Are super CEOs the answer for "failing hospitals"?

This morning’s piece on the BBC about getting the managers from “successful hospitals” to sort out “failing hospitals” made me feel pretty weary for a whole range of reasons. http://www.bbc.co.uk/news/health-24142618

The exercise is predicated on mortality statistics, which are increasingly and rightly being questioned, because they are simply not the robust indicators of quality that the media still persists in believing they are.  

The article predictably began with coverage of Mid Staffs that as usual presents historical anecdotal evidence as fact, with no context being given, but after five years of this, people in Stafford are pretty used to this!  

Julie Moore, who is one of the CEOs who will be parachuted in to save failing hospitals, made it clear that her starting point is that DGHs have had their day. To me that is problematic, as there are a great many people who actively question her view. It is certainly a view that needs national debate before it is allowed to re-shape our NHS by stealth.

The Interviewer took the view that it would probably be best to close down a lot of DGHs, but that this will not happen because politicians will not agree.  This analysis is simplistic, and it completely misses the point that politicians who resist hospital downgrades or closures are doing so because they represent their constituencies. Having been through the last year at Stafford, where we have been facing the active threat to our hospital, and having marched with the 50,000 who came out to support the hospital in April, I have learned a great deal about the way in which people here value their hospital and why it is important to them.  I have seen the political leaders from all parties in the borough marching side by side as a powerful response to the people of the borough. This is a process that has changed out town, for the good.

It is certainly true to say that some hospitals, probably a lot of hospitals are struggling in the current climate. The BBC article did not make any attempt to try to analyse this.  There was for instance no reference to the effects of the tariff system, where the shrinking income is forcing hospitals to concentrate treatments into larger units, in order to cover the costs. There was no mention of the way in which the tight budgetary constraints on hospitals and on commissioners are forcing hospitals to run with minimum numbers of staff, leading to increased pressure on staff, and staff burnout. There was no mention of the way in which small hospitals struggle to recruit specialists in areas where there are national shortages, and end up having to rely on expensive agency staff.

Chris Ham usefully made the point that the suggestions while far from perfect are infinitely preferable to trying to use either Management consultants or temporary CEO fixers to sort out the problems. Having seen both of these in action at Mid Staffs I would certainly agree with that.

He is right. Hospitals that are struggling need long term support, and they need access to networks of clinicians who can build a relationship with them over time.  He believes that a better option than the super heads would lie in these support networks.  I would agree with that. It is better for District General Hospitals to be working together to work out what their future role should be and how to support it, rather than being told how to act, by the leaders of super hospitals whose interests will be quite different.

Super hospitals have a role, so do District general hospitals. They are different kinds of organisations, with different functions.

Currently there are two drivers which are currently pointing the NHS in different directions.

There is the drive towards the big centres of technical excellence. These are the places to which all ambitious clinicians automatically gravitate. These centres of excellence require the surrounding hospitals to shrink and become feeders. Keeping these huge hungry hospitals functioning requires a constant stream of patients and the revenue that comes with them to feed the machine.

There is the drive towards integration, which really requires seeing hospitals in a different way, as part of a continuum of care which begins in the community, and brings Primary Community and Secondary care much closer together.  With this vision the patient, the individual, is central to the picture.  The Super hospitals are simply a part in this patient centred continuum. This is something that many people see as the future, but it really has not been explored or developed in the way that needs to happen. 

What I am seeing in Stafford now is what happens to a community where these two forces are in play.  The next few months will let us see if the combined influences of the Management consultants, the ambition of neighbouring super heads, and the way in which the politicians represent the people will help to find a solution that will satisfy the 50,000 people who marched for this hospital.

Stafford is an opportunity to reshape the NHS in a way that works for the people who use it. It needs to be seen as that.

 

 

Hospital mergers stir deep feelings.

Professor Mascie-Taylor is right to raise concerns about the element of US and Them rivalry that is now apparent in the responses to the TSA proposals.

If we look at some of the History of Hospital Mergers in the USA, which were all sparked by the drive towards centralised care, then it is clear that solutions which look perfectly sensible on an accountants spread sheet have a way of looking different when imposed on communities that have different histories and cultures and also have the natural level of rivalry that exists between neighbouring towns. Professor Mascie-Taylor drew fire for using the word “Tribal”, but it is a word that fits. It is what communities that feel under threat will naturally do.

The TSA process here has suffered from being the first in this country. The TSA have followed their brief to focus on the commercial and confidential process of finding “service providers” and I think they may reflect with hindsight that more could have been done to involve the staff, and to encourage the community to be a positive part of building a solution.

Sir Hugo understandably feels bruised by some of the heated response to the best efforts of the TSA, but if we are to work through this difficult part of the process and build a solid future for the health service in our communities it is important that he should understand why people are not willing to meekly accept that he is doing “what is best for them”.

The TSA process comes at the end of years of outside experts coming in to solve our problems. Many of these processes have had the unintended consequences of making matters worse. We are more than a little battle weary. The biggest problem that we have to deal with, as Sir Hugo correctly identifies, is the reputational damage to the hospital and the increased costs and decreased income that follow that damage.

The people of Stafford have always had their doubts about how fair this reputational damage may be, and as each new national report studies hospitals throughout the country this doubt is strengthened.  The Keogh report in particular has shown that small geographically isolated hospitals are struggling to meet the essentially political requirement for “financial sustainability” and may also struggle to recruit the skilled staff they need to perform some of the more complex medical processes. We are much clearer now that this is a real problem for small hospitals, and that is one reason why the solution for Mid Staffs matters nationally. Many people feel that this is an issue that requires national debate, and are concerned by the way in which downgrades all over the country are being hidden as “local issues”.

There is a largely unseen battle going on about what the future of the health service should look like. And Mid Staffs plays a central role in this.

There are many people who are alive now because the way in which medical skills, technology and drugs have developed with such speed over the last half century. Many people rightly see this as valuable and this drives them towards the idea of specialised super hospitals, which are hugely expensive and therefore have to be centralised. With this “Biomedical” model of the health service staff and patients need to fit the requirements of the health industry, and the health business. The TSA proposals have in fairness gone out of their way to minimise the negative effects of centralisation by ensuring that staff rotate between the networked hospitals and that as much care as possible remains in Stafford. Making this work will be a complex and difficult matter, and crucially it requires the good will of staff who will need to work together in new larger teams.

There is also a great deal of discussion and agreement about “Integration”, which really acknowledges that the technical wizardry that can be performed in acute hospitals is just a small part of what a genuine Health Service needs to do.  Integration places the acute health service within a wider picture of how do tackle preventable health problems and how do you make acute care and community based care fit seamlessly around the needs of the individual patients. This model which can be loosely described as “Bio Psycho Social” is a matter for the whole community, I saw potential support for this in  the 50,000 people who marched to support the hospital at Stafford. We are at the stage where many see “integration” as an essential way forward, but few areas have fully effective models in place.

The idea that most people would support is that you do what MUST be done centrally, and you do what CAN be done locally. If people of Stafford are shown clear evidence to support moving some processes to Stoke then I think that many can support this, especially if this is balanced by a very clear financial commitment to recognise support and develop existing teams that are doing very valuable work, and to make integrated care a reality.

Because the TSA process is a first time for all of us, it is difficult to know how far the TSA is able to listen, or to modify their proposals. I hope that that they will be able to do enough to allow the communities to support the final proposals and that they will also spend a lot of time and effort on assisting the staff and the communities to work together through the many difficult and emotive issues that face us all.

Our health service is a pact between the community and the staff who are willing to do this work.  What the staff need most of all now is certainty. It is in all our interests to find a way to make this work.

At some point we have to understand care pathways.

In Stafford we are currently facing the reconfiguration of the Health Service, through the agency of the TSA. This could set precedents for hospitals all over the country.  The verdict of the people on the receiving end of this process so far is “It is probably best not to do it this way”.

The Central question that the Trust Special administrator (TSA) has to try to answer, on the behalf of its boss Monitor, and Monitor’s boss the Secretary of State for Health is “How do we make health care financially sustainable whilst improving the quality of service?”

The most likely answer to this question is “By doing things differently”.

The challenge to the Health Service is so great that it needs a radical approach, which probably has to be centred around prevention, and integration, and also needs to take into account the issues of specialisation and the right place to perform the right tasks.

The role of the TSA in all of this is an uncomfortable one.

The TSA are here because the question is being phrased in terms of an individual hospital, which is “financially unsustainable”.  Because the question is about the future of an organisation it is probably not surprising that the proposals the TSA have made are structural. They are about what bits of the service should be performed where, and about who should commission what from where.  In the TSA's defence I am not sure what other options they had, given their remit?

The TSA do see the problem. They have had to focus on finding organisations that would offer to provide the service we need, and they see that this is not the end of the story. They know that integration plays a key role in making the future of the service work, and they know that they have not addressed it in their proposals. They are open to suggestions, and we need to help them with this.

The job of the TSA was to sort out the financial problems of one individual organisation that is part of a complex network of organisations and services. Delivering a health service and improving the quality of care depends on making “care pathways” work, and these pathways cross many boundaries.  The TSA cannot even begin to deal with this.

The TSA took a lot of stick at the first of the public consultation meetings because it emerges that they had not been to visit any of the departments whose services are now under threat. To those of us that see the importance of these services, the teams that deliver them, and the way in which they connect with the community around them this seems a very odd approach. Why would you not want to start by knowing what is there already?  To the TSA it clearly did not look like that. They needed to construct a viable structural solution from the ground up, and the existence of strong teams within the organisation were simply not relevant.

If you want to “Do things differently” then maybe beginning with what is there, the teams, how they relate to the wider health service, the way in which clinical pathways for a whole range of different conditions operate, the barriers which prevent people moving from one part of the pathway to the next, could have offered a better starting point.

We do not know what the outcome of the consultation will be, we do not know if we can make the case for the services that the TSA threatens. We are pretty certain that we can make a very strong case for ensuring that no other trust will go through a process quite like this again.

Whatever happens, when the TSA leave town we will be left with the task of trying to make a health service work for us, and if we haven’t got to grips with understanding integrated care pathways by then then this is where we will need to begin.  

Fragmentation and Kindness?

You might say that Stafford is currently faced with “re-configuration” of its Hospital service is because a number of people experienced care which they felt was unkind. As I look at the recommendations from the Trust Special administrators about the future of the service  a key question I am asking myself is "will this improve the chances of people being treated kindly"?

As an aid to asking these questions I am currently reading “Intelligent Kindness” which was written by John Ballatt and Penelope Campling as a reaction to many of the issues raised by the first Francis report.

There are so many powerful points in this book. This is selected almost at random. (P88 In the chapter Co-operation and fragmentation. Pulled in all directions. )

The writer’s parent was being assessed for a knee operation. She asking how long her hospital stay would be. The answer she got was that it all depends on which CCG you come under. If it is “city” then she would be discharged when clinically ready, if it was “community” then it would be after 2 days. This is because “community” CCG had commissioned community based care for people being discharged home.

The writer then goes on to think about how confusing this must be for the staff of the ward dealing with patients in the next bed to each other, and the same conditions, but being given aftercare in completely different ways, and how this confusion would communicate itself to the patients and their relatives.

The underlying point I would make is that a patients experience of treatment is made up of their whole "pathway". Diagnosis, preparation, treatment, aftercare, discharge. These all need to work together, and there are many barriers that make this difficult.

If more acute care is being directed to super hospitals (determined by “financial and clinical sustainability”) then each  hospital will serve patients from a large number of different Clinical commissioning groups, each with their own service level agreements. If this is so then you are adding a whole new layer of complexity to the work that the staff must do. Staff will in the above example also be aware that failure to discharge patients on time if they are “community” patients will incur financial penalties. This creates additional pressures for them. Will any of this add to kindness?

Commissioners will aim to reduce the length of hospital stays, so we can expect that periods is an acute ward will be as short as possible, this might then be supplemented by a stay in a step down ward, (I am not sure that we understand enough about this, what are the rules about how step down beds will be used? How will they be paid for? Are they time limited?) Will that add to kindness?

The aim will be to discharge to the community as quickly as possible, but how good are the services to support people when they are discharged? Will that add to kindness?

How well does the centralisation of acute care, coupled with the fragmentation of commissioning and of local service provision actually work together in practice?

What patients want is to be supported at each stage of their “pathway” by teams that co-operate effectively.  Will the new model of hospital care that we are moving towards make this more or less likely?

Watch out for the baby in the bath water!

After a first full day of reading my way into the TSA recommendations for Mid Staffs my thoughts are getting clearer. The report is very largely about money.

This is a small trust. Small trusts struggle financially. It is pointed out to us that it would be unfair to expect the other neighbouring trusts, many of whom are also struggling, to bail us out, in the way that we did for them in 2006. The extraordinary pressures on Mid Staffs over the last five years have added greatly to the costs of running the service here. The task that the TSA had to do was to find a way to make the service in the key word of the report “sustainable”.

It seems that the way in which the TSA have approached this task is essentially to start with a blank piece of paper. What are the services that must be offered, who is willing to provide them, how would that impact on other neighbouring hospitals. Their recommendations are built on this.

Let me first say I welcome the proposals to link Stafford and Stoke, because I believe that this does deal with the “small hospital” issue, and will mean that it is easier and cheaper to attract the staff that we need, and that by allowing staff to work at both hospitals it ensures that skills are maintained. This addresses the issue of making the service “clinically sustainable”.

I also welcome the proposals to bring more elective procedures back to Stafford, which gives a better financial basis for the hospital to go forward. It is the loss of the elective processes, on top of all the other pressures over the last few years that made Stafford “financially unsustainable”.

As Jeremy Lefroy has been pointing out regularly in parliament, the Tariff system for Acute and emergency medicine, which was put in place in 2009 with the idea of focusing more spending on prevention, means that acute medicine is being run at a loss, which largely explains the national crisis in A&Es. This needs to be addressed nationally as a matter of urgency.

I also cautiously welcome the development of assessment units for the Frail Elderly and for Paediatrics, though the way in which this is done will be important.   

What shocked me was the realisation that the TSA when they threw out bath water do not seem to have seen the baby.

We are asked to be thankful that A&E is to “remain as it is” and yes indeed it is a good thing that there will be a consultant led A&E if only for 14 hours a day. This is a decision that the TSA will have seen was inevitable, in part because of the strength of public feeling, but also because when they look at the emergency medicine networks in the region and read the incredibly strong representation from the neighbouring A&E leads that it is very clear that you cannot run this system without an A&E at Stafford.

The “remain as it is” leads us to the question – But Is it? The answer is “No”. Our A&E is currently supported by a level 3 Intensive care unit, which is able to deal with a given level of critically ill patients. If they downgrade this to Level 2, which is proposed, then this will mean that ambulances that currently stop at Stafford will for a number of patients carry on to Stoke. The effect of this experiment would only be discovered over time. We have been hearing for some time that there would be a new creation a level 2.5. It appears that this means that the ICU would deal with level 2 patients in house but with anything more serious they would “stabilise” and ambulance them off to where ever a level 3 intensive care bed could be found.

The ICU network that supports our health system is over stretched. There are not enough ICU beds. When there is a critically ill patient there can be frantic phone calls to find a bed, which can be at a considerable distance. There was the recent tragedy of a lady who finally ended up dying in Hereford some months back.  The distances are a problem, not only for the patients, but for the efficient management of staffing. When I asked the question the staff patiently explained to me that transferring a patient to another ICU ties up a doctor and a nurse to travel with them and to then travel back. In the hours this takes their skills are lost to the hospital.

The advice the hospital working group has been given by the Royal college of physicians is that having a level 3 ICU is central to the hospital being able to offer the services that we as the public wish from it.  With ICU level 3 then the hospital can deal with the majority of cases excluding Stroke and Trauma which already go elsewhere. Without it then the level of treatments will be limited, and Maternity and Paediatrics and any acute surgery become impossible.

A key part of the argument for the next few months will be about the level of critical care. How much would it take to give us back a Level 3 ICU? Is there a major cost implication in going from a level 2.5 to a level 3? Should as Jeremy Lefroy suggests the cost of a level 3 be met nationally as part of a national network of scarce Critical care beds?

Which brings us to the baby.

What did shock me last week is a visit to Maternity and Paediatrics, which showed me that some of the assumptions I had made about the way the TSA would carry out their work were wrong. I had assumed that the starting point for their task would have been to visit the different departments in the hospital and to develop an understanding of what people were doing and why, and find out what we already have here that is valuable.

It was clear to me as I listened to the people from Maternity and the Paediatric departments the immense pride that they have in their work, and the way in which the Paediatric service in particular has developed over the years to meet the particular needs of this community. The service may be unique, It is certainly valuable. The TSA do not currently know this, because they have had no discussion with these departments.

The future of medicine needs to be in the development of integrated care, linking primary, secondary and community care, and working with the wider community to prevent illness and support ill people. District general hospitals are perhaps the best placed organisations to be able to deliver this. The Paediatric service we have in Stafford does just this, and the TSA that are downgrading the service do not know, because they have not looked.

The TSA have come to this task armed with reports from the Royal colleges to support their decisions to centralise care in bigger hospitals. I know that there are many strong arguments against this. Are there enough people speaking out to make the case for the District General Hospitals of the future?

For me Stafford is not just about Stafford, it is about the future of the NHS and the future of the District General Hospital. We need the help of others who care about this to come to our aid now.

I do not know what the next few months will bring, but I hope that this period of consultation can bring us all a better understanding of the kind of service we need for the future, and the way we can build on valuable local knowledge to give us that.

If we go back to the Academy of royal medical colleges report http://www.aomrc.org.uk/publications/reports-a-guidance/doc_details/9692-changing-care-improving-quality.html they are very clear that reconfiguration of the health service can only be done successfully with the support of the community, and that the pressure that TSAs have to work under are not an ideal starting point to achieve that. I hope that that TSA will go into the consultation process prepared to listen, prepared to understand more, and prepared to help this community achieve the outcomes that it deserves.

A right to be furious.

After a weekend of looking at press coverage of the Keogh report, a number of people feel pretty furious

Let us think about this. We have seen huge headlines in most of the Sunday nationals telling us about thousands “Doomed to die by the NHS” We are told “Devastating report to reveal thousands dying needlessly as 21 hospitals probed in scandal that eclipses Mid Staffs Horror”

The front pages, and the media interviews are very interesting in that all of them are about a report that no one has yet seen because it won’t be published until Tuesday.  This mirrors the way in which the Mid Staffs report was highjacked in 2009 by people with an agenda leaking selective information to a very receptive press.

It reflects the way that all the reporting of the major milestones of the Mid staffs story have been handled, but this time is different because it is clear now that this is a national issue.

So what is the Keogh review?

Sir Bruce Keogh is a highly respected expert on quality in health care, who has played a prominent role working with the Department of Health for many years. He is a careful, mild mannered man, with the interests of the NHS at his heart.

One of the key things that triggered the investigation of Mid Staffs in 2008  was concern about mortality figures, produced by Professor Jarman’s system. The HCCs year-long investigation at Mid Staffs, began with these concerns, looked at everything with a fine tooth comb, and unsurprisingly found things to be worried about.

As with the Keogh review the HCC report was preceded by sensational leaks of figures that never appeared in the report. The media circus ensured that the HCC report led to the Alberti report, the Colin Thome report, the Francis Independent Inquiry and the Francis Public Inquiry. This also then made Mid Staffs a prime candidate for potential downgrade which led to the Contingency planning team report on “sustainability” which recommended bringing in the Administrators. We are currently waiting with various degrees of patience for the Administrator’s recommendations.

Sustainability is the current big theme for the Department of Health. They are asking the basic questions are the hospitals safe now and in the future, and can we afford to run them. This often boil down to the single question, can we afford the staffing that we need to run the service safely. The answer appears in a growing number of cases to be “No”. The direction of travel that the Department of Health has chosen is to centralise acute care in big hospitals with small cottage hospitals providing local care.  This is the downgrade threat that we face in Stafford now.

The Bruce Keogh review was set up to make a judgement about the sustainability of individual hospitals within the health service, perhaps as a justification for rolling out more downgrades. As a starting point they took 14 hospitals with apparently high mortality rates based on the Jarman figures, and sent in teams to investigate.

It will not come as any surprise to those who understand the detailed picture at Stafford, if the Keogh review finds pretty clearly that Mid Staffs is certainly not a one off, and that a number of other hospitals are facing very similar challenges. We expect this.  

The national press obviously have a bit of a problem with this. After years of trashing Mid Staffs as the worst hospital there ever was we are now coming round to variations of “Stafford was appalling and the worst but all these others are just as bad”.  

We are already hearing that Sir Bruce has let it be known that his report does not use the 13,000 deaths figure that the press are headlining. Of course it will not. Robert Francis’s report tried to make it clear that there is a major difference between “excess death figures” that are a statistical product that is affected by the quality of coding which is very variable, and “avoidable deaths” which can only be determined by detailed case note analysis. “Avoidable deaths” which do of course happen in all hospitals, are generally going to be in small numbers. The media seem unable or perhaps unwilling to grasp this.

I personally expect that the report will have something pretty useful to tell us about the real problems that hospitals are facing. It might even, if Sir Bruce is brave tell us something about data quality issues. It is just rather unlikely to be anything very sensational.

I believe that Sir Bruce cares about the NHS, and is seeking to find ways to make it “safe and sustainable” for the next 20-30 years. His review is an essential tool for finding out something about the current state of the NHS, and I think his review method is far better for the hospitals than the highly disruptive process that Stafford was subjected to in 2008. It is however perhaps unfortunate that the review comes at a time when there are huge financial problems that the NHS must face and when there are also undoubtedly individuals and organisations that do not wish the NHS well.

When I began the first petition for Stafford in 2011 because of the night time closure of A&E I had two main aims. I wanted it to be clear to the people of Stafford that the problems of our hospital were by no means unique, and I wanted it to be clear that downgrading of our hospital was part of a wider plan to downgrade hospitals nationally, and that it needed to be the subject of a national debate.

When the Keogh report comes out tomorrow I expect both of these points to be satisfied.

I do not know what plans Sir Bruce has for the release of his report. I hope that he will prompt the debate that we need on the future of the NHS, and indirectly on the future of Stafford Hospital.

I hope he will also have something to say about the way that the media has handled his report.  Sir Bruce is a very mild mannered man, but he has every right to be furious!



Some more blogs on waiting for Keogh - Roy Lilleyhttp://t.co/4ht7ooYMUF

& Steve Walker http://t.co/KNfTCNyHY2
 

Waiting for the Administrators.

For all of us who are concerned about the future of Mid Staffs and the health service for our future this is an anxious time.

We are waiting, because at this moment there is little else that we can do.

I know that many people feel frustrated that they are not doing something now. Lots of people have sent in lots of documents to the administrators, and received back lots of letters that effectively tell us very little. The Administrators have had many meetings with key people aimed at helping them to work out where the solution lies. The expressions of interest from a number of different bodies are in and are being scrutinised.

Within a matter of days now we will have a much clearer idea of where the administrators are pointing this process and the public consultation can begin in earnest.  

People will be aware of a number of things in the background that do have a real bearing on what will happen here.

Bruce Keogh from DoH  is coming to the end of his review of the first wave of 14 hospitals who were identified as having potential problems. (they are looking at over 50). He will be publishing this soon and it is likely to make interesting reading.  I would expect to see indications that that the underlying problems that gave rise to the pressures at Stafford are pretty widespread. The TSA certainly understand this clearly already.

There is recognition that the A&E system throughout the country is on the verge of collapse. The descriptions of what is happening and why mirror what we saw in the detailed evidence to the public Inquiry here, so there is now much clearer understanding that the problems we saw here are part of a much wider problem.

The report from the college of emergency medicine makes interesting reading http://secure.collemergencymed.ac.uk/Shop-Floor/Professional%20Standards/Quality%20in%20the%20Emergency%20Department/

I wrote some thoughts on it here http://viewfromstafford.blogspot.co.uk/2013/05/everyone-is-now-talking-about-it-is.html

There is a lot of talk about integrated care. http://www.guardian.co.uk/healthcare-network/2013/may/14/how-to-enable-integrated-care?CMP The Staffordshire Partnership trust http://www.staffordshireandstokeontrent.nhs.uk/ is playing a pioneering role in trying to make integrated care a reality. We need to understand more about what they are doing, why it matters, and what the difficulties are.

Integrated care is being seen as the best way of relieving pressure on the Health service and making it affordable, whilst at the same time improving the quality of care for patients. Everyone agrees with the principle, but there are real difficulties in making it work in practise. There is potential for making Stafford the blue print to make integrated care work.

An interesting article from David Rose who works for the Mail on Sunday, and has been one of the leading writers on A&E downgrades raises serious questions on the effects that A&E downgrades may have on mortality with his report on Newark  http://www.dailymail.co.uk/news/article-2323141/Shocking-proof-Accident-Emergency-closures-cost-lives-Death-rate-jumps-THIRD-department-closes.html As it says a minister has ordered an investigation, and I am sure that the results will not be as clear cut as indicated here, but it does raise the question has anyone really done an effective impact assessment on the unintended consequences of A&E downgrades.

I have been asked to be one of the people in the HEIA team (Health equality impact assessment) Once I have a clearer idea of how this will operate then I am sure I will be looking for guidance from many people.

Another couple of comment pieces.

http://viewfromstafford.blogspot.co.uk/2013/05/is-administration-process-for-mid.html

http://viewfromstafford.blogspot.co.uk/2013/05/why-would-downgrade-to-stafford.html

 

Everyone is now talking about A&Es - It is a relief!

It is a relief.

Finally people from all over the country, people who understand the issues, are talking openly about the very serious difficulties that the country is facing with Accident and Emergency services.

 

The openness we are seeing here now can be seen as one of the positive side effects of the Francis report into Mid Staffs. Here hundreds of people were pilloried for not having noticed anything unusual at Stafford Hospital

What Clinicians saw in Stafford was a run of the mill hospital suffering run of the mill problems. For a while I think it was worse than that and there were reasons why the impact of an ageing population which is now being blamed for the national crisis in A&E was felt particularly strongly in Stafford. I will explore these reasons in a later blog.

 

Now nationally clinicians and NHS Managers, perhaps mindful of the way their colleagues were attacked for not telling us about the pressures they were under, are speaking out. They are telling us loud and clear that the system faces collapse, and they have identified the key matters of the ageing population, how acute care is funded, the lack of viable alternatives to Acute Care, and the way in which Primary, Secondary and community care currently fail to work together.

It is good that we are finally hearing these voices. Finding the solutions to the huge problems they are telling us about is going to be a major challenge to the fragile and imperfect systems that we have for making decisions.  It is also going to be a huge challenge to the media. We do absolutely need the media to help get across to people the complex challenges, and the difficult choices we may need to make.

Stafford is again going to find itself at the centre of a very important story as over the next few months we move towards a conclusion to the Administration process that will decide the future of our hospital. For those of us who are deeply involved in this we know that any structural solution that is hammered out is really only the very beginning of a long process that will aim to work out how to deliver the right care in the right place, and how to manage rising demand with shrinking budgets.

I hope that Stafford will attract the support of many people who have the expertise to try to make an integrated care system happen. We are the forerunners. What happens here will matter across the country.

Here is some of the mainstream media coverage of the A&E crisis.

http://www.guardian.co.uk/society/2013/may/15/accident-emergency-gps-hospitals-report

http://www.telegraph.co.uk/health/healthnews/10057269/Fifth-of-casualty-units-rely-on-junior-doctors-at-weekends-and-evenings.html

Here is the report on Emergency medicine http://secure.collemergencymed.ac.uk/Shop-Floor/Professional%20Standards/Quality%20in%20the%20Emergency%20Department/

I am also going to make an exception to my normal practice and include a video from @chunkymark.  Please do not click on this link if you are easily offended, because it does contain a staggering amount of swearing. 

I have included it because it really does indicate the fury that is felt by so many people in the country about the perceived threat to the NHS. http://www.youtube.com/watch?v=WGW5cxFXb6Q

I think that the government has a choice, It can work with the people of Stafford who are trying quietly to express their needs, and their fears, http://www.supportstaffordhospital.co.uk/marchpics.html or it can wait for the wrath of @chunkymark and the many who feel as he does.

 

Is the Administration process for Mid Staffs a done deal?

Earlier today I saw a letter that one of the Support Stafford Stafford campaigners had from the Department of Health attempting to explain the administration process.  It appeared a bit confusing, so I thought I would have another go at explaining what I think is going on.

In September Monitor raised concerns that the hospital may not be sustainable, and they sent in the Contingency Planning team to check this out.

The CPT did loads of work into looking at the whole health economy of the area, but they then had to follow their remit, which was to make a judgement about whether Mid Staffs in isolation and in its current form is “sustainable”. They came to the conclusion that it is not.

As part of the CPT process they had to define what was at that time called “protected services” but is now called “location specific services”.  This means the services that really do have to be delivered locally. It is not the same as the services that we feel that we want. There was informal consultation on this, but in the end it was the Clinical Commissioning Group who determined the very limited list of Location Specific Services.  This exercise seemed important at the time, but will probably not be in the end.

The CPT prepared a report to monitor, which concluded that the trust is not Clinically or Financially sustainable (we dispute some of the reasoning behind this) and that an administrator should be sent in. Their recommendations, based on Mid Staffs alone, were to close A&E, ICU and maternity, and essentially take away all acute services.  I am not sure if anyone expected us to meekly accept this, but of course we did not. 

It may have taken 50,000 people on the streets, and a unanimous motion from the borough council to convince the administrators, but they now see the wisdom of finding a more acceptable alternative.

The Administrators do not have to accept the CPT recommendations.. They are now looking for solutions that are right in terms of the whole health economy. This is necessary because all the neighbouring hospitals have trouble of their own. None of them have the capacity to take on the acute patients form Mid Staffs. The expressions of interest are in, and as I write this I know that the administration team is working through the night to scrutinise the bids.

I believe that what the administrators are looking for is a proposal that gives the option of bringing together at least two hospitals, which will allow cost sharing and skill exchange, but would allow acute services, maybe at different levels, to be delivered on both sites.

The Administrators will be coming up with their proposals and presenting them to the community within the next couple of weeks, and this will then form the basis for the consultation process.

Up to now it has been very difficult for the public to work out how best to communicate with the administrators. When the proposals are made public then there will be a great deal of engagement.

Speaking personally I have always been very clear that this must be genuine consultation, with the public being given very good quality information on what is being proposed and why.  I also think it can become the start of a much longer process where the public becomes an active player in designing the services we need for the future.

In Stafford we have been learning a thing or two about ourselves over the last few months, or years, and I think it is now very important to us that we are not seen to be passive recipients of what someone else tells us is “good for us”.

Speaking personally, I am very very weary with Stafford being seen as a problem.  I want the country to start seeing Stafford as the forerunner. Somewhere that is getting things right against the odds, and somewhere where we can set out to build a positive future for the NHS. 

I think we can do this!

Why would a downgrade to Stafford Hospital matter nationally?

 

Why would a downgrade to Stafford Hospital matter nationally?

What is happening in Stafford now will set the pattern for hospitals nationally in the future. It is ingenious the way that hardly anyone nationally knows the extent of the threat to their services.

What we are seeing here is a battle about what the health service should look like in the future. The responsibility for finding the way has been delegated to a team of administrators, led by Ernst & Young, but the conditions which determine what is possible are set by the government and the department of health.

Most people nationally will have had their perception of Stafford coloured by years of bad publicity, some based on highly questionable material. They will assume that whatever is happening here is just about Stafford. They would be wrong. In Stafford we have seen this coming for the last 4 years, and we know that we are being used to set a precedent.

Why did 50,000 people march in Stafford?

When 50,000 people took the streets of Stafford on April 20th for what was probably the largest ever march to save a hospital. We marched to demonstrate our support for the staff of the hospital, to show that we value this service and wish to keep it, and to blow the whistle on the threat to the future of the NHS. We marched because we know we are in a unique position to see this threat.

You will not have heard that whistle blowing, because frankly none of us expected the demonstration to be quite on that scale, and the press gave minimal coverage to this story, which many of them would have found inexplicable.

It is worth taking a look at some of the photos of the event to get an idea of what this means to a town the size of Stafford.  If you have seen them all before then take another look – just for inspiration!

The group who organised the march and run the Support Stafford Hospital campaign are unusual. It is a community led group that has the active support of all major political parties who are choosing to put aside their differences and work together. The borough councillors voted unanimously to reject the Monitor proposals on the Hospital. The campaign has the backing of all major organisations in the town including the churches which are playing a key role. If you take a look at the extensive video coverage of the march http://www.supportstaffordhospital.co.uk/rallyvids.html you will see Middle England marching! Many people in their 60s and 70s were taking part in their first ever protest. Stafford will never see anything like this again!

The question.of Sustainability

The Administrators after their first bruising public meeting with 600 residents have been at pains to make it clear that they are here not because of the supposed “history” of the hospital, but because of “future sustainability”.

 

This is the argument that is putting the future of around 60 hospitals throughout the country in doubt, and will change the way in which health care is delivered in every hospital in the country. There are genuine questions here. We should be having this debate, but we need to do so openly, honestly, and nationally.

Financial sustainability.

The key reason why the administrators are here is because the hospital is in deficit. It is deemed to be “not financially sustainable”.  With Stafford there are a number of unique reasons for that.

·         The two site hospital is currently running with empty wards that are a drain on resources.

·         Recruitment and retention of staff has been expensive because of the reputational damage.

·         A one off grant authorised by Andrew Lansley to help the hospital meet the unique costs of the years of public attention, and to regain public confidence, was later re-designated as income, which had a major impact on break even plans.

·         Patient choice and GP recommendations have been artificially suppressed by the reputational damage.

There is also another major reason which applies nationally. The Tariffs for acute care are set at a level where they do not cover the cost.

 

The role of tariffs

This use of Tariffs is deliberate. The DoH wants, probably quite rightly, to minimise the admissions to A&E and to focus on preventative care and care in the community, so they have used the Tariffs as a lever. The only trouble is that the community care is not there, and A&E admissions keep on climbing, with the result that more and more hospitals are getting into deeper financial trouble and are struggling to meet the demands on acute care with insufficient funding. The newspapers are full of stories which illustrate this problem.

The Hidden costs of downgrades

The pressure to close A&Es, which are the most unprofitable part of the NHS, is growing. The “temporary” overnight closure of A&E in Stafford in 2011 (it is still closed) has been accompanied by pressure on the ambulance service, which is now starting to give us some leaks from Ambulance service staff who know they are not coping well with this pressure. There is pressure on neighbouring A&Es where breaches of waiting times, trolley waits and ambulance waits are regular occurrences, pressure on ICU beds, which led to one lady being transported to Hereford where she died. The Hospital reports daily blips in admissions, with large numbers coming in in the morning when A&E opens, and just before the closing deadline at night. There are reports of people who delayed calling ambulances, rather than be sent to other hospitals, and sometimes these decisions have been fatal. The anxiety that many families feel, especially elderly people and families that have to rely on public transport, is considerable but hard to measure. For many people who moved to Stafford the presence of hospital services was a consideration. Businesses fear the knock on economic effects if we lose acute services, there are consequences to the entire economy of the town which we do not know how to calculate.  

There is a genuine question here. The accountants who are making the decisions on the future of Stafford are taking an accountants view. How do we know that they have added in all the hidden add on costs, such as the increased costs to the ambulance service? How do we know that they are giving the right weight to all the quality of life and quality of service issues that concern the people who will use the hospital? These people have no connection with the town. They are here to make a quick decision and move on, probably to the next hospital on the list. They are almost certainly acting in good faith, but this is complex stuff. There is plenty of room for miscalculation. They will have no accountability for the unintended consequences of their actions. 

The Myth of Local Decision making

Whilst the government would like us all to accept that “financial sustainability” is a matter for local Clinical Commissioning Groups, and local choice, the reality is that the choice is rigged. The commissioning groups have to live within means that does not cover the costs, and are therefore in the unenviable position of making unpalatable choices on the behalf of the government.

The fact that we are not talking about this nationally shows us just how ingenious the restructuring of the health service has been.  These “local decisions” are dismissed as nothing to do with the Government or the Secretary of State. Whilst they may get some column inches in the local press they are currently remaining invisible nationally. This needs to change!

With Stafford we have seen that the “local” bodies cannot come to a decision, so we have the Administrator instead. Potentially they could play the role of making the preferred solution of the community clear and work out how to make it happen, but will they do this?  

The power of the Clinical Sustainability arguement

Any policy maker who accepts the arguments for re-configuration of the health service and who has read what the national press & media has to say on Stafford Hospital over the last half decade could be forgiven for believing that this was going to be pretty straightforward. Any objective scrutiny of standards at Stafford must surely demonstrate that conditions at Stafford Hospital, and by extension other hospitals of a similar size would be poor, and that the people of Stafford would be only too happy to have their services removed and have safe services from bigger and better neighbouring hospitals. Once such a precedent has been set then of course other hospitals that can be seen as comparable could then be lined up for downgrade too.

This may reveal the dangers of policy built as a response to the media. The reasons why much of the press coverage of the last five years has been quite seriously misleading is a subject for much more detailed explanation at another time.

The 50,000 people who marched for Stafford, even those who accept press coverage at face value, clearly do not accept that whatever trouble there may have been seven years ago should be the basis for decisions about the services that we need now and for the future. People who used their vote to call for a public inquiry in 2010 did so because they expected answers and improvement. Not because they wanted to lose services.

Standards in Stafford Now.

From 2007 when the concerns about Stafford’s supposedly high mortality rate first surfaced the hospital has been focused on turning the problems around. Under the three different CEOs that have been in place since 2007, and despite the obsessive interest of the media and of the regulatory bodies (14 unannounced Care quality Commission (CQC) inspections in 9 months – all good to excellent) the hospital has reformed. It has learned the lessons of the Francis inquiries in the way that few other hospitals will yet have done. Mid-Staffs is now deemed to be one of the safest 20 hospitals in the country. The systems of governance that are in place are robust. Recruitment has been challenging but the hospital is up to strength. On virtually all measures the performance of the hospital is “better” than in the surrounding hospitals.

Clinical Sustainability. 

So the arguments about clinical sustainability take as the starting point that what is being offered by the hospital now is of high quality.

The question mark over clinical sustainability is essentially about size. These are some main factors which all apply nationally:

·         A small hospital remains vulnerable to small changes in staffing levels. In A&E or ICU the loss of a consultant or middle grade doctor, for holidays, sickness or changing job may tip the department from having an adequate staffing level to one which is below optimum levels.

·         The flow of patients in A&E is always unpredictable, and this will be more marked in smaller hospitals.

·         There is a national shortage of Consultants and Middle grade doctors which means that small hospitals will always struggle to keep numbers up to strength.

·         In a small hospital the volume of cases passing through the hospital may not be sufficient to ensure that the clinician has experience of the problems they will see and can deal with them in the best possible way.

·         There are some conditions where better results are achieved by hospitals with specialist staff and equipment, and the expense of these services means that they need to be delivered in a limited number of sites. 

·         Clinicians value the support of colleagues that they can call upon in larger hospitals.

·         In an increasingly litigious society having second opinions on hand is reassuring for clinicians.

·         There is a proliferation of different sub specialisations. There are fewer and fewer generalist consultants, who are capable of dealing with a mixture of different medical needs, and the increase in the number of “experts” means we need larger and larger catchment areas for hospitals to be able to support the growing numbers of specialists. This trend is now actively under question, and there is a strong argument for reversing it and recruiting more generalists, which would help to make the future of District general hospitals  far more secure. 

Balancing Clinical and Financial sustainability. – can it be done?

The difficulty is this. Mid Staffs is now one of the safest hospitals in the country because it has stopped doing some of the processes that need to be delivered in specialist hospitals, it has invested in staff, and it has invested in quality. By doing all of this Mid Staffs is now safe, but not financially sustainable, and if it takes the measures to make it financially sustainable then it may become clinically unsustainable.

The margins under which the NHS is currently required to operate means that most hospitals most of the time are walking this tightrope.

When the numbers of hospitals in declared financial or clinical difficulties began to rise into double figures I felt we had to try and understand the reasons for this.

·         The tariffs are set to deter acute admissions and to encourage integration.

·         It is only possible to make the tariffs work by radical change of the way the health service is delivered.

·         Integration is the right direction of travel but is not in place.

·         Making Integration work means improving communication between organisations.

·         It could take ten years to get this right.

The aspiration of Integration.  

When you study the transcripts of what when wrong in Mid Staffs the matter is pretty clear. When staffing cuts and bed cuts were carried out in Stafford, at the same time as cuts in Community care was happening then there was a build-up of patients in Stafford Hospital, who probably should not have been there in the first place and could not be discharged. The expensive care that they needed was not met by the tariff system that was designed to prevent such admissions. With squeezed budgets the costs did not meet the care needs. Care suffered.

The reports coming out of Stafford, and others from age concern, the Kings fund, the Alzheimer’s society, and the ombudsman all pointed in one direction. It is important to find better alternatives to acute care beds for frail elderly people. It is important to find ways to make primary, secondary and community care work effectively together.

Everyone accepts the need for the integration of services, but most people are concerned that the cuts to acute care are being carried out before the necessary preventative and re-enablement care is in place. It appears that the right thing is being done in the wrong order.

The Stafford Blue Print.

The recommendation to the administrators was to downgrade Stafford to the status of a “local hospital” which would offer no acute services. This is not acceptable to the 50,000 people who marched on 20th April.

The Administrators have indicated that the recommendations were based on the remit that the Contingency planning team were set, looking at Mid Staffs in isolation. The administrators are not bound by this, and are now looking at solutions which fit the needs of the wider health economy. This means looking at the demands and capacity of the neighbouring hospitals and suggests the creation of a networked solution.

There is currently active consideration of the amalgamation of Stafford and UNHS to create a hospital where the size will give economies of scale, and which could relieve some of the capacity problems currently being experienced at UNHS. The plan preferred by the community would mean keeping a level of A&E, ICU, Acute care and maternity at Stafford.

It needs to be considered that amalgamating Stafford and Stoke would bring together two trusts, each with their own financial challenges. Whilst amalgamation would bring about some economies of scale it should not be assumed that this will be adequate in the longer term.

Building sustainability means investment in making integration work. Initially double funding may be necessary in order to make this happen. 

We have been used in Stafford to being seen as the “NHS problem”. In Stafford we would prefer that it should be seen as an opportunity. Stafford can be the testing ground, to build a blue print for the future for district general hospitals.

The 50,000 that marched in support of Stafford hospital are an asset. They are people who understand a lot about the pressures on our health service. They take a realistic view, and if invited to do so will assist with the design of a health service that works for the future. It would be crazy not to make good use of this extraordinary resource.

It’s your turn next.

Just remember, whatever happens here is Stafford has implications for people all over the country. The changes that are happening, driven by the accountants in the Treasury, the DoH, Monitor, Hospital Board rooms, Health scrutiny committees, The Management consultants and the CCGs are bringing change to your health service. If you live in a small town like Stafford your hospital services may be obviously threatened. If you live in a community with a large hospital the threat will be less obvious, but the change is happening whether you see it or not.

Many people will watch from the side lines to see what happens. In Stafford we know that the Support Stafford Hospital Campaign is being fought on behalf of the whole NHS. You can help us by pressing for open debate on “sustainability” and what it means for your services.