Progress

This last week has seen two stories that both help to show us the scale of the difficulties being faced by the A&E system throughout the country.

The first was the resignation of Dr Mark Newbold, a highly respected CEO from the Heart of England Hospital, and the second was the major incident declared at Colchester hospital

Both of these centred on the problems in meeting A&E waiting times.

A&E waiting times have enormous political significance, they are a recurrent theme in health questions and PMQs, they are taken as indicators of the performance of the health service.  Because of this a considerable amount of pressure is placed on hospitals from further up in the system to meet these targets.  As the General election approaches we might expect this pressure to increase.

This is actually quite surprising, given that one of the big themes of Andrew Lansley was that pressure to meet targets was a problem that should be avoided.

So when a hospital is failing to meet its waiting time targets what does it mean?  - The immediate response of the media is generally that the hospital and hospital management bear responsibility for this. It is a problem to be fixed by the removal of a CEO or a manager or two – but is this right? Are we actually looking at something much more complex?

When people ask the right questions in cases of “failing” A&Es some of the following elements are common:

·         Difficulties for patients in accessing GP appointment,

·         Large numbers of elderly patients

·         Seasonal variations,

·         Major difficulty in recruiting Staff to A&E,

·         Over reliance on agency staff leading to unstable teams.

·         Bed shortages in the hospital,

·         Difficulties in moving patients from A&E into hospital beds.

·         Cuts in Community care funding

·         Difficulties in discharging patients because of lack of community care,  

 

What is interesting about Colchester is that the new interim CEO (What happened to the old one and why?) saw rapidly that they were not coping with the pressure and called in the CQC.  This is perhaps progress in that it is now becoming possible, at least  in certain circumstances, to say we are not coping and we need some support.  

One of my favourite articles on the way hospitals approach A&E Targets is this http://gpaccess.uk/evidence/ae-has-a-mountain-to-climb/ which indicates that there may be a range of different approaches to managing A&E times. We need to understand why some hospitals may be coping with the pressures better. 

The BBC Radio4 Today program on 17/11/14 had two slots on Colchester. The first talking to the MP Bob Russell. The second talking to a patient who had raised concerns about the attempts of hospital to send him home, the health correspondent, Hugh Pym,  and Dr Cifford Mann from the college of emergency medicine.

The question that seemed to be exercising Bob Russell and John Humpries was should this be seen as a one off, perhaps due to management problems, or should it be seen as a systemic problem.

Hugh Pym and also Dr Clifford Mann were pretty clear in their response to this.  A&E  is under pressure throughout the country. Dr Mann points out that this is in part due to the Tariff system which does not cover the costs of emergency care, and now includes financial penalties to hospitals that fail to significantly cut hospital admissions

What I would like to see is the media, and especially important programs like Today, asking better questions.  Whenever we get a crisis in A&E, and there will be many more, this needs to be seen not as a problem with an individual department in an individual hospital, but an indicator of what is happening within the health economy as a whole.

When the Mid Staffs public inquiry took place, I sat through nine months of evidence to try to understand why there were problems in A&E. The witness who finally made sense of all this for me towards the end of the Inquiry evidence was Dr Clifford Mann.  Answering the big issues that DR Clifford Mann raised is still the focus of much of the work that is going on in Staffordshire to try to move towards better integration of services.

With Stafford it took around five years for anyone to really understand the importance of what emergency doctors were telling us. With Colchester, the BBC have interviewed Dr Clifford Mann less than an week after the declaration of a major incident. So well done BBC Today – That is Progress!

 

Do you fancy a Prefab grave?

The front page of the local paper was dominated by a striking picture of men in hard hats and High vis jackets assembling a plastic prefab  grave block.

This is in many ways an elegant solution to the problem that the local grave yards are running out of plots and though there remains some land most of it is currently unsuitable for burials. The system works by digging a very large trench – in this case in sandy ground – and filling it with a plastic framework that divides the trench into 12 compartments which are then backfilled until required.

The prefab system will allow graves to be closer together , and will of course make a little more space for those who really wish for this option.

This is the engineers solution to what will be an increasingly pressing problem for many communities. As the population ages more of us will die. More options for disposal of the dead will be required.  

Aesthetically perhaps it is more of a problem. Many of us live our lives in closely packed little boxes, The prospect of waiting for judgement day in another one does not strike me as immediately appealing.

So what is to be done? Having been to quite a few crematorium services this seems to me to be about efficient disposal – but not what I would wish for.

I much prefer the idea of a green burial - http://www.woodlandburialground.co.uk/What-Is-a-Woodland-Burial/  but so far there are very limited options for this. It is OK if you live in Dorset or the Wirral. 

I have probably got a few years to go yet – but I hope that by the time I need one there will be some green burial sites nearer to where I live.

Most of our graveyards are a legacy from the Victorians.  They are full up. We need a different option now. 

Tidying – one cupboard at a time.

 

I have spent a lot of the last few weeks on a task I have put off for a long time – Tidying the house. 

It is not a simple matter. A quick whisk with a duster and vacuum would have been impossible and would simply have moved mess from one place to another.  This has been a much deeper exercise on creating order one cupboard at a time; Removing things that are no longer needed; Shrink wrapping things to store for later; Finding the right place to store art equipment or sewing equipment that have built up in different places at different times; Working out ways to make the house work better for each of the three individuals that live here together; Finding ways to make the house meet our changing needs.  

Whilst I have been doing this I have listened to the adrenaline fuelled build up to the European elections, and now the more thoughtful reflective beginnings of a response to the results.

This morning I listened to the interviews with Ken Clarke interviewed by Evan Davies, and Tony Blair interviewed by James Naughtie on BBC radio 4 today. It was clear to all of these men Europe must be made more engaging and we need to restate what it is actually for. I believe that they all saw the importance of the role of broadcasters and politicians in ordering information, to help us all make sense out of it. I sense a change in the way that the broadcasters are approaching their task, a new sense of responsibility. I hope that I am right.

I have also spotted the emergence of a man who I have held twitter conversations with in the past, as a key member of UKIP. This is Patrick O’Flynn who used to write as political commentator for the Daily Express and is now a UKIP MEP and director of communications. The important thing to understand about Patrick is that he is a man of some charm and some intelligence. There is a tendency on the part of many people in established parties to see UKIP as nutcases and racists. This will not do. 

Around 10% of the electorate went out and voted UKIP – we need to understand why. Around 60% of the electorate stayed at home, and we need to understand that too. We have less than a year in which we need to rethink the way in which we do politics. We need to see why things are in a mess, what no longer fits or works, find out what matters and how we can make our politics fit the urgent and changing needs of the whole of our population.

For me this has to begin by looking at the non voters, and the voters that choose UKIP. These are I think two sides of the same coin – each saying “the way decisions are made has nothing to do with me”.  This is a question that I have been grappling with ever since I first became involved in politics – more than a decade ago.  Few people have the commitment to turn up to party political meetings. Public meetings when they occur are rare events, and often fractious. Public Consultations often pass completely unnoticed by the public, because no one in the media or press recognises them as news, Canvassing on the doorstep is worthy but curiously old fashioned, and may mean at best a brief conversation once every 5 years or so.

There is a way forward on this. I think it is about creating the right spaces to store the ongoing conversations about a number of key issues, such as NHS, Social care, Employment, Communities, Energy, all of which have a local and a national face, and inviting people to play a positive role in this. Once the conversations begin then consultations and public meetings work better, and we can begin to support elected representatives to ask much better questions on our part.

Subsidiarity is an ugly word – but the principle is a good one. It is about having a place for everything and having everything in its place.  It is not a simple once and for all matter, it is a continuous process, changing with our changing needs.

For me creating a politics that works for us all has to happen one cupboard at a time.  

What is the right place to give birth?

 

The Daily Mail has led with a story that NICE are now recommending that more women should give birth at home or in Midwife led units. http://www.dailymail.co.uk/health/article-2626670/NHS-push-home-births-Second-time-mums-told-need-hospital-high-risk.html

In Stafford this is a major current issue as our consultant led unit, which has a very good safety record, is threatened with being downgraded to a MLU as part of the reorganisation of the deficit hit health service in our region

The reaction of the people of Stafford to the TSA proposals for our hospital was pretty clear. People want to give birth in a Hospital that is close by. They want a hospital that can treat birth as is should be for most people –a normal natural occurrence. They also want a hospital that will be able to cope with the complications that may develop for a small number of people during the delivery some of which can have serious and expensive outcomes.

In the case of Stafford the TSA initially proposed that there should be no more births in Stafford.  They then (possibly as a response to public opinion, or possibly because it was what they always intended) took the advice of the Health Equalities Impact Assessment group that there should be  a choice for women, and that therefore there should be a Midwife led unit in Stafford, and that there should also be more provision for home births.

The NICE recommendations are making the point that MLUs are as safe as consultant led units for the majority of births.  There recommendations are I think based on this report. https://t.co/RaMdTdLmZn

Whilst most people can accept the principle that Midwife led units are as safe as Consultant led units for the majority of low risk births, the argument against accepting an MLU is based on the experience that they do not tend to attract public support, they are therefore expensive to run and  tend to fail after a short time.

The people of Stafford pointed out that the argument to down grade the maternity unit from Consultant led to Midwife led was based primarily on numbers. There is a recommendation that units with less than 2,500 should not be consultant led. If the logic were to be applied nationally then these numbers would mean that a very large number of consultant led maternity units throughout the country would be under threat.

It is clear that the Prime Minister took this point. Many of the maternity units in marginal constituencies would be affected if the bulk of births began to be shifted to the super maternity units that are being proposed in a handful of big hospitals.  We can presume that it is because he understood this threat that he chose to called at the last possible minute for a review of the possibility of having a consultant led maternity unit in Stafford.

The timing of the NICE recommendations may be purely coincidental, but NICE does what arguably needed to be done before trying to use Stafford as a back door route to reconfiguration of the health service. NICE has put forward recommendations that would radically reshape the provision of maternity services.

The trend towards super maternity units has been driven largely by the cost and availability of consultants. (It is suggested that the EU working time directive is a factor in this). Closing small maternity units and asking people to travel long distances in labour is politically difficult, and it may not be the best option for many women. What NICE is doing is asking us to think differently about Midwife led units, seeing these not as simply an additional choice, but as the normal option for most women.

It is clear that currently there are not enough midwives in employment to give the one to one service that is advocated, but it does appear that there are substantial numbers of trained midwives who could, with the required funding, be employed to do the job.

Adequate numbers of midwives would allow for much better assessment of the risk levels for individual women, and could therefore ensure that the small numbers of those identified as high risk could be directed to the distant consultant led units that would be an essential part of networks of Midwife led units.   

I would also hope that detailed thought is being given to the best way to make consultant support available to Midwife led units and to home births.

MLUs – if they become the normal choice – can give us a safe and good place to give birth. We are told that this may help to prevent the over medicalization that can occur in consultant led units, and can give women a better experience 

Perhaps the major barrier to this as a solution is our attitude to risk. The last few years have focused so heavily on the risks associated with medical treatments that the public may find it difficult to think of birth as a normal and natural process for the majority of women.

So now people throughout the country are being asked the question – What is the right place to give birth?

Where does that leave us here in Stafford? Your guess is as good as mine.

How should we handle complaints?

Woke up to the today program on BBC this morning with discussion about the failings of the complaints system for public services, - with predictable references to Stafford.  In some ways this is useful - Francis himself was pretty clear that what we were dealing with here is an incoherent complaints system. When I listened to the 9 months of evidence it was clear that different people wanted different things out of a complaints system, and that what we had was not well suited to the unique mix of personalities that we had here.  It is also useful that the problems here are now being seen in the context of the much wider problems of complaints systems throughout the country and throughout our services.

Dame Julie Mellor is right in saying that it is a common human response to something difficult happening to you, that you want to ensure that this does not happen to other people.  To satisfy that very understandable desire then there has to be a way to ensure that "lessons are learned" and then applied. Maybe being in learning mode always means not feeling threatened.

For some people the desire goes further - they would like compensation for their suffering - and that is problematic - because as soon as you have a situation where there is litigation costs and lawyers involved then it is inevitable that a public service will become much more guarded in its response.

What I would really like to see is the introduction of the kind of no fault compensation system that exists in New Zealand, which is focused on meeting the needs of the people who may have suffered some kind of harm, rather than having to try and first establish that someone was culpable. 

For some people it goes even further - with the desire for "accountability" which sometimes starts to look like the attribution of blame.   If that could be separated from the issue of compensation then I think that this would become a rather more pure exercise.

Accusations against individuals really do need to meet the requirements of justice - which would require careful timely balanced investigation of claims with all parties involved being able to give their view of what happened and why.  This of course never happened here.  It is not a feature of the complaints system as it stands.

Many people, including Don Berwick see  the whole notion of "blame" as being counterproductive in bringing the best out of the people working in our services. I tend to agree with that. Certainly in Stafford when you start to look at the complex set of circumstances that led to conditions where sub-optimal service was likely to occur then it seems very difficult to me to be able to attribute blame to anyone.  Who for instance do you blame for Geography, which is such a key feature of the issues here.

What is certain is, as Dame Julie Mellor indicates, that there are some people who are deeply damaged by their experiences of the complaints systems, and there does need to be a very much better way of supporting such individuals.

I find it hard to say exactly what is required to create a perfect complaints system. It is so often going to boil down to the chemistry between the person making a complaint, who will often be in a distressed state, and the person receiving the complaint who may often be defensive on behalf of their organisation.  This is seldom the best kind of situation for a rational discussion of what actually happened and why.

Dame Julie Mellor is I think right in saying that people are reluctant to make a fuss. http://www.theguardian.com/society/2014/apr/07/older-people-nhs-care-ombudsman  I think that this may well explain a lot of things about problems at Stafford. Most people saw staff under pressure and did not want to add to their burdens. We may have been too polite.  It seems to me that help is required firstly to help people raise concerns and be given support before it reaches the complaint stage. The options being offered by organisations like patient opinion may well be part of the answer, and one of the initiatives piloted at Stafford, the hourly comfort checks, must be helping to deal with issues at the earliest possible stage and may help to explain the very high levels of patient satisfaction that now exist here.

When complaints do occur they may often become difficult very quickly. I feel strongly that there needs to be the back up of professional mediators to assist when a complaint appears to be becoming a source of conflict. 

If a complaint does have features that may lead to "accountability" issues, then of course in the interests of natural justice to all concerned then there does need to be a credible process to establish the facts at the earliest possible opportunity.

Making a complaints system work is an intractable problem. Many of the things that are being attempted are welcome Only time will tell if they will do the job.

Maternity services - what does the future look like?

David Cameron’s answer to Joan Walley’s question on Mid Staffs at PMQs 26/06/14 made it very clear to people in Westminster that he personally wishes there to be a consultant led maternity unit at Stafford.

This may explain the last minute addition to the Secretary of State’s statement on Mid Staffs. The TSA recommendations went through on a nod but the SoS also announced a review by NHS England, to look again at the possibility of retaining a consultant led maternity unit at the hospital.   

This strange amendment is much more important than it may seem. The results of this review may set the “direction of travel” for maternity care in this country.   

If all the review does is retrace the steps of the TSA process then we will end up in the same place, and this will put at threat a large number of smaller maternity units throughout the country, many of which are in rural constituencies.

Stafford’s small maternity unit has run for years. It’s reputation is good. There are years of detailed data to back this up. But, as one of the side effects of a sensational hospital scandal  the numbers of women choosing to have their babies at Stafford began to fall when the hospital struggled through the years of negative publicity, even though there was never any criticism of the maternity unit.  

The drop in the numbers of women choosing to have their babies in Stafford at this very particular point in the hospitals history is hardly a fair reflection of the potential demand from a growing population.

Decisions about Mid Staffs are taking place in the middle of a fierce debate between clinicians and accountants  on the future of maternity services.  Some clinicians favour concentrating specialist care for high risk births in a small number of large units, but they also wish to keep the majority of births local where possible, and are therefore also promoting the rise of Midwife led maternity units.

2,500 births a year is seen by the clinicians who support the centralisation of care as the bench mark. Anything less seen as too small to be consultancy led. When the TSA invited bids from service providers they made this point clear so it is unsurprising that no one offered this service. The TSA then used the fact that no one was offering the service in their public consultation, saying there would be no more births in Stafford.  The public reaction to this was predictably strong so the TSA modified their proposals to say there should be a maternity led unit.

As there has been no consultation on this revised proposal we do not know if it will work. The selected provider appears unenthusiastic, the commissioners worry about costs, and the public are still to be convinced that this is a good option.  Many members of the public have well founded concerns about transferring women who develop complications during labour from one hospital to another.  

It is worth taking a look at the history of magical 2,500 births a year, and look at why this figure is so important to the future of maternity services in this country.  

The report High Quality Women’s Health care

looks at the number of maternity units of different sizes.

Fig 2.4 shows us that there are 56 units with less than 2,500 births, which it believes are generally too small to be consultant led, then it goes on to point out that geography means that some of these will need to retain consultant led units.

The argument is that specialist care for high risk births requires a high number of consultant hours, and that the level of consultant cover to which the profession aspires to provide the safest possible service is simply unaffordable for smaller units.

The report also goes on to tell us that very large units, of 6000 to 8000 births a year, have the potential to become unsafe. They would need very high staffing levels and they would need to work in parallel with midwife led units to reduce the size.  

The report is also looking at the serious underlying problem which is that there are not enough midwives or obstetric consultants to go round.   

The aspirational figure of 2,500 was elevated by the NHS litigation authority into the minimum number of births necessary to meet the NHSLA’s notion of safe consultant led care . For the Litigation Authority medical errors in child birth are the basis for the most expensive claims for compensation, and it is clearly in the interests of the Litigation Authority, and the hospitals that pay their premiums, to minimise risk. 

The Clinical Advisory Group set up to advise the Administrator is new, Studying the minutes of the meetings in Appendix 6 to the draft report shows us a body feeling its way and uncertain of its role. The meetings were strongly guided by Sir Hugo Mascie Taylor from the TSA, and included prominent figures such as Professor Terence Stephenson from the Academy of Medical Royal Colleges, The professor is clearly convinced by the arguments for centralisation. The minutes list the participants. We maybe need to ask other clinicians if these are a good representation of medical opinion as a whole? 

The TSA gave the CAGs an estimation of birth numbers for Stafford, (an estimation that is disputed) and the TSA  also explained why costs ruled out a Midwife led unit. The CAGs did not see any evidence from the existing maternity unit and knew nothing about the standard of care actually provided.  

The experience of Stafford has shown us how important the CAGs are in signing off the framework for the reconfiguration of services. Should the review take another look at the membership of the CAGs? Are they representative, or are they drawn from those clinicians who already accept a centralising agenda? Are the members of the CAGs happy with the way that their advice has been used? Is the CAG the best way of deciding the future of hospitals, where the CAG members will have very limited knowledge of specific local issues?

56 consultant led maternity units have less than 2,500 births. My question was  “Will these guidelines apply to them”. The answer I got was that it would not apply to existing units, but Stafford would now be seen as a new unit, because it is under administration.

This might sound reassuring to other smaller hospitals until you recognise how many of them are currently in deep financial trouble, and work out that it is only a matter of time before they are also subject to a financially driven administration process.

Reports like High Quality Women’s Health show that Clinicians favour the development of a networked maternity service providing more services closer to home with the back up of a small number of specialist units. This is a vision that I believe most people would accept, but when the vision meet the TSA process what emerges are decisions made primarily on costs, where centralisation of care into huge maternity units is favoured because it is the most cost effective option.

The review needs to look at the tariffs paid for maternity. Do these actually cover the costs? Or are hospitals being forced to offer maternity as a loss making service? 

Tariffs have been used as a clumsy tool to bring about changes in the way the health service operates. The unintended consequence of this is that many hospitals are being driven into deficit and will face closure or downgrade.  Are we seeing too many decisions being made on the basis of finances rather than health needs and public wishes, are we seeing these financially driven decisions dressed up as “clinical excellence’.

One of the things that bothered me a lot about the administration process here is that there seemed to be so little attention given to the existing service. The exemplary record of the existing maternity unit was simply dismissed as irrelevant. The TSA did not choose to talk to the staff, instead relying in the “direction of travel” set by the CAGs under the TSA guidance.

The people of Stafford focused attention on travel times and the safety of mothers and children. Studies conducted in the Netherlands show a correlation between travel times and risk to mothers, It is undoubtedly the case that if people are being transferred in labour to Stoke that this will be an uncomfortable and at times unsafe process for many women. There are certainly risks involved, but this may be a risk that does not impact on the NHS Litigation authority in the same way as medical errors once a woman reaches a hospital does. If a mother or child dies or is harmed in transit then who is deemed responsible for this?  

Looking at Europe we found that the large maternity units that seem to be the preferred option to the top ranking clinicians in this country are seen as actively undesirable.  2,500 births in Germany would be seen as an excessively large unit, and the 6,000 plus births that would occur if all Stafford births were shifted to Stoke would be seen as unthinkable.

I think that the review backed by the Prime Minister will be a test for the Clinicial Commissioning Board. I am encouraged by the fact that the CCG are doing what the TSA failed to do and are talking to the staff in the hospital so that they can better understand the strengths of the service that is being provided now. I hope that this will help them move towards the right solution for Stafford, which may lead to the retention of an effective maternity service here.

David Cameron’s last minute intervention is significant.  He knows that maternity units matter.  Accountants and powerful Clinicians have strong views on the future of the health service, but Politicians from all parties instinctively know the dangers of forcing these changes through against the wishes of communities.

If we are embarking on a “direction of travel” that will lead to the closure of a number of valued maternity units around the country we need to know that we are doing so for the right reason.   Women will hope that the review that the Prime Minister has backed will take a close look at what we actually want from our maternity units.

 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464671/ distance and mortality.

http://www.ncbi.nlm.nih.gov/pubmed/21138515 netherlands study.

http://www.theguardian.com/society/2012/jul/14/maternity-units-care-doctor

https://www.npeu.ox.ac.uk/downloads/files/birthplace/Birthplace-Q-A.pdf

http://www.reform.co.uk/content/4307/research/health/maternity_services_in_the_nhs

http://www.rcog.org.uk/files/rcog-corp/HighQualityWomensHealthcareProposalforChange.pdf

In view of the difficulties experienced across all specialties, careful consideration should be given to the need for the current number and configuration of delivery units, the majority of which remain within a hospital setting.

The range of delivery unit size is illustrated in Table 2.4. There are 56 units delivering fewer than 2500 babies/year and 17 units delivering more than 6000 babies/year. The need for some of the small units will be determined by geography (Figure 2.1).39 The larger units will often have co-located midwife-led units. Experience suggests that units delivering more than 8000 babies/year

will require a significant increase in staffing and facilities. This is predicated upon a co-located midwife-led unit delivering 25–30% of the total number of babies.

High quality womens health care table 2.4  Size of maternity units.

 

The RCOG reports The Future Role of the Consultant31 and The Future Workforce in Obstetrics and

Gynaecology33 set out a case for delivering services through a network approach similar to that used for gynaecological oncology, ensuring that resources are centralised for the infrequent but complex high-risk cases and localised where possible. These reports state that service reconfiguration across sites and working practices may be necessary to ensure the delivery of optimum care, since not all hospitals will be able to provide the full range of obstetric and gynaecological services required. Managed clinical networks are able to make more efficient use of staff,44,50,51 but evidence on the financial impact is both scarce and inconclusive. The primary source of evidence on the effectiveness of neonatal networks is the National Audit Office report,37 which states that it is very difficult to conclude whether neonatal networks have improved value for money.

 

http://tsa-msft.org.uk/wp-content/uploads/2013/07/TSA-Draft-Report-Volume-2-Annexes-to-main-report.pdf  Page 97 draft report Annexes.  Gives list of attendees.

http://www.theyworkforyou.com/debate/?id=2014-02-26b.263.0

http://www.theyworkforyou.com/debate/?id=2014-02-26b.263.1

http://www.rcog.org.uk/files/rcog-corp/HighQualityWomensHealthcareProposalforChange.pdf 

http://tsa-msft.org.uk/wp-content/uploads/2013/07/TSA-Draft-Report-Volume-2-Annexes-to-main-report.pdf

 

 

 

The future of maternity units and the last minute review at Stafford.

We are having a review of the possibility of retaining a consultant led Maternity service at Stafford Hospital – so what does that mean?

The Secretary of State for Health essentially nodded through the TSA (Trust Special Administrators) recommendations on the future of Stafford hospital, but with one puzzling addition; The announcement of a review by NHS England into the possibility of retaining a consultant led maternity unit at the hospital. The Prime Minister has made it pretty clear that he would like this to be provided.

This small last minute addition to the recommendations matters. It matters a lot. The results of this review will determine the “direction of travel” for maternity care in this country.  

For those of us watching the process carefully it is puzzling. We do not know what the review is intended to achieve.  The first question is what is the scope of the review and how will it be conducted.

If the review simply retraces the steps of the TSA process then it is very likely that it will reach the same conclusion, and in doing so it will put at threat a large number of smaller maternity units throughout the country.  If it goes back a step further and questions in some detail some of the assumptions behind the TSA recommendations then it is possible that a review may reach a conclusion that is in line with the wishes of many communities, and the many politicians that represent them.   

To understand the question it is useful to back track on what has happened here. Stafford has been running a small maternity unit for many years. Its results and its reputation are good and it has years of detailed data to back this up. This is something that the TSA did not really take into account at all.

The numbers of people choosing to have their babies at Stafford began to fall when the hospital struggled through the years of negative publicity, even though there was never any criticism of the maternity unit.  It is very hard to judge if the numbers of women choosing to have their babies in Stafford at this very particular point in the hospitals history is a fair reflection of the potential demand from a growing population.

The numbers fell below the number of 2,500 births a year which has been elevated by the TSA process to a magical number.

The model that the TSA put forward to potential service providers pointed out that the unit was below this number, and this was sufficient to ensure that no providers made a bid to provide a consultant led maternity service. Initially the TSA took the view that there should be no more births at Stafford. They modified this in response to the public demand, leading to the offer of a midwife led maternity unit, which is better than nothing, but is not popular with the service provider and may not meet with the approval of the public. The heightened sense of risk that clearly now exists in Stafford may mean that Stafford women will remain nervous about what may appear to be a risky option. They are unlikely to have the detailed information to allow them to make a fully informed choice.

It is worth taking a look at where this magical 2,500 came from.

The NMC did research which looks at maternity units and came up with an aspirational figure of the numbers of consultant hours that should ideally be available to maternity units of different sizes.   Larger units should move closer to having 24/7 consultants, though most including the unit at Stoke which will now be the main option for Stafford women does not and probably will not have 24/7 consultant cover.

The NHS litigation authority took the aspirational figures from the NMC and came to the conclusion that level of consultant cover was a key element in safety. For the litigation authority medical errors in child birth are the basis for the most expensive claims for compensation, and it is clearly in the interests of the Litigation authority, and the hospitals that pay their premiums, to minimise risk.  The NHSLA elevated the aspirational 2,500 figure to the number of births that hospitals should have in order to provide the number of consultant hours necessary to satisfy the NHSLA requirements.

The NHSLA figures were used by the Clinical Advisory Groups (CAGs) set up by the TSA in order to set up the model that was submitted by the TSA to service providers.

The membership of the CAGs is something that perhaps the review needs to revisit.  Were the CAGs an entirely objective and representative group of clinicians, or did the majority of them already accept the centralising agenda that seems to be the fashionable “direction of travel”.  I would also like to know to what extent the members of the CAGs expected their advice to be used in the way that it was? The minutes of the CAG meetings indicate a division of opinion.

One of the questions that I asked as a part of the HEIA Health equalities impact assessment group is what would the impact of the 2,500 rule have on the many hospitals that currently have less than this number of births. I was told that this would not apply to them as they were existing units, and the Mid staffs unit because the hospital was being dissolved counted as a new unit.  This might sound reassuring to other smaller hospitals until you recognise how many of them are currently in deep financial trouble, and work out that it is only a matter of time before they are also subject to an administration process.

I also had questions to ask about the tariff for maternity. Does this actually cover the costs? Or is maternity a loss making service for a hospital to offer.

One of the things that bothered me a lot about the administration process here is that there seemed to be so little attention given to the existing units. The good or even exemplary record of the existing maternity unit was simply dismissed as irrelevant. The TSA did not choose to talk to the staff, instead relying in the “direction of travel” set by the CAGs.

As the attention of the people of Stafford turned to the fate of the Maternity and Paediatric units the issue of travel times and maternal safety became a major focus of attention. Studies conducted in the Netherlands show a correlation between travel times and risk to mothers. It is undoubtedly the case that if people are being transferred in labour to Stoke that this will be an uncomfortable and at times unsafe process for many women. There are certainly risks involved, but this may be a risk that does not impact on the NHS litigation authority in the same way as medical errors once a woman reaches a hospital does. If a mother or child dies or is harmed in transit then who is responsible for this?  

Looking at Europe we found that the large maternity units that seem to be the preferred option to the top ranking clinicians in this country are seen as actively undesirable.  2,500 births in Germany would be seen as an excessively large unit, and the 6,000 plus births that would occur if all Stafford births were shifted to Stoke would be seen as unthinkable.

I think that the review will be a test for the CCG. The CCG has I believe done its best to rise to the public interest in Health in Stafford and to begin the task of working with the public to create the right solutions for the future. The CCG stress that they are the commissioners, and they have also indicated that a “creative solution” to the current  problem may be available.  I am with them on this. I am also encouraged by the fact that the CCG are doing what the TSA failed to do and are talking to the staff in the hospital so that they can better understand the strengths of the service that is being provided now. I hope that this will help them move towards the right solution for Stafford, which may lead to the retention of an effective maternity service here.

The last minute intervention of the Prime Minister in the Stafford situation matters. He is a politician, and he therefore knows that the opinion of the voters matters. Maternity units matter.  If we are embarking on a “direction of travel” that will lead to the closure of a number of valued maternity units around the country we need to know that we are doing so for the right reason.   I hope that the review that the Prime Minister has backed will take a close look at what we actually want from our maternity units. .

 

 

 

 

The Big Question - on Hospital Downgrades

The Big Question on BBC 1 this morning took a look at Hospital downgrades.

Hospital downgrades are always contentious, and they are starting to shape up to be one of the major flash points for the next election.

The program gave us in a nutshell the key reasons why this is going to matter.  The leading contribution was from Professor Terence Stephenson.  He represents the top ranking clinicians who are driving the re-configuration of the health service.  These are the people to whom Andrew Lansley handed power over the health service with the Health and Social Care act.  Professor Stephenson is head of the royal college of Paediatricians https://www.fmlm.ac.uk/terence-stephenson and he believes strongly in the need to centralise the medical treatment of children.

We also heard from Julia Manning who is part of the “independent think tank” 2020 health which has strong links with the Conservative party and with the insurance industry. Here is an article about Ms Manning http://www.opendemocracy.net/ournhs/andrew-robertson/2020-health-working-with-lord-howe-to-make-nhs-auk-plc-asset Ms Manning is all in favour of creative thinking to do health care differently – making it fit for the challenges of this century.   

We heard from Clive Peedell. Clive is an Oncologist, who is co- founder of the NHA party and has just announced that he will be standing for election against David Cameron in Witney, making sure that the NHS will be a central issue in 2015.  Clive speaks out for the role of generalist hospitals, and calls for adequate funding of the NHS.

Caroline Molloy who is the editor of “Our NHS” http://www.opendemocracy.net/ournhs was there to speak on behalf of the many hospitals that are facing downgrades.

The program was filmed at Peterborough which is in special measures under Monitor and where it looks increasingly likely that the hospitals deep rooted financial problems may be resolved by private sector take over http://www.opendemocracy.net/ournhs/caroline-molloy/peterborough-hospital-nhs-and-britains-privatisation-racket

Perhaps no one really knew what the results of the Health and Social Care Act would be, but we are starting to find out.

The confusing process that we have just been through with the Administrators at Stafford shows how it works.   The Secretary of State has given the power over the health service to clinicians – the CCG.  If, as increasingly happens, they hit a financial problem in the management of the hospitals that they cannot resolve then this means calling in Monitor or the TDA who will involve one or more of the big 4 accountants to act as TSAs.  The Accountants take the advice of the CAGs or clinical advisory groups which are newly created bodies packed with people like Professor Stephenson. The CAGs advise the TSAs on a model of care which is appropriate for the hospital. This is generally likely to include a strong element of centralisation.   The TSA can then invite bids from care providers willing to provide the model of care that has been stipulated, for the money available. Once the bids are in – and this is a process shrouded in secrecy, there is a consultation with the public, which the TSA seems to be at liberty to brush aside.  Monitor and the Secretary of State then rubber stamp the final recommendations.

All the stages of the administration process are controlled by the administrators who appoint the various experts, and minute the meetings. 

In a process that looks like this it is unsurprising that the end result is that there is a recommendation that there should be a downgrade.

The power over the future of the NHS is now in the hands of accountants and of a small number of powerful clinicians who strongly support centralisation.

These clinicians are probably acting in what they consider to be the best interests of patients, but they are not politicians, they do not appear to have a clear idea of the major political impact that their decision will have, and they are probably unprepared for what will happen when politicians across the country begin to wake up to the scale of the threat.

There are good reasons for doing things differently in the NHS.  One of the frustrations for those communities caught up in the process of reconfiguration is that the issues have not been aired nationally.  They need to be.  To make the NHS work for the future, to gain public support for any changes that have to be made it is essential that the public are openly and honestly given the information they need in order to  choose the changes and work with the clinicians to develop the systems we need.   

The paternalistic nature of the processes we are seeing now will simply not work.