Maiden test century for Joe Root on home ground

It was worth making the long journey from Norwich to Headingley yesterday. Interesting museum at the ground showing history of Yorkshire County Cricket Club. See video made for 150th anniversary.

British freestyle wrestling's villain dies

Mick McManus has died aged 93 (see Telegraph obituary). What has happened to Kendo Nagasaki, Jackie Pallo, Les Kellett, Adrian Street, Johnny Kwango etc and Kent Walton? I used to watch them on the telly with the old English working class, the Queen and Harold Wilson.

Disciplining Margaret Thatcher

Times article about the authorised biography of Margaret Thatcher by Charles Moore picks up (as does the Guardian) on the memo written by the then head of her policy unit, Sir John Hoskyns, which accused her of bullying her weaker colleagues. Sir John went on, "To survive you have an absolute duty to change the way you operate." The Falklands war followed and the rest is history. I don't think most people knew at the time that the sending of the task force would end in war but winning in the Falklands changed people's attitude to the prime minister.

AN Wilson (see Mail article) argues that Thatcher was not in the true sense a bully because she "reserved her fire for those who - if they had any spunk - were in a position to fight back". I'm not so sure. Her unwanted and unreasonable conduct itself determines whether it is regarded as bullying. I'm not advocating the bullying application of bullying policy (see previous post). She may well have believed that she alone rescued Britain from its post-1945 years of semi-socialist decline, but not everyone benefits from capitalism (see previous post). To analyse any situation from the perspective of the objective and reasonable person is never straightforward as personal experience and judgments will inevitably taint perception. However, she failed to create an environment in which people have the right to be treated with consideration, dignity and respect.

What was unique in severity and duration in case of Mid Staffs?

The government initial response to the Francis report has been published. I still worry that Mid Staffs has been unfairly singled out (see previous post). I'm also not convinced that the new Chief Inspector of Hospitals can provide a "single version of the truth", if there is such a thing, in his or her so-called balanced assessment of hospitals. These matters are always open to interpretation. How this will be helped by inspectors "looking the [Trust] board in the eye" I'm not sure.

Nor am I clear what embedding "a zero tolerance of avoidable harm" in the DNA of the NHS means (see previous post). Harm may appear avoidable in retrospect but not necessarily so before it happens.

It's also good to reduce "paperwork, box ticking and duplicatory regulation and information burdens" but why by at least a third and how will we know whether that target has been met (aren't we supposed to be moving away from targets)?

Can zero harm be a reality in NHS?

Press release from the NHS Commissioning Board confirms that "Professor Donald Berwick is being brought to the NHS to chair a National Advisory Group on the Safety of Patients in England" (see terms of reference and members). David Cameron has asked Berwick "to make zero harm a reality in our NHS". At least he's appreciated that the Francis report needs to be put in the context of patient safety research (see previous post).

Berwick talks well (eg. see video on BBC website). He recognises that most healthcare staff intend well and I too want the NHS to be the safest in the world. But it's misleading to expect no errors in healthcare (see another previous post) and Berwick might need to refine at least his language. Being a doctor is not the same as being an airline pilot.

Berwick must be glad to have left the vitriol of US healthcare politics behind him (see Who is Don Berwick?) It's difficult to relate to some of the emotive language used there (see previous post). But UK healthcare politics too can be based on misunderstandings (see previous post). Hopefully, Berwick and his group can help take the Francis report forward in a sensible way.

Too late to call for David Nicholson to resign

The Mail is keeping up its campaign to get David Nicholson, NHS Chief Executive, to resign (eg. see article) . If he was going to resign he should have done so in 2009 (see previous post). The previous government had already started to change the top-down approach (see previous post). This has got lost in the current government's wasteful reorganisation (eg. see previous post) but David Nicholson has been a steadying influence in the upheaval. That's why David Cameron can't let him go at present.

What Nicholson should be asked to state is where he stands on his claim on Mid-Staffs that “While this was an awful case, it was highly unusual that such poor quality care and patient complaints could go undetected in the NHS for so long and we will make sure this will never happen again.” This was wrong and he should be made to say so. Perhaps the government response to Francis report will say this.

Creating a patient-centred culture in medicine

She may not like me saying if she thinks I am not taking her seriously, but Part One of Julie Bailey's book From ward to Whitehall should be required reading for training health professionals. Part Two is about the politics that followed her mother's death up to the publication of the Healthcare Commission's report (see previous post). I'm not convinced that Robert Francis' recent report has yet answered how to "stop the suffering" in the NHS (see previous post), which has been the motivation for her campaign.

Francis makes no attempt, as far as I can see, to set his findings in the context of the literature about patient safety. A crucial document in this is To err is human, which recognised the common nature of iatrogenic damage. Patient safety has been framed as an explicit public concern since.

The problem is that protocols designed to reduce errors have actually made patient safety worse (see previous post). These factors meant that what was happening on the wards in Mid-Staffs was not appreciated. The Cure the NHS campaign was started because Julie Bailey had a poor response to her complaint. It was so bad (not that I'm blaming the matron who responded and the Director of Nursing that reinforced the response, because they were caught up in this manageralism) that, as far as I know, she has not yet had a proper answer. There clearly has been a culture of investigation at Mid-Staffs since but it sounds as though it has been destructive. According to the BMJ of 42 doctors referred to the GMC only four will face a hearing.

Francis, again as far as I can see, did not pick up on the evidence he was given about the Healthcare Commission "going out with a bang" in the report on Mid-Staffs (see previous post). This doesn't mean that I don't take the evidence from Cure the NHS seriously. It's just that the managerialism introduced by the Healthcare Commission did nothing to support health professionals in exercising their responsibilities in providing care (see previous post). Medicine still needs to become more patient-centred as Francis says. Hopefully the government's response to his report might help to take this forward.

Scapegoating Mid-Staffs

I may have missed something because it's four volumes, but I'm not totally happy about Robert Francis's Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. He wrote in his press statement:

There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. They had to endure filthy conditions in their wards. There were incidents of callous treatment by ward staff. Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care. Patients were discharged without proper regard for their welfare.

Although as far as I know he did not state this, he has done nothing to prevent press claims that the report has exposed "catastrophic standards of care at the trust, leading to at least 1,200 needless deaths" (see Telegraph story). The Trust had a high Hospitalised Standardised Mortality Ratio (HSMR) at the time (there were hospitals with higher rates - see previous post and my post at the time of the publication of the Healthcare Commission report), but in fact Francis makes clear that:

... it is not possible to conclude, without more information than the HSMR alone, that a high outlier is attributable to poor care. Nor is it possible to say that any specific number or proportion of deaths was from an avoidable cause. Nothing to the contrary has been suggested.

To reiterate:

Whether a subdivided or overall SMR is reviewed, it is always important to keep in mind that a high rate of “unexpected” deaths cannot be translated into a number of “avoidable” deaths, any more than a low rate of such deaths means that all is well.

So, the media shouldn't be making such claims about avoidable deaths. And, although the apparent improvement in HSMR rates at mid-Staffs may have been due to "manipulative coding" in Brian Jarman's words, this just reinforces the relative nature of the measure of HSMR and the need for caution in interpreting the data.

My main concern is that despite Francis' attempt to avoid scapegoating of individuals by emphasising institutional failure, he has scapegoated the hospital himself. As he says:

It will no doubt be said that episodes similar to those described ...  could be found during the period looked at in many trusts.

My problem is that he calls this a "complacent attitude". I don't think I'm being complacent by pointing this out. One of my first ever posts on this blog was taking Ian Kennedy to task for bragging that the Healthcare Commission had improved care in the NHS when I knew this was not the case. By saying this attitude is complacent, Francis has avoided dealing with the issue.

As an example, an article in the BMJ this week highlights that problems in the provision of appropriate nutrition and hydration have been reported in the medical literature for nearly 4 decades. As I indicated in a previous post, the BMJ authors note that the Health Ombudsman found a "lack of access to fresh drinking water and inadequate help with eating in half of cases during her investigations into care of older people".

Basic care needs to be taken seriously not only within hospitals but also in care homes and the community. Health care is not an easy job. Mid-Staffs is not the only place where there needs to be improvement in this respect.

Improving university education

Reading Ian Parker's resignation statement from MMU has made me think about the effects of the target culture on universities. MMU has a change agenda based on a corporate strategy that sets 14 key performance indicators. In the current competitive market with other universities, there must be  a question about whether these are achievable. For example, by the law of averages, half of the universities will score above average on student satisfaction and half will score below.

I'm sure Ian has been defending academic values. The Council for the Defence of British Universities (CDBU) has been set up because misguided policies are undermining universities. Target cultures arise from not being able to easily measure a broad social good like "health" or "education". This blog has commented several times on the problems this created in the NHS (eg. see Why do staff report high levels of bullying in the NHS? Note that Ian says he has been bullied and this should be taken seriously.). The boxes were being ticked by NHS Trust Boards in their reports to the Strategic Health Authority but in fact a poor culture of care had become endemic. In a culture that could punish people for failure to meet targets, managers and staff in general are likely to behave dysfunctionally.

It's perfectly reasonable for Ian to defend his students but this has cost his job. Hopefully university education can be improved beyond increasing the number of 3 and 4 star staff submitted to the REF (Research Excellence Framework). As CDBU says, universities should be "places where students can develop their capacities to the full, where research and scholarship are pursued at the highest level, and where intellectual activity can be freely conducted without regard to its immediate economic benefit".

Need for reappraisal of notion of errors in healthcare

Very good article by Sonja Jerak-Zuiderent argues that patient safety needs to be conceptualised in terms of 'living with uncertainty' rather than errors in healthcare. Errors do not necessarily detract from safety and to ensure safety it is important to allow for the possibility that errors will occur. Practitioners live with uncertainty and a margin of error will always occur in their practice. This is not being complacent about iatrogenic damage and harm which is a major concern.

It is problematic to assume that safety will follow from protocols designed to reduce errors. In fact, safe practice requires an openness to change and the need for new responses. Creatively understanding what safety means in a specific instance can even require disregarding established protocols or guidelines. Assuming that safety will follow from protocols loses the benefit of living and acting in the real world. Mistakes need to be valued as a core element of life itself. Living with uncertainty does not mean that anything goes or that one is complacent about errors and is a safer mode of clinical practice.

Sir Jimmy Savile groomed an entire nation

Excellent article in The Telegraph by a freelance journalist who has covered child protection issues, realising that she'd been "hoodwinked" [her word] by Savile on the set of 'Jim’ll Fix It’. She was dumbfounded by his hand licking and crude patter. I suppose from his point of view, however unconsciously, he dealt well with his physical repulsiveness. Quite an achievement to be "not far off being England’s very own Mother Teresa". Paedophiles may not be "everywhere" but they are widespread, and they may not be "impossible" but they are difficult to detect.  As I've said in a previous post, the government needs an independent inquiry to look at these wider societal issues.

HRH is a post-modernist?!

JRSM article by Prince Charles talks about his integrated approach to medicine and health. Includes too much of the spiritual and complementary for my liking but at least he quotes George Engel (eg. see previous post). And HRH knows that his is a wider definition of integration than is commonly used, so hopefully he won't undermine such an approach. However, he seems to have been taken in by psychoneuroimmunology and stress causing shortened teleomeres. The overenthusiastic  optimism of Paracelsus doesn't justify HRH's promotion of the irrationalism of alternative medicine.

Improving the NHS next year

Let's hope for better measurement of NHS performance in the New Year than MRSA bacteraemia, number of C. difficile infections, access to treatment times less than 18 weeks and mixed sex breaches. In fact let's hope NHS health care improves even if we can't measure it!

The price of NHS reorganisation in redundancy payments

Story in the The Telegraph highlights how much is being paid out in redundancy in NHS reorganisation. I had previously suggested (see post) that Sir Neil McKay might have made a good NHS chief executive.

Father of family medicine obituary

BMJ obituary for Ian McWhinney, who understood the importance of patient-centred medicine and the place of George Engel in this. He suggested that a paradigm shift in medicine would lead to the biopsychosocial model supplanting the anomalies of the biomedical model (eg. see my article).

What are the odds for a no-ball from a bowler’s third ball off his third full over on the second day?

Maybe I gave too much praise to the News of the World in a previous post. Extract in the Daily Mail from new book says that placing spot bets on no-balls is rare. Still, players obviously have been controlled by fixers and there is a question about the results of some matches.

Inefficient to make me redundant

BMJ news story refers to article that finds that less experienced doctors incur more treatment costs. So maybe it's better to keep experienced consultant psychiatrists, like me, when making cuts to meet the Nicholson challenge (see EDP24 news story).

Payment by results not panacea for problems of NHS

As I've indicated previously (see post), I find it difficult to understand why NHS Foundation Trusts (FTs) are in favour of payment by results (PbR). After all, the motivation for such a system is to encourage other providers into the NHS market. If an NHS FT has an almost monopoly, what does it gain by having competitors come into the market?

A report from the Kings Fund reviews the experience of PbR. It concludes that the current system as applied is not fit for purpose. PbR does not transmit much, if any, pressure to be more efficient. For example, it does not provide an incentive to reduce admission to hospital.

As, again, I've mentioned in a previous post, as far as mental health services are concerned, there has been a delay in implementing PbR. The motivation to introduce PbR in mental health is often said to be because mental health is losing out compared to the rest of medicine by not having PbR. The Kings Fund report puts such a claim in perspective. Any implementation of PbR in mental health should be postponed further until the issues raised by the Kings Fund report are taken on board.

Why do child sex abuse cases get dropped for "lack of evidence"

Times article takes the right tack about Panorama programme on Jimmy Savile, about the chance missed for him to face justice when he was alive. The BBC Newsnight editor seems to have decided not to broadcast their programme because initially he thought the case had been dropped because Savile was too old, but in fact it was because there was said not to be sufficient evidence to prosecute. There is an issue about how commonly the CPS drop such abuse cases that Panorama did not pursue in its programme, instead implying more about the pressure the BBC was under not to create a clash with its Savile tribute programmes. Ed Miliband was right to call for an independent inquiry (see video) which could deal with the wider societal issues.

Barriers to expressing concern in the NHS

Editorial in the BMJ about barriers to whistleblowing in the NHS. It talks about the bullying culture that existed in the NHS (on which I've commented previously several times, eg. see Why do staff report high levels of bullying in the NHS? and Who's bullying whom in the NHS?) at the time of the events that led to the inquiries into the Mid Staffordshire Foundation Trust (again, eg. see previous posts Poor quality of care should not have triggered Mid-Staffs inquiry, Healthcare Commission ends its time with "appalling" report and Bayoneting the wounded after the battle is over.)

Actually, the way in which 'whistleblowing' is being used here is probably wider than disclosures under the Public Interest Disclosure Act 1998 (PIDA). What is being talked about is having an open culture in the NHS about performance management. The problems in the past were created by Trust Boards having to self-report to the Strategic Health Authority (SHA). The temptation was for executive directors to say that things were going very well, and non-executives (NEDs) were not well enough in touch with services to know whether this was really the case and endorsed what they were told. Foundation Trusts introduced governors (which included staff governors, who probably were more in touch with what was going on in the Trust, and also governors took over the appointment of NEDs) but it has taken time for governors to realise what their role is. This has now been made transparent in the Health and Social Care Act 2012. And anyway, SHAs are in the process of being abolished.

So, I think the culture has genuinely moved on and changed. And, this makes me bold enough to talk about what happened to me when I was a 'whistleblower' in this wider sense. But the fact that I have not done so until now shows that 'whistleblowing' has been a genuine problem.

My concern was, and still is, about inquiries into homicide by psychiatric patients (eg. see my book chapter and my BMJ letter). Mine is not a maverick position, as evidenced by a letter to The Times with multiple signatories saying that such inquires can become destructive. The problem is that deflecting obloquy becomes an over-riding factor at the expense of professional consequences for staff. I think this is what happened with my NHS Trust's internal inquiry into the care and treatment of Richard King (2005).

The Trust had made efforts to 'beef up' its inquiry, making the case that this meant an independent inquiry from the SHA was not required. This was despite Department of Health guidance that an independent inquiry should be commissioned by the SHA when a homicide has been committed by a person who is under the care of specialist mental health services. I had reason to believe that the SHA had accepted the Trust argument but from my point of view the Trust report was of poor quality. The report was written to maintain public confidence in mental health services by identifying mistakes and errors of judgement. I discussed my concerns with colleagues and formally raised the matter in the Medical Advisory Committee, where I obtained some support. I produced a written critique of the Trust panel report but was refused permission to discuss my concerns with the Chair of the panel that produced the report.

I was unhappy with the Trust action plan, because of the injustices in it, and spoke informally about it to the Trust chair, who said the action plan could not be changed. I therefore made it clear that my understanding of my professional responsibility meant that I would go to the SHA.  I met and subsequently corresponded by e-mail with the Head of Clinical Quality at the SHA. E-mail correspondence followed with the medical director and chief executive, which led to me again emailing the SHA to say that I was unable to take the matter forward with the Trust.

I then received an answer to my critique from the medical director, who had been a member of the panel that produced the report,  to which I responded. Just before this a formal investigation had been initiated into me on another matter. This investigation led to me being told I had to face a disciplinary panel, which never happened after I involved the National Clinical Assessment Service (NCAS).

An independent SHA inquiry report was eventually produced, which I welcomed. I had seen the Trust report as part of a blame culture in the Trust. The independent report was helpful in its recommendations for developing services in the locality and Trust. It made clear that its recommendations may have appeared to replicate the rather imprecise recommendations and exhortations of the first inquiry, but they did not. I think members of the Trust Board found it difficult to hear this message.

I can't say for certain that the timing of the disciplinary matter was related to my raising concerns about the inquiry report. What I can say is that it made it more difficult for me to keep on top of the process of following through on my concerns. There are issues about homicide inquires by psychiatric patients that need to be discussed openly. I can now speak from my own experience about getting caught up in one (even though it wasn't even my patient).

Overtreatment harms patients

Recent BMJ article about unnecessary care, together with a video from the website. My book chapter "Clinician bias in diagnosis and treatment" from a few years ago. Would be nice to think there might be an overtreatment movement in medicine.

No easy rapprochment with Pietersen?

Article by Mike Brearley in the Observer thoughtfully discusses the Pietersen situation. Not sure exactly what he's done but it doesn't look like there'll be a quick resolution, which is unfortunate. Brearley had already pointed out before the last Ashes that Pietersen needs his confidence boosting (see previous post). 

South Africa deserve to take over from England as number one test team (see previous post). Enjoyed seeing two days of the match at Lords.

Proud to be British

Queen and Bond unite for London 2012 
A 12-part guide to the UK in 212 words each
Acquital of Paul Chambers 
For openers, London puts on a smashing show
Opening ceremony a jolly good show?

NHS block contracts for mental health continue for forseeable future

As I predicted (see previous post), payment by results will not be introduced into mental health services next April 2013. The department of health has confirmed to the Health Service Journal that next year was only ever seen as the earliest possible date and the roll-out will be delayed beyond 2014. HSJ blames the lack of reliability of clustering data, but the system also depends on pricing packages of care, and I haven't seen any attempts to do this - unless it's happening with AQP pilots for IAPT (again, see another previous post). It's up to Monitor and the NHS Commissioning Board to determine the future of mental health contracts.

David Southall's ordeal

BMJ article summarises David Southall's story, which I have mentioned before (see previous post).

British railways still in Lowestoft

Peter Aldous, Waveney MP, has raised the issue in parliament of the development of Lowestoft station, where I travel to work from Norwich (see full text of debate). It's about time Lowestoft caught up with denationalisation of the railways in its signage. British Rail (the trading name of British Railways from 1965) stopped operating in 1997.

Death of theologians

The death of Eric James (see obituary), biographer of John Robinson (see book review), my director of religious studies when I was at Trinity College, Cambridge, has prompted me to find out what has happened to other theologians who affected me. I find that Alaister Kee also died last year (see obituary notice).

I was influenced by death of God theology. Strange looking back the extent to which people were willing to go to hang on to religion.

What are the advantages of payment by results in NHS?

A press release from Monitor quotes its Director of Strategy as saying that "Improving the pricing of NHS services is essential to help commissioners make better decisions for their patients, and to ensure that hospitals and other providers of care are fairly reimbursed." It's sometimes difficult to understand what the motivation is for extending payment by results (PbR) in the NHS, when it's not clear that the cost is worth it (see previous post). After all, the report that this quote is taken from has been published to introduce a system for varying the national price if the costs of providing a service are too high or the revenues generated  too low. Some services are too essential to fail.

PbR in mental health services will be introduced in shadow form from this April. If the system works (which must be in doubt) and there are few advantages, it'll be interesting to see what Clinical Commissioning Groups do next year. Despite all the hype, it might actually make sense to continue block contracts. And I'm not saying this because I don't think that mental health services can be provided more cheaply (see another previous post). And, I'm happy for PbR to be experimented with at the edges of block contracts (see another previous post). This will be happening this year with psychological therapies in primary care in some parts of the country, but not in Norfolk and Suffolk where I work.

Reimbursing NHS-funded care

Monitor has published a report by PwC suggesting in its press release that "New pricing analysis highlights opportunities to improve patient care". The report suggests that what it calls incentives driven by pricing reimbursement are being undermined in the current implementation of Payment by Results (PbR). 

£28 billion out of a total secondary care budget of £66 billion is now contracted through PbR. What the report found is that the non-tariff  income is actually more volatile year on year. This is probably because non-tariff income is being used to smooth out any variations caused by PbR.

Actually this is not necessarily a bad thing. It means that trusts and PCTs minimise the risk of financial difficulties. As Alan Maynard says in his column on Health Policy Insight:-

Scrutiny of local budget bargaining usually shows that annual horse-trading about funding consists of negotiation about the level of investment for the year (de facto a global budget) with agreements that if the hospital stays within this budget and activity level, any misdemeanours on CQUIN and other regulations will be overlooked as far as applying financial penalties are concerned. 

It is this type of budget horse-trading which predominates but is rarely discussed outside tension-filled rooms when annual funding levels are fixed. It is the system that the clinical commissioning groups [CCGs] will inherit: a nice learning curve for the keen but rather naïve GPs whose survival will depend on their ability to play these well-established PCT-Trust games!

If the NHS is really going to be a clinician driven system, actually CCGs may even see an advantage in returning to block contracts. Commissioning support costs may be prohibitive and this money could be invested in services. Again as Alan Maynard says:-

So is it time to abandon PbR, revert to global budgets and use the savings to invest in sensible and simple management of cost, activity and outcome outliers and improving the mean performance of each? 

Reducing outliers and improving average activity, cost and outcomes is essential if The Nicholson Challenge is to be achieved. Squeezing PbR tariffs seems a crude and expensive method of achieving such efficiency gains.

If the Health and Social Care Bill gets through the House of Lords (see Ed Miliband writing in Sunday Mirror), I think it will be much more difficult for CCGs to use block contracts as they might wish because of the emphasis on competition by Monitor. But it would be a sensible way forward and, anyway, PbR can be developed at the edges of a block contract system through the introduction of any qualified provider arrangements (see previous post).

More on lack of fairness in medical discipline

Julian de Haviland makes a good point in BMJ letter about the lack of independence in medical disciplinary matters. Managerial power may be misused though medical disciplinary procedures (see previous post).

Bayoneting the wounded after the battle is over

The Mid Staffordshire NHS Foundation Trust Public Inquiry into the role of the commissioning, supervisory and regulatory bodies in monitoring the Trust has come to an end. This is the second inquiry Robert Francis has done on the Trust following the Heathcare Commission investigation published in March 2009. I commented in a post at the time that it was unclear how much Stafford Hospital differed from other NHS organisations. I have little doubt that there was unjustifiable singling out of the Mid-Staffs management team (see previous post). Its chief executive was only able to give evidence in writing to the inquiry rather than appear personally because of the induced stress.

A positive aspect of Robert Francis' first inquiry report was that it emphasized the importance of NHS staff feeling confident that they can raise genuine concerns and that these will be taken seriously. As I've mentioned in a previous post, a "pervasive culture of fear" developed in the NHS. Clinicians have not always been able to speak honestly and may have been subject to disciplinary procedures if they did. The second inquiry has heard further evidence about this top-down and bullying culture, although the Department of Health did not accept or even recognise some of the criticisms (eg. see closing submission from counsel to the inquiry). The previous government had started to change this culture (see another previous post).

A big problem was the annual health check. I expressed concern about this in a post before it was widely recognised to be an issue. Baroness Young seems to have lost her job as chair at the Care Quality Commission (CQC) (see previous post) for arguing against relying on it (see her evidence to the inquiry). Ian Kennedy in his evidence seemed to be distancing himself from the core standards which he says were handed down from the department. For whatever reason, form prevailed over content. To quote from the counsel to the inquiry:-

They [the core standards] provided a relatively simple route for the health service to be able to rate and rank hospitals. The annual health check may have been effective for public presentation purposes, but it was in reality, we submit, relatively useless if the intention was to present to the public a true and honest evaluation of the quality of care provided by the Trust assessed or indeed as the name implied the health of the provider concerned.

It also seems from Ian Kennedy's evidence that he saw the Mid Staffs inquiry as paralleling the Bristol inquiry, which, as far as he was concerned, had echoes of the Ely hospital inquiry by Geoffrey Howe years ago. Kennedy was never in favour of the Healthcare Commission being replaced by CQC, and I'm sure some of this dissatisfaction was displaced into the Mid-Staffs report.

The Ely hospital inquiry led to the setting up of the Health Advisory Service (HAS), which visited and reported on mental health health services over many years. It always surprised me how well HAS picked up what was going on in a hospital through its visits, which were intensively done over several days by a team of people. The problem with modern health regulation is the disparity between what the regulator picks up and what is happening on the ground. CQC now has more clout than HAS because of its system of registration of providers, so it could potentially be more effective if it had a system of visits that did properly establish how well an organisation is functioning.

Clinical governance that has developed post-Bristol, though, has encouraged a blame culture (eg. see my BMJ letter). As, again, I've mentioned in a previous post, it has become an accepted expedient of public administration in this country to make a public sacrifice of someone to deflect press and public obloquy. To my mind, Baroness Young was setting about correcting this problem but the politics was too difficult and she resigned.

Evidence was heard in the inquiry that CQC still hasn't got its methods right.  Robert Francis in his first inquiry was struck by first hand descriptions of poor patient experience. As I've commented on in another previous post, so has the Parliamentary and Health Service Ombudsman. David Nicholson, NHS chief executive, was criticised by counsel to the inquiry for suggesting Mid-Staffs was a singular rather than systemic problem. To quote:-

With respect to him [David Nicholson], this seems to be a very dangerous attitude to take. The assumption is that any other hospital providing such poor care would have been uncovered by the systems in place. That, frankly, is a naive assumption and one which places reliance on a regulatory system which has been demonstrated to have failed in a significant way.

I just want to go back to the reference I made to Ian Kennedy hoping the Mid-Staffs inquiry would have the impact of another Ely hospital inqury. This is of current relevance, as the situation at Winterbourne View, uncovered by a Panorama programme, clearly does have echoes of Ely hospital.

In 1967, a nursing assistant at Ely Hospital in Cardiff made a series of allegations about the treatment of patients and the pilfering of property by staff. These allegations were published in the News of the World. The inquiry that followed found examples of callous, ‘old fashioned and unsophisticated’ techniques of nursing control. Although in most instances this practice was not ‘wilful or malicious’, nursing standards were found to be low, supervision weak, reporting of incidents inadequate, and training of nursing assistants virtually non-existent. Staff were also found to have pilfered supplies of food. There were determined and vindictive attempts to silence complainants. It also transpired that members of the Nursing Division of the Ministry had visited Ely some years before and had reported ‘scandalous conditions, bad nursing’, and yet nothing had been done about it. In essence the inquiry report confirmed the basis of all the News of the World revelations.

Another example of an influential report at the time was the Whittingham Hospital inquiry. In 1969, two senior members of the staff at Whittingham Hospital near Preston, Lancashire, made allegations of ill-treatment of patients, fraud and maladministration, including suppression of complaints from student nurses. Two male nurses were convicted of theft. Shortly after the police investigation a male nurse assaulted two male patients, one of whom died. The nurse was convicted of manslaughter and imprisoned. An inquiry was set up after the trial was over. What was significant about the report was that it placed the responsibility on the management for the institutional conditions that led to callous and incompetent nursing and some deliberate cruelty. The inquiry also uncovered suppression and denial of student nurses’ complaints about ill-treatment.

So what's happened in Winterbourne View is a repeat of the worst aspects of institutionalised care in the asylums. We do need to relearn these lessons. As counsel to the inquiry concluded, a system for identifying failing hospitals besides Mid-Staffs needs to be developed.

By the way, "bayonneting the wounded after the battle is over" was attributed to David Nicholson by Baroness Young, but he denied ever using the phrase. What a mess! I suggested David Nicholson should resign some time ago in a post. Actually, he's been doing better recently, tempering the worse excesses of the current government's reforms (eg. see previous post).

News of the World's legacy to cricket.

Guardian article by Matt Scott "Pakistan spot-fixing trial offers chilling insight into genteel game".

Complacency about medical suspensions

A senior advisor to the National Clinical Assessment Service (NCAS) is quoted in the BMJ as saying that "increasing numbers of managers are using suspension and exclusion appropriately". She comes to this conclusion from the latest NCAS half-yearly report on the use of NHS exclusion and suspension amongst doctors and dentists in England.

Although there are indications that figures may be starting to plateau, there has been a steady increase in doctors excluded and suspended per year from 140 in 2005/6 to 216 in 2010/11. This increase can't be totally explained by the increase in the workforce.

Despite duration of suspensions falling (see chart), the provisional figures for mean length of concluded episodes to March 2011 was 35 weeks for GP doctors and 21 weeks for hospital and community doctors and dentists. This is a significant period out of the working life of a doctor, although  the median is lower than the mean as the distribution is highly skewed towards shorter episodes. Just under half (49%) return to work with the same organisation, with or without restrictions.

There's no mention of how many of these exclusions/suspensions were unnecessary or could have been dealt with informally. There is concern about how fair procedures are  (eg. see my review of Wendy Savage's book and BBC Inside Out programme from last October at the end of this post). Doctors who are seen as "difficult" or "different" are particularly vulnerable.  Personal malice or professional jealousy may play a role in trumping up charges and these factors are very difficult to prove.

All suspension/exclusion cases need to be sanctioned by NCAS but this is usually a perfunctory matter. NCAS could intervene much more than it does at an early stage to help resolve cases informally (see previous post). Mistakes can also be made in formal procedures because of managerial over-reaction and misuse of authority.  Trusts can react autocratically to problems in arbitrary and capricious ways, as they serve their own idiosyncratic interests (see my BMJ letter). NCAS should have more of a role in countering these factors.

Let's have a birthday tea party for Elvis.

Does Michele Bachmann know Elvis is dead? See video on Guardian website.

England top ICC rankings for first time since 1979

ICC news story. See result of England vs India Edgbaston test in 1979. That was a good England team as well.

The Sun knows better than the Supreme Court

There's an entry on my The Sun Says blog with the same title as this post because of an editorial saying that baby P is being denied justice. The way to do that is apparently to 'wipe the floor' with Sharon Shoesmith. The Sun accuses welfare officials of passing the buck. As I've also pointed out in a previous entry, the public sacrifice of Sharon Shoesmith seems to be an accepted expedient of modern day politics.

Maybe the political response to the News of the World phone hacking scandal might mean that this kind of kowtowing to the tabloid press can change. Ed Miliband has been praised for showing leadership on the phone hacking issue. He needs also to challenge the government on whether it thinks it is above the supreme court (see previous entry) on the Sharon Shoesmith case (and ignore Ed Balls' likely protests). He needs to ask why the Sun thinks it knows better than the supreme court. That would show real leadership.

I did warn before the election that David Cameron was 'backing the wrong horses' in Rebecca Brooks and James Murdoch (see blog entry) and this has been proved right with the phone hacking scandal. I specifically highlighted at that time the past misdemeanours in the Sun's campaign against Sharon Shoesmith. Politicians need to stand up to press influence on this kind of issue as much as phone hacking.

Supreme Court tells government to listen to Sharon Shoesmith

As I predicted in a previous post, the Supreme Court has refused leave to appeal in the Sharon Shoesmith case (see Guardian article). Worryingly, the government still thinks it was "right in principle for Sharon Shoesmith to be removed from her post as director of children's services".

Presumably the government thinks that the court ruling is just saying that Ed Balls went about dismissing Shoesmith in the wrong way. Again, as I said in the previous post, the court wasn't just saying there should have been a meeting between Balls and Sharon Shoesmith but that she should have been given the opportunity to put her case. The government still doesn't seem willing to listen to this case. I agree with Ed Balls that urgent action from the government is required, but not because of a "constitutional ambiguity", which is what he says is the problem.

Have NHS Foundation Trusts got a future?

The government has published its plans for the introduction of any qualified provider into the NHS (see operational guidance). This confirms that the implementation will be gradual and, at least initially, quite limited.

Nonetheless, as I said in a previous post, this is the main substantive reform of the NHS. The rest has mainly been yet another structural reorganisation, which staff in the NHS have become fatigued with over the years. Just changing the structure doesn't improve the service and it costs a lot of money that could have been spent on services.

And, as Oliver Letwin has made clear (see Guardian article), this government thinks the way to improve productivity in the NHS is to create fear that publicly provided services will not survive. Actually the way to stimulate NHS Foundation Trusts is to support them, not undermine them.

With the introduction of other providers, the share of the market for NHS Foundation Trusts will inevitably reduce. Unless the political will changes, Anglia Mental Health Community Interest Company is planning to provide primary care psychological therapies, including systemic family therapy for identified children's problems, before moving on to develop a full range of mental health services. And I say this as a current governor of a Foundation Trust (I have declared my interest), who believes in representing the public interest.

The bullying application of bullying policy

I feel uneasy about the way in which Andrea Hill has left her post as Suffolk County Council chief executive. She has been cleared of bullying and harassment but is still leaving the council (see Guardian story). It makes sense for her to leave as the council has changed its policy on its "virtual council" plans (see Guardian story). But has she been bullied out of her post?

The Sun says

Simon Jenkins in the Guardian writes about the influence of the tabloids on UK politics. I'm not sure if "those who live by the tabloids, die by them". An offshoot blog monitoring what The Sun says has been created.

Any qualified provider in NHS will start in April 2012

The government has made it clear in its response to the Future Forum that what they call "extending patients' choice of 'Any Qualified Provider'" will start in April 2012, even though it is in a "much more phased way" by limiting it to services where there is a tariff and not seeking blanket coverage. This is the main reform of the NHS and it is staying.

The recent amendments, although welcome and an improvement, are largely about rhetoric or would have probably happened anyway. For example, GP consortia couldn't have functioned without involving other clinicians. The emphasis on competition was potentially misleading, but essentially by opening up provision to any qualified provider that's what will be introduced (see previous post).

The earliest possible date for a national mental health tariff is 2013/14. It'll be interesting to see whether local tariffs can be set for April 2012. Anglia Mental Health Community Interest Company may need to wait before it can start operating.

Leadership in the NHS

Helpful BMJ editorial on clinical leadership in the NHS. As I've pointed out before in this blog (eg. see past entry), there has been a problem in the NHS with professionals feeling "that they have to carry out instructions in which they have little personal investment and hence ownership".

What's interesting is how this gets tied up with the latest NHS reforms, which seem to be designed to encourage more of a professionally based system. Perhaps it's just a way of getting professionals to go along with them.

We're still waiting for the outcome of the government's "listening pause", although David Cameron has given a speech ahead of the Future Forum report next week (see Guardian article). Ensuring Monitor is motivated by the interests of patients, introducing clinically-led commissioning rather than GP-led commissioning and only authorising commissioning groups when they are ready are not major changes to the thrust of the reforms. What we need more information about are the plans for the introduction of any qualified provider and how payment by results will work.

An accepted expedient of public administration

The concluding remarks of Maurice Kay LJ in the Sharon Shoesmith case (see previous post) compare her case with that of Rose Gibb (see Court of Appeal judgement in that case). Shoesmith's problem was a report by Ofsted, whereas Gibb had to deal with a report on the superbug, C. difficile, by the Heathcare Commission. As far as the learned judge was concerned, in both cases it seemed "that the making of a public sacrifice to deflect press and public obloquy ....  remains an accepted expedient of public administration in this country".

The problem is that regulators' reports may be written to maintain public confidence by identifying mistakes and errors of judgement, rather than being a truly independent assessment. Such inquiries therefore are used to achieve political aims. Written with the benefit of hindsight bias they rarely show that people have acted with bad faith or without reasonable care. Instead scapegoats are found.

Rose Gibb clearly thinks this happened to her (see I was victimised, demonised). As does Sharon Shoesmith. Similar processes were at work in the mid-Staffs inquiry (see past blog entry). As I've mentioned in a previous post, Robert Francis has the chance to correct this scapegoating in his review of health regulators.

Ed Balls says he would be unfair again

Government and Ofsted have got some learning to do about the Sharon Shoesmith case (see Haringey Independent story).

The Department for Education thinks it was right in principle to sack her. The principle has already been decided by the Court of Appeal and I think it's unlikely the Supreme Court will allow an appeal. And, the court wasn't just saying there should have been a meeting between Ed Balls and Sharon Shoesmith but that she should have been given the opportunity to put her case.

Her case was against the Ofsted report, which as I have pointed out in a previous post seemed light on detail to anyone who bothered to look at it. I don't think it's clear that Ofsted came to a sound conclusion based on evidence (again, see Haringey Independent story). There was no challenge to the Ofsted findings in the legal case, but as the judges themselves said (see their summary decision), their "task was the more limited one of deciding whether those whose decisions affected her [Shoesmith] followed procedures complying with the law’s requirements of fairness" [their emphasis]. In fact, they did not "feel able to accept that the adoption of a fair procedure would inevitably have led to the same outcome".

And David Cameron doesn't seem to understand that accountability is not about what the government decides is right or wrong (see Guardian story). It's this political error that society needs to correct. This kind of political pressure leads to regulators getting things wrong. Perhaps Cameron should think more about his politics (see past blog entry).

And the government should get on and implement the Munro report to improve child protection (see previous post). That's more important than Ed Balls' ego.