Could the press act as regulators for the health service?

I have been thinking about this article from Health Policy Insight

Editor's blog Thursday 2 June 2011: NHS quality regulation doesn't work; try this instead

I was alerted to it by a twitter exchange between the outgoing chief executive for Midstaffs and one of the journalists who has spent what must seem like a high proportion of his life covering the Midstaffs story.

The Health Policy Insight blog makes the point that regulation does not always do what it says on the tin, and given that in a series of recent NHS scandals the press have got to the problem before the regulator, he wonders if we should just forget about regulation and give the money to the press to do it for us.

Here is his solution.

Having read many of the witty and incisive pieces written by this writer, it is quite likely that this is a piece of kite flying, but it is interesting that both the CEO and the journalist were very taken by the idea.

Abolish poorly-functioning national quality regulation, and give the money as a subsidy with a range of conditions to local newspapers. A small sum needs to be paid to some independent regionally-based staff, to monitor and follow up on the output.

Regulation and the Stafford Inquiry

Like the Journalist and the CEO I have also devoted a lot of my time to days at the inquiry, or reading transcripts. I do so because I am interested in the challenge of regulation, and also because I have become fascinated by the many important issues that this case has raised about the press, and the real difficulties the press may sometimes face in painting a fully rounded picture. I have learnt a lot about the many sided and often un-graspable nature of “truth” in this process.

In my opinion the impetus for the public inquiry at Stafford came from four different directions.

·         Obviously there is the hurt of the individual campaigners and their need to make sense of their experience. This need quickly became enmeshed with the needs of politicians.

·         There is the press and their sense of duty and financial commitment to a  powerful public interest story

·         Then there is the political impetus. The story was an apparent opportunity to prove the “failure of the NHS“ and to prove the need for the Government’s now teetering health reform package.

·         And then there is the question of how to regulate the health service. It became abundantly clear that regulation, as it was at 2006-2007 was not doing its job. Regulation should either have been able to flag up problems, or give the health service a clear defence against disproportionate criticism. It could do neither. We are not looking back to a golden age of regulation in the past. Regulation has been developing for decades, partly as a response to political need, but this slowly evolving art has not yet reached a stage where we know it can do the job.

How Regulation is developing

What is clear to me is that the health service has learnt a huge amount about regulation as a result of the complex but demonstrable regulatory failure at Stafford. The service has responded with quiet reforms so that the regulatory systems and tools that we now have are unrecognisable from the systems as they were in 2007.  I am not sure that these major changes are yet widely understood. I would advise reading the evidence and statement of Richard Hamblin who served in both the Healthcare commission and the Care Quality commission as a good starting point on this.

The new tools are promising, but a crucial element of this new approach to regulation, is the recognition of the limitations of the statistical systems. The systems matter, and matter a lot, because they are the way in which we can build a framework to keep NHS standards national. It is clear from David Cameron’s recent speech that the government is depending upon them for this purpose. The practitioners, those who understand the systems best, know that what we have is at the very most a warning system. The data is subjective, quality of coding matters, there are few people with the skills to do this well, and human error occurs. As investment in “non essentials” is squeezed then this is an area of the health service performance that may well suffer.  What the statisticians tell us plainly is that simple statistics cannot be used to demonstrate that a hospital is “failing”. The League tables so loved by the press for their simplicity and dramatic effect should now be a thing of the past.

The CQC new philosophy of regulation combines use of the indicators that may flag up potential problems with skilled people on the ground to delve into areas of concern and to help hospitals begin to be able to identify clearly where they can do better. The weakness that the CQC has now, and I think this is demonstrated by the Winterborne case, is that there are simply not enough skilled inspectors to do the job. There is a serious recruitment problem.

The role for the press and the public.

The thing which I think appealed to the CEO and the journalist about the idea of the press as quasi regulators, is that the CEO has said there is a need for thousands of pairs of eyes. It is everyone’s responsibility to take care of the health and care services. We all need to raise concerns. The question that remains is what is the best way to be able to do this effectively?

One thing that was abundantly clear from the Midstaffs case is that the complaints system within the hospital was dysfunctional. It was quickly reformed and is or course being reformed again now.

Complaints directed outside the hospital were effectively useless, as many different people ended up with one or two pieces of paper on their desk. -Never enough to form a pattern.- None of this connected.

The need for an effective patient participation vehicle was of course completely recognised and the LINks system was in the process of forming as a replacement to earlier vehicles for participation when the Midstaffs problems kicked off. This small group of willing and well meaning volunteers was not in any way equipped to deal with the huge problems the Stafford Campaign group brought with them. Having witnessed some LINks meetings at this period the volunteers who might well have done a good job in other circumstances were paralysed by the truly astonishing level of animosity that these meetings generated. It is perhaps useful to mention that the LINKs system, which was crying out for more public involvement received virtually no support at all from the local press, and did not become visible until the press were in a position to criticise them.

So the channels which should have led to constructive engagement between the public and the hospital over the problems that existed failed, and we were left with a situation where the press perhaps rightly saw it as their job to side with the pressure group against the hospital. The hospital found itself on the receiving end of literally thousands of negative articles, ( I have boxes of them) which may arguably have contributed to the loss of staff morale, patient confidence and to the financial problems of the hospital. Energy that could have gone into resolving the problems that existed was diverted into simply surviving the barrage.

Changing the game

The public voice needs to be heard –but how?

I think there are a number of ways in which this has already been tackled:

·         The Hospital pioneered comfort checks, which means that potential “complaints” are tackled before they ever reach that point.

·         The hospital brought in simple boards for patients and families to raise suggestions.

·         The board meetings are all held in public, and actively encourage public engagement.

·         Training for staff brings the patient experience to the forefront.

·         The Trust holds meetings on a range of issues which are all designed to help the public make their voice heard.

·         NHS Choices was set up by the DOH and SHA and already functions as a way of channelling complaints and concerns  through to CQC and presumably to the hospitals.

·         LINks  in Stafford got adopted by County Council, Not sure what impact this has had, but it removed the temptation to use it as a political football.

·         Healthwatch will have a clearer integration path to CQC which will assist to ensure all problems channelled into a place where they can be collated.

·         One element of the CQC system which is still very new, but potentially game changing is the QRPs. Hard data, particularly hard data that tells you what you think it does, is hard to find. For it to be of any value it requires skilled people spending time collecting data, Some of this is essential, but it is at least for the time being politically unpopular. The QRPs will make it possible for many sources of “soft data“ such as patient complaints and press stories to be logged in a way that would give some idea of patterns or clusters of complaints.  If this takes off then the press will find that there is potentially more of a response to their efforts than was ever possible in the past.  This would help everyone. If low level complaints can be heard there should no longer be the necessity for vocal and potentially divisive and delaying campaigns. So with or without a “quasi regulatory” role the press should be able to play through the QRPs  a more effective role in helping to express people’s concerns. Richard Hamblins evidence is again helpful on this matter.

Could the press do more?

To go further, to actually direct public money at the press to help regulate the NHS and other services is a genuinely interesting proposal, but I think this raises some rather serious questions about what the press is actually for and how far the press is willing to modify their role.

If you had asked me this question 20 years ago I would have said that the local press was there to serve the good of its community, but 20 years of observing the press in practice has made me question this.  

What the press perhaps has to offer is the skills of individual journalists in assisting individuals to make their points. Many journalists would be able to do this job very well, and the community would be better for it. But does this sit comfortably with the role of the press?

A regulator – and anyone who would want to perform a regulatory role has to be accountable. Their first priority is to see clearly the truth of a situation from all sides. This will generally mean slow, careful research, the checking of facts, and making it possible for different people to give their side of a story.

The press – at least the press as we know it does not do this. The role of the press is to tell interesting stories and to sell papers and advertising space. We are dealing with businesses trying to make a profit in a market that is under some fairly extreme pressure.

Journalists do not have the luxury of time to research carefully. They must tell their story in the required number of words, in time to get the paper to press.

Papers belong to wealthy men, who have friends and have political allegiances. Running papers means attracting advertising revenue, and people who pay well are obviously important to any proprietor. Public services, and especially the NHS is deeply political. Journalists are hired and fired for a variety of reasons, and unless journalists acting as “regulators” can be protected from the subtle pressures to say “the right thing” they could not carry out this role objectively.

Beyond that there is the whole way in which the press sees the world. The press likes stories where people are shocked or disgusted or angry. They like stories of distress and human suffering. They like blame and retribution. These are the stories that set the tills ringing. Other stories, less dramatic but equally important do not have the same weight.

Just as an example, I spent 5 years trying to interest the press in the complex issues that were addressed in the Labour party White paper on social care, and are now going to be addressed by the Dilnot report.  These are issues that cause very real hardship and distress to thousands of families, but because I was interested in seeking solutions to the problem, and was working with people to do so, this was not really a very interesting story to the press. I was not prepared to blame anyone for the problems that I had personally encountered, and therefore there was no conflict to make this important story entertaining.

If we were to direct public money at the press it would need to carry the requirement for them to deal with stories, sometimes, complex stories, in which they might not actually be very interested.

So is the whole thing impossible?

Perhaps not.

Papers as we know them are at the end of their life. All journalists accept this. When papers go the influence of the powerful men who run them will go too. This influence is already waning as the internet continues to bring together clusters of individuals who work together to make their voice heard. Papers are already losing their monopoly of “the truth”.

But this is not enough. In five to ten years the press and the internet will have changed beyond recognition, but the skills that good journalists have to offer will still matter.

If we do go down the road of GP commissioning and shadowy new providers then it could be that the press really will have a vitally important role to play   When providers are not open, then real investigative journalism will be needed.

“The advantages for local papers are that a subsidy to deliver adequate health coverage would reinforce their curiosity about local provider (and indeed commissioner) performance. There are many good stories to be had.”

The internet is bringing a quiet revolution, the democratisation of information. NHS Choices is a part of this. But more need to be done to make this quieter more collaborative approach work for people. This kind of development is a tool for a healthier democracy.

Journalists have a role to play here. If everyone is helped to use their voice, if we get beyond the paternalism of the press in its current form, then there will be thousands of stories that at present we simply never hear.  Good journalists could help with the task of making these visible. If they really help to give people a voice they can play a part in transforming our communities.

The Problem of “Truth”

The writer makes the assumption that the libel laws we currently have are enough to ensure that the truth will generally be told by the press. My perceptions of the Stafford Story show why in this particular case – which may well be unique I would have deep reservations about this. Truth is not always a simple matter. That is why many millions of tax payers money are now being spent to find out what really did happen at Stafford, and even when we have with of hundreds of hours of clear evidence and witness statements to go on then we find that there is still some surprisingly radical differences in the interpretation of the “truth”. 

For the press to be able to play the part that I would like it to play in our communities, either as a “quasi- regulator” or simply as good newspapers I think there are some simple changes which need to happen.

This is perhaps most easily illustrated by looking at a single element of the Stafford Story.

The single biggest problem with the reporting of the Stafford Hospital story comes from the fact that the excess death figures were presented as authoritative fact, when in my favourite euphemism of the moment, they are “not an entirely uncontested version of events." They were something which came from a document that has been deleted, under circumstances we now clearly know, leaked by a person who has not been identified, based on data acknowledged by virtually all informed opinion to be seriously flawed, and using a calculation which the creator of the data system has clearly stated to be inappropriate. If this is fact it is certainly not fact as I recognise it. – but due to the extreme complexity I am not yet satisfied that the PCC would see it as a clear infringement of the editors code.

I am very easily satisfied. All that I ever required from the press is clear attribution. If they had begun with the premise all “facts” must be traceable back to their source, I do not believe they would have been tempted down the road they travelled. Repeated quotes of “hundreds of deaths” would be so much less appealing if it was immediately followed by the details of what was known and not known about this "information".

Health policy insights says

There are also the pitfalls of bias, grudge-settling and other such drivers – but the press are used to dealing with these motives, and to presenting both sides of a story. More to the point, the British press knows that it is subject to some of the world’s most stringent libel laws, in which absolute truth and the public interest are key defences.

This Is something that I would really like to be able to rely on, but at the moment I do not genuinely believe that I can do so.

The press is in the dock now, over a growing range of different abuses. All institutions must now come under scrutiny and it is the turn of the press. Maybe now is the time to set the ground rules for giving us the press reform that I believe both most good journalists and the public want and need. The Stafford Hospital story gives us valuable pointers to the reforms we should be looking for.

 I could be reassured if

·         journalists would always produce their source material if requested for it,

·         in the event of serious disagreements over the interpretation of “truth” that one could call upon an impartial expert tribunal to act as an “appeal court”,

·         in the case of science based stories these tribunals would be expected to call in people who understand the material in question,

If this were done then I would genuinely welcome the major improvements that this would bring to journalistic practice, and would welcome an appropriate role for the press in helping people hold public services to account.  

The road to a new philosophy of health regulation

I have raised the question, was Stafford Hospital the last of the big hospital scandals? One of the reasons that I think that it could be is because there has been a complete change in both the tools available to regulate the health service and the philosophy and structure of regulation.

It may help to look at what has happened in Stafford in historical terms.

I think that what we have seen in Stafford is a major milestone in the journey towards effective regulation of the NHS, and perhaps to complex systems in general.

Let us think back.

In the days before the National Health Service, the provision of health within a town was down to individual doctors, and to worthy citizens playing a role in governing their hospital. I perhaps have an unusual insight into this time, because my own family, Russell of Hitchin, combined two interests. Some of this small mafia were chiefly interested in running the town’s leather factory; others ran a chain of chemists which locally gave Boots a run for their money. All of them had a strong social conscience and were prominent players in local politics and in the running of the local hospitals.

This involvement in the health service persisted after the establishment of the NHS, something in which my own father played a part.

I suspect that the regulation my father would have been involved in at the numerous committee meetings that I remember from my childhood was pretty rudimentary. They would have heard reports from the Matron and hospital administrators, but also, because they were so well known in the town they would have been approached by local people who had any concerns. Maybe at that time this was enough.

The world I am describing here bears a closer resemblance to “Middlemarch” than it does to anything we would recognise now. Regulation is small scale, local, personal, and subject to variations in the quality of the individuals involved. 

The next point at which I pick up the thread of what was happening to regulation comes with the advent of the Labour government in 1997.

It is clear that what was happening in health was one of the major themes that contributed to Labours Landslide victory. We had the long trolley waits, and people dying on waiting lists, and the general sense that there was a great deal that the best of the rapidly developing world of health care could offer that was not being shared evenly across the country as a whole. Postcode lottery was becoming unacceptable.

I think there is a fundamental difference in the way that Labour and the Conservatives view regulation of services, which has its roots in how our different political parties evolved.

For Labour, providing good public services is central. It is why they exist. It is about the mutual good. For the conservatives the provision of public service is something they choose to do because it is necessary to maintain a productive workforce, and perhaps also because it is “right”.

The differences in attitude go deeper than this. For Labour public services are about ensuring that everyone has the chance to make the best of their life, for Conservatives, there is the additional driving motivation to use the provision of services to create entrepreneurial opportunities.

For Labour, because public service matters so much the state of the regulatory system as they found it must have been pretty disturbing. There was no effective way of comparing the quality of care across the country, and there was no way of identifying hospitals which needed help to improve.

We saw the emergence of systems to try and measure and drive up quality.

The simplest of these, which draws a very mixed response from practitioners and people with political views, is Targets. At their worst these are box ticking exercises and things that administrators with a mind to get round them will “game”. It is clear that in Stafford the hospital struggled to honour the targets in the “spirit” and found ways of working round them which were not good for patients.  Despite the problems with targets it is now widely admitted that they did work, they drove down waiting times in A&E and in waiting to see a specialist to a remarkable degree. It is clear that some powerful sections within the health service found this onerous, and these persuaded Andrew Lansley, during his 7 years as shadow secretary of state for health that we would be better off without the burden. We are now getting a chance to see how this experiment works. Waiting times are again growing, and perhaps as a consequence of this I am certainly noticing prominent adverts for Bupa and other health insurance companies cropping up in my daily papers with greater regularity.

A second development was Standardised Mortality Rates. This is an attempt to measure the very marked discrepancies in life expectance throughout the country and to relate that to the various factors which affect the health of the population. These variations are huge and shocking. If we take a local example then people in Stafford are on average dying more than ten years older than ten miles up the road in Stoke.

A minor factor, and it is only a minor factor in looking at mortality rates as a whole, is concerned with hospitals and hospital care. The Hospital Standardised Mortality Rate or HSMR is – or more accurately was – an honest attempt to look at the how good different hospitals were in keeping patients alive. This runs into all the kind of problems that you have with Stats in school. It is only telling you something useful about the performance of the hospital – crudely the value they are adding -  if you know what the condition of the patient when they are admitted.

How good HSMR could have been is something we will never now know. It did not work because admission coding throughout the country was almost universally poor, and because there were factors like the complexity of medical conditions, and options on places to die all skewed the results. HSMR effectively shot its bolt by the publication of the Dr Foster Intelligence league table in 2007. This was presented simplistically by the press as showing a whole lot of hospitals as “failing”. The furious response of many people within the health service to this league table was sufficient to prompt academic research into the system. The result of that is that HSMR, though it still exists as one tool in the hospital managers tool box, has been downgraded in its importance, it will never again be published in this league table form. A new system SHMI has been put in its place. The details of how this will work are still a little unclear.

Part of the controversy over HSMR was that it appeared as in the case of Stafford to be in total contradiction to the findings of other parts of the regulatory system, which included the annual health check. So you have the Health care commission carrying out its Annual health review and saying that the hospital is good followed by the Dr Foster HSMR indicating that mortality is amongst the worst in the country.

What you are effectively getting is some systems that are producing false assurances that everything is fine, and systems producing false alarms that things are dramatically and disastrously wrong.

Perhaps the best indicator of the effect of this comes in the extraordinary Westminster Hall debate led by David Kidney in April 2009 to look the Stafford Hospital question. I think it is widely known that I am a friend of David Kidney, and I am glad that I was able to give him some support in the dreadful days that followed the release of the Health care commission report, and the media hurricane that it brought to Stafford. Everyone in Stafford was traumatised by this, and David was thrust unwillingly into the spotlight. After weeks of seeing him under unbelievable pressure it is still remarkable to me that he could in this Westminster Hall debate clearly identify many of the points and conflicts which are only now emerging through the Inquiry, slowly, painfully and at very great public expense.

Many of the people who have been pilloried for “failing to see” the problems at Stafford have been perhaps correctly accused on not looking closely enough. No one could possibly accuse David of this. He is a man who has a rare capacity to see detail and to also see the broader picture (see blog on Granular still to follow) The problem that David faced at this point is that there were conflicts within the information he was being given. In the weeks that followed the HCC report he was hearing directly from patients about their experiences, and therefore knew definitively that there were some things that had gone wrong, he also knew that the blanket statement that hundreds of people had died was based on very shaky foundations.

He knew that the information that was available to him had not helped him to see clearly. He had actively wanted the tools to be able to measure the quality of service in his constituency and the tools that existed had failed him.

The evidence that I have seen through the Inquiry does give me reassurance that many of the issues he so clearly identified have now been tackled.

I have further blogging to do on this but as an interim would recommend reading the evidence and statements from Rashmi Shuckler, Peter Blythin, Steve Allen, Martin Bardsley, and Richard Hamblin,  

The limitations of the Dr Foster Intelligence system have now been recognised.

The Strategic health authority has developed clinical dashboards which bring together in one place a wide range of indicators that anyone with the ability to read this kind of information can understand and benefit from.

The creation of the SHMI system marks a major achievement in bringing together a range of Statisticians who might previously have seen themselves as rivals, to create a robust new approach.

The development of the Mortality outliers has got past the tentative beginnings, and is now giving CQC a real tool for raising questions about care in individual hospitals, a tool that can also be used by hospital managers themselves to help ensure that their performance is as it should be.

An important development of the philosophy of health service management that has occurred as a result of Stafford and as a result of the movement from the Health care commission to the Care Quality commission is that the way in which the regulator operates has completely changed.

In the Stafford case, we had a centrally placed investigations team spotting a potential problem, which its own locally based teams were not aware of, waiting months for supporting evidence, which no one understood how to give, and then sending in someone to look and starting what appeared to be a highly punitive form of investigation. This nature of this investigation process in itself made it very difficult for other agencies to support the hospital through the problems and created real divisions between the different “arms” of the health service. The investigation built in a year of delays as Monitor felt unable to take decisive action.

Everyone I think now accepts that the investigation process was not as it should have been and there is a radical change. We saw this in action with the recent CQC reports on the first 12 of 100 hospitals where they have carried out investigations. The CQC if they suspect a problem now directly involves their local teams at the earliest possible time to go into the hospital and work through the problem with them. They are not being left to sink or swim. This is a partnership approach.

The Outliers system is just one small part of the changes prompted by the response to the Dr Foster league tables and to the failure of complaints monitoring in Stafford.  One of the major themes within the Inquiry is that there have been lots of individual people who each had one or two clues that some things may have been going wrong, but there was no possible way of bringing this evidence together. No one saw the patterns and it has taken the Inquiry to bring this complex picture of who was able to see what to bring all of this together.  

There is an entire new arm of monitoring which is based on picking up the soft intelligence which forms the basis of much of the evidence to the inquiry. These QRPs are outlined in Richard Hamblin’s evidence. (will try and blog specifically on this evidence later) These systems, which are still developing, will allow us to aggregate “soft information” from complaints, websites such as NHS choices, Press reports and other sources, and will give the local regulators and managers an effective way of seeing how they are doing in a way which would have been completely unthinkable when Labour first came to power in 1997. The software to analyse text, and help draw out patterns and clusters will really help us to compare the quality of service between different hospitals, and trends over time, in a way that would never before have been possible.

This may seem an abstract discussion, but it is central to the questions which are now being asked about health reforms. Few people have yet seen or understood the fundamental importance of the evidence given by people like Richard Hamblin.

If we do not see or understand what is being done here there is a real danger that we are carrying out disruptive reforms, which will damage the health service, in order to find a solution to problems which have already substantially been solved.