Looking to the Future

Today we see national headlines on the sharp increase of over 90s being taken into A&E by ambulance, over the last 3 years. http://www.theguardian.com/society/2014/jan/29/use-ambulances-over-90s-hospital  It is good that finally we are reaching a point of understanding the huge and growing problems our hospitals face. 

Here in Stafford, where we have an unusually large number of elderly people, and we road tested the wrong solutions by cutting social care beds and hospital beds at the same time, we reached this crisis a little earlier than the rest of the country. Now we can see more clearly that the root problems are national. We can see that a number of the people who do end up in A&E would be better not being there, but come because of lack of suitable alternatives. 

There is no shortage of theories on the root causes of the increase:

Most people accept that people are living longer because of better drugs, & better surgery. This is a success story, but older patients have the potential to develop a more complex mix of illness, and need a different kind of care, something we have only just began to think through.  

The Conservatives say that the problem lies with the changes to the GP contracts leading to less availability of GPs out of hours.

Fingers have been pointed at services like 111 which mean that Nursing homes phoning for help with a sick resident are frequently being advised to call an ambulance.  

Labour points to the huge cuts that have occurred to social care, which has meant that many elderly people can no longer access the support they need in their own homes, or in day care centres, and this may mean that they are more at risk of becoming severely ill. 

Personally I am pretty bored with simplistic headline points.  The reasons for system failure are complex and will vary from place to place. And the solutions need to be built on an understanding of how the different bits of the picture fit together. 

The Effects are apparent  

 

The pressure point is always A&E. 

 

The pressures in A&E make recruitment of doctors difficult or are times impossible, leading to the use of agency staff, which can be problematic, and is certainly expensive.

The bed blocking and lack of community beds leads to such problems as breaches in 4 hour waiting times, A&E closures and Ambulance waits 

Lack of beds causes inappropriate use of Intensive care beds, contributing to a national shortage of intensive care beds. 

Pressure lead to cancellations in elective surgery, causing distress or worse to sick patients.   

        

All of this shows up in the indicators that the hospitals routinely measure and in the statistics that are used to make the political weather.  

There is political pressure to seek untried radical solutions. 

The high political profile of problems with the running of A&Es leads to a natural quest for magical solutions, and therefore to the use of management consultants. Many of which are to be found in this article on the way the NHS is now being managed http://t.co/zsf9FiYsLX

 

Politically the two biggest worries are the escalating costs of A&E and acute care, and public perception.  (This interview with Jeremy Hunt http://m.hsj.co.uk/5067494.article indicates how much importance he lays on the public perception of quality)

The expert advice on how to square this circle and give better quality for less outlay, is to reduce the demand by centralising service to centres of excellence with the hope that this will discourage “unnecessary” attendances and admissions.

The theory is that Hospitals will refocus on providing  acute medical care, The hope is that patients will perceive this as a better service because they are being offered better preventative services (to be developed) and better follow on services in the community (to be developed).

There is talk of rapid response services to help keep people at home, and different forms of telecare and digital interventions to help monitor people’s conditions without them needing to travel to surgeries or hospitals. (These novel solutions are to be developed)

Who is in Charge around here?  

The NHS is still reeling from the latest reorganisation, and the different organisations are still finding their own feet. 

The roles of the CCG, the Partnership Trust, the Hospital Trust boards, the patient participation panels. the Health and Wellbeing board, The Borough Health scrutiny board, The County council Health scrutiny board, or the Joint accountability board, let alone the CQC, Monitor and NHS England are all pretty unclear, certainly to the public, and maybe to some of the participants.

Communication between organisations may be less than perfect, and may be made problematic by the fierce competition for scarce resources, and for the need to shake off blame when the cracks in this imperfect service show up. The scale of the challenge and the potential problems are covered in this article http://www.theguardian.com/healthcare-network/2014/jan/28/integrated-care-needs-people?CMP=new_1194&et_cid=53286&et_rid=8769516&Linkid=http%3a%2f%2fwww.theguardian.com%2fhealthcare-network%2f2014%2fjan%2f28%2fintegrated-care-needs-people%3fCMP%3d%%_p_cmp%%

The channels for raising complaints when there are gaps between services are unclear, which will probably result in increased caseloads for MPs and Councillors, with cases that they cannot hope to resolve.  

Are we asking the right people?

The most influential people in determining the future shape of our Health services are organisations such as Monitor, which are packed with accountants and management consultants   http://t.co/zsf9FiYsLX  

Monitor have created the Clinical advisory Groups, or CAGS, which are selected groups of clinicians. These advisors, starting with the assumption of the budgetary cuts, in meetings run and recorded  by management consultants appointed by Monitor, set out the “direction of travel” that is the road map used to determine the future of individual hospitals. 

The models that the CAGs provide to the TSAs and to CCGs considering the future of services in their areas do not always fit well with the experiences of the people delivering care on the front line.  In Stafford we were surprised when the process did not involve contact with the front line, resulting in some very inaccurate assumptions being built into the process. 

Channels of Communication between TSAs and the front line, or CCGs and the front line seem poorly travelled.

There is plenty of talk of using new technologies to improve care and bring it closer to people. Is there enough communication between the people who understand care needs and the people who understand the technologies to make this happen? 

Great Expectations. 

In a few weeks we will know, at least in outline, who is to be given the responsibility for our hospital services in Stafford. The likely outcome is that some acute care will shift to Stoke, with the promise that the majority of care will be delivered in Stafford, or potentially even closer to people’s homes. 

I would love to say that this has been such a thorough process that we will be getting the best possible solution for our community. I am unable to say that. The process has been deeply frustrating,, and few people in the community believe that it has produced the right results , but the process rolls on regardless, and the announcement by the Secretary of State will mark a new chapter in our health service. 

The population of Stafford are now far more aware of issues within the health service than the majority of the country. We are pretty wary after the last six years of “process” inflicted on the community and we will be watching carefully. 

The promises that individuals in the community will not suffer as a result of the changes will need to be kept at the front of our minds, and they will need to be met. 

How the rest of the country will view events at Stafford remains to be seen. There has been a tendency to accept the apocalyptic vision of Mid staffs presented by the papers, something that does not fit the experience of the Stafford people, and over the last few years many people in the Health community have been happy to accept Stafford as a one off, and therefore nothing to do with them. Better informed people know that this is not the case, and if the reconfiguration of Stafford goes ahead as expected then I expect many other hospitals to follow us down the path laid out by the CAGs

An Opportunity 

The Government is keen to make Stafford disappear as an issue.  Because of that they have been prepared to pump a considerable amount of money into the area in order to help the CCGs commission a service with a strong community base that will work for us, whilst at the same time complying with the “direction of travel” set by the CAGs.  If this goes forward then I think it is in the interests of all if  people with specialist knowledge of community based services share their knowledge with us. 

This is an opportunity.  We can if we set our minds to it begin to create a health service for this area that will meet the future needs of our population. We have the potential to be a blue print for the future of District General Hospitals and also for Community based health care. Achieving that is going to take determination to communicate well.

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We have been through a difficult few years, in which communication within the community has not always been easy. Last year 50,000 people marched in Stafford, showing an astonishing commitment to the idea of the NHS. In the year that has followed the staff of the hospital and the people who use the services have had a chance to find their voice. The energy present in the public meetings over the last year has often been on the explosive side but if it is harnessed well, it can achieve a lot.

I do not know what Jeremy Hunt will decide in the next few weeks but I do know that collectively this community has the power to build something good. I hope he will give the right signals to make that possible.  

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