I don't want to discuss the substance of the report here as it is ably being discussed elsewhere. Rather I wanted to focus on the 30 minutes in the House of Commons.
Because of the current unpublished status of the report, even with Parliamentary privilege, MPs were rightfully careful of their language. Yet the manner of Jeremy Hunt's statement should leave no doubt as to the status held of it by the Government and NHS England.
Jeremy Hunt's Statement
The whole House will be profoundly shocked by this morning’s allegations of a failure by Southern Health NHS Foundation Trust to investigate over 1,000 unexpected deaths. Following the tragic death of 18-year-old Connor Sparrowhawk at Southern’s short-term assessment and treatment unit in Oxfordshire in July 2013, NHS England commissioned a report from audit providers Mazars on unexpected deaths between April 2011 and March 2015.The draft report, submitted to NHS England in September, found a lack of leadership, focus and sufficient time spent in the trust on carefully reporting and investigating unexpected deaths of mental health and learning disability service users. Of 1,454 deaths reported, only 272 were investigated as critical incidents, and only 195 of those were reported as serious incidents requiring investigation. The report found that there had been no effective, systematic management and oversight of the reporting of deaths and the investigations that follow.Prior to publication, or indeed showing the report to me, NHS England rightly asked the trust for its comments. It accepted failures in its reporting and investigations into unexpected deaths, but challenged the methodology, in particular pointing out that a number of the deaths were of out-patients for whom it was not the primary care provider. However, NHS England has assured me this morning that the report will be published before Christmas, and it is our intention to accept the vast majority, if not all, of the recommendations it makes.Our hearts go out to the families of those affected. More than anything, they want to know that the NHS learns from tragedies such as what happened to Connor Sparrowhawk, and that is something we patently fail to do on too many occasions at the moment. Nor should we pretend that this is a result of the wrong culture at just one NHS trust. There is an urgent need to improve the investigation of, and learning from, the estimated 200 avoidable deaths we have every week across the system.I will give the House more details about the report and recommendations when I have had a chance to read the final version and understand its recommendations, but I can tell the House about three important steps that will help to create the change in culture that we need. First, it is totally and utterly unacceptable that, according to the leaked report, only 1% of the unexpected deaths of patients with learning disabilities were investigated, so from next June, we will publish independently assured, Ofsted-style ratings of the quality of care offered to people with learning disabilities for all 209 clinical commissioning group areas. That will ensure that we shine a spotlight on the variations in care, allowing rapid action to be taken when standards fall short.Secondly, NHS England has commissioned the University of Bristol to do an independent study of the mortality rates of people with learning disabilities in NHS care. This is a very important moment at which to step back and consider the way in which we look after that particular highly vulnerable group.Thirdly, I have previously given the House a commitment to publishing the number of avoidable deaths, broken down by NHS trust, next year. Professor Sir Bruce Keogh has worked hard to develop a methodology to do this. He will write to medical directors at all trusts in the next week explaining how it works, and asking them to supply estimated figures that can be published in the spring. Central to that will be establishing a no-blame reporting culture across the NHS, with people being rewarded, not penalised, for speaking openly and transparently about mistakes.Finally, I pay tribute to Connor’s mother, Sarah Ryan, who has campaigned tirelessly to get to the bottom of these issues. Her determination to make sure the right lessons are learned from Connor’s unexpected and wholly preventable, tragic death is an inspiration to us all. Today, I would like to offer her and all other families affected by similar tragedies a heartfelt apology on behalf of the Government and the NHS.
No-one reading that should take credibly the claims in the HSJ article this morning which ran with the counter claims of a tame academic appointed by Southern Health and having a partial extract of the report shown to them. Still its another example of the desparate lengths the Trust are prepared to go that is in the public arena. NHS England take note.
This was a shocked chamber that listened to and responded to Hunt's statement. There were two questions that reoccurred that need highlighting.
The first question was when did the Secretary of State know about the concerns over Southern Health. The answer was early 2014. The issue about repeating this question is that there has been a delegation of power from the Department of Health to NHS England through the 2012 reforms. The Secretary of State cannot be hands on as previous secretaries of state were.
As a result of repeated marketisation reforms, the NHS banner contains numerous separate legal entities. The ability to act has to be lawful and consistent. It is, in my opinion, this space that has allowed Southern Health to make 300 challenges which will have been legally argued as required. Here its worth noting Jeremy Hunt's response to Andrew Turner:
The commitment I have from NHS England is that it will be published before Christmas. I am confident that, whenever it is published, it will generate huge media interest, rightly so and partly thanks to the shadow Health Secretary’s urgent question. When the draft report was sent to the trust, it came back with 300 individual items of concern, and it was right for NHS England, in the interests of accuracy and justice, to consider fully all those concerns. It has given me an assurance, however, that, whether or not it can reach an agreement with the trust about its contents, the report will be published before Christmas.
An agreement with the Trust. Yet also note what Hunt said to Heidi Alexander that [w]e will not allow any further arguments about methodologies to stand in the way of the report being published before Christmas. I would suggest that any goodwill within Whitehall towards Southern Health has been burnt up.
The second question was around families not having access to legal aid to challenge NHS bodies. This placed Jeremy Hunt in a difficult position because it isn't his turf but that of the Lord Chancellor Michael Gove and the members asking the question knew that. Hence the line that with a properly accountable NHS with full family involvement that there wouldn't need to be litigation. A sentiment that I would like to see fulfilled as it would be an extraordinary achievement. Until that perfect world, the Ministry of Justice needs to be lobbied in order that the scales of justice are balanced.
This 30 minutes merely sets the context for future events. Once the report is published then a full debate will follow. This is where the House of Commons can give direction to the Secretary of State and that then empowers NHS England. Publication shifts power balances and serious reports require serious actions.
I would want to see Southern Health broken up, the earth salted and its ashes scattered to the winds. Its board and senior management were too remote and separate from the actual practice of care. Its size and empire (property) building are emblematic of an unfit culture. I believe, based on experience, in rooting management in the community so that values are shared and mutually understood. This sector of the NHS appears aloof and outside of those processes. When the debate occurs, I hope consideration is made on that point.
