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 higher 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.

Why the delay in government response to Munro report?

The Final Report of the Munro Review of Child Protection has been published today. It'll be interesting to see if social work can really move on from "a defensive system that puts so much emphasis on procedures and recording that insufficient attention is given to developing and supporting the expertise to work effectively with children, young people and families".

Government should embrace the review but instead is going to take its time to consider it. It's been easier to scapegoat people such as Sharon Shoesmith (see previous post) rather than set up what Munro calls a 'learning culture'. Government has not taken any heed previously of this message. It must have been clear which way the review was going, so I think it would be helpful if ministers could explain why they haven't got their response ready.
 
An executive summary of a major research programme on safeguarding children has also been published. The concluding message from the research document is "A key question for policy makers is how to ensure that improvements are better implemented in the drive to increase the effectiveness of services, and why it is so difficult to do so". Maybe it's made more difficult because government is more concerned what the Sun thinks than Professor Munro.

Meanwhile, perhaps people can learn from some of Eileen Munro's publications:  Learning together to safeguard children and Learning to reduce risk in child protection

Prime minister does not think about things too much

" ... for me, politics shouldn't be some mind-bending exercise. It's about what you feel in your gut – about the values you hold dear and the beliefs you instinctively have."

Perhaps we shouldn't be too surprised that this is David Cameron's attitude to politics.

An important Court of Appeal case

Judgement has been reserved on Sharon Shoesmith's case in the Court of Appeal to annul her sacking by Haringey Council over the Baby P death (see Press Association report). The Sun sees the case as a waste of money.

Being sorry about such a tragedy is not the same as being made a scapegoat for it, as child killings cannot all be prevented. It was clear to anyone that read it that the Ofsted report, on which Ed Balls relied for recommending Shoesmith's sacking, was light on detail (see my previous blog entry at the time). And the Sun doesn't always get everything right (see Greenslade blog in the Guardian).

If this is a test of the Sun's ability to whip up moral panic, it deserves to lose, although of course, more fundamentally, society needs to move on from its blame culture. Let's hope the Court of Appeal gets it right in this important case, in which case it will have been worth the money.

The injustices of capitalism

Guardian magazine interview with Ed Miliband highlights the move on from New Labour to the injustices of capitalism. Not everyone benefits from capitalism.

NHS and competition

Useful BMJ editorial by Chris Ham about competition in the NHS. As he says, the question is whether competition is the right route to take for healthcare.

A "free service for all" was the defining principle of the NHS (Portillo, 1998). The subsequent introduction of prescription charges was intended to suppress unnecessary demand. One problem of the government's latest reforms will be how to control demand when patients have more choice. I suspect charges could well be introduced in the future for what is seen as treatment of a lesser priority. This will have moved us on from the defining principle of the NHS. Aneurin Bevan, minister of health in the Atlee government that introduced the NHS in 1946, resigned because of the introduction of prescription charges.

The NHS has also been a monopoly provider, which the government reforms are intended to challenge. The aim of the nationalisation of health services was to makes services more adequate, in terms of coverage and quality, and more rational, in terms of distribution of resources (Klein, 2006). Because of the kind of commodity health care is, the nationalised model may well fit it better than a free market model. Commercial dependence on the patient makes medicine less objective. Wasn't the NHS created to deal with exactly the muddle of healthcare that the current government's reforms could create?

Poor health care endemic

The Parliamentary and Health Service Ombudsman has produced a report describing the stories of 10 patients who suffered "unnecessary pain, indignity and distress while in the care of the NHS". It may be difficult to draw conclusions from just 10 cases, but she insists these are not exceptional or isolated cases. She does not understand why she needs to hold the NHS to account for the most fundamental aspects of care.
 
Providing basic care is not always easy and straightforward and the NHS would benefit from a re-focusing on the fundamentals. The politics of the NHS can distract it from its basic task. It's even worse when it gets the politics wrong. As I've pointed out before in a previous blog entry, unjustifiably singling out particular services, which may really be no worse than any other, is no help. I've also commented on how this seems to have been the case with mid-Staffs. Hopefully Robert Francis' second report which will be produced from the ongoing Mid Staffordshire NHS Foundation Trust Public Inquiry will take account of the Health Service Ombudsman's findings, and not continue to look for scapegoats.

Writing down thoughts on your mind for everyone to see

I agree with Robert Peston about the value of blogging (see How and why I blog). It's much easier to get ideas out because of blogging. It also can include all sorts of material which isn't going to get published in other media and work in progress. Perhaps this is particularly important for independent minded people like him (and me). And the same standards apply to blogging as other communications.

Intentions and risk for the NHS

As clearly stated by Left Foot Forward, the intention of the Coalition Government’s reform of the NHS is to make private GP consortia carry out all commissioning, although the government will still pay for NHS treatment. Service provision will be further opened up to private companies, including those which are not-for-profits. Market competition is intended to drive up standards and lower costs, bringing value for money for taxpayers.

The Guardian reports that John Healey, the Labour Shadow Health Secretary, has had a Freedom of Information request refused to release details of what risk assessment the health department or its advisers have undertaken to identify potential hazards of the reforms. In his letter to David Cameron before Christmas, the question about risk assessment was one of several that Healey asked.