Lansley’s Chaotic Legacy

There are few more exciting summer reads than the NHS Commissioning Board’s ‘Overarching Programme Update’ (19/7/2012). You can marvel at the ‘CB Operations Directorate’ and the ‘Clinical commissioning group authorisation draft guide for assessors undertaking desktop review.’  The ‘intelligence needs’ of commissioners are discussed, along with the obligatory ‘solutions roadmap.’  And there’s even ‘a revised ready reckoner tool to help CCGs calculate the costs and implications of how they will carry out their functions….’

But most of the fun comes from the latest version of the risk register.  Andrew Lansley still refuses to reveal the original, but it now seems most unlikely that the NHS Commissioning Board  Special Authority will be fully staffed and functioning by the target of April 2013. It needs nearly 4000 staff, but many of the best and most experienced  managers have either been sacked or taken a handsome redundancy package. Recruitment currently has ‘a very high risk of failure’ which would have a ‘level 5’ impact. All this was predicted by Lansley’s critics, including the Eye, but the board is doing its best to disguise the panic in ‘wonk’ speak:

‘There is a (very high) risk that the NHS Commissioning Board (NHS CB) may fail to populate its organisational structure by March 2013. This risk has a number of causes: 1. there may be delays in finalising the NHS CB organisational design, reducing the time available for recruitment; 2. there may be delays resulting from disagreements with sending organisations regarding the nature of functional transfers; 3. the NHS CB may fail to secure sufficient capacity to manage the large volume of recruitment required at the necessary pace; and 4. Trade Unions may challenge elements of the transition process if processes are not properly agreed and implemented.’

As MD is tired of repeating, the last thing the NHS needed in tough times was massive structural upheaval, and the chaos at the centre is such that experienced managers are walking away. This may have been Lansley’s master plan all along – to create space for the private sector to take over commissioning – but in the meantime, frontline care is suffering.  According to the ‘NHS safety thermometer’ (sic), launched in April, nine per cent of all NHS patients suffer ‘avoidable harm’ and in some trusts the figure is more than 20%.  The Department of Health had a target to deliver “harm-free care” to 95 per cent of patients “by 2012”.

In the first 6 months of this year, 66,845 patients waited between 4 and 12 hours for a bed once a decision had been taken to admit them, according to the DH. This is an increase of 31 per cent on last year, and patients are back to waiting in corridors or on trolleys. A+E is getting so crowded that NHS Suffolk posted this helpful message on its website. “Do you seriously think you’re dying? If the answer is no, then it’s likely you shouldn’t be at A&E looking for medical treatment”. The message has sadly now been taken down, but the Mid Staffs inquiry will have taken note. Parts of the NHS are currently too busy to be safe.

There are still job vacancies in the NHS, and not just on the commissioning board. Central and North West London NHS Foundation Trust has advertised for an Assistant Psychologist. ‘We are seeking an enthusiastic and committed individual to join a community service within the Addictions & Offender Care Directorate. You must be willing to work with individuals with substance misuse problems, many of whom also have complex mental health needs. You must possess the relevant skills and attributes to facilitate service users to engage in the service. You must have a strong commitment to teamwork and be able to work sensitively within a culturally diverse environment…. Please Note: These are UNPAID positions.’ Alas the closing date has passed, but more ‘unpaid NHS internships’ are sure to be along soon.

MD

Good News and Bad News

Is the tide finally turning for NHS whistleblowers?  Health Secretary Andrew Lansley has ordered the Care Quality Commission to keep its whistleblowing non-executive director Kay Sheldon on the board, despite CQC chair Dame Jo Williams asking for Sheldon to be sacked. Sheldon’s ‘crime’ was to speak up against the culture of the CQC at the Mid Staffordshire Inquiry last November, describing the strategy as “reactive” and driven by “reputation management and personal survival”.  Sheldon contacted the Inquiry herself, and told chair, Robert Francis QC:  “My main concern is the organisation is badly led with no clear strategy. The chair and the chief executive do not have the leadership or strategic capabilities required.” She was also concerned that the CQC kept repeating the same mistakes and did not consider whether it had sufficient capacity to do annual inspections.

Sheldon told the Inquiry that she had emailed chief executive Cynthia Bower with her concerns and received a phone call from a “quite angry” Williams, asking her whether she “knew what impact this email would have on Cynthia.” On the day Sheldon gave evidence, Williams wrote to Lansley asking for her removal. Instead, Bower handed in her notice and Williams must now consider her position after Lansley, following  lengthy consultation and legal advice, decided that Sheldon should stay.

Whether this represents a true change of culture in the treatment of whistleblowers, or is merely an arse-covering exercise from Lansley knowing that Francis praised Sheldon for her ‘great courage’ and his report is likely to call for more like her, remains to be seen. As for the CQC, new chief executive David Behan clearly has his work cut out. A survey of 63 NHS chief executives by the Health Service Journal found that 44% were either ‘not confident’ or ‘not at all confident’ that failures on the scale of Mid Staffs would currently be picked up.

This reflects poorly not just on the regulators, but also the trusts and their boards who often don’t know what’s going on under their noses and politicians like Lansley who keep restructuring and destabilising the service, rather than focusing relentlessly on quality and safety. When the Eye broke the Bristol heart scandal in 1992, MD criticised surgeons for ‘persistently refusing to publish their results in a manner comparable to other units’. Fast forward 20 years and the Safe and Sustainable review of child heart surgery didn’t base any of its recommendations on the outcomes of the individual units because ‘a meaningful analysis of outcome data was not possible due to the low volume of surgical procedures within centres.’

So twenty years after the Bristol scandal, we still have no outcome data to prove how safe the service is and no idea how much poor performance has been covered up in that time. Bristol was only picked up because its results were so bad, it was an extreme statistical outlier. Even then, it would have remained hidden if not for the extreme bravery of whistleblower Dr Stephen Bolsin, who lost his job.

The harm caused by the lack of action to make child heart surgery safe by reorganizing it into fewer centres that are properly staffed and do sufficient numbers of operations to train future surgeons and prove they get good results is hard to quantify. But following the entirely avoidable Oxford child heart scandal (Eye July 30^th 2010), a detailed analysis of results between 2000 and 2008 by Professor David Spiegelhalter uncovered more that 20 excess deaths at each of the Leeds, Leicester and Guy’s units (Eye June 2011). The number of excess deaths at Bristol was between 30-35.

Clearly something had to be done, and the reduction in the number of centres doing surgery from 11 to 7 is at least 10 years overdue. Several Eye readers have written to object about the proposed removal of surgery from Leeds (and to point out that Andy Burnham is not the constituency MP, as MD claimed) but on the evidence available, Leeds may not welcome having its outcomes over the last decade closely scrutinized. The Safe and Sustainable review was not perfect – making safety decisions without using outcome data is beyond ironic – but it has survived rigorous scrutiny by the Appeal Court and the current referral to the Independent Reconfiguration Panel supported by Burnham can only delay improvements to the service, something Labour did for a decade in office. Meanwhile, a father has written to MD about the death of his child following heart surgery in Leeds, asking if the unit is safe. Without comparative data, I have no idea. And neither does he.

The Coalition’s Creature

Well done Nick Timmins. The ex-FT public policy editor has written an insightful account of the Health and Social Care Act, from its Ken Clarke origins over 20 years ago to the incorporation of the Blair reforms and onto the political train crash it’s now become. And it’s free¹. Much is old news to Eye readers, except the extent to which Lansley was apparently gagged by George Osborne before the election.  As Lansley claims:  “I can remember it being said explicitly to me that ‘our presentation will be radical reform on education and reassurance on health’. And the reassurance was about spending.” According to some of his advisers, when Lansley protested that “he was not being allowed to set out his stall and that might lead to trouble,” he was over-ruled.

The justification for this lack of political honesty and mandate is beautifully encapsulated by an (unnamed)  senior health department official:  “Talking about reform almost seals its fate. The public hate this discussion. Going on the Today programme to talk about commissioning or economic regulation of health, is a) fundamentally boring, and b) not what people want to hear … people don’t want you to talk about the wiring.”

The extent of the subsequent public and professional opposition to the Bill suggest this was a bad call, as voters don’t enjoy having the largest structural changes in NHS history forced on them when the pre-election pledges were to end um pointless top-down reform. Again, Timmins argues that the massive disruption of the reforms isn’t entirely Lansley’s fault. His white paper became a victim of the coalition, as Danny Alexander and Oliver Letwin – neither of whom have the faintest idea how the NHS works – rewrote key pieces of it while Lansley was too loyal/ cowardly/ arrogant to protest.

Unlike Bevan’s Baby, the Health Bill had many fathers, each with a different agenda and caring more  about their party’s survival  than the NHS.  Primary Care Trusts and Strategic Health Authorities are being abolished with indecent haste, huge health responsibilities are being handed over to local authorities and GPs, many of whom lack the resources, desire and expertise to cope, and some very good NHS managers who might make sense of it all have instead decided to take very generous redundancy packages than stay to pick up the pieces. The Commissioning Support Groups (CSGs) who sit above Clinical Commissioning Groups (as SHAs do to PCTs) have struggled to attract talented managers with NHS experience – hardly surprising since CSGs didn’t even feature in the Health Bill and have been invented by chief executive David Nicholson to ‘catch’ senior managers rather than pay the exorbitant redundancy costs. But most are taking the exit money.

Timmins interviewed everyone bar Cameron and Clegg (too busy, apparently) and the consensus view is the reforms will fail, and at many levels. Politicians often claim to want to stand back from the day to day running of the NHS, but never do. Shadow health secretary Andy Burnham has already gone on BBC Look North ² to argue the decision to stop child heart surgery in Leeds is wrong. His ignorance and naked self interest is trumping the safety of babies. There isn’t the staff to keep all of the units open ³ and expertise needs to be concentrated in fewer centres. After extensive consultation, the one near Burnham’s constituency is earmarked to close. He should grow up and support the change. Similarly, Lansley will find it hard not to over-react to save his political skin when Mid Staffs reports.

The NHS has to make impossible savings to break even and the money, corporate memory and expertise already lost  from unnecessary restructuring will take years to recover. GPs in Clinical Commissioning Groups are waking up to the vast complexity of legislation they have to master on a management shoestring, while trying to cope with the increasing demand in their own practices. The government is wrong. Patients care  passionately how Bevan’s Baby became the Coalition’s Creature and although it will probably survive, it won’t be the NHS we’d hoped for.

1 http://www.kingsfund.org.uk/publications/never_again.html

2 http://www.bbc.co.uk/iplayer/episode/b01knp6b/Look_North_(Yorkshire)_12_07_2012/

3 http://www.rcpch.ac.uk/news/rcpch-president-outlines-challenges-paediatric-workforce

It’s the culture, stupid

Culture, according to Henry ford, eats strategy for breakfast. No amount of regulation or reform can protect patients from harm if the culture remains sick. Healthcare staff, politicians, civil servants, regulators and the pharmaceutical industry have to want to be open and accountable, rather than ordered to be. Which means owning up to and learning from mistakes when they happen, not burying them for years and being retrospectively contrite when an inquiry finally pushes them out into the open.

GlaxoSmithKline (GSK) agreed to pay a fine of $3billion last week, the largest healthcare fraud fine in US history, but just the latest in a long line (Ely Lilly $1.42 billion, Pfizer $2.3 billion, Astra Zeneca $.52 billion, Merck $.95 billion, Abbot $1.5 billion). GSK was found guilty of mis-selling the antidepressant Paxil to children, making claims about a diabetes drug (Avandia) unsupported by evidence, failing to disclose safety data about Avandia and lavishing hospitality on doctors to influence their opinions and prescribing. The company claimed that these various frauds were a decade old and had been sorted. In 2003, they promised to make outcome and safety data from all their clinical trials freely available. But safety data on Avandia was still withheld up until 2007.

GSK is a UKfirm and the Medicines and Healthcare products Regulatory Agency (MHRA) spent four years investigating the criminal charges in the case of Paxil (Seroxat, paroxetine). But whistleblowers were central to the exposure and the fact that the cases were all judged in America, rather than the UK, is in no small part due to the fact that the US takes whistleblowing seriously, has its own National Whistleblower Centre offering advocacy and advice, and gives whistleblowers a share of the fine (in this case 20% of $3 billion). Why? Because there is good evidence that whistleblowing is more effective than the regulatory authorities and saves vast sums of public money and many lives. And theUK should follow suit (Shoot the Messenger, Eye…)

But it won’t. Last week, the Today programme ‘broke’ the story of the super-gag of whistleblower Gary Walker, the former chief executive of the United Lincolnshire Hospital Trust, a story comprehensively covered by the Eye in July and November last year (Shoot the Messenger and Eye 1303 The Gagging Wars). Walker blew the whistle about the danger to patients of being forced to hit simplistic targets to both NHS chief executive David Nicholson (also in the dock over the Mid Staffordshire scandal) and his director of commissioning (and former SHA chief executive) Dame Barbara Hakin.

Walker was sacked on the trumped up charge of swearing and –  without a job, effectively unemployable in the NHS and facing the loss of his home – accepted a settlement of over £300,000 that contained a gagging clause preventing him from making his safety concerns public, and warning his colleagues and supporters not too. The settlement and legal fees for the gag were paid for out of the public purse in the full knowledge of the Department of Health and the Treasury. Now some of his supporters have decided to breach the gag and release documents to the media (including the Eye) which need to be analysed in public in a way that protectsWalkerfrom further persecution. Such is the seriousness of the allegations against Hakin – a former GP – that the Eye has passed them onto the GMC. Nicholson – as with the Mid Staffs inquiry – is unlikely to be held to proper account.

On a brighter note, the (hopefully) safe reorganization of child heart surgery has now been completed, just 20 years after the Eye broke the story of theBristolheart scandal and Professor Steve Bolsin sacrificed his NHS career to blow the whistle. Professor Bolsin has never been officially thanked (now would be a good time) and the structural reorganization can only work if units grow up, put their institutional loyalties behind them and work together to ensure the outcomes, research and training are the best in the world. It’s doable, but the staff have got to want to do it, and the politicians, managers and media must let it happen.