the private sector, Sir David said it was still possible for them to join the NHS but they usually left again fairly quickly because they could not handle the “politicis with a small p”.
He added: “When you do the job right there is nothing better than being an NHS manager.”
Sir David was asked about the decision of his colleagues in the DH to back the trust’s bid for foundation trust status, despite recognising its business case was “marginal”.
He told the inquiry he would not have put the trust forward to the health secretary and denied there was any pressure coming from Number 10 to push through trusts that were not ready.
He added: “There is no doubt if I was chief executive of an SHA and I couldn’t identify hospitals that were potentially sustainable financially and clinically someone would say to me ‘why are you different to everyone else?’
“But worse than that for me would be putting forward a set of organisations to become foundation trusts which were then turned down later… I don’t think it’s worth the risk.”
Asked if he thought the four lines of advice provided to then health minister Andy Burnham by civil servants was adequate Sir David said he would have expected more detail.
“Clearly we had got into a place where ministers didn’t really expect that much detail and so all we have is a relatively short statement. I genuinely don’t think it was driven by the fact we were frightened that Paul Corrigan [Tony Blair’s health adviser] would tell us that we hadn’t got enough trusts through [the foundation trust process].
He said he was “surprised” Monitor had put so much store in the health secretary’s backing of the trust and had expected it to carry out its own rigorous checks on quality.
“I’ve never heard Monitor saying in any circumstances we passed this trust because we were satisfied that the secretary of state was happy with the quality of it.”
Tuesday 27 September: morning
NHS chief executive David Nicholson has admitted the strategic health authority he ran was not “alert” to the kind of problems that happened at Mid Staffordshire Foundation Trust.
In his evidence to the public inquiry Sir David said Shropshire and Staffordshire SHA had been focusing on the trusts which had financial problems during his brief time as interim chief executive between August 2005 and April 2006.
He said: “Were alert of the potential of what was happening at Mid Staffordshire and [did we] build that into the work we were doing? The answer is we did not.
“We put a lot of effort and time into getting the organisations [with financial problems] in the best place we could possibly get them.”
Sir David was critical of the approach being taken by SASSHA when he joined for not being “big on intervention” and not stepping in to deal with budget problems when they first emerged.
At the time he was overseeing the handover from SASSHA, Birmingham and the Black Country and West Midlands South SHAs into NHS West Midlands. He appointed a managing director for each of those regions. Antony Sumara, who became interim chief executive of the trust, was appointed to SASSHA.
Sir David said there were no signals coming from the trust that anything was wrong and it had not come up on any “lists of concerns” that had crossed his desk. He said he would have expected the PCT to pick up concerns.
Asked whether the NHS had been overly concerned with finances during 2005-06, Sir David accepted the need to balance the books was a big focus but “not at any price”. He rejected a comment from William Price of the South West Staffordshire PCT; put to him by inquiry counsel, those SHAs “didn’t give a monkeys” how the books were balanced as long as it happened.
Asked about the trust’s 8.3 per cent cost improvement programme for 2006-07, Sir David admitted it was on the high side and said he would have had something to say about it if he had known about the scale of it at a time when the local PCT was getting a budget increase if between seven and nine per cent.
Sir David criticised Staffordshire for having too many public bodies relative to the population, compared to other parts of the country he had worked in, and said this made it difficult to work together.
Following a local consultation on the reogranisation in 2005-06 Staffordshire ended up with four PCTs rather than the one preferred by Sir David and the department.
“Part of it was critical mass; Staffordshire has a number of district general hospitals and the future of those district general hospitals have depends on their ability to work together cohesively. I think they were having some difficulties doing that and I thought a commissioning organisation which could look at the whole of Staffordshire would have a better chance of getting these organisations to work cohesively together,” he said.
Sir David was also asked about a board to board diagnostic he had taken part in with the trust in 2005. He said at the time he knew of concerns about the leadership of the previous chair and chief executive but was reassured by the fact they had now been replaced and new chair Toni Brisby had a reputation for being dynamic and tough.
“Most of the discussion at the board to board was about purpose and most worrying thing about all of it was that they couldn’t clearly articulate it. Part of the reason they were unable to articulate it was because they didn’t have detailed clinician involvement and engagement at the trust,” he said.
He accepted the board could have bought any clinician they liked with them but said he did not worry about their leadership as they acknowledged they had a problem with clinical leadership
Monday 26 September: afternoon part two
Former Department of Health permanent secretary Sir Hugh Taylor has defended the appointment of Cynthia Bower to head up the Care Quality Commission, despite failings at Mid Staffordshire Foundation Trust happening on her watch as chief executive of NHS West Midlands.
Asked by inquiry counsel Tom Baker whether he thought it was an appropriate appointment, Sir Hugh paused before answering.
He said: “When Cynthia Bower was appointed head of the CQC I don’t think the situation as it has now emerged was fully known. She had outstanding credentials to become the chief executive of the CQC and she was chosen after a very extensive selection process and I think it would be unwise to suggest it was a bad decision on those grounds.”
Asked how the public could still have confidence is Ms Bower and the CQC, Sir Hugh said that was a matter for CQC chair Jo Williams and “Cynthia herself”.
Sir Hugh told the inquiry he believed the failure to spot problems at the trust sooner was a “whole system failure” but the poor care was a failure of the individuals responsible.
Asked specifically what the DH could have done, Sir Hugh said a more “systematic and disciplined” approach should have been taken to ensuring a working relationship between Monitor and the CQC and more thought should have been given to what would happen if a foundation trust failed clinically.
He said: “If the whole system fails to work as it’s intended… then in the end the department has to take responsibility because it designed [the system]. That’s why a lot of us were genuinely shocked by the fact that the system didn’t pick this up in a satisfactory way.
“I would want to emphasise that all systems do depend on levels of professionalism operating throughout them and if people are deliberately or unconsciously misleading the system or operating in ways that are outside the system then that becomes quite a challenge.”
Monday 26 September: afternoon part one
Sir Hugh Taylor has denied he presided over a culture of fear in the Department of Health and the NHS during his time as permanent secretary, but admitted there was a “robust management style.
In his evidence to the inquiry Sir Hugh, who was permanent secretary from 2006 until 2010, said there was “undoubtedly a strong emphasis on delivery” particularly through the middle of the decade.
He was shown a copy of a report from Joint Commission International commissioned as part of the Darzi review into quality in the NHS which was never published.
Following interviews with more than 50 stakeholders the report concluded there was a “pervasive culture of fear” throughout the NHS and some parts of the DH with the main driver for quality improvement fear among chief executives of public humiliation or losing their jobs.
He added: “[There were] strong expectations on the part of the government that the improvements it was seeking in the NHS should happen and seen to happen, particularly in some of the priority areas.
“I don’t think that translates into a culture of fear across the NHS or that there was an all pervasive shame and blame culture pervading the NHS.”
Sir Hugh was asked by chairman Robert Francis QC how he could explain the fact there were other reports from around the same time which had reached similar conclusions about the culture of the NHS.
He said: “I’m not trying to pretend that mistakes weren’t made, that at times a level of stridency would have entered the way this programme was taken forward.”
Asked about the department’s use of targets, Sir Hugh said the four hour accident and emergency standards and the 18 week waiting time target meant trusts had to think about how the hospital operated as a whole in order to achieve them.
“I want to correct the impression that all the department did was set a target and shout at people until it happened,” he said.
Asked about his specific involvement with Mid Staffordshire Foundation Trust, Sir Hugh admitted it had come as a surprise when then health secretary Alan Johnson found out how bad the Healthcare Commission’s report was during a routine meeting with chair Sir Ian Kennedy on 4 February 2009, weeks before its publication.
The inquiry heard extracts from the report had been with the DH since 19 December but ministers had not been briefed as it was being fact checked.
Sir Hugh admitted finding out at the meeting, for which Mr Johnson had not been briefed on the investigation at the trust, was not the best way for the minister to find out about it. However, he said it was unlikely it would have made a “material difference” to the speed at which the DH dealt with the trust.oHO
Monday 26 September: morning
Reorganisation of the NHS in 2006 was a major factor in problems at Mid Staffordshire Foundation Trust going unnoticed, a former Department of Health permanent secretary Sir Hugh Taylor has told the public inquiry.
In his statement Sir Hugh said it was “inevitable” with any restructure that there would be a loss of corporate memory. He described the 2005-06 restructure, when primary care trusts and strategic health authorities were merging to form fewer organisations, as “difficult” and people rushed towards their new roles “as they sense their status and power in the old position diminishing”.
The inquiry has previously heard from witnesses who have criticised the handover between Shropshire and South Staffordshire SHA and NHS West Midlands and the merger of about five primary care trusts into South Staffordshire PCT.
Sir Hugh said: “The reorganisation does appear to have been one of the factors which contributed to the problems in identifying the concerns which I think should have surfaced to the commissioners of this trust.”
Asked further about the frequency of reorganisations, Sir Hugh conceded it was not “terribly sensible” that there were people in the NHS sitting at the same desk doing “broadly the same job” as they had done for years but under three or four organisations.
Sir High accepted there had been immaturity in the healthcare regulation system during the early part of the last decade but pointed out there had not been a regulatory system before 1999.
“If you create an organisation and then tell it almost immediately it’s not going to exist in a few years then it’s not the best way to encourage and organisation to really develop.
“I would hope that whatever it’s current problems the government gives the Care Quality Commission time to learn about how to do its job most effectively and to support it in doing that.”
Asked about eveidence from former HCC chair Sir Ian Kennedy and CQC chair Baroness Barbara Young, who claimed the DH had been difficult to work with, Sir Hugh accepted there was an inherent tension between ministers in the DH and the regulator. However, he insisted he had never seen ministers behave inappropriately and said they were right to test what they were being told by the regulator as they would be the ones answering questions on it.
Asked about former trust chief executive Martin Yeates’ plan to bring in consultants to review the trust alongside the Healthcare Commission’s investigation, Sir Hugh said “on the face of it it doesn’t sound like a good idea”.
He added: “If you’re asking me whether if I was running a trust under huge stress would it be the fist call on my resources, the answer would be no.”
However, he defended the role of consultants in the NHS saying their involvement had led to improved finances.
“It was the time when turnaround teams were created and there is no doubt that during that period there was a dependency on consultancy expertise to support trust in making some of the changes needed.
“It’s difficult to defend that sort of expenditure at the time. The fact remains that after that time, progressively, NHS finances improved to the point where there is not only a very small number of trusts operating a deficit,” he said.
Thursday 22 September: afternoon
The permanent secretary to the Department of Health has admitted the regulatory system failed patients and relatives at Mid Staffordshire Foundation Trust.
In the closing statement to her evidence at the inquiry Una O’Brien said she and colleagues at the DH had “taken to heart” the events which had happened at the trust and promised they would do all that was “humanly possible” to take on board the inquiry’s recommendations.
“We will do all that we can to take these lessons on board because there is no doubt about it the regulatory and supervisory system let people down.
“It’s a matter of personal regret to me that concerns of patients and relatives were missed. I hope the inquiry will recognise that we have endeavoured to make progress since 2009 and that a lot of effort has gone into [improving] the system.”
However, earlier in her evidence she denied the situation at the trust had been a “whole system failure”.
She said: “Dreadful through what happened at Mid Staffs was, and it’s not something I will ever forget, at the same time these systems and arrangements were functioning in other parts of the country.
She told the inquiry a key question was how to take the “regulatory mindset inside provider organisations” and confirmed the government’s commitment to introducing a duty of candour. However, she said no detail of how such a duty would work had been decided on.
Ms O’Brien, who was director general for policy and strategy during the period the inquiry is examining from 2005 to 2009,
She also apologised for the way complaints were handled by the DH in the past when it was policy to return complaints to the sender explaining they did not deal with them.
Local campaigner Julie Bailey, whose mother died at the trust, sent about a package containing aout 40 letters of complaint from herself and other relatives and patients to the DH. She received a letter back saying it was not the DH’s responsibility to deal with complaints and expressing condolences for the loss of her wife.
Ms O’Brien said the system had changed and staff had received more training to make sure the most serious complaints were picked up.
The inquiry was also shown a note written by Ms O’Brien which criticised foundation trust regulator Monitor for acting like a lobbying organisation and suggesting the situation at Mid Staffs “could have been quite different if Monitor had been more willing to work with other parts of the system”.
In her evidence to the inquiry she accepted the department could have done more sooner to provide “stewardship” of relationships between Monitor and others, particularly the Healthcare Commission.
Thursday 22 September: morning
Department of Health permanent secretary Una O’Brien has faced questions over the establishment of the Care Quality Commission during the morning’s evidence at the inquiry.
Ms O’Brien, who was involved in setting up the CQC in her previous role as director general of policy and strategy, admitted the DH was still learning “whether we got it right or not”.
The inquiry heard the creation of the CQC, which bought together the Healthcare Commission, Commission for Social Care Inspection and Mental Health Act Commission, was driven by the view of the then Labour government that there were too many public sector regulators.
The inquiry was shown a DH note suggesting that merging the regulators could save between £68m and £80m, equivalent to budget cuts of between 37 and 41 per cent in real terms.
However, Ms O’Brien denied it was a “simple cost reduction exercise” and said a lot of through had been given to the future design and responsibilities of the regulator.
Asked whether any consideration was given to the fact that the introduction of the registration regime was asking the new regulator to do more than its predecessors for less money, Ms O’Brien said she could not recall it being a “significant topic of debate at that time”.
The inquiry was shown a note prepared for former health minister Ben Bradshaw in February 2009 about the risks of setting up the CQC. It revealed CSCI had system failures which had led to a backlog of £400,000 of unbanked cheques, nearly 500 unpublished inspection reports and 3,000 lost pieces of data.
The document warned this and further problems with technology for the new regulator could be a distraction during the organisation’s early days. Ms O’Brien admitted the situation was not ideal but said the DH had responded to the challenge by increasing funding and delaying the 2009 deadline for registration of acute providers by a year.
In a broader discussion about the roles of regulators Ms O’Brien told the inquiry quality improvement was a “by product” of regulation rather than its main purpose with commissioners and provider boards acting as the main drivers of improvements.
She said: “It’s a matter of great sadness to me personally that that is not the case across the country, which is one of the reasons we are here today.
Referring to failures at Mid Staffs, she added: “I don’t think it was seriously anticipated at the time that there could be that degree of inadequacy within a single organisation which we now know to have been the case.”
Ms O’Brien was shown an article by HSJ’s sister publication Nursing Times highlighting the fact the CQC’s inspections of dignity and nutrition inspections were prompted by a report from the health service ombudsman and not its own intelligence.
Asked if that had raised concerns about the CQC’s methods she said it hadn’t and it was “exactly the sort of thing” they wanted the CQC to be doing.
Like almost all witnesses Ms O’Brien was asked for her views on why quality and economic regulation were carried out by two separate organisations.
She revealed it had been discussed during the establishment of the CQC whether Monitor should join the merger but it had been decided against.
She also revealed the Cooperation and Competition Panel had been set up because the Labour government at that time did not have the appetite for creating a “full blooded” economic regulator.
Ms O’Brien also told the inquiry the DH is planning to conduct a performance and capability review of each of its arms length bodies, beginning with the CQC in later October or early November.
She said the DH intended to collect information from organisations on the receiving end of the CQC’s regulatory activities as well as patients and the public before holding a board to board with the regulator.
Wednesday 21 September
Primary care trusts have not been given enough time to “bed in”, the man responsible for the world class commissioning programme has told the public inquiry.
Gary Belfield, who left his post as acting director general of commissioning at the Department of Health to join KPMG last September, was asked if he had any lessons from previous reorganisations that could be useful today.
He told the inquiry it was important to spend more time planning for change, before implementing it quickly and giving new systems longer to settle.
He said: “A number of the changes we made to commissioning over the last ten years have taken longer than they should have done which has unsettled people in the system and taken people’s eyes of the ball from their day to day job… There are times when we should have spent longer… working through some of the implications of some changes.”
Asked by inquiry counsel Ben Fitzgerald if there was a “recognition” in the DH that the reorganisation of primary care trusts in 2006 had caused a loss of momentum in commissioning improvement, Mr Belfield said it was not ever “articulated like that” but there was a frustration that PCTs had not progressed as they would have liked.
“I don’t think [commissioning] had the priority it needed to in the department of health until 2007 despite a number of documents produced extorting PCTs to do more, to do better. There was never really a sustained follow through to make that happen and it wasn’t really until 2007 with David Nicholson [in post as NHS chief executive] that commissioning really became a high priority.”
Asked why he thought this was, Mr Belfield suggested the acute sector backgrounds of most of the NHS management board and the need for political quick fixes could be factors.
He said: “Politically commissioning is a longer term solution and the things in health care are often immediate priorities and so maybe commissioning was pushed back because of that.”
Asked about the situation in Staffordshire, Mr Belfield said he was “surprised” that South Staffordshire PCT had not picked up more “warning signs” although he accepted many PCTS at the time did not have a focus on quality. He admitted it would have been common for PCTs to back a bid for foundation trust status relying on trusts self declarations to the Healthcare Commission to assure quality.
However, Mr Belfield told the inquiry that would not happen today and said the PCT would be less likely to miss warning signs as PCTs were more focused on commissioning and had less “distractions” now they were no longer providing community services.
Tuesday 20 September: afternoon
Mid Staffordshire Foundation Trust would have been an outlier under the new mortality indicator methodology as well as Dr Foster’s hospital standardised mortality ratio, the public inquiry has heard.
NHS medical director Sir Bruce Keogh told the inquiry the new summary hospital-level mortality indicator (SHMI) had been calculated using data for the trust during the period the inquiry is examining from 2005 to 2009 and had predicted similar levels of excess deaths.
Repeatedly high HSMRs and disease specific mortality alerts sparked the Healthcare Commission’s investigation into the trust which uncovered appalling standards of care.
Data for all trusts using the SHMI, which has been developed in a bid to put an end to disagreements on the methodology and validity of measures of excess deaths, is due to be published on the NHS Choices website later this year.
Sir Bruce told the inquiry two versions of the data would be published, one with the data adjusted for “noise”, which showed about five outliers, and one with the raw data that produced closer to 20.
Explaining the decision to publish both versions, he said: “If we do it without smoothing the data the academic statisticians will say ‘this is not robust’, and if we do smooth the data others will accuse us of a whitewash,”
He admitted it would be impossible to avoid “league table syndrome” but said it was the “right and proper thing” to publish the data.
The number of patients coded as palliative will now be adjusted for in calculating the SHMI but data on the proportion of deaths coded in that way would be published. The inquiry has previously heard evidence that some trusts were “gaming” the system by coding up to 70 per cent of patients as palliative.
Sir Bruce told the inquiry that publishing the level of deaths coded as palliative would “bring any outliers into line pretty quickly”.
As well as high HSMRs, the trust also had poor staff and patient survey results when it was authorised as a foundation trust in February 2008, weeks before the HCC launched an investigation.
Sir Bruce said there was “not a chance” the trust would have been awarded foundation trust status today.
During the afternoon’s evidence Sir Bruce was asked extensively about a wide range of issues including targets, quality and patient safety.
He revealed the National Patient Safety Agency’s National Reporting and Learning Service, which will become the responsibility of the NHS Commissioning Board when the Agency is abolished, is likely to be outsourced to an “NHS trust with an academic interest”.
He also told the inquiry he had asked NHS Choices to publish organisation level data on compliance with patient safety alerts after being persuaded by the charity Action Against Medical Accidents.
Sir Bruce repeatedly stressed the importance of patient voice in improving the safety and quality of care and said he had “become increasingly taken with the ability of patients to make a pretty objective assessment” of services.
However, asked how the patient voice was “embedded” in Richmond House, home of the DH, he admitted the flow of information was not good enough.
Sir Bruce was also asked about the development of quality accounts. All NHS organisations are required to publish a quality account describing their services but they have been criticised for a lack of comparability.
Sir Bruce accepted they would be “self certified spin” if a board wasn’t performing effectively and revealed the DH was “still taking a view” on whether to get some of “the big four” consultancy firms to audit them.
He refused to answer questions on the role of the medical director on the NHS Commissioning Board, telling counsel it remianed to be seen who would take on that role.
In his closing statement Sir Bruce listed four things that would improve quality: renewed focus on professionalism for clinicians, better surveillance and support of failing clinicians, a real focus on quality at board level and a national and regional system that “encourages, incentivises and regulates” for quality.
“In terms of delivering quality it wasn’t the CQC, it wasn’t the PCT, it wasn’t the SHA who treated patients badly at Mid Staffs it was individual clinicians.
“If you want to improve quality the first area you need to focus on is improving professionalism. Focus on quality with individual clinicians to help people focus on the values that bought them into clinical practice in the first place.”
He asked the inquiry to think about what healthcare would look like in the future when making its recommendations, citing increased use of technology and greater patient expectations as the biggest drivers for changes.
He revealed he and his family had suffered as a result of poor care and empathised with the “anguish” felt by families affected by poor care at Mid Staffs.
Tuesday 20 September: morning
Problems at Mid Staffordshire Foundation Trust were a “failure of clinical leadership and professionalism”, the medical director of the NHS Sir Bruce Keogh has told the public inquiry.
Sir Bruce said it was not right to “put all the blame on managers” as it was not the managers seeing the patients.
He said: “Hospitals are an aggregate of different service lines, each of which is serviced by various tribes of clinicians, doctors, nurses and managers all of who are professionals in their own right.
“And actually when I look at this kind of failure what I see is a failure of clinical leadership and professionalism.”
The inquiry heard that Robert Greatorex, a surgeon who had carried out a peer review of surgery at the trust with the Royal College of Surgeons, called Sir Bruce in October 2009 to inform him he had never seen “a more dysfunctional surgical unit anywhere”.
Sir Bruce contacted the trust to advise all laparoscopic surgery be stopped and was later contacted by one of the trust surgeons questioning his authority over them as a foundation trust.
Mr Greatorex broke the confidence of the trust, at whose behest the report had been carried out, to contact Sir Bruce because he was so concerned.
The inquiry was told the RCS had since amended its contracts to allow it to inform the regulator where serious concerns were found during a peer review. Sir Bruce said he hoped the rest of the royal colleges would follow suit and understood discussions were taking place at the moment.
Asked why the DH had not intervened sooner he blamed the HCC for not making them aware that problems were not being dealt with. He said he had not seen a letter sent to the DH in May 2008 warning of serious staffing problems in A&E, probably because it had been sent to South Staffordshire PCT and NHS West Midlands and it was assumed in the DH performance directorate they would be “getting a grip”.
If he had seen the letter he would have liked a “face to face” meeting with HCC chief executive Anna Walker and chair Sir Ian Kennedy as it raised questions about whether enough was being done quickly enough.
“The Department of Health is not the regulator and nor should it be. But the department should listen to the independent regulator and that regulator was telling us that there was no need for operational intervention,” he said.
Sir Bruce was also critical of NHS West Midlands for not investigating what was causing repeatedly high hospital standardised mortality ratios at the trust and instead commissioning a study into the methodology.
He said: “At the same time as allowing that argument [about the validity of HSMRs] to happen, it would have been sensible to go and look and see if there was fire where there was some smoke,” he said.
Asked if staff responsible for a never event should automatically face disciplinary action, Sir Bruce said that was not an “unreasonable” suggestion.
However, he said he was agnostic when it came to making duty of candour a legal requirement as there was a “grey zone” as it was not always immediately clear if something had gone wrong.
He said: “Whilst I’m absolutely in favour of the principle I think as a mandatory professional responsibility I find myself asking can you force people to do this by legislation? Often when a mistake is made there is only one person that knows and it will be a sense of professionalism that will cause that person to own up not a sense of threatening legislation.”
He said economically there was a need for some form of self assessment in regulation but the risk must be reduced by regular inspections either based on information in the self assessment or other information or, alternatively, at random.
He said random inspections had the advantage of making people “think twice” about not being totally honest in their self assessment.
Monday 19 September: afternoon
Healthcare professionals need to be trained to see patients as people, former chief medical officer Sir Liam Donaldson has told the public inquiry.
Sir Liam said people entering the professions knew “instinctively” how to care but often become “inured” to suffering in a modern care environment.
He said: “It’s vital you see that person as a person, not just a diseased object to be processed… It may be shocking to people but in another way it’s a genuine reaction to high stress high pressure jobs
Sir Liam told the inquiry undergraduate education for doctors and nurses was “completely lacking” in teaching on quality and safety and curricula were “full”.
“If you want to get a new subject into a medical curriculum it takes a long time and you’ve got to fight the people that already hold the teaching hours.”
He said a lot of learning in medicine and nursing is still from watching role models and the way they behave which can be bad if the people students are learning from are not the best.
Sir Liam told the inquiry it was still too difficult for trusts to get rid of bad doctors.
Sir Liam told the inquiry he supported a duty of candour but said it had to be handled in “a way that’s as positive as possible”.
“You can’t just send a distressed nurse straight down the corridor to disclose something.
He said the acute sector needed to take the involvement of patients more seriously in order to improve care and safety. He revealed he had suggested that disease specific charities or royal colleges could run hospitals on five year contracts as an alternative to the fpoundation trust policy which would help to embed patient involvement.
“The idea of the Royal National Institute for the Blind running an ophthalmology hospital is very exciting,” he said.
Asked about regulation of health services during his 12 years as chief medical officer, Sir Liam said CHI had done a good job as the first organisation to attempt regulation and the HCC had done the best with the “hand it was dealt” in terms of a lack of resources and few formal powers.
“There hadn’t been a particular tradition of quality and safety being specifically recognised, pursued and measured over many, many years… The principal idea in NHS management is about running an organisation that is sound financially and productive in the number of patients that it treats with quality matters being left to clinicians.
“It’s not like football managers; [NHS managers] are usually given a long time to perform before [they are dismissed].
The inquiry heard Sir Liam had been worried about whether the Care Quality Commission would have enough money when it was set up and was concerned amalgamating the health and social care regulators could create an organisation that was too big
Asked about why he had not made the reporting of patient safety incidents mandatory, Sir Liam said he had been “warned” that doctors would not report.
The inquiry heard the National Reporting and Learning system was finally set up six years after it was first suggested but that doctors were still much less likely to report to it than nurses.
Sir Liam said: “It’s a worldwide problem. I think it’s because on the whole nurses are more interested in contributing information from reports to a general system than doctors are. Doctors are more singular in their outlook on life.”
He said disciplining professionals for failing to report incidents was counter to the philosophy of patient safety.
Asked if he had any closing comments to make, Sir Liam asked the inquiry to consider his four criteria for a successful organisation: proactive use of data, continuity of leadership, patient involvement, and no distinction between management and clinical objectives.
Monday 19 September: morning
It’s too easy for the “higher echelons” of the NHS to forget about the impacts of their policies on “real people”, Sir Liam Donaldson has told the public inquiry.
The former chief medical officer said it was often the case that politicians had “the sharpest appreciation [of] some of the realities”.
Sir Liam was asked about patient safety, whistle blowing, and the impact of targets during the morning session.
Asked why there appeared to be a division between quality and finance Sir Liam said he ”wasn’t sure that in their heart of hearts everybody [in the NHS] was convinced that we could run a service which met the financial and productivity targets but also delivered quality”.
He told the inquiry targets had been an “important phase” but had the effect of “locking up” a lot of the NHS budget meaning other services lose out.
He said: “My view is always that the targets should be set more holistically so, for example, we should set a target for cancer that we specify that cancer care should be timely and excellent.
Asked about whistle blowing and the reporting culture of the NHS, Sir Liam said it had improved a little bit but was still “highly unsatisfactory” and inconsistent.
He said organisations needed to have the courage to stick to their policy even if they have tabloid newspapers on the phone calling for a member of staff to be dismissed, as only through consistency will people have the confidence to admit mistakes, reducing the likelihood of it happening again.
Sir Liam was questioned extensively about the Healthcare Commission’s core standards and the role of self assessment.
He refuted claims made by HCC witnesses that the core standards had been handed down like “tablets of stone” from the government.
“The HCC had a lot of input; whether they agreed with output or not is a different matter,” he said.
The inquiry was shown documents suggesting the HCC wanted the standards to focus more on outcome than processes but their concerns were rejected by then health minister Lord Warner who said the HCC would have to “fit in” with the government.
He said a degree of self assessment was necessary otherwise you would have “one half of the NHS out inspecting the other half every day of the week” but accepted Mid Staffordshire Foundation Trust’s one word assurances to the HCC were “inadequate” and lacked evidence.
Asked how he thought the events at Mid Staffordshire Foundation Trust had managed to go unnoticed, Sir Liam said it had “shocked” him that it had happened during a time when the National Service Framework for older people was such a prominent policy.
He added: “It’s possible that one isolated situation could have been overlooked but I think you have to look at Mid Staffordshire [situations] described in other reports.
“I think there are two things going on. One was that regulatory systems have not been able to detect those aspects of care because it’s a softer and less easily measurable aspect of care than other technical ways, but it could also be to do with society’s view of older people and the extent to which that’s reflected in one of our national institutions.”
Thursday 15 September: afternoon - part 2
NHS deputy chief executive David Flory found it “reasonable” that the chief executive of Mid Staffordshire Foundation Trust should continue to work in the NHS after reading the Healthcare Commission’s report, the public inquiry has heard.
The inquiry was shown a note written by Mr Flory in February 2009 which suggested trust boss Martin Yeates could “move to another post in the system”.
Mr Flory said that did not mean a chief executive post and he had changed his mind soon after the note was written after seeing more information.
Asked about the broader phenomenon in the NHS where managers of failed organisations move into new jobs or leave with big pay offs, Mr Flory said he had received significantly fewer requests to sign off unusual pay offs since the case of Maidstone and Tunbridge Wells Trust where the DH had ordered the chief executive leave without a pay out.
Former Maidstone’s chief executive Rose Gibb later won on appeal, but Mr Flory told the inquiry the fact the DH was seen to be “trying to do the right thing and not just pay off people for an easy life” had acted as a deterrent.
Asked about the controversial meeting where the decision was taken to remove excess death figures from a draft of the HCC report, Mr Flory said no one at the meeting had wanted to include the figure which suggested between 400 and 1,200 people had died unnecessarily.
Asked why the discussion wasn’t minuted he said he didn’t know. He admitted he had been at other meetings where the minister said “let’s put the pen down for a moment” but said that was “mostly” when the minister “switches” into politician mode and had not happened here.
The inquiry was shown another note written by Mr Flory in June 2009 to then health secretary Andy Burnham in which he makes the case against holding a public inquiry into failures at the trust.
As well as arguing it will cost millions and drag on for years, Mr Flory suggests it will lead to “criticism of government policy and be used for political capital”.
Asked if he thought that was an appropriate reason for not holding a public inquiry he said “on reflection, no”.
He told the inquiry people working in the NHS did things “differently as a result of learning” from Mid Staffordshire
“We failed people and it’s a scandal when that happens and I feel completely for those who have lost love ones.
“I do my job differently than I did before this happened. I think it’s an important responsibility for leaders in the system to learn and to improve and to reflect on what can be done.”
Thursday 15 September: afternoon - part 1
NHS deputy chief executive David Flory has criticised the Healthcare Commission and NHS West Midlands in his evidence to the Mid Staffordshire Foundation Trust Public Inquiry.
Asked for his view on the strategic health authority’s decision to commission a report into repeatedly high hospital standardised mortality ratios at the trust rather than investigate what was going on on the ground, he said the response had not been “wholly appropriate”.
Challenged by lawyers for the SHA who argued they had visited the trust and spoke to management about the HSMR, Mr Flory said they had been “too easily assured”.
Mr Flory also faced questions about why the DH had not acted sooner when the HCC copied them into three letters to the trust while its investigation was ongoing during 2008.
He told the inquiry that the first letter in May of that year, which expressed concerns about staffing and A&E, would have been enough to provoke intervention from the DH with an NHS trust, but as a foundation trust the situation was different with Mid Staffs.
“There was a whole stream of information all the way to this [meeting in October 2008] during which the people responsible for the HCC, the chair and chief executive at the top of the organisation, were not flashing serious concerns or warning about what they were finding.”
Thursday 15 September: morning
The crisis at Mid Staffordshire Foundation Trust was caused by the “biggest failure of clinical governance” NHS deputy chief executive David Flory had ever seen, he has told the public inquiry.
He said the size and significance of the failure meant it was impacting on the reputation of the rest of the NHS meaning it was inevitable ministers would have to intervene at the trust despite its foundation status.
Mr Flory said: “The secretary of state didn’t, and in my view couldn’t, have sat back and said this is nothing to do with me.”
During the morning’s evidence session Mr Flory was asked about NHS culture, targets and hospital standardised mortality ratios.
He told the inquiry on paper the trust’s cost improvement plan, which cut £10m from its budget, looked achievable as its reference costs were in line with other similar organisations.
Asked why the trust had required and received so much financial support since the publication of the Healthcare Commission’s critical report into the trust, Mr Flory said the money had been provided to recruit more staff in line with the recommendations of Professor Sir George Alberti’s subsequent report into the trust.
He described the suggestion that public humiliation and the fear of chief executives losing their jobs were the biggest drivers of quality improvement in the NHS as “outrageous” but accepted gaming on targets was often driven by a desire to be “left alone” and avoid performance management interventions.
Mr Flory said chief executives would rarely lose their jobs if they were trying to put things right but issues arose if they were ignoring what was required of them.
He said: “You can’t draw a tax payers funded salary and ignore the rules of the game that the tax payer, through the elected government of the day, is setting.
“Gaming is a failing and an inadequacy in the management of that organisation. It’s not an inevitable consequence of having a target.”
Asked why the Department of Health hadn’t embraced HSMRs Mr Flory said there was a danger that rather than being used “to pose questions, you jump straight to the answer”.
In response to further questions on why the DH didn’t have an in house analysis but instead paid the private company Dr Foster to analyse the data, Mr Flory said it was “a very uncomfortable position for the department and the department has sought to change that.”
Thursday 8 September: afternoon
Nursing needs its own dedicated royal college to drive up standards free from union concerns, the chief nursing officer has said.
Giving evidence to the public inquiry Dame Christine Beasley said there were some advantages to combining the union and the professional organisation but these were outweighed by the conflict of interest.
She said: “I don’t often want to emulate medicine in my role as a nurse but I do think one of the things that we lack is an independent royal college that can do some of the things that royal colleges of doctors and medicine do.
“The RCN do a lot of work on standards but because the [professional side and union side] are linked that can have some problems when you start to want to implement it.”
Dame Christine has the rank of director general in the DH. When she retires later this year she will be replaced by a chief nurse on the new NHS Commissioning Board and a director of nursing in the DH focusing on public health who will only have a director level role.
However, Dame Christine said the role was envisaged as a powerful position advising across the department although she agreed it was “confusing” that the chief nurse role will sit on the commissioning board.
Asked whether she supported the regulation of healthcare assistants Dame Christine told the inquiry she did not think it was a “proportionate response”.
“[Healthcare support workers] covers a really broad area and I think to regulate in terms of professional regulation the whole of this workforce I strongly believe is not proportionate in terms of patient safety and cost to whoever pays and to the individuals themselves.”
Asked by inquiry chairman Robert Francis QC if she had changed her mind since the Prime Minister’s Commission into Nursing, of which she was a member, recommended regulation for HCAs, she said there could be a case for regulating a higher level of HCA but not the whole workforce.
She called for more support for whistleblowers and suggested individuals who raise the alarm should have someone from human resources or the nursing team designated to them to look after their interests.
Thursday 8 September: morning part 2
England’s chief nursing officer has admitted the NHS is at a time of “heightened risk” due to the twin challenges of reorganisation and the need to make £20b of efficiency savings by 2015.
Giving evidence to the Mid Staffordshire Foundation Trust public inquiry, Dame Christine Beasley said she doubted a similar situation – where the trust was short of 120 nurses after slashing £10m from its budget – would happen today.
“The refrain [around the NHS] is often: Are we sure we’re not in a Mid Staffs situation,” she said.
Dame Christine suggested the CQC could look at what processes organisations had in place for determining and monitoring there staffing levels as part of its licensing process but rejected calls for statutory guidance on staff numbers and skill mix.
She conceded that a 60:40 registered to unregistered was as low as you should go in an acute hospital ward but said her “concern” with mandating minimum staffing levels from the DH was that “instead of becoming the floor they become the ceiling.
She criticised former Mid Staffs nursing director Helen Moss, who arrived at the trust to find skill mix as low as 40 registered to 60 unregistered on some wards, telling the inquiry she couldn’t think of any circumstance where that skill mix “would be acceptable”.
Asked if she shared concerns expressed by Nursing and Midwifery Council chief executive Dickon Weir-Hughes at an earlier hearing that the abolition of SHAs would lead to a loss of professional support for nurses she said she did.
England’s 9 SHAs are in the process of clustering to form four organisations.
Dame Christine said: “We are still keeping an SHA role but covering much bigger areas. I have lived through so many changes of that sort of level and what nursing is very cery good at is that they a very strongly networked profession and in my experience when the changes happen they regroup around whatever the structure is.”
Thursday 8 September: morning part 1
Chief nursing officer Dame Christine Beasley has told the inquiry nursing “lost its way” as not enough attention was paid to the “values” of new entrants to the profession during the recruitment drive at the turn of the century.
Dame Christine said although there was a need for rapid recruitment, following years of underinvestment during the 1990s, potential recruits were not challenged enough to “make absolutely certain nursing was right for them”.
Dame Christine’s comments came in response to questions from inquiry counsel about why problems with basic nursing care had arisen.
She accepted the problem of poor car went beyond a few rogue trusts but denied it was endemic or that nursing was in crisis.
Staffing levels and levels of agency and temporary staff were other factors that had impacted on quality, she said, and also criticised boards and nursing directors had been to easily “reassured rather than assured” about the quality of care in their trusts.
She warned against looking back through “rose tinted” glasses to the era of the matron, and argued when she trained in that system it sometimes produced “such fear that you never said anything if things went wrong”.
She also said patients expectations had changed.
“When I trained patients were passive recipients of care because that’s where society was. Now patients are much, much more assertive and want care to be individualised to themselves .”
She blamed an increasing burden of paperwork for taking away ward sisters and charge nurses’ focus from their core responsibilities on the ward and said although it was right that nurses should understand the “business of the ward” and make decision they did not need to do all the paperwork that went with it.
However, she argued the burden of paperwork is now disappearing.
Asked whether she thought there should be government guidance on staffing levels and skill mix, Dame Christine said there was a wealth of information out there boards and nursing directors could use to aid their judgements.
UPDATED: Wednesday 7 September: afternoon
The Healthcare Commission did not share the seriousness of problems at Mid Staffordshire Foundation Trust with Monitor or ministers until just before the publication of its report, the inquiry has heard.
Former health minister Ben Bradshaw told the inquiry he had asked HCC chief executive Anna Walker at the beginning of the HCC investigation whether problems at the trust were as bad as those at Maidstone and Tunbridge Wells and she had said “no and it’s not going to be”.
He had also been reassured by a press release put out in September 2008 ,while the investigation was ongoing , reporting the trust was cooperating with the HCC’s demands.
The HCC, which was replaced by the Care Quality Commission soon after the publication of the report, has been accused of using the report as its swansong to go out in a blaze but all HCC witnesses have denied the accusation.
Mr Bradshaw said: “It was only clear when we got the report or we got indications shortly before we got the report that it was going to be much, much more serious than we had first been led to believe at the start of the investigation of even quite a way through the investigation.”
He defended Monitor for not taking more action, saying it was for the HCC to recommend the trust be put in special measures or if other action needed to be taken.
Mr Bradshaw was also asked about the decision to remove figures from the HCC report extimating between 400 and 1,200 people had died unnecessarily at the trust based on a hospital standardised mortality ration.
Mr Bradshaw, who worked as a journalist before he became an MP, said he was of the view the figures should be published as they would probably come out anyway. They were leaked to the press.
Mr Bradshaw said there had been more discussion at the meeting about the future of the trust chief executive Martin Yeates than about whether the figures should be included or not.
Asked about the fact that NHS managers responsible for failing trusts are rarely disciplined Mr Bradshaw said he and Alan Johnson had been clear that the priority should be to take action “regardless of the fact that it can sometimes be more expensive and troublesome”.
Asked how he would balance the need to hold chief executives accountable with the need to put strong leadership in place, Mr Bradshaw said it was a “matter of public confidence in the system” that senior managers be held to account for failure.
He said: “I felt very strongly that… the way that these situations were being managed too much consideration was given to making the process easy for the system in terms of getting people in and out and keeping it cosy, and not enough recognition was being given to the genuine and justified public outrage about what had happened and the expectation that somebody would be held responsible.”
He told the inquiry “everybody in a leadership position” during the period had to take responsibility for what happened but said he did not feel “culpable” for the failings which he had no knowledge of until the day before the HCC investigation was announced.
Mr Bradshaw defended the record ofC the HCC and other independent healthcare regulators but said the health secretary could never be absolved of all responsibility for health services.
UPDATED: Wednesday 7 September: morning
Monitor boss Bill Moyes emailed the prime minister’s health adviser to complain that health secretary Alan Johnson was misrepresenting his powers over foundation trusts on the day the Healthcare Commission report into Mid Staffs was published.
The inquiry was shown an email from Mr Moyes to Tony Blair’s health adviser Greg Beales where Mr Moyes complains about a statement Mr Johnson is planning to put out promising to resolve problems at the trust as it was Monitor’s responsibility.
Commenting on the email Ben Bradshaw, who served as a junior minister under Mr Johnson, told the inquiry it “wasn’t the first time” Dr Moyes had gone to Downing Street behind the health secretary’s back.
“This is an example of Bill Moyes having a rather legal and pernickety approach to lines of demarcation.
“The very last thing that should have been on anyone’s mind [that day] was worrying about whether Alan had overstepped the mark in his statement… I’m afraid I think Bill Moyes should have had better things to do with his time than fire off emails to number 10.”
Asked whether the possibility of bringing Monitor back into the DH had been discussed during his time as minister, Mr Bradshaw told the inquiry he expected it was something they would have given some thought to.
He added: “When me and Alan Johnson were talking about deauthorisation, I may be wrong about this, but I don’t think we would have been talking about making a request Monitor could have refused.”
Mr Bradshaw said he felt Mr Johnson’s view on the need for the health secretary to have more powers of intervention over trusts “hardened” after the scandal at Maidstone and Tunbridge Wells.
“For the secretary of state to be in a position where all he could say was ‘nothing to do with me guv, ask Bill Moyes, he may come to a select committee in three months time’ was unacceptable”.
Earlier during the morning’s evidence Mr Johnson refused to criticise department of health officials for not giving his predecessor Andy Burnham, who backed the trust’s FT bid, adequate information on which to base his decision although he accepted with hindsight four lines stating the trust had a “marginal business case” but a “can do” attitude was not sufficient.
He repeatedly stress that the foundation trust policy was not to blame for problems.
“This hospital was already a disaster; it didn’t become a disaster as a result of the FT application or the FT application process.”
He said the “most inexplicable element to this whole sorry saga” was the lack of concern being raised by the public, GPs and local media prior to December 2007.
The inquiry was shown an internal DH email describing the “context” of the decision to sign off the trusts’ FT bid as the “momentum of the pipeline and relatively weak wave of applications”.
Having requested and reviewed the paperwork upon which advice to Andy Burnham was based, Mr Bradshaw is reported to have complained the submission to the then health minister did not “adequately” reflect the situation presented in the supporting documents.
One of the supporting documents, which was shown to the inquiry, revealed the trust had had to significantly rework its long term financial model on advice from the DH and the historic due diligence exercise had found “significant improvements” needed to be made, making it “difficult to support” the application.
However, the advice to the minister simply stated that the trust’s business plan was “marginal” but management had a “can do” attitude.
The inquiry was shown another internal email that revealed prime minister’s health adviser Paul Corrigan was “not happy about the size of wave five” because it was “half of what we’d told him SHAs have promised”.
Mid Staffs was one of only two out of six trusts in wave five to go through.
The email from Warren Brown continued: “Have you any sense we can retrieve ground in wave six? Ie. That we get the lost eight or so trusts back. Can you think of any clever tactics?”
Mr Bradshaw, who admitted him and then health secretary Alan Johnson had not been “pushing hard” on bringing forward more trusts for the pipeline, denied there was pressure coming from Number 10.
“You shouldn’t interpret a desire to see more hospitals coming through… as pressure being put on the system for hospitals that weren’t up to scratch to be pushed through,” he said.
Tuesday 6 September: afternoon
In response to further questions as to why he had not questioned officials advice on Mid Staffs foundation trust application Mr Burnham said he had not had any reason to and said where he had, such as in the case of University Hospitals Coventry and Warwickshire Trust where local MP and junior health minister Mike O’Brien had concerns about management of the trust.
Asked why he had interfered with Monitor’s performance management of Mid Staffs when he returned to the DH as health secretary in June 2009 Mr Burnham told the inquiry the regulator had been “overwhelmed” by the situation and was not acting quickly enough.
In particular, he said he had been concerned by Monitor’s failure to get a full time chair and chief executive into the trust three months after the publication of the Healthcare Commission’s report into the failings at the trust and that it was “quite clear that the best person to advise me” on who to appoint was NHS chief executive David Nicholson.
Mr Burnham told the inquiry it was “a very real grievance” that trust chief executive Martin Yeates had not faced disciplinary action over the performance of the trust and renewed calls for regulation of health service managers.
“At a senior level in an organisation a manager is capable of causing real damage to patient care. It seems the regulatory system as it applies to senior professionals in the health service doesn’t adequately reflect that.”
Mr Burnham, who set up the first independent inquiry into failings at Mid Staffs, defended his decision not to hold a public inquiry saying he did not want to risk jeopardising improvements at the trust through the distraction of further bad publicity.
He told the inquiry he had “resisted” the advice of civil servants in the DH, including NHS deputy chief executive David Flory, who were against holding an inquiry at all following reports from Dr David Colin Thome and Professor Sir George Alberti.
However, he said the problems at the trust were ultimately a “local failing by the trust, its board, its senior management”.
He added: “That’s not to say that I don’t accept that lots of people that have had a role should have done more.”
His comment that he wondered if he could have done more were met with shouts of “yes” from members of campaign group Cure the NHS in the public gallery.
In his closing statement to the inquiry, Mr Burnham said: “The very fact that I didn’t accept departmental advice [against holding the first inquiry] and allowed that report to come out… shows that I wanted the full [story] of what went on here to come out.
“I feel dreadfully sorry for what the families locally have been through.”
Tuesday 6 September: morning
Andy Burnham backed Mid Staffordshire Foundation Trust’s bid for foundation trust status after looking at just four lines of civil service advice, the public inquiry has heard.
The former health secretary, who signed off the bid when a junior minister under Alan Johnson in June 2007, told the inquiry his support for the bid did not automatically mean the trust would be granted foundation trust status as that was a decision for Monitor.
Mr Burnham told the inquiry he had expected Monitor to evaluate the quality of the trust as well as its financial position.
However, inquiry counsel Tom Kark QC presented Mr Burnham with evidence from four previous witnesses to the inquiry who had worked for Monitor, including its former executive chair Bill Moyes, stating the regulator had not carried out independent assessments of quality as part of its authorisation process..
Mr Burnham said it was sensible for Monitor to rely on the Healthcare Commission to judge quality but criticised the two regulators for not talking to each other.
The inquiry has previously heard evidence that the HCC failed to share its concerns about the trust with Monitor, leading to the situation where it was authorised as a foundation trust days before the HCC launched an investigation.
Pushed to defend his decision, Mr Burnham said he was following advice from department officials and the bid has already won approval from the primary care trust, the strategic health authority and been through a period of public consultation.
“If all of this hasn’t flagged up any issues on what basis am I coming in to overturn the advice of civil servants,” he said.
Mr Burnham told the inquiry that if there had been more information in the submission he would have been more likely to ask questions.
He said he was reassured by the fact that of the six trusts presented to him as part of wave five, of which Mid Staffs was a part, four were rejected.
Asked if he thought it was bad advice, he said he couldn’t be sure as he didn’t know whether the problems had started before or after the advice was presented. However, the Healthcare Commission report into the trust, published in 2009, exposed poor standards of care dating back several year.
Earlier Mr Burnham was quizzed about his attitude to the Healthcare Commission’s annual health check and why he had ignored requests from HCC chair Sir Ian Kennedy and his successor at the CQC to get rid of it as it was ineffective.
Only trusts with the top two ratings under the annual health check could apply for foundation trust status.
Mr Burnham said he hadn’t ignored the request but had instead relied on “considerable expertise” within the DH who were arguing to keep it and was reluctant to change things uneccesarily.
The inquiry was shown a note prepared by Una O’Brien and David Flory for Mr Burnham when he took office as health secretary in June 2009 stating between 20 and 30 trusts would not be ready to apply for foundation status by the end of 2010.
It listed Barts and the London Trust, Nottingham University Hospitals Trust, North Bristol Trust and Univeristy Hospitals of Leicester Trust as particular causes for concern.
He said the foundation trust policy had been an attempt to introduce more localism into the NHS and move away from a top down, centralised, target culture.
“I think we had come to a view as a government that trying to run it all in this was in terms of national targets, national standards, straitjackets essentially, being handed down for all organisations to get into at a local level is not going to be the way to see continuing improvements in the NHS in the years to come so the FT model was part of the answer to that.”
Asked what he thought the weaknesses of the foundation trust policy were, Mr Burnham pointed to the “failure of hospitals to grasp the local accountability side of the FT model” and the failure of the Government to give “adequate thought to what happens when things go wrong”.