Paid by compassion: Hospital horror story changes the rules for nurses
Nurses will be paid by the care and compassion they show towards patients, not just how long they have spent in a hospital, according to the prime minister.
David Cameron announced the changes during a Commons statement on the Francis report into appalling treatment of patients at the Mid Staffordshire hospital between 2005 and 2009.
"Nurses should be hired and promoted on the basis of having compassion as a vocation not just academic qualifications," Cameron told a subdued Commons chamber.
"We need a style of leadership from senior nurses which means poor practice is not tolerated and is driven off the wards.
"And another issue is whether pay should be linked to quality of care rather than just time served at a hospital. I favour this approach."
He was responding to the final report from Robert Francis QC, whose three-year inquiry examining failings at the heart of the NHS which surfaced in the Stafford hospital scandal reported today.
"This is a story of appalling and unnecessary suffering of hundreds of people," Francis said earlier.
"They were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety. I have put forward 290 recommendations to change this culture and make sure patients come first."
He has recommended introducing a new chief inspector of hospitals post as part of a radical shakeup of the health system.
Causing death or harm to a patient should become a criminal offence, gagging clauses should be banned and only those registered to do so should care for patients.
Complaints should be published on hospital websites and staff should have a 'duty of candour' forcing them to confirm poor treatment when it takes place, Francis suggests.
Among his recommendations is a request for the Commons' health committee to monitor the application of his proposals, which committee chair Stephen Dorrell "certainly" pledged to do.
"The key to high care standards will always be the commitment and professionalism of the clinical staff," Dorrell commented.
"Management objectives are important, but they can never be allowed to become an excuse for poor care."
It is estimated up to 1,200 people died unnecessarily at Stafford hospital between 2005 and 2009 because of an excessive concentration on targets and lack of communication between the hospital board and other management bodies.
Francis said today: "The most basic standards of care were not observed and fundamental rights of dignity were not respected… they were deprived of dignity and respect… they had to endure filthy conditions in their wards."
Some patients depended on relatives to clean them after having soiled themselves because staff would not do so. Others were left on commodes or toilets for too long, and were "often left in sheets soiled with urine and faeces for considerable periods of time".
Other serious problems identified included failure to provide meals for patients, poor hygiene practice, patients left inadequately dressed in full view of passers-by and some clear cases of misdisagnosis.
Francis' preliminary report of 2010 also noted patients were often reluctant to complain because they wanted to avoid upsetting healthcare professionals and said staff "described a forceful style of management (perceived by some as bullying)".
Staff feared the sack if they did not meet targets, the report found.
Julie Bailey, founder of Cure The NHS, and the Unite union are now calling for NHS commissioning board chief executive Sir David Nicholson to resign.
"In 2005, he was the regional NHS official who had the oversight of Mid-Staffs when the clinical failures were taking place," Unite national officer for health Rachael Maskell said.
"Later, as a NHS chief executive, he had accountability as to how the NHS responded as the scandal unfolded.
"The words 'buck', 'stopping' and 'here' have a certain resonance. The recommendations of the Francis report make his position untenable."
Cameron statement in full
Today Robert Francis has published the report of the Public Inquiry into The Mid Staffordshire NHS Foundation Trust.
Mr Speaker, I have a deep affection for our National Health Service. I will never forget all of the things doctors and nurses have done for my family in times of real pain and difficulty. I love our NHS, I think it is a fantastic institition, a great organisation, it says a great deal about our country and who we are.
I always want to think the best about it.
And I have huge admiration for the many brilliant doctors, nurses and other health workers who dedicate their lives to caring for our loved ones.
But we do them – and the whole reputation of our NHS – a great disservice if we fail to speak out when things go wrong.
What happened at The Mid-Staffordshire NHS Foundation Trust between 2005 and 2009 was not just wrong, it was truly dreadful.
Hundreds of people suffered from the most appalling neglect and mistreatment.
There were patients so desperate for water that they were drinking from dirty flower vases.
Many were given the wrong medication, treated roughly, or left to wet themselves and to lie in urine for days.
And relatives were ignored or even reproached when pointing out the most basic things which could have saved their loves ones from horrific pain or even death.
We can only begin to imagine the suffering endured by those whose trust in our health system was betrayed at their most vulnerable moment.
And that is why it is right to make this statement today.
Mr Speaker, there was a Healthcare Commission investigation in 2009….
….a first independent inquiry from Robert Francis in February 2010….
…and long before that, the testimony of bereaved relatives like Julie Bailey and the Cure the NHS campaign…
They all laid bare the most despicable catalogue of clinical and managerial failures at the Trust.
But even after these, some really important questions remained unanswered.
How were these appalling events allowed to happen – and how were they allowed to continue for so long?
Why were so many bereaved families – and whistleblowers – who spoke out, why were they ignored for so long?
Could something like this could ever happen again?
Basic questions about wider failures in the system – not just at the hospital, but right across the NHS –including its regulators and the Department of Health.
That is why the families called for this public inquiry…
…and why this government granted one.
And I am sure the whole House will want to join with me in expressing our thanks to Robert Francis and his entire team for all their work over the past three years.
The Inquiry finds that the appalling suffering at Mid-Staffordshire hospital was primarily caused by a “serious failure” on the part of the Trust Board which…
…failed to listen to patients and staff…
…and “failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities.”
But the Inquiry finds that the failure went far wider.
The Primary Care Trust assumed others were taking responsibility and so made little attempt to collect proper information on the quality of care.
The Strategic Health Authority was “far too remote from the patients it was there to serve, and it failed to be sufficiently sensitive to signs that patients might be at risk.”
Regulators, including Monitor and the then Healthcare Commission, failed to protect patients from substandard care.
Too many doctors “kept their heads down” instead of speaking out when things went wrong.
The Royal College of Nursing was “ineffective both as a professional representative organisation and as a trade union.”…
…and the Department of Health too remote from the reality of the services they oversee.
The way Robert Francis chronicles the evidence of systemic failure means we can not say with confidence that failings of care are limited to one hospital.
But let us also be clear about what the Report does not say.
Francis does not blame any specific policy.
He does not blame the last Secretary of State for Health.
And he says we should not seek scapegoats.
Mr Speaker, looking beyond the specific failures that he does catalogue so clearly…
…you can identify in the report three fundamental problems with the culture of our National Health Service.
First, a focus on finance and figures at the expense of patient care. He says that explicitly.
This was underpinned by a pre-occupation with a narrow set of top-down targets…
…pursued to the exclusion of patient safety or listening to what patients, relatives – and indeed many staff– were saying.
Second, there was an attitude that patient care was always someone else’s problem.
In short, no-one was accountable.
Third, defensiveness and complacency…
…instead of facing up to and acting on data which should have implied a real cause for concern…
…Francis finds all too often a culture of only explaining the positives rather than any critical analysis.
Put simply, Mr Speaker, managers were suppressing inconvenient facts in favour of looking for comfort in positive information.
Mr Speaker, this is one of the most disturbing findings.
It is bad enough that terrible things happened at that hospital.
But what this Inquiry is telling us is that there was a manifest failure to act on the data available…
…not just at the hospital but more widely.
And as Francis says – and I quote –
“In the end, the truth was uncovered…mainly because of the persistent complaints made by a determined group of patients and those close to them.”
Mr Speaker, the anger of the families is completely understandable.
Every Hon Member in this House would be angry – would be furious – if their mother or father were treated in this way – and rightly so.
The last government commissioned the first report from Robert Francis…
…and when he saw that report, the former Secretary of State – now the Shadow Health Secretary – was right to apologise for what went wrong.
This Public Inquiry not only repeats earlier findings but also shows wider systemic failings…
…so I would like to go further as Prime Minister and apologise to the families of all those who have suffered for the way that the system allowed this horrific abuse to go unchecked and unchallenged for so long.
On behalf of the government – and indeed our country – I am truly sorry.
Mr Speaker, since the problems at Mid Staffordshire hospital first came to light a number of important steps have been taken.
The last government set up the National Quality Board and the Quality Accounts System.
This government has put compassion ahead of bureaucratic process-driven targets…
…and put quality of care on a par with quality of treatment.
We have set this out explicitly in the Mandate to the NHS Commissioning Board, together with a new vision for compassionate nursing.
We have introduced a tough new programme for tracking and eliminating falls, pressure sores and hospital infections.
And we have demanded nursing rounds every hour, in every ward of every hospital.
But it is clear we need to do more.
We will study every one of the 290 recommendations in today’s Report and respond in detail next month.
But the recommendations include the three core areas – patient care, accountability and defeating complacency – on which I believe we should make immediate progress.
Let me say a word about each.
Let me explain how we put patient care ahead of finances.
Today when a hospital fails financially its Chair can be dismissed and the Board suspended.
But failures in care rarely carry such consequences.
That’s not right.
We will create a single failure regime where the suspension of the Board can be triggered by failures in care, as well as failures in finance.
And we will put the voice of patients and staff at the heart of the way hospitals go about their work.
In Mid Staffordshire as far back as 2006, there was a staff survey in which only around a quarter of staff said they would actually want one of their own relatives to use the hospital they worked in.
Over the following two years, bereaved relatives and campaigners produced case after dreadful case and campaign after chilling campaign.
But these voices and these horrific cases were ignored.
Indeed the hospital was upgraded to Foundation Trust status during this period.
Mr Speaker, we need the words of patients and front line staff to ring through the Boardrooms of hospitals and frankly beyond, into the regulators and Department of Health itself.
So from this year every patient, every carer, every member of staff will be given the opportunity to say whether they would recommend their hospital to their friends or family.
These will be published and the Board will be held to account for their response.
Put simply, where a significant proportion of patients or staff raise serious concerns about what is happening in a hospital…
…immediate inspection will result and suspension of the hospital board may well follow.
Quality of care means not accepting that bed sores and hospital infections are somehow occupational hazards and a little bit of these things is somehow ok.
It is not ok. They are unacceptable.
Full stop. End of story.
That’s what zero harm means.
So I have asked Don Berwick – who has advised President Obama on this issue – to make zero harm a reality in our NHS.
Francis makes other recommendations.
Today you can give hands on care in a hospital ward with no training at all.
Francis says this is wrong.
And I agree.
There are some simple but quite profound things that need to happen.
Nurses should be hired and promoted on the basis of having compassion as a vocation not just academic qualifications.
We need a style of leadership from senior nurses which means poor practice is not tolerated and is driven off the wards.
And another issue is whether pay should be linked to quality of care rather than just time served at a hospital.
I favour this approach.
Second, accountability and transparency.
The first Francis report set out very clearly what happened within Stafford hospital – and it should have led to those responsible being brought to book.
By the board. By the regulators. By the professional bodies. And yes even by the courts.
But this didn’t happen.
Most people will want to know what on earth not.
We expect hospitals to take disciplinary action against staff who abuse their patients.
We expect professional regulators to strike off doctors and nurses who seriously breach their professional codes.
And yes we expect the justice system to prosecute those suspected of criminal acts whether they take place in a hospital or anywhere else.
But in Stafford these expectations were badly let down.
The system failed.
And that is one of the reasons we so badly needed this inquiry.
Now the recommendations about systemic failure are public – the regulatory bodies in particular have difficult questions to answer.
The Nursing and Midwifery Council and the General Medical Council need to explain why so far no one has been struck off.
So the Secretary of State for Health has today invited them to explain what steps they will take to strengthen their systems of accountability in the light of this report.
And we will ask the Law Commission to advise on sweeping away the Nursing and Midwifery Council’s outdated and inflexible decision-making processes.
The Health and Safety Executive also needs to explain their decisions not to prosecute in specific cases.
Indeed Robert Francis makes a very strong argument that the Health and Safety Executive is too distant from hospitals and not the right organisation to be focusing on healthcare and criminal prosecutions in these cases.
So we will look very closely at his recommendation to transfer the right to conduct criminal prosecutions away from the Health and Safety Executive to the Care Quality Commission.
Third, we must purge the culture of complacency that is undermining the care in our country.
This requires a clear view about what is acceptable and what is not.
Mr Speaker, in our schools we have a very clear system of deciding whether a school has the right culture– and whether it is succeeding or failing.
It’s a system based on the judgement of independent experts, who walk the corridors of the school and analyse more than just the statistics.
The public know which schools near them are outstanding and which are failing.
They have a right to know the same about our hospitals.
We need a hospital inspections regime that doesn’t just look at numerical targets but examines the quality of care and makes an open, public and explicit judgement.
So I have asked the Care Quality Commission to create a new post – a Chief Inspector of Hospitals to take personal responsibility for this task.
I want the new inspections regime to start this autumn.
And we will look at the law to make sure the inspector’s judgement is about whether a hospital is clean, safe and caring – rather than an exercise in bureaucratic box ticking.
In the meantime I have asked the NHS Medical Director – Professor Sir Bruce Keogh – to conduct an immediate investigation into the care of hospitals with the highest mortality rates…
…and to check that urgent remedial action is being taken.
Mr Speaker, complacency in the system has meant that all too often patient complaints have been ignored.
So I am today asking the Hon Member for Cynon Valley…
…and the Chief Executive of South Tees Hospitals NHS Foundation Trust, Tricia Hart…
…asking them specifically to advise how hospitals in the NHS should handle complaints.
Mr Speaker, I have talked today about some of the systemic failures.
But at the heart of any system is the people who work in it and the values they hold.
As Francis says – and it’s worth me quoting in full
“Healthcare is not an activity short of systems intended to maintain and improve standards, regulate the conduct of staff, and report and scrutinise performance.
Continuous efforts have been made to refine and improve the way these work.
Yet none of them, from local groups to the national regulators…
… from local councillors to the Secretary of State…
…appreciated the scale of the deficiencies at Stafford and, therefore, over a period of years did anything effective to stop them.”
Mr Speaker, what makes our National Health Service special is a very simple principle:
That the moment you're injured or fall ill…
…the moment something happens to someone you love…
…you know that whoever you are, wherever you're from, whatever's wrong, however much you've got in the bank…
…there's a place you can go where people will look after you and do their best to make things right again.
The shocking truth is that this precious principle of British life was broken in Mid-Staffordshire.
We would not be here today without the tireless campaigning of the families who suffered so terribly…
…and I am sure the whole House will join with me in paying tribute to their incredible courage and determination over these long and painful years.
When I met Julie Bailey and the families again on Monday, she said to me that she wanted the legacy of their loved ones to be an NHS safe for everyone.
That is the legacy that together we must secure.
And I commend this Statement to the House.