Reasons to be cheerful at the Midstaffs inquiry.

At the end of the seminar held at Leeds on information in the NHS the Chairman Robert Francis said that the day had cheered him up. I shared this feeling.

We heard from people who are actively using information technology now within the NHS to drive up the quality of care.  There is a quiet revolution in progress. 

We heard how in 2000 Information technology was still in its infancy. We heard about the long time lags between events and the eventual statistics, and the very variable quality of data. All this meant  meant that clinicians did not have any trust in the emerging early systems, of which HSMR is an example.  We heard about the problems of Clinicians accepting information that was provided to them by outside agencies, and how important it is for clinicians to feel they own the information.

We heard how the speed of the information revolution has been accelerating, over the last four to five years.

The people who presented papers to the seminar included Professor Martin Elliot form Great Ormond street and Dr Dave Rosser from University Hospitals Birmingham NHS Foundation trust. They are both part of organisations that have completely bought into the use of information.

Great Ormond street did this by closing an intensive care bed, to fund the project. The savings and quality improvements that they have made through good information have now made it possible for them to fund two intensive care beds.  

Birmingham has 16 analysts who work on giving the clinicians real time information. They allowing the clinicians to develop the indicators that they believe they need and help them use these systems to improve quality. This is paying off both in terms of quality of care and demand for their services.         

The work they are doing is remarkable.

The trail to the seminar that I heard on BBC Radio 4 Today
http://news.bbc.co.uk/today/hi/today/newsid_9618000/9618445.stm  told us that one of the things the Birmingham system can do is to issue prompts to ensure that nurses do not miss giving doses of medication to patients.  This is a remarkably common problem within the NHS. Giving antibiotics or insulin late does cost lives.

This system is particularly relevant to the Midstaffs story because the Gillian Astbury Case, is one of small number of symbolic cases that Cure the NHS have pursued. This is an all too common case of an elderly lady with dementia and diabetes who did not get the specialist diet that a dietician had prescribed, and died because she had not received insulin at the right intervals.  Failure to administer insulin on time is common throughout the NHS wherever hospitals are relying on paper based note systems.  Dr Rosser reckons that potentially 16,000 lives a year can be saved by using his prompt systems.

We also heard about decision support systems, which act as guides to help doctors and nurses through their decision making processes. When this was first implemented the analysts were surprised by the 400 occasions a day where the system was challenging the course of action that the clinician was planning to take, though they point out that this represents only 1.8% of the clinical decisions that are made. I in 10 people in hospital currently experience an adverse incident. These information systems have done the work to understand how many common errors are made, and to help eliminate them by supporting doctors and burses better.

Dr Rosser also told us about their system to cut MRSA.  If a swab tests positive then as soon as it is entered on the system the ward is alerted by an email message. Action to prevent spread of the infection can be started within seconds, rather than the 30 hours that was common when they used paper based systems. This saves lives.

Dr Rosser showed us a series of graphs where the information systems had alerted the hospital and clinical teams to opportunities for improvement. There are two key ingredient in making the system work. There are the statistics, and there are face to face round table meetings with staff on a regular basis when they look at the issues raised, challenge each other where there are weaknesses  and decide collectively on the action to be taken. The Birmingham graphs show a dramatic story of what happens when a problem is identified and the clinical teams take a concerted effort to make a significant change.  You get a “step change” where you can see the shape of the graph change radically. Whenever that happens it means many individual patients get a far better service.  

What makes me cheerful about all these developments is that it shows that getting information right can move us from a position where we a seeking to punish individuals for failings so far after the event that no one really knows what happened, to using information to support decision making, help people get it right first time, and allowing clinicians to drive a process of continuous improvement.

A good aspect of this is that it cannot possibly be seen as political. This is about harnessing the new potential of information systems and combining it with the real creativity of some of the brilliant analysts that we have within the NHS.  Everyone should support these developments.

There is a bit of politics though!  Birmingham has offered to release their system free, to get it in use throughout the country and start saving lives. The government wish it to be issued on a commercial basis.

The seminar papers will be available on the Midstaffs Inquiry website in the future.

Should Stafford Hospital be cited as support for the Health bill?

Most of the speakers lined up to speak on the health bill in the Lords are not Conservative. One that was took the view that it was self evident that the health service must be subject to structural reform because it had failed.  I know this is the perception that has been fostered for more than two years now in much of the national press, and I question where it comes from, and how well founded it is.

There are all the ingredients that we have heard so many times, Nurses that are “too posh to wash”; Hospitals full of bureaucrats rather than nurses and doctors;  Top down targets causing bullying and lack of emphasis on quality; Doctors that do not speak English as their first language; all these “explanations” for what may have caused perceived “failure”, a perception which ignores all the international evidence on productivity and the national evidence of patient satisfaction.

I have spent a great deal of the last nine months sitting in the public gallery at the Mid Staffs Inquiry. Stafford is “exhibit A” of as an example of a hospital that failed, and I suspect Andrew Lansley set up the inquiry with the full expectation that it would be the justification for the major structural reforms that he wishes to make.

The press and media coverage of the Stafford Hospital story has been seriously distorted from the very start, relying on the “excess death” figures.  This has fostered the story of a hospital where hundreds of people died unnecessarily, without anyone apparently noticing anything unusual.  If it had happened that way it would of course be deeply disturbing. The inquiry has heard a great deal of evidence to show why it is that these figures, which were based on data that is accepted to be seriously flawed, and a calculation that no one accepts as legitimate  and was leaked by an unknown person, are in the words of the Inquiry Chairman “unsafe”.  None of this evidence has yet been adequately reported.

The Inquiry has also of course heard of a variety of real problems that did exist. I have looked at all of these to see if they are telling us that these “unsafe figures” could possibly be true. I found evidence of many problems that do occur in many hospitals throughout the country: Staffing problems at A&E, the problems of cover at nights and weekends, the wrong staffing levels and staffing mix to deal with the highly dependent frail elderly that make up the majority of the patients in our district hospitals. Some “adverse incidents” like slips, trips, falls, muddles with medicines, that do occur throughout the health service.  All of these are matters that do need national attention, None of these appear, from the view of the experts to be happening to an extraordinary degree in Stafford.

There were certainly some real problems which are linked to the idea that is currently very fashionable. This involves cutting costs by reducing the number of staff in hospital and getting more care out into the community.  This theory was unsuccessfully tried in Stafford from 2006 onwards.  The problems this caused came to a head at a time when the regulatory structure was under stress because of re-organisation, so the regulators were slow to identify the fact that were major teething problems and staff were coming under intolerable stress.  In the final week of the inquiry hearings we heard evidence which explained why a number of different factors came to a head at the end of 2007 and start of 2008. It is these events which I believe triggered the Health care commission investigation process. 

We have also heard how destabilising this investigation process was for many of the staff working in the hospital, Many witness have spoken strongly to question the investigative methods and conclusions drawn from them.  None of this evidence has yet been adequately reported.

What we perhaps saw at Stafford is a hospital that went through a temporary bad patch. It needed support and instead it got something close to the Spanish Inquisition.

What we have also seen as a result of Stafford and concerns about other hospitals is a complete overhaul of the regulatory systems. This includes some remarkable work on information systems and also some continuing work to be able to pick up “soft information” about any local concerns that the public may be expressing.  We have also seen a complete change in the philosophy of regulation, which aims now to use experts to monitor the new sophisticated early warning information tools, and use these to prompt “intelligence driven” inspections, which are aimed at supporting hospitals through problems, rather than seeking to explain retrospectively what went wrong.

These important reforms have been carried out by the SHA and CQC and other bodies recognising that they need to share information effectively. They have reformed the systems from within. There is no need for structural change.

The 2006 Stafford experiment of passing more care into the community was not wrong, it was just something that needed to be worked out much more carefully. It is happening again now in Stafford, on a very much larger scale, and I suspect it will happen elsewhere too.   Again, this does not need structural change, it simply needs Hospitals, Primary care and Social care to work together effectively. It also needs managers and commissioners to listen carefully to the concerns of staff, and to ensure that the service they are trying to offer can be realistically delivered.  

From the time that Stafford first came to be used by the Conservatives as a justification for their health reforms I have felt deeply uneasy. If Stafford is the image of a failed health service  in the mind of the Tory Lord I think it is important for him to know that the current public perception of what happened in Stafford is very far from the reality. 

The one thing that we do know for certain from the Stafford experience is that structural re-organisation makes things much more difficult.

We are told that we "cannot do nothing". I would suggest that doing nothing, or doing the bare minimum to stabilise the system is exactly the right thing to do until we have seen the recommendations from the Midstaffs Inquiry. 

Please stop the bill!  

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.

The report is here http://www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient/

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.

http://www.dailymail.co.uk/health/article-2042963/Tens-1000s-surgical-patients-die-needlessly-poor-NHS-care.html

http://www.telegraph.co.uk/health/elderhealth/8795146/Emergency-NHS-surgery-for-elderly-at-point-of-neglect.html

 http://www.guardian.co.uk/society/2011/sep/29/nhs-health?CMP=twt_gu

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.     

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.

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.

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.

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)

Insulin, badly drafted law, & the threat of No win No Fee claims.

An increasing amount of time at the Stafford Hospital inquiry is being spent on looking into the circumstances surrounding one individual case.

A press report of the inquest of this case is here.

Last week we heard from the Health and Safety executive who unexpectedly found himself at the centre of the Stafford Hospital mess. He came under astonishing pressures from a number of different directions to use a legislative loophole and open up a legal case.

The HSE took the best advice it could get and backed away from this action, for reasons that were very thoroughly explored in the evidence.  The HSE may have had a theoretical power to act, due to a very loose piece of legislative drafting on an old bill, but taking action in this particular case would set precedents that would have had major implications for all of us. 

The main function of the HSE is to protect the health and safety of people at work. Their 500 inspectors cover the entire working environment for the entire country. They have to prioritise their work. Within hospitals they are often concerned with matters like safe lifting, techniques, they also have some requirement to look at the safety of the premises and equipment.  Here are examples of work that they have done in a hospital setting. The delivery of treatment is not normally considered to be within the remit of the HSE. This is covered by other regulators, and therefore the HSE is instructed to avoid duplication of effort.

The arguments for using this legislation to take this particular case are highly unusual. The case might potentially be winnable, but the effects of this would potentially to a huge increase in the numbers of health and safety claims in all manner of working environments. It would require a massive increase in the numbers of HSE inspectors, and it would mean taxpayers and insurance payers channelling a lot of public money through No Win No Fee lawyers.      

We frequently hear from the press about the unintended consequences of over use of Health and Safety legislation. Here is the most recent example.

This quote is in relation to school trips but does flag up the worrying impact of a claims culture

The people behind unreasonable rulings were often "well-meaning but misguided jobsworths" who go too far, said Hackitt, adding that many organisations imposed restrictions not out of concern for people's safety but due to fears of no-win no-fee lawsuits for personal injury. Other bodies used the guidance as a cynical excuse to cut services, she added.

This government is keen to reduce red tape and the number of burdensome insurance claims.

The particular case at Stafford is about the failure to give insulin at the right time. This is clearly wrong, The Coroner is clear that it did contribute to the death of a very sick lady, and the family have every reason to be hurt and angry.  

I was certain that I had heard that this is in fact an extreme example of what is a very common occurrence.

I found this study from the US.

And in UK The NPSA is able to help us with this. 

The Patient Safety Alert follows a review of 16,600 patient safety incidents involving insulin, reported to the National Reporting and Learning System (NRLS) over a six year period between 1 November 2003 and 1 November 2009. Six deaths and 12 incidents resulting in severe harm were reported. Of the 16,600 incidents, 26 per cent were due to the wrong insulin dose, strength or frequency and 20 per cent were due to omitted medicine. Patients being prescribed or dispensed the wrong insulin product accounted for 14 per cent of incidents.

The NPSA analysis shows the main categories of failings.

administration of a wrong dose,

● administration to the wrong patient,

● use of the wrong insulin type,

● administration via the wrong route,

● wrong timing of doses,

● omission of doses,

● failure to properly adjust insulin therapy, and

● improper monitoring, timing, and assessment

of blood glucose (BG) results.

One of the main things that many families want when their family member has been involved in a tragedy of this nature is to ensure that lessons are learned and that other families should not suffer in the same way. They often have a very generous wish that other people should benefit from the mishap that they have suffered. If we look at the actions being taken by NPSA we can see there is now a detailed programme to improve the care of patients with diabetes in hospital. This will involve a widespread training programme for staff and new safety protocols.

I have no way of knowing if all this was triggered by this individual case, but if it was then it is a major achievement for the family. If this has the effect of reducing the very substantial numbers of insulin related incidents that take place in our hospitals all the time, then they can have the satisfaction of knowing that they will have made a substantial difference to health care.  

It would be good the think that this knowledge, in addition to the great many apologies the family have received may go some way to healing the hurt.

As to taking the case through the courts, maybe for some families there does need to be a way to do this.  It is clear that there was at the time of this incident a real gap in the powers of the Health Care commission. The Inquiry evidence shows us that the clear focus of the HCC was to learn from things that went wrong, and work to improve matters. It was not their remit to focus on individual cases.  That goes a long way to explaining the very real frustration suffered by the families. I am sure that Robert Francis will be ensuring that in the future there are simpler and more effective ways of a addressing the needs of families who feel that the problems they have suffered crosses the line into injustice.

The HSE would certainly see it as preferable that this should not be done through the legislation that they have to operate. They do not believe it would be in the public interest, and I think the figures I have quoted on insulin related cases above indicate that they may well be right.  Cases related to insulin would just a tiny proportion of the potential cases that no win no fee lawyers could seek to bring if this particular legislation was to be used.

The local and national press have been campaigning for justice for the individual family. I am sure that Robert Francis will be taking a great deal of trouble to find a solution that is good for this family and good for the wider public interest.

When we do campaign for a particular course of action it is I would suggest always worth listening very carefully to those individuals who have detailed knowledge of what this would imply; People who can show us the unintended consequences of the actions we take. We need to be careful what we wish for.

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.

http://www.ombudsman.org.uk/__data/assets/pdf_file/0020/8237/PHSO-0137-Research-report-web-or-mail.pdf

http://is.gd/WSzUSR