Lack of political leadership on child protection

Ed Balls continues to say he knows better than the Court of Appeal in the case of Sharon Shoesmith (see BBC report). I'm not sure if the bad taste in my mouth about this is worse than his about her payout. Thank goodness Tim Loughton got sacked as Children's minister before his outburst on the Today programme this morning about the same payout (again, see BBC report).

Loughton seems to be just point scoring against Balls, saying that Balls made a botched job of sacking Shoesmith. However, it's fairly clear that the Court was saying more than that Balls merely made a procedural mistake (see previous post).

What we need is for politicians to give a clear lead about the way forward for child protection. At least the chief inspector for Ofsted has said that good child care directors shouldn't be made scapegoats (see Times article). Michael Gove has been reported to be "furious" about the agreement with Haringay council, but this may just be about the confidentiality agreement.

We do need an open discussion about this issue, and the resignation or sacking of Ed Balls should be pursued by Ed Miliband (see another previous post). This would also allow Labour to rebuild its economic credibility and clear out the past poisonous role Balls had in Gordon Brown's inner circle.

Letter to Private Eye

Better value for health care

In July this year, NHS England issued a call to action to debate the issues about the future of the NHS. Monitor's paper about closing the NHS funding gap is in part a response to this debate.

Monitor correctly highlights that staff will have to work "differently and smarter". However, in general its response seems to me to be much of the same eg. reducing waste and a belief that community care is cheaper than hospital care.

There is some emphasis on self-management of long term conditions, but not enough in general about the potential financial savings of more patient-centred care. There is no mention of reducing over diagnosis and over treatment (see previous post). Monitor is going to have to get a bit more imaginative if it is going to sustain flat funding for the NHS.

Lord's will be pleased

Which was the more "ruthless" option? At least England carrying on to a 556 lead (see scorecard), rather than enforcing the follow-on, has guaranteed a fourth if not fifth day for Lord's finances. Still, nice to see another hundred from Joe Root (see previous post).

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.