29 September 2011

How do you really know you have the right staffing levels at your hospital?

Calculating the right level of staff for a ward is not a simple matter. Midstaffs shows us some of the pitfalls that other Hospitals are falling into right now.
The Background.
Two things I have learned from the months of listening to evidence at the Mid Staffs Public inquiry are : that there is nothing easy about running the health service; and that we go through periods were thinking  about the NHS is focused on particular themes.  
The priorities of the last ten years were how to stop people dying on waiting lists, or on trolleys at A&E, and how to tackle alarming hospital infections.  Now that these problems are largely resolved we are thinking about quality in other ways.
As life expectancy has grown, we are now seeing many very old and very frail people in our wards, and the Mid Staffs story is in part about what happens when we have not fully grasped the size and complexity of this problem.
The current focus on staffing levels and staffing mix.
A major criticism of Stafford Hospital is that the Staffing levels and staffing mix were wrong.
Midstaffs is by no means alone in this, and the high profile statements from Peter Carter of the Royal College of Nursing show us this is a major national problem. The staffing levels that we have in the hospitals are not high enough to allow us to deal as well as nursing staff would like with the very frail and very dependent people that there are in many wards.
Peter Carter is provocative on this issue. He uses the press to forcefully make the point that hospitals are not doing a perfect job, and that they cannot do all that is needed. He suggests that families can and should play a part in providing some of the basic care including getting people mobilised and making sure they eat.  It was designed to get a reaction and it did.
There have also been a series of high profile statements about the fact that increasing amounts of care are being provided not by trained nurses, working within a professional code, but by untrained and unregulated care staff, who may or may not be able to do what they are expected to do.
Why Midstaffs got into a tangle with Staffing.
The Mid Staffs Public Inquiry has been wrestling for weeks with the question of staffing levels and staffing mix. What all the witnesses have said is that you cannot set staffing levels. There is no hard and fast measure, no formula a manager can refer to, you have to work out what is right for each ward.
 David Nicholson, in his evidence finally threw some light on why the levels were probably wrong at Stafford, and why the managers did not at first see the problem.
The hospital had, as all hospitals now have to do, to work out how to balance their books. David Nicolson explained this had happened when the big story run by all the media is that we were spending too much on the NHS, and it was therefore essential to cut back any unnecessary spending. This meant rationalising the work that hospitals did. Stafford were perhaps ahead of the game in believing that the right thing was to have less beds, and to keep people in for less time, so they reduced the number of beds and reduced the number of nurses in line with this. So far so good!   
But …. This only works if you actually have less people coming in and you are able to move people out faster.  Achieving this means that there has to be a fully co-ordinated approach with the GPs and primary care, in treating more people at home, and with Social care in having transitional care or residential care beds to pass patients on through the system.  These things did not happen.
The result of this is not good. The same number of people kept on coming through A&E. The beds filled up so that some patients end up in an assessment unit, for which the hospital had insufficient trained staff. More people are passing through the beds in the wards, causing increased pressure on admin, cleaning and nursing, and because many of the care homes in the area had recently closed you end up with bed blocking with a build up of the most highly demanding patients who are simply unable to be discharged to their own homes.  My guess, though I do not have access to any records to prove this point, is that the level of nursing and care needs of the patients within the ward increased dramatically.
This is like boiling a frog. Maybe in the first few weeks people would have been coping, but the effects of this are cumulative. It would have been steadily more pressured, and once managers had understood the problem it then took months to get the approvals to recruit more staff.
What do you count? Beds or Patients?
David Nicholson explained it simply.  The Hospital management thought in terms of nurse to bed ratio which looked pretty much as it always had been.   The changes to have a higher level of care assistants to nurses would also have looked justifiable, because the case load did have many people with low nursing needs but high care needs.  The measure that he says the hospital should have used is the Nurse to Patient ratio, which would have told a different story.
This, as an indicator of how many staff you might need, (and the Vacancy factor which attempts to tell you how many staff you have - I could not get my head around this!), are not straightforward, and the fact that the managers, the board, the govenors, and anyone else with an interest in the hospital could not see the problem should come as no surprise. David Nicholson himself said he would have been hard put to see it.
Like everything else that I have seen about the Mid Staffs story, this is not a story of callous disregard for the welfare of patients, it is about something that did not work out the way it was intended to do.  
Why we urgently need to learn these lessons now.
The reasons why it is important to tell this story are apparent if you look at David Nicholson’s vision for the future of the NHS. What the management of  Midstaffs were trying to do, is something that many other hospitals are trying to do right now.  Everyone is looking for Cost improvement programs. Where are they going to find them?
Look at the intention.
·         Keep costs to a minimum.
·         Do not use more wards than you need.
·         Do not carry surplus staff.
·         Employ care staff to carry out caring functions.  
·         Put in the community support to keep patients at home under primary care.
·         Discharge patients to their homes or to other care facilities unless they need acute care.  

All of that sounds like good practice, and it is exactly what Midstaffs probably tried to do.

For any hospitals that are working on their cost improvement programs the only safe lesson to take from Stafford is that you have to assume for any action that you take that there may be unintended consequences. You have to actively monitor the effects of any change you make on staff and patients.  If your staff are telling you they are feeling the heat, you had better believe them.   

Why the Royal College of Surgeons report is a good news story.

I woke to the radio telling me what appears on the face of it another terrible story about the NHS. The Royal College of surgeons report on the Higher Risk Surgical Patients has been issued and shows the real possibility that substantial numbers of seriously ill patients, who perhaps could have been saved, may have been dying.
First let me give some well deserved praise to the BBC Radio 4 Today Program. This is a story which lends itself to the kind of sensational reporting that I as a close observer of how the Mid Staffs story am all too familiar with.  Today gave the story time. They gave it two separate slots  http://news.bbc.co.uk/today/hi/today/newsid_9602000/9602878.stm and http://news.bbc.co.uk/today/hi/today/newsid_9602000/9602924.stm
They attempted to get behind the alarming headline figures and explain that this is about very seriously ill patients whose low risk of survival might possibly have been improved by better organisation of the way in which the hospitals work.
They avoided blaming the problem on junior doctors, and allowed it to be seen in the context of how hospitals work and the priorities the NHS has needed to follow over the last decade.  
There have been enormous improvements in elective surgery over the last 10 years, largely as a result of getting huge waiting times down,  but this might have happened in part at the expense of the Accident and Emergency systems, which are now showing signs of stress, as the report shows, throughout the country.  It is clear that as surgical techniques have improved the possibility of helping people who would have been seen as beyond help some years back is now real, and should be acted on to give people the best chance of survival.  
One particular thing I would praise the BBC for is that in the second interview they had two specialists being interviewed together. This completely changed the dynamic of the interview and allowed a much more balanced picture to emerge. Well done BBC. Please do this again!
The papers were perhaps less nuanced Here are a few reports.
My personal feeling is that this report is some of the best news I have heard on the health service for some time.
Viewed from the perspective of Mid staffs It certainly put the most worrying problems that the #midstaffsinquiry has mentioned into a very different perspective.  The problems that did occur in Midstaffs A&E need to be viewed as problems of the whole care pathway in the hospital, but also to be seen as something that is common across the country as a whole.
I have been watching with interest as the Care Quality Commission develop their Specific Mortality Alert system and I think this is what has made it possible for the Royal College of Surgeons to begin to pin point the problems that are occurring. If so this is a positive story for the amazing strides being made with NHS information systems.
It is clear listening to the #midstaffsinquiry that many specialists have close links with specialists in different parts of the world and are actively looking to how performance can match the best the world can offer. So this is a positive story of international co-operation.
The Midstaffs story has been a nightmare for anyone from Stafford, where we found ourselves at the heart of a confusing media storm, but it has had positive effects. The Public Inquiry has done much to show where there were real causes for concern, and even if the general public does not yet know this, many within the NHS know that many of the problems that occurred in Stafford are common throughout the NHS. So this is a positive story of an NHS ready to be much more self aware.
The big positive effect of Midstaffs will I think be that Clinicians will assert themselves. They will  see the point of raising concerns themselves, and demanding the support they need to take the right actions.  
The RSC report is of course a tragedy for all those very ill patients that could not be saved, but it is a moment of real hope for a very positive future.     

27 September 2011

Could there be any common ground on the Health Bill?

When the eminently reasonable Stephen Dorrell spoke at the #healthdebate at Labours conference I was glad that he was given well deserved applause. He was doing something that far more politicians should do; Venturing into enemy territory, speaking directly to people and searching for common ground. 
He made the point that we often hear from Conservative speakers that the Health Bill continues policies that were already in place. Until last week I might have dismissed this, but as I have listened to the witnesses from the Department of Health at the #midstaffsinquiry  I think he may well have a point.
The Mid Staffs Inquiry has been an astonishing experience; A rare opportunity to see and begin to understand the complexity of the NHS; A chance for all the different organisations that make up this vital part of our countries life to re-evaluate what they are, what they do, and how they relate to the other parts of the system.  It has also laid out for us where things went wrong in what the chairman is now tentatively describing as a whole system failure, and pointed to the changes we may need to make.  
I do not think there will ever be a clear cut agreement about what actually went wrong at Stafford, though the Inquiry will remove many of the false certainties, but Stafford can show us the way forward for the NHS.
The inquiry has been an exercise in trying to find the truth, and that is not at all easy. What we hear as the general public is always filtered. The press and the media give us fragments of stories, and fragments of what politicians say.  The politicians use the media to try to sell the policies that they are attempting to drive through the wheels of government.
The press do what the press do. They present issues in terms of debate and conflict; This side, that side; Dramatic changes in direction.  The battles that turn it all into soap opera; matters of personality, people we love, people we hate. 
Listening to the Ex ministers and to the Department of Health spokesmen I see that this is not the way it is.  Ministers are there to represent us.  In some cases, as with Andrew Lansley, and Michael Gove, they have arrived in position with their own set of passionately held dreams – a vision of the future they wish to create. When they get there, they always find that power is not all it is cracked up to be. Having a vision is one thing, turning it into reality is another.
The DoH as everyone who has listened to the evidence at the Midstaffs Inquiry has heard is packed with people who really do know their subject matter inside out. They understand the sheer difficulty of bringing about change in something as complex and interconnected as the NHS. They will bring to the minister’s sketchy vision the depth of knowledge that can make parts of it work, and they work with tact and diplomacy to modify or remove those parts that are potentially damaging.  It is the Civil Servants job to keep the spirit of their service alive from one minister to another and one government to another. They are there to help us.
It is in this complex dance between elected politicians and appointed civil servants that legislation is brought together, and as the tools for public consultation become stronger the public and potentially the press can play an increasingly strong part in helping legislation take shape. 
As a grass roots Labour party member my dislike of the Lansley plans was strong; Strong enough to get me marching for the first time in 30 years.  But now, having listened to both Andy Burnham and the civil servants I can see that there is much within the Lansley plans which are as he has claimed – a continuation.
·         The quality agenda is being driven in part by the embryonic new information systems which developed under the last government and are now reaching maturity. It is also driven in part by professional concerns about how best to improve standards.  This would have happened anyway.
·         The decentralising of responsibility and the integration of primary and secondary health care with social care is necessary to deal with the challenges of the future and was happening under Labour anyway. 
·         The impetus to help or force hospitals into governing both quality and finance better is necessary and would have happened anyway.
·         The emphasis on the patient voice is in part what Midstaffs has added into the equation. All parties theoretically agree that a stronger patient voice is needed but there is no agreement about how this can be effectively done. I suspect we will spend the next decade trying to work this out.
There is substantial common ground. There is no need for many of the changes to be presented as radical or new. They are simply stages on a journey.  There is no good reason why all parties cannot drop the rhetoric and co-operate on the areas I have outlined.
There is a stumbling block is this – The major structural changes, and increased competition which Andrew Lansley sees as essential , look from the viewpoint of the Midstaffs inquiry room to be both unnecessary and harmful.
There are two main theories on what happened at Midstaffs:
·         The orthodox version, espoused by the press, is that this was a major disaster which nobody saw because of faulty regulatory systems and the failure of communication between a series of organisations that had just undergone major structural re-organisations and were therefore in turmoil.   
·         The alternative version, which I share with many of those closest to the hospital and many of the regulators, is that there has been a significant distortion of the facts.  See http://pressreform.blogspot.com/2011/04/what-forms-our-perception-of-stafford.html , and that the problems at Stafford are both less serious and much more widespread than we have been told. These problems that do exist reflect the key challenges that Andrew Lansley has correctly identified for the NHS; Challenges that are set to increase over the next three decades.  Those people who are close to my way of thinking on Midstaffs  believe the turmoil caused by the series of structural re-organisations left the regulators in a weak position to deal adequately with the major moral panic that arose.  
 The one thing which unites most of the people watching from the public room at the Midstaffs Inquiry is that Stafford cannot and should not be taken as a justification for the changes Andrew Lansley wants to make. The Inquiry will not prove the case for structural change, and it may well prove why structural change is the wrong answer. Whatever it was that happened in Midstaffs is much more likely to happen at times of structural change and financial pressure.  We are creating the perfect breeding ground for future scandals right now.
If I had the opportunity to talk to Stephen Dorrell and Andrew Lansley this is what I would ask them to do. Put the Health bill on hold. Do the bare minimum to stabilise the system and to stop the haemorrhage of talent that has already taken so many people from the system.   Allow people to see the Midstaffs report and learn from it; Consult widely; Trust the Clinicians and the patients and set them free to devise the structures they require to do the job; Seek the common ground that does exist, and continue to build on this.  Then come back with a better and more consensual bill.

22 September 2011

Midstaffs inquiry: First impressions of the Department of Health

Early impressions on the Department of Health witnesses.
I wanted to put up a holding blog to let you know there is more to come!  This is a busy time of the year dealing with the harvest, but also the hearings over the last couple of weeks have been so dense and so interesting that it is quite hard to know where to begin.
I feel the need to work on the material slowly and carefully to do it justice.
I will say that hearing from the two ex ministers, Andy Burnham and Ben Bradshaw, and hearing from a number of people from within the Department of health has been a real education.
We are all used to seeing Ministers called to account at the dispatch box whenever there is some scandal within their realm of responsibility. This gives the impression that they are intimately involved with the detail of decisions. I think this is in large measure an illusion.
Listening to the explanations of how a particular decision was signed off has made it very plain to me that things are not remotely the way they are portrayed in the press.  In many cases it is nonsense to think in terms of blaming a minister for following the carefully made recommendations of his advisors.  
A minister sits at the centre of a huge web of information.  They can at the end only know what is fed up the line to them, and information is filtered and refined at many stages before recommendations are passed by the civil service to the minister.  The question that has been asked all the way up the line on the Midstaffs question, is if things were going so badly wrong at the hospital how is it that no one knew.  It is pretty clear that the minister could not have known. No one close to the hospital saw a problem, so there was nothing to ring any alarm bells at any level.
In the Midstaffs case, most of the dealings with the hospital were not a matter for the department of health. The Health care commission, the Care Quality commission, and also Monitor are all set up with the explicit intention that they should act as independent regulators. The minister cannot, should not, and does not involve himself in their operations. In the case of Midstaffs the ministers were concerned and they or their advisors asked questions and offered support, but they also respected the independence of the regulators.
One thing that should be clear is that a minister is not there as an expert. That is not their function. They are there essentially as an ordinary people, elected by us in order to represent us and to ask questions on our behalf.
It is clear that the Department of health contains many incredibly skilful civil servants with a deep knowledge of both their specialist fields of knowledge and of the constraints on action.
In the event of some public crisis is the minister that is sent in to bat. In the matter of carrying out policy the civil service will do what they can to carry out the ministers bidding, but they also have a role to advice ministers against ill-considered actions. It is good for us that this is the case. People often comment on the way that big scandals or tragedies tend to bring about illconsidered and ineffective legislative responses. That is often what happens when public and press pressure override the natural caution of the civil service.
There is a tension. Many of the things that we need government to set in motion, improvements that will give us better services, forward thinking proposals, are ideas that are worked through and tested for years. Ministers often think in a much more short term manner. They need to be able to stand up at the ballot box and answer hostile questions today.  They need to be able to fight for scarce resources. They need to be able to persuade the press and the electorate that they are doing a good job, with eye catching initiatives.
If we think of “Yes minister” there is the sense that the civil service can at times prevent things from being done, I am not sure that that is how it is.
At the inquiry We have been looking at four themes, Foundation trusts, Quality, The Patient voice and Commissioning.  What is striking with all of these is the degree of continuity that exists. 
Foundation trusts began under the last Conservative government,  continued and developed under Labour, and have now been given additional impetus by the coalition. They have been seen as desirable by all parties because they all recognise that there is a genuine need for organisations to manage their affairs more closely themselves, in accordance with local need.  (Ministers all probably also want to ensure that when a hospital scandal blows up, as they do all the time, that a Foundation trust is a sufficiently independent entity for the minister to be able to say "This is not my responsibility").  Ministers all recognise that there is an element of unreality in the claim that your hospital can be “run” from Whitehall.  Midstaffs has revealed some serious problems with the Foundation trust model, but these will need to be resolved, because this is the direction of travel.  
Quality, if you listened to the press in the run up to the election,  and to the current government was the discovery of Andrew Lansley, but we discover that Sir Liam Donaldson has been working on the agenda of quality continuously since 1998, and that there are many very well developed tools for developing and driving up quality, some of which are now going to be dropped, or placed within new organisations. Much progress has been made, but like many of the big challenges faced by successive governments it is very difficult to do. There are real breakthroughs now. The idea of measuring quality has been made possible by the development of impressive new statistical and information tools, and made essential because of the political imperative of listening to the patient voice.  
The Patient voice, is also claimed by Lansley as his creation, but again it has been a growing pre-occupation of the last decade.  The success of the midstaffs  pressure group in attracting the political patronage of the conservative party has now meant that ways have to be found to pick up complaints more effectively. This is another area where everyone agrees that it must be done, but no one has yet found an effective way. The methods are still evolving, but the information technology to help do this job is very likely to be in place within the next few years.
These are good developments, It should make government much more responsive. No doubt if it all works out much credit will be taken for it, but it owes much more to developments in the wind and the skill of the civil servants than it does to any genius on the part of ministers!
GP Commissioning is the big new idea of the Lansley Health reforms, but it has been emerging since 2002 as practice based commissioning, These have acted as trial runs for the reforms that will happen in some form.
The civil servants are showing us how much can be done by evolution.
I am left after hearing from the civil servants with a strong wish that we could calm down the noise around politics, the need for big initiatives, big changes, eye catching stories for the press. We can do all of the things that need to be done without the big structural changes.
So far, the ministers in this government have been in a mad tearing hurry. If they could slow down do less and listen more maybe we would all be better served.

21 September 2011

Care of the elderly can be shocking.

For most people their first experience of seeing Geriatric care can come as something of a shock.
I was speaking to a retired NHS manager who told me about the geriatric hospitals he saw in the 60s. Nightingale wards with 90 patients. At night there were two staff. The beds were around 2 feet apart.  It was part of the night staffs duty to get the ward up, dressed and sitting out by the time the day shift took over. In order to achieve this they began getting patients up at 4.30 in the morning.
This style of ward is perhaps ideally suited to being able to keep an eye on vulnerable and confused patients at minimum expense. The cost is that there is no peace, and no privacy.
I remember visiting geriatric wards in a converted poor house in Edinburgh in the 70s and seeing  40 or 50 elderly confused people sat round the walls of the day room. The television was on, but no one was watching. Sometimes an old lady would try to get up from her chair, and would be sat down again by an assistant, fearful of falls. This kept old people safe, but denied them their most basic freedoms.
By the time my own mother was suffering from dementia some 30 years later things had changed. The improvements to medicine and surgical care meant that people were surviving much longer, so that many of the patients were dependent in ways that were quite new.
Patients who suffered strokes, could be treated with very effective drugs to prevent a second stroke, and could survive for years in a highly impaired state. If they could no longer swallow then they could be fed through peg tubes.
Operations for Cancer and for broken hips, that would have killed patients in the 70s were routinely survived, leaving patients alive but in very poor health.
When you see care in action you see the casual indignity of the use of incontinence pads, for people who would rather be helped to a commode. You see people being dressed in clothes that are not theirs. You see all the small choices that we take for granted stripped away.
The press now has an interesting relationship with stories of care of the very old. It is something that does touch us all, because we can so easily see this could be our parents, our friends. It could be us.
The convention is that we do not see faces, because this could be exploitative, so we tend to see pictures of withered hands.  In many cases this is all we see. Our elderly are locked away in nursing homes. They are invisible. The connection is not there.
We have had, perhaps especially since the Midstaffs Healthcare commission report hit the press, something of a vogue for bad care porn, where we hear in all the shocking detail the highly uncomfortable facts about management of bodily functions.  Perhaps I am not as shocked as many are by this. After nursing my mother for many years, changed many wet pants and seeing her pretty dramatically covered in faeces on three occasions I am aware that on occasion s*** happens.    
Our willingness to accept that on many occasions these indignities are no one’s fault, is a little further eroded by every new press scandal or undercover television special that we see.
The willingness of decent caring people who are really suited to providing the compassionate care older people need to become nurses, is probably also eroded by every emotive story we hear of cruel and uncaring staff.
What has bothered me as I listen to the evidence from the #midstaffsinquiry is that we have wasted so much precious time in seeking to find out “the truth” and who is to blame.
There have been real benefits from the Stafford process.  Valuable systems to help judge the quality of care better have been created over the last four years.  The Dilnot report on Care funding which is this government’s response to the work on Care funding done by the Labour Government in its last term has now reported and may be offering us better ways to fund the quality of care that we want, in different settings. This is a separate issue, but essential to make hospital care work.  All this is good – but there is so much more to be done.
One of the distinctive features of this government is that it is decentralising and cutting, so we in our communities will now have the responsibility of specifying and taking the financial decisions on the care that we want for our older people.  For all the people who have been watching the #Midstaffsinquiry the level of responsibility that will now fall on local people without the expertise to do this job is terrifying.
Will the press who brought us the care porn, and relished the search for people to blame now turn its hand to helping communities work together, putting party barriers aside, to find solutions to our shared problem.

18 September 2011

Dr. Foot v the Daily Express

My Grandmother was a reader. She had shelves stuffed with every genre of book imaginable. As a small child, one in particular held a particular morbid fascination for me: 'Dr. Foot's Handbook of Health Hints and Ready Recipes.' It was printed in the late 19th Century and Gran's copy had hand-drawn illustrations of 'humours' as well as the outward manifestations of smallpox, consumption and the like. I'd spend long minutes staring at these with an almost delicious frisson of fear, unable to resist their lure.

The book was published long before the appearance of the modern Desmond-owned Daily Express, but even though it would now only be considered useful as an interesting, amusing historical document, it probably held between its covers far more reliable information and remedies than those to be found between those of that paper!

As a fully paid up, card-carrying hypochondriac, easily convinced whenever a symptom of the latest disease is mentioned that I have it and am about to shuffle off this mortal coil, the frequently sensationalist and misleading front page headlines of the Daily Express are cold comfort. 

Headlines like the one below from September 17th:

Is new radical treatment offered? It seems not judging by the article itself which quotes from a medical source:
'Taking more exercise, eating more fruit and vegetables, reducing alcohol intake and slashing the amount of saturated fat in our diet could drastically reduce the toll of Britain’s biggest killer and save the NHS up to £3billion a year.'
Jo Willey, Health Correspondent
 Really? Good Heavens! Who would have imagined such a simple course of action might do the trick? Thankyou Jo Willey, 'am forever indebted...

And then there are the contradictory statements, in this case in articles by Jo Willey and Jeremy Wright:
'Every year 17,500 people die in the UK from cardiovascular disease and strokes caused by eating too much salt...'

'SALT is safe to eat – and cutting our daily intake does nothing to lower the risk of suffering from heart disease, research shows.'
July 6th 2011 Jo Willey, Health Correspondent

One wonders if they often meet to bicker over health scares by the newsroom coffee machine......

Speaking of health scares - below is a very small sample of the often lurid, usually scaremongering, always exaggerated and misleading headlines which have probably caused palpitations in the hearts of even the most stoic, fatalistic of readers: 

How on earth, one might ask, did people all those years ago manage without the Express to discover a new threat and then the cure for it?

Dr. Foot, for all his failings, was writing well over a hundred years ago and could at least plead lack of scientific evidence - what's the Express' excuse, I wonder?

8 September 2011

What the NHS can learn from Stafford's ordinary hospital?

The following piece has been written for Guardian Health Care Network  You will find it here  http://www.guardian.co.uk/healthcare-network/2011/sep/08/mid-staffordshire-nhs-learn-diana-smith.

Should we treat Mid Staffordshire as a pretty average trust which hit a bad patch without seeing any warning signs?

Stephen Moss, the chairman of Mid Staffordshire foundation trust, worries that the NHS has not learned from what happened at Stafford Hospital. In June, he asked a session of 120 hospital managers if they had read the key reports. Only 20% indicated they had. http://www.expressandstar.com/news/2011/08/31/nhs-turning-blind-eye-to-stafford-hospital-scandal-says-boss/
Why is the interest so low? Here are some possible reasons:

1. The media coverage of Stafford shows us something so extreme that it clearly has nothing to do with any ordinary hospital;
2. Within the NHS there are major doubts about the Healthcare Commission investigation and specifically about the leaked 'excess death figures' that dominated the press coverage. Given these doubts the report may not be top of the required reading list.
3. Robert Francis' independent report is a remarkable piece of work offering deep insights into the workings of the hospital and the sobering perceptions of patients, but it is 800 pages long and it was dismissed by both the protest group and health secretary Andrew Lansley, both of who wanted a public inquiry. Senior NHS staff may therefore have been uncertain of its importance.

I would strongly suggest that NHS managers should take interest because Stafford is to all appearances such an ordinary hospital. The press coverage of the public inquiry - which started again this week - may focus on the three minutes of a day when a witness appears to say something dramatic, but this is selected from six hours of nothing very remarkable.

We have heard from many people who get on with their jobs in the face of frustrations shared by service providers everywhere. We saw staff, managers, regulators, councillors, governors, GPs and politicians who all shared the same experience. No one had any warnings that there was a problem until the press stories began, at which point everyone was overwhelmed.

What does this mean? I think there are two equally worrying propositions. Either there were problems on a truly appalling scale but none of our regulation systems could see them, or this was a pretty normal hospital going through occasional bad patches. If the latter is the case, then the scandal which has toppled the management, caused massive loss of public confidence, forced dozens of people out of their jobs and cost well over £10m so far of tax payers money may be effectively based on the failure of the hospital complaints system.

It is worth remembering that the events that led to the inquiry began with one very determined and very unhappy relative. How well would your hospital deal with that? If I were an NHS chief executive I would be asking myself the following questions:
- How do we know how good our basic nursing care is?
- Do we have systems to help us learn from mistakes?
- Are my staff actively supporting people visiting sick relatives?
- What help do we offer to people who are suffering a difficult bereavement process?
- Does the complaints system work for the patients and their families? Do we give good support to staff who are handling difficult complaints?
- Are there advocacy services which will support angry patients or relatives to conduct an effective dialogue with us?
- Is the Links/HealthWatch system in our area working?
- Does our community see our service as open, transparent and responsive?
- Do local politicians know enough to ask the right questions?
- If we had an implacable complainant would we be able to convince regulators, the press, the public and politicians that our hospital is doing a good job even in the face of hostile questions?

Whatever it was that went wrong at Mid Staffordshire occurred at a time of cut backs, staff reductions, structural re-organisations and political turbulence. The specific mix of circumstances that produced Stafford is unique, http://pressreform.blogspot.com/2011/04/what-forms-our-perception-of-stafford.html  but other hospital scandals will occur. The question is, when and where? Studying Stafford Hospital may help to ensure that it is not your hospital.

Diana Smith @mulberrybush runs community website Stafford Direct where she writes on local issues(http://stafforddirect.ning.com/),
blogs about media reform and Stafford Hospital http://www.pressreform.blogspot.com/
and comments on Guardian.co.uk as Wildsloe (http://www.guardian.co.uk/discussion/user/wildsloe)