Helen Mary Jones AM, Plaid Cymru Shadow Minister for Health and Social Services
Calling for the resignation of a minister is not something that should be done lightly. Indeed there have only been two occasions when a vote of no confidence has been tabled in a minister since the establishment of the Assembly.
The threshold for making such a call needs to be rightly high, for example when the performance or decision making of a Minister goes beyond simply ‘things we don’t agree with’ and becomes negligent, criminal, or a case of extreme misjudgement of the facts.
Last week’s report on maternity services in Cwm Taf (now called Cwm Taf Morgannwg but we will use Cwm Taf for this article) was one of the most shocking reports into the governance of any organisation under the control of the Welsh Government that has ever been written. ITV Wales presenter Kylie Pentelow described it as the worst report she had ever seen in 18 years.
To put it in simple terms. The culture of the organisation did not take patient safety seriously and babies have died as a result.
It is difficult to think of a more serious scandal.
There is for us no doubt that major changes need to happen in Cwm Taf. The report itself makes several recommendations.
But the question of who should be responsible for implementing those changes is important. We cannot have confidence in the existing management who presided over a culture in which staff were afraid to raise concerns, who presided over a culture in which they frequently misled external members of the board, and who presided over systemic failures that have led to tragedy.
It remains a fact that doctors, nurses and midwives can be struck off and even jailed for many of the things highlighted in the report. In Bridgend, for example, two nurses were jailed for falsifying medical records. In Cwm Taf, the regulatory in which medical notes went missing was described as a ‘systemic issue’, and it seems no one has been held individually accountable.
Poor performance by managers doesn’t lead to criminal investigations, and managers are not struck off. In fact, they frequently end up doing similar roles in other health organisations.
An obstetrician who makes the wrong clinical decision can face prosecution for manslaughter. A manager who fails to ensure lessons are learned from mistakes faces no consequences.
There are a different set of rules for management and frontline staff.
There were two options available to the Health Minister last week.
The first option was to use his considerable powers over the NHS – he is by law responsible for the NHS – to ensure the dismissal of the Chief Executive who had overseen this shocking performance, and the senior management who created and maintained a culture in which staff were afraid to raise concerns.
He would have had considerable evidence to support this decision from the report, and from the individual complaints that have been lodged by families. He would have had our support had he done so.
After all, many of the concerns highlighted have been cited in previous reports dating back to 2012, and the Board failed to act on those reports then.
The second option was to side with the management culture that let down families and allowed children to die and offer standard management-speak nonsense about putting things right and shared ownership of responsibility.
He took the second option.
Supporters of the Minister will point to the apology, the fact he ordered the investigation in the first place, and the decision to take the service into special measures as evidence that he takes the issue seriously.
I have no doubt that the Minister himself was shocked by the scale of the incompetence, but we should remind ourselves he has been responsible for the day to day running of the NHS for almost five years. If he did not know the extent of the problems in this service earlier he should have known.
There have been eight reports over six years highlighting concerns that should have triggered action, by the Board and by the Minister. He did not act, families suffered and children were lost.
Those families want people to be held accountable for the failures and they want to see change so that other families don’t suffer in future. How can they be expected to believe that change will come when the same people who allowed the poisonous culture to develop are still in charge?
The Minister stated in his response to the report that one of the actions he had taken was that he asked all other Health Boards to review their own procedures and report how the findings could be relevant to them.
This is not an action that specifically improves Cwm Taf. However, we really cannot see how if a similar situation were happening elsewhere, the Board involved would hold their hands up and say ‘yes, we too preside over a culture of systemic mismanagement’.
If the Minister thinks this is what would happen he is astonishingly naïve. The Welsh Government needs to have systems in place to provide early warnings – fire alarms if you will – that can identify problems early and make sure they are rectified.
Despite those eight reports raising concerns the problems in Cwm Taf weren’t rectified – they were allowed to continue. The response to the alarms was to rely on an assurance that the fire was put out. Each time it had not been.
It isn’t as if this is the first occasion when the sound of the fire alarms have failed to result in the containment and extinguishment of the fire. For example, in Betsi Cadwladr Health Board, two doctors working in a Mental Health Ward expressed major concerns over patient care over a year before the Tawel Fan scandal broke.
Yet no action appears to have been taken to investigate and address those concerns, with the scandal over a year later resulting in the Board being put into special measures that continue to this day.
Another major scandal of patient abuse was in Abertawe Bro Morgannwg University Health Board, where standards of care on some wards in both the Princess of Wales Hospital and Neath Port Talbot hospital were appalling.
Yet in this case, the fire alarms themselves failed to go off, with a Health Inspectorate Wales (HIW) dignity and essential care inspection failing to recognise signs of declining standards.
Instead, the patients and their families – whose concerns and complaints should have been an additional fire alarm – were dismissed and patronised, and effectively had to act as their own investigators during a time of bereavement.
It isn’t as if the Health Minister would have been unaware of the potential for his fire alarms to fail either. In 2014 the Health Committee, in response to the Francis report about poor patient care in Mid-Staffs, released a highly concerning report into HIW – warning that it did not have confidence in the ability of the organisation to be able to identify a similar scandal should it be occurring (and arguably the Cwm Taf maternity services is of a similar level of gravity). The response to that concern was inadequate.
When it came to other potential fire alarms, the previous Health Minister (and now First Minister), when faced with higher than expected mortality rates (RAMI figures) attacked the usefulness themselves of the figures, and asked his officials to draw up Welsh versions of RAMI.
Whilst the limitations of such figures themselves are widely acknowledged, their usefulness is that they can act as a fire alarm to trigger further investigations, provided of course there are people interested in establishing whether each alarm is a false alarm or not.
Such complacency has been endemic for too long. Rather than have a healthy scepticism and inquisitive manner towards what officials and managers report, and establish independent sources of advice and intelligence over what is happening, the recent hallmarks of Labour Health Ministers have been to exclusively rely on a managerial culture that has routinely been found to come up short.
The law over responsibility for the health service in Wales is clear – I helped draft it at the time of the One Wales Government, so I know. The aim of the legislation was to ensure that the health service was democratically accountable, through the Minister, to the National Assembly and, through the Assembly, to the people.
Responsibility for the health service lies with the Health Minister. The Minister is the one who appoints the Health Boards, the Minister is responsible for issuing guidance to the Health Boards and setting how they operate, he sets the budgets, he sets the strategic direction, and he is also responsible for ensuing the fire alarms work to warn them when things go wrong.
And, when the alarms go off he is responsible for ensuring that what has gone wrong is put right. That’s his job.
We have had three major scandals in the last six years which have resulted in serious harm to patients. All of them have been characterised by stories of overworked and under-appreciated front line staff, management cultures where bad news is suppressed and where managing the reputation of the organisation takes priority over improving it, and where complaints and concerns of patients and their families have been dismissed and ignored.
We are unaware of a single manager who has been disciplined for contributing and maintaining these cultures. Indeed we are aware of one manager holding a senior position with responsibility for patient care in both Cwm Taf and Betsi Cadwaldr during the periods concerned, who also secured employment in a similar position after the Tawel Fan scandal in both Cwm Taf for a second time and ABMU.
At the same time, there are doctors and nurses who have been struck off and faced criminal investigations for these scandals.
The Health Minister has failed to tackle this managerial culture of denial and lack of accountability. He does not seem to believe there is a problem. If he doesn’t dismiss senior managers over a scandal that involves traumatised mothers and lost children then we have to ask what exactly would he sack them for?
We can contrast the behaviour of the Health Minister over the past week with that of the former Health Minister in Tunisia. In March this year, 11 babies tragically died in a hospital in Tunis following an infection outbreak attributed to poor practices on the ward. The Health Minister in Tunisia took responsibility and resigned, despite being in the post for just four months.
Compare and contrast the standards which a minister in a country struggling to establish democracy following years of dictatorship and under serious threat from terrorists held himself to with the apparent complacency of this Minister. Asked in a media interview last week if he accepted that the buck stopped with him he replied ‘The buck stops with everybody.’ It doesn’t. It really does stop with him.
We do not take the decision to hold a vote of no confidence in the Minister lightly. But, faced with repeated examples of complacency and inaction, and his apparent unwillingness to accept responsibility, we feel we have no choice but to hold him to account.
Nothing can bring back those lost children, or make up to the mothers and families for the traumas they went through or the appalling disrespect with which they were treated. Nor will holding the Minister to account by itself lead to the improvements that need to happen.
But the families need justice, and they need to be able to believe that others will not suffer as they did. And by sending a message that enough is enough we at least ensure the next Health Minister knows that we expect action and accountability.
We send a message that it is no longer acceptable for our NHS to be run by people with no professional standards or accountability, who keep their jobs even when faced with massive institutional failure.
Then we can begin to establish the framework for making sure this doesn’t happen again. Such a framework must include the following:
- A professional body for NHS managers with the ability to strike off managers for poor performance.
- A genuinely independent Healthcare Inspectorate Wales
- An independent body for collecting and publishing statistics on performance, one that has the power to require health boards to provide data.
- A legal duty of candour applied to all health professionals including management.
- A genuine and robust complaints system that supports families and patients.
We seriously doubt whether any Labour minister is capable of instituting this. As a Party they are too close to the management culture that needs overturning.
But a Health Minister who isn’t even capable of understanding that a Chief Executive who presides over poor standards of care that result in the death of babies needs to go cannot remain in post is clearly incapable of seeing the need for any change.
Whatever the outcome of this motion of no confidence I have promised Cwm Taf families that I will never forget what they went through.
We will do all we can to hold Government and the Health Board to account to try to ensure that the needed change is delivered.