Jeremy Hunt – 2018 Speech on Social Care

Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, on 20 March 2018.

“Grow old along with me! The best is yet to be.”

The famously optimistic line by Robert Browning might seem out of place to many worried about how we will cope with an ageing population

In modern-day Britain, one of the most developed countries on the planet, our aspiration should be to prove those worries wrong. Because how we care for our most vulnerable citizens is the true litmus test of whether we are a civilised society – not only the care for older people but for younger disabled people who are living much longer.

Progress has been made: the Better Care Fund is transforming the way councils and the NHS work together to treat the whole person: nearly 7 in 10 service users were extremely or very satisfied with their care and support over the last 3 years, and 81% of adult social care providers are rated as good or outstanding. Spending will rise by 9% this year, the number of care home agencies is up 55% since 2010, and we recently set out a new package of measures to protect care home residents from unfair practices.

But today I want to be honest about how well we are meeting that litmus test. In truth, not well enough.

Many families find it incredibly hard to access the care they want with or without means-tested support from the state.

Many people employed in the system find themselves working too hard as they struggle with fragmented services coming under unprecedented pressure.

The CQC has itself expressed serious concerns about the state of the adult social care market and the risks of provider exit.

And that pressure is feeding through to the NHS with A&Es becoming overcrowded because hospitals find themselves unable to discharge patients who cannot access social care support packages.

Behind these systemic issues sit many ordinary human beings in a great deal of distress. Families coming to terms with a relative with dementia. Older people living on their own who won’t admit they are lonely. Care home residents with clinical depression, as we know happens in 4 in 10 cases.

So let’s be brutally honest. In a country that prides itself on kindness, neighbourliness and respect this does not sit easily, and we need to do better.

Now no-one could accuse this or any government of not talking about the issue. In the past 20 years there have been 5 Green or White Papers, numerous policy papers, and 4 independent reviews into social care. So it would not be unreasonable to expect scepticism about yet another one this year – and as the new Health and Social Care Secretary I do rather feel the weight of stalled reform programmes on my shoulders.

So in order to get things right this time I want to outline the 7 key principles that will guide our thinking ahead of the Green Paper. And in doing so I wish to pay tribute to the work done by Damian Green, my predecessor, on whose thoughtful foundations much of our thinking has developed.

1. Quality

The first key principle relates to the quality of care. 81% of adult social care providers are good or outstanding according to the CQC – testament to many hardworking and committed professionals working in care to whom we owe a huge debt of gratitude.

But still too many people experience care that is not of the quality we would all want for our own mum or dad. They describe a daily visit from a rotating cast of care workers, perhaps as brief as 15 minutes, with barely time to get help washing or getting dressed and no time to build the friendly relationships that are only possible with proper continuity of care.

And then, despite some improvements, we also still get cases of demonstrable neglect, such as a few weeks ago when a worker at a care home in Norwich was jailed for bullying vulnerable patients, including humiliating a resident with incontinence problems in front of others.

So my first of the 7 principles will be that we need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition. This means a commitment to tackle poor care with minimum standards enforced throughout the system so that those using social care services are always kept safe and treated with the highest standards of dignity and compassion – or as our Chief Inspector for Social Care puts it, that all provision passes the “good enough for my mum” test.

Part of this will be tackling the unacceptable variations in quality and outcomes between different services and different parts of the country.

How can it be, for example, that, according to the NHS atlas of variation, there is around a 90-fold difference in the over 75s’ rates of admission to hospital from care homes or nursing homes between the highest and lowest performing local authority areas?

Over the last 5 years enhanced CQC inspections have been central to the journey of improvement that the NHS has been on. And thanks to the superb leadership of Andrea Sutcliffe and her team, those principles have been extended to the social care provider sector. No longer do we worry in the same way as before that abuses in a small minority of cases will go undetected for long periods and we see demonstrable improvements in the majority of cases when people are inspected a second time round.

But the recent local systems reviews conducted by the CQC have demonstrated that an independent approach to reviewing commissioning as well as provision can also be a powerful force for good. These reviews have highlighted variation in performance between local authorities across a range of measures, including how the local authority commissions care from local providers.

So we now need to ask whether the time is right to expand that approach, and one of the questions the Green Paper will pose is whether we can build on the learning from the introduction of independent Ofsted-style ratings for providers to spread best practice to commissioners as well.

2. Whole-person integrated care

Secondly we know that right now, despite many warm words, if you have complex needs our current health and social care system can be confusing and fragmented.

An 85 year old living alone with multiple conditions such as diabetes and early stage dementia often faces a bewildering range of services and organisations.

And the risk is that too often an individual and their family are passed from pillar to post, giving the same information repeatedly without receiving joined up, personalised care that makes them feel like a valued human being and not just another task on someone else’s to do list.

So my second key principle is the full integration of health and social care centred around the person. We know when this happens people stay longer at home, healthier, more independent and needing fewer hospital services.

There are many good examples of progress from around the country:

In Waltham Forest they have introduced a managed network of care and support to meet the needs of local residents through individually selected services – and seen emergency admissions reduced by a fifth during 2015/16.

In Leeds an integrated care record is now used by over 5,000 health and social care professionals so hospitals arrange faster discharges with care packages put in place more quickly.

The Better Care Fund, too, has incentivised local areas to work more closely together, and many now have mature systems in place to bring together health and care services around the needs of their older populations.

But the key to this progress is that users of the social care system should have just one plan covering all their health and social care needs based on a joint assessment by both systems. So today I can announce new pilots in Gloucestershire, Lincolnshire and Nottinghamshire which will mean that over the next 2 years every single person accessing adult social care will be given a joint health and social care assessment and – critically – a joint health and care and support plan, where needed.

Why does this matter? Because integration must never be a bureaucratic exercise that makes life easier for professionals but makes no difference to people using the services. We will fail if we only join up the structures – we have to focus relentlessly on joining up the actual care experienced by vulnerable adults and service users on the ground – and these 3 pilots are intended to be trail-blazers for how to get this right.

3. Control

My third critical principle is control. What matters to individuals and families is the ability to direct the care they receive and autonomy to lead the lives they want.

Personalisation isn’t new, and there is a strong consensus that it is the right path to follow, but progress has often been slower for older people than for working age adults with disabilities. Whilst over 90% of older people receive some type of self-directed support, only around 1 in 6 take it as a direct payment with take-up stubbornly low for older people.

Yet we know that the greater control people have over their care, the better their outcomes and the lower the cost. I heard the story of Malcolm Royle, who had dementia, from his son Colin. His personal budget meant that Malcolm no longer had to go to the day centre 8 to 5, but could have regular carers when he needed them. He got back control of his life – and we need to help everyone do this if they have the mental and physical capacity to do so.

So I want to turbo-charge progress on integrated health and care budgets, making them the norm and not the exception when people need ongoing support.

And today I can announce that we will be consulting on Personal Health Budgets, in order to achieve better integration for those with the greatest ongoing social care needs as well as health needs.

And as part of that I commit that over the next 2 years in Gloucestershire, Lincolnshire and Nottinghamshire – our 3 pilot areas – every single person with a joint care plan will also be offered an integrated health and care personal budget.

Control also means transparency and access to reliable information. Where individuals and families have the necessary information to make informed choices, it usually drives quality up. Yet the truth, as set out in a comprehensive report by the Competition and Markets Authority last year, is that the current social care market is anything but transparent. We also need to make sure that anyone who needs to can get the right information to make a meaningful comparison between services so that they end up with a fair and straight deal on their choice of care provider. This isn’t just fairer, it will also spur quality and innovation in the sector.

4. Workforce

My fourth principle is to respect and nurture the social care workforce.

People who work in care homes, who do home visits, who look after people with care needs with kindness and love in every street in every town – these are our society’s modern-day heroes. Often highly skilled, they are typically also the lowest paid.

I am deeply proud that the introduction of the National Living Wage means that the average salary for a care worker in the independent sector has gone up by 4%, with those on the minimum wage seeing a pay rise of up to £2,000 since 2015.

But to attract more people into this sector, financial support must be matched with recognition of the value of this vital work and action on the wider set of challenges facing the workforce.

Today is World Social Work Day. So it is right to acknowledge that as a society we have ascribed too little value to these vital caring roles: yet the quality of care our parents get in their final years is as important as the quality of education our children get at the start of their lives.

So it is time to do more to promote social care as a career of choice and to ensure there are better opportunities for progression into areas like nursing which span both the health and social care sectors. And we need coherent workforce planning that is better aligned with that now being undertaken by the NHS. Alongside social workers, occupational therapists and nurses in social care we have many care workers who could benefit or be inspired by new progression ladders similar to those that are being developed in the NHS including roles such as associate nurses and nurse degree apprenticeships. These must be as available to those working in social care as in the NHS.

We have many registered professionals including social workers, occupational therapists and nurses in social care; and many more care workers and other unregistered professions. We need to ensure we have enough people within all of these skilled roles to support people to live the best possible lives. That means making sure that the new routes in to professions that we have developed for those working in the NHS, and the new roles such as nurse associates, also work for those wanting to build their careers in social care.

We need to recognise that people move between the NHS and social care systems – and will do more so as the 2 systems join up. So part of our thinking must be to think about health and care workforce issues in a joined up way. I can therefore confirm today that later this year we will not now be publishing an ‘NHS 10 year workforce strategy’ – it will be an ‘NHS and social care 10 year workforce strategy’ with the needs of both sectors considered together and fully aligned.

5. Supporting families and carers

Ronald Reagan famously quipped that “the nearest thing to eternal life we’ll ever see is a government programme.” A big danger in this debate is to see it purely as a government solution.

So my fifth principle is to make the needs of carers central to our new social care strategy.

Of course we need to foster the deep, innate and human responsibility we all feel to look after our loved ones, families and friends. But we should never take it for granted.

If we can make it simpler to look after a loved one, if we can make it easier to juggle working and caring responsibilities, if we can encourage volunteering – whether by more flexible working, better employer support or harnessing new technologies, then that is what we should do.

Over the past months we have been listening to the views of carers so ahead of the Green Paper we will publish an action plan to support them.

And alongside support for carers, as a society we also must tackle the epidemic of loneliness. It is truly a scandal that over 30% of people in Britain over the age of 65 say that television is their main form of company. So the appointment of Tracey Crouch as Minister for Loneliness is a welcome sign of the Prime Minister’s personal determination to address this issue, and we will work with her as we develop the Green Paper to address the underlying causes of loneliness by building an active and creative partnership between the state, individuals and wider civil society.

6. A sustainable funding model for social care supported by a diverse, vibrant and stable market.

Person-centred care means nothing if the individual’s choice and control is undermined by a lack of high-quality services to provide the support they need. Too often we hear of people unable to find the care they want, or of services which are only available in some places but just don’t exist in others.

We have to make sure that we have a vibrant and diverse base of care services for people to draw on. So the sixth principle running through our Green Paper will be the question of how we ensure a sustainable financial system for care, delivering a stable and vibrant market which delivers cost-effective, quality services for all including the debate we need to have with the public on the challenges of sourcing additional social care funding.

We should not assume that the best long term answer will be necessarily the same for different age cohorts. There may be changes that are equitable and achievable for younger people that would not be either of those for the generation approaching retirement. And part of the outcome of this process must be much greater public understanding of where the costs – often inappropriately – currently lie both for the state and individuals in every age cohort.

We also know the economics of the publicly funded social care market are highly fragile so we need to transform and evolve our models of care.

We will therefore look at how the government can prime innovation in the market, develop the evidence for new models and services, and encourage new models of care provision to expand at scale.

This will specifically include looking at the role of housing, including how we can replicate the very best models that combine a home environment with quality care and how we can better support people through well-designed aids and adaptations.

We must also recognise the potentially transformative role of new technology. We British are good at innovation, although sometimes less good at its application: so let’s see the brightest and best new ideas put into action to help us tackle the challenges we face and that will help us stay at home independently for longer.

Which is why the Ageing Grand Challenge announced as part of the Industrial Strategy needs to play a definitive role. Only last week the Government announced a new £98 million innovation fund to support healthy ageing. This funding will aim to catalyse public-private investment in technologies and innovations so that we don’t just invent great ideas here, we see them taken up throughout our system.

Going forwards, I will be working closely with other government departments, industry, civil society, academia and local government to ensure we make the most of the opportunities that the Industrial Strategy presents.

A more vibrant and diverse market offer will give people greater choice and more effective support. But it is also vital because if we do nothing to support people’s needs more creatively or efficiently, the cost of simply delivering these services today will double in a decade.

And of course we must make sure there is a long term financially sustainable approach to funding the whole system.

Resolving this will take time. But that must not be an excuse to put off necessary reforms. Nor must it delay the debate we need to have with the public about where the funding for social care in the future should come from – so the Green Paper will jump-start that debate.

7. Security for all

The final principle, which lies at the heart of this debate, is the question of security.

We are proud that 70 years ago this country made a big statement of our values when we established the National Health Service. It is, to this day, the most powerful expression of what we believe in as a society, the central idea that no-one – rich or poor, young or old – should have to worry about affording good healthcare.

But this year is also social care’s 70th birthday. The National Assistance Act that abolished the Poor Law and created many of the core elements of the modern social care system came into effect on the same day as the NHS Act.

The National Assistance Act established a related but different principle: that of shared responsibility for care. Whilst the State has always accepted – and continues to accept – its duty to provide decent care for those unable to afford it – notably for those born with a disability or developing a care and support need early in life – our system has also reflected the principle of personal responsibility for care by individuals and families.

And the principle of shared responsibility continues to be right and people should continue to expect to contribute to their care in the future as they prepare for later life – but we are clear that there has to be a partnership between the state and individuals.

But the way our current charging system operates is far from fair. This is particularly true for families faced with the randomness and unpredictability of care, and the punitive consequences that can come from developing certain conditions over others.

If you develop dementia and require long-term residential care, you are likely to have to use a significant chunk of your savings and the equity in your home to pay for that care. But if you require long-term treatment for cancer you won’t find anything like the same cost.

So people’s financial wellbeing in old age ends up defined less by their industry and service during their working lives, and more by the lottery of which illness they get. We therefore need a system that includes an element of risk-pooling and, as the Prime Minister promised in the election campaign, we will bring forward ideas as to how to do this alongside their potential costs in the Green Paper.


The Green Paper will be published before the summer and will be framed by thinking on the 7 principles that I have set out today:

quality and safety embedded in service provision

whole-person, integrated care with the NHS and social care systems operating as one

the highest possible control given to those receiving support
a valued workforce

better practical support for families and carers

a sustainable funding model for social care supported by a diverse, vibrant and stable market

greater security for all – for those born or developing a care need early in life and for those entering old age who do not know what their future care needs may be.

Innovation is going to be central to all of these principles: we will not succeed unless the changes we establish embrace the changes in technology and medicine that are profoundly reshaping our world.

By reforming the system in line with these principles everyone – whatever their age – can be confident in our care and support system. Confident that they will have control, confident that they will have quality care and confident that they will get the support they need from wider society.

Let me finish by quoting the words of Fauja Singh, who at a mere 100 years of age became the oldest person ever to complete a marathon: “Anything worth doing”, he said, “is going to be difficult.”

The path to a long-term settlement for social care, built around a strong social contract, has been equally long and arduous, and there will no doubt be further twists and turns.

But Britain has a proud pedigree in establishing one of the first comprehensive healthcare systems in the world. Our innate sense of decency, kindness and common humanity will also drive us to the right solution for social care as it has for health.

Jeremy Hunt – 2017 Speech to Conservative Party Conference

Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, at the Conservative Party conference held in Manchester on 2 October 2017.

We have a great team at the Department of Health so let me start by thanking them: the wise Philip Dunne, the savvy Steve Brine, the smart James O’Shaughnessy, the street-smart Jackie Doyle-Price and our perfect PPS’s Jo Churchill and James Cartlidge.

Sometimes something happens that reminds you how lucky we are to have an NHS.

That happened right here in Manchester in May.

When that bomb went off at the Arena, we saw paramedics running into danger, doctors racing to work in the middle of the night, nurses putting their arms round families who couldn’t even recognise the disfigured bodies of their loved ones.

One doctor was actually on the scene picking up his own daughter when the bomb went off. Thankfully he found her – but instead of taking her home he quietly dropped her off with friends and went straight to work at his hospital – without telling colleagues a word about where he’d been.

It was the same heroism after the London attacks too. So let’s start by thanking all those superb NHS staff for being there when our country needed them.

Of course they’re there for us not just in national emergencies but in personal ones too.

When you’re losing a loved one, when you’re sick unexpectedly, when you’re knocked sideways by a mental health crisis – the NHS is there. A National Health Service and a national symbol of British professionalism and British compassion.

But it only exists because of its people. So today I want to recognise that supporting NHS staff is one of our most important priorities.

We need more doctors. So last year I said we’d increase the number of doctors we train by a quarter, one of the biggest ever increases.

We also need more nurses. So today I can tell you we’ll increase the number of nurses we train by 25% – that’s a permanent increase of more than 5,000 nurse training places every single year. And we’ll do that not just by increasing traditional university places, but also by tripling the number of Nursing Associates so people already in the NHS can become a registered nurse after a four year apprenticeship without having to do a traditional full time university course. Derby, Wolverhampton and Coventry Universities have already offered to run apprenticeship nursing courses on hospital and community sites and others will follow, always making sure we maintain the high standards required by the nursing regulator. We’ll also launch a new initiative to encourage nurses who have left the profession to come back.

Our NHS is nothing without its nurses: we need your skills, we need your compassion and with today’s announcement we are backing the biggest expansion of nurse training in the history of the NHS.

For nurses, as for all of us, pay and conditions matter. I’ve already said we’ll decide next year’s pay awards after listening to the independent pay review bodies. But there are other things we can do today.

Nurses look after us – but they also have their own families to look after: kids at school, a mum or dad with dementia, a partner coping with cancer.

If we’re to get the best out of them we need to be much better at supporting them with their own caring responsibilities.

They need to be able to work flexibly, do extra hours at short notice, get paid more quickly when they do and make their own choices on pension contributions. So today I’m also announcing that new flexible working arrangements will be offered to all NHS employees during this parliament. And we’ll start next year with 12 trusts piloting a new app-based flexible working offer to their staff.

And like many people, NHS staff can also struggle to find homes near work they can actually afford. So from now on when NHS land is sold, first refusal on any affordable housing built will be given to NHS employees benefitting up to 3,000 families.

And there’s one more group who are understandably a bit worried at the moment and that’s the 150,000 EU workers in the health and care system. Let me say to them this: you do a fantastic job, we want you to stay and we’re confident you will be able to stay with the same rights you have now – so you can continue being a highly valued part of our NHS and social care family.

I became Health Secretary five years ago. It’s a long time ago – but I’ll never forget my very first week.

Someone gave me the original Francis report into Mid Staffs to take home to read. I was gobsmacked. How could these terrible things really happen in our NHS?

The Chief Executive of the NHS told me I’d better get used to the fact in hospitals all over the world 10% of patients are harmed. Another senior doctor told me there were pockets of Mid Staffs-like problems everywhere. And academics told me that 3.6% of all hospital deaths were probably avoidable – that’s 150 deaths every single week – causing immense heartache to families as we heard so powerfully from Deb just now.

People like Deb – and what a privilege to listen to her this morning – made a choice.

Instead of drawing a line under their personal tragedies and moving on they chose to dedicate their lives to campaigning, reliving their sadness over and over again, just to make sure other families wouldn’t have to go through what they did.

They also made my mind up for me: my single ambition as Health Secretary would be to transform our NHS into the safest healthcare system in the world where this kind of thing never happened.

But where on earth do you start?

The first thing is to be honest about where the problems are. My kids are 3, 5 and 7 and as a Dad I know exactly how good all the local schools are – thanks to Ofsted. We had nothing like that in health – so against a lot of opposition in 2013 we became the first country in the world to introduce the Ofsted system to healthcare, giving independent ratings to every hospital, care home and GP surgery.

The results were, to say the least, a big surprise. Look at this.
14 hospitals got an ‘outstanding.’ We assumed it would be the famous teaching hospitals, but in fact it was often trusts no one had really heard of outside their area. Like Western Sussex, under the inspiring leadership of Marianne Griffiths, which has the best learning culture I have seen anywhere in the NHS. Or in mental health Northumbria Tyne and Wear which I visited on Friday and is blazing a trail on the safety of mental health patients.

Then we asked ourselves a difficult question. Is quality care just something you have to buy? Of course money matters – you need enough nurses on the wards and that costs money. But it turned out to be a more complex relationship.

All Trusts are paid the same NHS tariff. But on average the ‘good’ or ‘outstanding’ trusts were in surplus and the ‘requires improvement’ and ‘inadequate’ ones were in deficit. Why’s that? Because poor care is about the most expensive care you can give. If someone has a fall and stays in hospital an extra week, it’s not just terrible for them it costs us more too.

But our biggest worry was what would happen to the trusts we put into special measures. Would they get trapped in a vicious circle of decline? 35 trusts went into special measures – nearly one in five of all NHS trusts – and so far 20 have come out. What happened?

Take Wexham Park Hospital in Slough. When they went into special measures, the CQC said their care was unsafe, 6 of their 8 clinical areas needed improving and if you asked staff the majority said they would not recommend their own care to a friend or member of their family. Think about that: the staff themselves said their own hospital’s care was not to be trusted.

Two years later under the extraordinary leadership of Sir Andrew Morris and his Frimley team things were transformed: all 8 clinical areas were good or outstanding, more than two thirds of staff started recommending their own care and the Trust became one of only 8 in the country to go straight from special measures to being rated ‘Good.’

And we learned perhaps the most important thing I have learned as Health Secretary. The staff in every Trust going into special measures were exactly the same as the staff coming out. In other words it wasn’t about the staff, it was all about the leadership.

We also learned that you can’t impose quality or safety from above – it has to be part of a culture that comes from the bottom up. And that starts with openness and transparency.

Let me show you that works.

After Mid Staffs we were worried about staffing levels on wards. But rather than a top-down edict telling Trusts to recruit more staff, we did something simpler. We just asked every trust to publish every month the number of nurses employed in each of their wards. What was the impact?

This is the total number of adult nurses employed in the NHS. And you can see in the first two years from 2010 they went down by just under 5,000. Then we introduced ward by ward transparency and what happened? The blue line is the number of nurses Trusts planned to recruit. The green line is what they actually recruited. In other words once we started being transparent about nurse numbers the NHS ended up with 18,000 more nurses than it planned.

And the public noticed – inpatient satisfaction over this period rose to record highs.

We also introduced transparency in areas like mental health, our major priority under Theresa May’s leadership. We are leading probably the biggest expansion of mental health in Europe right now. But progress across the country has been patchy – so we are using transparency to make sure that wherever you live mental health conditions are always treated as seriously as physical health conditions.

So by shining a light on problems, transparency saves lives. But it also saves money.

Every time someone gets an infection during a hip operation it can cost £100,000 to put right. So under the leadership of Professor Tim Briggs we started collecting data on infection rates across the country. What did Tim find? He found that our best hospitals infect one in 500 patients. But our least good ones it is as many as one in 25 patients.

Putting that right is now saving hundreds of millions of pounds as well as reducing untold human misery. So never let it be said you can’t afford safe care – it’s unsafe care that breaks the bank.

Now what’s been the overall impact of this focus on safety and quality? We all know the pressure the NHS is under. But despite that the proportion of patients being harmed has fallen by 8% and 200 fewer patients harmed every single day.

Staff are happier than ever with the quality of their care and the proportion of the public who agree their NHS care is good is up 13%.

This July an independent American think tank, the Commonwealth Fund, said the NHS was the best – and safest – healthcare system in the world. That’s better than America, better than France, better than Germany and most importantly ahead of the Ashes better than Australia.

But – and there is a ‘but’ – we still have those 150 avoidable deaths every week.

Twice a week somewhere in the NHS we leave a foreign object in someone’s body.

Three times a week we operate on the wrong part of someone’s body.

Four times a week a claim is made for a baby born brain damaged.

We may be the safest in the world – but what that really means is that healthcare everywhere needs to change.

In America Johns Hopkins University says medical error causes 250,000 deaths a year – the third biggest killer after cancer and heart disease. Conference I want the NHS to blaze a trail across the world in sorting that out.

So we have big campaigns right now to tackle e-Coli infections, reduce maternity harm, make sure we learn from every avoidable death and most of all keep our patients safe over winter.

But we need to do something else too: and that’s get much better at supporting doctors and nurses when they make mistakes. Everyone makes mistakes – but only doctors and nurses have been brave enough to choose a career where the price of those mistakes can sometimes be a tragedy.

And when that happens no one is more devastated, no one keener to learn and improve than those same frontline staff.

But we often make that impossible. They worry about litigation, the GMC, the NMC, the CQC, even being fired by their trust. Unless we support staff to learn from mistakes we just condemn ourselves to repeat them – and that means dismantling the NHS blame culture and replacing it with a learning culture. The world’s largest healthcare organisation must become the world’s largest learning organisation – and it’s my job and my mission to make that happen.

Now next year the NHS has an important birthday. Like Prince Charles and Lulu it will turn 70.

Here are the words of the Health Minister who announced its formation back in 1944.

Nye Bevan deserves credit for founding the NHS in 1948. But that wasn’t him or indeed any Labour minister.

That was the Conservative Health Minister in 1944, Sir Henry Willink, whose white paper announced the setting up of the NHS.

He did it with cross-party support. And for me that’s what the NHS should always be: not a political football, not a weapon to win votes but there for all of us with support from all of us.

So conference when Labour question our commitment to the NHS, as they did in Brighton, just tell them that no party has a monopoly on compassion.

It’s not a Labour Health Service or a Conservative Health Service but a National Health Service that we built and are building together – as I’ve said many times.

And the next time they question our record, tell them we’ve given our NHS more doctors, more nurses and more funding than ever before in its history.

Tell them when they left office the NHS wasn’t even rated the best in Europe, let alone best in the world as it has been twice on our watch.

And most of all tell them that if they’re really worried about the NHS being destroyed, then there’s one thing they can do: ditch Corbyn and McDonnell’s disastrous economic policies which would bankrupt our economy and bring our NHS to its knees.

Because the economic facts of life are not suspended for the NHS: world-class public services need a world-class economy and to ignore that is not to support our doctors and nurses, it’s to betray them.

However unlike Labour we don’t make the mistake of saying the challenges facing the NHS are only about money.

If they were, we wouldn’t have had Mid Staffs, Morecambe Bay and all those other tragedies that happened during bumper increases in funding.

As Conservatives we know that quality of care matters as much as quantity of money.

So when we battle to improve the safety and quality of care we are making the NHS stronger not weaker.

And we’re reinforcing those founding values of the NHS we just heard, namely that every single older person, every single family, every single child in our country matters – and we want all of them to be treated with the same standards of care and compassion that we’d want for our own mum or dad or son or daughter.

That, conference, is why we’re backing our NHS to become the safest, highest quality healthcare system in the world and we will deliver the safest, highest quality healthcare system in the world. Thank you.

Jeremy Hunt – 2016 Statement on NHS England Annual Assessment


Below is the text of the statement made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 21 July 2016.

Today, I am laying before Parliament my annual assessment of the NHS commissioning board (known as NHS England) for 2015-16. I am also laying NHS England’s annual report and accounts for 2015-16 (HC311). Copies of both documents will be available from the Vote Office and the Printed Paper Office.

NHS England’s annual report and accounts includes a self-assessment of performance which describes an organisation that has experienced a year of both progress and challenge. NHS England continues to deliver high-quality care as it progresses with implementing the vision set out in the five year forward view delivering constancy of direction, consistency of leadership and effectiveness of delivery.

In response, my annual assessment welcomes the good progress that NHS England has made against many of its objectives including managing the commissioning system. Additionally it has continued to deliver the specialised services and primary care commissioning systems and improved the operation and management of the NHS. There does, however, remain much to do in order to achieve our agreed goals by 2020. In particular, I have drawn attention to the need to address year-round performance against the standards reflected within the NHS constitution, many of which have been routinely missed this year, as well as the need to make further progress on achieving parity of esteem between physical and mental health.

Although NHS England met its objective to deliver financial balance in the commissioning system this year, the provider sector remains financially challenged. To achieve its financial objective in 2016-17, NHS England must work with its system partners and the Department of Health to jointly deliver a balanced budget across the NHS as well as delivering its share of the productivity and efficiency savings identified in the NHS five year forward view.

Overall NHS England has made progress during 2015-16 but there remains much more to do. The extra real-terms investment of £8.4 billion agreed as part of the 2015 spending review is evidence of this Government’s continuing commitment to the NHS. My Department and I will continue to work with NHS England and its partners to ensure that this investment is used to build on the good work seen so far and to deliver an NHS that provides safe, compassionate and reliable care for those who need it while living within its means.

Jeremy Hunt – 2016 Statement on Junior Doctors Contracts


Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 19 May 2016.

Mr Speaker, for the last 3 years there have been repeated attempts to reform the junior doctors contract to support better patient care 7 days a week, culminating in a damaging industrial relations dispute that has lasted over 10 months.

I am pleased to inform the House that after 10 days of intensive discussion under the auspices of ACAS, the dispute was resolved yesterday with a historic agreement between the government, NHS Employers (acting on behalf of the employers of junior doctors) and the BMA that will modernise the contract making it better for both doctors and patients. The new contract meets all the government’s red lines for delivering a 7 day NHS and remains within the existing pay envelope. We will be publishing an equalities analysis of the new terms alongside publishing a revised contract at the end of the month. It will now be put to a ballot of the BMA membership next month with the support of its leader, the Chair of the Junior Doctors’ Committee of the BMA, Johann Malawana.

Mr Speaker, I would like to first of all express my thanks to the BMA for the leadership they have shown in returning to talks, negotiating in good faith and making an agreement possible. I would also like to put on record my thanks to Sir Brendan Barber, the Chairman of ACAS, for his excellent stewardship of the process, and to Sir David Dalton for his wisdom and insight in conducting the discussions on behalf of employers and the government both this time and earlier in the year.

Reforming an outdated contract

This agreement will facilitate the biggest changes to the junior doctors’ contract since 1999. It will allow the government to deliver a 7 day NHS, improve patient safety, support much-needed productivity improvements, as well as strengthening the morale and quality of life of junior doctors with a modern contract fit for a modern health service.

The contract inherited by this government had a number of features badly in need of reform, including:

– low levels of basic pay as a proportion of total income, making doctors rely too heavily on unpredictable unsocial hours supplements to boost their income

– automatic annual pay rises even when people take prolonged periods of leave away from the NHS

– an unfair banding system which triggers payment of premium rates to every team member even if only one person has worked the extra hours

– high premium rates payable for weekend work which make it difficult to roster staff in line with patient need

– risks to patient safety with doctors sometimes being required to work 7 full days or 7 full nights in a row without proper rest periods

Seven day NHS

This government has always been determined that our NHS should offer the safest, highest quality of care possible – which means a consistent standard of care for patients admitted across all 7 days of the week. So the new contract agreed yesterday makes the biggest set of changes to the junior doctors’ contract for 17 years including:

– establishing the principle that any doctor who works less than an average of one weekend day a month (Saturday or Sunday) should receive no additional premium pay compensated by an increase in basic pay of between 10 and 11%

– reducing the marginal cost of employing additional doctors at the weekend by about a third

– supporting all hospitals to meet the 4 clinical standards most important for reducing mortality rates for weekend admissions by establishing a new role for experienced junior doctors as ‘senior-clinical decision makers’ able to make expert assessments of vulnerable patients who may be admitted or staying in hospitals over weekends

– removing the disincentive to roster sufficient numbers of doctors at weekends by replacing an inflexible banding system with a fairer system that values weekend work by paying actual unsocial hours worked with more pay to those who work the most.

A better motivated workforce

The government also recognises that safer care for patients is more likely to be provided by well-motivated doctors who have sufficient rest between shifts and work in a family-friendly system. So the new contract and ACAS agreement will improve the wellbeing of our critical junior doctor workforce by:

– reducing the maximum hours a doctor can be asked to work in any one week from 91 to 72

– reducing the number of nights a doctor can be asked to work consecutively to 4 and reducing the number of long days a doctor can be asked to work to 5

– introducing a new post, a Guardian of Safe Working, in every trust to guard against doctors being asked to work excessive hours

– introducing a new catch up programme for doctors who take maternity leave or time off for other caring responsibilities

– establishing a review by Health Education England to consider how best to allow couples to apply to train in the same area and to

– offer training placements for those with caring responsibilities close to their home by giving pay protection to doctors who switch specialties because of caring responsibilities

– establishing a review to inform a new requirement on trusts to consider caring and other family responsibilities when designing rotas.

Taken together, these changes show both the government’s commitment to safe care for patients and the value we attach to the role of junior doctors. Whilst they do not remove every bugbear or frustration they will significantly improve flexibility and work life balance for doctors, leading we hope to improved retention rates, higher morale and better care for patients.

Reflections on industrial action

But whatever the progress made with today’s landmark changes, it will always be a matter of great regret that it was necessary to go through such disruptive industrial action to get there. We may welcome the destination but no one could have wanted the journey: so today I say to all junior doctors whatever our disagreements about the contract may have been, the government has heard and understood the wider frustrations that you feel about the way you are valued and treated in the NHS.

Our priority will always be the safety of patients but we also recognise that to deliver high quality care we need a well-motivated and happy junior doctor workforce. Putting a new, modern contract in place is not the end of the story in this respect. We will continue to engage constructively with you to try to resolve outstanding issues as we proceed on our journey to tackle head on the challenges the NHS faces and make it the safest, highest quality healthcare system anywhere in the world. Today’s agreement shows we can make common cause on that journey with a contract that is better for patients, better for doctors and better for the NHS and I commend it to the House.

Jeremy Hunt – 2016 Statement on Junior Doctors Contracts


Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 18 April 2016.

This House has been updated regularly on all developments relating to the junior doctors contract, and there has been no change whatsoever in the Government’s position since my statement to the House in February. I refer Members to my statement in Hansard on 11 February, and to answers to parliamentary questions from my ministerial colleagues on 3 March, which set out the position clearly. Nevertheless, I am happy to reiterate those statements to the hon. Lady.

The Government have been concerned for some time about higher mortality rates at weekends in our hospitals, which is one reason why we pledged a seven-day NHS in our manifesto. We have been discussing how to achieve that through contract reform with the British Medical Association for more than three years without success. In January, I asked Sir David Dalton, the highly respected chief executive of Salford Royal, to lead the negotiating team for the Government as a final attempt to resolve outstanding issues. He had some success, with agreement reached in 90% of areas.

However, despite having agreed in writing in November to negotiate on Saturday pay, and despite many concessions from the Government on this issue, the BMA went back on that agreement to negotiate, leading Sir David to conclude that

“there was no realistic prospect of a negotiated outcome.”

He therefore asked me to end the uncertainty for the service by proceeding with the introduction of a new contract without further delay. That is what I agreed to, and what we will be doing. It will start with those in foundation year 1 from this August, and proceed with a phased implementation for other trainees as their current contracts expire through rotation to other NHS organisations.

Let me be very clear: it has never been the Government’s plan to insist on changes to existing contracts. The plan was only to offer new contracts as people changed employer and progressed through training. This is something that the Secretary of State, with NHS organisations as employers, is entitled to do according even to the BMA’s own legal advice. NHS foundation trusts are technically able to determine pay and conditions for the staff they employ, but the reality within the NHS is that we have a strong tradition of collective bargaining, so in practice trusts opt to use national contracts. Health Education England has made it clear that a single national approach is essential to safeguard the delivery of medical training and that implementation of the national contract will be a key criterion in deciding its financial investment in training posts. As the Secretary of State is entitled to do, I have approved the terms of the national contract.

The Government have a mandate from the electorate to introduce a seven-day NHS, and there will be no retreat from reforms that save lives and improve patient care. Modern contracts for trainee doctors are an essential part of that programme, and it is a matter of great regret that obstructive behaviour from the BMA has made it impossible to achieve that through a negotiated outcome.

Jeremy Hunt – 2016 Speech on a Blame Culture in the NHS


Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, at Lancaster House in London on 3 March 2016.

Every year an estimated million patients die in hospitals across the world because of avoidable clinical mistakes.

It is difficult to confirm the exact number because of variability in reporting standards, but if it is of this scale it sits alongside hypertensive heart disease and road deaths as one of the top causes of death in the world today.

In the US they estimate it at up to 100,000 preventable deaths annually and in England the Hogan, Darzi and Black analysis says that 3.6% of hospital deaths have a 50% or more chance of being avoidable – that’s potentially 150 avoidable deaths every week. Holland and New Zealand make similar estimates.

So today is historic.

Distinguished guests, health ministers from across the world, Director General Chan from the World Health Organisation thank you for attending this first ever ministerial-level Global Patient Safety Summit. A special welcome to my friend and colleague the German Health Minister Hermann Grohe with whom I am jointly hosting the summit and who will organise a follow up summit in Berlin in a year’s time. And a warm thank you to the many people who have travelled long distances to be here as we aim to make a decisive step towards improving standards of safety in healthcare.

In 1990 a bright 24-year old medical school graduate started his first job in medicine. He was a pre-registration house officer looking forward to a glowing career in surgery.

In his first month he was attending to a 16-year old boy undergoing palliative chemotherapy. The boy needed two different injections, one intravenously and a second by lumber puncture into the spine.

The intravenous drug was highly toxic – indeed fatal – if administered to the spine. But it arrived on the ward in a nearly identical syringe to the other injection. Both syringes were handed to the young doctor for the lumber puncture procedure and both injected into the patient’s spine.

As soon as the doctor realised what had happened, frantic efforts were made to flush out the toxic drug from the boy’s spine. But it was to no avail and tragically he died a week later.

So what happened next?

You might think the most important priority would be to learn from what went wrong and make sure the mistake was never repeated. But instead the doctor was prosecuted and convicted for manslaughter. He and a colleague were given suspended jail terms.

In this case the convictions were eventually overturned at the Court of Appeal. But the real crime was missed: as the legal process rumbled on, exactly the same error was made in another NHS hospital and another patient died because our system was more interested in blaming than learning.

The blame culture doesn’t just create fear for doctors. It causes heartbreak for patients and their families as I discovered when I met the parents of 3-year old Jonnie Meek.

Jonnie tragically died unexpectedly in hospital in 2014. His parents found their grief at losing Jonnie compounded several times over by the immense difficulty in establishing what actually happened. An independent report found: ‘Two different [hospital] trusts… Both responded in the same closed, unhelpful manner…[Jonnie’s parents] on the outside, unable to find a way in to ask simple questions. [NHS employees] blocked by fear…expectation of blame lead[ing] to defensive behaviours.’

We are now working with Jonnie’s family to seek an order for a second inquest.

But it shouldn’t need an inquest to find out the truth. Instead we need to ask what is blocking the development of the supportive, learning culture we need to make our hospitals as safe as they should be.

Too much avoidable harm and death

In England we have made much progress in improving our safety culture following the Francis Report into the tragedy of what happened at Mid Staffs.

According to the Heath Foundation the proportion of patients being harmed in the NHS dropped by over a third (34%) in the last 3 years. MRSA bloodstream infections have fallen by over half in the last 5 years. We have introduced a new and much tougher peer-led inspection regime which has led to 27 hospitals being put into special measures, 11 of whom have now come out. The law has changed placing on all hospital trusts a statutory duty of candour to patients and their families when things go wrong. The government was elected on a firm commitment to make NHS care safer across all 7 days of the week and we are making good progress.

But today I want to talk about the profound culture change necessary if we are to complete this journey: the change from a blame culture to a learning culture.

A learning culture not a blame culture

In his book Black Box Thinking, Matthew Syed talks about how that same blame culture used to exist in the airline industry.

He tells the tragic story of United Airlines flight 173, where 10 people died in a crash that happened in December 1978. The pilot, Captain Malburn McBroom, was trying to rectify a potentially dangerous problem with the landing gear but failed to notice that the plane was dangerously low on fuel. When he was forced to crash land the plane, he did so with extraordinary skill saving the lives of over 150 passengers. But because of his mistake, he got tied up in a 7-year long court case, came close to suicide, lost his pilot’s licence, and ultimately died a broken man.

But that tragedy had a surprisingly positive ending.

Because it became the moment the airline industry realised that if it was going to reduce airline fatalities, it needed to change its culture. They realised that ‘human factors’, rather than technical or equipment failure had been at the heart of the problem. Anyone could have failed to notice low fuel levels when they were trying to fix the landing gear. Why didn’t other crew members spot the problem and speak out? The issue was not that particular person, but what could have happened to any person in the same situation.

As a result the airlines transformed their training programmes. They mandated reforms that required pilots to attend group sessions with engineers and attendants to discuss communication, teamwork and workload management. Captains were required to encourage feedback, and crew members were required to speak up boldly.

And the result? There were dramatic – and immediate – reductions in the number of airline fatalities. The number of deaths overall halved over 30 years – at the same time as air travel increased nine fold. 10 people died in the United 173 crash, but experts are unanimous that the learning that resulted has saved thousands more.

Healthcare is of course very different to aviation.

When someone dies in an airline accident you know there has been a mistake – whereas with over 1,000 deaths every year in the average hospital it is not always so clear. And while modern airplanes are undoubtedly highly complex, they are nowhere near as complex as the human body.

But the airline industry did change its culture. And so can we.

How? In my speech to the Kings Fund last June I talked of the 3 stages necessary.

Intelligent transparency

The first step is intelligent transparency.

Intelligent transparency leads to action – and that means we need to understand the scale of the problem not just nationally but where we actually work.

So following a request to NHS hospitals by Dr Mike Durkin, NHS National Director of Patient Safety, the NHS in England will this month become the first country in the world to publish estimates by every hospital trust of their own annual number of avoidable deaths. Methodologies vary, so the numbers cannot be compared, but it is a major step forward for every hospital trust to make their own estimate of avoidable mortality and be open about what they find.

What you can compare, however, is the quality of reporting culture. Just how easy is it to speak about things that have gone wrong? Do hospitals listen to doctors raising genuine concerns or do they punish them as we saw happened to Dr Raj Mattu and other whistleblowers? So we yesterday published a table that grades the openness and honesty of reporting cultures in our hospitals. Chief Inspector of Hospitals Sir Mike Richards and NHS Safety Director Mike Durkin have looked at a range of indicators including staff survey measures of how supported frontline staff feel if they raise safety concerns, whether staff feel able to contribute towards improvements at work, and how effectively a trust uses the national reporting and learning system. On the basis of these indicators every trust has been graded as having an outstanding or good reporting culture – or as requiring improvement.

Once we have validated both sets of data, the CQC will include them in a new annual report on the state of hospital quality which will be published from this year.

The world’s largest learning organisation

The second stage in changing culture is to use intelligent transparency to turn the NHS into what I have long wanted it to be: the world’s largest learning organisation.

There is of course a huge amount of learning that goes on every day in our NHS. One study found doctors take 158 clinical decisions every day and we should never diminish their efforts to extract every possible piece of learning from daily work.

The government too, has played its part by introducing the new CQC inspection regime; legislating for a statutory duty of candour; making progress – not always smoothly – towards a 7-day NHS; asking every trust to appoint independent freedom to speak up guardians so clinicians can relay concerns to someone other than their line manager; launching the Sign up to Safety campaign and recently the campaign to halve the number of stillbirths and neonatal deaths.

But if we really are to tackle potentially avoidable deaths, we need culture change from the inside as well as exhortation from the outside. A true learning culture must come from the heart.

And this means a fundamental rethink of our concept of accountability.

Time and time again when I responded on behalf of the government to tragedies at Mid Staffs, Morecambe Bay, Winterbourne View, Southern Health and other places I heard relatives who had suffered cry out in frustration that no one had been ‘held accountable.’

But to blame failures in care on doctors and nurses trying to do their best is to miss the point that bad mistakes can be made by good people. What is often overlooked is proper study of the environment and systems in which mistakes happen and to understand what went wrong and encouragement to spread any lessons learned. Accountability to future patients as well as to the person sitting in front of you.

The rush to blame may look decisive. It may seem like professionals are being held accountable. In fact, the opposite can happen. By pinning the blame on individuals, we sometimes duck the bigger challenge of identifying the problems that often lurk in complex systems and which are often the true cause of avoidable harm.

Organisational leadership is vital if we are to change this – and we can see world class organisations inside and outside healthcare have a very different approach. They have the boldness to probe more deeply, thus learning precious lessons. They see a medication error as an opportunity to make labelling clearer, a mistake in an operating theatre as a chance to improve teamwork and communication, just as airlines did after the crash of United 173.

Which is why we need a new mindset to permeate the entire ethos of the NHS, where blame is never the default option. Justice must never be denied if a professional is malevolent or grossly negligent. But the driving force must be the desire to improve care and reduce harm – fired by an insatiable curiosity to pursue improvement in every sphere of activity. This is what I mean by the world’s largest learning organisation.

And when we give patients an honest account of what happened alongside an apology, what is the impact? Countless academic studies have shown there is less litigation, less money spent on lawyers and more rapid closure, even when there have been the most terrible tragedies.


Some say that is all very well, but with hospitals in deficit what happens if you can’t afford to implement the lessons you learn about how to improve the standards of care?

Even after the significant rise in the NHS budget announced at the autumn statement, the resources to tackle these deep-rooted issues are finite. But as Sir Mike Richards and many others have pointed out, it is quite wrong to make out there is a choice between safe care or balanced budgets because the evidence shows that hospitals with better care usually have better balance sheets as well.

Of course there are times when safer care requires more resources, but unsafe care is even more expensive – in fact we know from the 2014 Frontier Economics report it costs the NHS up to £2.5 billion a year due to longer hospital stays, repeat visits and expensive litigation.

A compensation culture costs money – £1.4 billion of the NHS budget – but it also costs lives by creating a culture of defensive medicine which means avoidable harm remains stubbornly higher than it should be because we make it so hard for frontline clinicians to speak openly and honestly about how to learn from mistakes.

Next steps

That means a profound change in culture.

The recommendations from Sir Robert Francis’s Freedom to Speak Up review have not yet taken effect and there are still too many stories of whistleblowers being bullied or hounded out of their jobs.

We must go further.

Just as the Carter process announced last month will harness the power of transparency to improve our use of resources, so today I want to harness that same power to bring down the rate of avoidable deaths by turning the NHS into a true learning organisation.

Following the commitment I made to Parliament at the time of the Morecambe Bay investigation, we will from 1 April set up our first ever independent Healthcare Safety Investigation Branch. Modelled on the Air Accident Investigation Branch that has been so successful in the airline industry, it will undertake timely, no-blame investigations.

Harvard Professor Dr. Lucian Leape has said that ‘the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes’. So just as the Air Accident Investigation Branch gives a legal ‘safe space’ which protects those cooperating with its inquiries, we will bring forward measures to give similar legal protection to those who speak honestly to HSIB investigators so that the principle of a ‘safe space’ is at the heart of what the Healthcare Safety Investigation Branch does.

Affected patients or their families will need to be involved as part of the safe space protection. And while the findings of investigations will be made public, the details will not be disclosable without a court order or an overriding public interest, with courts being required to take note of the impact on safety of any disclosures they order. This legal change will help start a new era of openness in the NHS’s response to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.

I have asked the new organisation to consider focusing initially on maternity and neonatal mortality investigations to give us time to examine and understand its effect before rolling it out to other areas of clinical activity. It is intended to make a major contribution to our new ambition to halve still births, neonatal injury and death and maternal death rates where we still rank unfavourably to many other high income countries.

But it will not be limited to maternity. And as we create the legally safe space for learning that has long benefited the airline industry, we will in the words of NHS National Director of Patient Safety Dr Mike Durkin be taking ’the biggest single step in a generation to foster a positive learning culture that will support NHS hospitals to become safer for patients.’

I can also announce some other important steps to help foster a true learning culture.

The GMC and NMC guidance is now clear – where doctors, nurses or midwives admit what has gone wrong and apologise, the professional tribunal should give them credit for that, just as failing to do so is likely to incur a serious sanction. As in the airlines, doctors, nurses and other health professionals need to know that they will get credit for being open and honest and the government is committed to legal reform that would allow professional regulators more flexibility to resolve cases without stressful tribunals, where professionals have admitted their mistake.

NHS Improvement will ask for this to be reflected in all trust disciplinary procedures and ask all trusts to publish a Charter for Openness and Transparency so staff can have clear expectations of how they will be treated if they witness clinical errors.

From April 2018, we will be introducing the system of medical examiners recommended in the Francis Report. This will bring a profound change in our ability to learn from unexpected or avoidable deaths, with every death either investigated by a coroner or scrutinised by a second independent doctor. Grieving relatives will be at the heart of the process and will have the chance to flag any concerns about the quality of care and cause of death with the independent clinician.

NHS England is working with the Royal College of Physicians to develop and roll-out across the NHS a standardised method for reviewing the records of patients who have died in hospital.

The objective of these changes is to make it unnecessary for anyone ever to feel they have to ‘blow the whistle’ on poor care. But as we make this transition, it is vital that we offer whistleblowers protection wherever they are in the NHS so if we discover that there are any gaps in the law protecting whistleblowers, we will act to close them.


Karl Popper said true ignorance is not the absence of knowledge but the refusal to acquire it. So now is the time to use the power of intelligent transparency to make sure that we really do turn our healthcare systems into learning organisations – and offer our patients the the safe high quality they deserve.

Jeremy Hunt – 2016 Statement on Mistakes in the NHS


Below is the text of the statement made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 9 March 2016.

With permission, Mr Speaker, I would like to update the House on the steps the government is taking to build a safer 7-day NHS. We are proud of the NHS and what it stands for and proud of the record numbers of doctors and nurses working for the NHS under this government. But with that pride in the NHS comes a simple ambition: that our NHS should offer the safest, highest quality care anywhere in the world. Today we are taking some important steps to make that possible.

In December, following problems at Southern Health, I updated the House about the improvements we need to make in reporting and learning from mistakes. NHS professionals deliver excellent care to around 650,000 patients every day, but we are determined to support them to improve still further the quality of the care we offer. So this government has introduced a tough and transparent new inspection regime for hospitals, a new legal duty of candour to patients and families who suffer harm and a major initiative to save lives lost from sepsis. As a result of these measures, according to the Health Foundation, the proportion of people suffering from the major causes of preventable harm has dropped by a third in the last 3 years.

But still we make too many mistakes. Twice a week in the NHS we operate on the wrong part of someone’s body and twice a week we wrongly leave a foreign object in someone’s body. The pioneering work of Helen Hogan, Nick Black and Ara Darzi has estimated that 3.6% of hospital deaths have a 50% or more chance of being avoidable, which equates to over 150 deaths every week.

We should remember that, despite this, our standards of safety still compare well to many other countries. But I want England to lead the world in offering the highest possible standards of safety in healthcare so today I am welcoming to London health ministers and healthcare safety experts from around the world for the first ever ministerial-level summit on patient safety.

I am co-hosting the summit with the German Health Minister, Hermann Grohe, who will host a follow-up summit in Berlin next year. Other guests will include Dr Margaret Chan, Director General of the World Health Organisation, Dr Gary Kaplan, Chief Executive of the renowned Virginia Mason Hospital in Seattle, Professor Don Berwick and Sir Robert Francis QC.

In the end, Mr Speaker, no change is permanent without real and lasting culture change. And that culture change needs to be about 2 things: openness and transparency about where problems exist, and a true learning culture to put them right.

With the new inspection regime for hospitals, GP surgeries and care homes, as well as a raft of new information now published on My NHS, we have made much progress on transparency. But as Sir Robert Francis’s Freedom to Speak Up report told us, it is still too hard for doctors, nurses and other frontline staff to raise concerns in a supportive environment.

Other industries – in particular the airline and nuclear industries – have learned the importance of developing a learning culture and not a blame culture if safety is to be improved. But too often the fear of litigation or professional consequences inhibits the openness and transparency we need if we are to learn from mistakes.

So following the commitment I made to Parliament at the time of the Morecambe Bay investigation, we will from 1 April 2016 set up our first ever independent Healthcare Safety Investigation Branch. Modelled on the Air Accident Investigation Branch that has been so successful in reducing fatalities in the airline industry, it will undertake timely, no-blame investigations.

As with the Air Accident Investigation Branch, I can today announce that we will bring forward measures to give legal protection to those who speak honestly to Healthcare Safety Investigation Branch investigators.

The results of such investigations will be shared with patients and families, who will therefore get to the truth of what happened much more quickly. However, unlike at present they will not normally be able to be used in litigation or disciplinary proceedings, for which the normal processes and rules will apply. The ‘safe space’ they create will therefore reduce the defensive culture patients and families too often find meaning mean the NHS can learn and disseminate any lessons much more quickly so that we avoid repeating any mistakes.

My intention is to use this reform to encourage much more openness in the way the NHS responds to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.

Fundamental to this is getting a strong reporting culture in hospitals where mistakes are acknowledged and not swept under the carpet. So today NHS Improvement has also published a Learning from Mistakes ranking of NHS Trusts. This draws on data from the staff survey and safety incident reporting data to show which trusts have the best reporting culture and which ones need to be better at supporting staff who wish to raise concerns. This will be updated every year in a new Care Quality Commission (CQC) State of Hospital Quality report that will also contain trusts’ own annual estimates of their avoidable mortality rates and have a strong focus on learning and improvement.

Furthermore, the General Medical Council and the Nursing and Midwifery Council guidance is now clear – that where doctors, nurses or midwives admit what has gone wrong and apologise, the professional tribunal should give them credit for that, just as failing to do so is likely to incur a serious sanction. The government remains committed to further reform that would allow professional regulators more flexibility to resolve cases without stressful tribunals.

This change in culture must also extend to trust disciplinary procedures. So NHS Improvement will ask for a commitment to openness and learning to be reflected in all trust disciplinary procedures and ask all trusts to publish a Charter for Openness and Transparency so staff can have clear expectations of how they will be treated if they report clinical errors.

Finally, from April 2018, the government will introduce the system of medical examiners recommended in the Francis Report. This will bring a profound change in our ability to learn from unexpected or avoidable deaths, with every death either investigated by a coroner or scrutinised by a second independent doctor. Grieving relatives will be at the heart of the process and will have the chance to flag any concerns about the quality of care and cause of death with an independent clinician, meaning we get to the bottom of any systemic failures in care much more quickly.

Taken together, I want these measures to help the NHS to become the world’s largest learning organisation as part of our determination to offer the safest, highest quality standards of care.

An NHS that learns from mistakes. One of the largest organisations in the world becoming the world’s largest learning organisation – that is how we will offer the safest, highest quality standards of care in the NHS and I commend this statement to the House.

Jeremy Hunt – 2015 Statement on Junior Doctors


Below is the text of the statement made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 4 November 2015.

This government is completely committed to the values of the NHS – the same values that encourage aspiring doctors to take up a career in medicine.

Junior doctors are the backbone of the NHS, but the current contract has failed to prevent some working unsafe hours, and doesn’t reward them fairly. We know also that they feel unsupported because consultants and diagnostic services are not always available in the evenings and at weekends.

Today a firm offer for a new contract has been published by NHS Employers. The new contract will be fairer for doctors, safer for patients and juniors alike, better for training, and will better support a 7-day NHS.

This offer builds on the cast-iron guarantees that I have previously offered the British Medical Association (BMA) including that we would not remove a single penny from the junior doctors’ pay bill, and we would maintain average earnings for junior doctors. The proposals offer an 11% increase to basic pay, with further increases linked to progressing through training and taking on roles with greater responsibility –instead of being based on time served.

Our ambition for the NHS to be the safest healthcare system in the world is underpinned by reducing, not increasing, the number of hours junior doctors work each week. Juniors will be supported by improved contractual safeguards – the best protection junior doctors have ever had against working long, intense and unsafe hours. For example, no junior will be required to work more than a weekly average of 48 hours without consent and those who opt out of that legal limit in the European Working Time Directive will not be able to work more than a weekly average of 56 hours. The number of hours that can be worked in any single week by any junior will be limited to 72, down from 91; there will be a 13 hour limit on shifts; and there will be no more than 5 consecutive long days or 4 consecutive nights, compared to the current contract which permits 7 consecutive night shifts or up to 12 consecutive day shifts.

Putting patients first is the responsibility of employers and staff. Where doctors are asked to work in conditions that they believe are unsafe, including being asked to work patterns that put patient safety at risk, they will be asked to use reporting mechanisms available to them to raise the issue with the Board of their Trust, and reporting data will now be available for the Care Quality Commission (CQC) to use during inspections. We would expect Trust Boards to look at any such report and decide how to respond to it; and we would expect the CQC, when it carries out an inspection, to look at how the Board has responded to this and other data reporting safety incidents and concerns – a tough new measure to ensure safe working.

In order to better support a 7-day NHS, basic pay will increase by 11% to compensate for an extension in plain time working on Saturdays during the day and on weekday evenings, and there will be an enhanced rates for hours worked at nights, on Saturday evenings and Sunday.

The government has also decided that plain time will be extended only to 7pm on Saturdays – instead of 10pm on Saturdays – and wants to improve training and ensure better clinical supervision from consultants as well.

We will offer new flexible pay premia for those training in hard-to-fill training programmes where there is the most need – such as general practice, emergency medicine and psychiatry – and we will protect the salaries of those who return or switch to training in these programmes.

Junior doctors who take time off for academic research that is part of their NHS training, or which contributes to the wider NHS and improvements in patient care, will get additional pay premia to make sure they don’t lose out.

Today, I have also written to all junior doctors in England confirming that no junior doctor working legal hours will receive a pay cut compared to their current contract during transition. Around three quarters will see an increase in pay and the rest will be protected.

The exception to this is those who currently receive up to a 100% salary boost as compensation for working unsafe hours. Instead, new contractual safeguards will ensure they are not required to work unsafe hours at all.

To see how the offer affects them, junior doctors can now log on to a pay calculator published by NHS Employers where they can calculate projected take home pay.

Our preference throughout has been, and continues to be, to reach agreement through negotiations. We have maintained that, in reforming the contract, we must put patients right at the heart of everything the NHS does every day of the week. A fair, sustainable contract with stronger safeguards, together with the greater availability of consultants at the weekends and evenings, is good for patients and good for junior doctors.

The details published today represent the government’s offer in England, which will be for doctors and dentists in postgraduate training programmes overseen by Health Education England.

Since they withdrew from negotiations in October 2014 – despite agreeing the need for change as far back as 2008 – the BMA have refused to return to the table. In light of today’s announcement we hope that the BMA will now agree to return to negotiations.

Jeremy Hunt – 2015 Statement on Junior Doctors


Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 30 November 2015.

With permission Mr Speaker I would like to update the House on the junior doctors strike.

Earlier this month, the union representing doctors, the BMA, balloted for industrial action over contract reform. Because the first strike is tomorrow I wish to update the House on contingency plans being made.

Following last week’s spending review, no one can be in any doubt about this government’s commitment to the NHS, but additional resources have to be matched with even safer services for patients. That is why, on the back of mounting academic evidence that mortality rates are higher at weekends than in the week, we made a manifesto commitment to deliver truly 7-day hospital services for urgent and emergency care.

However, it is important to note that 7-day services are not just about junior doctor contract reform. The Academy of Medical Royal Colleges noted that “the weekend effect is very likely attributable to deficiencies in care processes linked to the absence of skilled and empowered senior staff in a system which is not configured to provide full diagnostic and support services 7 days a week.” So our plans will support the many junior doctors who already work weekends with better consultant cover at weekends, 7-day diagnostics and other support services, and the ability to discharge at weekends into other parts of the NHS and the social care system.

But reforming both the consultants’ and junior doctor contracts is a key part of the mix because the current contracts have the unintended consequence of making it too hard for hospitals to roster urgent and emergency care evenly across 7 days. Our plans are deliberately intended to be good for doctors – they will see more generous rates for weekend work than those offered to police officers, fire officers and pilots. They protect pay for all junior doctors working within their legal, contracted hours, compensating for a reduction in anti-social hours with a basic pay rise averaging 11%. They reduce the maximum hours a doctor can work in any one week from 91 to 72 and stop altogether the practice of asking doctors to work 5 nights in a row. Most of all they will improve the experience of doctors working over the weekend by making it easier for them to deliver the care they would like to be able to deliver to their patients.

Our preference has always been a negotiated solution but, as the house knows, the BMA have refused to enter negotiations since June. However, last week I agreed for officials to meet them under the auspices of the ACAS conciliation service. I am pleased to report to the house that, after working through the weekend, discussions led to a potential agreement early this afternoon between the BMA leadership and the government. This agreement would allow a time-limited period during which negotiations can take place, and during which the BMA agrees to suspend strike action and the government agrees not to proceed unilaterally with implementing a new contract. This agreement is now sitting with the BMA junior doctors’ executive committee, who will decide later today if they are able to support it.

However, it is important for the house to know that right now strikes are still planned to start at 8am, so I will now turn to the contingency planning we have undertaken. The government’s first responsibility is to keep its citizens safe. This particularly applies to those needing care in our hospitals so we are making every effort to minimise any harm or risks caused by the strike.

I have chaired three contingency planning meetings to date and will continue to chair further such meetings for the duration of any strikes. NHS England are currently collating feedback from all trusts but currently we estimate the planned action will mean up to 20,000 patients may have vital operations cancelled, including approximately 1,500 cataracts operations, 900 skin lesion removals, 630 hip and knee operations, 400 spine operations, 250 gall bladder removals and nearly 300 tonsil and grommets operations.

NHS England has also written to all trusts asking for detailed information on the impact of the strikes planned for 8 and 16 December which will involve not just the withdrawal of elective care, but the withdrawal of urgent and emergency care as well. We are giving particular emphasis to the staffing at major trauma centres and are drawing up a list of trusts where we concerns about patient safety. All trusts will have to cancel considerable quantities of elective care in order to free up consultant capacity and beds. So far, the BMA has not been willing to provide assurances they will ask their members to provide urgent and emergency cover in areas where patients may be at risk and will continue to press for such assurance.

It is regrettable that this strike was called even before the BMA had seen the government’s offer, and the whole house will be hoping today that the strike is called off so that talks can resume. But whether or not there is a strike, providing safe services for patients will remain the priority of this government as we work towards our long term ambition to make NHS care the safest and highest quality in the world. I commend this statement to the house.

Jeremy Hunt – 2016 Statement on Junior Doctors


Below is the text of the speech made by Jeremy Hunt, the Secretary of State for Health, in the House of Commons on 11 February 2016.

Mr Speaker, nearly 3 years ago to the day the government first sat down with the British Medical Association (BMA) to negotiate on a new contract for junior doctors. Both sides agreed that the current arrangements, drawn up in 1999, were not fit for purpose and that the system of paying for unsocial hours in particular was unfair.

Under the existing contract doctors can receive the same pay for working quite different amounts of unsocial hours; doctors not working nights can be paid the same as those who do; and if 1 doctor works just 1 hour over the maximum shift length it can trigger a 66% pay rise for all doctors on that rota.

Despite the patent unfairness of the contract, progress in reforming it has been slow, with the BMA walking away from discussions without notice before the general election. Following the election, which the government won with a clear manifesto commitment to a 7-day NHS, the BMA Junior Doctors Committee refused point blank to discuss reforms, instead choosing to ballot for industrial action. Talks did finally start with the ACAS process in November but since then we have had 2 damaging strikes with around 6,000 operations cancelled.

In January I asked Sir David Dalton, Chief Executive of Salford Royal, to lead the negotiating team. Under his outstanding leadership, for which the whole House will be immensely grateful, progress has been made on almost 100 different points of discussion, with agreement secured with the BMA on approximately 90% of them. Sadly, despite this progress and willingness from the government to be flexible on the issue of Saturday pay, Sir David wrote to me yesterday advising that a negotiated solution is not realistically possible.

Along with other senior NHS leaders and supported by NHS Employers, NHS England, NHS Improvement, the NHS Confederation and NHS Providers, he has asked me to end the uncertainty for the service by proceeding with the introduction of a new contract that he and his colleagues consider both safer for patients and fair and reasonable for junior doctors. I have therefore today decided to do that.

Tired doctors risk patient safety, so in the new contract the maximum number of hours that can be worked in 1 week will be reduced from 91 to 72; the maximum number of consecutive nights will be reduced from 7 to 4; the maximum number of consecutive long days will be reduced from 7 to 5; and no doctor will ever be rostered on consecutive weekends. Sir David Dalton believes these changes will bring substantial improvements both to patient safety and doctor wellbeing.

We will also introduce a new Guardian role within every Trust, who will have the authority to impose fines for breaches to agreed working hours based on excess hours worked. These fines will be invested in educational resources and facilities for trainees.

The new contract will give additional pay to those working Saturday evenings from 5pm, nights from 9pm to 7am, and all day on Sunday. Plain time hours will now be extended from 7am to 5pm on Saturdays. However, I said the government was willing to be flexible on Saturday premium pay and we have been: those working 1 in 4 or more Saturdays will receive a pay premium of 30%, that is higher on average than that available to nurses, midwives, paramedics and most other clinical staff. It is also a higher premium than that available to fire officers, police officers or those in many other walks of life.

Nonetheless it does represent a reduction compared to current rates, necessary to ensure hospitals can afford additional weekend rostering. So because we do not want take home pay to go down for junior doctors, after updated modelling I can tell the House these changes will allow an increase in basic salary of not 11% as previously thought but 13.5%. Three-quarters of doctors will see a take home pay rise and no trainee working within contracted hours will have their pay cut.

Mr Speaker, our strong preference was for a negotiated solution. Our door remained open for 3 years, and we demonstrated time and again our willingness to negotiate with the BMA on the concerns that they raised. However, the definition of a negotiation is a discussion where both sides demonstrate flexibility and compromise on their original objectives, and the BMA ultimately proved unwilling to do this.

In such a situation any government must do what is right for both patients and doctors. We have now had 8 independent studies in the last 5 years identifying higher mortality rates at weekends as a key challenge to be addressed. Six of those say staffing levels are a factor that needs to be investigated. Professor Sir Bruce Keogh describes the status quo as ‘an avoidable weekend effect which if addressed could save lives’ and has set out the 10 clinical standards necessary to remedy this. Today we are taking one important step necessary to make this possible.

While I understand that this process has generated considerable dismay among junior doctors, I believe that the new contract we are introducing – shaped by Sir David Dalton, and with over 90% of the measures agreed by the BMA through negotiation – is one that in time can command the confidence of both the workforce and their employers.

I do believe, however, that the process of negotiation has uncovered some wider and more deep-seated issues relating to junior doctors’ morale, wellbeing and quality of life which need to be addressed.

These issues include inflexibility around leave, lack of notice about placements that can be a long way away from home, separation from spouses and families, and sometimes inadequate support from employers, professional bodies and senior clinicians. I have therefore asked Professor Dame Sue Bailey, President of the Academy of Medical Royal Colleges, alongside other senior clinicians to lead a review into measures outside the contract that can be taken to improve the morale of the junior doctor workforce. Further details of this review will be set out soon.

Mr Speaker, no government or health secretary could responsibly ignore the evidence that hospital mortality rates are higher at the weekend, or the overwhelming consensus that the standard of weekend services is too low, with insufficient senior clinical decision-makers. The lessons of Mid Staffs, Morecambe Bay, and Basildon in the last decade is that patients suffer when governments drag their feet on high hospital mortality rates – and this government is determined our NHS should offer the safest, highest quality care in the world.

We have committed an extra £10billion to the NHS this Parliament, but with that extra funding must come reform to deliver safer services across all 7 days. That is not just about changing doctors’ contracts: we will also need better weekend support services such as physiotherapy, pharmacy and diagnostic scans; better 7-day social care services to facilitate weekend discharging; and better primary care access to help tackle avoidable weekend admissions. Today we are taking a decisive step forward to help deliver our manifesto commitment, and I commend this statement to the House.