My Lords, first, I welcome the noble Lord’s very positive comments about the various reviews that have been commissioned in recent months. I am glad that he agrees that, in broad terms, the Government are on the right lines in accepting the recommendations that have come forward.
The noble Lord asked a number of questions, the first of which was about why we have not implemented all the recommendations of Robert Francis in full. Most of the recommendations have been accepted in principle, in part or—in the main—in their entirety. In some cases, we are taking an alternative approach to that suggested in the inquiry if we believe it is likely to be more effective in reaching the intended outcome. In total, we have rejected just nine of the 290 recommendations and where recommendations have been rejected, a full response outlining the reasons for doing so and the alternative action that organisations are taking is provided in our system-wide response.
The noble Lord asked about the regulation of healthcare assistants, a matter to which we return at regular intervals in this House. I assure him that the Government keep this issue under regular review but, for the time being, our view is to tackle the key issue at its root, focusing on making sure that healthcare support workers have the right training, values, support and leadership to provide the high-quality care that we all want patients to receive. We are committed to ensuring that this part of the workforce receives high-quality and consistent training. We have commissioned Skills for Care and Skills for Health, as the noble Lord knows, to develop a code of conduct and minimum training standards. We have also announced the development of a care certificate, which I am sure will be particularly welcome to a number of my noble friends.
The noble Lord asked me about a situation in which employers might find that a healthcare assistant or social care support worker no longer met the standards required by the care certificate. In that event, Health Education England and the sector skills council will set out in guidance the requirements for ensuring that appropriate retraining is given or other disciplinary action is taken. The guidance will be that the worker in
question should not work unsupervised until the problem has been resolved and the employer is confident that their care certificate remains valid. Of course, if a healthcare assistant is found to have harmed patients or have been a serious risk to patients, the Disclosure and Barring Service needs to be considered as the ultimate remedy to make sure that that person does not put patients at risk in future. However, that is an extreme situation, which I believe will not be the norm.
The noble Lord referred to the nurse numbers. In the last spending review, the NHS budget was protected in real terms, with cash funding rising by £12.7 billion by 2014-15. Alongside that, Health Education England has been working with NHS trusts to develop the overall workforce plan for England for next year, reflecting the strategic commissioning intentions. That work indicates that a number of trusts have already increased their nurse staffing levels during the current year and others are planning to do so, as I mentioned in the Statement. Initial plans indicate that trusts intend to employ an increase of more than 3,700 nurses this year.
Moving to staff ratios, nursing leaders have been clear—indeed, there is a letter in today’s Times about this—that hospitals should publish staffing details and the evidence to show that staff numbers are right. However, we do not think that prescribing a rigid set of rules from the centre is the right way forward. The National Quality Board and the Chief Nursing Officer are publishing a guidance document that sets out current evidence on safe staffing. By next summer, NICE will produce independent, authoritative, evidence-based guidance on safe staffing and review and endorse associated tools for setting safe staffing levels in acute settings. From next April, by June at the latest, NHS trusts will publish ward-level information on whether they are meeting their staffing requirements. A review every six months will allow for those staffing levels to be quality assured.
On the issue of candour, we have had a number of debates on this subject, both during of the Health and Social Care Act and, more recently, in the Care Bill, and I believe that we have reached a place for which this House can take some credit because the Government have moved a considerable distance from their original position. We agree with Don Berwick’s intention that professional regulators are in the best position to strengthen the duty of candour for individual professionals working in a hospital. Of course, the duty of candour applies to the corporate entity but the GMC and the NMC will be working with the other regulators to agree consistent approaches to candour and the reporting of errors, including a common responsibility to be candid with patients when mistakes occur, whether serious or not, and clear guidance that professionals who seek to obstruct others in raising concerns or in being candid would be in breach of their professional responsibilities. The professional regulators will issue new guidance to make it clear that it is the responsibility of professionals to report near misses for errors that could have led to death or serious injury as well as actual harm, and they must do so at the earliest opportunity. We will seek advice from experts on how
to improve the reporting of patient safety incidents, including whether the threshold for the statutory duty of candour should include moderate harm.
The noble Lord referred to the NPSA. He is right that the NPSA’s function of reporting safety incidents has transferred to NHS England, into which the National Reporting and Learning System has been absorbed. I do not see that transfer as, in any way, inhibiting staff confidence in reporting safety incidents. The essence of the system remains as it always has been.
The noble Lord asked about the responsibility for patient safety being transferred back to the CQC. I am sure that, on reflection, he will agree that patient safety is everybody’s business. In part, it is the business of the CQC but, above all, it is the business of those who work in the NHS. It is the business of trust boards and of commissioners. It is also very much the business of those whose job it is to look at the performance of the NHS on behalf of patients—chiefly Healthwatch, but also patient organisations. Therefore one cannot single out an individual organisation as taking sole responsibility for this.
I will write to the noble Lord about the Freedom of Information Act. However, he should not forget that the standard contract that the NHS operates binds anyone who provides services to the NHS into certain contractual terms, and the disclosure of relevant information is a part of that.
On death certification, the noble Lord asked me about medical examiners. We agree that they must be independent of the deceased person and their medical practitioner. That is because medical examiners need to carry out independent scrutiny of the medical circumstances and cause of apparently natural deaths to make sure that the right deaths are notified or referred to a coroner. However, we need to ensure that there are sufficient numbers of medical examiners to carry out this work, particularly in rural areas, so appointees are likely to have some sort of professional relationship with local care providers. Therefore the draft death certification regulations for medical examiners do not require that medical examiners are independent of the organisation whose patients’ deaths are being scrutinised. However, we are mindful of the need for a greater level of independence within the spirit of this recommendation and the Government will review how they can include further safeguards on this front.
The noble Lord suggested that the NHS constitution was not the right means of changing the culture of the NHS, and I agree with him. However, declaratory statements in the constitution are an important part of signalling to the NHS its vision and values in the broadest terms, and the duties that people should feel they are under. The values, rights and pledges set out in the NHS constitution form the basis of everything the NHS does. NHS England, Health Education England, the department and CCGs are developing a joint strategy to embed the constitution further, as we promised they would during the passage of the Health and Social Care Act.
On the system that we have put in place and the complexity that the noble Lord sees in that system, I say, simply, that the system we now have is more transparent than the one we had before. Accountabilities
are clear, responsibility is clearly placed where it should be and it is backed by robust lines of accountability, including to Ministers and Parliament.
I hope that that answers most of the noble Lord’s questions, but I will of course write to him if I have omitted anything.
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