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.
Monday, 14 April 2014
Wednesday, 5 March 2014
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.
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.
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.
Monday, 3 March 2014
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. .
Sunday, 2 March 2014
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.
Friday, 21 February 2014
The courts will fine Mid Staffs on the Astbury case
The Courts will today decide
how much to fine Mid Staffs foundation trust for its failings in 2007 in
the case of Gillian Astbury.
The timing of course will upset some people as it always inevitably
seems to be the case that there is a bit of bad news about the history of Mid staffs
immediately before the announcement of something to do with downgrading
services. The fine will be effectively
the last chance to punish the trust before it is dissolved next week.
The Astbury case formed one of the two main cases that were
the backbone of the Mid Staffs Public Inquiry. It involves a very ill lady with
complex medical needs, including diabetes
and dementia, who died because she did not get the insulin that she needed.
This is of course shocking. What did
also shock me greatly is finding out how extremely common the issue of poor
management of insulin in hospitals actually is. A study by Birmingham University
estimated 600 deaths a year occur because of these problems, and also offered
software that would help hospitals avoid missing insulin treatment, an offer
that the DoH has not so far taken up.
The coverage of the story on 21 Feb 2014 by BBCR4today was
very interesting. (sorry they have not
put up a clip – but it is worth taking the trouble to listen to the interview) Emma
Jones, the solicitor for Leigh Day, who has been supporting her client in
taking the Astbury case through the courts stressed that her client does not want
there to be large fines for the hospital. They want care to improve, and other hospitals to be warned, which of
course everyone wants.
It will be interesting to see if the courts take into
account the wishes of Leigh Day’s client when they announce the level of the
fine. A token amount would probably be
the right answer.
The BBC picked up on the absurdity of one public body fining
another, and also questioned if it was reasonable to keep the focus on Stafford
for what is such a widespread problem. The BBC also picked up on the fact that the
trust continues to have difficulty in recruiting staff, in part because of the
constant drip feed of bad news.
Next week 20 nurses, volunteers, come down from Stoke, to
help resolve the staffing problems at Stafford. They will be very welcome, and
it should be the beginning of regular exchange of staff between the
hospitals. This is really good news. Let
us hope it is the start of a bright future for Healthcare in Stafford and
Stoke.
Wednesday, 29 January 2014
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.
.
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.
Thursday, 19 September 2013
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.
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