26 April 2011

Stafford Hospital: The Inquiry enters a new phase.

Over the next couple of weeks the Stafford hospital inquiry will enter an interesting new phase.
We have heard from the group of patients who undoubtedly suffered poor care, and from the many different groups of people, including the GPs, Hospital board, Scrutiny committees, elected representatives, and patients participation groups,  who “failed to see” anything particularly unusual at Stafford. We have heard from many people from within the hospital about the challenges they faced, at a time of re-organisation and cut backs, and we have heard from the Primary Care Trust and Strategic Health Authority who have the task of monitoring and supporting the health service providers in their area.
Questioning of the PCT and SHA looked at why they “failed” to see the problems in Stafford. There are several parts to this answer. These organisations both underwent major top down re-organisations. Roles were being redefined, relationships with other key organisations were unclear, and key posts vacant. With the systems and staffing they had at the time these organisations saw nothing to make Stafford stand out from the 43 other hospitals that the SHA was managing.
Mortality figures are central to the inquiry. About a third of the questions each day relate to these. I find it interesting that none of this has so far been reported by the press. Maybe this is because it challenges the assumptions that they made. The assumption made by the press, from the release of the Dr Foster figures as a league table in 2007, is that these figures are a true reflection of the quality of care in a hospital.
Stafford and five other hospitals in the SHA’s area all had high mortality rates. The PCT and SHA responded robustly to these figures, but they responded as scientists and as managers. They began by in depth discussions with the hospitals, and by triggering a process for the hospitals to demonstrate that they were managing effectively.
The health service had been shocked by the publication of the Dr Foster league table, because there were major doubts that these figures were sufficiently robust to be used in this way. The PCT and the SHA both triggered a series of investigations to look into the accuracy of the figures.
These investigations showed that poor coding was endemic throughout the NHS, and that correcting the coding would quickly have a dramatic effect on reducing the mortality rate for hospitals as it did straight away with Stafford. Stafford’s figures fell from 127 to 101 immediately, and continued to fall until Stafford shows as the ninth “safest” hospital in the county.  
It is as a result of the investigations into mortality rates that the "league table" which is so loved by the press has now been discontinued, and there a much more sophisticated way of measuring hospital "quality of care".   This for those who are interested in such things involves a clinical dashboard which brings together a whole range of key indicators, and displays them across a range of hospitals. As someone who knows the limitations of most statistical systems, this "richer" approach to monitoring looks much better to me.
What I expect to hear in the next couple of weeks is the Healthcare Commissions defence of its reasons for choosing to single out Stafford Hospital from the 54 hospitals which were identified by the Dr Foster 2007 figures as problematic. I believe that a lot of reference will be made to what they saw in the press and the political imperative to respond to the "public concern" that this indicated.  
The HCC will also get an opportunity to defend itself against the many criticisms we have heard about the conduct of the investigation, and I believe that we will see differences of opinion emerging from within the HCC.
This is an interesting slow burning drama, but it is more than that. We should remember that the major “reforms” that are now threatening the future of the NHS as we know it, have been justified by the “failure” of the PCT and SHA. Maybe it is worth asking the question, what if they did not fail?

Footnote: I have been looking, for the sake of balance, for a really good defence of the proposed health reforms. Just found this which is billed as the best defence we can read.