Saturday, February 16, 2013

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.

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