And Now - Hinchingbrooke

Over the last few weeks we have seen dozens of hospitals declaring major incidents. As Chief executives take to the airways a consensus has emerged. The same words are heard.

Accident and Emergency is coming under “unprecedented demand” and the patient flow through hospitals becomes impossible because of “delayed discharges”.

Coincidentally or not these represent the political explanations of the phenomenon from Conservatives and Labour respectively.

To me the point where the rash of major incidents became predictable came with the resignation of one of the most respected CEOs Dr Mark Newbold, some weeks ago.  He appeared to go because of the pressure applied from above to meet targets that had effectively become impossible to meet, for reasons beyond his control.

I think what we may be seeing with the contagious major incidents is a sign both of the instability within the wider health economy, and the refusal of management to continue to carry the can for problems that lie outside their hospital walls.

Hinchingbrooke was effectively the test bed for a private sector body running an NHS hospital. This presupposes the possibility of being able to do the job and make a profit. Because of the very peculiar structure of the tariff system this is only possible if there is the right balance between elective care and emergency care.  The announcement that Circle is withdrawing from the Hinchingbrooke contract , because of unprecedented demand for A&E and the problem of delayed discharges is about as clear a signal as we need that making a profit from the NHS at the moment, given the structure of the Tariff system and the state of social and community care, is simply not a realistic possibility.

Controlling spending within the NHS is a perfectly legitimate aspiration. Managers have a role to play in ensuring that money is spent well, but if we expect hospital managers to provide answers to the incoherent structures of our health and social care systems then I think that we are likely to be disappointed.  If we want to judge our hospitals on their "financial sustainability", which is what has been happening for the last few years then health service managers need at the very least to have a climate that makes sustainability possible.

The current crisis is a useful wake up call. What we need from our politicians is the courage to ask difficult questions, not least about funding health and social care, and to provide the framework for the different organisations involved to begin to work towards a more coherent system.

There are just a few weeks for politicians to give clear signals that they intend to do so.

 

 

 

Some of the coverage on Hinchingbrooke.

http://www.theguardian.com/society/2015/jan/09/circle-exit-private-contract-hinchingbrooke-nhs

http://t.co/0pDEtH4IvD

http://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news/franchising-hinchingbrooke-peterborough-stamford-hospitals/

Understanding the A&E Crisis in 2015

I usually find myself feeling sympathy with anyone getting the John Humphrys treatment. This extended to Jeremy Hunt working hard to explain why increasing numbers of hospitals are declaring major incidents, because their A&Es reach the point of not being able to cope with demand.

The ground was well prepared by Clifford Mann the spokesman for the College of Emergency medicine, who raised the crucial matter of funding for A&Es, where the tariff does not cover the costs of treatment. This effectively means that hospitals cannot afford to recruit and retain permanent staff and end up with the pernicious and expensive dependence on agency staff. http://www.bbc.co.uk/programmes/p02gcq7d

A manager from one of the hospitals which had declared a major incident also explained the pressures that he was experiencing.  These included: All the bed spaces full, all the overflow beds full, Discharges to community care beds or home difficult, Surrounding hospitals already on ambulance divert and therefore unable to accept a divert from them, the sheer impossibility of getting more staff, as all available agency staff were already spoken for.

Jeremy Hunt of course talked about the extra nurses that they had been employed, and the extra winter funding he had authorised, and he also talked about the growing demand from aging population. He was also gracious about the heroic effort by staff under difficult circumstances.

Jeremy Hunt did not mention the request to Chief execs of Foundation Trusts to see if they have any clever ideas for fixing the problem, but then the results of that plea are not due back to him until later today.

The problems are of course complex, and involve a whole series of organisations trying to find ways to work together to meet the needs of a rapidly aging population. Anyone honestly trying to get to grips with this should have our sympathy, and our support.

The point in the interview where Jeremy Hunt lost my sympathy was when, feeling the pressure, he used the Mid Staffs card. I do understand that in the face of the persistent and growing problems within the NHS the temptation to say “well at least it is not Mid Staffs” is a strong one. What frustrates me is that if we had learned the real lessons from Mid Staffs we might not now be facing a crisis throughout the NHS with so little apparent preparation.

What I think is still escaping Jeremy Hunt, though I think it is understood by growing numbers of health professionals, is that the parallels between the problems that actually existed at Mid Staffs in 2007, and exist in the NHS as a whole now, are very strong.

Staffordshire is a part of the country where people live to be old, and many young people move away for work, so the population here got old a little before it did in other parts of the country.

The “new” element of patient choice led to competition between hospitals for staff and patients. Smaller hospital surrounded by other larger ones found that they were under increasing pressure. More of the profit making elective care drifted away to the bigger neighbouring hospitals, leaving Mid Staffs and other small hospitals increasingly trapped into loss making emergency care.

The fashionable solution of the time, which seems since to have lost its appeal, was for the hospital with the active encouragement of the Department of Health, to become a foundation trust. This was probably the wrong answer. The process of becoming a foundation trust forced the hospital to attempt to balance its books, which it could only do by cutting beds and cutting staff. The application process would certainly not have encouraged the hospital to appeal for help when it needed it.

An additional factor, which was oddly never mentioned in the Mid Staffs inquiry, is that the local authority, faced with the increasing costs of its aging population, took the questionable decision to close most of its loss making care homes, on the basis that public consultation had shown that the majority of people would wish to remain in their own homes. The level of community care needed to support this aspiration did not and probably still does not exist.

With the aging population, cuts to beds, loss of permanent staff, growing dependency on agency staff, and a rapidly escalating “exit block” problem all of the pieces for an A&E crisis were in place. All it took to tip the balance was winter.

If you want to understand what the pressures were like for the staff and patients read this excellent account of what happened when a a neighbouring centre of excellence tipped into a black alert last week. http://t.co/dCR8g4bCuj

There is one substantial difference between the pressures at Mid Staffs in winter 2007 and the pressures on the NHS now. That is the wider awareness of the scale of the problem. In 2007 the staff at Midstaffs were isolated at the centre of a storm. As the hospital beds and the overflow areas filled up and bed blocking became critical they and their managers should have been in a position to call for help, but if they did then no help came.

In Mid Staffs the Emergency staff, and the managers took the blame, for a situation that was entirely beyond their control. I think what we are seeing now, as hospital after hospital declares a major incident, is a refusal to be the fall guys for a hugely complex major problem that is the responsibility of us all.

Mid Staffs is of course a terrifying symbol, largely because of the persistent mis-use of the excess death figures – which never appeared in any report, and do not reflect the facts. I have no doubt at all that there were days in 2007 when the A&E at Mid Staffs, and the emergency wards attached were unpleasant places to be, both for staff and for patients. In part the problems were exacerbated by the pressure to meet waiting time targets, and the unintended consequences of this pressure. The breaches of A&E waiting times, which today’s figures show us http://www.bbc.co.uk/news/health-30679949?ns_mchannel=social&ns_campaign=bbc_breaking&ns_source=twitter&ns_linkname=news_central are now occurring routinely throughout the NHS are just one indication of the huge pressures that staff are experiencing now, which inevitably has an impact on patient experience.

This winter it is much too late for magical solutions. Getting through the pressures is going to take patience and tolerance from everyone. Some of the national papers are requesting stories from people who have experienced A&E and I am sure that stories will be found. It would be great to see papers also exploring some of the potential solutions.  

What I would really like to see, (I am not holding my breath), is the simple recognition that solving these deep problems is difficult, and that we could do better by ending the blame game, trying to understand the complexity, and work towards potential solutions. Understanding the pressures that caused problems at Mid Staffs just a little better would be an excellent place to start.

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.