Tuesday, 20 March 2012

The Health Bill: A perspective on risk from Mid Staffs.

What risks do the Health and Social Care bill pose to the Health system: A perspective from Mid Staffs

As we reach the end of the troubled progress of the Health bill through the parliamentary system,  the call is to wait for the risk register, so that we can see the potential risks that professionals have identified if the Health Bill goes forward.
Whilst Labour, many health professionals and a growing number of the public would like this risk register to be published before the health bill is passed, the Government continues to resist this request.
In the absence of this register I am tempted to note down some of the risks that I see from the perspective of someone who has spent nine months watching the Mid Staffs inquiry.
For me, the risk register is important, but perhaps less important than waiting another few months so that all of us can get the benefit of the many millions of pounds of tax payers money spent on the Mid Staffs Inquiry, which will I believe give us, if we have the patience to wait, a solid basis for debating the reforms that the NHS actually needs.
Some of the risks that I am picking up here may be less to do with the changes that the bill may bring than they are to do with changes being triggered by the NHS response to Mid Staffs, and to the £20bn cuts.
I believe that when Andrew Lansley called for the Public inquiry at Mid Staffs he would quite simply have expected the Inquiry to prove his case for health reform. When we see the report from Mid Staffs and the challenges that it raises I think we may find that the Health Bill is taking us in the wrong direction. 
One of the big gaps for me at the Inquiry is that we did not hear from Andrew Lansley, so we did not hear what his assumptions were, or what he knew or did not know. We do not know to what extent his plans for health reform were based on assumptions he made about what had happened at Mid Staffs.

Basic assumptions about Mid Staffs
The assumptions made by the press and media is that there was a catastrophic failure at Stafford, something quite out of the ordinary, and that the different tiers of management and the regulators all failed to spot this. The press assumes that there were very high numbers of “excess deaths” at Stafford. The numbers 400-1200 are still regularly quoted, and that therefore the failure of anyone to notice this must mean that there was a total system failure.
A key witness to the inquiry made the statement that there was “no mortality problem at Mid Staffs”. This assertion is well supported by the evidence given under oath by many different witnesses. For the assertion of large numbers of “excess deaths” to be true it would require large numbers of people to have lied under oath or to be self deceived.  

Risks: The assumption that Mid Staffs demonstrates the Health service is broken and that there was a total system failure may be ill founded.

What did Andrew Lansely assume?
 We do not know what Andrew Lansley believes about this.  If Stafford is the justification for his plans to scrap the PCTs and SHAs then there may be serious questions about the entire basis of the bill.

Risks: The assumption that the PCTs and SHAs fundamentally failed and are expendable may be wrong. They may actually be performing an essential function.

The effects of Structural re-organisation
What the Inquiry does show us very clearly is that structural re-organisation puts the NHS under real pressure. There were real problems for Stafford.  The period investigated by the inquiry showed us re-organisation of the PCTs, the SHA, the Regulator, The Hospital board, and the process of becoming a foundation trust, together with changes of a number of key personnel.  These re-organisations brought with them major disruption of the communication networks and meant that key information was not being shared effectively across a range of different organisations.  It meant that at times the hospital needed support that support was not available to it. All of this also occurred at a time that the NHS was being pressed to make financial cut backs. 

Risks: Major disruption is caused by structural Re-organisation. Especially at a time of financial cut backs.  These conditions are being created throughout the health service now.

Weaknesses of local scrutiny bodies
The inquiry also clearly shows us the weakness of a number of different local bodies with a responsibility for the hospital. The Foundation trust board was not well equipped to be able to ask the right questions.  The Scrutiny committees did not scrutinize, effectively, though their basic assumptions about the hospital may have been essentially correct.  LINks  was new, and unformed. It never acted as intended and found itself unsettled by the hospital protest group that sought to use it as a vehicle for their concerns.  The GPs had no methods of collating or sharing concerns, and clearly never saw it as their role to act as scrutinizers of local health services.

Risks: It may be unsafe to assume that elected, selected or voluntary local bodies have the necessary skills or experience to be able to be able to replace professional health managers in overseeing the running of the health service.  The evidence that GPs are willing or able to perform this role is not found in the Mid Staffs Inquiry.

The effect of Cost improvement programs, financially driven targets, and pressures of being a Foundation Trust.
The Inquiry evidence seems to indicate that many of the problems that were experienced by Mid Staffs occurred during a period when Cost improvement programs were being imposed on hospitals throughout the country, and when they also needed to meet targets in order to ensure that they maximised their income.  The pressure on both of these aspects was intensified because the hospital was expected to become a foundation trust.  Most of the failings that did occur in Mid Staffs can be attributed to these pressures.

Risks: CIPs, Targets as an essential part of maximising income, and pressure to become a foundation trust are all part of the existing pressures on hospitals.  These conditions are currently being re-created throughout the country.

Early attempt at Integration
The main approaches to the CIP were to cut back office staff, and to move towards integration. The intention was that people would stay for less long in hospital and that more care would be provided in the community.   In practice both of these approaches led to major difficulty.

Risks: Cuts to back office staff can result in failure on essential administrative tasks that can seriously affect the performance of a hospital.  Integration and speedy discharge of patients into the community can only work if the community based services exist.  

Knock on effects when integration fails.
The impact of the failure of this early attempt at integration was major. Because the hospital cut bed and staff, but did not have the means to discharge patients into the community, the pressure on bed spaces mounted, and backed up into the A&E.  A&E waits increased, leading to problems with meeting targets. Work arounds were established including the use of Clinical decision units (which were essentially waiting bays for admission to wards or to social care beds) and the pressure on A&E staff increased to unacceptable levels, leading to staff sickness, breakdown in morale, short staffing and an increased chance of error.

Risks:  If “Integration” is not implemented effectively this can have a serious effect on the quality and safety of the service.  Integration as a means of reducing cost of NHS is being tried all over the country. In many cases the structures to make this work do not exist.

The conditions for creating successful integration.
Integration requires Primary, Secondary and Social care, to work together, often with the involvement of voluntary organisations and with the co-operation of families.  This is not an easy task.  It is a task that would have been overseen by the PCTs and SHAs.

Risk : May be difficult for the CCGs to take the strategic position necessary to co-ordinate integrated care. It may be difficult to make combine this with providing opportunities for competing organisations.

Patient choice as a driver of quality.
Once Mid Staffs became a foundation trust, the pressures of financially breaking even which was always going to be challenging, meant that patient choice, and reputation assumed a new importance. This reduced the willingness of the organisation to be as open as it should have been. It also made the hospital extremely vulnerable to attacks through the media, and this became a massive problem.  The complaints process failed when relationships between key individuals broke down. This then spilt into the media. The resulting damage to reputation had a knock on effect on recruitment which has led to the current threat to the A&E service.  This may illustrate that Choice is unpredictable and may not be the best mechanism for regulating a system that fits the needs of the population.

Risk: In a system dominated by choice and competition managing PR and media management will become major pre-occupations for health organisations.  There will need to be adequate protection against ill founded criticism, which could make essential organisations financially unviable. 

Basic Care of the Elderly: The pressure for early discharge > Dilnot. 
The biggest criticisms made of Mid Staffs, which were re-enforced by the Robert Francis Independent inquiry, is that basic care of the elderly was not as good as it should have been. A series of other reports conducted since 2010 have shown that this is not a matter restricted to Mid Staffs, it is widespread.  The response that the Health service is making to this, in the context of the £20bn cuts, is to look at ways of reducing the amount of time the elderly spend in hospital. The Hospitals are increasingly being regarded as for acute care only.  As yet the alternatives to Hospital care are not in place, and social care budgets have been cut. There are increasing numbers of stories of the pressures being caused to families by early discharge.  What no one is openly discussing so far is the fact that for many families the cost of care will pass from free health care to means tested social care, when it is available, or to the best the family can afford if it is not. There is no commitment yet to implementing Dilnot, which is essential to make these major changes fair and affordable.  

Risk: The public are not yet aware of the financial implications for families of reducing the role of Hospitals to acute care only.

Regulation of the quality of care
One of the major themes of the Mid staffs inquiry was the difficulty of regulating the quality of care. When it comes to hospitals there have in fact been major improvements in measuring outcomes since 2007, made in part because of concerns within the NHS to the limitations of the systems that triggered the Mid Staffs scandal.  There are however still real difficulties in measuring quality of basic care in care homes, or particularly in domiciliary care. These are the sectors where more care of the most vulnerable will be carried out.

Risk:  Regulation of quality of care in Homes and in domiciliary care is problematic, and nationally we will be relying on these services to a much greater degree. 

Staffing levels & Staffing mix
One of the identified problems in Mid staffs was that there was an unusual staffing mix, with more Care staff to Nursing staff than is usual.  The staffing levels were also sub optimal. It was recognised that Care staff receive less training and are not registered in the same way as nursing staff, and that it is therefore far harder to control the quality of their work. The DoH has so far refused to set guidelines on staffing levels or staffing mix, and it is also resisting the call to register Care staff.  This resistance may be in part because of the unwillingness of the private sector to embrace clear guidelines on staffing.
The realities of how domiciliary care staff work, often with people with dementia who would find making complaints difficult or impossible, means that the only real guarantee about the quality of service is through staff training, status and reputation.  The Bill looks unlikely to foster the improved status of staff.

Risk:  Private sector companies providing care will have no incentive to register, train, or pay care staff in a way likely to improve their status or the quality of their work. Patient choice becomes meaningless when dealing with very vulnerable patients who are in no position to choose.

Patient Complaints
Patient complaints. The Mid Staffs story is essentially about trying to find an effective way to ensure that patients feel their complaints are listened to, understood and acted on, and that the general public can feel satisfied that the complaints of an individual have been dealt with in a fair and appropriate manner.  This is by no means a simple matter. It is presumably Andrew Lansley’s intention that any future complaints within the NHS remain a strictly local matter and are not “visited upon” the Secretary of State for health.

Risk: It is unclear that the current proposals on hearing and resolving health and social care complaints are sufficiently robust

A wider role for the patient voice.
Beyond complaints there is a real role for patients to play in helping to drive the incremental improvements required in Health care. There have been significant improvements in capturing the patient voice, made by the NHS in response to the questions raised by Mid Staffs.  
The bodies which were proposed by the Health Bill initiailly to give patients a stronger voice appear now to be on hold. It is unclear why that has happened.   

Risk: Why are bodies to increase the effectiveness of the patient voice no longer part of the bill?

Democratic control. – Accountability.
The Mid Staffs board operated behind closed doors in the period leading up to the problems. It now operates a very open process with the public present in some numbers at the board meetings and with regular question and answer sessions for the public. 

Risks: The CCGs will be in a position of having to make difficult and potentially very unpopular decisions. It is not clear what provision there is to make these bodies fully accountable to the public, or if the local councillors will have the necessary skills, time or inclination to carry out an adequate scrutiny role.

The Role of the press.
Much has been made in the press of the fact that the press were the key players in uncovering and exposing the problems at Mid Staffs, which they clearly feel to have been a matter of public interest.  The day to day coverage of the story and of the inquiry created a high level of local interest and will have increased sales of local papers.  Now that that has died down the papers are perhaps more dependent on advertising revenue to keep them solvent in what is an increasingly hostile climate for local papers.  The New Private sector health providers that are emerging, and also the new level of interest in PR from the NHS providers are all a useful source of advertising revenue for the press. There is some evidence that this could have an effect on the way in which papers might choose to report or not to report issues affecting their advertisers.

Risk:  Patient choice is largely driven by “what the papers say”. Can we rely on the press to be impartial?

Choice – variability
What the public need is a stable service based on need. It is not clear that this can be driven by choice or the market. The story of Mid Staffs shows that choice can easily be distorted. High levels of press interest can have a major effect on an organisation, creating real problems.  

The public reaction to the part time closure, and threat of downgrading of A&E caused by these problems is interesting, as though the public had gone through a period of real concern about the hospital, prompted by the press interest, when it became clear that their services were under threat there was a massive ground swell of support for the hospital with thousands of the public signing a petition to re-open the A&E.  

Risks: Patient Choice is volatile. It can be affected by poor quality evidence and it may not reflect what is needed.

The role of the Unions
One of the key witnesses from one of the union made the point that in Mid Staffs the unions had been tolerated rather than encouraged. The unions were weak, and though they did hear of some concerns about the level of staffing and the degree of pressure that staff were experiencing because of this they did not manage to raise these effectively.  If staff had felt more able to raise concerns clearly is likely that many of the issues raised by the failure of the early attempts at integration would have been identified at a much earlier stage.

Risks:  The rise of the use of private sector organisations in health care is likely to lead to weaker union representation, lower job security and an increased reluctance on the part of staff to speak out when they encounter problems.

Is Control the right way to a better workforce
Andrew Lansley has often indicated that he believes that the NHS is broken, and needs radical surgery to fix it.  The Health bill appears to make the assumption that the best way of getting a better NHS is to have more control over the workforce. Some of the thinking from people who support the bill is expressed in very mechanistic ways. We have blue print thinking – exact safety protocols, which if followed to the letter will produce safe results. There is an assumption that if staff do not follow procedures to the letter then there should be easy ways of getting rid of them.
My concerns about all of this is that there is a basic misunderstanding of what health care is. Health care is about people and relationships. It is about the quality of communication and finding the ways to assist patients to become partners in their own care choices.
The major – no doubt unintended consequence - of the troubled passage of the health bill is that the Government now finds itself seen as the enemy of many health professionals, who believe that the government simply fails to understand the profession.  The rhetoric of “liberating the NHS” is simply not the way in which the NHS workforce are experiencing the Health Bill.  

Risk:  The difficult relationships that now exist between the government and the health professions will need to be cured in order to meet the objectives of the government. This will entail coming to a better understanding of the needs of the workforce.

Ways forward.
The Bill is a mess. Relationships between government and the Health profession are a mess.  The structures to replace the professional managers removed from the NHS do not exist. Local bodies will struggle to replace these. The upheaval caused by the bill will have a major detrimental effect on health provision. Morale amongst Health professionals is low and many key people will leave the profession.
The Government cannot deliver any of these changes without the willing help of the professions. This cannot be forced. There is an urgent need to work towards better understanding.
The Mid Staffs inquiry report will provide useful starting points for the dialogue on evidence based reform which now needs to take place.   

Monday, 5 March 2012

The Francis Report

The Francis report

Because the protest group, Bill Cash, and the press remained unsatisfied with the HCC report, the Colin Thome report, The Alberti report and the Case Note review, there was continued pressure for a public Inquiry. This was resisted by Alan Johnson, but when Andy Burnham took over as SoS David Kidney was able to persuade him of the need for an Independent inquiry.
The Francis report heard detailed evidence from many patients and relatives and from some staff. Many people felt able to take part in this because it was not conducted in public, and the evidence that was collected was very powerful.
What was immediately apparent to anyone reading this report is that the focus of problems was not on some disastrous breakdown of medical care or widespread medical accidents, it was about basic nursing. It begins with a graphic chapter on continence, and goes on to look at a range of dignity and comfort issues that have since become familiar to us with numerous reports conducted throughout the country.
These are distressing problems. They are also very familiar to people who have had any dealings with hospitals or care homes over the last few decades.
Robert Francis also clearly identified that the excess death figures were unsafe, He gave introductory details of the major disagreements between the proponents of different statistical systems for measuring mortality and he recommended a major review of the way in which mortality statistics are collected.
Robert Francis recommendations have been taken seriously by the health profession, and much quiet careful work has been going on to address these problems.
It is unlikely that Structural reform of the health service has much to offer, and it is also unlikely that there are any magical solutions on offer. The problems are deep seated. They are about our willingness to pay for the care we all need, and about some of the attitudes to the elderly and vulnerable that permeate our society.

The Case Note Review

The Case Note review.

There was  widespread public concern, and many people who had lost relatives needed reassurance. Alan Johnson arranged for a case note review which was set up to allow families to go through case notes with a specialist, to find out what they could see about the deaths.
It had been anticipated that this exercise might give an indication of the true number of “unnecessary deaths”, but the Doctor assigned to this task makes it clear that this was not possible. After a lot of press coverage designed to reach as many people as possible around 120 people eventually came forward for this service.
Some of these were people who had lost family members In difficult circumstances as much as 10 years previously.
He are my impressions of the Evidence given to the Inquiry.
Tom Kark notes in his final submission that the Dr was asked the question how many of these cases were people were excess deaths. He thought that there was a possibility that one may have been.

Reports by David Colin Thome and Professor George Alberti

Reports by David Colin Thome and Professor George Alberti
Alan Johnson as soon as the Health Care commission report was released Commissioned reports from David Colin Thome and Professor George Alberti These were completed promptly.
Alberti  laid out the simple steps that were needed to solve the problems of A&E and the acute wards in the hospital. David Colin Thome looked at the weaknesses in the regulatory systems.  David Colin Thome also provided the first official confirmation that the excess death figures should not be taken as fact 
He describes

Both the SHA and PCT state that they first detected problems in patient care from the 2007 Hospital Standardised Mortality Rate (HSMR) data. HSMR data has featured prominently in the Mid Staffordshire investigation and prompted much ill informed speculation and comment as to suppose excess deaths at the hospital.
HSMR data is not a measure accurate enough to be used as an absolute indicator of quality and safety, but like all indicators, it is one measure, and can indicate a problem. No one data source is sufficient to provide the full picture of an organisation, and triangulation of data is key.

I have written a number of letters to the local press on the matter over the last three years, but this is the only means by which local people may have begun to question the accepted stories.

There was a public meeting for the public to hear from Alberti & Colin Thome about their findings.

 There was a question from the floor regarding the supposed excess deaths, and Colin Thome explained that these figures could not be relied on. This was then immediately denied by the pressure group, who clearly believed that they were better informed than Sir David Colin Thome.
Dr David Colin Thomes report is brief – but clearly identifies many of the themes concerning regulation and governance that have been developed by the Public Inquiry.

The public meeting in Stafford.

Looking back at April 2009
The public meeting in Stafford.
In Stafford the Hospital story dominated the press day after day, and public concern was reaching boiling point. A public meeting was set up by the pressure group with the assistance of Bill Cash.
The purpose of this was to put individuals who felt that they might have a claim against the hospital  in touch with a number of legal companies who were offering to represent their interests.
The Lawyers were given time at the meeting to explain what they could offer, and then had opportunities to meet with their potential clients over coffee.
The other two local MPs also attended this meeting and I and a number of other people went along as an observer.
There were around 100 people there, many of whom were genuinely angry with the hospital and had stories to tell. Many of these are people I have never seen since, though we should presume that they were involved in the group compensation claim made against the hospital  The core pressure group of people with serious committment to dealing with their concerns has dwindled to around 15.
The pressure group and Bill Cash were of course using this meeting to reiterate their call for a Public Inquiry, which David Kidney also felt was necessary. Tony Wright explained why he felt this was the wrong course to take.
I found the meeting shocking. I still do. Perhaps it was just the excitement of the occasion, but Julie Bailey used the platform to call “lets shut the hospital, lets sack all the staff”. This was met by loud cheers from her band of followers.
Her anger as an individual is something that is completely understandable in human terms.
What concerned me was the toxic nature of the politics which meant that one party appeared to be willing to stimulate and ride public anger in this way. If politicians behave like this then essential trust is eroded and it becomes impossible to work together, to solve the difficult problems that face us all.

The Broken Health Service

The Broken Health service story spreads.
When the story was confined to Stafford, it alienated the hospital staff who best understood what had really happened
When the HCC report was published in the middle of international media frenzy this had the same effect nationally as it had done in Stafford. People read the stories and felt that they had experienced something similar. The level of complaints soared. The Patients association which had been running with a staff of two and a half volunteers, needed to increase its numbers to six. Well respected organisations like Age Concern and the Alzheimers society recognised that issues for which they had been trying to attract attention for decades were now in the public eye, and important reports were commissioned to look at the real shortcomings in the way we care for the frail elderly. These are continuing. This latest one looks at the issue of Dignity in care.
Some of this recognised the scale of the challenge presented by our growing elderly population, Some of it was presented as criticism of a failing nursing profession. As the simplistic criticism of the health service grew, with wdespread media criticism of uncaring nurses who were too posh to wash,  this gradually drew the Conservative front bench into a hostile relationship with the NHS.
David Cameron visits Stafford.
One of the first public events that David Cameron was involved in following the tragic death of his son was a visit to Julie Baileys café to meet with the grieving relatives. A flavour of that visit can be found here  
I personally found that visit a shock.  He was coming to a town that was in a highly volatile state. Up until that time I had no difficulty in accepting the widely help public perception of a courteous and caring young man. I had genuinely expected a statesmanlike attempt to calm public emotion, We did not get that. He stoked the fire, and the papers the next day included his angry response to the suggestion that he was using Stafford Hospital as a political football.
David Cameron was riding high in the polls then. His intervention, and the fact that we were into a pre- election period meant that tackling the essential misconception about Stafford became even harder than it had been. Any attempt to put the problems of Stafford into context was seem as an attack on the integrity of the pressure group, and as being “in denial”.
The stories of Stafford, as told in the press had now become "fact" that no-one was permitted to deny.

The Conservative Party calls for a Public Inquiry

Looking back at events of March - April  2009
Calls for a public Inquiry
We can I think make the assumption that Bill Cash, who was by this time calling for a Public Inquiry will have had discussions with the communications team, and that this will have been instrumental in bringing Andrew Lansley and David Cameron to Stafford, as part of the astonishing stream of VIPs who came to Julie Baileys café. 
The call for a Public Inquiry is of course a well established method used by oppositions to cause embarrassment to a government.
The Government will not have wanted it because they would rightly see it at expensive, distracting for the hospital, unlikely to reveal significant new information, punitive and potentially embarrassing.  The opposition wanted it because it was potentially embarrassing, and it would ensure that the story continued to attract maximum press attention for the maximum amount of time. It was clearly also a way of satisfying the demands of a pressure group and ensuring their support for the forthcoming elections, and the combination of the graphic stories and the excess death figures meant that it appeared to be the ideal way of proving that the Health service under Labour was broken and needed fixing.
We do not know how much Andrew Lansely or David Cameron knew about the complex circumstances surrounding the story, but the evidence from Bill Cash shows us clearly that he knew remarkably little. It is one of the less edifying facts about political life that politicians may not always wish to check the accuracy of a potentially powerful story. Greener  
What we do know is that David Cameron is someone who understands very well the importance of symbols and the powerful nature of NHS stories in political campaigning.  David Cameron and the Tale of Jennifer's Ear  
There is always the danger that the short term benefits from a sensational story may turn sour if the story is not as well based as it might be.

The Storm Breaks

The meeting at Richmond House.

A couple of days before the release of the report all the key people involved were gathered at Richmond house to meet Alan Johnson, and discuss how the report was to be released. Drafts of the report had been circulating, giving different bodies a chance to respond to the sections that concerned them. Feelings were running pretty high. Someone, and we do not know who this is, brought to the meeting a new appendix, which raised the matter of “excess deaths” This – and we do not know the wording – apparently said that 400-1200 people may have died as a result of poor care.  The feeling of the room was very clear. These figures were an extrapolation from the HSMR figures which were generally known to be misleading for the reasons previously discussed. The extrapolation in itself is something that the HSMR system is not designed to do. It would be very damaging to public confidence, and it would be upsetting for people in Stafford who had lost family and were left wondering if they should have acted differently.
Recommendations were made to Sir Ian Kennedy Chair of HCC that the figures should not be published, and he makes it clear that he made up his own mind not to do so. The instructions were given that the appendix should be destroyed. 
The leak to the Mail.
The day before the release of the HCC report there was an article in the Daily Mail. This article brings together the Excess deaths, a quote from Bill Cash about the way in which Cynthia Bowers from the CQC and David Nicolson from the DoH were implicated in the tragedy, and stories from Julie Bailey.
The storm breaks.

This prepared the ground for the release of the HCC report and Stafford found itself at the heart of a major media storm, In which the Excess deaths of 400-1200 are quoted as simple fact, as the background to the expertly presented  stories of the bereaved.
SoS Alan Johnson made what can in hindsight be perhaps seen as a misjudgement.  He was I think completely right in ordering quickly the A&E expert George Alberti to go to Stafford and ensure that everything was put right as soon as possible. He was right to call in Dr Colin Thome to investigate why the early warning systems had failed, He was right to call for a case note analysis that would allow any patients or relative who had concerns to go through their records with an expert to see if mistakes were made.
I think that his reluctance to start talking about statistics was understandable, and it is infact not until I had seen the evidence at the public Inquiry that I really felt confident in saying why these figures were misleading. But by steering clear of these figures the idea of the excess deaths was allowed to take hold.
David Nicholson may also have made an error of judgement at this point. He again did not choose to challenge the excess death figures, It is clear from the evidence given by the DoH to the Inquiry that the understanding of the value and limitations of the HSMR figures within the DoH was at best uncertain, and of course Professor Jarman’statement that the Excess death figures were not something that he recognised would not be publicly available until the publication of the Francis report in 2010. David Nicholson did not question the HCC report, or more specifically the press coverage of the report. He made the assumption that whatever it was that had happened at Stafford this was a one off.
One of the big gaps in the Public inquiry from my point of view is that it did not interview Andrew Lansley. We have no idea of what he knew when, and who if anyone was briefing him, but the fact that no one was publicly questioning the media version of events meant that he simply may not have known that there was any reason to doubt them. The quality of information available to ministers is as the public inquiry shows us pretty variable. The quality of information available to the opposition is probably worse.   He continued to use the excess death figures, certainly up until the release of the Robert Francis report in 2010, and they were used either directly, or by implication in the conservative election campaign.
The Effect of the Storm.
The effect of the storm on Stafford should not be underestimated.  Whatever the problems that may have existed prior to March 2009, they were compounded by the level of attention from regulators and from the press. In Stafford we are still suffering the effects of this today, as the A&E is closed part time, and the hospital continues to fight to ensure it has a secure future. 

Sunday, 4 March 2012

Protest and Resignations

As the date of the report release drew close in early 2009 everyone grew more agitated. The pressure group wanted resignations. There was a protest in the town square involving an interesting collection of people. All called for the sacking of Martin Yeates and Toni Brisby. In this public protest CuretheNHS, were supported by the Socialist workers party and the Green Party, and were planning to meet up with Bill Cash later on.  
The decision had already been made by Monitor that the CEO should go, and both he and the Chair stepped down a couple of weeks before the release of the report.
The Staff at the hospital were dismayed by this. There was a meeting in which hundreds of them expressed their support for Martin Yeates and Toni Brisby, and their anger at the way in which the hospital was being portrayed. The staff were then publicly attacked in the local press for being in denial, because of their allegiance to the management. This set up bad feeling between the staff and the pressure group which persists to this day.

The Investigation

It is clear from listening to the evidence at the inquiry that the investigation, conducted by a team led by Dr Heather Wood, evoked some very strong responses from the different people caught up in the process.
The investigation was set to be one of the last of its kind, as the investigation team, which was a part of the HCC, was to be disbanded once the CQC took over the regulatory role in April 2009. It is not clear at what point this decision was made or what effect if any this might have had on the way in which the team approached the assignment.  
It is clear to anyone who reads the evidence from the Inquiry that the relationship between the HCC Investigation team and the CQC was a very strained one.
It is not clear how this model of investigation arose, but it involved a team coming into the hospital and spending more than a year looking at every possible detail.  Hospital staff speak of their shock. We hear of the huge burden that the investigation placed on the hospital in seeking to respond to the highly detailed demands for information. Whereas the relationship with the Local HCC team was essentially an open and supportive one, the Investigation team made it clear that they were not there to help, they were there to find out what had gone wrong and why and to identify who  was to blame
We heard from many people who felt the impact of this. The CEO, the Chair, Members of the management and the board, a number of staff, The Coroner, The SHA, Monitor, the Health protection agency, the Health and safety executive, the DoH. All of these individuals and organisations had their reservations about the conduct of this Investigation.
There are comments about the way in which people were interviewed, the level of demand placed on the hospital, the sheer length of the investigation, the lack of communication with other bodies, either in letting them know an investigation was in progress, or in informing people how it was going, and the way in which it delayed people being able to take action to support the hospital to deal with its problems.
The Health and Safety Executive had no direct involvement with the HCC investigation team, but were asked at a much later time to use the report as a basis for legal action against the hospital. They found that this was impossible as little if any of the “evidence” had been corroborated to the standards that their quasi legal processes required. They found some of the evidence had even been drawn from newspaper reports. 
The effect of the investigation on the patient group was interesting. The fact that the investigation was taking place confirmed their impression that something highly unusual had taken place in Stafford, and this fuelled the coverage of the story in the local press. The reporters understandably  saw themselves as playing a key role in a very important public interest story.
Before the investigation team moved in,  the public Inquiry has established that there was virtually nothing in the way of complaints from the public about the hospital. The regular items now appearing in the press may have helped to generate new complaints, and the creation of a hotline to capture public opinion, which was publicised in the press on numerous occasions helped to increase the flow. Some of these appear to have dated back some years. The protest group on a number of occasions demonstrated outside the hospital, making the investigators very aware of the strength of their feeling, and this was of course all reported in the press. No one at this time would have dreamt of questioning the appropriateness of any of this. There were a group of people who had suffered, they wanted answers, and the Investigation team should be able to provide them.
The question of why there were so few complaints before this time is an interesting one. Did people simply take it for granted that they would receive bad care and that there was nothing they could do about it, did they see that the staff were doing as well as they could given the pressure they were under, did the press reports and the publicity prompt them to see their experiences in a different light?
Julie Bailey, who became the spokesperson for the pressure group, tells us in her evidence to the inquiry that when things became too much for her that she would be able to ring Dr Heather Wood. Dr Wood was someone that she seemed to feel really understood her point of view well.
As time passed the DoH, the SHA and Monitor were all concerned about the major effect that the investigation was having on the hospital and wanted to be able to take action to help, but preserving the independence of the regulator meant that they could not force this process. They had to allow things to take their course. 
The HCC had originally raised a number of immediate concerns, which were addressed by the hospital, but then as late as October 2008 they were reassuring the DoH that the hospital was safe and that the scale of problems was not as great as in the previous “scandal” hospital at Maidstone & Kent.  This would appear to indicate that whatever the problems were they did not appear to be on a massive scale to trained investigators even after many months of investigation, I believe that this means if would also be unreasonable to expect any less expert people to have “known”  what was wrong at Stafford. 
Bill Cash
Towards the end of 2008 the pressure group made contact with Bill Cash MP He was very supportive, and instead of submitting a report based on his own knowledge of the hospital to the HCC investigation as the other MPs had done, he encouraged the pressure group to prepare a dossier of their complaints which he then submitted to the HCC on their behalf.  Will the HCC have viewed these complaints any differently coming through this source? Will they have expected that he would have made independent enquiries to verify the details? He also later claimed to a public meeting that he had taken on the role of being the media mentor to the group. We do not know the details of how he discharged this role.

Mid Staffs in 2007- the road to the investigation

The road that led to the Midstaffs inquiry has been a long one,  The Inquiry saw over a hundred witnesses, thousands of documents, and millions of words. This has been a unique opportunity to study a complex situation involving many thousands of individuals and see it in the round. The sheer size and complexity of this huge archive of material perhaps inevitably means that people have approached the Inquiry selectively. They latch on to those pieces of information that seem to confirm their beliefs, and they leave aside information that may appear to uncomfortably conflict with their version of the story. So far the press have given us a picture from a single view point. My view is different. It is not definitive, it does not pretend to be, but it does open up a new perspective. After four years of watching this story this is what I believe happened.
HSMR:  Hospital Standardised Mortality Rate   
The background to the HSMR is that it is established that 1 in every 10 patients within the NHS and within other health systems will experience some kind of adverse incident in hospital. Clearly there are some hospitals which will perform better than others. It is a matter of anxiety for anyone managing a health system to try to drive continual improvement, and there are a number of different approaches to this including NiCE guidelines, the NPSA, Professional codes, and statistical systems to attempt to measure and compare outcomes.

In the summer of 2007 the private sector information company Dr Foster Intelligence published as a league table in the Telegraph the HSMR morality rates for hospitals throughout the country. This system had been evolving for some time, but it fitted the wish of the government to be able to cast a light on variation of quality within the NHS. It was the first time the Doctor Foster company had published it this publically in this form, and they made the claim that the figures reflected quality of care. As with any league table some score high some score low. The highest 50 included six hospitals in the West Midlands. Mid Staffs was one of these. This publication caused a great deal of immediate concern in the West Midlands Strategic Health Authority SHA, who brought together meetings of the hospitals, triggered mortality review groups and commissioned some academic research to try and understand what the  HSMR system was actually telling them.
The purpose of HSMR is to try to systematically distinguish between deaths that are expected, and deaths that are not, and to allow comparison of the levels of unexpected deaths throughout the country.  The HSMR system depends on two sorts of coding. The primary admission code is the reason why the patient was admitted to hospital. In the example given to us by Doctor Foster Intelligence in their evidence this might be an In-growing toe nail. The Secondary coding or co-morbidity records background health factors that may affect the outcomes so using the same example from Dr Foster this might be Diabetes. It will be immediately apparent to most people that an in-growing toe nail probably should not kill someone, but the Diabetes very well might, so it is clear that recording Co-morbidity is important for the HSMR system to have any validity. Co-morbidity becomes particularly important if your main case load consists of elderly people who will routinely have four or five Long term conditions. This is the case in Stafford. The information to be-able to complete the co-morbidity coding properly may depend on the quality of information coming through from primary care, and the quality of note-making by consultants. 
The result of the SHA probe into mortality in Stafford was reassuring. It showed a one off problem in that Stafford had failed to use a newly created primary code for Palliative care, something that had been brought in at the request of Dr Foster customers who found that the system did not allow them to adequately code people who were known to be receiving end of life care. This together with an exercise called Rebasing, which sets a new bench mark for the HSMR meant that Mid Staffs HMSR figure was significantly higher than it should  have been.  (It is like being in a straight line, when everyone else takes one step back! )
The probe also showed that in the case of Mid Staffs that the secondary coding which lay behind the figures was particularly poor. This was in part due to the long term sickness of the coding officer. (Which is documented in the HCC report). What was particularly apparent is that the co-morbidities were not being recorded effectively. 
A further academic study into HSMR was commissioned by the SHA, from individuals who could be seen as the intellectual and commercial rivals of Professor Jarman and of the Dr Foster Intelligence company.  One of the unintended consequences of this was that it deeply offended Professor Jarman who had devised the HSMR system. This study raised concerns about the overall validity of the Jarman system and is part of an ongoing statistical spat on methods of measuring mortality.
In Stafford a new coding officer was employed and the figures began to fall rapidly. She was later to be accused by Professor Jarman of gaming the system. Her rebuttal of this, together with her account of how she went about correcting the coding was not published until it became part of Counsel to the Inquiries final written submission. It has never been covered by the press.
 In addition to the academic work on coding a mortality review group looked in detail at 36 cases and concluded that in all but 2 of these cases the deaths were expected and the cases had been coded incorrectly.

CIPs – Cost improvement programmes & foundation Trusts

To say that all was well at the hospital apart from the coding would be to oversimplify. It was not. The hospital like many others was under financial pressure. This was the result of a strongly held political belief that the cost of the NHS was too high. This continues to be a live political issue today, with some people , mainly from the right wing arguing that the NHS is not as productive as health services in other countries, and others including many from the health system strongly contesting this with convincing evidence. It is interesting that the Department of Health at this time came strongly under the influence of a number of private sector management consultants who were offering what they claimed were solutions, often market led, to reducing the cost of the health service.
The Department of Health  were pushing hospitals to take far more responsibility for their budgets, and to increase productivity. That is why they wanted more hospitals to shift toward becoming Foundation Trusts. This trend has accelerated now under the Coalition Government, where the intention is that all Trusts should become Foundations Trusts. These independent bodies would, at least in theory, be responsible for financial solvency and for the quality of care they provide. The Secretary of State could at least in theory claim that it was nothing to do with him.  
Mid Staffs was invited to become one of a wave of new Foundation trusts. This meant being subjected to a supposedly rigorous assessment process. The Inquiry report is likely to be critical of the process of judging if the Hospital was ready to take this step, and may suggest that the board did not have the necessary maturity or knowledge to be able to discharge its duties. This matters as the Foundation trust model becomes central to how NHS care is delivered.^
 As part of preparing to become a foundation trust It was important to meet targets, because this had an effect on income. It was also essential  to implement a CIPs or Cost improvement program, which was causing a lot of pain to hospitals all over the country. CIPs will generally be presented to the public as “efficiency savings” but they will be experienced by staff as cuts.  In Stafford the cuts took the form of reducing admin staff, cutting beds, cutting nursing staff and replacing some nursing staff with lower cost but lower skilled care staff. All of these measures have a bearing on the problems that arose.^
Early attempt at integrated care.

The hospital had a new CEO, and chair and an inexperienced board. The next tiers of management the PCT and the SHA were also undergoing major re-organisation, had key people missing, and were not operating as well as they should be. For all these reasons the advice available to the hospital on how to safely implement its CIP was limited.
One reason why Ben Bradshaw’s fears about future Mid Staffs is justified is that the Mid staffs CIP took it down a road that is now being followed by hospitals all over the country. In Stafford in 2006 there was real anxiety about the CIPs. We heard from the CEO, the unions, The MPs and others who were all concerned that the CIPs could potentially lead to deterioration in service. The right people asked the right questions.  The answers they were given then look very much like the answers people are hearing now. “These are not cuts. There would be less beds so the ratio of nurses to beds would remain unchanged. The reduction of numbers will be achieved by natural wastage. It is a matter of doing things smarter. This can lead to better patient care.”  These answers were right then as they are now. It is the right thing to do in theory- it is making it work in practise that is the difficult part, and making it work is often simply not within the control of the hospital.
The most obvious inefficiency came from patients spending too long in hospital. This is the central plank of the move towards integration which is being rightly heralded now as the way forward for the NHS. Unnecessary admissions should be prevented, and people should be discharged into the community once their need for acute care was past. In the case of Midstaffs  the Primary care and Social care organisations, which would be crucial to the success of this policy were not ready for this shift.
The results of this were slow but inevitable. The Hospital cut beds and nursing posts. To begin with everything looked fine, but gradually there was a build up of problems. The easy to discharge patients went home, but more demanding patients remained as bed blockers. This often included patients with dementia. The level of care needs within wards increased, putting nursing staff under increasing pressure. People continued to pile in through the doors of A&E and as all the beds were full there was a daily struggle to admit people onto wards, or to prepare for admission to the diminishing number of social care beds available in the community. As the bays and trolleys in A&E filled up, waiting times increased, staff came under intolerable pressure, staff sickness levels increased, and sometimes care was not as it should be.  When an organisation is under great pressure then this will also significantly increase the chances of serious medical mistakes being made.
The lessons of Midstaffs need to be learned. This is one of them. Take a look. As the current round of CIPs bites then I am pretty sure that the same pattern is being repeated in a hospital near you right now.
The Regulators develop their approach to intelligence
One of the big questions raised by the Mid Staffs Inquiry is how can we know about the quality of care being delivered in our hospitals and care homes. The evidence traces the changes that have taken place in this process, and points to the limits of what regulation can achieve.  The big structural changes that Andrew Lansley has sought in his bill are partly about looking for new ways to  answer this question, but is he looking in the right places?

Within the intelligence section of the Health care commission, (the predecessor of the CQC Care Quality commission as regulator in the quality of health and social care), there were concerns that they were not really able to see well enough into how hospitals were performing, and that the HSMR system, which had rightly been heralded as a break through, was in practise too slow, and too full of “statistical noise” to give a clear picture. They were beginning work on much more sensitive and immediate methods of picking up on mortality concerns that could pinpoint problems to individual specialisms within individual hospitals.
This new system for specific mortality indicators, which involved collaboration between the HCC and the Dr Foster Unit under professor Jarman, was effectively a commercial secret, and it was kept under wraps. Only a handful of people knew about it, and even the participating hospitals like Midstaffs were not party to the detail. The people developing the system did not know at this early stage if it would be effective.
In the autumn of 2007 Midstaffs triggered a specific mortality indicator, first one, and then more. The number of indicators was striking, but when one looks at the graphs it is clear that in all cases these amounted to blips rather than plateaus. The intelligence team wanted to know if the blips were corresponding to anything going wrong at the hospital and sent letters asking for information. These, as the CEO Martin Yeates explains in his evidence, were something coming out of the blue and unexplained. The hospital probably assumed it was just another manifestation of the coding problem that they had already identified.  
As the hospital failed to give the explanations the intelligence team needed and the mortality indicator blips continued to occur the anxiety in the HCC intelligence team about what might be happening at the hospital grew. The HCC local team could not see any problems, but they did not know about the specific mortality indicators, the Intelligence team began to press for an on the spot inspection.
The Crisis in A&E

At the hospital as 2007 drew to a close the problems I describe in A&E were mounting. An unusual cluster of A&E waiting time breaches on one particular day led to management seeking explanations, and a young woman, who later became one of the stars of the public inquiry, (the only witness to be clapped) used this opportunity to explain that some senior staff in A&E were regularly covering up minor breaches of waiting times, and were bullying other staff to do the same.
The Management reacted promptly to her allegations of bullying by suspending two of the most senior staff members. This left the A&E department without its most senior staff and in a volatile and deeply divided state.
Inspection, complaints and Investigation

When the HCC inspection team came to call in January 2008 they found A&E understaffed, dispirited, poorly led, and they had major concerns about the EAU which was the area where patients waiting for admission onto the already packed wards were being held. They found one confused old lady trying to get out of a bed in an unattended EAU and at risk of falling.
The founder of the Stafford Patients pressure group, lost her mother in November 2007 and had been very distressed by the conditions she observed on the ward. She began making complaints about the treatment. This process did not go well, and one particular telephone conversation with a senior member of staff tipped the lady from being a grieving bereaved relative into becoming a determined health campaigner. The lady began what turned out to be a comprehensive exploration of organisations that might have a responsibility to answer her concerns.  (see JB evidence) This included sending a letter to the HCC, in which she drew attention to some of the press coverage she had attracted.
The final corrections issued by HCC to the public inquiry clarified that this letter from Julie Bailey letters, together with the concerns raised by the on the spot inspections were the decisive factors in moving to carry out an investigation.

If it aint broke dont fix it.

One of the worst things about our political system, is the heavy use of negative campaigning to persuade voters to X the right box. This has been going on for as long as most of us can remember, we almost take it for granted. Many voters really dislike it, and many politicians who took up the political calling because they want to “make a difference” recognise that it damages their ability to find solutions.  But it still happens. Why is this?
The common sense phase we all trot out is “if it ain't broke – don’t fix it.” but a cursory glance at the political campaigning from 2005-2010 will show the sustained development of the broken Britain theme, designed to convince us that  many of our social systems were broke and did need radical change to fix them. The fact that this radical change would mean creating many new opportunities to convert public service into profit making enterprise was not stressed and is only slowly becoming apparent.
One of the most important parts of the Broken Britain theme was the NHS and the symbolic heart of the “broken NHS” was the Midstaffs story.
There is plenty of evidence that the NHS is actually doing quite well.  This latest academic study  gives us some objective indicators to compare NHS  with a range of other countries . http://www.delicious.com/redirect?url=http%3A//costhome.eu/management/images/b/bc/How_NHS_compares_BMJ.pdf  but people are often uncertain about what statistical information is telling them. Graphs lack the emotional impact of grieving relatives shaking hands with Andrew Lansley or David Cameron.
In a rational world we would have waited for the outcomes of the Mid Staffs inquiry, which will give us much deeply useful information on the challenges that the NHS faces. The evidence supplied to the Mid Staffs Inquiry by so many professional organisations can give us solid ground for informed debate on the best way to reform the health service, but the government is in a hurry and the Mid Staffs report will come too late to influence the Health bill.
Without the report people are free to use the symbol of Mid Staffs in the way that suits them best. It was interesting to see a vitriolic exchange on Health questions,  between Ben Bradshaw and Andrew Lansley. Ben Bradshaw was pointing out that the Health bill is likely to lead to more cases like Mid staffs, and Andrew Lansley angrily responded using  Mid Staffs as proof of a broken NHS and proof of the need for his bill.
Andrew Lansley wants us to “look at Mid Staffs” so let’s take a look at this symbol, and work out how it can possibly mean such different things to different people. Let’s really look at Mid Staffs.

Why the risk registers matter

The government is strongly resisting the call to release the national risk assessment regarding the health reforms. In the mean time the Strategic Health Authorities have carried out their regular regional risk assessment process. A quick scan of these risks sounds all too familiar to anyone who has studied the Midstaffs Inquiry.

There will I am sure be a tendancy to present these risk registers as an indication that the reforms could create “another Midstaffs”. Now that the government will for the first time find that the Midstaffs evidence is actually being used against their bill they may find it timely to clarify that the still prevalent myth about hundreds of “excess deaths” at Stafford is ill founded and based on a leak of some unauthorised and actively contested figures.

I am sure they will also wish to bear in mind that Tom Kark, the counsel for the inquiry has made it clear that he does not think it is safe to take the view that Midstaffs is unique. The failings at Mid Staffs are very unlikely to have been on the scale that has commonly been portrayed, but they are problems that can easily be replicated anywhere subject to the wrong set of circumstances.

The effect of restructuring

What the Mid Staffs inquiry does show us in detail is the effect of the huge disruption that occurred over the period of 2005/2006. Over that period we saw the restructuring of the Strategic health authority, The formation of the Primary care trust, the expansion of the Health care commission to create the Care Quality commission, and the process of becoming a Foundation trust, under the control of Monitor , rather than under the support of the PCT and SHA.

With all these organisations in turmoil and tight budgets, key people left or moved or had their jobs redefined. There was a lack of clarity about the roles of the different organisations, or their mechanisms for communication with each other. There was duplication and gaps in cover, paper work went missing, and people were generally unsettled, demoralised and lacking in support when they really needed it.

So these current concerns from the Midlands and East sound as if they could have been lifted directly from the Midstaffs Inquiry.

§ In the Midlands and east of England, officials are most concerned that a combination of targets to reduce spending, and the management changes, will cause upheaval during the transition, and similarly warn of worse quality and safety, conflict between organisations, neglect of primary care, overspending, and failure to meet key targets such as limiting the number of patients who wait more than 18 weeks for treatment.

§ Moderate risks in the region include loss of key personnel, staff working in "silos" and so not co-operating as they need to, a rising risk of fraud, lack of clarity about structures for commissioning treatment for patients, staff distracted or overloaded by the upheaval leading to worse service and higher sickness levels among health service staff themselves, confused and unclear accountability leading to "organisational and system failures", culture clashes, "mission critical" staff leaving, lack of leadership skills among key staff, and loss of confidence among clinical staff leading to the reforms failing.

If the risk assessment is to be believed the “reforms” appear to be unnecessary, They will be highly disruptive, they will do serious damage to communication and staff morale, and they are unlikely to deliver the governments underlying aims. 
Midstaffs Helps Us Understand What the Regional Risk Assessments Actually Mean

Midstaffs helps us understand what the Regional Risk Assessments actually mean.

The health bill is a mess: lets pity the politicians

 Wednesday 15th February

The Health Bill is a mess: let’s pity the Politicians.

When you look at the health bill, what most people are agreed upon is that this is a chaotic mess. It has taken the NHS, which most of us understandably regard as precious. It has made a number of assumptions that many people strongly contest, and it is absorbing vast amounts of time money and energy in what appears to many to be entirely the wrong battle. In the process it is damaging our already fragile trust in politicians and the political process.

The battle that is currently going on in the Lords is trying to do two different things. It is about trying to save what the majority of people see as the essentials of the NHS, whilst opening a face saving option for both parts of the coalition government. The suggestions from Shirley Williams look as if they could potentially achieve both of these aims. It remains to be seen if her proposals will be followed. I want to take a look at how we could have got to this point and how can we stop it from ever happening again.

There has been a clue to this over the last couple of days.
 An article in the Lancet questions the assumptions by the Audit commission about the productivity of the NHS. The Audit commission had looked at a report based in an area where there was “patient choice”. It had seen improving results, and drew the conclusion that the patient choice caused the improvements. It also claims that NHS productivity as a whole had fallen over years that Labour were in power. This report was used by David Cameron to justify his view that a multiplicity of providers and patient choice would be the way to drive up quality.

The Lancet article by Nick Black strongly contests the findings of the Audit commission report, and draws the conclusions that productivity, quality and outcomes had actually improved. It drew attention to flaws in the Audit commission report, and the common error of confusing correlation with causation.

A spokesman for the Office of national statistics then appeared briefly on BBC Radio 4 Today and contested Nick Blacks report – pointed out that there are misunderstandings. They offered
the opinion that productivity had actually been more or less flat over the last 10 years.

The BBC interviewer at this stage understandably shifted to the view that if there is this amount of disagreement between experts then the whole exercise is essentially meaningless, and you might as well forget trying to measure quality and productivity. He also I am sure correctly made the point that where there is a conflict of this nature you will get the government using one set of findings and the Labour party using the other. 

 The ONS I think correctly replied that measurement matters, and that it is important to try and have transparent discussions about what these complex studies are actually showing us.

So if you ask me if productivity improved or got worse under Labour or as a result of choice I really do not have the answers, and would feel that I have to know a lot more about the writers of the reports, and what they were aiming to do before I could even venture an opinion.

Productivity is one of the areas when the politicians may have made false assumptions. I have written much over the last 4 years about the unreliability of the evidence behind the Midstaffs story, which may well mean that the basis of the assumption of a “broken NHS” and the “failure of bureaucracy” is also seriously flawed.

We know also of the extent of the lobbying that has been directed at the politicians that may well have distorted their assumptions about the virtues of the private sector. Politicians are overwhelmed by reports, and opinions. How are they to judge which ones to trust. So I pity the politicians.

Think about the process of coming up with a manifesto. To “serve” us politicians must first “win” elections. The electoral calendar is relentless. Politicians are not experts. They are elected to represent us, and their level of knowledge is very variable. There are some who do have a strong sense of the importance of getting the best evidence they can access, in order to form their opinions, there are other s who are happy to find “stories” that seem to prove the points they wish to make. Manifesto making is kept under wraps, to ensure that good ideas are not filched by the opposition, Politicians and communications experts want to “win” and will focus their message on what “public opinion” is likely to support.

In the 2010 election that public opinion had been shaped for several years by an astonishingly compliant media. Lobbyists and researchers know what you would like to hear and that is what they tell you. The reports and statistics that seem to confirm the opinions you want to hold are the ones that find their way to your desk.

Nowhere in all of this is there the necessary challenge to false assumptions or prejudices. And I pity the voters. We get the stuff filtered through the media, the press, election leaflets, all boiled down to the point of being more or less meaningless, and without the benefit of balanced debate. Then we get the political theatre – like 2010 TV debates, which are an attempt at trying to present balance, but turn out to be a dangerous distraction, a performance where the appearance and voice of the actor counts for more than the message they are trying to convey.

Going back to the Conservative party literature that came through my door in 2010 there is nothing, nothing at all, that could have led me to believe that a full scale structural re-organisation, or increased role for the “market” in the NHS was in any way considered. 

 As I am writing this the petition to “dropthebill” is gathering signatures at the rate of over 10,000 an hour. The public begin to see what is happening. They are concerned and they are angry. They feel that a sleight of hand has been performed, and as more and more of the assumptions that lay behind the bill are openly questioned they feel that the government is also incompetent. This is too simple. It would be wrong to blame the chaos that surrounds this bill on Mr Lansley, or Mr Cameron, or even on the people who fed them the information that led them to conclusions we now question.

The Health service professionals have been galvanised by this bill. We hear that that there have been more extraordinary general meetings by the professional bodies than have ever previously been called. The professions now see the importance of finding their voice and using it. For the moment the focus is on this process of stopping or at least neutralising the harm that this bill can do. But that is not enough. What we need to do as a result of what we have learnt is to create forums and bodies that can analyse the real challenges that do face the NHS, and can work together to look for evidence based solutions.

Let us be realistic in our expectations of politicians. If we want them to pass good legislation that helps to resolve the problems that we see, we must accept that it is our responsibility to ensure that they have good information. Good government is a matter of partnership. We have to begin to play our role. We are all learning valuable lessons about the kind of government we want from this bad bill. We should apply these lessons to give ourselves better government.