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.   

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