30 June 2011

What the Ombudsman said.

When I first heard about what would become Cure the NHS, right at the end of 2007 it became immediately apparent to me that there had been a failure of the complaints system at Stafford Hospital.  This raised big questions for me then, and it continues to do so now.
The ombudsman matters.  This is the end of the road for complaints. It is our guarantee that if someone has suffered injustice or hardship as a result of failure of the service, or failure to provide a service or, maladministration, that their case can be examined.  You will find more about the service here

Ann Abrahams is clear that the ombudsman is very much a last resort. People only come to her when they have exhausted other possibilities. For some people this works, and for other people and Julie Baileys evidence shows that this includes her, the process is frustrating.
The ombudsman has to work within the clear confines of a act.
what the ombudsman is empowered to investigate is a complaint that a person has sustained injustice or hardship in consequence of service failure or maladministration.
The case has to satisfy both of these requirements.
Often the cases are not cut and dried. Here is an example that Ann Abrahams used to illustrate the problem
So it may be that somebody comes to us and says: there was a delay in diagnosis and as a consequence, my loved one is no longer with us, and if that diagnosis had been done when it should have been done, because, you know, the referral time for -- for tests had been adhered to, then my husband wouldn't have died. And -- and we can look at that and we can, with the benefit of expert advice from our clinicians, we may well be able to say that: yes, there should have been a referral and there should have been a diagnosis, you know, six months previously; but we may also be advised by our professional advisers that it would have made no difference; and therefore that the consequence in terms of injustice as the complainant, you know, quite reasonably believes it to be the case, actually isn't sustained as a result of one of our investigations. So, you know, the -- the two legal concepts of service failure and injustice have to be both present and the injustice has to be as a consequence. That's what the law gives me to work with.

THE CHAIRMAN: But presumably in a case such as the one you mention, an injustice might be identified in terms of the distress caused by the late diagnosis, even if it has no physical causative effect. 

A. Absolutely, chairman, and I can think of a number of cases in -- in which what we've concluded is that the - the outcome in terms of the person's death may not have been any different, but that doesn't mean there has been no injustice.

There was a discussion on the concept of “worthwhile outcome”.  This is something which is not defined in law, but has been used by the ombudsman’s office as an internal measure to test if anything meaningful can be achieved by pursuing a complaint. There is a clear meaning for this within the office, but this can be less clear to other people.
Ann Abraham says that this has been flagged up by the parliamentary select committee as a concept that can cause offence to some complainants, and they are going to review the use of the language.
For Ann Abrahams what she is trying to identify is if the ombudsman’s action can achieve what the complainant wants. If it can’t do that then is it in the wider public interest? If the complaint has specific wishes like seeking the disciplining of an individual doctor then this is best pursued by other means.
 if somebody is really concerned about the professional conduct of an individual clinician, and that's what's eating away at them, then there really isn't any point in the ombudsman taking that case on for investigation, because at the end of that, we might, if we felt there was sufficient concern about the professional conduct of an individual, make our concerns known to the relevant professional regulator, but it would be a very indirect way of supporting the outcome the complainant was looking for.

There may be cases where there is no point in trying to do more than has already been done in other ways.
And in a case where something may well have been seriously substandard, but the NHS body has acknowledged that and accepted that and apologised for that, and there has been an appropriate remedy for the individual, and there has been an appropriate systemic remedy put in train, and there's been learning, and the regulator is on the case in terms of follow-up action, then I would say, and I think my staff would say: what is to be gained by an ombudsman investigation for this individual and for the wider public interest in these circumstances?

Ann Abrahams feels strongly that the right way is to aim for local and immediate response to complaints. This shows some of the work being done to establish better complaint handling. They have been supporting the process of improving the complaints process at a local level by visits and training sessions with the 50 trusts with the highest complaints level. With the first of these there has already been a major drop in complaints to the ombudsman.
( I will add my own suggestion here, It may be that the process they are trying to bring about here needs to mirror that of the NSPA, where the aim is to increase the level of low level reporting – which could here be comments or concerns – with the aim of raising issues before they ever reach the stage of being complaints )

She Reacts to Health Select Committee's report

I suppose I'm always concerned with recommendations which seek a change in the law, when actually what people want is a change in behaviour and it may well be that my office needs to behave differently and we needto use some different language, but I don't think there's anything in the legislation which stops us doing that.

She is keen that there should be no major structural changes. It has taken from 2002 to 2009 to get the system to current 2 stage process and she is certain this is the right solution
Previously there was a three stage process, starting local – then going through Health Care commission and then ending up with ombudsman.  The fatigue of dealing with this cumbersome system could well have deterred people from complaining.
The new system is working faster. Ann Abrahams sees complaints coming through now within 6-12 months. Previously it was much longer.
The Inquiry wanted to know why are there so many more complaints?
in 2010 to 2011 you received 13,625 enquiries.
The Healthcare Commission during its time as the second stage received roughly 8,000 referrals  a year.
Ann Abrahams did not have an answer to this.  (I would personally suggest that this may be to do with greater prominence of these issues in the press we have seen that the patients association had to increase its staffing levels from 2 to 6 following the publication of the HCC report, and that there have been a stream of high profile reports, which will all have had the effect of increasing the likelihood of people complaining.

Ann Abrahams was asked if this might reflect worse handling of complaints at a local level. She does not think this is the case. Her caution is that we should try to understand the story, rather than try and deduce the story from the numbers.

The inquiry looks at numbers of contacts, and the numbers that were pursued to investigation . in 2009-2010 there were 15,579 contacts, and only 219 interventions and 349 accepted for full investigation. Ann Abrahams was at pains to say that the presentation of the is data may be a little misleading, and there may be an element of double counting, but she agreed with Robert Francis that investigations were a tiny proportion of total complaints.  This is useful to know as it puts Julie Baileys disappointment that her case did not proceed to investigation into a wider context. The most likely reason why her case did not proceed was that by the time a decision was made she had already been very heavily involved in the healthcare commission report. and the David Colin Thome report and Alberti Report had already taken place. The steps to learn from and remedy the issues her case raised had already been taken and it was unclear that any further benefit could be gained from pursuing an ombudsman’s investigation.
There was some discussion about if it is right that the numbers should be so small? Ann Abrahams thinks that it is. The priority should be to improve the quality of local complaints handling, so that complainants are not subjected unnecessarily to long, drawn out processes.  She feels that the NHS has a long way to go before it can be said to be offering a good complaints service.  In the 2010-2011 year only 2 trusts did not have a complaint to the ombudsman.  
if the NHS is doing the sort of job it should be doing, in resolving complaints locally, and the ombudsman is the last resort in that; well, what size should the ombudsman's office be? What sort of numbers of complaints should it review and should it investigate? And how much public money, you know, should go into that part of the system? So they're all, you know, perfectly proper questions. And it has always been my overriding objective to work in a way that drives improvements in the way the NHS handles complaints and delivers healthcare, rather than to suck huge volumes of complaints into a -- a national ombudsman's office.

Ann Abrahams was at pains to add
I'm not for a moment suggesting that everything's okay out there, because we all know it's not.

She was asked to look at the reasons why some people will remain  dissatisfied with the system? What are the causes for dissatisfaction
·         outcome of their complaint,
·         no one to help them make their complaint, so the advocacy services were poor.
·         People may be unhappy with how long it took.
·         Is it about the culture in the NHS which provides defensive responses?

She told us that  I can't shed much light, if any, on the events at  Mid Staffordshire NHS Foundation Trust between  January 2005 and -- and March 2009. the pattern of complaints that we received  didn't provide any information to distinguish  Mid Staffordshire from any other NHS trust, and we had  no other information that would have led us to do so.
With regard to the Health select committee she strongly argues that there should be no major changes to the service. It needs time to settle into the new structures set up in 2009
I spent the five years in this job arguing for reform, and then I spent the following two years working to implement reform, and to achieve a smooth transition and we did that. And what I said in my evidence to the Health Select Committee earlier this year was that the two-stage NHS complaints system introduced in April 2009 is quicker, simpler and more effective than the previous system. And that the new system is already demonstrating its potential and needs to be given time to prove its worth. So the design is good.
But that doesn't mean that everything is working as well as it should be, and it doesn't mean everything is working as well as it could be. It doesn't mean the NHS is performing as well as it should be, it doesn't mean that there's no scope for my office to improve the service it provides. But it does mean that we don't  need to redesign the system.

Her recipe for a  better complaints system  includes
·         Advocacy
·         Information
·         Leadership
·         Time.
Both Robert Francis and Ann Abrahams were concerned about the effect that the complaints process can have on the complainant.  This exchange shows a little of this.
 THE CHAIRMAN: What is the answer to the problem of the complainant who makes a complaint in which they believe and have very strong feelings, which can then, of course, be exacerbated by the system that they have to go through, but you find, as perhaps others in the organisation have found, that there is no actual justification for the particular subject matter of the complaint, but the individual remains firmly of the belief that there is some substance to it?
I mean, in a sense, by definition that's an impossible problem, but it seems to me from my previous inquiry, and generally my experience, that there is a diaspora of complainants who are damaged by a process, whether or not their original complaint had any foundation to it?

A. Well, I think, you know, your experience and mine is the same. And I think what my office tries to do is ensure that -- that we give proper consideration to -- to complaints, that we make a decision which is fair to both sides in this dispute and that's our job, and that we explain the reasons for our decision, if it's a decision that the complainant's not going to be happy with, we do this for everybody, but if -- if somebody's not going to be happy with our decision, then our challenge is to explain that with the proper combination of analysis and empathy for what's happened to them. And we have in place a review process which is my safety net, so that if people think we have -- have got it wrong, that somebody who has not had any previous involvement can have a look at it, and -- and if we still think that there's nothing more that we can do or, you know, our analysis of these events is very different, then we will write a final letter and we will usually say that we will look at anything else that the person sends us, but we may only acknowledge any further correspondence, because we have to draw a line. And we try and do that as sensitively as we can.

Here is some more information from the Ombudsman website.

26 June 2011

How brave was the Dowler family to stand up and criticise their ordeal... ? Then there is this afternoon's breaking news...

During the last couple of days since Levi Belfield was convicted there has been much press coverage about the sad case of the young girl Milly Dowler who disappeared, later to be found dead. http://is.gd/CE0eh9

However, much of the press coverage has been about  Milly's family - her father, mother and sister who bravely stood up outside the Courthouse to deliver their verdict on the process to which they'd been subjected.  The jury took seven hours to debate and as the verdicts were read out the family broke down sobbing and Mrs. Dowler collapsed, clearly very seriously upset.  But was their upset about the verdicts or the fact that the episode of the inquiry into Milly's death had ended...  probably both.

The four-week trial saw Milly's father, Robert Dowler and her mother Sally subjected to cross-examination by Bellfield's defence team.  Each of them had broken down in the witness box - it was suggested that Milly may have run away because she was unhappy at home.  In their statement outside the courthouse the Dowler family said that the process had been "mentally scarring" and that the justice system was loaded unfairly in favour of the criminal   http://is.gd/T57Hfx.

There have been different accounts of this from the Police and the Defence team, defending their actions although the Police did apologise and has called for changes. Surely the Chief Constable was aware of how the family were being treated? This was a high profile case. Wonder if an apology would have been made had the Dowler family not read out their statements?  http://is.gd/7kRgug. 

The defence barrister, Jeffrey Samuels QC, has been unavailable for comment. A spokesperson for the Criminal Bar Association (CBA) argued that the adversarial nature of trials is fundamental to justice. http://is.gd/ogZfCM.  He may have a point. But what about the reporting. Should parts of this trial been held in private.

Finally, it transpires that although the jury debated for seven hours, and this was on the issue of whether Levi Belfield had abducted another girl Rachel Cowles,  the judge discharged the jury without reaching a conclusion.  The judge blamed the media coverage of the trial. http://is.gd/MXtmLW,

So basically the media got the in way of a fair trial of Levi Belfield the man suspected of also trying to abduct Rachel Cowles.  The attempted abduction file will lie on file. Clearly questions will be asked about the Judge's decision to dismiss the jury..   it appears that the Attorney General's office will be looking into it. 

Yet again the media is in the spotlight.   In May the Attorney General's office won permission from the high court to bring contempt of court proceedings against the Sun and the Daily Mirror over their coverage of the Chris Jefferies in December last year. He was the man who was arrested on suspicion of murdering Joanna Yeates in Bristol. A date is awaited for the case to be heard.

This afternoon, as I write this blog, the death and reported possible suicide has been announced of Mr. Christopher Shale, a Snr Conservative in David Cameron's constituency.  I won't say too much as it is early days but as the circumstances of Mr.Shale's death unwinds, one has to wonder if external bodies had a role to play - all roads appear to point in that direction!  http://is.gd/Tqk15v and http://is.gd/YwrYMZ.  Questions arise here too...

At this stage, despite what our political beliefs may be, we should consider the feelings of  Mr.Shale's family. This will be a very sad time for them.

But watch this space...

Some of the latest media coverage : Dowler family
The Telegraph - Chief Constable talks about 'shock' of experience for the Dowler family http://is.gd/fOi4ES
The Indy - Lawyers defend cross-examination of Dowler family http://is.gd/ogZfCM
The Mail - Murder tore Milly's family to shreds, and the legal jackels feasted on what was left  http://is.gd/XojSJ4
The Mail -  Police & Lawyers blame each other for 'inhumane' court ordeal http://is.gd/MkCCoD
The Guardian Milly Dowler's family solicitor re phonehacking Milly's voicemail http://is.gd/YvqeJA

Some of the latest media coverage : Christopher Shale
The Guardian - Christopher Shale found dead.. http://is.gd/Au05rZ
Daily Mail - Did Cameron's 'rock' die of a heart attack 20 hours before his body was discovered in a portable toilet at Glastonbury? http://is.gd/yRw5HN
The Telegraph - Tests to reolve mystery death... http://is.gd/BBW0sg
The Telegraph - Christopher Shale - big society man http://is.gd/zX72OT 26th June 2011
Sky News - announces Post Mortem on Christopher Shael is 'unascertained'  27th June 2011
The Indy - 'Top Tory's festival a mystery'  Undetermined pathology findings re death of Christopher Shale http://is.gd/YWC5lI

End of life care: some straws in the wind.

It is clear that we are not doing end of life care well.
We have powerful medicines and wonderful delicate surgery which can do things that would have been seen as impossible even 10 years ago. These mean that the conditions which people were dying of just a few years back are treatable. People survive, and that often means surviving in a very frail and dependant state for many years.
During John Major’s government we saw a big shift. We had already begun to see the extending of the “twilight years” and at that point many people were ending up in Geriatric wards in hospitals. It was seen as a problem then, and the cost was crippling the NHS.  The solution put forward by John Major’s government was the community care act which encouraged the creation of private nursing homes, and meant that the burden of costs passed to the individual, with the safety net of means tested payments from Social Care once a life time of savings had gone.
The fact that many people were likely to lose their life savings to pay for care was quickly recognised by the Labour Party and it was one of the issues on which they stood in 1997.
Resolving the question of how we pay for care has proved very difficult. A series of commissions and reports all recommended that we needed major surgery, but offered sticking plaster options. In the face of resistance to anything that looked as if we needed to spend more on the issue we got the sticking plaster. My family was one of the many casualties of this period, with care costs for my mother close to the £100,000 mark.
I recognised that this was not acceptable and spent five years working quietly with my MP to find a fairer solution. I think it is partly because of his quietly insistent work on this that we got the major rolling consultation led by Caring Choices, followed by a well publicised green paper.  We also held a seminal conference here at Stafford University which the MP organised to answer some of my questions. This brought together all the key players from Whitehall, the insurance industry, Health and social care, the voluntary sector and many representatives from our community.
It was not until the white paper of 2010 that we finally had a brave solution offered. For a brief period there was real hope offered on this, with the health spokesmen from the three main parties working secretly together to talk about the solutions. Then the lure of electoral advantage was seized by the Conservative party who broke away from the talks and got the tabloid press into a frenzy with the now infamous “death tax” posters.
My husband’s humorous suggestion that it is all my fault, that I brought down the Labour Government, is I think going a little too far, but I accept that it has at least a few grains of truth in it! Sorry!   
So where are we now?
The Stafford Hospital inquiry has show us that a hospital, especially a busy hospital with chronic staffing shortages and the wrong kind of ward layout, may not be the most restful or dignified place for people to come to the end of their life. The very effective media management methods used by the Stafford pressure group have been successful in forcing many people who would rather not have seen, to face the uncomfortable fact that some of what is on offer as elderly care is simply not good enough.  The media and the press are also completely tied in to this issue. People throughout the country are now being vocal about failures of care in a way that would never have happened before Stafford. The extent to which the Conservative party have aligned themselves with this sentiment means that failures in care under their leadership will not be tolerated. It is now a political imperative to find good solutions.
From the point of view of my interest in the press and elderly care, I am wondering about the press and media stories that will affect the difficult decisions ahead, and wondering if the media can this time play a positive role in allowing all the arguments to be clearly heard.
So how can we do elderly care better at a time of austerity?   Here are a few of the straws in the wind.
The Alzheimer’s society recommendations.
There will be a lot of anxiety that the decisions taken by this government about end of life care . Many people will believe – fairly or unfairly – that cost will be the deciding factor.
It is worth putting a counter argument. The Alzheimers society report "Counting the Cost" showed clearly that people are ending up in hospitals because of failures of primary care, and they are staying too long because good social care options for re-enabling after a period of acute illness do not really exist.
The prolonged hospital stays are a huge and potentially avoidable expense for the NHS. Confused but mobile patients can completely wreck the running of otherwise viable wards as we have seen at the Stafford Inquiry, so the cost and efficiency arguments matter, but long hospital stays for confused elderly patients is something that can be distressing, undignified, at times life threatening, and can destroy future quality of life.
It is a priority to get people out of hospitals if they do not need to be there. We need to recognise that. We need to create the right pathways.
Making the NHS cost effective  
Cost cutting in the NHS and the move towards the GP commissioning is aimed to concentrate minds and stop people passing the problem from one budget to another. It will be in the financial interests of commissioners to ensure that no one ends up in hospital because of lack of support from primary care, and that people do not stay in hospital too long because of lack of good options for helping people return home or to more appropriate care settings.  These priorities fit with the Alzheimers report and also with the Alberti report on Stafford Hospital.
The increased focus on quality.
The NHS has been talking about quality and the ways to improve it and measure it for at least the last decade. Many improvements have been made. The Stafford Inquiry has spent a lot of time looking at this issue, and has ensured that quality will remain high up on everyone’s agenda. This will happen not least because the Stafford Hospital case, coupled with the ubiquitous presence of mobile phones has now made speaking up against poor care fashionable. The media now notices these issues in ways which it never did in the past.  
We need to start asking the deeper questions. What do we actually mean by quality for end of life care. What is a good death and how can we create the conditions for more people to experience this.
Dilnot comes at the end of a decade of commissions and reports on the vexed question of how to pay for Care costs. It will have taken as a starting point the Labour White Paper on social care from 2010. Dilnot will report very soon.  All the indications are that this is going to be very stormy 
It sounds as if there is a preference from some parts of the cabinet for an insurance based care funding solution. This is bad news. It is what John Major tried. It did not work, and that is why by 2009 people were being offered an insurance package by only one remaining insurance company that still thought there was any point in this at a cost of £80,000.
For those who are very rich, too rich to worry about care costs, there is clearly an interest in voluntary insurance packages to fund care risk. For everyone else the best option is for universal risk sharing.  The “Death tax” is only one way of doing this – there are many possibilities.  We need to understand the options better. The media have a major part to play in this.

Southern Cross
The problems with Southern Cross have helped focus our minds. This is the kind of company set up in response to John Major’s Community Care legislation, and fostered under New Labour. Many people feel a great distaste at the idea that this business which is now in real financial trouble, and threatens the security of many very frail elderly people, has been the source of major profits to big business through maximising the profits from property speculation.
There is a need to do things differently. People do not like the sense that their misfortune is the source of profit for other individuals. We should remember Southern Cross and start thinking seriously about community ownership of the care of our elderly.  
The media and local press could be playing an important part in helping promote discussion on these issues.
Steve Field Future Forum.
Steve field has completed his listening exercise for the NHS “pause”.  One of the roles for competition, choice, and other providers that he identified is for better options for end of life care.
Communities have a clear interest in understanding this. If we come together there is an option for community led and community owned solutions. If we do not there will be plenty of big businesses willing to come in and give us “choice” of Southern Cross mark 2!

It is the Job of NICE to lay out guidelines for Cost effective options for the NHS and care systems. They will research and issue guidelines on ways of delivering the best quality we can achieve at the price we are willing or able to pay. They are now beginning a consultation on end of life care which will end in November.  It would be very useful of the Media can share with us the opinions that are feeding into this consultation. The results of it may be rather important.
Terry Pratchett
Terry Pratchett matters. He is doing a wonderful job of presenting the dilemmas that face Alzheimer’s sufferers. He wants us to talk about the right to die. He has made this an issue that far more people have thought about.
A conversation about better ways to die
There are many taboos in this country. One of them is about dying. We have shied away from this. When I was a child many people died at home. They died quietly and peacefully with their family around them and a little reassurance from visiting doctors and nurses.  Perhaps we were less afraid of it. Now for all sorts of reasons death has become a “medical issue”. The incredibly frail elderly people that we are now seeing often need experts working in pairs to move them, and we are frequently looking at families where the person dying is in their 90s and the person caring is in their 70s.
Many people believe that they need the full range of feeding tubes, drips, help with breathing, and pain relief in order to die a good death. This need not be the case. In the case of my own mother, after having seen three distressing deaths with a lot of medical intervention, and after having read up on some of the more modern approaches to death, I chose minimal intervention. In her case at least it was a very peaceful and positive way to die.
We have lost the art of the good death. Maybe it is now time for the media can tackle this taboo and help us to understand the options more fully.

Over the next few weeks I predict an outbreak of discussion on Death Taxes. Death and Taxes are the two certainties in life. Let us hope that we use this opportunity to ensure we all have the comfort of knowing we are creating the conditions for ourselves and all the people we care for to die well.

22 June 2011

A quiet revolution at the NHS Information Centre

Tim Straughan came as a surprise to me.  I am not sure how after three years of following the Stafford Story that day 99 of the inquiry was the first time I heard of the NHS Information Centre. Probably because I have a blind spot for acronymns.
The NHS information system is an important part of the journey to better information about health care. This journey has been going on for many years, and it will continue under this government. It became very apparent that we will be hearing a great deal more of it as it takes the central role in bringing about the “Information revolution” which is one of the key pieces of the NHS reforms.
Take a look at their website http://www.ic.nhs.uk/ which is astonishing.
About us
The NHS Information Centre is England's central, authoritative source of health and social care information for frontline decision makers.
Our aim is to revolutionise the use of information to improve decision making, deliver better care and realise increased productivity.

I have plenty to say about the NHS reforms, most of it uncomplimentary, but where the plans for the NHS Information centre come in I think I feel reassured.
Mt Straughan is a quietly humorous and diplomatic man. He speaks with precision and economy.  He runs a 500 strong team that deals with the data collection, analysis, processing and dissemination of an astonishingly varied mass of data designed to help us see what is going on in the NHS and social care systems.
We do need an information revolution, and the Midstaffs story shows us many of the reasons why.
Midstaffs and information
Throughout the Mid Staffs Inquiry we have been repeatedly hearing about problems with access to information
·         There are people who had access to a piece of information but were missing out on another bit which might help complete the picture. 
·         Bits of information that people think have been hidden have attracted huge and unwarranted attention. This has created ideal breeding grounds for Conspiracy theories.
·         Information has been seriously misunderstood and misused.
·         There are question marks about the quality of quite a lot of data, and it is clear that staff collecting and inputting data do not always have the same understanding as the system designers.
·         There have not been enough trusted people to advise on the quality of information, and many decisions, some of them important ones, have been taken by people who do not understand the limitations of the data they are using.
·         There have been simmering rows and resentments between different statisticians with different ways of measuring things.
·         There has been a major problem with the use of information by the press, which must relate to both the way in which information is given to the press and media, the responsibilities they have to use information correctly, and the options we have for challenging them when they need to be challenged.
Statisticians and Clinicians
What we perhaps see, when we look at the way in which Statisticians and Clinicians interact is a kind of mutual incomprehension. The Statisticians that I have listened to within the course of the inquiry are people who care very deeply about the health service and know that they have something valuable to offer. They know that by helping people to challenge their thinking and see things differently that they can help to transform the delivery of health care. Clinicians are too often swamped by dealing with day to day pressures of looking after individual patients in an overstretched health service, and will often feel quite irritated with what looks like additional things that they are required to do.  
Both Clinicians and Statisticians would agree that the task is to improve safety and quality of care for patients but perceptions of what helps with this will vary.
The interface between statisticians and Clinicians is further complicated by political rows about the effectiveness and cost of the health service.  This often leads, as it did in Stafford, to statistical tools which were designed as an honest tool for assisting clinicians make better decisions, being abused as a political weapon to beat the NHS and the government of the time.  
Often the pressure to complete data inputting is financial or part of the regulatory burden. As the health service attempts to measure performance to ensure value for money then failing to complete paper work on time, or in the right way can have consequences.  The pressure to complete the task without the necessary understanding or attention to detail is a real issue.
The private sector issue
None of this is helped by the conflict between different information companies that has erupted in the case of Stafford Hospital where the views about the quality of the information are in direct conflict, or by the deep hostility that many people within the NHS instinctively feel towards the involvement of commercial companies.
Distrust of statistics used by the media and politicians.
Many people do have a natural scepticism about Statistical information. This is not surprising. A huge number of news stories and the kind of rows that routinely erupt in PMQs are based on Statistics, often wrongly used or wrongly presented, so trust in statistics is being routinely undermined.
The media love dramatic stories, and most journalists are come from an arts background and are not good at dealing with the intrinsic difficulties of probability data, so we get the “swine flu” scenario, with Jeremy Paxman demanding that the chief Statistician tell us how many millions of people are going to die.
Statistics used well can help the NHS save lives, and can help the public and politicians see that they do so.  Statistics that are misused can cause distress, and confusion. 
The Role of the NHS information Centre.
All of this forms a background to the role of the information centre.
We have seen a huge proliferation of different sorts of data, and huge arguments about the quality of data. We are, as Tim Straughan says, data rich and information poor. The mission of the NHS information centre is to cut through these arguments. To make data available to anyone who can make effective use of it.
The aim of the information centre is very ambitious. It is there to gather as much information about the health service as possible in one single place. It will make it available for people to see in the most transparent way possible. The centre aims to cut out duplication, and will work with a range of people who can provide a service of analysing the data. Some will be within the NHS, many will be private sector firms or individuals. The uses to which this information will be put are only just beginning to be imagined. The users will make use of the data with clear understandings of the rules of use. Much of the information they produce will then come under the umbrella of the Information centre. Users are already being invited to set up their home pages within the Information centre website.
Tim Straughan talks about the need for greater confidence in information – The need to be free from political interference. There also need to be the possibility of sanctions against people who breach strict rules governing the use of official statistics. He mentioned that there has already been an occasion where a minister has misused figures on Knife crime which came from NHS sources, and has been given an official reprimand by the National Statistician. 
Given how much time and energy is wasted by exercised like having to fact check just about everything that is said in PMQs and ministerial questions, and the lack of public trust that this generates then I would personally welcome this. We need our politicians to be using good information. We need the press to be using good information, we need both of them to be able to check with authoritative sources, and we need there to be effective ways of challenging them and getting corrections made when they are wrong.
I am not expecting miracles here, but I think that the intention behind this information centre is genuinely to improve the quality of information that informs the public and informs political decision making.
Tim Straughan was asked about what data gets collected. He says that there is a remarkable degree of global agreement on what it is needed to collect.
In the Stafford Case we have got very bogged down in the issues surrounding one particular set of data, the HSMR system. Tim says that we are moving away from the idea that one figure can possibly tell the story, There needs to be ways of cross checking with a wide range of other information. He says the centre is working with 300 indicators that can show us a much more rounded and complete picture.
Health service managers and the public will have access to a dashboard of indicators that will both prevent simplistic observations and help us to see better.
The intention is to carry information about many things including :
·         Outcomes.
·         Complaints
·         Work force Data
·         HSMR
·         Prevention
·         Population health
·         Lifestyles
·         Primary Care
·         Community care
·         Social care.
Moving towards consensus.
The kind of issue that happened in Stafford with the eruption of a dispute between rival information companies is unfortunate, and the information has already played a significant role in bringing the parties together to more towards a mutually agreed system for the future.
Views on Dr Foster.
Tim tells us that there are very mixed views within the health service about the company. Some are firm believers in the system, others are not. Many people felt strongly that the publication of the League table without having made the methodology available, and gained universal acceptance of their methods was certainly premature, and probably inappropriate.
On the subject of transparency Tim can see both sides of the argument. He defends the DFI because He says that they did in fact believe that they had published their methodology in a transparent way, but he also accepts that people found in practice that there was not enough detail to permit people to replicate the results and so people were still not convinced.
Tim is very clearly determined to get people to work together. I believe that it is possible for him to do this. Many of the disagreements that have existed are down to extraneous factors outside the substance of the statistical material. When viewed calmly, and out of the glare of publicity that has bedevilled this issue people can see that this is the case. 
Tims view of the individuals he has met in relation to the Stafford case is a refreshingly generous one. He values the skills, the creativity and the integrity of the individuals involved.  He describes DFI people in particular as sparky people, pushing the boundaries of knowledge.  
One of the issues that did emerge about Dr Foster is that as they were working with the DoH to advise on statistics that they could not bid for the work that they wanted to do. There has been a separation of the DoH from DFI so now there is no longer a conflict of interest.
Francis report and SHMI
The problems between the different groups of statisticians became fully apparent during the first Francis inquiry. He recommended work to resolve that and that is why the NHS information centre brought the Statisticians together to thrash out the framework for the SHMI system.
The Concordat on HSMR
As a result of the work towards SHMI there is now a definitive statement on the limitations on HSMR and the assumptions that can be drawn from it. This clarifies that the use of the 400-1200 excess death figures for Stafford is inappropriate. This concordat which we saw briefly on the screen at the inquiry shows that most of the key players in the NHS, including Doctor Foster Intelligence have signed this.
The Future.
Tim is very proud and optimistic about what is being to develop information systems. It is clear from what we have heard from him and from Richard Hamblin that there is real potential for something remarkable.
Restoring Trust.
Robert Frances picked up on the issues of political interference with statistical information and the need to protect statistics against misuse.  He is suggesting that NHS statistics should be issued through the National Statistics office, and that there should be clear codes of practice to prevent misuse, with penalties for those who do.
The complicated and as yet little understood saga of Stafford and HSMR has been the trigger for beginning a remarkable information revolution.
The future should be very interesting indeed. 

Some people are having problem in posting responses. We are not sure why that is. If you do type a response, please save it, and if you have a problem in posting it contact me through twitter, @mulberrybush
Diana Smith

21 June 2011

A focus on Patient Safety: Stafford Hospital Inquiry. NPSA

MidStaffs Public inquiry Day 102.
Suzette Woodward  is Director of the National Patient Safety Agency. http://www.npsa.nhs.uk/
The NPSA is a small organisation working quietly in the background to try and understand issues which affect patient safety and to try and see what lessons can be learnt, and ways of changing practice for the better.  The existence of this organisation and the amazingly detailed work that it does goes some way to disprove the allegation that the Health service has not had sufficient emphasis on Quality and Safety. The output on their website is impressive. I would advise taking a look. Many safety issues have been identified and directed back the health service for action to be taken. A lot of progress has been made. One could perhaps argue that greater resources would have brought greater results, but funding is always an issue. The organisation is now set to close as a result of the “health reforms”, though some of its functions may be retained.
Dr Woodward worked with the agency since 2003 and became director in 2010.
The perception that people in Stafford may well have formed over the last few years is that adverse incidents quite rare and we have had an unusually high level of them in our hospital. I was of course interested to see if the evidence of Dr Woodward would support this perception.
She tells us that the NPSA now has data on over 7 million incidents.  These incidents are reported to the NPSA at the rate of around 3000 a day; Over 1 million every year.  Dr Woodward says this was initially a surprise to the organisation. They of course knew that “adverse incidents” do occur to around 1 in every 10 people who are treated in hospital, but they had initially been told that the culture of the NHS would be too defensive, and that people would not come forward on a voluntary basis to report things that go wrong.  They expected very small numbers of reports, and Dr Woodward thinks it is a measure of success that people came forward with reports from the beginning and the level of reporting has become steadily higher and more open.
It is probably worth saying that these incidents are graded. They vary from an incident in which there is no harm done, through to actual harm, severe harm and death.  We saw charts of how the pattern of reporting has changed over the 7 years.

As part of the task of bringing about an open and learning culture and moving away from an environment where staff are afraid to own up to mistakes  staff have been asked to get in the habit of reporting very minor incidents, as well as more worrying severe events.   In the open culture that Dr Woodward would like hospitals to foster there tends to be an increasing reporting of No harm and Low harm events, and a very much smaller number incidence of severe harm and deaths. This is where Stafford now is, though it is clear from Dr Woodward’s evidence that they did take time and training to get to this level.

One of the minor issues she picked up on was a matter of Coding. (The legal team are now correctly interested in how the hospital copes with coding whenever we see it, because we know that this was such a major contributor to the concerns about the mortality rates.)  We heard that the hospital initially was misunderstanding the coding requirement. They were coding a number of incidents where there was the potential of severe harm, as severe harm, when in no actual  harm or low harm had resulted. This is of particular importance with issues like falls which are one of the most common kinds of adverse incident.  

Dr Woodward indicated that coding anomalies are quite common with many smaller hospitals, and it did cross my mind that bigger hospitals may be able to support more specialist staff who can handle more of the paperwork and reporting systems. – this is just a thought – I do not know if it is accurate, or if anyone has done any research on this.  What do we know about the way in which different hospitals handle reporting and coding?

At the coffee break in the inquiry a number of people indicated their surprise about the numbers of severe harm and death related incidents for this hospital.

If there really had been unusually high numbers of people dying in Stafford Hospital it might be expected that we should see significantly high numbers in these categories.

Deaths related to an adverse incidents in 6 month swathes from April 2006 – to Sept 2009 came up as 0, 1, 0, 0, 4, 4, 5

Severe Harm incidents for the same period came up as 9, 23, 23, 28, 51, 68, 11

The System does rely on voluntary reporting so it may not give us a full picture, but with the more severe incidents and death it is reasonable to assume that reports would have generally been filed.

What we are seeing here is of course only those deaths and severe harm related to something identifiable that went wrong. Every one of these cases is clearly awful for the families involved. A real tragedy, and it is the job of the NPSA to try to find ways of learning as much as possible from every tragedy like this and to help the NHS to avoid such tragedies in the future.  But the pattern of reporting of adverse incidents for Stafford is something that does not stand out within the NHS.

If there have been unusually high numbers of deaths in Stafford, (which is of course an open and hotly disputed question) it does not look – at least on the evidence we saw- as if the explanation lies in terms of an unusually high level of adverse incidents.

Dr Woodward pointed out that there is a pattern across the NHS that nurses are far more likely to file adverse incident reports than doctors.

Dr Woodward explains that they had different levels of success with different kinds of problems, and there was a tendency to pick the low hanging fruit. If you have a tiny organisation it makes sense to do things that actually make a difference.   If you have a procedure that people were doing wrongly, then it was a simple matter to put out an analysis with this and advice, and work with the locally based advisors to change the procedure. If is something bigger, and she cited the matter of being more open with patients – something we all see as desirable – then this actually entails a massive cultural change, and Dr Woodward felt that you were looking at a minimum of 7 to 10 years to bring this kind of change about.

They had three and a half staff members to cover the 1 million reports they received each year. They had to prioritise, and they concentrated on the Deaths and Serious harm cases. These key cases picked on important things that had gone wrong with serious effect. They then drilled down into the huge data base to bring out evidence of how widespread the problem behaviour actually was within the NHS and to research ways of remedying the problem.

The Big issue of Staffing Levels
We saw some of the reports that had been sent in from Stafford internal Safeguarding system. Most  related most strongly to staffing levels. Some were clearly being written by nurses who were at the end of their tether, had just been doing a really difficult shift, and felt that the staffing levels had made it impossible for them to do their job properly. They read as if the nurses involved were “letting off steam”. They were using this avenue to emphasis the simple point that they did not have enough staff, and using it (as we know from previous evidence) with the clear knowledge that the reporting would increase the evidence in the ongoing staffing level review to argue for an increase in resources.

What we have heard from many witnesses to the inquiry is that during the period 2006 to 2007 staffing shortages were present throughout the NHS. More money had been spent on the NHS than was politically acceptable to the electorate. Money was tight everywhere, and there was no simple formula which would allow a hospital to demonstrate that it did not have the level of staffing it needed to cope with the kind of case load it was carrying.

With no formula to prove need and financial cut backs hospitals all over the country were struggling. For those nurses who were suffering and felt their patients were suffering because of this the reports which reached the NPSA leave us a powerful record of what it felt like to be there at that time.

There is a lengthy section on staffing starting at page 40 of the transcript.  This is worth reading in full. Here are some of the points I picked up on.

·         Staffing levels would not be seen as an issue that NPSA could focus on.
·         It would be seen as a local issue.
·         Royal colleges should be the lead bodies in ruling on staffing level needs.
·         THE CHAIRMAN: So if all trusts happen to be suffering the same sort of staffing shortage/safety issue, they're not  going to stand out? A: Correct.
·         940 incident reports relating to staffing levels at Stafford  between 2005 and 2010

Three reports from nurses given verbatim.

A report from a nurse: "For 18 bedded acute ward only one trained nurse and
6 one untrained on duty. Most of the night shift I start
7 with lots of outstanding jobs from previous shift.
8 Two/three confused patients who climbs out of bed. Some
9 patients who needed one to one care. 2200 hours
10 medications patients are getting at midnight or after.
11 Leaving the ward an going around to ACU/ward 2 to ask
12 for help. Checking IV antibiotics. This staffing level
13 at night shift particularly in ward 2 seriously
14 dangerous and this incident form I have done many times.
15 No action no feedback. I am very unhappy about patient
16 care."

"During the late shift there was no allocation of
21 staff to the four bedded CDU. Upon transferring
22 a patient from minor injuries to the CDU I found one
23 elderly a very distressed patient shouting for help.
24 Another patient said she had been shouting for hours.
25 When I assisted the patient on to the commode her bed
1 was soaked in urine which had started to dry. None of
2 the patients had nurse call buzzers. None of the
3 patients had been given any food or drink."

Yet again the experience and quantity of the
8 trained staff is not adequate to cover the floor safely.
9 There were only two trained staff who have experience to
10 do three jobs ..."

There is a lengthy exchange detween the Chairman and Dr Woodward on P49 of which this is part

THE CHAIRMAN: But if we look at the period during which
11 this was happening, what look on occasions to be quite
12 distressed members of staff are reporting distressing
13 incidents saying nothing has been done about it. If we
14 assume for the moment that the trust management was not
15 listening or capable or for whatever reason doing
16 anything about it, who else was?
17 A. Those types of incidents would not, unless the patient
18 had died, been generally reported as serious untoward
19 incidents. So it's unlikely that the PCT or the SHAs
20 would have been looking at those incidents. So it is
21 highly reliant on a good local risk management system.

This all raises some very difficult issues. It raises a stream of questions in my mind.
If it is something as fundamental as the level of staffing required to run the service well, then this is essentially like the elephant in the room.  You cannot see it in comparative data, because it is something that is happening across the board.  You cannot resolve it because there is neither the money nor the political will to do so. People will vote to protect the NHS, they will not vote for the taxes necessary to carry this through!
It is virtually impossible to agree a formula for staffing levels, because there are so many different vested interests. It becomes increasingly difficult as we shift to Foundation Trusts where staffing levels becomes commercially sensitive.
If the staffing levels are too low either in some or in all hospitals, then I think it is reasonable to assume this will increase the likelihood of adverse incidents.  As we heard in the evidence from the HPA a hospital operating under great stress is much more likely to suffer problems with infection.
People are not superhuman. If you put them under too much pressure individual staff will either work themselves to a standstill or standards will slip.

Mortality Rates
Dr Woodwards statement makes mention of the HSMR mortality rates, she has been asked to comment on why the NPSA did not pick up on the increased mortality rate identified by the Dr Foster Figures. Perhaps the underlying assumption behind this question is that if there were to be unusually high levels of mortality in a hospital then one might reasonably expect that some of these additional deaths would have to be accounted for by adverse incidents.
Dr Woodward points out that the NPSA does not rely on HSMR. The NPSA is looking at actual incidents and will only be notified of those  deaths which have been caused by an incident.
Dr Woodward does make reference to the need for a hospital to understand the systems for coding mortality, and especially co-morbidities well, in order to be able to gain reliable data from their mortality rate systems. 
The Seven Steps to Patient Safety
This is a simple way in which the NPSA has tried to bring about a safer culture within the NHS. You will find all the documentation related to this on their website.
The steps provide a simple checklist to help NHS organisations plan their activity and measure performance in patient safety. Following them will help ensure that the care they  provide is as safe as possible, and that when things go wrong the right action is taken. They will also help NHS organisations meet their current clinical governance, risk management and controls assurance targets.
The steps are:
1. Build a safety culture.
2. Lead and support your staff.
3. Integrate your risk management activity.
4. Promote reporting.
5. Involve and communicate with patients and the public.
6. Learn and share safety lessons.
7. Implement solutions to prevent harm.
 Looking to the Future.
Like many organisations in or close to the NHS, the future is uncertain. The NPSA will cease to exist, some of its functions will be taken up by the Commissioning body.  It remains to be seen what effect this will have on peoples willingness to report adverse incidents. Will this improve or threaten the desire to create an open culture.
There are many things that Susan Woodward would like to be doing now, but the re-organisation is taking its toll. Many new projects cannot now begin until after 2012. At the moment the priority is to  write legacy documents. I suspect these will be the matter of many future academic studies where we look back to see what we have lost.

Here are a few items off the NPSA website. Take a look! Nil by mouth study and recommendations http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94854 http://www.nrls.npsa.nhs.uk/resources/collections/never-events/ never events