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Archive - Month: November 2013

November 21, 2013

Medicine Balls, Private Eye Issue 1353
Filed under: Private Eye — Dr. Phil @ 9:53 am

Bully for Hakin

Bullying is the cancer at the heart of the NHS. It stops staff, patients and relatives from raising concerns about their care, it destroys many that do and it allows political directives to be enforced on the frontline even when they’re unsafe or untrue, just to keep Downing Street happy. The only time politicians see the light is when they’re forced to in response to a disastrous public inquiry. On 6 February, David Cameron said of the Francis Report into Mid Staffordshire hospital; ‘You can identify in the report three fundamental problems with the culture of our National Health Service. First, a focus on finance and figures at the expense of patient care. He says that explicitly. This was underpinned by a pre-occupation with a narrow set of top-down targets pursued to the exclusion of patient safety or listening to what patients, relatives – and indeed many staff – were saying.’

These were precisely the reasons that MD and Eye journalist Andrew Bousfield referred Dame Barbara Hakin, now deputy chief executive of NHS England, to the General Medical Council. We alleged that she oversaw a ‘hit your targets or else’ policy when she was chief executive of the former East Midlands Strategic Health Authority, despite concerns raised by Gary Walker, then chief executive of United Lincolnshire NHS Trust, that this – combined with an unprecedented rise in demand – was putting patients at risk of harm. Indeed, it is alleged that one died and another had an avoidable amputation. Walker also raised his concerns in detail to NHS chief executive Sir David Nicholson and asked to be protected as an NHS whistleblower. He was subsequently sacked for ‘swearing’, gagged from voicing his concerns to anyone and £500,000 of public money was spent getting rid of him. Surely somebody has to be accountable for all this?

It’s certainly not Hakin, at least not according to the GMC who, just 15 months after we referred her, have decided that anything that she may have said or done does not bring into question her fitness to practice, nor the safety of patients, and she can carry on as usual. The GMC found “some support” for the core allegation, that Hakin told Walker the four hour accident and emergency and 18 week waiting time targets must be met despite his concerns that to do so could compromise patient safety. In March 2009 Hakin sent an e mail to all East Midlands chief executives stating ‘I need to make it very clear that I expect you personally to ensure that your organisations deliver 100% for the next three weeks…. We cannot afford even one day when one single organisation falters.’ Whether this constitutes bullying is beside the point. The Francis inquiry found such an approach is very unsafe and puts patients at risk. And Walker was telling her precisely that.

The GMC accepted Hakin’s argument that ‘effective and suitable chief executives ensure patient safety whilst meeting targets and that she did not bully or harass Mr Walker… Safety and targets are inextricably linked and the complaint is based on a false dichotomy between the two.” The targets themselves make some sense – no one wants to wait more than 4 hours in casualty or 18 weeks for an operation – but healthcare is very complex and dangerous, especially when there is overcrowding, and even Sir David Nicholson has recognized the dangers of ‘hitting the target and missing the point.’ A ‘100% insistence’ is particularly dangerous, and creates a climate of fear. Francis found at Mid Staffs that the fear of breached targets created bullying in A&E, and an “emergency assessment” room where “breached patients” were stuffed and suffered. How can the GMC be so misinformed?

MD asked the GMC who their independent experts were (they’re not saying) and to forward Hakin’s evidence (not allowed, even though passages in the judgement are strongly disputed by Walker). MD has asked Hakin for her evidence (no reply yet). MD has asked the GMC what their definition of bullying is (yet to be provided) and whether they considered the evidence of Francis on the dangers of enforced targets (they hadn’t). They also hadn’t considered evidence from the urgent investigation of ULHT by Sir Bruce Keogh triggered by consistently high mortality rates after Walker was sacked. In June 2013, ULHT was rated red for MRSA infections and clinical negligence payments. It had 12 ‘never events’ (severe harm to patients that should never occur) since 2009. 8 out of 13 mortality indicators were ‘outside the expected range’ with severe concerns about emergency care. There were serious concerns about fluid balance monitoring, delayed treatment, poor documentation, palliative care, failure to spot deteriorating patients, risks of falls and patients not being properly reviewed after operations. On a ‘patients with cancer’ survey, 22 of 58 responses were ranked in the bottom 20% in the NHS whilst only 2 were in the top 20%. ‘The main negative focus relates to overall care and care and treatment for inpatients’.

There is much else besides to show not just a hospital now in crisis, but a crisis predicted by Walker. Patients have suffered severe harm and deaths at ULHT that would have been avoided with proper standards of care. The GMC’s response? “The GMC (whilst aware of the recent publication of the Keogh Review) is unclear what, if anything, could be added at this late stage in the investigation”. The GMC also rejected key parts of Walker’s evidence. Findings of an Employment Tribunal Judge determined Walker had made protected disclosures regarding patient safety to Hakin. The Parliamentary Health Select Committee also found the NHS was wrong to attempt to sue Walker for raising ‘genuine patient safety concerns’. The GMC claim that they were restricted by a gagging order and confidentiality clause in examining the matter. Yet the GMC has powerful legal privileges that extend to obtaining this information. In any case, the gagging order was waived by the NHS and Secretary of State for Health in March 2013.

The GMC’s decision is puzzling but unsurprising. No-one at the top of the NHS is ever accountable for anything. They are only ever carrying out the orders of politicians as interpreted by civil servants. If you try to tell them it’s putting patients at risk, you’re told to hit the targets or else. Walker has ample evidence to back up his claims and his and Hakin’s evidence need to be tested fairly in public. In MD’s view, the process of the GMC investigation was manifestly unfair and proceedurally unsound (no equal and full disclosure of the evidence, relevant evidence not considered fairly or rejected, and a breach of the GMC’s duty to protect the public). ULHT is now one of the most dangerous trusts in the country and has had 9 CEOs in 11 years. Could the two be related? Don’t ask the GMC. Last week, police were called into Colchester General hospital, another on the Keogh special measures list, following allegations that staff were bullied into falsifying cancer care records to meet targets. Move on. Nothing to worry about here. They were only following orders. Over two years ago, MD reported the medical director of Great Ormond Street Hospital to the GMC for failing to act on the concerns of Baby Peter whistleblower Dr Kim Holt. They are apparently still investigating, hampered by the lack of an independent expert. David Prior, chair of the CQC, recently berated doctors for not blowing the whistle in the NHS but, having done it for 21 years and seen the cast of brilliant, brave people destroyed in the process – blackballed, smeared and gagged by the NHS and not protected by the law or regulators – it’s hard to see why anyone would be mad enough to do it.

November 6, 2013

Medicine Balls, Private Eye Issue 1352
Filed under: Private Eye — Dr. Phil @ 10:56 am

Simon Says Yes

And so Simon Stevens, the global president of an American private healthcare firm, is to be chief executive of NHS England. Stevens is currently President of UnitedHealth’s Global Health division. The American Association for Justice – an international coalition of attorneys and law professors promoting a fair and effective justice system – ranked UnitedHealth as the eighth worst insurance company in the US. ‘Plagued by accusations that its greed has endangered patients. Physicians report that reimbursement rates are so low and delayed by the company that patient health is compromised. Money that should have been spent on medical treatment for policyholders has instead gone to the company’s former CEO, who faced criminal and civil charges for backdating stock options’1 One of Steven’s many challenges will be to prove the NHS is not going to be carved up for corporate profit. He has to be trusted to act in the best interests of patients.

UnitedHealth UK could certainly do with a boost. It recorded a £8.2m loss and a 27 per cent fall in turnover in 2012 – its eleventh loss-making year in a row. UnitedHealth Group is set to wind up its loss-making UK arm and ‘shift staff into another subsidiary with a more pan-European focus’. The Heath and Social Care Act certainly gives the private sector more opportunity to bid for NHS contracts, and with their corporate muscle they stand a good chance of winning them. But as UnitedHealth and others have found, there’s precious little profit in the NHS at the moment. Stevens knows this, and has voluntarily taken a 10% cut in the NHS CEO salary to £189,900.

Stevens also knows the NHS well. He was a Labour councillor, spent nine years working in the NHS and in 1997 became Frank Dobson’s and then Alan Milburn’s chief advisor, before becoming Blair’s health policy director. Stevens was one of the authors of Labour’s NHS Plan, which was accompanied by a huge increase in NHS funding. There were some notable improvements – huge falls in waiting times for treatment, improved performance by A&E units, better outcomes for patients with cancer and heart disease – but there were also huge missed opportunities. Productivity hardly budged for all the extra money, scandals passed unnoticed, the promised IT system that would link up the entire NHS and give patients control over their records never materialised, and vital reorganisations of specialist care into fewer, safer, better-resourced centres didn’t happen.

MD met Stevens when he was Dobson’s adviser to discuss the Bristol heart scandal. The fact that child heart surgery still hasn’t been safely reorganized 16 years on is deeply troubling, and the NHS is only now starting to publish outcomes and patient experiences to prove which services do more good than harm and to guide patients where to go (should they wish to travel).

Stevens’ biggest challenge will be to end the culture of bullying, blame and fear in the NHS. This will not be easy in the run in to an election, with Hunt already accused of tweet-libel by Burnham and Burnham threatening to sue. This week, Professor Steven Bolsin was finally honoured by the Royal College of Anaesthetists for his courageous whistleblowing in Bristol over 20 years ago. Meanwhile, the tribunal of whistleblower Dr Raj Mattu v University Hospitals of Coventry & Warwickshre NHS Trust (Eyes passim), looks set to become the most protracted, divisive and expensive in NHS history. Whistleblowing Alder Hey surgeon Ed Jesudason (Eyes passim ) has sent his evidence to the Public Accounts Committee and the CQC, and whistleblowing Walsall paediatrician David Drew (Eyes passim ) is publishing a truly shocking book to get his story out.

These doctors are not mad, just brave people who tried to speak the truth to power about patient safety and had their NHS careers destroyed. The Nursing Times has started a brilliant Speak Out Safely campaign to support frontline whistleblowers but less than 50 Trusts and CCGs have signed up to it. Stevens knows that the chief executive of NHS England has surprisingly little power to influence care on the ground. But he must try to ensure those of the front line – patients, carers and staff – feel safe to speak up, stop harm and finally make the NHS transparent about its failures, as well as its successes.


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