Sunday, 4 March 2012

The Road to a new philosophy of health regulation

Monday, May 30, 2011

The road to a new philosophy of health regulation
I have raised the question, was Stafford Hospital the last of the big hospital scandals? One of the reasons that I think that it could be is because there has been a complete change in both the tools available to regulate the health service and the philosophy and structure of regulation.
It may help to look at what has happened in Stafford in historical terms.
I think that what we have seen in Stafford is a major milestone in the journey towards effective regulation of the NHS, and perhaps to complex systems in general.
Let us think back.
In the days before the National Health Service, the provision of health within a town was down to individual doctors, and to worthy citizens playing a role in governing their hospital. I perhaps have an unusual insight into this time, because my own family, Russell of Hitchin, combined two interests. Some of this small mafia were chiefly interested in running the town’s leather factory; others ran a chain of chemists which locally gave Boots a run for their money. All of them had a strong social conscience and were prominent players in local politics and in the running of the local hospitals.
This involvement in the health service persisted after the establishment of the NHS, something in which my own father played a part.
I suspect that the regulation my father would have been involved in at the numerous committee meetings that I remember from my childhood was pretty rudimentary. They would have heard reports from the Matron and hospital administrators, but also, because they were so well known in the town they would have been approached by local people who had any concerns. Maybe at that time this was enough.
The world I am describing here bears a closer resemblance to “Middlemarch” than it does to anything we would recognise now. Regulation is small scale, local, personal, and subject to variations in the quality of the individuals involved. 
The next point at which I pick up the thread of what was happening to regulation comes with the advent of the Labour government in 1997.
It is clear that what was happening in health was one of the major themes that contributed to Labours Landslide victory. We had the long trolley waits, and people dying on waiting lists, and the general sense that there was a great deal that the best of the rapidly developing world of health care could offer that was not being shared evenly across the country as a whole. Postcode lottery was becoming unacceptable.
I think there is a fundamental difference in the way that Labour and the Conservatives view regulation of services, which has its roots in how our different political parties evolved.
For Labour, providing good public services is central. It is why they exist. It is about the mutual good. For the conservatives the provision of public service is something they choose to do because it is necessary to maintain a productive workforce, and perhaps also because it is “right”.
The differences in attitude go deeper than this. For Labour public services are about ensuring that everyone has the chance to make the best of their life, for Conservatives, there is the additional driving motivation to use the provision of services to create entrepreneurial opportunities.
For Labour, because public service matters so much the state of the regulatory system as they found it must have been pretty disturbing. There was no effective way of comparing the quality of care across the country, and there was no way of identifying hospitals which needed help to improve.
We saw the emergence of systems to try and measure and drive up quality.
The simplest of these, which draws a very mixed response from practitioners and people with political views, is Targets. At their worst these are box ticking exercises and things that administrators with a mind to get round them will “game”. It is clear that in Stafford the hospital struggled to honour the targets in the “spirit” and found ways of working round them which were not good for patients.  Despite the problems with targets it is now widely admitted that they did work, they drove down waiting times in A&E and in waiting to see a specialist to a remarkable degree. It is clear that some powerful sections within the health service found this onerous, and these persuaded Andrew Lansley, during his 7 years as shadow secretary of state for health that we would be better off without the burden. We are now getting a chance to see how this experiment works. Waiting times are again growing, and perhaps as a consequence of this I am certainly noticing prominent adverts for Bupa and other health insurance companies cropping up in my daily papers with greater regularity.
A second development was Standardised Mortality Rates. This is an attempt to measure the very marked discrepancies in life expectance throughout the country and to relate that to the various factors which affect the health of the population. These variations are huge and shocking. If we take a local example then people in Stafford are on average dying more than ten years older than ten miles up the road in Stoke.
A minor factor, and it is only a minor factor in looking at mortality rates as a whole, is concerned with hospitals and hospital care. The Hospital Standardised Mortality Rate or HSMR is – or more accurately was – an honest attempt to look at the how good different hospitals were in keeping patients alive. This runs into all the kind of problems that you have with Stats in school. It is only telling you something useful about the performance of the hospital – crudely the value they are adding -  if you know what the condition of the patient when they are admitted.
How good HSMR could have been is something we will never now know. It did not work because admission coding throughout the country was almost universally poor, and because there were factors like the complexity of medical conditions, and options on places to die all skewed the results. HSMR effectively shot its bolt by the publication of the Dr Foster Intelligence league table in 2007. This was presented simplistically by the press as showing a whole lot of hospitals as “failing”. The furious response of many people within the health service to this league table was sufficient to prompt academic research into the system. The result of that is that HSMR, though it still exists as one tool in the hospital managers tool box, has been downgraded in its importance, it will never again be published in this league table form. A new system SHMI has been put in its place. The details of how this will work are still a little unclear.
Part of the controversy over HSMR was that it appeared as in the case of Stafford to be in total contradiction to the findings of other parts of the regulatory system, which included the annual health check. So you have the Health care commission carrying out its Annual health review and saying that the hospital is good followed by the Dr Foster HSMR indicating that mortality is amongst the worst in the country.
What you are effectively getting is some systems that are producing false assurances that everything is fine, and systems producing false alarms that things are dramatically and disastrously wrong.
Perhaps the best indicator of the effect of this comes in the extraordinary Westminster Hall debate led by David Kidney in April 2009 to look the Stafford Hospital question. I think it is widely known that I am a friend of David Kidney, and I am glad that I was able to give him some support in the dreadful days that followed the release of the Health care commission report, and the media hurricane that it brought to Stafford. Everyone in Stafford was traumatised by this, and David was thrust unwillingly into the spotlight. After weeks of seeing him under unbelievable pressure it is still remarkable to me that he could in this Westminster Hall debate clearly identify many of the points and conflicts which are only now emerging through the Inquiry, slowly, painfully and at very great public expense.
Many of the people who have been pilloried for “failing to see” the problems at Stafford have been perhaps correctly accused on not looking closely enough. No one could possibly accuse David of this. He is a man who has a rare capacity to see detail and to also see the broader picture (see blog on Granular still to follow) The problem that David faced at this point is that there were conflicts within the information he was being given. In the weeks that followed the HCC report he was hearing directly from patients about their experiences, and therefore knew definitively that there were some things that had gone wrong, he also knew that the blanket statement that hundreds of people had died was based on very shaky foundations.
He knew that the information that was available to him had not helped him to see clearly. He had actively wanted the tools to be able to measure the quality of service in his constituency and the tools that existed had failed him.
The evidence that I have seen through the Inquiry does give me reassurance that many of the issues he so clearly identified have now been tackled.
I have further blogging to do on this but as an interim would recommend reading the evidence and statements from Rashmi Shuckler, Peter Blythin, Steve Allen, Martin Bardsley, and Richard Hamblin,  
The limitations of the Dr Foster Intelligence system have now been recognised.
The Strategic health authority has developed clinical dashboards which bring together in one place a wide range of indicators that anyone with the ability to read this kind of information can understand and benefit from.
The creation of the SHMI system marks a major achievement in bringing together a range of Statisticians who might previously have seen themselves as rivals, to create a robust new approach.
The development of the Mortality outliers has got past the tentative beginnings, and is now giving CQC a real tool for raising questions about care in individual hospitals, a tool that can also be used by hospital managers themselves to help ensure that their performance is as it should be.
An important development of the philosophy of health service management that has occurred as a result of Stafford and as a result of the movement from the Health care commission to the Care Quality commission is that the way in which the regulator operates has completely changed.
In the Stafford case, we had a centrally placed investigations team spotting a potential problem, which its own locally based teams were not aware of, waiting months for supporting evidence, which no one understood how to give, and then sending in someone to look and starting what appeared to be a highly punitive form of investigation. This nature of this investigation process in itself made it very difficult for other agencies to support the hospital through the problems and created real divisions between the different “arms” of the health service. The investigation built in a year of delays as Monitor felt unable to take decisive action.
Everyone I think now accepts that the investigation process was not as it should have been and there is a radical change. We saw this in action with the recent CQC reports on the first 12 of 100 hospitals where they have carried out investigations. The CQC if they suspect a problem now directly involves their local teams at the earliest possible time to go into the hospital and work through the problem with them. They are not being left to sink or swim. This is a partnership approach.
The Outliers system is just one small part of the changes prompted by the response to the Dr Foster league tables and to the failure of complaints monitoring in Stafford.  One of the major themes within the Inquiry is that there have been lots of individual people who each had one or two clues that some things may have been going wrong, but there was no possible way of bringing this evidence together. No one saw the patterns and it has taken the Inquiry to bring this complex picture of who was able to see what to bring all of this together.  
There is an entire new arm of monitoring which is based on picking up the soft intelligence which forms the basis of much of the evidence to the inquiry. These QRPs are outlined in Richard Hamblin’s evidence. (will try and blog specifically on this evidence later) These systems, which are still developing, will allow us to aggregate “soft information” from complaints, websites such as NHS choices, Press reports and other sources, and will give the local regulators and managers an effective way of seeing how they are doing in a way which would have been completely unthinkable when Labour first came to power in 1997. The software to analyse text, and help draw out patterns and clusters will really help us to compare the quality of service between different hospitals, and trends over time, in a way that would never before have been possible.
This may seem an abstract discussion, but it is central to the questions which are now being asked about health reforms. Few people have yet seen or understood the fundamental importance of the evidence given by people like Richard Hamblin.
If we do not see or understand what is being done here there is a real danger that we are carrying out disruptive reforms, which will damage the health service, in order to find a solution to problems which have already substantially been solved. 

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