Bristol Histopathology Timeline

Nearly seven years ago I had an unexpected encounter with cancer. Following my treatment, I decided I wanted to give something back to Bristol’s cancer services and in 2006 I joined the Breast Cancer Unit Support Trust (BUST), a small, independent charity that raises funds to support the work of the Breast Care Team at Frenchay Hospital, Bristol and has also donated equipment to the Avon Breast Screening Service.

I became involved in patient advocacy and joined Breakthrough Breast Cancer’s Campaigns and Advocacy Network and was fortunate enough to be selected by Breakthrough to attend scientific training courses and conferences with the National Breast Cancer Coalition in the United States.

I am also a consumer member of the National Cancer Research Institute Breast Clinical Studies Group, a founder member of Independent Cancer Patients’ Voice, a UK based advocacy organisation, a member of University Hospitals Bristol NHS Foundation Trust and a member of the Patients Association.

I have given evidence to the Bristol Histopathology Inquiry and was pleased that the Inquiry Panel Chair, Miss Jane Mishcon, demonstrated the Panel’s recognition of the importance of informed patient advocacy when she told me, on behalf of the Panel, that patients are very lucky to have an advocate like me.

Bristol has experienced and is still experiencing service reconfigurations to rationalise services and integrate clinical teams as part of the Bristol Health Services Plan, now called the Healthy Futures Programme, and also as part of the National Cancer Action Team’s Improving Outcomes Guidance.

No one would argue that it makes sense to rationalise services and consolidate clinical expertise. However, to deliver measurable improvements to quality of care and patient safety, careful planning is required, in full consultation with clinical and patient service users.

In my view, in Bristol, clinical reconfigurations have been implemented without proper planning of supporting pathology to ensure that histopathology is reported consistently across the city to the same agreed standards and processes. I believe this has significantly contributed to the Bristol Histopathology problem.

Although I have mentioned my membership of a number of organisations, none of them has been involved in the production of this timeline and any comments are solely mine.

However comments are largely unnecessary. Much of the source material for the timeline has come from the NHS – from correspondence, information publicly available on the internet and from Freedom of Information responses. The timeline speaks for itself. It has a number of references to “a member of the public”, obviously me. However the timeline is not about me, it is about the public accountability and probity of NHS managers (including doctors), as demonstrated by their actions when faced with very serious allegations that patients have been harmed.

Whether or not the managers were told specific clinical details of the concerns when first informed about them is irrelevant. The first rule of effective problem solving is to thoroughly investigate and define the extent and seriousness of the problem.

My reason for publishing the timeline before the Bristol Histopathology Inquiry reports is that the actions of NHS Bristol, the Avon, Somerset and Wiltshire Cancer Services Network, NHS South West and North Bristol NHS Trust are not within the official terms of reference of the UHB Histopathology Inquiry, yet, in my view, the adequacy of their responses to the allegations is key to understanding what has gone wrong in Bristol. This must be acknowledged and openly addressed if we are not to risk having yet another “Bristol” in future.

Daphne Havercroft

September 2010

This is the reason given by Soo Sing Patel, Monitor’s Legal Adviser:

“The documents comprise of information provided to Monitor by a third person, NHS Bristol. I am of the view that if NHS Bristol were to take Monitor to court for breach of a duty of confidence, on the basis of probabilities, NHS Bristol would win”.

The document in question must be this timeline produced by Deborah Lee, NHS Bristol’s Co-Director of Commissioning (now on secondment to University Hospitals Bristol), which comes to an abrupt end 3rd March 2009, when, after apparently being given the runaround by Jonathan Sheffield, UHB’s Medical Director, and Martin Morse, North Bristol NHS Trust’s (NBT) former Medical Director, she “admits defeat and escalates to Chief Executives”.

Deborah Lee’s timeline

Deborah Lee had known of concerns about UHB’s histopathology services since at least 15th October 2007, when she was acting Chief Executive of NHS Bristol, leading an NHS presentation on reconfiguration of Breast Surgery to a Local Authority Joint Health Scrutiny Committee, and heard a clinician tell the councillors and members of the public that “some aspects of pathology services at UBHT are not up to standard” (UHB was known as UBHT before achieving Foundation Trust status on 1st June 2008).

According to a 2010 Freedom of Information Response from NHS Bristol, the PCT invited NBT to substantiate in writing and with detail the verbal allegations made at the Joint Health Scrutiny Meeting. NHS Bristol claims that NBT did not provide any evidence in support of the allegations, yet Martin Morse had received details of 15 specific cases four months earlier, in June 2007.

Despite having no evidence that patients were not being put at risk, according to Deborah Lee’s timeline, it appears that NHS Bristol did not take the misdiagnosis allegations seriously until Ms Lee was informed about them again on 22nd September 2008, eleven months after she first heard about them in public.

Ms Lee’s timeline was obligingly provided under the Freedom of Information Act to the public member of UHB by Strategic Health Authority, NHS South West.

Will Deborah Evans, Chief Executive of NHS Bristol take Sir Ian Carruthers’ SHA to court for breach of a duty of confidence?

The facts are rather more complex, as illustrated by this complaint made by a member of the public to North Bristol NHS Trust (NBT):

“Dear Complaints Department,

Contradictory Freedom of Information Responses

I write to complain about a Freedom of Information response I have received from NBT that contradicts a previous response.

Contained in my FOIA request dated 15th November 2009 was a request for this information:

Details of all circumstances (including the specialities of respiratory, breast, gynaecological and skin) whereby the patient pathway of any patients receiving any part of their treatment at NBT will require them to have histopathology reporting done by UHB. Please list all specialities where this is the case.

In respect of respiratory histopathology, on 20th January 2010, NBT answered:

Patients managed by respiratory physicians at NBT have lung biopsies performed at UHBristol and these are intially reported by UHBristol histopathologists. The histopathology is then reviewed by NBT histopathologists with the clinical team in a multi-disciplinary meeting.

In a Freedom of Information Request to NBT dated 2nd August 2010 I asked NBT to:

Explain the process for reporting NBT patients’ respiratory pathology prior to August 2008 and the process agreed from August 2008.

This was given reference number 0825-08-10 and replied to as follows on 1st September

The process for reporting respiratory histology before August 2008 was as follows:
NBT patients requiring thoracic biopsy were referred to UH Bristol. The biopsy was taken there and reported by UH Bristol pathologists. Patients with malignant diagnosis, and sometimes with a benign diagnosis were discussed at the NBT MDT and their histology was requested for review at the MDT, by NBT pathologists.
Agreement was reached in August 2008 that thoracic biopsy histology specimens on all NBT patients would be directly sent to NBT pathologists for full reporting and subsequent discussion at the NBT MDT. UH Bristol pathologists were no longer involved in reporting these specimens.

It is obvious that the process agreed between NBT and UH Bristol in August 2008 was not implemented, as is clear from the NBT response 20th January 2010 and the fact that the Sunday Telegraph 29th August 2010 reported that there had been two alleged UH Bristol respiratory misdiagnoses identified by NBT earlier this year.

Please explain why your 1st September response says that, following the August 2008 agreement, UH Bristol pathologists were no longer involved in reporting NBT respiratory specimens when that is obviously not true.

There is also the matter of what appears to be a serious issue of misleading the public. UH Bristol’s published methodology uses the following case to justify the decision to audit 3,500 cases for only one year, 2007, as one of its actions in response to allegations made by NBT staff concerning serious pathology errors made by UH Bristol in respiratory pathology reporting:

“After consideration of the number of adult cases for these years, and in discussion with the Medical Director, it was decided to take the samples from year 2007, because this was the most recent year prior to concerns being formalised by the North Bristol NHS Trust Medical Director, but was before the process changes in respiratory pathology agreed between the Trusts in August 2008″ 

As the agreement was never implemented by the Trusts, the process for respiratory pathology reporting in Bristol remains the same as it was before August 2008, with alleged errors still being discovered as recently as 2010. Therefore any argument for only auditing 2007 is destroyed.

NBT may argue that this is a matter for UH Bristol, who unilaterally commissioned the 3,500 audit. But it isn’t, it’s a matter for NBT as well because a number of your employees have raised serious concerns through proper channels over many years about potential harm to your patients.

And it is still happening because the Sunday Telegraph has reported that there have been at least three alleged misdiagnoses since the UH Bristol Inquiry commenced in 2009. Also it has now been publicly confirmed by UH Bristol that, of the 26 cases involving your patients, the Trust admitted two patients had been harmed. One of them was featured in the Sunday Telegraph.

What is NBT doing to protect its patients from possible errors made at UH Bristol? Please explain.”

Medical Solutions (now called Source Biosciences), is the company with whom UH Bristol already had a commercial relationship before commissioning it to manage the 3,500 audit. UH Bristol has confirmed that, as at the end of June 2010, Medical Solutions costs in relation to the audit were contained in a line item of £212,814 labelled “other”.

All very strange and the two Trusts seem unconcerned that with NBT staff alleging several serious errors since the Inquiry started, the question remains as to how many errors UH Bristol’s patients could be subjected to that are never identified.

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

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

Meanwhile the Primary Care Trusts of Bristol, North Somerset and South Gloucestershire are pressing ahead with a long overdue review of Bristol’s Pathology Services and have included Weston Super Mare as well.

Local patient groups support changes to Bristol’s Pathology services that will lead to safer, higher quality, more cost effective services. They were looking forward to involvement in a post-election style NHS Service Review – “no decision about me without me”.

But the PCTs don’t seem to have got the message. Without consulting any patient or public groups, they decided to recruit an Independent Lay Member, through an NHS recruitment process, to the Pathology Review Project Board. Although the role is to be “independent” of the NHS, the PCTs have indicated that former Non-Executive NHS Directors are especially welcome to apply.

The successful applicants have been shortlisted by an NHS panel and were to be interviewed by a panel made up entirely of NHS staff, until patients and members of the public objected.

The NHS has now unilaterally decided that two Lay Members of the Project Board will be appointed to be “independent” of the NHS by an interview Panel – where one interviewer is a representative of a Local Involvement Network (LINks) and the rest (three) are NHS staff. Patient and public members of the review will be permitted to elect two additional lay people to the Project Board.

The result of all this is that there will be four lay members of the Project Board – two appointed through an NHS appointments process (where the lay interviewer is outnumbered three to one by NHS staff), to be “independent” of the NHS, – and two elected by their peers.

The role of the NHS appointed Lay Members of the Project Board is to “ensure that the review is open and transparent”. Perhaps they could start with scrutinising the openness and transparency of their own appointment process?

It’s not clear what happens if the two NHS lay appointees disagree on any issue with the patient/public lay appointees.

NHS has the casting vote perhaps?

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

General blogs appear below, more specialised medical stuff, such as Private Eye columns, NHS Inquiries, books, DVDs  and tour dates are on the fringes.  I thank you.

NEWS…. Dr Phil’s Rude Health Show continues into the Autumn.
Pleasure yourself safe and sustainably.

BYO interesting lump

STIs on the increase (again). Time to invent a condom you can put on first time, the right way around, with less than five hands.

Phil Hammond is a GP, writer, broadcaster and possibly the only comedian to have appeared at a public inquiry. He is Private Eye’s medical correspondent and has appeared on Have I Got News for You, The News Quiz, The Now Show, The One Show and Countdown.

These action shots were taken in 1988, when glasses were riduclously big and babies were ridiculously slippery. If you think you might be one of them, please let me know.  You may be entitled to compensation.

“One of the most entertainingly subversive people on the planet” The Guardian

“Sceptical, irreverent, very funny and like a mighty gush of fresh air in a field that’s bedevilled with cover ups and cloaked in a vow of silence” Time Out

“Generates dozens of laughs and more ire than any amount of tentative taboo-breaching” The Financial Times

“In the long and brilliant tradition of comedy doctors” Sunday Times

“Funny, sensible and rude, like eating a penis-shaped vegetable” David Mitchell

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NEWS: Oxford heart inquiry: read my response on the Private Eye tab. And isn’t it time we honoured Steve Bolsin? http://www.steve-bolsin.com/

Bristol Pathologiy Inquiry: Why have the whistleblowers received warnings that they may be criticised?

My toughest case: Baby Phil (The Independent, July 2010)

Early in my medical career, in-between stitching my glove onto the top of a man’s head and watching my spectacles fall into an open wound, I realised a career in surgery probably wasn’t for me. So I joined a GP training scheme and prepared for a life of therapeutic gossip and viral probability. But to get there, I still had to do two years of hospital jobs, starting with the most inappropriate one imaginable; 6 months on a special care baby unit.

It was the toughest time of my life, trying to put drips, drains, tubes and catheters in the tiniest of babies. Luckily, the nurses saw me coming and when it was quiet, we’d swap roles. They’d do all the high-tech fiddly stuff and I’d fetch the coffee and Hobnobs. But when it was busy, I’d be called into action. In 1988, the training mantra was ‘see one, do one, teach one’. As one consultant advised: ‘If you’re not sure what you’re doing, put on  a mask of relaxed brilliance.’ But no mask can calm the panic of a premature birth and dash to special care.

The baby was 32 weeks and not breathing. I looked around for sister. Sister was busy with another baby. I’d done six successful intubations (passing a tube into the trachea to allow ventilation) but never on my own. I chose a tube, I picked up the laryngoscope and prayed my glasses would stay on my sweaty nose long enough to get a good view of the vocal cords. I eased the tube in and fate directed it to the correct hole. As the tiny lungs inflated, Mum placed a lump of amethyst next to her baby ‘for the healing energy.’ An unlikely juxtaposition, even for the West Country.

Some babies get rapidly better, others rapidly worse, but this baby remained in limbo for weeks, unable to come off the ventilator but hanging in there. I’d take blood and fiddle with the ventilator, willing him to thrive with science, while Mum brought in a succession of totems. Healing beads, horse’s hair, homeopathic creams. Nothing either of us did seemed to work. Then one morning, she stuck a picture of the Pope on the incubator and went for a coffee.

Sleep deprivation does odd things to the mind, and for some reason I decided to fashion the Pope a Jimmy Saville wig out of a yellow X-ray form. Sister spotted it, just as Mum returned, whipped it off and turned it upside down. “What’s that?” asks Mum. “It’s Dr Phil’s lucky horseshoe. He made it especially.” From that miraculous moment, her baby picks up.  Within a week, he’s off the ventilator. Mum’s overwhelmed, Dad wants to name the baby after me and I’m presented me with an enormous box of chocolates.  I give them to sister, obviously. Baby Phil may have escaped special care, but I’ve still got 5 months to survive.

Learning from Brain Failure

What can the NHS learn for England’s footballing failure? Let’s pretend Fabio was leading a crack surgical team in a race to perform the world’s first brain transplant. It’s  stretching it to imagine John Terry holding a scalpel, at least in a surgical context, but  by the time the England team has got the patient on the trolley, the Germans have already performed two brain transplants and are pushing for a third. Where did it all go so wrong?

Let’s start with the theatre manager. I have enormous respect for Fabio Capello, at least I would do if I could understand him. Even when he’s speaking through an interpreter, I struggle to make sense of him so what 22 overpaid numpties make of it all is anybody’s guess. The more people fail to understand him, the angrier he gets, like Postman Pat’s psychotic Italian half-brother. You don’t want to upset him, for fear of finding a horse’s head in your bed, but you can’t help yourself because you don’t know what he wants.

Spanish TV rather unkindly hired someone to translate what Fabio shouts pitch-side, and aside from a lot of earthy abuse, there was an almost forlorn repetition of ‘Wayne? Wayne? Wayne?’ Much of the dugout discussion with Stuart ‘Psycho’ Pearce was an argument about whether Psycho should stand up and shout before Fabio, or whether Fabio should always been the first to stand up and shout.

If Fabio was in charge of an NHS operating theatre, there’d be carnage. We know that good communication is crucial to performance and after the disastrous case of German doctor Daniel Ubani, who killed a pensioner with an overdose of analgesia after confusing the drug names, there have been calls to ensure oversees doctors have a proper command of English before being allowed to work in the UK. Football may not kill anyone, but there’s an ugly association between England losing and domestic violence. European law currently prevents us enforcing language tests on European employees, although testing is compulsory for doctors and nurses from Australia and America where English is the first language.

Fabio can’t be entirely blamed for his team defending like the Keystone Kops on gripe water. Granted, we saw off the mighty Slovenia, a nation which boasts more brown bears than professional footballers. And probably brown beers. It was the surgical equivalent of a routine hernia repair in preparation for the biggest and most complex operation ever.  Germans succeed in football because they work as a team, and the same is true of surgery. In a good surgical team, there is no hierarchy. Everyone knows what they’re doing, anyone can raise a concern and checklists are used to ensure absolutely no stone is left unturned (or swab undiscovered).  England operated like a team of prima donna locums who’s hardly met, didn’t know what they were supposed to be doing and didn’t much care because they earned a much better living over the road at the BUPA Premier League hospital.

You could tell all was not well with England when John Terry tried to blow the whistle on team disharmony. I’m not sure whether the Public Interest Disclosure Act covers professional footballers, but it soon emerged that Terry hadn’t exhausted all the correct internal channels before taking his concerns to the media. Fabio’s door may always have been open but the last time Terry knocked on it, he was sacked for copping off with his registrar’s girlfriend, so you can understand his preference for public revenge.

Dysfunctional teams never deliver. Life is complex and to err is human, but if we don’t learn from our errors, we keep repeating them. It requires difficult conversations between skilled communicators to get out of a really big hole, and Fabio’s English simply wasn’t up to the task. The FA have given him time to learn but until he does, I wouldn’t let him anywhere near my brain.

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

This is the methodology, acquired under the Freedom of Information Act, that University Hospitals Bristol NHS Foundation Trust (UHB) used to select 3,500 cases/specimens (it’s never been made clear which), for one year only, 2007,  in response to an “allegation that there was a high error rate in the Bristol Royal Infirmary Histopathology Department”. Except nobody made that allegation. It was alleged that some serious errors have been made in the areas of respiratory, breast, gynaecological and skin histopathology, affecting patients of North Bristol NHS Trust (NBT) some of them going back to 2000.

The rule of selecting every fourth case was used until the methodology was found to have selected more specimens for one pathologist than the others. UHB then changed the rules so that each pathologist contributed approximately 550 things (cases or specimens?) to the audit. Whether these numbers reflect the relative caseloads of the pathologists is not known.

This methodology is likely to have delivered UHB’s desired audit result of an error rate of less than 2% for the 3,500, but it won’t answer the question of whether there have been serious, avoidable errors in the reporting of breast, respiratory, gynaecological and skin histopathology for both UHB and NBT patients from 2000 to the present.

Over a year after the 3,500 audit was announced we still don’t know whether it is 3,500 cases (an occurrence of disease or a disorder in a patient) or specimens (samples of tissue used for analysis and diagnosis).

As many cases will each have more than one specimen that has been considered in making a diagnosis, it would seem rather important to understand what exactly has been audited. Odd that Jane Mishcon’s Inquiry Panel hasn’t sought clarification for the public on this matter.