Sunday, 4 March 2012

Is Stafford Hospital the Last big hospital scandal?

Monday, May 30, 2011

Is Stafford Hospital the Last Big Hospital Scandal?
We are reaching the end of the Health reform listening exercise, something that has been forced on the government by their recognition that many people within the health service do not accept their reasoning for major health reform.  There are still big questions, Does the health service need major reform? Do we understand well enough the reforms that have already taken place from within the health service? Are the reforms proposed by the government taking us in the right direction.
Because I live in Stafford and have lived with the impact of the Stafford Hospital story over the last three years I think that understanding what happened at Stafford or because of Stafford gives us some clues on these questions.
The truth about Stafford is many sided, and we are still learning what this truth may be, but I think that many people now agree that the prolonged process of investigation and inquiry has been costly, damaging to the hospital, staff and patients and relationships the NHS and also very damaging to political relationships.
As the process of “learning the lessons of Stafford” plays itself out, significant lessons have already been learnt about how to monitor health care, but people have also been very keen indeed to ensure that nothing as destabilising as the Stafford Hospital Scandal can ever happen again.
So the question I am asking in this post is “has enough been done to ensure that Stafford will be the last of the big hospital scandals?”
What do I mean by this question? Do I think that “learning the lessons of Stafford” will ensure that there will be a magical overnight improvement in the delivery of health care? No, Not at all!
The evidence from all those who are skilled observers of the health service tells us a similar story. This is a service which ultimately depends on people. I think that the assessment of Peter Carter from the RCN was pretty accurate. Hospitals are made up of a series of micro climates. The quality of the patient’s experience of hospital health care will continue to be dependent on the unique mix of individuals present on an individual ward on an individual day.
What I mean is that the unique set of circumstances which made up what Robert Francis describes as the “perfect storm” for Stafford can now never occur again.
For those who have not already seen it, it may help to look back at the short video in which I describe the anatomy of this perfect storm. 
Here in a little more detail are some of the key elements.
·         The story has to begin with Julie Bailey, the creator of the pressure group, who has been described by so many people including herself as the reason why we have the Public inquiry. Julie Bailey is unique in her determination and in her distinctive approach to the problems she found in 2007, but many people around the country have learnt from her experience about effective ways to use the media in furthering their campaigns. There is the potential for many more pressure groups to form.
·         A central reason for her discontent was that the complaints system and also the forums for patient participation were both dysfunctional. All parties are united in their recognition that this had to be improved. The Labour government brought in a reform of the complaints process, created NHS choices, and carried out work on patient and public participation, There is interesting work underway to be able to pick up “soft intelligence” A stronger framework for listening effectively to the concerns of patients and families at an early stage should mean that it is never again necessary for dissatisfaction to get out of hand in the way it did in Stafford.
·         Creating a really effective way of finding out what patients feel and responding to it is always going to be challenging but Stafford hospital has made a number of changes. It has pioneered ideas like the two hourly comfort checks which will cut of potential problems before they ever reach that point. It has carried out restructuring of the hospital to ensure that there are easier ways of monitoring high dependency patients, and it has created an ethos of openness which brings patient stories into the heart of the board room (the CEO has now started tweeting board meetings) and makes patients the clear focus of the service.
·         The funding squeeze in the NHS in 2006 was of course not unique to Stafford. This lay at the root of many of the problems of understaffing that did occur. It will have affected many other hospitals in 2006-7. The financial pressures which caused the staffing shortages and care problems are of course present again now, so we should expect that hospital front line staff may at times find themselves under intolerable pressures, and may still deliver care which they know to be less than perfect.
·         The Dr Foster Intelligence Hospital Standardised Mortality Rates HSMR, which came to the national attention through the publication of a league table in the Telegraph in 2007 has as a result of the eruption of the Mid Staffs scandal come under very serious scrutiny by politicians, Health service managers and statisticians. It is perhaps unfortunate for Dr Foster intelligence that the press coverage by the Daily Telegraph greatly over claimed what it is possible for these figures to show us. Different parts of the Health service have now looked at the use of these figures in detail and there is now clear agreement by the experts in the field that the figures are a tool which have a value as part of a range of tools. It will often produce misleading results, and it cannot meaningfully be used to demonstrate the quality of care in a hospital (the Statement by Richard Hamblin is the clearest expression of this). ·         There will never again be the publication of the HSMR figures as a league table, and the HSMR system has now been superseded by SHMI  which was created by experts working together as a response to set of problems identified by David Kidney in his Westminster hall debate of April 2009  and the recommendations of the Independent inquiry.
·         The reason why Stafford Hospital performed so poorly in the HSMR league table is due to a mix of circumstances. Stafford deals with a very high number of elderly patients, who have a complex mix of illnesses. If the co-morbidities (which reflects the total risk to a patient) are not recorded accurately for hospitals with this kind of case load then there will be an elevated HSMR figure
·         There is only a very small hospice provision in Stafford so most people will die in hospital. This will lead to an elevated HSMR figure.
·         Coding of co-morbidity was being done badly in most hospitals throughout the country, because it was not seen as a priority until the 2007 league table. It was being done particularly badly in Stafford due to the long term sickness of the coding manager (See HCC investigation report)and cuts in administration support staff.(highlighted by the evidence of Dr Singh. The repercussions from poor coding at Stafford have been so major that the health service as a whole is now fully aware that whatever else you might cut in times of financial difficulty, that you cannot afford to cut the time given to code information accurately.
·         The publication of the Dr Foster league table by the daily telegraph in 2007 is a fairly typical way of how the press operates. They took the simple but flawed and misleading figures to build a story which damaged the reputation of Stafford and a number of other hospitals. I see no prospect of this changing unless the press is ready to learn the lessons that they should learn from the Stafford story. This irresponsible use of information by the press is the central reason why I am personally fighting a campaign for #pressreform . The press problem remains, but we can be certain, that in the case of the HSMR figures at least that these will never again be presented to the press in the same damaging way.
·         Here are a few references on the statistical row sparked by the use of the Dr Foster figures. It will be seen that the statistical world splits into different camps on the issue of how you can measure quality in the health service. Professor Jarman and the Dr Foster unit end up on one side of this divide, and Dr Mohammed from Birmingham university ends up on the other side.  
These different philosophical approaches to how you measure quality become politically important as a substantial part of the Conservative parties claims on the NHS is that their “outcome” measures would be a good way of measuring quality, and that the “targets” and “process” tools which were available to the NHS during the “noughties” were now a thing of the past. The Daily telegraph helps us with an outline of the conservative led philosophy here
I suspect that few of the politicians espousing one side or other of this argument actually understood the intricacies of the argument. They just wanted a system that would give them reliable information on how the health service was doing and help to drive up standards.
Management systems and statistical methods evolve over time. They are getting better, but this is something that all political parties should welcome and none should try to claim the credit for! I have put together some information on how I see the philosophical approach to monitoring developing here. (to follow)

·         The Strength and ultimately the weakness of the Cure the NHS campaign is that they drew the conclusion that the poor care they witnessed was part of a pattern of high mortality “proved” by the Dr Foster Figures. Because of this firmly held belief they had no hesitation in calling for heads to roll and pointing out the errors of large numbers of people within the community. This has put Stafford through an extraordinary experience. the best analogy is probably found here. The effort which perhaps could and should have gone into bringing the community together to address the genuine concerns raised by Cure the NHS may have been dissipated because of this.
·         All of this is just a prelude to the HCC investigation. The unique factors about this are that the HCC was about to be disbanded and the style of investigation favoured by the investigation team, something of which they were naturally proud, was about to be discontinued. A strong theme in the evidence given by the HCC investigation team is that they do not believe the Stafford Hospital Scandal could have been “discovered” in any other way. This may well be correct – but what is that they actually discovered? And how can we assess the scale of the problem? After years looking intently at this matter I cannot answer that question. Richard Hamblin’s joke is an interesting insight into why this is so tricky (to follow)
·         There are other factors that make the position of the HCC unique at that particular period of time. They were just beginning to see the very first alerts from a new statistical pilot scheme to identify “outliers”. They had no way of knowing how reliable these new untested figures might be. Their investigation at Stafford was in part a live test to see if the new figures were telling them anything useful.
·         Because the outliers system was so new, and so controversial the HCC deliberately did not share any information about it with the rest of the health service.
·         Because the rest of the health service was unaware that the HCC had already discounted the value of HSMR and was working secretly on the new outlier system the SHA focused its attention on looking at the Dr Foster figures and the impact this had had on 6 hospitals in the west midlands region. They commissioned Prof Mohammed from Birmingham University to look into HSMR, other mortality systems and other ways for measuring quality.
·         Over the course of time the operational basis of the HCC investigation team had shifted. Previously they would only “investigate” if they had clearly identified that a problem existed. In the case of Stafford this was quite different. They had figures. They did not know what these figures were telling them, and they did not know if there was anything to worry about or not. The “inspection” at Stafford happened because they did not receive the answers they were looking for when they were looking for more information on the areas identified by the outliers.
·         When the HCC asked for information to help with their concerns on the outliers Martin Yeates would have been completely in the dark. I suspect that he would have assumed that this was simply an extension of the problems he was having with the Dr Foster league table, and that the response to this by Prof Mohammed would cover the questions that were being raised. This would have been the wrong assumption. What the Stafford Hospital scandal has firmly impressed on Hospital managers all over the country that if the CQC is asking for further information then it is absolutely in the best interest of the hospital to comply with their requests!  
·         In practice coding problems could, and I believe did play a part in the alerts being triggered by the Mortality outlier system, just as they did with the Dr Foster system. This is recognised in the evidence from Martin Bardsley, but the investigation team saw the coding issues for the two systems as completely separate matters.
·         Martin Yeates will have believed that the research being conducted for the SHA by Prof Mohammed would answer all the points being raised by the HCC. The HCC did not explain adequately why this would not satisfy them, and in addition the use of Prof Mohammed will have appeared to the sensitivities of the Dr Foster Unit to be a direct and calculated insult with political overtones.(blog to follow on the sensitivity of statisticians).  In the fog of confusion created by all of this the effective communication between the HCC investigation team and the Trust broke down in a fairly dramatic fashion.  Martin Yeates, for reasons completely beyond his control found himself the unfortunate pig in the middle of a statistical spat.
·         The combination of the Mortality outliers that no one but the HCC knew about, the sensitivities of the investigation team, the different philosophies about monitoring, the lack of clarity about the roles of the different organisations and perhaps also some clashes in personality meant that Monitor did not step in to take action to support the hospital,  because they were reluctant to tread on the toes of the investigation team. This led to substantial delays in taking action to rectify the problems that were found. One substantial lesson that the health service has thoroughly learned from Stafford is that there has to be better communication between the different sections of the NHS. This problem should not occur again. Investigations if they occur will go hand in hand with steps to rectify the problems.
·         There is now much greater openness about the statistical underpinning of health service monitoring systems. The Dr Foster HSMRs are no longer considered as sufficient basis for investigation by any sector of the NHS and this source of misunderstanding has therefore now been eliminated.
·         All of this was coming to the boil at the start of 2008 which coincides with the time that Julie Bailey shifted from being a one woman band, to being the head of Cure the NHS. Cure the NHS began a forceful campaign to draw attention to the HSMR league table and its supposed implications. This was a campaign that was taken up by the local press and spread further as the Campaign group began systematically contacting and putting pressure on an extensive list of organisations which are listed in Julie Baileys evidence to the inquiry.
·         It should be remembered that because of the changing nature of HCC investigations and because of the “testing” of the new mortality outlier system the decision to inspect the hospital was not taken because the HCC had clearly identified a problem at Stafford. It was taken because they could not rule out the possibility that there might be a problem, and because the hospital was not providing the answers they were looking for.
·         There is one single incident which tipped the HCC into the decision to carry out a full investigation. This came when members of the investigation team, including Heather Wood, carried out an unannounced visit to the hospital, and Heather Wood saw one elderly lady about to fall out of bed in the Emergency Admissions Unit. (This is of course an issue which faces all hospitals and all care homes every day. I can vouch for this. My own mother suffered a broken hip when she fell over the cot sides aimed to protect her in a care home in Stafford. Short of having one to one 24 hour care which is of course impossible, I suspect these accidents will always happen).
·         Once the investigation began this sparked huge interest from the local press, and saw the beginnings of what is perhaps an unusually close relationship between sections of the local press and the pressure group. It is of course inevitable that the personal stories of the bereaved relatives, which formed a regular part of the local media coverage, will have made a strong impression on the minds of the journalists involved, and will have created a real bond between the journalists and the pressure group. This is quite a common phenomena when people find themselves at the centre of a tragedy. It can appear that the press are the only ones who understand, but the press always have their own agenda.
·         The level of press interest and the growing self confidence of the pressure group will have left the investigation team in no doubt that they needed to clearly identify “the problem” at Stafford. Their credibility depended on this. There was no middle way.
·         In the last few months before the issue of what was to be the last major report from the outgoing HCC investigation team, we also have the additional complication of growing political interest. At a local level this was interesting. The two MPs involved were David Kidney the Labour MP in Stafford, and Bill Cash the prominent Euro sceptic Tory MP in Stone. David Kidney was the first to become caught up in the matter. The pressure group experimented with a form of direct action that they subsequently used against a number of prominent people. They turned up at David Kidney’s surgery en mass, with placards, and with a hidden video camera. They were not interested in dialogue, but in making a point. Their “film” was then posted on Youtube.
·         David Kidney’s response to this difficult encounter is characteristic. He listened, identified things that he could do to help them follow up their complaints and set the wheels in motion. He then kept them informed of progress. He was in regular contact with the hospital trying to understand the concerns that were being raised.
·         In the summer of 2008 he made the decision to spend a number of days at the hospital on work experience in order to see more clearly what conditions were like. He worked in various areas of the hospital. It is of course true that he, like the governors, and councillors who have some responsibility for the hospital, was a lay person, without any specialist skills in inspection, and it is also true that he was instantly recognisable by staff who might well behave better in his presence than normally, but this was nevertheless a very serious attempt to see what was happening, and to make it possible for staff to talk very informally with him. He actively took part in the in deep cleaning which was part of the national efford to tackle the very serious issue of hospital acquired infections, which was killing people throughout the country at this time, and he saw nothing during this work experience to cause him any serious concerns. This is in line with the impressions of every lay person and every health professional who visited the hospital during this period. If what was happening in Stafford was in anyway unusual there was nothing that would be immediately apparent to most people on most days in most wards.
·         David Kidney's report on his work experience was taken as a gross insult by the pressure group who formed the idea that he was undermining their position.
·         What we can say clearly about David Kidney is that he went to very considereable efforts to inform himself about the hospital, he visited regularly, he read reports in detail, he talked to the different agencies involved, and he also knew from his dealings with these agencies that the Mortality Statistics had their limitations, and that they should not be taken at face value. This meant that he could not simply accept some of the less accurate assertions of the pressure group.
·         With Bill Cash, we see an entirely different approach. Mr Cash’s evidence  to the inquiry tells us that he had no contact with the hospital since before 2003, he never met Martin Yeates, He took no direct action in any complaints involving the hospital, but simply sent copies of complaints to the department of health, He had no understanding of the statistical systems or the systems for monitoring the quality of the hospital. He had not accepted a series of invitations to attend briefings. His information about the hospital came from the newspapers, and when Julie Bailey made contact with him in winter 2008 he simply accepeted her version of events unchallenged and took steps to assist her to  gain wider media coverage.
·         From the local perspective this will have looked to the Conservative party like a godsend. David Kidney had, for very good reasons, the reputation for being one of the most trusted and competent politicians in the country. Finding someone who believed that he had let them down, and was prepared to say so as publically as possible, and who was essentially unassailable because of the genuine sympathy with their suffering, will have seemed like a gift from heaven.
·         In the months before the publication of the HCC report major battles broke out between the different parts of the health service involved. Drafts of sections of the reports circulated to interested parties were actively contested by people who felt that the report misrepresented them. There was a major discussion on an appendix which included “excess deaths”. I can give you no reliable information on what this appendix contains, because it was removed from the report on the authority of Sir Ian Kennedy, who was Chair of HCC, after discussions with Bill Moyes, from Monitor. What I can say about these figures is that Richard Hamblin, who has to be seen as the expert on what these figures mean, is firmly of the opinion that the figures should not be used, and that there could be no proof about how many people might have died as a result of poor care without a full case note review. The case note review which did take place found it was also impossible to give any estimate of numbers. The coroner could not help with this either. 
Cure the NHS on the other hand see the “excess death figures” as completely central to their case against the hospital. They have used them extensively, they appear in hundreds of press articles, they have been quoted by David Cameron on their behalf in PMQs, and they are now a firmly embedded “fact” in the minds of thousands of people in Stafford, as well as many millions beyond Stafford. It should be noted that Cure the NHS have been directly told of the weaknesses of these figures by David Colin Thome, and by Robert Francis, but they still continue to use them. 
·         The day before the publication is highly significant. An article appeared in the Daily Mail, Using the excess death figures, and quoting Cure the NHS and Bill Cash, This article formed the background of understanding with which the press took in the information from the HCC press conference.
·         The coverage of the release of the report was entirely dominated by the excess deaths which do not form a part of the report to the exclusion of many specific problems identified by the report which had already been resolved.
·         Once these figures were out, in a way that no one could contest because they were not in any printed material, they dominated headlines not just in Stafford, or Britain, but across the world. They played a significant part in the republican election campaign for Massachusetts where they were used successfully to persuade American voters that they should not back health reform.
·         In this country the prominence if the story in the tabloid press meant that it was inevitable that Andrew Lansley and David Cameron should grasp this opportunity to show that the NHS had “failed” under labour, and that there was a need for major reform of the NHS. Videos and press coverage of David Cameron with the Cure the NHS fulfil many different functions. ·         The HCC report left many lose ends and raised as many questions as it asked so since then we have had the Alberti Report, The David Colin Thome report, The report into the conduct of Martin Yeates, and the Independent inquiry by led by Robert Francis. All of these which provided significant pointers for action, were belittled by the Conservatives who declared, as Bill Cash had always insisted, that a Public Inquiry was the only possible answer. Locally and nationally the demand for a public inquiry was the sound bite response of the pressure group, press and Conservative politicians to the hospital issue.
·         As we moved towards the 2009 elections the eruption of the MPs expenses scandal through the Daily Telegraph expose formed a climate in which “the voice of the people” became increasingly powerful and more rational voices amongst MPs were effectively silenced. 
·         This hospital story, alongside indiscriminate coverage of the expenses scandal dominated the press in the run up to the local elections in this area in 2009, where they played a part in unseating a number of Labour councillors. The issue of NHS “failure” then moved to centre stage for the Conservative election campaign in 2010, where images of Stafford, and the perception of failure still firmly in most peoples minds were skilfully used by the Conservative party to overcome deep rooted distrust in their relationship with the NHS.
·         The Conservatives very wisely took the public position that there would be no top down reorganisation of the NHS, which is something that would have resonated with many people, including many health professionals who had lived through the upheavals of 2006-2007.
·         The Election of 2010 brought us a Conservative MP in Stafford and a Conservative led government, which meant that the hospital issue no longer had to play a part as an election winning tool , though it has continued to be used by the Conservatives as a means to “sell” their proposed reforms, with a totemic appearance of the pressure group on the platform for Andrew Lansley as part of the 2010 conference.
·         Throughout all the period from 2007 with the first release of the Dr Foster league table, until now the Health service has been effectively healing itself from within. The relationships between the different tiers of management, which the Health reforms now threaten, have been worked through and new systems of communication worked out. A significant coalition formed to reform the statistical basis for Monitoring health care as a result of the Robert Francis Independent inquiry and alongside these new and robust systems of monitoring there is a complete new philosophy on how to manage the health system, of which the essential element is that hospitals are not left to sink or swim through periods of difficulties.

The unique mix of ingredients which created the perfect storm over Stafford Hospital will never occur again. There are massive and growing problems in the delivery of a health service, poor care will continue to be an issue in hospitals, care homes, and in private houses throughout the country, This needs the co-operation of all regardless of political affiliation to resolve the problem, but Stafford could be the last of the big hospital scandals, because the NHS has recognised and acted on the real problems which did exist and has removed some of the triggers which made it possible for the media and politicians to turn a limited local problem into an international scandal.

The Health Reforms which this government – or more precisely the Conservative element of the government- wishes to put forward are based on a false idea of the failings of the NHS, and on an attempt to solve problems that the NHS has already resolved organically from within.

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