26 October 2011, Andrew Lansley, Rooting Out Poor Performance, Reform

This speech was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government

Andrew Lansley's speech about poor performance.

Check against delivery

At its best, the NHS outperforms every health service in the world. 

And I am proud, in my eight years as Conservative health spokesperson and now Secretary of State, to have witnessed the extraordinary care it so often provides to patients.

A system of general practice, admired across the world.

The surgical team at Great Ormond Street Hospital, admired across the world, without whom the Sudanese conjoined twins, separated there last month, would not have survived.

And hospitals who are not internationally known, like Robert Jones and Agnes Hunt Orthopaedic hospital in Shropshire where the quality of care is so outstanding that 95 per cent of staff say they would be happy to have a friend or family member treated there.

All these examples embody everything that’s brilliant about the NHS.  

And where the NHS is great, we should be enthusiastic in our celebration of its achievements.

 And let me be clear that I really do recognise that, every day, all over the country, NHS staff are caring exceptionally well for sick and vulnerable patients.

Look at our results for cardiac surgery; or our mental health services, acknowledged by the World Health Organisation to be among the best in Europe; the system of General Practice; our strides forward in preventing venous thromboembolism. 

Yes, I want the NHS to lead the world in everything it does, not just some of what it does.

And so - without taking anything away from the standards so often achieved - I want to focus on when things go wrong.

Because unless we face up to the challenges…

…Unless we take action when patients are let down

….We will never be able to achieve the consistent high quality we need.

Yes, we have hospitals that are respected across the world for what they do.

But there are others that simply aren’t good enough.

At times, it can seem as though there is a conspiracy of silence about poor performance. 

That doctors and nurses who were not up to the job go unchallenged by their colleagues.

That institutions that deliver poor quality care, that keep patients waiting for treatment months on end, or who run up massive debts, are excused, or are bailed out by the government.

We allowed a system to develop where, sometimes, failure was rewarded.

Last year, I ordered a programme of work to turn around hospitals that had struggled for years under Labour, but whose problems Labour chose to ignore.

In addition to the Labour bailouts, which rapidly snowballed into huge debts, some trusts are also dealing with the consequences of badly-negotiated PFI deals and years of revolving-door management.

The recent NAO report shows that of all NHS trusts yet to reach foundation trust status:

• 80 per cent face financial issues;
• 65 per cent face quality and performance issues;
• 39 per cent face governance and leadership issues.
Labour turned a blind eye to these problems for a decade.

In some cases, they exacerbated them - through the bungs and bailouts that papered over the cracks of poor performance.
They did nothing to tackle the root causes of the problems they were facing.

Well no more. 

No more sticking plaster solutions.

No more back room deals.

We need to be honest about the problems - burdensome debt and onerous PFI payments - and transparent about how we go about fixing them.

First and foremost, it is for organisations, working with others locally, to put their own houses in order.  To show how they can achieve the quality and sustainability of services consistent with Foundation Status.

But where the underlying issue is not of their making, where they face difficulties through no fault of their own, we will help them.

We will provide ongoing support to the small number of hospitals struggling with PFI deals, to ensure that local services are protected.

And one-off transparent loans to help recapitalise hospital trusts and enable them to sustain high standards of care and service

But these hospitals will only be able to access this once they have met four key tests:

• the problems they face must be exceptional and beyond those faced by other organisations;
• they must show that the problems are historic and that they have a clear plan to manage their resources in the future;
• they must show that they are delivering high levels of annual productivity savings; and
• they must deliver clinically viable, high quality services - including delivering low waiting times and other performance measures.

These are tough tests, but they are fair.

Fair to the hospitals that are facing up to these problems.  And fair to the rest of the NHS.
These hospitals owe it to their local communities to take the tough decisions to improve the quality of care.

For hospitals that are financially out of control cannot properly serve the needs of their patients. 

That is why we have established a transparent and open process to help them do this.  NHS Trusts have set out and signed up to plans to make themselves clinically and financially sustainable.

It is now up to them to deliver.  It’s not an easy job.

I have the greatest respect for the management teams who not only recognise that they have to face up to difficult decisions about how local health services can meet communities’ changing health needs, but are doing this in partnership with local people.

Like Winchester and Eastleigh NHS Trust, who know they provide good care now, but that they simply cannot sustain it, on their own, into the future.

So they are partnering with Basingstoke and North Hampshire Foundation Trust, because they know that, in doing so, they will be better able to develop services that can best meet the needs of local people.

Replacing Management Boards

Sometimes the root of a problem lies in the wider health community - which is why we are making the whole system more transparent and accountable.

But sometimes, the problem rests with a hospital’s management team - unable to take the difficult decisions needed to turn things around.

For them, I have a stark warning.

You have signed agreements telling us and your local communities by when you will be clinically and financially sustainable, and I wrote directly to the chairs of those trusts in the Autumn of last year.

If your hospitals are not there by the time you say, you’re not getting there at all.

The Secretary of State has the power to remove and replace management teams that fail to deliver and I will not hesitate to use that power if needed.

I can’t pretend that this is going to be easy.  But trusts owe it to their own communities and their own patients to do so.

Dealing with poor quality care

And neither will we turn a blind eye to poor quality care.

Many hospitals offer care that the most successful health systems in the world would be proud of.

But there are others whose past problems have become by-words for failure: Stafford General, Maidstone and Tunbridge Wells, Basildon and Thurrock to name but a few examples.

Extreme cases?  Perhaps.  And we were told by Labour Ministers each time that there were no others.  Perhaps not exactly the same.

But as we saw from the report I ordered from the CQC into the care of older people, poor care is more common in our hospitals than many would like us to believe, or, in some cases, admit.

During their 100 unannounced nurse-led inspections, around half of the hospitals visited gave cause for concern.  Twenty hospitals were not delivering care that met the essential standards the law says people should expect.

And I was also alarmed to see that, in fourteen hospital trusts, fewer than half of staff say that they would be happy to see a friend or relative treated there - in their own hospital.

So there are hospitals at the top like Robert Jones and Agnes Hunt, where 95 per cent of staff say they would be happy for friends and family to be treated by their colleagues.

Then towards the bottom, like East Lancashire Hospitals Trust, or Scarborough and North East Yorkshire.

I am often told by some people that satisfaction with the NHS is high, and that therefore nothing must change.  Others tell me of poor care, and claim that it is typical and everything must change. 

Neither is right.  We have to modernise.  We have to improve.

We have to raise quality for all, and especially, we have to shine a light on poor performance and know that it will change.

It is not about being anything other than committed to the NHS.  It is, also, about being uncompromising in our commitment to the best for patients.

That means both celebrating the NHS’s achievements and being prepared to shine a spotlight on poor performance.

Because poor performance is not simply a statistic or a line in a graph.

It means an older person being left for hours in soiled bed linen, or not being given help to eat or drink.

It means someone with diabetes losing a limb unnecessarily because they didn’t get the foot checks they needed.

Or the 200,000 older people who break a hip each year - for half of them it will be the second bone they’ve broken in quick succession, because after their first fracture, they didn’t get the right preventative care.

In challenging the case for change in the NHS, many have pointed to Ipsos MORI’s research on public perceptions, which shows most people - 70 per cent - say they are satisfied with the NHS.

That is great. But we want it to be higher.

The fact that satisfaction rates are high and have remained consistently high for some time is a credit to the many NHS staff who have worked hard to keep them that way.
But the question I would pose to those who don’t believe we need to change the NHS is this:

Is 70 per cent enough?  What about the remaining 30 per cent?

Can we be content that so many are not satisfied?

Can we really comfortably disregard the experience of the unhappy minority?

Work like Ipsos MORI’s public perceptions survey gives us some indication of how well the NHS is doing.

But it does not tell the whole story, and it cannot be used to hide the pockets of poor performance that we know exist.

Just as the CQC’s report showed how different wards in the same hospital could have very different standards of care.

People might similarly say they were satisfied with their bank or telecoms company.

The difference is that, if a bank lets a customer down, most customers have a choice - they can take their business elsewhere.

The older person who is rushed to A&E after a fall doesn’t have that choice.

If we ignore poor care, we undermine the efforts of the many great NHS staff who do an excellent job - even in circumstances that are far from ideal. 

And we damage - sometimes irrecoverably - public confidence in the NHS.

Because when problems finally burst out into the open, they are usually so serious that the public asks - and rightly - why such poor care has been tolerated for so long?

And too often, we deny the experience of patients and their family members who have been at the sharp end of appalling treatment.

This is why asked the CQC to  first perform one hundred unannounced inspections. of hospitals and care homes to identify and drive out poor care of older people. And why I have ordered an additional 700 inspections today.

The inspections won’t just focus on clinical care, but dignity, privacy and nutrition.

Where they identify poor care, they will take tough action - including ordering the closure of services where standards are unacceptable. 

I want to change the NHS because I believe it can and should offer excellent care to every patient, no matter where they live, how old they are or how sick they are.

And that means doing everything possible to root out poor quality care.

A modernised NHS means greater transparency - where both great care and poor care is visible in equal degree.

There was some effort by the last administration to encourage openness.

Star ratings were an instrument introduced a decade ago to help the NHS focus on the quality of what it did.

More recently, Quality Accounts allow trusts themselves to give a more sophisticated account of the standard of care they deliver. And they include perspectives of patients to tell it like it really is.

But we must move beyond star ratings.

We are not yet at the stage where any member of the public can tell at a glance how well their local hospital or GP practice is doing in a way that’s meaningful to them.

Anyone who is going into hospital for a serious operation has the right to know how well their surgical team performs that procedure.

Or how many of those procedures they perform each year.  And how long they keep patients waiting for treatment.

Or whether a general practice manages its patients well, avoiding emergency admissions, and how its prescription rates compare with others.

If patients don’t have this information, any notion that they have choice is little more than an illusion.

It’s why we now publish complaints data for hospitals.

It’s why all providers will have a duty of candour - so their contracts will set out their obligation to be open and transparent in admitting mistakes.

And it’s why tomorrow, for the first time, we will publish summary hospital-level mortality indicators, broken down by hospital trust, that will cover all deaths in all settings - including up to 30 days after discharge.

And in a modernised NHS, staff who raise concerns when things go wrong are supported. 

Too often, in the post mortem after a major failure, we hear story after story about how staff who tried to alert senior colleagues or managers and were ignored or even victimised.

There is a culture - not everywhere, but in too many places - where some staff simply don’t feel safe to speak out when they think patients are being put at risk.

That culture has no place in the NHS.

The NHS Constitution sets out in no uncertain terms that patients have the right not only to the best clinical care, but also to be treated with dignity and respect.

It is also unequivocal on the duty of care that staff owe their patients.

And we will be updating the Constitution so it is equally clear on the duty that managers have to support staff who raise concerns about the quality of care.

The Health and Social Care Bill strengthens the position of the NHS Constitution - so anyone who commissions health services will have to make sure that its principles and values are reflected in the services they commission for patients.

A modernised NHS is one that prizes clinical leadership - giving clinicians the autonomy they need to deliver better services for the patients.

This also means addressing poor care.

It is clinical leadership - of medical directors, of directors of nursing and other health professionals - that  will address the deeply disturbing issues raised in the CQC’s report.

It must be the people who work on the wards every day who know if patients aren’t being fed properly, or if they are not getting pain relief, who have the power to change these things.

And it is up to people working on those wards to take whatever action is necessary to make sure that all patients are being treated with dignity and respect they are entitled to.

We are doing everything in our power to make sure that every NHS trust offers the best possible quality of care and is financially sustainable

Greater transparency so patients and the public know how well the NHS performs.  A stronger voice for patients.  Support for whistleblowers. Stronger leadership. More focus on treating patients well, less on bureaucracy.

But where things are clearly going wrong, we won’t stand by.

We won’t wait on a repeat of a scandal like Mid Staffs.

Under the 2009 Health Act, there is an Unsustainable Providers Regime, but it’s not been used once.  I will not flinch from using it if NHS trusts are clearly failing patients or failing financially.


So, my message today is this.  Wherever there are pockets of poor performance, we will root it out.

Where there are institutions that are letting patients down or are financially unsustainable, we will expose them.

But where hospitals are doing the right thing but struggling with debts that are no fault of their own; where they have good plans in place; where they are  facing up to the tough decisions they need to make to offer the best possible care to people in their communities. Where the local health system has done everything in its power to help. In those cases, we will help them.

And, most of all, where there is excellence, we will reward it, and celebrate it.  As I said right at the beginning, there is much excellent care in the NHS, and we have very many truly dedicated and inspiring staff, and they have our recognition and admiration.

Their ambition is for the NHS to be excellent in every aspect.  And for patients and the public to be confident that they will get the best possible care.