Andy Burnham: The Duty of Candour
I interviewed Andy Burnham, the shadow health secretary, for The Independent on Sunday today. He defended himself from the charge thrown at him by David Cameron that he had presided, as Health Secretary 2009-10, over a “sinister culture of cover-up” in the NHS; but he also talked about lessons learned and set out his vision of a “renewed settlement” for the health service based on integrating physical, mental and social well-being.
Here is a full transcript of the interview, apart from the bit where we talked about music, and his view that The Smiths have not stood the test of time, on which I shall post a longer transcript later.
Burnham: Attacked by the Prime Minister, plagiarised by the Chancellor: I must be doing something right. The talk [in the Chancellor’s spending review about integrating NHS and social care] was good but I’m not sure the reality will be up to much.
They are throwing around all kinds of unpleasant things which aren’t true. The language is unbelievable. It’s minor, but the so-called report [CQC report on its failure to sport fatal errors at Morecambe Bay hospitals], if it was deleted, was deleted under them. I think there are some serious questions about that report, about whether that was a fair process, and that will come through more and more.
The NHS was never perfect and no party should claim that it was under them. But I think it is an attempt by someone on the other side to try to damn the whole system, to pick on examples of poor care that should never have happened, and in the case of Mid Staffs appalling care, but it is not possible to say, and the whole thing is sinister, corrupt – that isn’t possible. There have been periodically problems in the NHS, in Bristol, there was Alder Hey, there was Shipman. These things sadly have been there in the past. The NHS is such a complicated, vast thing that there will always be things that are wrong with it.
[Systemic problem of culture?] On that, I think that at very local level, when people bring complaints, the shutters do come down and they push people away. There is a culture of that at local level, without a doubt.
[What’s the answer to that?] It’s difficult because it’s very deep rooted, and I don’t think the answer is ever more dictatorial top-down inspection or central regulation – I’m not saying I’m against a chief inspector of health.
I support the Francis report recommendations, particularly the duty of candour on individuals. If there is a different feeling about how an individual speaks up and reports when things do go wrong, instead of fearing sanction or reprisal by their employer, then that is the way. This thing will be solved at local level, but what’s been happening is more societal than the detail of policy. Hospitals are increasingly full of very frail, very elderly people, and the job of caring on the front line has become ever more complex, as people in their late 80s and their 90s are in hospital in ever greater numbers – and that is the real issue, the fundamental issue that is driving the concern around the older person lost in the acute hospital, dehydrated, disoriented, struggling – it is a product of a 20th-century system. When an older person goes into hospital, immediately some of their needs are being neglected; their social, their mental needs are often neglected in the acute hospital environment. And that explains why they often plummet, or drop like a stone, or go on a downward spiral very quickly, because it’s really not the right place for them to be. Between 09/10 and 11/12 there was a 66 per cent increase in the over-90s coming into A and E in a blue-light ambulance: it equates to 100,000 very frail, very frightened people in the backs of ambulances, and you just think something is changing and changing very quickly. It is linked to the collapse of social care and the withdrawal of care at home by councils.
[But how do you change the incentives, system-wide, so people feel they will be rewarded for being open and honest?] It is a difficult question. The caricature of us now is that we were closed and secretive, and you remember the opposite. We brought in an independent regulation. There wasn’t an independent regulator before the Labour government. We began a process of publishing clinical data so that outcomes could be published, we began rating hospitals – that didn’t exist so we had no objective information before, admittedly it was quite crude in the beginning, it was a star rating then it became good, fair or -
[But that put pressure on staff to suppress bad news.] Alongside that, Liam Donaldson [Chief Medical Officer for England] did lots of reforms around patient safety, so we had this national reporting and learning system where any adverse incident happened people were meant to – and did – put it onto the system. A whole range of other things that Liam was very keen on around professional revalidation.
We reformed the GMC [General Medical Council] because it was a doctor majority in the old days and we made it parity between lay [people] and doctors, and that was something that I did.
But that tendency to pull the shutters down and push people away is very very deep rooted and I couldn’t say, hand on heart, we managed to crack that. So I think duty of candour is interesting in that context. It means a legal duty to be open about failings. It means the organisation can’t come down on the individual and make them feel intimidated.
Let’s go with what Francis said. Detailed, sensible recommendations. Shouldn’t we be going with those rather than writing our own?
[What about the Friends and Family Test?] No objection to that. I in a similar way prioritised staff satisfaction and patient satisfaction as two good catch-all indicators. If patients are satisfied and staff think they’re working in a good environment they tell you much more than you can get from a four-hour target, so I began to prioritise those more human indicators, so I’ve no objection to the Friends and Family Test but it’s only one of a number of things.
[I asked him about the exchange a Prime Minister’s Questions a few hours earlier:
Charlotte Leslie (Bristol North West) (Con): In 2008 Labour buried three reports warning of a culture of fear in the NHS and warning about inspections. Now we find that its Care Quality Commission has buried concerns over baby deaths. Will the Prime Minister support a root-and-branch review of the sinister culture of cover-up in our NHS over the past decade?
The Prime Minister: First, I commend my hon. Friend for this campaign that she is fighting for openness, transparency and clarity in our NHS. She makes an important point, which is that there was a culture under the previous Government of not revealing problems in the NHS. The former Health Secretary is shaking his head, but this is what the former head of the CQC, Baroness Young, appointed by the previous Government, said—[Interruption.] I know the Opposition do not want to hear it, but they are going to have to hear it, because it is important that we understand the culture that went wrong under Labour. She said this: “There was huge government pressure, because the government hated the idea that—that a regulator would criticise it by dint of criticising one of the hospitals or one of the services that it was responsible for.” That is what Barbara Young said. And she said: “We were under more pressure. . . when”— the right hon. Member for Leigh (Andy Burnham)— “became minister, from the politics.” There was a culture problem under Labour, and the sooner the Opposition admit it, the better.]
It’s frustrating, isn’t it, when you’re sitting there and people are throwing stuff and you obviously can’t reply and you reject it entirely, it’s when my job loses its appeal. Firstly, I’d say we had a three-year public inquiry [into Stafford hospital] where all of the papers of my time in government were looked at. And I gave evidence and Ben Bradshaw [health minister 2007-09] gave evidence and all of our paperwork was looked at, emails, everything. It is quite hard, then, having gone through that process, and that report saying that ministers didn’t act in any way wrongly or improperly, for then somebody in the House of Commons to stand up and chuck casual allegations around like that. That is pretty difficult.
The sense of it [the quotation from Lady Young] was we were trying to minimise bad publicity. I want to answer that directly. I appointed Robert Francis to begin the process of inquiry on Stafford. People have forgotten that but I did. It was one of the first things I did as Health Secretary, and my mindset – the reason I mention that is that it illustrates my mindset at the time, which was the opposite of what they are saying. I was in the mindset of “bring it all out, we need to know if other hospitals have serious problems”. So I brought forward this process of registration, which was a 360-degree look at all hospitals to give a full picture of their problems. That led to literally – I mean literally, the eve of the last general election – I’m talking a matter of hours before it was called, 27 hospitals were registered with conditions.
[What does that mean?] It meant that they couldn’t be registered as safe. They couldn’t be given a clean bill of health. It meant that the CQC couldn’t say this hospital is operating to an acceptable standard. And that was the purpose of the exercise: it was to flush out the hospitals that needed to be looked at, rather than them coming out in a drip-drip of a hospital looms into the headlines here and another one there. The idea was that we had to survey the whole scene and find out where these problems were.
Again, people say “pressure”. I was asking tough questions of the CQC in that period. There was a feeling in the department that they weren’t on top of this enough, that they didn’t have evidence to back up some of the positions they were taking. And so there was a big process of change under way. In November 2009, having been discussing with the CQC, “Were we getting to the bottom of things?” I made a statement to Parliament saying I was going to bring forward this process of registration, I was going to refocus the CQC on that job. So that before the election we could give a clear statement about where all the [problems were] and that exercise was completed.
But – it didn’t register Morecambe with conditions. That clearly in the end was the wrong judgement. But that wasn’t my judgement. That was a judgement for the independent regulator. The point I really want to get over is: Judge me by what I did.
[But you set up that regulator and it was faulty.] We brought in independent regulation. The slight concern I have about the current debate is, we’re in danger of starting to ask too much of central regulation, because, with the best will in the world, it isn’t going to spot the problem on a ward in the north of England immediately. It’s not going to do that.
It plays to the old “bedpan in Tredegar” thing. Here we are approaching the 65th anniversary [of the creation of the NHS in 1948] and it could potentially reinforce a culture that isn’t the way to go, that everything should be done by a top-down approach. That’s why the duty of candour is the antidote to that whole approach. My worry a little bit here is that the CQC or the Health Commission before it has got a broad job to do, surveying the system, looking for early warnings, monitoring a range of data, asking questions, going and inspecting, but you have to always understand the limitations of that exercise. And then you do have to have the right culture at the local level. The truth is that the NHS hasn’t always had the right culture at a local level. It can put the lid on things. And I understand the families in this case, the Morecambe case, and indeed in the Stafford case, become very frustrated and alienated, because they are pushed away. And the NHS cannot carry on doing that. When people bring legitimate worries or when they’ve have a personal tragedy; the only thing for the NHS to do is to be open, listen, respond, because they’re not doing it to try to do the NHS down, they are trying to make it better. They just don’t want it to happen to someone else, that’s their motive in 99 cases out of 100. And the NHS needs to do a much better job, a much better job.
[How do you give patients power?] What I’m looking at the moment is how we might give patients more fundamental rights in the NHS constitution. I’ve reflected carefully on our time in government – and much of it I’m proud of. The NHS was utterly transformed from a service that was offering a two-year wait for a heart bypass operation when we came in – people were dying on NHS waiting lists when we came in – that situation was turned around completely. But I look at a lot of the things we said about choice and control: I think we offered people fairly meaningless choices, you know, “Where do you want to go for your hip operation? “Which provider of these five do you want?” I think there is a yearning for much more fundamental control. “Do you want to give birth at home, have dialysis at home, or fundamentally, do they want to die at home?”
And that isn’t something that the system currently offers people. The percentage of people dying in hospital is appallingly high. The point is that I believe you can offer much more advanced notions of choice and control in a more integrated, collaborative system than you can in a more fragmented and competitive system.
[But those are just words.] I think we had a very simplistic notion of choice, almost applying the supermarket test – care is much more fundamental human endeavour than which place you want to go to. Can I be where I want to be with my family around me? And if you are to provide those kind of choices, you often need a much more sophisticated organisation that is able to cover home to hospital with all the back up that is necessary. It is quite an important break, really, with where we were.
For me, fragmentation – if you endlessly go down the market based approach to health, you bring ever increasing numbers of providers onto the pitch. And that intensifies peoples -
[That’s what Blairites want.] I think it’s a different notion of reform. This is about more fundamental reform, I would argue. If you get stuck with lots of providers with lots of contracts I don’t think you can see the whole person.
[But Blairite reform is about putting the interest of the patients at the heart of it.] That in the end isn’t the fundamental choice that people are looking for. [The idea of whole-person care is what] makes those providers start with people and fit in around people – rather than what they currently do: they start with the established ways of working, the rotas that they have always had, the idea that people will drift in to see them. I’m saying [we need] a more fundamental reordering of the system.
I don’t think what Osborne announced today comes anywhere near what I’m talking about. I’m talking about the full integration of health care. Quality comes from a number of ways, doesn’t it? You could say that competitive pressure builds quality, but also sense of professional satisfaction and a one-team approach to looking after one person.
[Is Osborne doing what you were accused of doing, of trying to cut NHS spending by diverting it to social care?] Oh my god I feel so frustrated about this because for three years Cameron has read a quote of mine out at PMQs. “Irresponsible” to promise real-terms increases, I said, IF the way you paid for that was by ransacking social care – that is indeed what’s been happening for three years. Social care has been cut to the bone and hospitals have been so-called protected.
On the terms that he set for me then he’s now cutting the NHS. My argument was: protect NHS spending but don’t give a real-terms increase to the NHS; if there is money give it to social care.
The NHS is feeling under siege at the moment. Battered, bruised, demoralised. It doesn’t agree with the direction of travel that this Government has placed it on. It sees Hunt – it was a strange thing for him to say – say that he’s now the Gove of the NHS.
[Well, he is pursuing a different course from Andrew Lansley.] Lansley. If you look back at it, honestly. One man inflicted a vanity project on 1.4m people and has caused utter misery and chaos. But Jeremy Hunt hasn’t helped. Hasn’t helped at all. Blamed GPs, callousness of nurses. In March he said hospitals are coasting. He hadn’t visited an A and E at the time. He visited his first A and E in April: St Thomas’s, across the road.
He’s got to build morale. We don’t think they’ve planned anything to celebrate the 65th anniversary of the NHS. People think they don’t believe in it. We’ve got a pretty healthy poll lead there now. The thing is fragmenting at a pretty alarming rate.
The first thing we shall do is repeal the Health and Social Care Act 2012. It puts us on the fast track to fragmentation.
[Fabian pamphlet to be published on 3 July about whole-person care for the 21st century.] Ageing is one of the things that’s bringing to the door of the NHS; lifestyle: obesity, drugs, alcohol, smoking; but mental health as well: modern living is stressful, people are living very strung-out lives. Setting a new vision for health in the 21st century I do see it as that big, what we are trying to do, it’s about renewing the NHS settlement.
The 1948 the World Health Organisation defined health as a state of “physical, mental and social well-being”. My analysis is, today in 2013, [that we are] still trying to meet one person’s needs through three separate systems. When you get to your 80s and your 90s your needs become a blur of the physical and social.
I am trying to build a bit of a movement around the whole-person integrated agenda. This isn’t party policy yet. If you just integrated health and care now you would still leave two care worlds, a free-at-the-point-of-use world and the world that people have to pay for that may or may not have a Dilnot cap imposed on it. The question is, if older people pay differently for social care, on an all-in basis, could you extend the NHS principle fully to all care, physical, mental and social? Deep integration will only happen when you don’t have two systems that work by different rules. They can’t really connect with each other.
You can get deep integration when you have a system that can see the whole person, that can see all of one person’s needs and can provide all the services that are needed on the same basis. I am really, really clear that we will never get the care that we aspire to for our parents or anyone’s parents from this malnourished minimum-wage social care system that we’ve got today, where your care is delivered in these 15-minute slots in people’s homes and there’s barely time to make them a cup of tea.
[Fantastically expensive?] The Torbay experience has shown – [He knocks the photographer’s camera.] Sorry, I get animated. That World Health Organisation thing, physical, mental, social: the social bit of that, getting out of bed, getting them up and about, washing, dressing. It’s all the things that keep you out of hospitals. Yet in the current system all the incentive is to disinvest in that preventive kind of thing because councils want to keep council tax low, and hospitals get paid by how many people go through the door. So the whole system at the moment pushes people towards the expensive end of the care world. And Torbay has shown that if you do integrate properly you can move money decisively towards prevention.
I’m not talking about older people not paying for care, I’m just saying they could pay for it in a different way. At the moment they are paying for it randomly, it’s pre-NHS health care, isn’t it? You pay as much according to how vulnerable here. There is a New Labour thing here and I want to get this over to you – I said when I ran for the leadership I want the best of Old Labour and the best of New Labour – if I can persuade the party to do it: imagine if we could say to people, your care needs taken care of in one integrated system, and all of your mum and dad’s needs, physical, mental, social, taken care of, one point of contact for all of their care. Just imagine what a step forward that is.
And then secondly, the vast majority of what they’ve worked for, protected. So that aspirational message: you don’t go into later life with everything on the roulette table, where it all can be washed away by the costs of care. That is what we’re doing at the moment and the Dilnot thing won’t solve that. For me there is a really important thing there about Labour values – everyone looking after each other. In the same way when we created the NHS we didn’t let people get financially ruined by the cost of medical care, we’re not going to let people be financially ruined by the costs associated with ageing. I’ve got a strong sense that if Labour can be that bold, it’s the best antidote to the people on the doorstep who say you’re all the same there’s no point in voting. I feel we’ve got to come up with policies that break that feeling that politics has been trading in micro initiatives that don’t really change that much.
There we are. That’s the world according to me.Tagged in: andy burnham, nhs, nhs reform, public service reform
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