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Archive - Month: June 2010

June 26, 2010

South West cancer service reconfigurations “on the fly”
Filed under: FOI Balls — Dr. Phil @ 6:13 am

Cornish people who campaigned against imposition of Cancer Improving Outcomes Guidance (IOG) without public consultation may well wonder why they appear to have been treated differently to Somerset people. Cornwall lost its Upper GI Cancer Surgery to Devon, despite John Watkinson, former Chief Executive of the Royal Cornwall Hospitals Trust (RCHT), obtaining legal advice indicating that to transfer the surgery without public consultation could be unlawful. Health Secretary Andrew Lansley recently ordered an inquiry into the circumstances leading to Mr Watkinson’s dismissal by the RCHT, including whether it was motivated by his position on the Upper GI transfer.

However in Somerset, despite Taunton not serving a sufficiently large population to be IOG compliant, a Freedom of Information response confirmed that “the establishment of Taunton as a specialist cancer centre for gynaecology was approved by the National Cancer Action Team, the Strategic Health Authority and the Avon, Somerset and Wiltshire Cancer Services (ASWCS)Network. The rural nature of Somerset as a county and its distance from Bristol was a strong influence on this decision”

Campaigners involved in an NHS Bath & North East Somerset (BaNES) led controversial review on reconfiguration of Bristol/Bath Gynaecological Cancer Surgery questioned why Taunton was allowed to be an IOG exception. One was told by a management consultant employed by the NHS to “forget Taunton”.

When quizzed at a July Steering Group 2009 meeting, NHS BaNES’ official transcript of the meeting records its former review Chair, Dr Kieran Morgan saying “Yes, well we took the view…….. NHS BANES took the view that that was Taunton and this is here. Whatever the reason for taking that decision is in the past and isn’t really anything to do with us”

The Steering Group was unable to agree whether the service should be centralised at Bath or Bristol. Later in the transcript, the former Medical Director of the Royal United Hospital, Bath, is recorded saying to Dr Morgan “you set up a process, you have reached the end of that process and beyond that we are now making up a series of things on the fly”

According to NHS BaNES, the Bristol/Bath Gynae. Review is now on hold following “a new policy direction from the Secretary of State for Health requesting PCTs to review health service reconfigurations”. Presumably to see whether local people have been properly consulted or had change foisted on them “on the fly”.

June 25, 2010

Dr Phil’s Private Eye Column Issue 1266, June 22, 2010
Filed under: Private Eye — Dr. Phil @ 8:41 am

Commissioning Balls

 Health secretary Andrew Lansley has a touching faith in GPs if he thinks we can spend a £60 billion NHS commissioning fund wisely. Clinical staff should have the power to purchase services for patients, but the commissioners need to include representatives from hospitals and primary care, across all specialties, and the care they purchase needs to be integrated to avoid duplication and make sure patients get treated in the right place at the right time.

 MD does however have several commissioning suggestions. Firstly, stop commissioning NHS inquiries in secret. If a scandal has reached the level of requiring an inquiry, you can be sure lots of people knew about it and failed to act, and there are lots of powerful vested interests trying to minimise the fall-out.  Being able to give evidence in secret in the knowledge that it will never be made public is a strong incentive to continue the deception. Clinical staff and NHS managers are public servants, and if they can’t tell the truth in public, they aren’t fit to serve.

 The fact that Lansley has ordered a public inquiry into the Mid Staffordshire scandal after several expensive private inquiries is a case in point. But Lansley has also announced a private inquiry into the sacking of Cornish chief executive John Watkinson after he blew the whistle on the lack of proper public consultation before cancer services were moved. The management consultancy Verita has been tasked with ensuring its independence, but the same company is overseeing the secret Bristol pathology inquiry, which patient groups fear will be a whitewash.

 The Eye has had a hand in both inquiries, breaking the Bristol story and coming out strongly in favour of an inquiry into Watkinson’s dismissal. MD has given evidence to the pathology inquiry but has been asked not to reveal any details. The inquiry and statistical analysis have been commissioned and paid for by University Hospitals Bristol (via the taxpayer), the very hospital at the centre of the allegations, and UHB will decide how much of the final report to make public. Patient advocate Daphne Havercroft has written an open letter to the Panel1 outlining her concerns about perceived bias, especially in the investigation of 26 alleged cases of serious pathological misreporting.  

 Most alarmingly, ‘the patients affected (if still alive) and/or their families, appear not to have been informed that their case is part of the Inquiry and invited to give evidence to the Panel’ and ‘pathologists who raised the concerns were not asked to verify that the slides, reports, existing external opinions and any other material that UHB sent for review are the ones that are the subject of the allegations.’ The inquiry has responded by asserting its independence but unless these issues are openly addressed, there will be mounting calls for a public inquiry. Far easier to have inquiries in public at the outset.

 MD would also stop commissioning complex treatments from hospitals that only do a few a year, lack the appropriate experience and have no possible statistical proof of competence. MD has made this case repeatedly over 18 years, from child heart surgery to child liver surgery to cleft lip and palate repair, cancer surgery, endocrine surgery, neurosurgery, penile surgery and aneurysm repair. Major trauma and complex surgery needs to be carried out in specialist centres who have the staffing levels and resources, and do enough to gain the expertise and prove their statistical worth. We’ve known this for decades but the fact that child heart surgery still hasn’t been safely reconfigured 18 years after the Eye broke the Bristol scandal shows just how unsafe NHS commissioning is. Now the Health Service Journal reports (June 10, 2010) that in 2007-08, three unnamed London trusts performed just four Abdominal Aortic Aneurysm (AAA) repairs between them, Ealing did 6, Lewisham 7, Whipps Cross 10, Hillingdon 18, Barnet and Chase Farm 22, Epsom and St Helier 23, North West London 32 and UCL 43. High volume centres have a third the mortality of low volume centres and MD wouldn’t commission AAA repair from any centre that did less than 50 a year or didn’t subject its results to independent validation. Patients unhappy with this decision could simply choose another GP.


Freedom of Information
Filed under: FOI Balls — Dr. Phil @ 8:13 am

This bit of the site is an extension of my Private Eye column, Medicine Balls, which alas only gives me 800 words a fortnight to highlight all those vested interests and abuses of power in the NHS. My in-tray is forever full and some stories I never get round to covering in sufficient depth, or at all. By putting them in the public domain here, I hope they’ll gather their own momentum.

Health stories are often difficult to get to the bottom of, and complex to understand, but generally benefit from having a light shone on them.  Please feel free to post here, particularly any Freedom of Information responses (enlightening or otherwise) you’ve managed to drag out of the system, and responses to posts you’d like to challenge or clarify. The aim is to debate.  I’d rather you added your name, but understand that whistleblowers can still be vilified in the NHS. However, please don’t use anonymity as a mask for something clearly libellous.  The bottom line is simple. If it’s true, it isn’t libel. And who knows, we might gather enough truth for another book!

PS The title FOI Balls was suggested by tenacious patient advocate Daphne Havercroft who already has enough FOI responses to fill two books.

June 21, 2010

Letter to Andrew Lansley

Andrew Lansley has said that  “all service changes he NHS must be led by clinicians and patients and not driven from the top down”. This letter to him from patient advocate Daphne Havercroft should test whether he means it.

 20th June 2010

 Dear Mr Lansley,

 NHS South West – Fitness to be a Pilot Site for recommendations of the Carter Review of Pathology and concerns about transparency of the Bristol Histopathology Inquiry

Patient Advocates in the South West welcome your commitment for NHS service changes to be led by clinicians and patients.

 “all service changes must be led by clinicians and patients and not driven from the top down”

In the Bristol area, we are surprised and disappointed to find ourselves being subjected to a review of Pathology Services imposed from the top down that has been instigated by NHS South West and NHS Bristol without proper and full involvement of clinical users of the service and patients.

 NHS Bristol has produced a review initiation document that states “There is a requirement on Strategic Health Authorities (SHA’s) (sic) to ensure that all PCT’s (sic) develop plans for establishing the consolidation of services into managed pathology networks in the annual Operating Framework for the NHS in England in 2009/10.  By 2011/12 the review recommends that consolidated networks should be fully established and performing to the revised quality standards. The South West Strategic Health Authority is to be one of the two national pilot sites to deliver the Carter review recommendations and savings”

 Local patient advocates fully support a review of local Pathology Services to modernise, improve quality and safety and deliver cost efficiencies. However the top down imposition of the Carter Review recommendations looks depressingly like a variant of the same top down dogma that people in the South West have endured, without appropriate consultation, by the way in which Cancer Improving Outcomes (IOG) reconfigurations have been implemented.

 There is an urgent public debate to be had about the fitness of NHS South West to be one of the two national pilot sites to deliver the Carter review recommendations in the light of the following:

 1. Your ordering of an Inquiry into the part played by NHS South West in the dismissal of John Watkinson by the Royal Cornwall Hospitals Trust, including consideration as to whether the SHA “acted appropriately, proportionately, in keeping with its role and within its statutory responsibilities”.

 2. Public calls for the suspension of SHA Chief Executive Sir Ian Carruthers, and other implicated South West managers while the Inquiry proceeds.

3. The resignation of a highly respected and experienced patient advocate from a Cancer Group in Cornwall, alleging “bullying and intimidation” by the NHS in the South West.

 4. The poor quality of the IOG driven Bristol/Bath Gynaecological Cancer Services Review, where local patient advocate opinion is that clinicians were intimidated and bullied into silence, and similar attempts were made to do the same to patients. We believe local NHS Organisations, including NHS Bristol, tried to avoid their statutory responsibilities to consult and this was because the SHA clamped down on proper consultation, as it did for Upper GI service reconfiguration in Devon and Cornwall. Fabian Richter, Conservative Prospective Parliamentary Candidate for Bath at the 2010 Election, saw for himself the injustices that took place with the Gynaecological Review, including  NHS Bath and North East Somerset repeatedly trying to mislead patients and clinicians into believing that implementation of IOG is a legal requirement, when it clearly isn’t, being guidance. We are very grateful to Fabian for publicly articulating the concerns of local people and clinicians.

 5. The fact that NHS South West has officially known about the UH Bristol (University Hospitals Bristol NHS Foundation Trust) Histopathology misdiagnosis allegations (now the subject of a UH Bristol commissioned inquiry) since at least August 2008, and has not shown the public that it acted promptly and responsibly to protect those who raised the concerns, protect patients and ensure the allegations were properly investigated. According to a Freedom of Information Response I received from NHS Bristol on 19th June, it is alleged that the SHA knew about the serious allegations before July 2008, a year before they were reported by Private Eye Magazine.

 6. The question as to whether NHS Bristol and other local NHS organisations within the NHS in the South West, acted appropriately and responsibly when they first became aware of the Pathology concerns. In NHS Bristol’s case, this was in October 2007 and may even have been before.

 7. The extremely disappointing start to the Bristol Pathology Review where it appears that the NHS has tried to appoint a lay representative to its Project Board behind the backs of local people and without giving them any say in patient and public involvement in the Review. NHS Bristol appears to have used this extraordinary incorrect and patronising statement as a reason to exclude patient representation from the Pathology Review:

 “We must recognise that patients have little direct contact with pathology services and therefore cannot contribute their own experiences of using the services”.

 It seems that NHS Bristol will only allow patient views to be represented through local LINks Local Involvement Networks) organisations. Although I am a LINks member, I believe this is an inadequate substitute for the direct involvement of patient advocates who have actually used pathology services and have a good, basic understanding of the science of pathology and how it is central to diagnosis, treatment decisions and research.

 At the root of the Bristol Histopathology Inquiry are these and similar allegations “misdiagnosis of patients with thoracic, gynaecological and breast disease whose histopathology specimens have been reported by pathologists at the Bristol Royal Infirmary. Some of these have had fatal outcomes, and other patients have been treated for malignant disease (e.g. mastectomy and node clearance; intrapleural chemotherapy) when subsequent review showed benign disease.”

 In two of the cases the BRI admitted liability and settled with the families. Yet astonishingly, NHS Bristol appears to claim that patients have no useful contribution to make to the pathology review and will only allow tokenistic representation via LINks organisations. In our opinion, based on all the evidence of lack of consultation in the South West mentioned previously, Sir Ian Carruthers is behind this exclusion of patient advocates from direct involvement and decision making in the Pathology Review. The South West has highly experienced, well educated patient advocates and we suspect that Sir Ian fears their ability to best represent patient interests by questioning and challenging the NHS and demanding good evidence and quality assurance to support decision making.

 Following the Bristol Histopathology Inquiry, managed by Verita since December 2009, and widely  perceived as heading for a whitewash because of secrecy and lack of confidence in the way it is being conducted, Bristol’s Pathology Services urgently need to be reviewed.  It is looking increasingly unlikely that patients and the public can entrust such important work to local NHS organisations while they display obvious resistance to allowing the Pathology Review to be led by patients and clinicians, in defiance of Government expectations, and when the fitness of NHS South West, under Sir Ian Carruthers, to be a pilot region for the top down Carter Review, is highly suspect.

 South West patient advocates support the recommendations of the Carter Review in principle. However, we fear that in Sir Ian Carruthers’ South West, they will be imposed on us and clinicians without full, open and transparent consultation that meets statutory requirements. We believe that     this may lead to less safe and lower quality Pathology services in the South West.

 We ask you to consider and advise whether, with its track record of suppressing patient and clinician leadership of NHS service change, and with a Chief Executive widely regarded as fostering a bullying and intimidatory culture, NHS South West is an appropriate and safe site to be a pilot for the Carter Review recommendations.

 We would also appreciate knowing the coalition Government’s position on the importance and validity of the Carter Review recommendations in respect of local pathology service reconfigurations. As it is a top down recommendation it is unclear to the public whether it can be easily reconciled with the requirement for all service changes to be led by clinicians and patients, not imposed from above. 

 As you have asked Verita to conduct the Inquiry into the circumstances surrounding the John Watkinson Industrial Tribunal, we suggest that you may also wish to inquire into public concerns I mentioned earlier about the Bristol Histopathology Inquiry, which is managed by Verita. One of the reasons for the concerns (there are others) is that the Terms of Reference of the Inquiry do not include investigation into role of NHS South West, NHS Bristol (and other local Primary Care Trusts) and the Avon, Somerset and Wiltshire Cancer Services (ASWCS) Network in respect of their response to the allegations. A lesson learned from the Bristol Royal Infirmary Heart Inquiry is that it is important to know from the organisations and individuals responsible for patient safety and quality of care the answer to these questions:-  what did you know? when did you know about it? what did you do about it? It appears that NHS South West, NHS Bristol and ASWCS will be protected from being accountable to the public to answer these questions. This is not right.

 We also request your intervention to protect our rights and those of clinical users of pathology services to be fully involved and consulted by insisting that NHS South West and the organisations that report to it ensure that any Bristol area Pathology Review is led by local clinicians and local patients, without intimidation and bullying by NHS South West and other local NHS organisations.

  Yours sincerely,

 Mrs Daphne Havercroft

 Consumer Member, National Cancer Research Institute, Breast Clinical Studies Group

Trustee, Independent Cancer Patients’ Voice

Member, South Gloucestershire LINks

Member, Breakthrough Breast Cancer Campaigns and Advocacy Network

Member, Bristol & Weston Breast Care Services Review Project Board

Independent Patient Adviser, Bristol & Bath Head and Neck Cancer Services Review.

Graduate, Project Lead & Project Lead Clinical Trials

copied to:

Steve Webb, MP for Thornbury and Yate

Jack Lopresti, MP for Filton and Bradley Stoke

Fabian Richter

Paul Burstow, MP, Care Services Minister

June 16, 2010

An Open Letter to the Bristol Histopathology Inquiry
Filed under: Bristol Pathology Inquiry — Tags: , — Dr. Phil @ 11:50 am

Daphne Havercroft, an experienced Patient Advocate,  has written an open letter to the inquiry that encapsulates all the concerns of those who fear we’re heading for a whitewash.  

Dear Miss Mishcon,

Bristol Histopathology Inquiry – Open Letter

I write concerning the 26 alleged cases of misdiagnosis that UHB (University Hospitals Bristol NHS Foundation Trust) arranged to be externally reviewed. They cover four specialist areas:- respiratory, gynaecological, breast and skin.

 From UHB and NBT (North Bristol NHS Trust) Freedom of Information Act responses, I understand the following:

  1. NBT identified the 26 cases following histopathology case review, with little involvement of the clinicians who raised the allegations.
  2.  The patients affected (if still alive) and/or their families, appear not to have been informed that their case is part of the Inquiry and invited to give evidence to the Panel, as demonstrated by the Jane Hopes case reported in the Sunday Telegraph 11th April 2010.
  3. UHB’s laboratory staff extracted slides to send to Medical Solutions, a company with a financial relationship to UHB, for review by pathologists whose names are secret.
  4. Pathologists who raised the concerns were not asked to verify that the slides, reports, existing external opinions and any other material that UHB sent for review are the ones that are the subject of the allegations.
  5. There appear to be no formal plans to communicate the findings of the external review to pathologists who raised the concerns and those whose work is the subject of the concerns, to allow them to comment on the findings.
  6.  UHB’s Acting Chief Executive has confirmed that, of the 26 cases, there were “2 cases of misdiagnosis leading to patient harm where the Trust admitted liability and a settlement was reached”. He does not say whether the settlement included a “gagging” clause that prevents the families from meeting the Panel.
  7. The 26 cases may be the tip of the iceberg. UHB’s apparent reluctance to investigate this  indicates that fear of litigation overrides exposure of the facts. The 26 cases are a small sample of the caseload in the four areas of concern. If an audit of just these subspecialities was performed, covering all years for which allegations have been raised, the error rate may be higher than the 1-2% claimed as a “normal” error rate by the Trust.
  8. The 3,500 random audit of cases or specimens (it has never been made clear which),   commissioned by UHB for 2007, includes large specialities for which no concerns have been expressed. As well as causing anxiety to pathologists in those specialities, the audit is likely to mask the extent of any serious errors made in the specialities of concern.

The public wants to know whether or not serious, avoidable misdiagnoses have occurred, which have harmed or could harm patients; not whether UHB’s Histopathology Department had an overall error rate of less than 2% for 2007.

 The public wants the truth about the extent to which the concerns were dealt with in an open, honest and constructive manner. Or have no lessons been learned from the Bristol Heart Inquiry?

All histopathologists make some mistakes. However UHB has admitted that two of the 26 cases involved patient harm. We want to know whether other avoidable mistakes have been made that harmed patients, or had the potential to do so if not spotted and corrected by colleagues in other Trusts.

We want to understand whether histopathologists working in the areas of concern have been performing to standards that are expected of their position as specialist pathologists in a tertiary referral centre and whether all have been participating in EQA (External Quality Assurance) schemes for the subspecialities of breast, respiratory, gynaecological pathology and dermatopathology.

The secretive conduct of the review of 26 cases does not inspire confidence that these questions will be answered.

Public confidence will be further undermined if the Panel is not seen to acknowledge this and demonstrate its independence now by insisting on full transparency in the investigation of the 26 cases.

Adverse public and press reaction is inevitable when the organisation against whose staff the allegations have been made, selects the evidence for investigation without any input from those who made the allegations, pays for its existing contractor to handle the evidence and engages and pays for a Panel to provide assurance that all is well.

 I am confident that the Panel has the opportunity to exert its independence by ensuring full transparency in uncovering and publicly reporting the facts about the 26 cases as an urgent prerequisite for developing the consistent high quality, safe pathology services that Bristol desperately needs.

 The issue is whether the Panel has the will to seize this opportunity.

 I hope that this letter is helpful to you and your colleagues on the Panel in clarifying the expectations of patients and members of the public.

 Daphne Havercroft

 Patient Advocate

 14th June 2010

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