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Archive - Month: February 2013

February 7, 2013

The Times Opinion, February 7, 2013
Filed under: Private Eye — Dr. Phil @ 11:55 am

The boss must go, NHS staff must step up

 

How many people have to die unnecessarily in the NHS before someone takes responsibility? It’s a question I pondered as Robert Francis QC delivered his verdict on the appalling care failings at Staffordshire hospital. Francis was angry at the collusion of anonymity, where clinical staff, managers, the trust board, the PCT, local health scrutiny committees, the SHA, the CQC, Monitor, the Health and Safety Executive, the GMC, the Royal Colleges and the Department of Health all passed the buck instead of preventing hundreds of undignified deaths. So what does Francis recommend for this complete absence of accountability? That no named individuals be held to account. Thirty years ago, Roy Griffiths famously said: ‘If Florence Nightingale were carrying her lamp through the NHS today she would be searching for the people in charge.’ I fear Robert Francis has been given the same lamp.

 

Francis shows a distressing lack of understanding of the difference between scapegoating and demanding accountability from those responsible. In 2006, when the NHS ran up a half year deficit of £600 million, its chief executive Nigel Crisp resigned. Yet when up to 1200 people die unnecessarily in a single hospital, no senior NHS manager resigns. David Nicholson, the chief executive of the NHS, was in 2005 the head of the West Midlands Strategic Health Authority, the body supposedly responsible for supervising standards at Stafford hospital. He should step down, a view privately shared by many of the NHS staff I’ve spoken to, including hospital chief executives.  But only brave relatives like Julie Bailey from Cure the NHS will join me in public. The culture of fear, blame and bullying in the NHS is as prevalent as ever.

 

Sir David and his top down command and control team have an undoubted talent for sticking to budget, keeping waiting lists down and hitting politically driven targets. But the Department of Health under Nicholson’s leadership existed to ‘manage’ bad news, protect reputations, suppress dissent and deliver only good news to Downing Street. Nicholson is no Nigel Crisp and would only have gone if Francis had decided he was willfully blind to the deaths at Mid Staffs, rather than just asleep at the wheel. But Francis decided that no politician, policy or senior manager is to blame for Mid Staffs. He has conveniently directed a little bit of blame at every level but not enough to get close to accountability. The judge delivers no justice.

 

So why did the vast army of NHS inspectors and regulators fail to act on the Mid Staffs scandal? Whatever the answer, it’s unlikely to be ‘because there wasn’t a chief inspector of hospitals.’ If that’s the best Cameron can come up with having had a sneak preview of the Francis report, I fear he may have missed the point. NHS regulators are like dozy fielders on the boundary rope. They only have the faintest notion what’s happening on the front line if someone hits the ball straight at them and other fielders wake them up. Even then, there’s a fair chance they’ll drop the catch.  Regulators can only do their job if they listen and act when patients, staff and relatives are brave enough to speak up.

 

It’s now 21 years since I broke the story of the Bristol heart scandal in Private Eye thanks to the courageous whistleblower Dr Stephen Bolsin. 12 years on from that public inquiry report, which found up to 35 babies had died unnecessarily, we still haven’t safely reorganized child heart surgery. The omens for the Francis Inquiry are not great. Sir Ian Kennedy made 198 recommendations after Bristol, many of which are near identical to the 290 produced by Francis. Kennedy wanted an absolute focus on quality and safety, a culture of openness, humanity and transparency, a duty of candour, better information for patients, better protection for whistleblowers and better training of staff. Much of the NHS produces great care, some is average and small pockets are scandalously bad. Why? Because bad news is still brutally suppressed for political or corporate gain.

 

Francis’ recommendations read well, but they’re  three years too late. The lessons from Mid Staffs were needed to inform Andrew Lansley before he launched into his vast, untested reforms in 2010. Reorganizations on this scale are invariably dangerous for patients, as was Labour’s desire to make every hospital a self-governing Foundation Trust, a policy pursued by the coalition. Mid Staffs should never have been forced down that route. It was too small and simply not up to the task, just as child heart surgery in Bristol was not fit for purpose twenty years ago. Both sacrificed lives to balance the books and satisfy political edicts.

 

Was it ever thus? Kennedy complained that the NHS has been “littered” with previous inquiries that were “consigned to gather dust on shelves”. In 1965, a letter to the Times complained about the shocking treatment of “geriatric patients in mental hospitals” and the casual attitude of the Ministry of Health in dealing with these problems. In 1967, an investigation called Sans Everything concluded that the NHS hierarchy denies problems and dismisses complaints as unfounded, even when supported by strong evidence. There is a tendency to lie low and hope the criticism will fade. And complainants are discredited and victimised. This is as good a summary of the Bristol and Mid Staffs Inquiries as you could find.

 

Nurse Helene Donnelly tried to blow the whistle at Mid Staffs, was told to watch her back and became frightened to walk to the car park. Chris Turner, a junior doctor, described the A&E department as ‘a complete disaster…. immune to the sound of pain.’ A consultant who raised concerns was suspended. NHS whistleblowers seldom win, and often pay for their bravery with redundancy and illness, but they are far more likely to spot problems early than any number of chief inspectors. We need to encourage, cherish, support and protect them, as well as responding promptly to the concerns of patients and relatives.

 

I do agree with Francis that it’s up to all of us to improve the NHS. If Nicholson releases his infamous ‘grip’ on the NHS, doctors and nurses must step up to the mark to motivate and inspire those around us. Labour made some big improvements in NHS care, but they didn’t deliver a ‘zero harm’ culture in times of plenty. Making the NHS safe and humane when so many organizations are on the brink of going under is a huge task. In the gap between Bristol and Mid Staffs, we’ve learned that large, distant regulators and centralised, bullying management doesn’t deliver safety. More regulation would be a mistake. Great care comes from motivated, frontline staff with good training and humane working conditions who listen to patients and aren’t afraid to speak up when they spot a problem. Time for a bottom up revolution rather than more top down pressure. We need a bidet, not a shower, to get out of this mess.

 

Dr Phil Hammond is a hospital doctor, broadcaster and journalist.





February 5, 2013

Private Eye: Medicine Balls 1333
Filed under: Private Eye — Dr. Phil @ 9:10 am

Jumping the Gun

 

This week sees the much-delayed publication of the public inquiry report into disastrous care at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. The Eye will consider the findings in the next issue, but whatever Robert Francis QC recommends, it’s 3 years too late. The lessons from Mid Staffs were needed to inform Andrew Lansley before he launched into his vast, untested reforms in 2010. Reorganizations on this scale are invariably dangerous for patients, as was Labour’s desire to make every hospital a self-governing Foundation Trust. Mid Staffs should never have been forced down that route. It was too small and simply not up to the task, just as child heart surgery in Bristol was not fit for purpose twenty years ago. Both sacrificed lives to balance the books.

 

Bristol happened on the Tory watch but, as with Mid Staffs, it took a change of government to order a public inquiry. This took so long, it post-dated Labour’s NHS Plan and so none of its 198 recommendations were included. The chance to rebuild the NHS around transparency, humanity and safety was lost, despite all the extra funding.  It’ll be depressing to see how many of the recommendations in Sir Ian Kennedy’s 12 year-old report are repeated by Francis.

 

The culture of fear, blame and bullying in the NHS is as prevalent now as ever, and you’d need a career death-wish to blow the whistle on unsafe care (see Shoot the Messenger). Part of the responsibility lies with NHS chief executive Sir David Nicholson and his command and control team, whose talent for sticking to budget, keeping waiting lists down and hitting politically driven targets is matched with an ability to ‘manage’ bad news and suppress dissent. Nicholson, doubtless wary that Francis may criticise him, has come out fighting with interviews in the Health Service Journal and the Independent saying why he should stay on as chief executive of the NHS Commissioning Board (a post he walked into unopposed, aided by the delays in investigating Mid Staffs). The on-line responses on the HSJ site were near unanimous that Nicholson should go, a view held by Ken Lownds and Julie Bailey of Cure the NHS. But Nicholson is no George Entwistle and is unlikely to go unless Francis decides he was willfully blind to the deaths at Mid Staffs, rather than just asleep at the wheel.

 

The Coalition has the power to reject every one of Francis’ recommendations, but Labour has the luxury of reflecting on the findings before releasing its plans for further reform. Alas, Andy Burnham has jumped the gun and unleashed Labour’s proposals ahead of Francis. This seems nonsensical, until you remember it was Burnham who approved the proposal for Mid Staffs to become a Foundation Trust in 2007 based on just four lines of civil service advice. He then pointed the finger at the regulatory bodies (Monitor and the Healthcare Commission) for not scrutinising the proposal properly and spotting the appalling care, conveniently ignoring that Labour set the regulators up, decided their remit and budget, and appointed their leaders.

 

Unsurprisingly, Burnham resisted a public inquiry into Mid Staffs in 2009 as being ‘too distracting to managers’, just as Tory health secretary Stephen Dorrell resisted a public inquiry into the Bristol heart scandal that showed how the department of health and medical establishment knew babies were dying but refused to act. Both inquiries were delayed long enough for the findings to be dismissed as ‘historical’. In reality, they’re anything but. Child heart surgery still hasn’t been safely reorganized 21 years after the Eye broke Bristol and the horrors of appalling care of the most vulnerable patients are still too common across the NHS. There are no easy solutions in such a prolonged funding crisis, but the bullying, fear and absurd imperative to deny harm and deliver only good news to Downing Street must end.

 

Health secretary Jeremy Hunt now has to digest not just Mid Staffs, but reports on the reorganizations of child heart surgery – which should save lives –  and hospital mergers in south London – which almost certainly won’t. The excellent Lewisham hospital is collateral damage in a war it did not start, its services under threat not to improve quality but to bail out a bankrupt neighbour. There is no evidence that forced reconfigurations to save money ever succeed, and every chance of sacrificing more lives to try to balance the books. Let’s hope the lessons of Mid Staffs don’t fail at the first hurdle.





February 4, 2013

Evidence-based challenge to Lewisham hospital changes
Filed under: Private Eye — Dr. Phil @ 1:47 pm

‘We believe that the clinical evidence underlying last week’s decision is deeply flawed, and therefore call on you to reconsider urgently your advice to the Secretary of State.’

LETTER TO SIR BRUCE KEOGH, CLINICAL DIRECTOR OF THE NHS

04 February 2013

Professor Sir Bruce Keogh

NHS Medical Director

Dear Professor Sir Bruce Keogh,

We noted with great interest your letter to the Secretary of State for Health dated 30th January 2013i following his request for an independent clinical view on the recommendations by the Trust Special Administrator (TSA) for South London Healthcare NHS Trust (SLHT). The Secretary of State for Health’s decisions were influenced by your advice, including the amendments made to the TSA’s recommendations regarding Lewisham Healthcare NHS Trust.

We write with particular reference to the Secretary of State’s decision to recommend the downgrading of University Hospital Lewisham’s (UHL) emergency admissions and maternity services. We consider it a matter of public interest that you make available the evidence on which you have based your advice to the Secretary of State. This advice may ultimately have proved pivotal, since it has underpinned the assertions he made during the announcement to parliament on 31 January and has therefore provided clinical justification for the changes now proposed at UHL.

1. We would be grateful if you would supply us with the clinical evidence behind the Secretary of State for Health’s claim i:

“Already, her constituents who have a stroke or a heart attack do not go to Lewisham hospital. They go to Tommy’s or Guy’s or other places where those specialist services can be delivered, and they get better treatment. We are expanding that principle through what I am announcing today, and it will save around 100 lives a year. That is something that she should welcome.”

In your letter to the Secretary of State, there is no mention of, or clinical justification for, the assertion that extending ‘that principle’ would save around 100 lives a year.

We have investigated the origin of this assertion. A similar assertion has been made by NHS London: Adult emergency services: Acute medicine and emergency general surgery; Case for change. iii In pages 16-17, the main source for this assertion is the analysis performed by Aylin et al of the Dr Foster Unit at your own institution iv of 4.3m emergency admissions from 2005-6. Reference is also made to smaller studies which present similar results v vi vii.

The interpretation of the Aylin study by NHS London (viii p age 17) is as follows:

In a national study Aylin et al found that this effect is of the order of 10% nationally for in hospital mortality, and may be even greater if the period extended to 30 days post admission.

London data is [sic] in line with these findings. This suggests that across London there will be a minimum of 500 deaths each year which may be avoidable if services functioned more effectively.

From the Aylin study, the excess mortality for England is estimated as 3369 deaths. We can see how, proportional to population share, a London figure of 500 can be derived from this by NHS London as above, and a figure of 100 could be derived for SE London for use by the Secretary of State for Health.

But if we examine the Aylin study itself from which this figure was derived, there are fundamental flaws with this deduction.

The calculation of excess mortality makes an unwarranted assumption:

On the assumption that patients admitted at the weekend have the same risk of death as those admitted on weekdays, we estimate a possible excess of 3369 deaths (95% CI 2.921 to 3.820) occurring at the weekend for 2005/2006, equivalent to a 7% higher risk of death.

This is indeed a heroic assumption: that patients admitted as an emergency to hospital have the same risk of death (prior to admission) as patients admitted during the week. In the discussion, the authors themselves acknowledge the limitations of this assumption:

There could have been differences in case mix between patients admitted during the week and at weekends. We attempted to take some account of case mix in our model, but there may be still some residual confounding, which could lead to either an overestimation or underestimation of risk. There were indeed fewer patients admitted on average at the weekend, and this might point to a different case mix for which we have not adequately adjusted.

A major weakness of the study is the lack of calculation of severity score of the presenting illness. This cannot be resolved without the source data. A proper analysis would also require the severity score at time of admission and the duration from point of admission to death. The fact that the daily emergency admission rate at the weekend is only 75% of that during the week may well indicate that patients who present at the weekend are a sicker subset of those who present through the working week, with heir more severe illness explaining their higher mortality. That the weekday-admitted and weekend-admitted groups were matched for age, sex, co-morbidity and deprivation in no way proves that the severity of the presenting illness leading to death was equivalent. A more recent study ix has found similar differences in mortality in patients admitted at the weekend, in particular Sunday, but has cautioned against the interpretation that this is as a result of differences in quality of care.

A second weakness is the assumption that higher mortality in patients admitted at the weekend results from a decreased level of staffing at the weekend. There are other explanations, including a reduced level of specialist intervention and access to diagnostic services at weekends. It is noteworthy that Lewisham Hospital has had a robust system of twice-daily consultant ward-rounds and access to out-of-hours diagnostics for 8 years.

The conclusion made by the Secretary of State is therefore not founded on robust clinical evidence. It is troubling that such an unsafe conclusion could be used to make an assertion that has obviously influenced his decision, not just in the case of Lewisham Hospital but in general, that larger units will achieve better clinical outcomes.

2. We would also be grateful for your urgent clarification of the evidence for the following assertions made by Mr Hunt in parliament x:

“To meet the London-wide clinical quality standards, which are not being met in south-east London at present, it is necessary to centralise the provision of more complex services in the same way that we have already successfully done for heart attacks and strokes. That principle applies as much to complex births and complex pregnancies as it does to strokes and heart attacks, and it will now apply for the people of Lewisham to conditions including pneumonia, meningitis and if someone breaks a hip. People will get better clinical care as a result of these changes.”

Our maternity care is well-regarded: of women booked into antenatal care at Lewisham, there have been no maternal mortalities in the past 7 years. This is despite the fact that high-risk pregnancies form the majority of our maternity workload

xi. A free-standing midwifery-led birthing unit at Lewisham could only be expected to accommodate low-risk women who had already had at least one baby (RCOG, 2011), amounting to only 12% of the present total, rather than the “up to 60%” claimed by Mr Hunt.

You may in fact be unaware, or have not informed the Secretary of State, that UHL is in fact one of the highest performing Trusts nationally for the management of hip fractures.

Guidance on the management of meningitis emphasise the speed of administration of definitive treatment and not the size of the hospital it is treated in. Furthermore, a recent UK study of over 19,000 patients with meningococcal disease shows that mortality is the same (4.9%) whether the patient is admitted during the week or at the weekend

xii. Neurology guidance recommends that that the patient with suspected bacterial meningitis should be transferred immediately to the nearest secondary care hospital xiii. There is therefore no basis in clinical evidence for the assertion made by the Secretary of State.

The overall standardised hospital mortality index for UHL is 0.91 (NHS Choices), which compares favourably with hospitals in the South London Healthcare Trust. Lewisham ICU is one of the better performing ICUs in the country xiv

We are aware of the need for financial prudency and the drive towards the proposed clinical standards. Our alternative proposal put to the TSA was that the future merged Lewisham/ Greenwich Trust would achieve these clinical standards and within budget, but retain its discretion to allocate emergency and elective services across the Lewisham and Woolwich sites as commissioners require.

We are sure that you, a fellow medical professional, would agree that the evidence-base upon which we practice should be sound in order to deliver high-quality care to our patients. This duty extends to those members of the profession, like you, who have put themselves forward to provide medical advice on matters of public policy. This is especially true where that evidence is being used to inform a decision on reconfiguration and centralisation of acute services: if the clinical evidence base is wrong, or the deduction from the evidence is flawed, patients may actually be harmed. We believe that there is a significant risk of this resulting in Lewisham, if high-quality local emergency services are withdrawn in the mistaken belief that they will be provided to a higher standard elsewhere.

Your advice to the Secretary of State may also have a profound impact nationally if these specious grounds for centralisation of most emergency admissions are accepted, and as a result other high-quality DGHs are sacrificed as a result.

We believe that the clinical evidence underlying last week’s decision is deeply flawed, and therefore call on you to reconsider urgently your advice to the Secretary of State.

Yours sincerely,

Dr John O’Donohue, Consultant Physician, Lewisham Healthcare NHS Trust

Dr John Miell, Consultant Physician and Director of Service for Specialist Medicine, Lewisham Healthcare NHS Trust

Dr Tony O’Sullivan, Consultant Paediatrician and Director of Service for Children

Dr Elizabeth Aitken, Consultant Physician and Director of Service, Acute and Emergency Medicine, Lewisham Healthcare NHS Trust

Mr Dan Zamblera, Consultant Obstetrician and Director of Service, Women and Sexual Health, Lewisham Healthcare NHS Trust

Mr Nabil Salama, Consultant Surgeon and Director of Service, Surgery and Anaesthesia, Lewisham Healthcare NHS Trust

Dr Chidi Ejimofo, Consultant, Emergency Dept, Lewisham Healthcare NHS Trust

Miss Ruth Cochrane, Consultant Obstetrician, Lewisham Healthcare NHS Trust

Dr Asra Siddiqui, Consultant Neurologist, Lewisham Healthcare NHS Trust

Dr Richard Breeze, Consultant Intensivist and Director of ITU, Lewisham Healthcare NHS Trust

Dr Louise Irvine, General Practitioner, Lewisham PCT

i

https://www.wp.dh.gov.uk/mediacentre/files/2013/01/SLHT.pdf

ii

Hansard-31 Jan 2013: Column 1080, the Right Hon Jeremy Hunt, in reply to Dame Joan Ruddock

iii

http://www.londonhp.nhs.uk/wp-content/uploads/2011/09/AES-Case-for-change_September-2011.pdf

iv

Aylin P, Yunus A, Bottle A, Majeed A, Bell D. Weekend mortality for emergency admissions. A large, multicentre study. Quality and Safety in Health Care 2010; 19:213-217

v

Bell, M. D., Redelmeier, D. A. (2001). Mortality among patients admitted to hospitals on weekends compared with weekdays The New England Journal of Medicine 345: 9

vi

Barba, R., Losa, J. E., Velasco, M., Guijarro, C., Garcia de Casasola, G. & Zapatero, A. (2006). Mortality among adult patients admitted to the hospital on weekends The European Journal of Internal Medicine 17: 322-324

vii

Riciardi, P. (2011) Mortality rate after non-elective hospital admission. Arch. Surg. 2011; 146(5): 545-551

viii

http://www.londonhp.nhs.uk/wp-content/uploads/2011/09/AES-Case-for-change_September-2011.pdf

ix

Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and additional risk of death: An analysis of inpatient data. Journal of the Royal Society of Medicine. Published online on February 2 2012

x

Hansard, 31 Jan 2013 : Column 1081

xi

In 2012, there were 4,129 Lewisham deliveries: 898 women delivered in our Birth Centre, of whom 509 were multiparous women.

xii

Mortality from meningococcal disease by day of the week: English national linked database study

J Public Health (Oxf) 2013;0:2013 fdt004v1-fdt004 RCOG (2011) http://www.rcog.org.uk/what-we-do/campaigning-and-opinions/statement/rcog-statement-results-npeu-birthplace-study

xiii

EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. European Journal of Neurology 2008, 15: 649–659 doi:10.1111/j.1468-1331.2008.02193.x

xiv

www.ICNARC.org

References





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