Sunday, December 04, 2011

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.

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 posta "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).