Monday, February 25, 2013

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.

Sunday, February 24, 2013

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 humanwhich 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.

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.

Saturday, February 02, 2013

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".