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 Private Eye

September 1, 2010

Dr Phil’s Private Eye Column, Issue 1270 September 1
Filed under: Bristol Pathology Inquiry,Private Eye — Tags: , — Dr. Phil @ 6:01 pm

A solicitor writes…

MD has received a disturbing e mail Huw Morgan, a Medical Protection Society solicitor representing a pathologist who has given evidence to the University Hospitals Bristol (UHB) Pathology Inquiry: ‘It has been alleged that it was he who provided you and/or Private Eye with the information regarding such services which appeared in the 2009 issue(s) of that magazine, shortly before the Inquiry was set up. This is not the case; however he is concerned that such any such mistaken belief on the part of Panel members might be an adverse factor in their assessment of the evidence which he has given to them.’

MD has never had any contact with the pathologist, and the public money used to fund the Inquiry (£464,000 to the end of June 2010) would be better spent focusing on the specific allegations of misdiagnosis in specialist adult and paediatric pathology. Equally important is to ascertain whether appropriate action was taken to investigate the allegations. Concerns about the lack of specialist paediatric pathologists date back to 2001: ‘Over the next 2 years paediatric work was done by adult pathologists with disastrous results, particularly in the fields of childrens’ cancers and Hirschsprung disease.’ An overseas paediatric pathologist was appointed but he was reported to the GMC and removed his name form the medical register in 2004 to avoid investigation.

Allegations about the misreporting of specialist adult pathology were first raised in 2004, and NHS Bristol, the lead commissioner for UHB, has known about concerns at least since October 2007. Detailed allegations were put in writing ‘through the correct channels’ in 2007 and 2008, and the Royal College of Pathologists were aware of them long before the inquiry prompted by the Eye’s exposure in June 2009. UHB is a Foundation Trust, largely divorced from central control and supposedly accountable to its patients. It has ordered and paid for its own inquiry, agreed the terms and the statistical analysis and controls how much of the final report enters the public domain. This story is as much a failure of management as of pathology. In the 15 months since the first Eye column, UHB’s chief executive has resigned, the medical director and head of pathology have found jobs elsewhere and the report seems delayed by an ill-advised hunt for the Eye’s source.

Oxford critics beware…

In 2004, a public health specialist wrote a paper published in the British Medical Journal1 which suggested on the basis of an analysis of administrative data that Oxford had high mortality for paediatric cardiac surgery. Well before publication, two letters were sent to the Radcliffe Infirmary giving details of the results, and a reply from the Medical Director of the Trust did not dispute the figures. After publication, 16 doctors from the Oxford unit wrote to the GMC, disputing the figures and asking whether the author had ‘acted unprofessionally in bringing potentially very harmful information into the public domain in this manner.’ The author underwent a very stressful 4 month investigation, before the GMC decided that the publication of a scientific article in a major peer reviewed journal did not amount to a malicious or unfounded criticism of colleagues. Child heart surgery in Oxford is now suspended following the latest independent analysis which revealed long-standing cultural and management problems, and that ‘between 2000 and 2008, 9 deaths occurred in children undergoing less common procedures, 5.29 times the expected death rate.’ This was before a new surgeon arrived in 2009 and suffered four deaths in fifteen operations (4.8 times the expected death rate). (see Eye 1268) The authors are doubtless awaiting their letters from the GMC…..

1 BMJ 2004;329:825-9

MD





August 22, 2010

Dr Phil’s Private Eye Column Issue 1269 20.8.10
Filed under: Private Eye — Tags: , , — Dr. Phil @ 1:01 pm

Rewarding Whistleblowers

Well done Channel 4 News and the Bureau of Investigative Journalism for their exposure of the widespread use of taxpayers’ money to silence NHS whistleblowers (Ch 4 news, 2.8.10). Many employment contracts still have gagging clauses and most doctors who invoke the Public Interest Disclosure Act (PIDA) to raise concerns about unsafe or fraudulent practice reach a settlement with their employer to prevent concerns being made public. Superficially, this smells of whistleblowers bottling it and taking the money, but when you look at the experience of those who refuse to be silenced, there’s no great incentive to do the right thing.

The NHS’s most famous whistleblower, Dr (now Professor) Stephen Bolsin, was praised in Parliament for raising concerns about standards of child heart surgery in Bristol nearly 20 years ago, and his actions were fully vindicated by a Public Inquiry. Yet he became unemployable in the NHS and relocated to Australia, where he continued his excellent work in monitoring clinical outcomes. Had Bolsin remained in the NHS, it is inconceivable that small units would have been allowed to continue operating and the Oxford heart scandal would have been avoided (Eye last).

If Andrew Lansley is genuine in his desire to support whistleblowers, he should consider formal recognition of Bolsin’s bravery1. The Mid Staffs inquiry will doubtless show that staff were either too afraid to blow the whistle, or too easily silenced, despite the many avoidable deaths occurring around them. NHS whistleblowers are vulnerable and isolated, and have few role models. The public recognition of Bolsin’s legacy would go some way to making it acceptable to speak up.
For whistleblowers who want to go the distance, the best chance of being heard is to go to court. In the UK, any payouts tend to be swallowed up by legal expenses and loss of earnings. But in the US, whistleblowers are rewarded handsomely if they help the government bring a successful case. In May, the New England Journal of Medicine followed up 26 successful whistleblowers from the pharmaceutical industry 2. On average each received $3 million for speaking up, with the range going from $100,000 to $42 million. Last September, Pfizer paid $2.3 billion to settle allegations that they illegally marketed a painkiller, Bextra, which has now been withdrawn. A proportion of the settlement was divided between the 6 whistleblowers.

Whistleblowers are rarely motivated by money, and nearly all try to ‘go through the correct channels’ first before going public. And even a large payout is scant consolation for the emotional exhaustion and stress of speaking out. In May, an employment tribunal found that John Watkinson, a former chief executive of the Royal Cornwall NHS Trust, was sacked for blowing the whistle on the failure of the Trust and Strategic Health Authority to consult the public adequately before moving cancer services. An independent review has now agreed that public consultation was inadequate, but the Trust is appealing against the tribunal findings. They accept that Watkinson was unfairly dismissed but challenge that he was a whistleblower, wary off the unlimited damages that are supposed to be awarded to sacked whistleblowers under PIDA. In the meantime, Watkinson remains unemployed – and like Bolsin, probably unemployable in the NHS.

As well as publically recognizing whistleblowers, Lansley needs to place a statutory duty on all NHS employers to report all serious concerns about patient safety or fraud to the Care Quality Commission (CQC) and Monitor for investigation and publication. Gagging clauses, and attempts to buy the silence of public sector workers raising genuine concerns in the public interest, must be outlawed. Whether the CQC and Monitor have the independence, expertise and resources to deal with all the NHS’s dirty secrets remains to be seen, but the practice of damage limitation, either by paying off staff or ordering secret ‘independent’ inquiries that never see the light of day, must end.

1 www.steve-bolsin.com/ 2 www.nejm.org/doi/full/10.1056/NEJMsr0912039





July 30, 2010

Dr Phil’s Private Eye Column Issue 1269, August 4, 2010
Filed under: Private Eye — Tags: — Dr. Phil @ 8:00 am

Oxford Heart Inquiry

Ever since exposing the Bristol heart scandal in 1992, the Eye has argued that complex child heart surgery should concentrated in fewer, more specialized centres. Now, thanks to the rank amateurishness exposed in the Oxford heart inquiry, small units may finally have to merge. The report has many echoes of Bristol, where between 30 and 35 children less than one year died than might have been expected at a typical unit at the time. In Oxford, the numbers were smaller, because surgeon Caner Salih blew the whistle himself after four deaths in fifteen operations between December 2009 and February 2010 (4.8 times the expected death rate). But between 2000 and 2008, 9 deaths occurred in children undergoing less common procedures, 5.29 times the expected death rate. In a nutshell, such a small unit should have ceased doing complex paediatric cardiac surgery after the Bristol report a decade ago, and must never be allowed to again.

Prior to the arrival of Mr Salih in December 2009, the Oxford Radcliffe Infirmary had a single paediatric heart surgeon, Professor Steven Westaby, dividing his time between adult and paediatric work. For over four years, Oxford had the equivalent of half a child heart surgeon, on call twenty four hours a day, every day of the year. When Mr Salih arrived from Melbourne, Professor Westaby took a deserved three week holiday. So a new, relatively inexperienced surgeon started on the unit with inadequate induction, no on-site mentoring and no senior operating help for the more complex cases.

Professor Westaby told the inquiry ‘that he did not expect Mr Salih to operate during his absence. On learning from the panel that Mr Salih had operated during that time, he said that he did not expect that the operations were complex.’ Unfortunately, they were. Mr Salih told the inquiry he did not regard Professor Westaby’s absence as ‘relevant to what operations he carried out’, and it was clear that the two had ‘not satisfactorily discussed the matter.’ By the time Westaby returned, Salih had announce his intention to leave his job. Westaby presence didn’t improve matters, because he had an ‘idiosyncratic’ approach to operating and so they worked in isolation, rather than as a team.

Having been promised two operating lists at interview, Mr Salih wasn’t given any to start with, having to cram operations in whenever a slot arose. He was finally given one on a Friday morning, not enough to improve his skill levels, and intensive care was often full and monitoring of sick babies over the weekend harder. There was no dedicated paediatric perfusionist able to offer the life support back-up he was used to, and neither was the surgical equipment he needed available from the start of his appointment. He did manage to find a mentor, over the phone in London, but this was hardly ideal given the complexity of the operations he was attempting. The review concluded that ‘all the cases were complex and surgery was high risk. We found no errors of judgement that directly lead to any of the deaths…. we found no evidence of poor surgical practice… it was an error of judgement for him (Mr Salih) to undertake the fourth case.’

The review found plenty of evidence of the dismal monitoring of safety by the Trust. In December 2009, Mr Salih expressed concerns about the support he was receiving, but by February 2010 he still hadn’t met the Paediatric Directorate manager. On February 19, he informed colleagues that he was ceasing to operate because of the string of deaths, but no formal action was taken to suspend services on that day. Surgery was not officially ‘paused’ until February 24, but no-one considered this warranted reporting a ‘Significant Untoward Incident’ or telling the SHA. Only when a journalist threatened to leak the story was an SUI declared on March 3. Once the story broke, an extraordinary mortality meeting was held to discuss the four deaths, 21 days after the last had occurred. Prof. Westaby didn’t attend and neither did one of the paediatric anaesthetists. Most damning of all is that parents don’t appear to have been told the true, surgeon or unit specific risks of the operations their babies were undergoing but rather national average risks. It’s as if Bristol never happened. Labour ducked the opportunity to safely sort out child heart surgery. The coalition mustn’t make the same mistake.

MD





July 23, 2010

Dr Phil’s Private Eye Column Issue 1268, July 21, 2010
Filed under: Private Eye — Tags: , , — Dr. Phil @ 2:20 pm

OXFORD HEART INQUIRY LATEST

Just had a phone call from a very reliable source about the Oxford heart inquiry, due to report on Thursday, I believe. Apparently big failures in clinical governance and oversight at trust level, lessons not learned from Bristol etc but despite that, the Oxford unit has asked to be allowed to continue paediatric cardiac surgery. I strongly believe it should remain suspended pending the findings of the latest paediatric cardiac services review. Decision rests with the SHA. Who will take these decisions when there’s no SHA?

 Medicine Balls: The White Paper

How does Andrew Lansley’s Equity and Excellence: Liberating the NHS compare to White papers past? Frank Dobson’s  1998 bestseller, ‘A First Class Service – Quality in the new NHS’  gave us 191 mentions of ‘quality’ and promised to ‘publish outcomes to end unacceptable variations in health care.’ A decade later, Lord Darzi gave us ‘High Quality Care For All’ with 359 exhortations of ‘quality’ and a warning that the ‘unacceptable variations that have grown up in recent years must end.’ Lansley is also a firm believer that the way to achieve ‘quality’ (110) and to end ‘unacceptable services’ is to publish ‘outcomes’ (85). But after 13 years of Labour, we have precious little access to robust and valid comparisons of different clinical services. And without outcomes, offering patients ‘choice’ (Darzi 62, Lansley 84) is pointless, and you can’t ‘commission’ (Lansley 184) excellent services.

 There will always be variation in healthcare, and collecting and analyzing outcomes to try to understand which variations are due to chance and which to unacceptable practice is both complex and expensive. Labour made little headway and most commissioning was done on the basis of cost. So various PCTs gave Out of Hours Services to a company called Take Care Now because the price was right and they sounded as if they cared. Alas, they employed overseas doctors who didn’t know the patients, didn’t know how the NHS worked and didn’t understand how to use drugs like diamorphine. Dr Daniel Urbani killed David Gray by injecting him with ten times the safe dose because he was exhausted, had poor English and the drug was not routinely used in Germany. Prior to his death, two other German doctors had made similar errors (without causing death) but despite warnings from one of its own doctors that ‘it was only a matter of time before a patient is killed’, Take Care did not take note.

 One way to stop doctors giving ten times the dose of diamorphine is to not allow them to walk around with it in their bags. I’ve only ever carried one 5mg ampoule, so why Dr Urbani had 50mg or more on him is a mystery to most GPs. Lansley said before the election that he was going to put GPs back in charge of commissioning out of hours care, and it makes sense that clinicians should help commission and manage the services they know most about. Indeed Lansley is very big on services being ‘clinically commissioned, credible, approved, led and justified.’

 But just who are these clinicians? Midwives get 1 citation in Liberating the NHS, nurses 2, pharmacists 2, consultants 5 and GPs….. 75.  ‘Manage’ gets 43 citations but ‘manager’ only 3. GPs, apparently, can do it all by organizing themselves into ‘consortia’ (new entry, 64). Lansley has picked up the Tory baton from where it was discarded 13 years ago, just as fund-holding GPs were pooling themselves into multifunds, only to be scrapped by Labour and replaced by PCTs. In seven years as shadow health secretary, Lansley has had his ear bent incessantly by GPs complaining about the control-freakery and lack of clinical understanding of PCTs. So he’s calling their bluff, taking out the Strategic Health Authorities and the PCTs, and giving GPs the responsibility for commissioning nearly everything, while saving £20 billion and making sure the mighty Foundation Trusts don’t hoover up what’s left.

 GPs have always seen themselves as NHS gatekeepers, managing as much illness as possible in the community to present precious NHS resources being squandered in expensive hospitals. But emergency admissions to hospital are up by 12% and unless GPs can put a brake on this, they’ll be taking on an impossible job. It’s a bit like being handed the steering wheel just as the runaway coach approaches the cliff edge. And amidst all the financial pressure, it’s hard to see who will find the money to collect and analyze comparative outcomes in a meaningful way to guide commissioning and choice. Lansley’s catch phrase of ‘no decision about you without you’ sounds great for patients (217). But when they ask me which of my local hospitals is best for, say, hip replacements and which is ‘unacceptably poor’, I haven’t got a clue. And I’m supposed to be in charge. Now I must find out which consortium I belong to.

 MD





July 9, 2010

Dr Phil’s Private Eye Column Issue 1267, July 7, 2010
Filed under: Private Eye — Tags: , — Dr. Phil @ 2:39 pm

Tory Health Policy

 ‘Health secretary Andrew Lansley has just spoken to more NHS managers than he will ever do again’. So observed the Health Service Journal after he told the NHS Confederation conference that management costs (i.e. jobs) would be ‘shaved’ by a minimum of £220 million this year. Redundancy packages and Brazillians all round.

 According to Lansley, we’ll need fewer managers because targets will be abolished, GPs will be in charge of the money and an independent NHS board will ensure fair play. If only it was that simple. Targets per se are not a bad thing. If you can prove they improve outcomes for patients and the staff are given a degree of flexibility in implementing them intelligently, they work. If you enforce them with a rod of iron, irrespective of the clinical context – as Labour did too often – then they lead to bullying and disillusionment,  and harm as many patients as they help.

 Too many targets are inevitably counter-productive, like squeezing a tube of toothpaste in ten places at once. Labour’s failing was to believe that the NHS was a linear system, easily controlled by central levers. Doctors have never have been easy to control but any central dogma that clearly isn’t helpful to patients breeds resentment. Lansley is right to focus on outcomes but to improve these, he will need some targets, whatever he chooses to call them. They just need to be relevant and evidence-based.

 As for GP commissioning, Lansley wants a ‘full system roll-out’ rather than the patchy adoption of budgets under the previous Tory administration,  where GP fund-holders negotiated much better care for their patients at the expense of patients who’s GPs weren’t interested or able to hold their own budget. This year’s model will require 500-600 ‘consortia’ who will be held accountable for £60 billion of spending money by ‘fiscal control and proprietary mechanisms’ of the yet to be established NHS board. And most of this should be up and running by 2012.

 Theoretically, it might work. The NHS is a clinical service and clinicians (not just doctors) should be in charge of it, rather than bleating about the management from the sidelines. GPs are generally good with budgets and can hire the cream of the redundant crop of NHS managers to help them spend it wisely, but they’ll also need to involve their hospital colleagues. Some GPs aren’t remotely interested in commissioning, so will need to be herded into consortia with some ‘can do’ enthusiasts, otherwise we’ll end up with the winners and losers of fund-holding.

 The Treasury is understandably twitchy about handing so much money over to one clinical specialty, and Lansley’s vision isn’t helped by  ‘no-can do’ NHS chief executive David Nicholson, who closed the Confederation conference by saying he doubted the Tory reforms would be ‘anywhere near ready for full implementation by  2012.’  Hardly the rousing call to arms Lansley was hoping for, but perhaps realistic given Nicholson’s failure to introduce GP commissioning under Labour. This was launched in 2005 with a target of ‘100% voluntary coverage’ by 2007, but there has only been sporadic interest.  Overall, Nicholson’s commissioning regime was rated ‘poor to mediocre’ by the common’s health select committee. Clearly something needs to be done and Nicholson possibly isn’t the man to do it.

 What the NHS needs more than ever was nailed in the Bristol Heart Inquiry 10 years ago: a change of culture. Lansley already has a public inquiry at Mid Staffs in his in-tray and private inquiries into the sacking of Cornish chief executive John Watkinson and Bristol’s dysfunctional pathology service. And there are strong calls for inquiries in East Midlands from allegations by Professor David Hands and Gary Walker, a former boss of United Lincolnshire Hospitals NHS trust. What appears to link all these allegations is a defensive, power-obsessed management culture that bullies whistleblowers into submission. Health care is complex and mistakes inevitably happen. But if we keep hiding them, we keep making them. Perhaps Lansley is right. Time to transfer the power to GPs. We may not have all the answers, but at least we won’t beat them out of you.

 MD