Hard Truths about the NHS
‘Hard Truths’, the government’s response to the Mid-Staffordshire scandal contains three fundamental omissions. It doesn’t legally require NHS staff to tell the truth. It doesn’t set out legally enforceable safe staffing levels for the NHS. And it doesn’t tell you what to do if you turn up on a ward or care home to find your mother caked in faeces and at serious risk of harm.
A legal duty of candour for staff is essential to protect whistleblowers and to give them the courage to speak up knowing they are immediately legally protected and immune to gagging threats (rather than trying to prove they have been victimised for speaking out under the ineffectual Public Interest Disclosure Act). It would also, under Robert Francis’ recommendations, have been a crime for any NHS employee (including managers) to obstruct or suppress whistleblowers and to cover up harm. Instead, the government has decided that NHS institutions must give a corporate view of the truth about harm, doubtless after closing ranks and consulting their lawyers, which is pretty much what happens at the moment. The government also places unwarranted faith in the regulators (NMC, GMC and CQC) to police the NHS, pick up harm early and protect patients. Their track record thus far has been lamentable.
Francis did not himself recommend legally enforced safe staffing levels in the NHS, but he later regretted this omission as the evidence mounts that harm in the NHS occurs when staffing levels fall below a critical level (Eyes passim). Different wards will clearly have different demands at different times, but NICE needs to present the best evidence on what safe staffing levels are in a given situation, and the NHS should be legally obliged to enforce these. Instead, staffing levels will be published on a website somewhere, to enable the demented and frail elderly to shop around for the safest care, and the CQC to spot trouble.
Many of the Francis recommendations, and the government’s response to them, are identical to those that followed the Bristol heart scandal. The only difference is that the Kennedy inquiry in 2001 was followed by the most unprecedented increase in NHS funding ever, and Labour fluffed this golden opportunity to rebuild the NHS around quality and safety. The NHS is now facing the biggest financial slowdown in its history and the largest increase in demand. What hope is there of making it safe without spending every available penny on properly staffing and training the frontline (rather than bankrolling the most unnecessary, destabilising and divisive set of ‘reforms’ ever? And NHS England is losing a further £0.9 billion to social care.
The government will introduce a new law of wilful neglect, so relatives can spend years in court after their loved one’s death trying to prove it. At present, well over 90% of medical negligence cases find in favour of the clinician so this route seems unlikely to provide anything more than a gravy train for lawyers. As for what to do if you think the poor care your relative is getting is currently endangering a life, the government is silent. The name of a responsible clinician (doctor and/or nurse) should soon be above the bed of every inpatient, so that would be a good place to start. If the staff can’t or won’t put things right, you could phone the CQC hotline (03000 61 61 61) or take a photo and march down to the chief executive’s office.
You could also tweet the photo, and e mail it with your concerns to the trust board, the CQC, Monitor, the GMC, the NMC, your MP, your GP, the CCG, NHS England, local Healthwatch, PALS, the Health and Safety Executive, Jeremy Hunt, Andy Burnham and local and national media. If you want to try to complain by phone, you have a choice between the NHS Complaints Advocacy Helpline 0300 330 5454, NHS England Complaints Helpine 0300 311 2233 and the Ombudsman complaints helpline 0345 015 4033. All are weekday working hours only. And there are huge backlogs.
This sounds extreme until you remember Mid Staffs. An old man forced to stay on a commode for 55 minutes wearing only a pyjama top; a woman whose legs were “red raw” because of the effect of her uncleaned faeces; piles of soiled sheets and vomit bowls left at the end of beds, a woman arrived at 10am to find her 96-yearold mother-in-law “completely naked… and covered with faeces… It was in her hair, her nails, her hands and on all the cot sides… it was literally everywhere and it was dried.” Another woman who found her mother with faeces under her nails asked for them to be cut, but was told that it was “not in the nurses’ remit to cut patients’ nails”. If this happens again, dial 999 and insist your loved one is moved to a place of safety. Such negligent care is, in the end, a medical emergency and a safe-guarding issue.
BELOW IS THE GUIDANCE FROM THE CQC ABOUT WHAT TO DO IN THESE CIRCUMSTANCES
CQC’s advice on what to do if someone is at risk of harm in care setting
If possible, raise your concern with provider staff and/or local and more senior managers, through face to face contact and then formal procedures as needed in the circumstances. Providers have internal procedures by which service users/patients, their families friends and carers, the public and staff can raise concerns.
If your concern relates to a particularly urgent situation involving immediate avoidable harm and/or abuse, and for whatever reason it is not appropriate to approach staff at the provider for help (or you have done so but still feel someone is at serious risk), then contact the relevant emergency service(s).
If you are concerned about abuse or alleged abuse but it is not appropriate to call in the emergency services or contact the provider or its staff, raise your concerns with the relevant local authority safeguarding team, for adults or children as relevant.
If there are reasons why a person feels unable to take the actions above, they can contact CQC by telephone (03000 61 61 61), listen to the opening message, and select the appropriate service (option 2) to immediately be put through to our safety escalation team. They can also email us at Enquiries@cqc.org.uk , contact us via our online form or write to us at CQC National Customer Service Centre, Citygate, Gallowgate, Newcastle upon Tyne NE1 4PA. Please note however that our telephone opening hours are Monday to Friday between 8.30 am and 5.30 pm.
Some of the reasons that people contact CQC are because they:
- are a patient, carer, friend or member of the public who wants to share concerns anonymously
- are an employee, volunteer or contractor to the provider and want to act as a ‘whistleblower’ under the Public Interest Disclosure Act
In general, please contact CQC with any information about a health or care service that you want to share (good or bad) – this information can then be used to inform the judgements CQC make about providers.
Do CQC produce simple guidance for patients/carers to follow in such circumstances (often at nights and weekends).
Our website has a section for members of the public, accessed via a clickable tab. There is information about our telephone number, email address and an on-line form for people who want to express a concern. The public can also find our telephone number on posters and leaflets left in NHS services, in Trust Literature and via directory enquiries. The website also has links to a ‘share your experience’ form, for people to use to pass on any information about a regulated service that they want to share with us (good or bad). Our safety escalation team can support and advise people who have urgent concerns about a service. Anyone contacting CQC via our National number (03000 61 61 61) outside of normal operating hours are advised to contact the Police or Local Social Services Duty Team if they suspect someone is at immediate risk of harm.
CQC phone-line operating hours for registering concerns
Opening hours are Monday to Friday between 8.30 am and 5.30 pm.
Should the police or emergency services be informed to take a patient who is dehydrated/starved/soiled/infected to a place of safety?
People should use the provider’s internal procedures rather than call the emergency services if at all possible in urgent situations. Calling the emergency services is an extreme measure and should only be considered if this is in the best interests of the patient and would not cause further harm. However if internal processes fail or cannot be used for some reason then they may wish to use the emergency services as a last resort.
Executive Director of Strategy & Intelligence
Care Quality Commission
103-105 Bunhill Row
London EC1Y 8TG