30 May 2011

Is Stafford Hospital the Last Big Hospital Scandal?

We are reaching the end of the Health reform listening exercise, something that has been forced on the government by their recognition that many people within the health service do not accept their reasoning for major health reform.  There are still big questions, Does the health service need major reform? Do we understand well enough the reforms that have already taken place from within the health service? Are the reforms proposed by the government taking us in the right direction.
Because I live in Stafford and have lived with the impact of the Stafford Hospital story over the last three years I think that understanding what happened at Stafford or because of Stafford gives us some clues on these questions.
The truth about Stafford is many sided, and we are still learning what this truth may be, but I think that many people now agree that the prolonged process of investigation and inquiry has been costly, damaging to the hospital, staff and patients and relationships the NHS and also very damaging to political relationships.
As the process of “learning the lessons of Stafford” plays itself out, significant lessons have already been learnt about how to monitor health care, but people have also been very keen indeed to ensure that nothing as destabilising as the Stafford Hospital Scandal can ever happen again.
So the question I am asking in this post is “has enough been done to ensure that Stafford will be the last of the big hospital scandals?”
What do I mean by this question? Do I think that “learning the lessons of Stafford” will ensure that there will be a magical overnight improvement in the delivery of health care? No, Not at all!
The evidence from all those who are skilled observers of the health service tells us a similar story. This is a service which ultimately depends on people. I think that the assessment of Peter Carter from the RCN was pretty accurate. Hospitals are made up of a series of micro climates. The quality of the patient’s experience of hospital health care will continue to be dependent on the unique mix of individuals present on an individual ward on an individual day.
What I mean is that the unique set of circumstances which made up what Robert Francis describes as the “perfect storm” for Stafford can now never occur again.
For those who have not already seen it, it may help to look back at the short video in which I describe the anatomy of this perfect storm. 

Here in a little more detail are some of the key elements.
·         The story has to begin with Julie Bailey, the creator of the pressure group, who has been described by so many people including herself as the reason why we have the Public inquiry. Julie Bailey is unique in her determination and in her distinctive approach to the problems she found in 2007, but many people around the country have learnt from her experience about effective ways to use the media in furthering their campaigns. There is the potential for many more pressure groups to form.
·         A central reason for her discontent was that the complaints system and also the forums for patient participation were both dysfunctional. All parties are united in their recognition that this had to be improved. The Labour government brought in a reform of the complaints process, created NHS choices, and carried out work on patient and public participation, There is interesting work underway to be able to pick up “soft intelligence” A stronger framework for listening effectively to the concerns of patients and families at an early stage should mean that it is never again necessary for dissatisfaction to get out of hand in the way it did in Stafford.
·         Creating a really effective way of finding out what patients feel and responding to it is always going to be challenging but Stafford hospital has made a number of changes. It has pioneered ideas like the two hourly comfort checks which will cut of potential problems before they ever reach that point. It has carried out restructuring of the hospital to ensure that there are easier ways of monitoring high dependency patients, and it has created an ethos of openness which brings patient stories into the heart of the board room (the CEO has now started tweeting board meetings) and makes patients the clear focus of the service.
·         The funding squeeze in the NHS in 2006 was of course not unique to Stafford. This lay at the root of many of the problems of understaffing that did occur. It will have affected many other hospitals in 2006-7. The financial pressures which caused the staffing shortages and care problems are of course present again now, so we should expect that hospital front line staff may at times find themselves under intolerable pressures, and may still deliver care which they know to be less than perfect.
·         The Dr Foster Intelligence Hospital Standardised Mortality Rates HSMR, which came to the national attention through the publication of a league table in the Telegraph in 2007 has as a result of the eruption of the Mid Staffs scandal come under very serious scrutiny by politicians, Health service managers and statisticians. It is perhaps unfortunate for Dr Foster intelligence that the press coverage by the Daily Telegraph greatly over claimed what it is possible for these figures to show us. Different parts of the Health service have now looked at the use of these figures in detail and there is now clear agreement by the experts in the field that the figures are a tool which have a value as part of a range of tools. It will often produce misleading results, and it cannot meaningfully be used to demonstrate the quality of care in a hospital (the Statement by Richard Hamblin is the clearest expression of this). ·         There will never again be the publication of the HSMR figures as a league table, and the HSMR system has now been superseded by SHMI  which was created by experts working together as a response to set of problems identified by David Kidney in his Westminster hall debate of April 2009  and the recommendations of the Independent inquiry.
·         The reason why Stafford Hospital performed so poorly in the HSMR league table is due to a mix of circumstances. Stafford deals with a very high number of elderly patients, who have a complex mix of illnesses. If the co-morbidities (which reflects the total risk to a patient) are not recorded accurately for hospitals with this kind of case load then there will be an elevated HSMR figure
·         There is only a very small hospice provision in Stafford so most people will die in hospital. This will lead to an elevated HSMR figure.
·         Coding of co-morbidity was being done badly in most hospitals throughout the country, because it was not seen as a priority until the 2007 league table. It was being done particularly badly in Stafford due to the long term sickness of the coding manager (See HCC investigation report)and cuts in administration support staff.(highlighted by the evidence of Dr Singh. The repercussions from poor coding at Stafford have been so major that the health service as a whole is now fully aware that whatever else you might cut in times of financial difficulty, that you cannot afford to cut the time given to code information accurately.
·         The publication of the Dr Foster league table by the daily telegraph in 2007 is a fairly typical way of how the press operates. They took the simple but flawed and misleading figures to build a story which damaged the reputation of Stafford and a number of other hospitals. I see no prospect of this changing unless the press is ready to learn the lessons that they should learn from the Stafford story. This irresponsible use of information by the press is the central reason why I am personally fighting a campaign for #pressreform . The press problem remains, but we can be certain, that in the case of the HSMR figures at least that these will never again be presented to the press in the same damaging way.
·         Here are a few references on the statistical row sparked by the use of the Dr Foster figures. It will be seen that the statistical world splits into different camps on the issue of how you can measure quality in the health service. Professor Jarman and the Dr Foster unit end up on one side of this divide, and Dr Mohammed from Birmingham university ends up on the other side.  
These different philosophical approaches to how you measure quality become politically important as a substantial part of the Conservative parties claims on the NHS is that their “outcome” measures would be a good way of measuring quality, and that the “targets” and “process” tools which were available to the NHS during the “noughties” were now a thing of the past. The Daily telegraph helps us with an outline of the conservative led philosophy here

I suspect that few of the politicians espousing one side or other of this argument actually understood the intricacies of the argument. They just wanted a system that would give them reliable information on how the health service was doing and help to drive up standards.
Management systems and statistical methods evolve over time. They are getting better, but this is something that all political parties should welcome and none should try to claim the credit for! I have put together some information on how I see the philosophical approach to monitoring developing here. (to follow)

·         The Strength and ultimately the weakness of the Cure the NHS campaign is that they drew the conclusion that the poor care they witnessed was part of a pattern of high mortality “proved” by the Dr Foster Figures. Because of this firmly held belief they had no hesitation in calling for heads to roll and pointing out the errors of large numbers of people within the community. This has put Stafford through an extraordinary experience. the best analogy is probably found here. The effort which perhaps could and should have gone into bringing the community together to address the genuine concerns raised by Cure the NHS may have been dissipated because of this.
·         All of this is just a prelude to the HCC investigation. The unique factors about this are that the HCC was about to be disbanded and the style of investigation favoured by the investigation team, something of which they were naturally proud, was about to be discontinued. A strong theme in the evidence given by the HCC investigation team is that they do not believe the Stafford Hospital Scandal could have been “discovered” in any other way. This may well be correct – but what is that they actually discovered? And how can we assess the scale of the problem? After years looking intently at this matter I cannot answer that question. Richard Hamblin’s joke is an interesting insight into why this is so tricky (to follow)
·         There are other factors that make the position of the HCC unique at that particular period of time. They were just beginning to see the very first alerts from a new statistical pilot scheme to identify “outliers”. They had no way of knowing how reliable these new untested figures might be. Their investigation at Stafford was in part a live test to see if the new figures were telling them anything useful.
·         Because the outliers system was so new, and so controversial the HCC deliberately did not share any information about it with the rest of the health service.
·         Because the rest of the health service was unaware that the HCC had already discounted the value of HSMR and was working secretly on the new outlier system the SHA focused its attention on looking at the Dr Foster figures and the impact this had had on 6 hospitals in the west midlands region. They commissioned Prof Mohammed from Birmingham University to look into HSMR, other mortality systems and other ways for measuring quality.
·         Over the course of time the operational basis of the HCC investigation team had shifted. Previously they would only “investigate” if they had clearly identified that a problem existed. In the case of Stafford this was quite different. They had figures. They did not know what these figures were telling them, and they did not know if there was anything to worry about or not. The “inspection” at Stafford happened because they did not receive the answers they were looking for when they were looking for more information on the areas identified by the outliers.
·         When the HCC asked for information to help with their concerns on the outliers Martin Yeates would have been completely in the dark. I suspect that he would have assumed that this was simply an extension of the problems he was having with the Dr Foster league table, and that the response to this by Prof Mohammed would cover the questions that were being raised. This would have been the wrong assumption. What the Stafford Hospital scandal has firmly impressed on Hospital managers all over the country that if the CQC is asking for further information then it is absolutely in the best interest of the hospital to comply with their requests!  
·         In practice coding problems could, and I believe did play a part in the alerts being triggered by the Mortality outlier system, just as they did with the Dr Foster system. This is recognised in the evidence from Martin Bardsley, but the investigation team saw the coding issues for the two systems as completely separate matters.
·         Martin Yeates will have believed that the research being conducted for the SHA by Prof Mohammed would answer all the points being raised by the HCC. The HCC did not explain adequately why this would not satisfy them, and in addition the use of Prof Mohammed will have appeared to the sensitivities of the Dr Foster Unit to be a direct and calculated insult with political overtones.(blog to follow on the sensitivity of statisticians).  In the fog of confusion created by all of this the effective communication between the HCC investigation team and the Trust broke down in a fairly dramatic fashion.  Martin Yeates, for reasons completely beyond his control found himself the unfortunate pig in the middle of a statistical spat.
·         The combination of the Mortality outliers that no one but the HCC knew about, the sensitivities of the investigation team, the different philosophies about monitoring, the lack of clarity about the roles of the different organisations and perhaps also some clashes in personality meant that Monitor did not step in to take action to support the hospital,  because they were reluctant to tread on the toes of the investigation team. This led to substantial delays in taking action to rectify the problems that were found. One substantial lesson that the health service has thoroughly learned from Stafford is that there has to be better communication between the different sections of the NHS. This problem should not occur again. Investigations if they occur will go hand in hand with steps to rectify the problems.
·         There is now much greater openness about the statistical underpinning of health service monitoring systems. The Dr Foster HSMRs are no longer considered as sufficient basis for investigation by any sector of the NHS and this source of misunderstanding has therefore now been eliminated.
·         All of this was coming to the boil at the start of 2008 which coincides with the time that Julie Bailey shifted from being a one woman band, to being the head of Cure the NHS. Cure the NHS began a forceful campaign to draw attention to the HSMR league table and its supposed implications. This was a campaign that was taken up by the local press and spread further as the Campaign group began systematically contacting and putting pressure on an extensive list of organisations which are listed in Julie Baileys evidence to the inquiry.
·         It should be remembered that because of the changing nature of HCC investigations and because of the “testing” of the new mortality outlier system the decision to inspect the hospital was not taken because the HCC had clearly identified a problem at Stafford. It was taken because they could not rule out the possibility that there might be a problem, and because the hospital was not providing the answers they were looking for.
·         There is one single incident which tipped the HCC into the decision to carry out a full investigation. This came when members of the investigation team, including Heather Wood, carried out an unannounced visit to the hospital, and Heather Wood saw one elderly lady about to fall out of bed in the Emergency Admissions Unit. (This is of course an issue which faces all hospitals and all care homes every day. I can vouch for this. My own mother suffered a broken hip when she fell over the cot sides aimed to protect her in a care home in Stafford. Short of having one to one 24 hour care which is of course impossible, I suspect these accidents will always happen).
·         Once the investigation began this sparked huge interest from the local press, and saw the beginnings of what is perhaps an unusually close relationship between sections of the local press and the pressure group. It is of course inevitable that the personal stories of the bereaved relatives, which formed a regular part of the local media coverage, will have made a strong impression on the minds of the journalists involved, and will have created a real bond between the journalists and the pressure group. This is quite a common phenomena when people find themselves at the centre of a tragedy. It can appear that the press are the only ones who understand, but the press always have their own agenda.
·         The level of press interest and the growing self confidence of the pressure group will have left the investigation team in no doubt that they needed to clearly identify “the problem” at Stafford. Their credibility depended on this. There was no middle way.
·         In the last few months before the issue of what was to be the last major report from the outgoing HCC investigation team, we also have the additional complication of growing political interest. At a local level this was interesting. The two MPs involved were David Kidney the Labour MP in Stafford, and Bill Cash the prominent Euro sceptic Tory MP in Stone. David Kidney was the first to become caught up in the matter. The pressure group experimented with a form of direct action that they subsequently used against a number of prominent people. They turned up at David Kidney’s surgery en mass, with placards, and with a hidden video camera. They were not interested in dialogue, but in making a point. Their “film” was then posted on Youtube.
·         David Kidney’s response to this difficult encounter is characteristic. He listened, identified things that he could do to help them follow up their complaints and set the wheels in motion. He then kept them informed of progress. He was in regular contact with the hospital trying to understand the concerns that were being raised.
·         In the summer of 2008 he made the decision to spend a number of days at the hospital on work experience in order to see more clearly what conditions were like. He worked in various areas of the hospital. It is of course true that he, like the governors, and councillors who have some responsibility for the hospital, was a lay person, without any specialist skills in inspection, and it is also true that he was instantly recognisable by staff who might well behave better in his presence than normally, but this was nevertheless a very serious attempt to see what was happening, and to make it possible for staff to talk very informally with him. He actively took part in the in deep cleaning which was part of the national efford to tackle the very serious issue of hospital acquired infections, which was killing people throughout the country at this time, and he saw nothing during this work experience to cause him any serious concerns. This is in line with the impressions of every lay person and every health professional who visited the hospital during this period. If what was happening in Stafford was in anyway unusual there was nothing that would be immediately apparent to most people on most days in most wards.
·         David Kidney's report on his work experience was taken as a gross insult by the pressure group who formed the idea that he was undermining their position.
·         What we can say clearly about David Kidney is that he went to very considereable efforts to inform himself about the hospital, he visited regularly, he read reports in detail, he talked to the different agencies involved, and he also knew from his dealings with these agencies that the Mortality Statistics had their limitations, and that they should not be taken at face value. This meant that he could not simply accept some of the less accurate assertions of the pressure group.
·         With Bill Cash, we see an entirely different approach. Mr Cash’s evidence  to the inquiry tells us that he had no contact with the hospital since before 2003, he never met Martin Yeates, He took no direct action in any complaints involving the hospital, but simply sent copies of complaints to the department of health, He had no understanding of the statistical systems or the systems for monitoring the quality of the hospital. He had not accepted a series of invitations to attend briefings. His information about the hospital came from the newspapers, and when Julie Bailey made contact with him in winter 2008 he simply accepeted her version of events unchallenged and took steps to assist her to  gain wider media coverage.
·         From the local perspective this will have looked to the Conservative party like a godsend. David Kidney had, for very good reasons, the reputation for being one of the most trusted and competent politicians in the country. Finding someone who believed that he had let them down, and was prepared to say so as publically as possible, and who was essentially unassailable because of the genuine sympathy with their suffering, will have seemed like a gift from heaven.
·         In the months before the publication of the HCC report major battles broke out between the different parts of the health service involved. Drafts of sections of the reports circulated to interested parties were actively contested by people who felt that the report misrepresented them. There was a major discussion on an appendix which included “excess deaths”. I can give you no reliable information on what this appendix contains, because it was removed from the report on the authority of Sir Ian Kennedy, who was Chair of HCC, after discussions with Bill Moyes, from Monitor. What I can say about these figures is that Richard Hamblin, who has to be seen as the expert on what these figures mean, is firmly of the opinion that the figures should not be used, and that there could be no proof about how many people might have died as a result of poor care without a full case note review. The case note review which did take place found it was also impossible to give any estimate of numbers. The coroner could not help with this either. 
Cure the NHS on the other hand see the “excess death figures” as completely central to their case against the hospital. They have used them extensively, they appear in hundreds of press articles, they have been quoted by David Cameron on their behalf in PMQs, and they are now a firmly embedded “fact” in the minds of thousands of people in Stafford, as well as many millions beyond Stafford. It should be noted that Cure the NHS have been directly told of the weaknesses of these figures by David Colin Thome, and by Robert Francis, but they still continue to use them. 
·         The day before the publication is highly significant. An article appeared in the Daily Mail, Using the excess death figures, and quoting Cure the NHS and Bill Cash, This article formed the background of understanding with which the press took in the information from the HCC press conference.
·         The coverage of the release of the report was entirely dominated by the excess deaths which do not form a part of the report to the exclusion of many specific problems identified by the report which had already been resolved.
·         Once these figures were out, in a way that no one could contest because they were not in any printed material, they dominated headlines not just in Stafford, or Britain, but across the world. They played a significant part in the republican election campaign for Massachusetts where they were used successfully to persuade American voters that they should not back health reform.
·         In this country the prominence if the story in the tabloid press meant that it was inevitable that Andrew Lansley and David Cameron should grasp this opportunity to show that the NHS had “failed” under labour, and that there was a need for major reform of the NHS. Videos and press coverage of David Cameron with the Cure the NHS fulfil many different functions. ·         The HCC report left many lose ends and raised as many questions as it asked so since then we have had the Alberti Report, The David Colin Thome report, The report into the conduct of Martin Yeates, and the Independent inquiry by led by Robert Francis. All of these which provided significant pointers for action, were belittled by the Conservatives who declared, as Bill Cash had always insisted, that a Public Inquiry was the only possible answer. Locally and nationally the demand for a public inquiry was the sound bite response of the pressure group, press and Conservative politicians to the hospital issue.
·         As we moved towards the 2009 elections the eruption of the MPs expenses scandal through the Daily Telegraph expose formed a climate in which “the voice of the people” became increasingly powerful and more rational voices amongst MPs were effectively silenced. 
·         This hospital story, alongside indiscriminate coverage of the expenses scandal dominated the press in the run up to the local elections in this area in 2009, where they played a part in unseating a number of Labour councillors. The issue of NHS “failure” then moved to centre stage for the Conservative election campaign in 2010, where images of Stafford, and the perception of failure still firmly in most peoples minds were skilfully used by the Conservative party to overcome deep rooted distrust in their relationship with the NHS.
·         The Conservatives very wisely took the public position that there would be no top down reorganisation of the NHS, which is something that would have resonated with many people, including many health professionals who had lived through the upheavals of 2006-2007.
·         The Election of 2010 brought us a Conservative MP in Stafford and a Conservative led government, which meant that the hospital issue no longer had to play a part as an election winning tool , though it has continued to be used by the Conservatives as a means to “sell” their proposed reforms, with a totemic appearance of the pressure group on the platform for Andrew Lansley as part of the 2010 conference.
·         Throughout all the period from 2007 with the first release of the Dr Foster league table, until now the Health service has been effectively healing itself from within. The relationships between the different tiers of management, which the Health reforms now threaten, have been worked through and new systems of communication worked out. A significant coalition formed to reform the statistical basis for Monitoring health care as a result of the Robert Francis Independent inquiry and alongside these new and robust systems of monitoring there is a complete new philosophy on how to manage the health system, of which the essential element is that hospitals are not left to sink or swim through periods of difficulties.

The unique mix of ingredients which created the perfect storm over Stafford Hospital will never occur again. There are massive and growing problems in the delivery of a health service, poor care will continue to be an issue in hospitals, care homes, and in private houses throughout the country, This needs the co-operation of all regardless of political affiliation to resolve the problem, but Stafford could be the last of the big hospital scandals, because the NHS has recognised and acted on the real problems which did exist and has removed some of the triggers which made it possible for the media and politicians to turn a limited local problem into an international scandal.

The Health Reforms which this government – or more precisely the Conservative element of the government- wishes to put forward are based on a false idea of the failings of the NHS, and on an attempt to solve problems that the NHS has already resolved organically from within.

The road to a new philosophy of health regulation

I have raised the question, was Stafford Hospital the last of the big hospital scandals? One of the reasons that I think that it could be is because there has been a complete change in both the tools available to regulate the health service and the philosophy and structure of regulation.
It may help to look at what has happened in Stafford in historical terms.
I think that what we have seen in Stafford is a major milestone in the journey towards effective regulation of the NHS, and perhaps to complex systems in general.
Let us think back.
In the days before the National Health Service, the provision of health within a town was down to individual doctors, and to worthy citizens playing a role in governing their hospital. I perhaps have an unusual insight into this time, because my own family, Russell of Hitchin, combined two interests. Some of this small mafia were chiefly interested in running the town’s leather factory; others ran a chain of chemists which locally gave Boots a run for their money. All of them had a strong social conscience and were prominent players in local politics and in the running of the local hospitals.
This involvement in the health service persisted after the establishment of the NHS, something in which my own father played a part.
I suspect that the regulation my father would have been involved in at the numerous committee meetings that I remember from my childhood was pretty rudimentary. They would have heard reports from the Matron and hospital administrators, but also, because they were so well known in the town they would have been approached by local people who had any concerns. Maybe at that time this was enough.
The world I am describing here bears a closer resemblance to “Middlemarch” than it does to anything we would recognise now. Regulation is small scale, local, personal, and subject to variations in the quality of the individuals involved. 
The next point at which I pick up the thread of what was happening to regulation comes with the advent of the Labour government in 1997.
It is clear that what was happening in health was one of the major themes that contributed to Labours Landslide victory. We had the long trolley waits, and people dying on waiting lists, and the general sense that there was a great deal that the best of the rapidly developing world of health care could offer that was not being shared evenly across the country as a whole. Postcode lottery was becoming unacceptable.
I think there is a fundamental difference in the way that Labour and the Conservatives view regulation of services, which has its roots in how our different political parties evolved.

For Labour, providing good public services is central. It is why they exist. It is about the mutual good. For the conservatives the provision of public service is something they choose to do because it is necessary to maintain a productive workforce, and perhaps also because it is “right”.
The differences in attitude go deeper than this. For Labour public services are about ensuring that everyone has the chance to make the best of their life, for Conservatives, there is the additional driving motivation to use the provision of services to create entrepreneurial opportunities.
For Labour, because public service matters so much the state of the regulatory system as they found it must have been pretty disturbing. There was no effective way of comparing the quality of care across the country, and there was no way of identifying hospitals which needed help to improve.
We saw the emergence of systems to try and measure and drive up quality.
The simplest of these, which draws a very mixed response from practitioners and people with political views, is Targets. At their worst these are box ticking exercises and things that administrators with a mind to get round them will “game”. It is clear that in Stafford the hospital struggled to honour the targets in the “spirit” and found ways of working round them which were not good for patients.  Despite the problems with targets it is now widely admitted that they did work, they drove down waiting times in A&E and in waiting to see a specialist to a remarkable degree. It is clear that some powerful sections within the health service found this onerous, and these persuaded Andrew Lansley, during his 7 years as shadow secretary of state for health that we would be better off without the burden. We are now getting a chance to see how this experiment works. Waiting times are again growing, and perhaps as a consequence of this I am certainly noticing prominent adverts for Bupa and other health insurance companies cropping up in my daily papers with greater regularity.
A second development was Standardised Mortality Rates. This is an attempt to measure the very marked discrepancies in life expectance throughout the country and to relate that to the various factors which affect the health of the population. These variations are huge and shocking. If we take a local example then people in Stafford are on average dying more than ten years older than ten miles up the road in Stoke.
A minor factor, and it is only a minor factor in looking at mortality rates as a whole, is concerned with hospitals and hospital care. The Hospital Standardised Mortality Rate or HSMR is – or more accurately was – an honest attempt to look at the how good different hospitals were in keeping patients alive. This runs into all the kind of problems that you have with Stats in school. It is only telling you something useful about the performance of the hospital – crudely the value they are adding -  if you know what the condition of the patient when they are admitted.
How good HSMR could have been is something we will never now know. It did not work because admission coding throughout the country was almost universally poor, and because there were factors like the complexity of medical conditions, and options on places to die all skewed the results. HSMR effectively shot its bolt by the publication of the Dr Foster Intelligence league table in 2007. This was presented simplistically by the press as showing a whole lot of hospitals as “failing”. The furious response of many people within the health service to this league table was sufficient to prompt academic research into the system. The result of that is that HSMR, though it still exists as one tool in the hospital managers tool box, has been downgraded in its importance, it will never again be published in this league table form. A new system SHMI has been put in its place. The details of how this will work are still a little unclear.
Part of the controversy over HSMR was that it appeared as in the case of Stafford to be in total contradiction to the findings of other parts of the regulatory system, which included the annual health check. So you have the Health care commission carrying out its Annual health review and saying that the hospital is good followed by the Dr Foster HSMR indicating that mortality is amongst the worst in the country.
What you are effectively getting is some systems that are producing false assurances that everything is fine, and systems producing false alarms that things are dramatically and disastrously wrong.
Perhaps the best indicator of the effect of this comes in the extraordinary Westminster Hall debate led by David Kidney in April 2009 to look the Stafford Hospital question. I think it is widely known that I am a friend of David Kidney, and I am glad that I was able to give him some support in the dreadful days that followed the release of the Health care commission report, and the media hurricane that it brought to Stafford. Everyone in Stafford was traumatised by this, and David was thrust unwillingly into the spotlight. After weeks of seeing him under unbelievable pressure it is still remarkable to me that he could in this Westminster Hall debate clearly identify many of the points and conflicts which are only now emerging through the Inquiry, slowly, painfully and at very great public expense.
Many of the people who have been pilloried for “failing to see” the problems at Stafford have been perhaps correctly accused on not looking closely enough. No one could possibly accuse David of this. He is a man who has a rare capacity to see detail and to also see the broader picture (see blog on Granular still to follow) The problem that David faced at this point is that there were conflicts within the information he was being given. In the weeks that followed the HCC report he was hearing directly from patients about their experiences, and therefore knew definitively that there were some things that had gone wrong, he also knew that the blanket statement that hundreds of people had died was based on very shaky foundations.
He knew that the information that was available to him had not helped him to see clearly. He had actively wanted the tools to be able to measure the quality of service in his constituency and the tools that existed had failed him.
The evidence that I have seen through the Inquiry does give me reassurance that many of the issues he so clearly identified have now been tackled.
I have further blogging to do on this but as an interim would recommend reading the evidence and statements from Rashmi Shuckler, Peter Blythin, Steve Allen, Martin Bardsley, and Richard Hamblin,  
The limitations of the Dr Foster Intelligence system have now been recognised.
The Strategic health authority has developed clinical dashboards which bring together in one place a wide range of indicators that anyone with the ability to read this kind of information can understand and benefit from.
The creation of the SHMI system marks a major achievement in bringing together a range of Statisticians who might previously have seen themselves as rivals, to create a robust new approach.
The development of the Mortality outliers has got past the tentative beginnings, and is now giving CQC a real tool for raising questions about care in individual hospitals, a tool that can also be used by hospital managers themselves to help ensure that their performance is as it should be.
An important development of the philosophy of health service management that has occurred as a result of Stafford and as a result of the movement from the Health care commission to the Care Quality commission is that the way in which the regulator operates has completely changed.
In the Stafford case, we had a centrally placed investigations team spotting a potential problem, which its own locally based teams were not aware of, waiting months for supporting evidence, which no one understood how to give, and then sending in someone to look and starting what appeared to be a highly punitive form of investigation. This nature of this investigation process in itself made it very difficult for other agencies to support the hospital through the problems and created real divisions between the different “arms” of the health service. The investigation built in a year of delays as Monitor felt unable to take decisive action.
Everyone I think now accepts that the investigation process was not as it should have been and there is a radical change. We saw this in action with the recent CQC reports on the first 12 of 100 hospitals where they have carried out investigations. The CQC if they suspect a problem now directly involves their local teams at the earliest possible time to go into the hospital and work through the problem with them. They are not being left to sink or swim. This is a partnership approach.
The Outliers system is just one small part of the changes prompted by the response to the Dr Foster league tables and to the failure of complaints monitoring in Stafford.  One of the major themes within the Inquiry is that there have been lots of individual people who each had one or two clues that some things may have been going wrong, but there was no possible way of bringing this evidence together. No one saw the patterns and it has taken the Inquiry to bring this complex picture of who was able to see what to bring all of this together.  
There is an entire new arm of monitoring which is based on picking up the soft intelligence which forms the basis of much of the evidence to the inquiry. These QRPs are outlined in Richard Hamblin’s evidence. (will try and blog specifically on this evidence later) These systems, which are still developing, will allow us to aggregate “soft information” from complaints, websites such as NHS choices, Press reports and other sources, and will give the local regulators and managers an effective way of seeing how they are doing in a way which would have been completely unthinkable when Labour first came to power in 1997. The software to analyse text, and help draw out patterns and clusters will really help us to compare the quality of service between different hospitals, and trends over time, in a way that would never before have been possible.
This may seem an abstract discussion, but it is central to the questions which are now being asked about health reforms. Few people have yet seen or understood the fundamental importance of the evidence given by people like Richard Hamblin.
If we do not see or understand what is being done here there is a real danger that we are carrying out disruptive reforms, which will damage the health service, in order to find a solution to problems which have already substantially been solved.  

28 May 2011

Media influence in the 'Baby P' case: positive or negative?

Sharon Shoesmith and team following Appeal Court ruling.
Yesterday, the Court of Appeal handed down the ruling that Sharon Shoesmith, former Director of Children's Services of Haringey Council, had been unlawfully dismissed following the death of 'Baby P' (Peter Connolly) at the hands of his Mother and her partner. 

A timeline of the events surrounding and subsequent to Peter Connolly's death can be found here

Sharon Shoesmith, since the verdict was announced yesterday, has given an interview on BBC Radio 4, during which she clearly feels that she was not given sufficient opportunity to answer accusations against her. A recording of that interview can be found here.

How much did the media affect the way Parliament and the public dealt with a difficult, emotional issue?

This little boy's murder affected many people and became the focus of displays of anger and frustration throughout the country. 

The public were quite naturally appalled by the murder of Peter Connolly and wanted answers as to how it had happened under the watchful eyes of social workers and medical practitioners.

 The media took up the cry for justice and retribution. There were increasingly shrill calls in print and from television screens for the Prime Minister, Gordon Brown, and his Children's Minister, Ed Balls, to deliver 'someone' to blame and to punish.. 

The Government was subjected to enormous pressure to bring about a speedy end to what was by then considered by the public and politicians in Opposition, the Tories and Libdems, inordinate delay in investigating the obvious problems within the relevant department at Haringey Council.

At Prime Minister's Questions in the Commons Chamber on November 12th 2008, matters soon reached a vitriolic pitch: Video of exchanges between Gordon Brown and David Cameron.

The press began to call for heads to roll and, although both Brown and Balls insisted they would take more time to make a judgement after two recently completed official reports on the conduct of Haringey Social Services officials, in a press conference on Monday December 1st 2008, Balls removed Sharon Shoesmith from her post.

Some examples of newspaper articles from that time:
Daily Mail


The Sun, in particular campaigned for sackings at Haringey Social Services and a petition signed by 1.2m people was delivered by the sack load to Downing Street.

Excerpt from article in the Sun on 26th November 2008, (the words in bold print are as they appeared in the original article):
 "And as the biggest ever newspaper petition was delivered Children's Secretary Ed Balls gave The Sun a clear hint that heads MAY roll following an emergency probe into the scandal in Haringey, North London.

Baby P died of horrific injuries last year following months of abuse after social services allowed him to stay with his twisted mother and stepdad.

The Sun petition demands the SACKING of social workers Sharon Shoesmith, Maria Ward, Sylvia Henry and Gillie Christou. And it calls for the doctor in the case, Sabah Al Zayyat, to be DISCIPLINED for failing to spot the 17-month-old's broken spine. 

Mr Balls made it clear he will wait until he receives the report into the failings on Monday before acting. He refused to single out individuals. And he insisted he would not act out of anger - but after a full study of the report."

Today, May 28th 2011, the media are running with the Court of Appeal's decision and in several newspapers are articles with a definite bias against Ms. Shoesmith. Those same papers who whipped up all of the fury and hatred in 2008. Ms Shoesmith, should she win the next round of appeals on behalf of the Government, stands to be awarded a large amount of compensation.

Judging by the tone of some of the most resent press, she should perhaps prepare for some very negative publicity:


Daily Mail  1

Daily Mail  2
Mail on Sunday Comment 

Is the battle to sell newspapers and raise ratings making it impossible for legislators and politicians to come to rational decisions in a calm and thoughtful way? How much does the media in this country dictate the agenda and tempo of our lives?

27 May 2011

They counted them in, they counted fewer out.

Small selection of Daily Express front-page headlines
The Daily Express has long campaigned to convince the nation that the whole fabric of Society is in danger from an influx of immigrants bent on securing jobs, housing and benefits from under the noses of indigenous 'Brits'.

Articles which accompany these startling headlines are often long on scare - mongering hyperbole and short on accuracy.

All three of the main political parties agree that there is indeed a problem which needs to be rectified. The Daily Express, however, is embarked on another course completely. Its tactics are designed to engender hatred, mistrust and resentment. 

An article in today's Daily Express, here, the statistics, taken from the latest ONS study, (ONS podcast), appear at first glance to be accurate if somewhat alarming! Using language which backs up the article writer's understandable alarm, the spokesman from Migration Watch, the oft quoted Sir Andrew Green opines thus:

“This sharp rise in immigration comes as a shock. These figures show just what an enormous task the coalition Government has inherited as a result of Labour’s mass immigration policy.
Firm measures are now absolutely essential. The impact on British-born workers is a particular concern that has been brushed under the carpet for too long.” 

Words to strike at the very heart of those struggling to find jobs, a roof over their heads or enough in the benefit pot to go round. Except, -  and this is the crux of the matter - nothing in the article is quite as the writer and Sir Andrew Green of Migration Watch would have us believe!

As can be seen from this Full Fact investigation, several supposedly reliable newspapers have omitted to mention, deliberately or otherwise, that the ONS net immigration figures include emigration statistics. Emigration has fallen by more than 25% since 2008 and this tends to skew the net migration total. 

To its credit, the Daily Express does mention this in the last two paragraphs of the piece, but it is disingenuously used as a stick to beat the Government with and with luck, bring about legislation to curb the 'flood' of low skilled migrant workers. 

'Matt Cavanagh, of the Institute for Public Policy Research, said:
“When they set the target in opposition, the Conservatives clearly hadn’t planned for emigration continuing to fall.
Today’s figures show that emigration of British nationals is down by more than 25 per cent since 2008. This means the Government will have to take even more drastic measures to meet their target.”

Perhaps, if successful, the Government could take much of the credit for forcing the Daily Express to come up with a different theme for its front page headlines?

26 May 2011

Lost in translation - or another Daily Mail 'wind-up'?

Press Conference Lancaster House, London. State Visit 25.05.2011
Yesterday, Barack Obama and David Cameron held a joint press conference at Lancaster House in London following official bi-lateral talks at Downing Street that morning.

Barack Obama was asked by a journalist for his thoughts on the progress of the on - going Gary McKinnon case, accounts of which can be found here  and here.

Gary McKinnon and his mother, Janis Sharp
This Morning, the Daily Mail has an article, written by James Slack and Michael Seamark, giving an account of what Barack Obama's answer was and what it means for Gary McKinnon.

The headline

"Fresh blow for Gary McKinnon as President Obama refuses to halt extradition"

implies a flat refusal by the President to support the moves to allow Gary McKinnon to remain in Britain for any ensuing trial. They go on to assert:

"Gary McKinnon’s hopes of avoiding extradition to the U.S. suffered a severe setback yesterday when Barack Obama declined to allow him to be tried in Britain.
Campaigners had hoped the President would halt the legal proceedings because of the Asperger’s sufferer’s precarious mental state.
But Mr Obama – despite previously saying he wanted to find an ‘appropriate solution’ to end the computer hacker’s ordeal – effectively endorsed the extradition process."
The rest of the article can be found  here.

Also this morning, the BBC News online page carries an article describing the same question Barack Obama was asked and his answer, together with a video clip.

The BBC's version of events are completely different in tone and interpretation from those of the Daily Mail. In fact, the BBC also carry reaction from Janis Sharp, Gary McKinnon's mother, whose optimism and lifted spirits are evident.

So why the wildly conflicting accounts and interpretation of exactly the same event?

Is it an attempt by the newspaper to 'chivvy' up the slowly-grinding wheels of the law? 

Is the Daily Mail using hyperbole and inaccuracy to push Obama and Cameron into a decision which would please campaigners and Gary McKinnon's family?

Public pressure has largely died down in this case as the years have rolled by and perhaps there is a case for a re ignition of public awareness to bring things to a head. But is this the way to do it? By misreporting and attempting to whip up anger instead of reasoned argument? 

Is this not just yet another example of the use of misreporting and misrepresentation in order to manipulate public opinion?

The Daily Mail describes the 'fury', 'horror' and 'anger' of the nation on almost every issue it gives page space to - strange how very quickly it is able to canvass millions to gauge our mood....!

24 May 2011

A predicatable outbreak of moral outrage - 2

Let me make a simple prediction.
Tomorrows front pages will be sharing space between the Obama visit, the Ashcloud, and the Pilkington report.
My feelings on the Pilkington case are complicated. As a former welfare service officer on tough housing estates specialising in dealing with anti social neighbours I am very aware how much pain difficult families can cause to vulnerable people living around them. I suspect that this is something that has always been the case.
It is clear that Mrs Pilkington had many very difficult years, was not well supported, and that the horrible end to her life should remind us all of how much quiet suffering goes on around us. Mrs Pilkingtons death may have been highly shocking and unusual, her suffering is regrettably all too common.
It is also clear from listening to the police media briefing today that they have since 2007 been working hard to resolve the problems they identified through this tragic case.
The case report can be found here
The police force have not wasted time waiting for recommendations from the Inquiry, they have changed the way that they do things. There is a much higher level of awareness of the impact of antisocial behaviour, they are using emerging technology to enable them to link complaints in a way that was simply not possible three years ago, and they have developed better policies for case managing anti social behaviour cases.
This to me bears many parallels with the Stafford Hospital case, where the problems encountered have prompted the NHS to take huge steps forward in managing complaints and identifying patterns of problems. If these steps can be taken in the NHS and the Police, then that now indicates that we can and should be monitoring all public service with this degree of sophistication, and then taking the action to deal with the problems that will inevitably be identified. That is a challenge that this government now needs to rise to.
What bothered me when the Pilkington case emerged as the central theme of David Cameron’s 2009 conference speech is the willingness to make simplistic party political points about a deeply tragic but unusual case. Here is my reaction to the speech.
Just listening to his speech again, one of the things that struck me is this. He clearly says that he learnt about the case by reading the newspapers. I wonder if before rushing to the microphone if any attempt was made to contact the police force concerned and find out more about the complex facts of the case?
David Cameron’s empathy with people who find themselves on the front pages of the tabloids would serve him better if it was balanced by showing some understanding of the difficulties faced by those people who are trying hard to deliver a public service, often in very difficult circumstances.