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.

England retain ashes

 

Happiness is 517 for 1

England narrow the odds.

(With thank to a Times letters correspondent)

Social enterprise in the NHS

Two front page articles in the Guardian this week emphasise the government's committment to social enterprise in the NHS. The first emphasised the principle of common ownership, as in John Lewis-style cooperatives. The second made clear that GP consortia will go ahead despite all the opposition.

The concern expressed in the second article by the new President of the Royal College of GPs about GPs having to bear the brunt of rationing in the NHS may be misplaced as a new system of drug pricing is to be introduced. It seems to me likely that the new NHS Commissioning Board will determine what happens about the prescribing of expensive cancer drugs, rather than individual GP consortia.

Nonetheless, she's right that "this is the end of the NHS as we currently know it". I'm not convinced the NHS needs to be as bureaucratic and risk-averse as it currently is. However, that said, there is a sense in which the impetus to increase social enterprise is welcome. But it brings all sorts of problems with it and it's still very unclear how the government measures will work out.

Despite that, I'm preparing for the new system and have set up Anglia Mental Health Community Interest Company. In a letter to all GPs, the Secretary of State has encouraged them to "begin now to establish the knowledge of, and approach to services, which will inform their approach to later decision-making". Health professionals are not being given any alternative.

Why has the NHS National programme for IT failed?

A Department of Health press release says that a "review of the National Programme for IT (NPfIT) has concluded that a centralised, national approach is no longer required". But where is this review? There's no link in the press release, as one might expect. There's no explanation on the Connecting for Health website, beyond a reference to this press release.

We need to know why the programme has failed. At face value the concept of the Summary Care Records system made sense. It seemed as though money had been wasted by allowing the individual parts of the NHS to develop their own patient information systems. But then the NHS just seemed to get locked into contracts that were never delivering.

The Computer Weekly Editor's blog suggests lack of clinical involvement and changes in technology were amongst the reasons, but these do not seem a sufficient explanation to me. You can understand the government abandoning the project when so much money has been wasted. But the NPfIT has hindered Trusts developing their own hypertext linked systems, which are not that brilliant anyway, because it was always said we had to wait to see what NPfIT could produce.

Have we just all been naive and trusted people who did not really know what they were doing? The people working in the project and the developers have done alright out of it. Why was it so difficult to produce a national system that worked?

Coalition government's reorganisation of NHS

Chris Ham in a BMJ article Why the plans to reform the NHS may never be implemented points out the uncertainty about whether the Coalition government's NHS White Paper will be implemented. It's not clear how negotiations with the BMA will go. GP consortia may not be that much different from PCTs. I also suspect that Payment by Results will introduce too much instability and distortion of priorities for it to be implemented without more controls. Consultation on the proposals closes next month.

KP wants to be loved

Mike Brearley in the Observer points out that Kevin Pietersen needs his confidence boosting. England have just beaten Pakistan (see Guardian report, who beat Australia in England (again, see Guardian report). England are likely to need Pietersen in good form to beat Australia in Australia.

Has the NHS been liberated by the white paper?

As Chris Ham says in his BMJ editorial, Andrew Lansley came into government with a plan for the NHS. This has moved on rapidly from the Tory manifesto. The encouragement of the enterprise culture is welcome, but the implications are unclear.

Blaming the wrong people

I hope the The Independent Police Complaints Commission judgement about the individual police officers in the Kirk Reid case does not have the same pompous disdain as Kathy Lette writes about. Isn't the problem us, society and the police, rather than three individuals?

UK not interested in 13th century education in Afghanistan

Liam Fox's interview in The Times quotes him as saying "We are not in Afghanistan for the sake of the education policy in a broken 13th-century country". I think he must be meaning that the war isn't about the Taliban banning education for women and making the madrassa the main source of education. I presume he doesn't mean that Islam is not a 21st century religion.

Richard Gregory obituary

Richard Gregory explains the Charlie Chaplin mask in this video.
Read his Times obituary. His book Eye and Brain is known to just about every psychology undergraduate. The use of illusions is important for understanding the dynamic nature of perception. Mind Hacks sums up Gregory's significance well.

Even though Kieswetter was born in South Africa, England still win T20

Report from The Australian.

Poor measures of quality should not have triggered Mid Staffs inquiry

In a previous post, I said we needed independent academic opinion to publish comment on the use of hospital mortality data to justify the investigation into Mid Staffordshire NHS Foundation Trust (also see another previous post). The recent BMJ editorial by Nick Black is pertinent.

The hospital standardised mortality ratio (HSMR) depends on the proportion of deaths that take place in hospital. Availability of alternative forms of end of life care, such as hospices and community palliative services, as well as characteristics of the local population, therefore, influence the different figures between hospitals. To score well, it's better for a hospital not to admit a dying patient. In fact Mid Staffs has improved its mortality ratio by 34% over the past three years. There are also shortcomings with the HSMR measure itself.

Cavalier use of such data by government and NHS management does not give clinicians confidence that their work is really understood. Unjustifiably singling out a management team that may be no worse than many others is no help. Robert Francis, who conducted an independent inquiry into Mid Staffs, is supposed to be doing a scoping exercise for a further inquiry of the commissioning, supervisory and regulatory bodies, which has draft terms of reference.

Need for inquiry after David Southall wins appeal

PACA press release. Why is it that the GMC gets these sort of matters wrong? Doctors need to have trust in the GMC that it will not make defensive risk averse decisions. I have always supported David Southall (see previous post and letter to THES).

David Clark obituary

Guardian obituary of David Clark. His book Social therapy in psychiatry influenced me. I also trained at Fulbourn Hospital, although Clark had just retired before I started as a junior psychiatrist there. His history of Fulbourn Hospital (The story of a mental hospital) is of interest. It's important the history of the therapeutic movement in psychiatry is not forgotten. A major advance in psychiatric care was the opening of the doors of the traditional asylum. Unfortunately, to some extent, there has been a reinstitutionalisation of psychiatric care and sometimes the worst excesses of the asylum are now repeated in the community. Risk averse policies and interventions can actually cause problems for patients in terms of their rehabilitation and recovery.

NHS and the general election

Chris Ham's BMJ editorial describes the situation in the NHS that the next government needs to improve:-

"... the destabilising effects of constant organisational restructuring, the negative consequences of a command and control style of leadership, and the lack of engagement of clinicians—especially doctors—in quality improvement."

There has been a "pervasive culture of fear" in the NHS, and clinicians are not always able to speak honestly and may be subject to disciplinary procedures if they do. For example, Mr Ramon Niekrash gives his story in the Independent on Sunday.

I'm not sure why three government reports prepared for the Department of Health only came to light through Freedom of Information requests from Policy Exchange (see its press release). It is clear that the government had indications that there was something wrong with healthcare regulation. Lady Young, who was chair of the Care Quality Commission (see previous post) was someone who may have been able to put it right. Her post-office interview in The Times reinforces that the problem is political sensitivity to criticism.

Breach of contract to discipline Gillian Mezey

Remarkable successes of John Hendy, QC, to obtain an injunction twice in the case of Gillian Mezey: firstly in September 2006 to bar her employing NHS Trust from suspending her from non-clinical duties; and secondly in December 2008 to restrain the Trust from taking disciplinary action. The court of appeal has recently upheld the second injunction (see BMJ story and court judgment).

Mezey gave one hour's ground leave to an informal, previously conditionally discharged, patient readmitted to a medium secure unit. This was at the end of a phone on a day when she was away giving a speech at a Home Office conference. Unfortunately, the patient absconded over the fence, attacked a stranger in the park with a knife and killed him. In retrospect, it is difficult to see what the purpose of the ground leave was, although the patient was informal anyway, and an investigatory panel set up under disciplinary procedures criticised her decision.

Mezey may have been fortunate in that new Maintaining Higher Professional Standards had not been implemented by the Trust, so this panel report was produced by a QC and two reasonably disposed psychiatrists. The court decided that it would be a breach of contract to proceed on this basis. It is possible though that intervention by the National Clinical Assessment Service could have had the same effect under the new procedures.

Nonetheless, Mezey has been humilated by Trust processes and the temptation to find a scapegoat in cases of homicide by psychiatric patients needs to be countered. As far as I know, her case for compensation is still outstanding (see story in The Sun).

Doctrine of the "new interventionism" is not the legacy Blair hoped for

Blair's case at the Chilcot inquiry was that intervention in Iraq had saved us from the more dangerous threat we would now face from a richer and more defiant Saddam Hussein. His beliefs behind his foreign policy are said to be set out in his Chicago 1999 speech (large sections of which were written by Sir Lawrence Freedman, a member of the Chilcot panel).

I think the Kosovo situation was different. Blair seems to be less clear now that he did get as far as advocating a "new interventionism" (see my webdomain page from March 2004). It was NATO that intervened in Kosovo. Article 2 of the UN Charter says: "All Members shall refrain in their international relations from the threat or use of force against the territorial integrity or political independence of any state." Blair decided he would act without UN support, and for that the Chilcot committee, even with Lawrence Freedman on it, should damn Blair's legacy, which meant so much to him.

Smart mental health services

The latest NHS 5 year plan NHS 2010-2015: From good to great. Preventative, people-centred, productive is written in the context of the Chief Secretary to the Treasury's document Putting the frontline first: Smarter government. The plan confirms the need for £15 - 20 billion in so-called efficiency savings over the three-year period from April 2011.

Growth in health services does not necessarily lead to improved outcomes. The myth of massive psychiatric need was pointed out in a paper More and more is less and less in 1985. Psychiatry does have its limits, as I described in my 2002 paper in the BMJ.

Mental health teams can recognise the limitations of what can be achieved and will respond to challenges to improve care in this context. Mental health is not a technologically driven service, although CNS drugs are now the highest net ingredient cost to the NHS of all drug groups. Still, drug costs are a fraction of the main expenditure on staff. There is evidence that mental health services create a vulnerability to relapse but they understand the need to encourage independence. Creating a more patient-centred service can actually reduce costs.

Dr Foster stepped in a puddle right up to his middle

Dr Foster believes itself to be the leading provider of comparative information on health and social care services. It's latest hospital guide has caused controversy.

Nigel Hawkes in his BMJ column notes that it is a company that has been "granted at least one sweetheart deal — and possibly two — by the Department of Health". It tied the Healthcare Commission up in knots with its results (see previous post) and may be responsible for Baroness Young's resignation from CQC (see my post today).

We need independent academic opinion to publish comment on its latest hospital mortality data. Previous analysis in BMJ paper has suggested their "Claims that variations in hospital standardised mortality ratios ... reflect differences in quality of care are less than credible".

Rough NHS politics

Why's Baroness Young leaving the Care Quality Commission (CQC)? As CQC says on its website she resigned on 26th November. It can't be a coincidence that this was the day before the regulators demanded improvement at Basildon and Thurrock University Hospitals NHS Foundation Trust. It's also true that she has been a breath of fresh air in NHS regulation and to my mind a sad loss.

The Mail on Sunday story says Government sources have personally attacked her for causing problems because of her strong personality. It's only someone with strong opinions that can produce the necessary reform. I think the wrong person has gone (see previous post).

Who's bullying whom in the NHS?

More on better direction for NHS (see earlier post). Mike O'Brien, health minister, has described the kind of NHS manager that will be named and shamed (see HSJ article):

“It’s those who duck the difficult decisions, who hide in the quiet safety of their offices, or employ consultants to make decisions for them - who won’t put their heads above the parapet, not daring to engage staff and patients, putting off the inevitable for another day and not learning from others.

“These are the ones who should worry. But we will continue to support leaders and managers who show how we can deliver better care for patients”.

Managers are not used to this. They've even accused O'Brien of bullying them when he says he doesn't want them to slash and burn budgets. Managers have become more used to "top-down", centrally driven management, which could in itself become bullying when clinicians were not involved (see another previous post - Why do staff report high levels of bullying in the NHS?).

I guess the political stance must be gearing up for the election next year. It's about time Labour got it right on the NHS. O'Brien's speech even talks about looking at how a bigger proportion of budgets could be devolved to primary care trusts. This may not be that different from the Tory policy of giving GPs real budgets.

And anyway, clinicians have always said there needs to be better integration between primary and secondary care. I'm not saying that there wasn't a need to shift care from being too doctor-centred to more patient-centred, but the underming of professional values and opinions in doing this has been very damaging for the NHS.

New accountability framework required

The theme of a "call for evidence" by the Local Government Association (LGA) is liberating local public sector partners to serve local people rather than serving the machinery of Government.

For example, LGA has set an agenda for Ofsted, which says it should:

■be a voice of reason rather than feeding people’s fears
■be independent of external influence, basing its conclusions on facts and research
■use expert and knowledgeable inspectors who can offer advice and support
■assess how well children are being looked after and protected rather than measuring processes and procedures
■be focused on making services better rather than on delivering detached, public judgements

Barry Sherman MP, chair of the Children, School and Families select committee spoke out about Ofsted on BBC2's Daily Politics.

Better policy direction for NHS

Speech by health secretary to King's Fund spells out that the NHS for a fourth-term Labour government will be "preventative and people-centred, placing quality at the heart of all that it does". He also made clear that the NHS is moving on from top-down reform. "It led to a feeling that reform was imposed; done to people, rather than with them. It gave unintended messages at ward level – ‘public bad, private good’ – and process targets implied a lack of trust." He also recognised that "there is a danger that people in the service try to read the runes and conduct their own mini spending reviews".

The NHS chief executive took up the comment about the NHS as preferred provider and sent a letter to SHA and PCT chief executives. He again reiterated that "Service improvement and re-design should not be something which is imposed on NHS staff but something which they own and lead." The preferred provider policy has union support eg. as Mike Jackson from Unison says in a letter to the Guardian, "NHS services will not be improved by wholesale tendering, fragmentation and privatisation."

Are medical professionals conscientious?

Article in Student BMJ about medical professionalism. It notes how professionalism is viewed differently by doctors, nurses and patients. A conscientiousness index has been proposed as a measure of professional behaviour in medical students.

This issue is complicated if medical students playing loud music or having a messy kitchen in halls are regarded as being unprofessional. In fact, doctors can be defensive about their income, style of practice, prestige, and power. It's actually the conscientious doctors that can be seen as different and difficult by their colleagues in this context.

The article mentions a roadshow to engage medical students in the issues round professionalism. This project by the King's Fund and others has already produced a report Understanding doctors.

Read Norman Lamb in Mail Online

Norman Lamb, MP for North Norfolk, has written about the Cawston Park fiasco (see my previous post) in Mail Online. I agree that it is important to get to the bottom of what happened to Andrew Breeze and Dominic Wilson. I still think there must have been envy (or similar) motivating the criminal prosecution. The background national scandal of shipping difficult to manage and place psychiatric patients out of the NHS into expensive private care barely figures in public statements about central NHS mental health policy thinking.

This isn't the first article that Norman Lamb has written for Mail Online. The other describes his successful investment in Tinchy Stryder via his son.

Would you vote Tory because of James Murdoch and Rebecca Brooks?

Observer story about Father and Sun highlights how James Murdoch, Rupert's son, is steering the Sun, together with Rebecca Brooks, previous editor, and now CEO of News International.

There must be a question as to whether James can really step into Rupert's shoes. Rebecca Wade (as she was) has a lot to answer for in Sun campaign against Sharon Shoesmith, and previous misdemeanours as Sun editor.

Has David Cameron backed the right horses?

The Sun says Gordon Brown doesn't even know how to write his own name

The Sun says it's bloody shameful that the Prime Minister doesn't know how to spell his own name. Instead of putting Gordon, he's put Gorm. Instead of putting Brown, he's put Bum.

We do expect a Prime Minister to be able to dot the i's. And he shouldn't have to repeat the word "sincere".

It's serious that young British soldiers are dying in Afghanistan.

Improving patient experience in the NHS

Patient experience can't be the be-all and end-all of NHS care. After all, doctors have always been easily able to please patients with quackery.

However, medicine has tended to be more doctor-centred than it should be, so an emphasis on patient experience may help to right the balance. An editorial in the BMJ discusses the use of patient experience within pay for performance (P4P) programmes. This sounds as though it has more merit that service-line reporting and management (SLM) promoted by Monitor, although the way SLM has been implemented locally where I live in Norwich has focused on the patient experience (see Monitor example of SLM implementation).

Don't say you feel let down by inpatient psychiatric care

If you do say you feel let down by psychiatric inpatient care, you might incur the wrath of Louis Appleby, the Mental Health Tsar. Thank goodness the Care Quality Commission (CQC) is independent of government, because Appleby thinks they've "deliberately distorted" the results of a survey of mental health acute inpatients (see Community Care news). At least Kay Sheldon, one of the CQC Board, who has herself been detained under the Mental Health Act and received a payout from the NHS for wrongful diagnosis of schizophrenia, has answered him (see blog).

Highly popular teacher of pathology

Sorry to see the Times obituary for Austin Gresham, who was my Professor of Morbid Anatomy and Histopathology when I was a clinical medical student in Cambridge. I was hopeless at pathology, but I turned up fairly regularly for the 1.30pm meetings in the dissection room when the results of postmortem examinations were presented. Gresham's morbid interest in pathology fascinated me, as did his gruesome particular interest in forensic cases.

Mixed feeling about mental health

My chief executive retires today (see EDP story). Her legacy is said to be a Norfolk's first NHS provided psychiatric intensive care unit (which is locked) whereas her "biggest goal has been to keep people with their families and out in the community wherever possible".

Is this mixed? I'm still working at the NHS Trust.

England win the Ashes

Oval test scorecard. Pity about my fifth day ticket.

Lookalike

Lockerbie Bomber

Robin Gibb

Does Colonel Gadaffi like the Bee Gees?

What's wrong with affecting private insurers' business in health care?

More on the anti-rational opposition to the Obama health reforms (see Guardian article).

"We cannot stop until this attempt to open what could be one of the biggest gates of hell into our country is stopped", says Rick Joyner. His fear is rationing and the collapse of "the whole system". He goes on, "Through this crisis, we may be looking at the ultimate form of controlling people, which the present Administration is obviously trying to do in many ways. This has to be stopped."

Betsy McCaughey says the proposed legislation is a "violation of your rights and a threat to your health".

"Downright evil"

The Obama health plan has created emotive language. See Sarah Palin's post on Facebook. Must be powerful vested interests involved.

And yet PhRMA (Pharmaceutical Research and Manufacturers of America) is supporting health care reform, although it still believes the "best way to expand coverage and reduce the number of uninsured is through private health insurance with businesses and families having a range of private options".

We need to be cautious, though, about Barack Obama's apparent support for personalized medicine and innovation - see Innovation.org (a PhRMA project) welcoming the nomination of Dr Francis S Collins as NIMH director and the Personalized Medicine Coalition case. Let's hope the President is not going to stuff PhRMA's mouth with silver to get his health care reforms through.

Globalisation benefiting from the recession.

The rundown of the high street is worrying (Guardian article). Pubs are also closing but branded pubs and cafe-style bars are expanding (BBC News online). Globalisation, at least, seems to be benefitting from the recession - as am I. (See My perspective on the economic crisis).

Incompetence and injustice damaging democratic politics

Charles Clarke (Independent article) is right to point out the damaging nature of arbitrary power. I'm not sure how much of this comes from Gordon Brown personally, as Charles Clarke seems to think was behind his own demise from the cabinet. However, a society that panders to public opinion and a government that is not motivated by principles, creates an unreasonable, bullying culture. I'm not convinced Ian Gibson's was the best test case, but the point needs to be taken seriously. Living in a state of denial doesn't help either, which at least the Queen realises (Observer article). The irony is that, as Will Hutton puts it, "At last Brown may be getting it right".

Ricky Ponting gracious in defeat

Ricky Ponting was gracious in his comments after the defeat by England at Lords. It may have earnt him some credit.

If the last wicket had fallen at Cardiff, things would have been very different for Ponting's reputation. His captaincy would have been acclaimed. He plays to win. He would have succeeded in getting the most out of a side without as much talent as previous Australian sides he has captained.

As it was, he just became a target for his pressurising tactics. When he complained about England's time wasting, it seemed like something he would have done himself.

Congratulations to Andrew Strauss, although I'm not convinced he's the best captain in the world. Surely he should have had more of a plan than waiting for the new ball when Clarke and Haddin took control on Sunday evening (I was there). Let's look forward to the rest of the series.

People who are feeling ill not wanted in hospital

A notice has gone up at my NHS Trust saying that people who are feeling ill should not come into the building. Actually when you look at the small print, what it says is that people with symptoms of swine flu should not come in. But has the hospital unconsciously disclosed its real wish?