Medicine Balls Eye 1345 July 26
Sir Bruce Keogh’s review into the quality of care and treatment provided by 14 NHS trusts with high death rates was shrewd and thorough, but his proposals for proper NHS inspections lead by doctors are nothing new. In 2000, MD endorsed the idea of an independent medical inspectorate in his evidence to the Bristol Inquiry and the Eye (Feb 3?), based on the work of Dr William Pickering.
“Shipman got away with it for so long was because he knew that in the NHS, and in general practice in particular, doctors can do more or less what they like. They call it ‘clinical freedom’ and cherish it. No one (except the law) can meaningfully challenge their actions, and then only if they are found out. Medical ethics do not include commenting on another doctor’s practice, nor do they insist upon an open mentality. The ‘self-regulation’ of doctors is, therefore, equivalent to no regulation.”
‘Most medical disasters start with single errors or near misses, and yet they only come to light much further down the line when many more mistakes have been allowed to occur. Even then, it needs the strident clamour of patients or the press to get near the truth. So-called regulators have been of singular irrelevance; had it been left to them, many recent disasters would be continuing yet.”
“The only way to exact such basic clinical standards is to have a person in each district of the country undisguisedly looking for sub-optimal clinical practice, working within an Independent Medical Inspectorate. Each Inspector should be informed (a doctor) and impartial (paid from outside the NHS). The Inspectorate will glean its information for any source, including whistle blowers and patient complaints. All clinical complaints, plus a copy of the written response and explanation to the patient from the doctor, will pass across the Inspectorate’s desk. This will press medical personnel into prompt, open and accurate explanations. If indicated, the Inspectorate would examine the medical records and if sub-standard clinical practice is evident, it will swiftly inform the doctor and the regulatory bodies. It’s very presence will force all clinical staff to examine their practice. Clinical standards may be expected to quickly rise. Expensive legal defence costs and awards are likely to drop. Above all, patients can be sure that their doctors are, at last, meaningfully clinically accountable.”
13 years and many disasters later, Keogh and Mike Richards, the new chief inspector of hospitals, have reached the same conclusions, adding in patient assessors too. It remains to be seen how many clinical staff and patients volunteer to be inspectors (MD will), and whether they will be completely independent, properly funded and able to speak the truth to power without getting bullied, ostracised and silenced as has happened to those who raise concerns in the past (Eyes passim ad nauseum). By calling Mike Richards the whistleblower in chief, Jeremy Hunt has at least given the appearance of getting the importance of whistleblowing. Whether he remains so enthusiastic as failures in NHS care under his watch emerge near election time remains to be seen.
Hunt’s Commons response to Keogh was a dangerous game of trying to hole Andy Burnham below the waterline and damage Labour’s credibility as saviours of the NHS. Where Keogh had wisely avoided blame and sensationalism, and focused on the complexities of providing safe NHS care in a cash-strapped service in parts of the country that find staff recruitment tough, Hunt and Cameron went straight for the Labour jugular. MD repeatedly exposed Labour’s missed opportunity of using all the extra funding to rebuild the NHS around quality and safety, the woeful variations in standards of care, toothless regulators fearful of government and appalling treatment of staff, patients and relatives who try to raise concerns. But this has continued under the government’s watch and divisive, political point scoring is ludicrous, particularly given that all political parties have endorsed Sir David Nicholson as NHS leader, despite overseeing such an unsafe and bullying culture. Hunt started off not blaming Labour, but in changing horses while keeping the same jockey, he is setting himself up for a fall. Politicians need to unite around what’s best for the NHS, and the best way to encourage clinical leadership is to have a wise clinical leader. The sooner Keogh unseats Nicholson, the better.
The Truth About Death Rates
The Hospital Standardised Mortality Ratio represents the number by which the deaths in a hospital exceeds the number that would have occurred if the hospital had had the national death rate for each age, sex, diagnostic group etc for which adjustments are made. It is a statistical estimate, and so can’t be used to determine precise numbers of deaths or whether any individual death might have been avoided with better care. It is however, an excellent warning alarm to go and dig deeper. All fourteen trusts targeted by Keogh because of high death rates turned out to have serious safety problems.
The media habit of attributing a precise number of avoidable deaths to HSMRs is nonsense, but it has been used by Labour and its activists to discredit both Sir Brian Jarman and his methodology, and to cover up the fact that hospitals with high HSMRs were either not investigated by Labour, or reported to an incompetent regulator set up by Labour to perform an inadequate investigation. Labour’s booing of Jarman during the Keogh debate is just another example of shooting the messenger. As Keogh himself said to the Mid Staffs inquiry: ‘I am reasonably confident that the process which is now in place would have picked up the situation at the trust before it was granted Foundation Trust status. The HSMR information and the question in the staff survey about whether the member of staff would be happy for someone in their family to be treated at the hospital are two examples of where the problems at the Trust would have been identified by the current position’. No one method is perfect at picking up avoidable harm. But to avoid the warning signs is unforgiveable.
Medicine Balls Eye 1344 July 12
Trust and Transparency
The BMA’s vote of no confidence in health secretary Jeremy Hunt, a year after the same outcome for Andrew Lansley, is no surprise. The government promised an end to structural reform of the NHS and then landed it with the largest structural reform in its history. Lansley, and now Hunt, also promised a new era of transparency whilst simultaneously refusing to publish the ‘risk register’ for such absurdly complex and unnecessary legislation. And most NHS staff believe that increasing private competition will lead to fragmentation and cherry picking more than integration and improved services.
Lansley even predicted an end to political interference in the NHS, leaving the running of the NHS to chief executive Sir David Nicholson and his ‘people’. But a succession of scandals and cover-ups on Nicholson’s watch has given the ambitious Hunt an open invitation to interfere. Hunt is keen to deflect blame, and so Mid Staffs was a good opportunity to claim there was too much mediocrity in NHS care and too many hospitals were “coasting”.
The out-of-hours service 111, introduced on Hunt’s watch without proper safety standards and despite repeated warnings from clinical staff that it was dangerous, has resulted in at least 3 deaths and queues in accident and emergency, both of which Hunt tried to blame on a 9 year-old GP contract. The Mid Staffs and Morecambe Bay scandals are in Hunt’s view Labour’s fault, even though the government has stuck the same NHS leadership and the cover-up by the CQC happened in March 2012, two years after the coalition took office. In the new transparent NHS, this high level meeting wasn’t minuted and has no audit trail nor evidence to show who in the DH was aware of the scandal and its suppression. As Kay Sheldon, the CQC whistleblower put it: ‘The CQC was not fit for purpose and patients’ lives were at risk. But the only thing the Department of Health and the CQC cared about was maintaining the illusion that the system was working.’
Sheldon was bullied and branded mentally ill for exposing the CQC, and threatened with dismissal by Lansley although he backed down after the counter-threat of legal action. Lansley was also well aware, but seemingly unable to help, Dr Hilary Cass, the whistle-blowing paediatrician and now president of the Royal College of Paediatrics and Child Health, who was gagged by Great Ormond Street Hospital in 2010 and warned that support for her palliative care training would be withdrawn if she spoke out (Eye last).
Ministers seldom, if ever, get involved in individual cases and the promise of NHS England boss David Nicholson to support any whistleblower who contacts him does not appear to be bearing fruit. Instead it’s left to Hunt to profess to be outraged, shocked and disgusted by each new scandal, when a properly briefed health secretary would be anything but surprised. But Hunt is just a caretaker health secretary with no intention of staying in the job after the next election. As such, he’ll happily play ignorance for as long as he can get away with it. He landed one of the most complex jobs in the cabinet after claiming, as culture secretary, he had no idea that his hand-picked special adviser was passing confidential and market-sensitive information to BskyB.
The government’s best chance of restoring both transparency and trust in the NHS is to accurately measure standards and experiences of care, and publish them. The friends and family test, and the release of named-surgeon data, could prove how good the bulk of NHS care is, and show where it needs to be improved. But staff have to trust the government and NHS England to do this fairly and sensibly, without politicisation, victimisation and press histrionics. Many doctors don’t trust Hunt or Nicholson and until they do, even the best intentioned stab at transparency could fail. But patients will happily provide feedback on their care when asked, and the early results are very encouraging for the NHS.1
Medicine Balls Eye 1343 June 28 2013
How High Can You Gag?
Private Eye has finally got Great Ormond Street Hospital (GOSH) to release details of its gagging settlement with Dr Hilary Cass, a consultant in disability and the current President of the Royal College of Paediatrics and Child Health. GOSH told Cass that if she didn’t accept a gag, her palliative care training for terminally ill children would be withdrawn. Bullied and wary of the consequences for children, Cass agreed to judicial mediation and an ‘off the book’ payment of £35,000 in settlement of her claim for constructive dismissal.
In the compromise agreement, drawn up by Beachcrofts, Dr Cass must “warrant” that she has talked to nobody but her immediate family, and “must not disclose in future to anyone the circumstances of your termination of employment” and “must not directly or indirectly make any statements derogatory of GOSH”. Dr Cass could still be sued today if she makes a true statement about GOSH that is deemed “derogatory” by them. So why was GOSH so keen to shut her up?
On January 11th 2007 Dr Cass, as Deputy Medical Director at GOSH, heard a grievance from Dr Kim Holt (Eyes passim), who had raised safety concerns about the Haringey clinic where the abuse of Baby Peter Connelly was subsequently missed. Dr Holt was put on special leave by GOSH and made allegations of widespread bullying and harassment by managers. Dr Cass found in favour of Dr Holt, but was asked by senior management make substantial changes, including a statement that Dr Holt’s grievance was not upheld. This was seen as crucial to GOSH’s business plan to take over the management of children’s services in Haringey. Cass did not accept the outcome should be changed, but agreed some amendments to the outcome letter.
When Baby Peter died on August 3, 2007, GOSH’s huge error in not investigating Dr Holt’s safety and bullying allegations became apparent. As the reputational clean-up operation kicked in, Holt was offered, but refused, a gag. In October 2007, Cass raised concerns that cuts in junior doctor staffing were putting patients at risk and was swiftly removed from her educational post by chief executive Dr Jane Collins. Cass later filed a grievance against Collins, claiming she had breached her managerial code of conduct. Cass also wrote to London Strategic Health Authority in June 2009, blowing the whistle on the bullying conduct of GOSH senior management and their failure to address the safety concerns. Nothing happened. In June 2010, Cass sent her concerns to the Care Quality Commission. Again, nothing happened.
In 2009, Cass secured a new post at Guy’s and Thomas Hospital which did not have a specialist palliative care service for children. GOSH allowed Cass to train in palliative care in order to set up the service at her new hospital, but made the training conditional on her silence. In a statement, GOSH said: “The Trust recognises that some clauses in the agreement could be interpreted as restricting what Dr Cass could speak about publicly. In hindsight those clauses should not have been included. No clauses of this nature will be included in any future agreements.’ GOSH could not recall who put the threat of palliative care training withdrawal into the gagging agreement, as papers relating to early drafts of the agreement had ‘gone missing’. Dr Jane Collins has since deregistered from the GMC and now works as the head of Marie Curie, a charity responsible for… palliative care. On 30.9.2011, the Eye referred consultant Dr David Elliman to the GMC for not acting on the concerns of Dr Holt. Nearly 2 years later, the GMC is still sitting on the case. Meanwhile, MP Stephen Barclay has unearthed 50 such ‘off the book’ payments to silence NHS whistleblowers at a cost to the taxpayer of £2 million.