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Private Eye

April 7, 2010

Dr Phil’s Private Eye Column, Issue 1259, March 31, 2010
Filed under: Private Eye — Tags: , , , — Dr. Phil @ 5:38 pm

Whistleblowing under Labour

It’s now over a decade since the Public Interest Disclosure Act was introduced to protect whistleblowers but the bullying of and discrimination against those who raise concerns in the NHS is still rife. Consultant paediatrician Dr Kim Holt used to work in the Haringey clinic, run by Great Ormond Street Hospital, where the imminent danger to Baby Peter was not spotted. In April 2006 – a year before Baby Peter was seen –Dr Holt was removed from her post after she and three other doctors wrote to management warning of tragedy due to failings including staff shortages, dangerous over-working and poor record-keeping. When Baby P was found dead, the hospital allegedly offered Dr Holt money to remain silent about her complaints.

Dr Holt claimed the hospital managers panicked after Baby Peter’s death: ‘They said I had to withdraw my allegation or the money was off the table. They were trying to buy my silence.’ Dr Holt refused to sign a statement saying all her concerns had been addressed. ‘I was not going to be gagged. I must speak about this because it is so wrong. If our concerns had been taken seriously at the time we raised them, then we could have prevented the death of Baby Peter. The children had no one else to speak up for them and we felt passionately that we were letting them down. The response of management was hostile and bullying.’
So what has happened to Dr Holt since she was sent on ‘special leave’ three years ago? Surprise! She’s still on special leave. In December 2009, Great Ormond Street promised to reach a ‘swift and amicable solution’ with Dr Holt after a damning NHS London report largely vindicated her criticisms of the Haringey clinic and recommended her reinstatement. However, Dr Holt has yet to be offerd her job back. NHS management remains notoriously intolerant of dissent, and yet Dr Holt is just the kind of brave clinician needed to speak up when patients are put at unacceptable risk. To support her reinstatement, sign here 1

Sir Ian Carruthers, the chief executive of the South West Regional Health Authority and a former acting Chief Executive of the NHS, is not a man to get on the wrong side of. Former Cornwall hospital boss John Watkinson quotes him as saying: ‘To teach chief executives to listen, I only have to put one head on a pole and put it outside the strategic health authority.’ Graham Rich, the chief exec of University Hospitals Bristol, offered his head on a pole in January, after the hospital failed to hit targets set for it by Monitor and became the subject of an inquiry into its pathology services. But – as with the heart scandal previously – the pathological allegations were long-standing and well-known not just to the hospital management but the PCT, local cancer networks and Royal College of Pathologists. Carruthers should have known about them too, but the culture in the South West is still to suppress bad news rather than encourage open debate.

The inquiry triggered by the Eye in June 2009 is being held in private and may not report until summer 2010. So is there a current threat to patients? UHB’s website would suggest not. The information for patients, last updated on 25/1/10, says: ‘University Hospitals Bristol NHS Foundation Trust and North Bristol Trust have been working jointly for some years to minimise any procedural obstacles to effective diagnosis. Both Trusts agree that no new concerns have been raised since 2008.’ 2 And yet MD has discovered that new concerns were made in November 2009, and that the Inquiry Panel, both hospitals, the GMC, the CQC and the NHS Medical Director are aware of them. Just don’t tell the patients….

1 www.gopetition.co.uk/online/34319.html

2 http://www.uhbristol.nhs.uk/histopathology-review-june-2009

Note: UHB have now updated their website in response to this article





March 22, 2010

Dr Phil’s Private Eye Column, Issue 1258, March 17, 2010
Filed under: Private Eye — Tags: , , — Dr. Phil @ 10:02 am

 Labour’s dead babies

‘The death of a child is an unbearable sorrow that no parent should have to endure’ said Gordon Brown a year ago. And yet Labour’s record in providing safe services to critically ill babies is lamentable. Whatever cause the current inquiry finds for the deaths of four babies following heart surgery in Oxford, it’s patently clear that the unit simply isn’t fit for purpose. With just one dedicated paediatric cardiac surgeon (now departed) and one surgeon mixing adult and paediatric work, it beggars belief that – after the Bristol scandal – Labour could have allowed such a small unit to carry on performing such complex surgery.

This is not a new argument. Since exposing the Bristol scandal just 18 years ago, MD has argued ad nauseum that highly specialised healthcare must be concentrated in fewer units that are safely staffed and equipped. Hardly rocket science. The Kennedy Inquiry reached the same conclusion in 2001 and triggered an expert review, chaired by cardiac surgeon James Munro, which recommended that the number of child heart surgery centres be reduced to six. Labour ignored the recommendations. NHS Medical Director and cardiac surgeon Bruce Keogh realised that another disaster was imminent, and instigated a second service review last year, saying that ‘Failure to reconfigure child heart surgery will be a stain on the soul of the specialty and will compromise the treatment of the most vulnerable members of the next generation.’ (Eye 20.1.10).

This review will shortly recommend that each unit must have a minimum of four surgeons and perform at least 400 procedures a year. Oxford did less than a hundred, but at least surgeon Caner Salih realised he worked in an unsafe environment and reported the run of deaths himself before leaving for another job. Labour should have decommissioned the Oxford unit back in 2003, along with several others with only two surgeons. But that would have been politically awkward. As MD predicted in January 2004,  ‘All the units will continue to provide a miraculously safe service with inadequate staffing until one cracks under the pressure… The seeds have already been sown for another Bristol, and the blame lies firmly with this cowardly government.’

Eye reader Joanne Ferguson is equally unimpressed with Labour’s failure to adequately fund neonatal care. The NHS Neonatal Taskforce was set up in February 2008, prompted by a National Audit Office report criticizing the organisation of neonatal services and staff shortages. Last November, the taskforce launched a Toolkit for High Quality Neonatal Services, describing it as ‘the best opportunity in 30 years to raise special care baby services up to the standard that babies and their families deserve.’ Alas, there is a shortfall of over 2,700 nurses and 300 supporting therapists that are needed to give premature babies one on one care. Labour has done very little to reverse this shortfall in paediatric intensive care, and labour wards are also perilously understaffed with 500 potentially preventable deaths a year still occurring in childbirth (see Eye November 2009).

Mrs Ferguson has set up a website1 linking expert recommendations that Labour hasn’t funded with harrowing stories of unsafe care. Brown may claim he wants no parents to endure what he has, but plenty still are thanks to a lack of courage from his government. And if he bumps into Mrs Ferguson on the stump, he’ll get some tough questions. Such as why, if £105 billion goes into the NHS, is she reporting the story of a premature baby lying all day in shit?

 1 www.signitgordon.org/

2 www.signitgordon.org/pages/stories_emma.html





March 4, 2010

Dr Phil’s Private Eye Column, Issue 1257, March 3, 2010
Filed under: Private Eye — Tags: , — Dr. Phil @ 8:56 am

Medicine Balls: A Tale of Two Scandals

What goes around, comes around. The Bristol heart scandal of 1984-1995 occurred under the Tories’ watch but it was the incoming Labour government that ordered a Public Inquiry and used the results to impose sweeping, centrist health reforms. Now the Mid Staffs scandal – which in many ways is worse than Bristol – has occurred under Labour’s watch and it’s the Tories lobbying hard for a Public Inquiry, the results of which – if they get in – will doubtless be used to force their own ideology on the NHS.

The Bristol heart surgeons at least cared deeply about their work and were trying their best, even when their results for complex heart surgery were demonstrably poor. The Francis Inquiry into Mid Staffs, held behind closed doors but published last week, is more troubling: “It was striking how many accounts related to basic nursing care as opposed to clinical errors leading to injury or death”.

The Kennedy Inquiry found that from 1991 to 1995, between 30 and 35 more children under one died after open heart surgery in Bristol compared to a typical NHS child heart surgery centre at that time. 198 recommendations were made to prevent avoidable deaths happening on such a scale again.  The largest ever increase in NHS funding was coupled with the largest and most complex regime of targets and scrutiny. But in March 2009, the Healthcare Commission uncovered ‘appalling standards of care’ at Mid Staffs, and estimated that from 2005 to 2008, between 400 and 1,200 excess deaths occurred compared to comparable NHS trusts. And in these years, the Commission itself had judged the hospital to be performing well and Monitor awarded it Foundation status for its managerial excellence.

Labour’s centralised monitoring of quality and safety just doesn’t protect patients.  It’s expensive, retrospective data collection is slow, insensitive, inaccurate and misleading. Hospitals can game their mortality rates by fiddling with the coding system and unsurprisingly, the crude results and rating scores aren’t believed by NHS staff, politicians or the public. Health secretary Andy Burnham caused insult of Hewitt proportions, describing Mid Staffs as ‘ultimately a local failure’ and claiming the NHS has had its ‘best year ever’. Five separate panic reviews have been ordered that are unlikely to see the light of day this side of an election, if ever.

The take home message at Bristol came from Steve Bolsin, the anaesthetist who first raised concerns and paid for them with his NHS career. ‘If you want to avoid another Bristol, never lose sight of the patient.’ This is strikingly similar to the conclusion of Robert Francis QC in the Mid Staffs report: “If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies are being made and implemented”.

The difference now is that we have the technology for patients and relatives  to provide valid and timely feedback on their care that will spot problems in the NHS years ahead of any quango. What’s needed is a cultural change that invites constructive scrutiny and has zero tolerance of avoidable harm to patients. Most NHS staff would love to work in such an environment, free from the tosh of political control and focusing entirely on the needs of the patients in front of them. That ‘new’ Labour could contrive a culture where £105 billion goes into the NHS and it’s still no safer then bungee jumping, with widespread staff shortages, over-crowded emergency departments, disillusionment and patient harm, suggests that much of our increased funding hasn’t gone where it’s needed. Oh, and we’re desperately short of inspirational managers who’ll stick two fingers up to Whitehall (when necessary) and focus on helping their staff to serve their patients.





February 18, 2010

Dr Phil’s Private Eye Column, Issue 1256, February 17, 2010
Filed under: Private Eye — Tags: , , , — Dr. Phil @ 8:18 am

THE EDITOR ASKS M.D. TO PEER REVIEWS PRIVATE EYE’S MMR COVERAGE

M.D. writes: Private Eye got it wrong in its coverage of MMR. It gave undue prominence to unproven theories based on a small number of uncontrolled observations, and paid far less attention to the weight of evidence from large comparative studies that failed to find any association between MMR and autism. While the Eye cited potential conflicts of interest in many of the key supporters of MMR, it failed to point out any unethical or prejudicial behaviour by Andrew Wakefield.

The 1998 Lancet paper that started the scare has now been removed from the medical literature on ethical grounds; and Wakefield, its leading author, may soon be removed from the medical register. Clearly what precious research money there is should now be used to test more credible hypotheses for the causes of autism.

The Eye has never claimed that the link between MMR and autism or bowel disease was proven; rather that better research was needed to answer the question conclusively. And it stressed the danger of infectious disease and the importance of vaccination. M.D. twice asserted that he had no safety concerns about MMR and that both his children had been vaccinated (Eyes 1045 and 1096); but overall the Eye sided with parents who were suing the vaccine manufacturers, and its coverage was consequently one-sided.

The parents were supported not just by Wakefield but by 27 expert witnesses who submitted files to support their case, and an equal number behind the scenes. The 1998 Wakefield paper and press conference caught the medical community on the hop, and there was little evidence to refute the proposed link because trials simply hadn’t been done. When the Eye joined the controversy in 2001, there were plenty of specialists willing to support the possibility that Wakefield might be right.

So when should the Eye have bailed out?

Small trials and observations can eventually lead to proof, but only if their findings can be replicated in larger trials. The best attempt to replicate Wakefield’s original observations and hypothesis – that the measles component of the MMR vaccine can lead to inflammation in the bowel and cause the release of chemicals that promote autistic disorders – was headed by Ian Lipkin MD, of the Mailman School of Public Health of Columbia University, published in 20081. This was a case-control study looking at the timing of the onset of autism and gastrointestinal (GI) disorders, in relation to the MMR vaccine.

The study also looked for the presence of measles in the bowel tissue of 25 children with both autism and severe gut disorders and matched them for age with 13 children with similar gut symptoms but not autism. The median age of the autistic children and the control group was 5.5 and 5.1 years, respectively, and they got the first dose of MMR vaccine at about the same age – 15.3 versus 16 months.

The children were selected because their gut symptoms were sufficiently grave that a biopsy was indicated for clinical reasons, which allowed the researchers to obtain tissue samples for the current study and try to replicate the Wakefield research, which found measles virus RNA in bowel tissue of 77 percent of children who had both autism and gut disorders, but not in children in a non-autistic control group.

However, the Lipkin research found no difference between the two groups, with evidence of measles viral RNA found in only one case and one control, despite using three labs and the best molecular detection methods available. Neither did the timing support a link between the vaccine and either autism or gut disorders. Only 13 of the 25 children with autism had the vaccine before the onset of autism, and in only 16 had the gut symptoms preceded the autism.

Such invasive research on children is extremely difficult to recruit volunteers for, and get ethical approval for. Given the GMC’s condemnation of Wakefield for taking unethical shortcuts, it may now be much harder to perform similar or larger studies to add to the evidence base.

However, by far the strongest evidence that has failed to find a link between MMR and autism is epidemiological. Because autism is common, any association between it and the MMR vaccine would show up clearly in large population studies compared to a control group that had not had the vaccine.

In 2002, a large retrospective cohort study of 450,000 children who’d had MMR, and 100,000 who hadn’t, found no difference in rates of autism2. So if a link did exist between MMR and autism, it was so weak as to be statistically undetectable.

The trial was not perfect (a Cochrane review – the most rigorous and independent analysis of medical trials in existence – adjudged it to be of moderate risk of bias and the follow-up of children should have been longer3); but it had far more statistical weight than any trials preceding it. All of Wakefield’s four papers were excluded from the Cochrane review as they lacked any scientific weight (one was a small case series, two had no comparative data and one had no data at all).

Another large trial published in the Lancet in 2004 also found no evidence of a difference in the rates of autism in the two groups4 and the Eye reported the Cochrane findings in 2002 and 2005 that, when all the best available trials were analysed together, there was no credible evidence of a link between MMR and autism (Eye 1066 and 1145).

The Eye was right to keep asking questions on behalf of parents. There have been plenty of medical scandals exposed by investigative journalism, and plenty more to expose. This could have been one, but it wasn’t. By the time of the second Cochrane review, the Eye should have conceded the argument.

1 Hornig M, et al “Lack of Association between Measles Virus Vaccine and Autism with Enteropathy: A Case-Control Study” PLoS ONE 2008; 3(9): e3140. DOI: 10.1371/journal.pone.0003140

2 Madsen KM, Hviid A, Vestergaard M, Schendel D, Wohlfahrt J, Thorsen P et al. A population-based study of measles, mumps, and rubella vaccination and autism. N Eng J Med (2002); 347 (19): 1477–82

3 www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004407/pdf_fs.html

4 Smeeth L, Cook C, Fombonne E, Heavey L, Rodrigues LC, Smith PG et al. MMR vaccination and pervasive developmental disorders: a case-control study. Lancet (2004); 364 (9438): 963–9





February 16, 2010

Dr Phil’s Private Eye Column, Issue 1255, February 3, 2010
Filed under: Private Eye — Tags: , , , — Dr. Phil @ 10:05 pm

Very human errors

Last year, MD met an Australian surgeon who tells his junior staff: ‘Your job is to stop me killing anyone.’ Nurses, receptionists, patients and relatives are all encouraged to speak up if they think something isn’t right, and it’s looked into promptly without knee-jerk blame. As a result, his cock-ups and complaints are commendably sparse and he has no shortage of applicants for his training posts.

The NHS has been trying to develop a grown-up safety culture for over a decade, but there is still a huge reluctance for staff to comment on each other’s work. A senior nurse who helped developed the national guidelines for the safe and sterile insertion of central venous lines recently observed a junior doctor putting a central line with a clearly dirty technique. The drapes weren’t in place and there was a danger he would introduce infection directly into the patient’s blood stream. But because it wasn’t her patient and she didn’t know the doctor, she didn’t feel in a position to comment.

The reticence of some NHS staff to offer constructive criticism and the unwillingness of others to accept it is at the heart of many clinical errors. When serious errors are analysed in detail, staff have often spotted something wrong but not said anything, or tried to raise concerns and not been taken seriously. In the infamous ‘wrong kidney’ disaster, both the medical and nursing students tried to point out the surgeon was operating on the wrong side. And in the death of Elaine Bromiley (Eye 8.5.08 ), nurses recognised that she needed an emergency tracheotomy after a failed anaesthetic,  and even brought the kit into the operating theatre, but didn’t feel able to interrupt the consultants.

Elaine’s husband Martin, a pilot, founded the Clinical Human Factors Group (CHFG) to help the NHS learn that guidelines and checklists are pointless without behavioural and cultural change. Under pressure, even the most senior doctor can panic, develop tunnel vision and go badly off piste, and without a team ethos that allows someone more junior to point this out, a disaster inevitably happens. The CHFG has now joined forces with the Patient Safety First campaign for a series of webcasts on the importance of addressing human factors in preventing medical error. One relatively simple idea is to encourage anyone performing a procedure to say: ‘If you think I’m going to make a mistake, please tell me.’ This also applies to patients and relatives. A change of pill colour or site of infusion is always worth querying. And given that 1 in 10 patients are harmed by their treatment, even a modest reduction in medical error could pay huge dividends.

Picking up errors after the event is also important. Pathologists are particularly vulnerable because tissue patterns are complex and subtle, and samples reported under stress are then stored for others to analyse at leisure. Specialists are also in short supply and this makes it imperative that pathologists work in teams and networks across regions, double checking difficult samples and seeking expert opinions. In Bristol, where pathologists in one hospital have tried to raise concerns about errors at another, the culture appears to be stuck in ‘how dare you question my reporting?’, rather than ‘let’s work together to make sure this patient gets the correct diagnosis and best treatment.’ Whether the current inquiry sorts it remains to be seen (Eye last), but the pathology departments of both hospitals could do worse than sitting down together for the Truth and reconciliation following serious harm webcast (Thu 4 Feb, 10.30-11.30)1

1  www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-support/humanfactorsweek/.