Sunday, 4 March 2012

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.

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