More Chaos theory

When MD  asked health secretary Andrew  Lansley to reduce his unintelligible 358 page health bill to 140 characters or less, he wrote: ‘Putting patients and their doctors and nurses in charge, accountable for the results they achieve.’  Some staff were initially won over by the promise of liberation from political meddling,  less bureaucracy and more control over how the money is spent. But while most now long to be liberated from Lansley, they’ve now realised there is no freedom  if you’re  shackled to an unelected  economic regulator,  Monitor, and an unelected National Commissioning Board.  Worse still, the complexities of competition law and competitive tendering are likely to make the NHS more bureaucratic, not less.  And it’s the economists who’ll be in charge, stupid.

If Lansley had wanted evolution, rather than revolution, he would simply have slimmed down the existing Primary Care Trusts, put clinical staff on the board alongside the best of the NHS managers and let them figure out how best to spend the  money and focus on the quality and safety of care. By throwing all the cards up in the air, he’s created chaos, uncertainty and the perfect storm for another Mid Staffordshire scandal. The fact that even the more moderate  health unions – the Royal College of Nurses and the Royal College of Midwives – now oppose the Bill outright and are calling for its withdrawal should make the Government reconsider. But it won’t.

Equally alarming is the confusion at the very top. Monitor is the make or break organization of the government’s reforms.  David Bennett – an ex-McKinsey Blair adviser – is both chair and chief executive. Monitor was set up by Labour to be the independent regulator and assessor of NHS Foundation Trusts but under the Bill it becomes the sole economic regulator for the whole of healthcare – including the independent sector – in England. It has to regulate prices, licence providers, integrate care, prevent anti-competitive behaviour and support the continuity of services.

So Monitor has a special and long-standing relationship with NHS Foundation Trusts and yet also has to regulate the entire health sector. It sets the exam for everyone but has a vested and conflicting interest in ensuring Foundation Trusts pass it with flying colours. In an article in the Health Service Journal, Bennett warns that Monitor may face “numerous” allegations of improper conduct unless it can clearly separate its future healthcare regulatory role from its responsibility for Foundation Trusts. The revamped Monitor is hardly up and running in its new role and it looks as if the quango may have to split in two, or at least have two chief executives.

Given the financial climate, Monitor is going to have to make tough decisions and if it is perceived to have favoured Foundation Trusts over, say, the private sector than the NHS will be submerged in a succession of legal challenges. If a quango stuffed full of competition economists hasn’t got a handle on how competition law will affect the NHS, spare a thought for the virgin clinical commissioners. The bureaucratic complexity of having to make local decisions in the interests of patients while obeying national guidelines, regulatory rules and competition law will either make them panic and put everything out to competitive tender. Or they’ll spend a fortune on ‘commissioning support services.’ Or both.

The Scottish and Welsh NHS eschew a competitive market because there is insufficient evidence that it delivers better healthcare. In England, forty one ‘commissioning support organisations’ have already been proposed to help GPs make sense of the Health Bill. The only certainty in this chaos is that lawyers and management consultants will do rather well out of it. As for patients, Lansley’s promise of ‘no decision about me without me’ is beyond satire.

Dear Dr Hammond,

I am writing to you early this week as we are about to announce the results of our latest survey on the Health and Social Care Bill. I’d like to again thank the very many of you who took the time to respond; you have no idea how much this has helped me to determine how the College moves forward, as well as providing me with personal assurance that we are doing to right thing for our patients and our profession. We received more than 2,500 replies, and nearly three quarters of you who responded said that you felt that it is now appropriate to seek the withdrawal of the Health and Social Care Bill.

When asked if the College should call for the Bill to be withdrawn as part of a joint approach with other medical royal colleges, more than 98% of you strongly supported or supported such action. Even without a joint approach, more than 90% of you still said that you either strongly supported or supported the College in proceeding alone in calling for the Bill’s withdrawal. I expected a good return, but I am staggered at the level of response.

The results are very revealing, but we must look before we leap, which is why I have written again to the Secretary of State and given him another opportunity to meet with us, inviting him to suggests ways in which we can move forward. Ultimately, should the situation warrant it, we will call for the withdrawal of the Bill itself, but I really hope that these survey results will prompt some positive action, and tangible change to the Bill as it progresses to the Report Stage in the House of Lords. The three areas which remain of key importance – and which the responses to the survey reiterated are: The Secretary of State’s existing duty to provide, or secure the provision of, a comprehensive health service throughout England, must be retained Clarification on the face of the Bill that commissioners will not be required to open up services to competition unless it can be demonstrated that this would be in the patient’s best interests and compatible with the requirements of patient safety and the ability to provide integrated care

The introduction of further safeguards on education and training, including robust mechanisms to ensure the provision of sufficient post graduate training places, and the long term retention of post graduate deaneries But let me be clear. We are not a trade union. This is not about political point-scoring. It is about protecting the principles of the NHS for our patients now and in the future. I will of course keep you informed as things unfold. Other news this week in brief. You may have seen my comments responding to the second phase report from the independent NHS Future Forum. While it does concern me that questions about patients’ lifestyle choices are being proposed as part of every consultation, we did a fulsome response to the report in which we welcomed many of the recommendations. It contains some excellent proposals for strengthening the role of the GP within the NHS, and I am particularly delighted to see the emphasis on extended training.

Getting more GPs, who are trained for longer, and spending more time with their patients through longer consultations, are our priorities and it is reassuring to see them gaining wider support. Its really good to see Steve Field continuing to lead the Forum. The Forum is increasingly becoming a driving force for Government policy making, so it can only be to our benefit to have a former Chair of Council, and practising GP, at its helm, particularly as we progress with our bid for extended training.

 Best wishes,

Clare Gerada, Chair RCGP

Hotline Fever

January 1 saw the launch of a new whistleblowing hotline – 08000 724 725 – for NHS and social care staff. It’s free, publically funded and available at weekdays between 08.00 and 18.00 with an out-of-hours answering service.  It’s run, for no obvious reason,  by the Royal Mencap Society. The charity understands the importance of protecting vulnerable patients but whether it has the advocacy and employment expertise to support staff  in what is often a suicidal career move remains to be seen.

Health Secretary Andrew Lansley is very keen on his new gimmick – “This will play an important role in creating a culture where staff will be able to raise genuine concerns in good faith, without fear of reprisal” – but it beggars belief that he can glibly promise both confidentiality and protection from retribution given how whistleblowers have been hunted down in the past (see Shoot the Messenger  Eye ). As soon as concerns are raised, the NHS pretty soon draws up a list of who the secret snitch might be in an attempt to shut him or her up. Threatening, counter smearing, paying off and gagging the source is far easier than investigating the allegations.

Theoretically, the hotline could be a force for good. It should document that an employee legitimately raised concerns through channels approved by the employer and demonstrate that the employer had knowledge of the concerns on a certain date. But there is no guarantee that NHS and social service employers will properly investigate the concerns or do anything other than pay lip service to promises of accountability and transparency. And if the concerns implicate those at the very top of the organization – such as the Mid Staffs scandal and the Gary Walker case (Eyes passim) – the NHS protects the most powerful at all costs.

Lansley would have been better advised to wait for the findings of the Mid Staffs inquiry before launching his hotline. Hundreds, perhaps thousands, of patients died as a result of substandard care, the chief executive claimed the mortality statistics were wrong and the strategic health authority and Care Quality Commission were complicit in the cover up. Only one nurse, Helene Donnelley, blew the whistle by reporting on the appalling care she witnessed on 50 occasions. She got no help from her union, was bullied by other staff and was sometimes too afraid to walk to her car in the dark. One consultant had also seen many patients put at risk and had reported it up through the organisation but again got no action. When asked at the Inquiry why he had not blown the whistle he replied: “Because I’ve got a mortgage to pay.”

Whistleblowers shouldn’t have to live in fear or remain anonymous on distant phone lines. They – along with patients and relatives – should be able to raise concerns openly and in person – and then be acknowledged if they help expose and prevent poor care. Each year, the chief executive of every NHS trust should be giving awards to those who have raised concerns and protected patients. Without a change of culture, a phone-line is pointless.

Meanwhile, solicitors representing a group of NHS whistleblowers may launch judicial reviews against the Care Quality Commission, NHS London and two London acute trusts – Ealing Hospital NHS Trust and South London Healthcare NHS Trust –  for failing to comply with their duties in supporting whistleblowers under the Department of Health guidance. (www.patientsfirst.org.uk). Just having a whistleblowing policy and a hotline does not make whistleblowers safe, and a professional duty to speak up is pointless if there isn’t a commensurate duty on managers to listen and act.

This point cannot have escaped Robert Francis QC, chair of the Mid Staffs inquiry, who sat through 139 days of public hearings, warned of a ‘tsunami of public anger’ and heard some limp buck passing between the Department of Health and the Care Quality Commission. He’ll also have discovered  how an organization that purports to care can be so brutal to those who challenge the system and put patients first. If you want a career in the NHS or social care  it’s often  safer to keep your head down and ignore bad care. That has to change in 2012.

 Christmas Lottery

 Politicians hate variation in healthcare. Anything that hints of a postcode lottery inevitably means bad press. Labour’s 1998 White Paper – ‘A First Class Service’ – opened with a very bold promise. ‘All patients in the National Health Service are entitled to high quality care. This should not depend on the geographic accident of where they happen to live. The Government is determined that all patients should receive a first class service. The unacceptable variations that have grown up in recent years must end.’ Thirteen years later, the NHS Atlas of Variation has found that disparities in treatment and funding across the service are as wide as ever.

There will always be some variation in the NHS. By random chance alone, some services do better than others and at any point in time, half of all doctors/ nurses/ managers will be below average. What the NHS needs to do is to ensure all services reach defined standards of quality and – given the money that has poured into the NHS – what’s most unacceptable is that this has yet to happen.

There has been a longstanding time lottery in the NHS – if you’re fortunate enough to have your life-threatening illness ‘in hours’, the chances of survival are greater than if you have it ‘out of hours’.  The notion that there are designated hours for illnesses that predict whether you make it out of the NHS alive is ridiculous yet, even in the twenty first century, you don’t want to get sick at Christmas. Department of Health research has found that you’re 11% more likely to die on a Saturday and 16% more likely to die on a Sunday compared to being admitted on a Wednesday. As one DH source put it: ‘We’re thinking of renaming every day Wednesday.’

The major predictors of unnecessary death were the fact that diagnostic equipment and experienced, senior staff tend not to be used at the weekend. The NHS needs to concentrate resources in fewer hospitals with high tech equipment and senior staff available around the clock. London would be much safer if it had nine  properly funded super hospitals rather than thirty not-so-super ones struggling for survival , yet no politicians – least of all Lansley and Cameron before the election – have had the balls to argue for hospital closures. So the NHS is stuck with a few centres of  excellence in a sea of mediocrity.

At least it now publishes the Atlas of Variation to show just how mediocre care can be. Last year, the Atlas found that 70 amputations a week are carried out in type 2 diabetic patients in England, that 80% of them were probably preventable and that if you lived in the South West you were almost twice as likely to get one than if you lived in the South East. The variation in the treatment of mini-strokes was equally shocking, with some areas treated 100% of patients within 24 hours and some treating virtually none.

The treatment of strokes in London has at least improved dramatically, with patients going to eight designated centres of excellence offering round the clock expertise rather than any one of thirty variable quality hospitals. This rare example of life-saving hospital reconfiguration encountered some political opposition, and the equally important centralisation of child heart surgery services – something MD has been advocating for nearly 20 years – has been delayed by judicial review. But ask any doctor where they’d send their baby for heart surgery and they’d choose a unit with round the clock expertise, safe staffing levels and top of the range equipment, not some small unit that mixes adult and child surgery and where the survival of the child depends on who’s on holiday that week.

This year’s Atlas has found patients in North Lancashire are prescribed 25 times as many anti-dementia drugs as those in Kent. There were also wide variations across England and Wales in the length of hospital stay after breast cancer surgery, access to care homes and angioplasty. Understanding what the variations mean is more complex, as is knowing how to tackle them. America has even wider variations in healthcare which suggests that Labour’s experiment with a market system – and the government’s persistence with it – may not be the answer.  Benchmarking services, publishing the results and concentrating services in centres of excellence that remain excellent at weekends and bank holidays  is likely to do far more good.