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Archive - Year: 2013

June 3, 2013

Why is patient funding the lowest in the North West?
Filed under: Private Eye — Dr. Phil @ 12:42 pm

Interesting letter from GPs at Holmes Chapel Health Centre in Cheshire saying that some other  CCGs receive approximately 50% more money per capita than Eastern Cheshire CCG. Is this true? If so, how can it be justified?

CCG unfair funding


May 20, 2013

Private Eye Issue 1340
Filed under: Private Eye — Dr. Phil @ 11:35 pm

Legal duty to tell the truth must apply to all

‘How can you trust a doctor who doesn’t tell you the truth?’ So said Maria Shortis, founder of the Bristol Heart Baby Action Group, 15 years ago. Will Powell, father of Robbie, agrees. He’s spent 23 years, and all his savings, trying to get the truth about how and why Robbie died. He was promised a public inquiry, which never materialised, although he did make it to the European Court of Human Rights in 2000, which judged that ‘doctors have no (legal) duty to give parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even to refrain from deliberately falsifying records.’ (Eye…. )

For the 65 years of its existence, NHS organizations and staff have not been in breech of any statutory rule if they cover up a medical accident. The Bristol Inquiry recommended that ‘when things go wrong, hospitals and healthcare professionals have a duty of candour: to be open and honest.’ In 2003, chief medical officer Liam Donaldson observed ‘to err is human, but to cover up is unforgiveable’ and recommended a legal duty of candour. Labour resisted. Professional codes of conduct laid out by the GMC and NMC for clinical staff make telling the truth a duty, but these have been so widely ignored, not least at Mid Staffordshire, that Robert Francis QC recommended both a statutory duty of candour and criminal liability  if serious death or harm results from a breach of ‘fundamental safety and essential care standards.’ It would also be a criminal offence to make false statements in a trust’s quality accounts or to a regulator, and to knowingly obstruct another in the performance of these statutory duties.

Francis makes a convincing argument for candour. ‘How can patients and relatives be involved in their care and make informed choices if they are not told what has happened to them and the reasons why?’ He also believes that if telling the truth became a legal obligation in the NHS, it would give whistleblowers the authority, confidence and support to speak up, and it would become legally impossible to gag them.

The government’s response thus far has been an acceptance that gags on whistleblowers have to go, but it is far from clear whether those who have already taken gags will not be legally threatened if they now break them. And the whistleblower support group Patients First believe they’re still being used in various guises as lawyers are employed by NHS trusts to protect and defend their corporate and financial interests, not to be open and honest. There will also be a contractual and statutory duty of candour for NHS organizations to tell the truth to patients and relatives, but no such legal duty yet for individual members of staff. And there will be legal sanctions on NHS organizations that deliberately withhold information or mislead. The government is awaiting the outcome of the Berwick safety review before deciding on criminal liability for a serious breach of standards.

Whatever legislation emerges, fair and meaningful enforcement would require ethical behaviour at every level of the NHS, including its lawyers, and the criminal sanctions would need to extend up to managers and politicians, not just clinical staff. The 111 disaster is a great example. Coordinating out of hours (OOH) care is complex and a joined up service staffed by clinicians is critical for safety. Instead, Andrew Lansley fed the OOH service to the market and put it out to tender. There are now over 40-odd independent call centres, who are making a profit margin by manning the phone lines not with nurses as NHS Direct did, but with ‘non-clinicians’, who are trying to sort out urgent from less urgent calls using algorithms. NHS staff warned of the dangers and called for a slow down, the government’s response was to rush it through while the PCTs were in meltdown and now, with at least 3 deaths and 22 serious incidents  alleged to have occurred, the blame is passed from Dr Barbara Hakin at NHS England back to the GP commissioners who had no say in the services when they were introduced but must now sort out the mess. In response, GP leaders are kicking the blame back to the government, Hakin and the rest of the NHS England board.

If death and harm has occurred in the 111 cock-up, who should the Francis recommendations criminalise under these circumstances? And who’s version of the truth should patients and relatives accept? Francis rightly observed that there needs to be a relentless focus on the patients’ interests and the obligations to keep patients safe and protected from substandard care’ but no senior manager or politician was held accountable for Mid Staffs. It remains to be seen whether the proposed criminalisation of appalling care in the NHS reaches all the way to the centre. Don’t hold your breath.

Private Eye Issue 1339
Filed under: Private Eye — Dr. Phil @ 11:28 pm



Political Freedom for the NHS? Er…. No


Andrew Lansley’s promise that his health bill would depoliticise the NHS is proving as fruitless as trying to depoliticise the economy. The theory is that ‘clinical leaders’ will now run the NHS on behalf of patients while politicians calmly retreat from the fray and let them get on with it. But at PMQs on April 24th, Ed Milliband revisited the Thatcher taunt that the NHS was ‘not safe in Cameron’s hands’. And Cameron responded by rubbishing the NHS in Labour-controlled Wales, before signing off with “that is what you get under Labour: cuts to our NHS, longer waiting lists and all the problems we saw at the Stafford Hospital would be repeated all over again”.


Although Labour should accept accountability for Mid Staffs, as should the NHS senior managers who have glided unopposed into the top NHS jobs under the Tories, it’s absurd not to recognize the extra funding and improvements to the NHS under Labour. It’s also absurd, and very dangerous, to suggest another Mid Staffs would only happen under Labour. In doing so, Cameron is creating the same culture of denial that lead to Mid Staffs.


Don Berwick, Cameron’s newly appointed safety tsar, takes a more cautious approach. He has told NHS staff ‘Don’t think you’re different to Mid Staffs staff. You should not be confident you would have acted differently.’ Some staff at Mid Staff tried to speak up but were shut up, leading the Nursing Times to launch an excellent Speak Out Safely campaign ‘to help bring about an NHS that is not only honest and transparent but also actively encourages staff to raise the alarm and protects them when they do so.’ But as the pressure mounts to make the NHS look good in time for the next election, it’s hard to see how this will become a reality.


The NHS has done remarkably well in the last 2 years given the slow-down in funding, but the wheels are starting to loosen. The dramatic rise in 12 hour trolley waits in A+E was the main thrust of Miliband’s attack but winter has been tough, most of the patients are frail and elderly, and there is nowhere else for them to go.  Discharge may be delayed because of a lack of social care beds and so elective operations are cancelled. It’s hard to see how it would have been any different under Labour.


NHS funding may have flat-lined but adult social care has had cuts of £1.89 billion in the last 2 years. The NHS and social care might work better if the services were integrated, and Torbay is trying to merge its services but the Office of Fair Trading now has to assess any merger involving an NHS foundation trust, and to ascertain whether it could be seen as anti-competitive. Don’t expect progress soon.


Competition law in the new NHS seems likely to delay the integration of services and make lots of money for competition lawyers. It could also, in the long term, open the door to whole-scale privatization. Section 75 regulations set the legal framework for NHS competition under the reforms, and a Labour motion to annul them  was defeated by 145 votes to 242 in the Lords on April 24th, with Lib Dems siding with the Tories. Many who voted in favour of section 75 have vested interests in private companies which stand to benefit, so the result was unsurprising.


The new laws make it harder to award NHS contracts without competitive tendering, and although in theory some services can be protected from cometition, the commissioners have to make the case that there is ‘only one provider capable of meeting their requirements’. Lawyers will love it, commissioning could become a protracted and very expensive nightmare, and the private sector could cherry pick profitable services and completely destabilise the fragile eco-system of the NHS.  That’s what Dr Clive Peedle, co-founder of the NHS Action Party believes, and they will be contesting 50 marginal seats at the next election and trying to force legislation through to make the NHS the preferred provider of services. The NHS will never be politically free, and it’s pointless to suggest otherwise.


April 20, 2013

Private Eye Issue 1338
Filed under: Private Eye — Dr. Phil @ 4:36 pm

Medicine Balls: Lessons from Leeds

First the good news. Data just released shows that survival rates for child heart surgery in the UK are as good as anywhere in the world, if not better. What’s more, no unit in the UK has a significantly higher death rate that the others. So why is the NHS in England considering cutting the number of units from ten to seven? Why all the fuss about Leeds? And why are we not praising and celebrating child heart surgery teams for the incredibly difficult work they do under enormous pressure and scrutiny?

The answers are all related. The most recent data is all the more miraculous in that some of the smaller units have only 2 or 3 permanent surgeons who work ridiculous hours and are heavily reliant on locums, mostly overseas, to cover leave and sickness. The low death rates are as much to do with the pre and postoperative care as the surgery itself. This requires adequate numbers of skilled staff such as cardiologists, anaesthetists and specialist nurses, and highly sophisticated imaging equipment. At present, many units operate with a bare minimum of staff and suboptimal equipment, and sometimes operations are cancelled because there are unsafe staffing levels. Staff are under so much stress that turnover of nurses is high and paediatric surgery is not seen as a popular career option. At least two talented consultant heart surgeons left the UK in the last year.

The reorganization into fewer, larger, better staffed and equipped units is vital to reduce the stress on staff, make the training of future surgeons viable and make the outcomes even better (Eyes passim ad nauseum). Unlike adult heart surgery, where the range of operations is limited, child heart surgery is so varied and complex that a newly qualified consultant needs the supervision and wisdom of a senior colleague at hand for the first 5 years to master the full range of procedures required. In the current system, with too few experienced surgeons per unit, training is suffering, hence the reliance on overseas locums to plug the gaps. And money is so tight in the NHS that units are not given the resources to have their data independently collected, completed and verified in a timely way, particularly as the specialty has been in limbo for so long, awaiting the results of the review. Corners are being cut in the name of safety.

Everyone who works in paediatric cardiac surgery knows this, every unit signed up to a reduction in the overall number but when specific units were outlined for closure, some have backtracked and the Safe and Sustainable process has been derailed by its own incompetence and by internecine fighting between units and their supporters (relatives, MPs and the press). Supporters in Leeds won a High Court case to have the closure of the unit reconsidered because the Safe and Sustainable review team failed to submit all its data to the public consultation. Shortly afterwards surgery at Leeds was suspended ironically, as it turned out, because Leeds itself had submitted incomplete data.

Could the Leeds circus have been handled better? The stress on staff has been
enormous, with some in tears. Hardly conducive to a safe operating culture now that surgery has resumed. In a safety culture, a ‘no blame’ suspension of services is entirely appropriate given the concerns raised not just by the data but by clinicians and parents. This should be happening all the time in the NHS, but not as a big media circus to very publically show how the NHS has toughened up since Mid Staffs and Bristol.

In a safe culture, heart surgery units would be obliged to submit all their data or simply not be commissioned. They would be fully aware of how the data was being analysed to reflect the complexity and risks of different procedures, and they would know and accept precisely what investigations would automatically ensue, in a calm measured way, should the data trigger an alarm. The report and its conclusions would then be put into the public domain.

Bruce Keogh, the Clinical Director of NHS England, has argued that this is exactly what he did on hearing that provisional data showed Leeds had double the mortality of other units. In a unit treating 350 babies and children, there would be an average of 10 deaths a year. If there really has been 20 deaths a year in Leeds for the last few years, Keogh – a heart surgeon – should have known about it long before. It was always more likely that the problem was incomplete data, but in being seen to have put safety first so publically, Keogh has conveniently holed Leeds below the waterline before the final decision on closures is made.

Perhaps, with the derailing of the Safe and Sustainable review, this was the only way to get the specialty to see sense and force through the centralisation of surgery. Keogh will swat away the calls to step down by Leeds MPs, but the lack of trust in NHS England under David Nicholson remains. Keogh has pledged his loyalty to Nicholson, despite his role in the Mid Staffs scandal, and has now said he would allow his own child to have heart surgery in Leeds. Meanwhile, Professor Sir Roger Boyle, director of the National Institute for Clinical Outcomes Research, has said he would not. Keogh called on Boyle to resign, and he has. NHS England is already   committed to publishing outcomes for individual consultants in ten surgical specialties by the end of the summer. NHS staff are not convinced this will be done fairly, and without risk of media crucifixion. Such sensitive data data needs to be explained to the public and staff by gifted communicators who are trusted. Nicholson is beyond repair, and Keogh has much work to do.

Listen to my interview on Radio 4’s PM programme, 13.4.13

Radio 4 PM 13.4.13 Child Heart Surgery Interview


April 12, 2013

Investigation of mortality from Paediatric Cardiac Surgery 2009-2012
Filed under: Private Eye — Dr. Phil @ 4:56 pm

Here’s the report Sir Someone leaked to the BBC. It actually shows all units are performing within safe limits, with outcomes as good as anywhere in the world and better than most. So huge congratulations all round. Let’s start praising our child heart surgery teams for the incredibly difficult work they do under huge stress, rather than abusing them. But we still need to reorganize. Why? Read next week’s Private Eye, out on Tuesday


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