Medicine Balls: Lessons from Leeds

First the good news. Data just released shows that survival rates for child heart surgery in the UK are as good as anywhere in the world, if not better. What’s more, no unit in the UK has a significantly higher death rate that the others. So why is the NHS in England considering cutting the number of units from ten to seven? Why all the fuss about Leeds? And why are we not praising and celebrating child heart surgery teams for the incredibly difficult work they do under enormous pressure and scrutiny?

The answers are all related. The most recent data is all the more miraculous in that some of the smaller units have only 2 or 3 permanent surgeons who work ridiculous hours and are heavily reliant on locums, mostly overseas, to cover leave and sickness. The low death rates are as much to do with the pre and postoperative care as the surgery itself. This requires adequate numbers of skilled staff such as cardiologists, anaesthetists and specialist nurses, and highly sophisticated imaging equipment. At present, many units operate with a bare minimum of staff and suboptimal equipment, and sometimes operations are cancelled because there are unsafe staffing levels. Staff are under so much stress that turnover of nurses is high and paediatric surgery is not seen as a popular career option. At least two talented consultant heart surgeons left the UK in the last year.

The reorganization into fewer, larger, better staffed and equipped units is vital to reduce the stress on staff, make the training of future surgeons viable and make the outcomes even better (Eyes passim ad nauseum). Unlike adult heart surgery, where the range of operations is limited, child heart surgery is so varied and complex that a newly qualified consultant needs the supervision and wisdom of a senior colleague at hand for the first 5 years to master the full range of procedures required. In the current system, with too few experienced surgeons per unit, training is suffering, hence the reliance on overseas locums to plug the gaps. And money is so tight in the NHS that units are not given the resources to have their data independently collected, completed and verified in a timely way, particularly as the specialty has been in limbo for so long, awaiting the results of the review. Corners are being cut in the name of safety.

Everyone who works in paediatric cardiac surgery knows this, every unit signed up to a reduction in the overall number but when specific units were outlined for closure, some have backtracked and the Safe and Sustainable process has been derailed by its own incompetence and by internecine fighting between units and their supporters (relatives, MPs and the press). Supporters in Leeds won a High Court case to have the closure of the unit reconsidered because the Safe and Sustainable review team failed to submit all its data to the public consultation. Shortly afterwards surgery at Leeds was suspended ironically, as it turned out, because Leeds itself had submitted incomplete data.

Could the Leeds circus have been handled better? The stress on staff has been
enormous, with some in tears. Hardly conducive to a safe operating culture now that surgery has resumed. In a safety culture, a ‘no blame’ suspension of services is entirely appropriate given the concerns raised not just by the data but by clinicians and parents. This should be happening all the time in the NHS, but not as a big media circus to very publically show how the NHS has toughened up since Mid Staffs and Bristol.

In a safe culture, heart surgery units would be obliged to submit all their data or simply not be commissioned. They would be fully aware of how the data was being analysed to reflect the complexity and risks of different procedures, and they would know and accept precisely what investigations would automatically ensue, in a calm measured way, should the data trigger an alarm. The report and its conclusions would then be put into the public domain.

Bruce Keogh, the Clinical Director of NHS England, has argued that this is exactly what he did on hearing that provisional data showed Leeds had double the mortality of other units. In a unit treating 350 babies and children, there would be an average of 10 deaths a year. If there really has been 20 deaths a year in Leeds for the last few years, Keogh – a heart surgeon – should have known about it long before. It was always more likely that the problem was incomplete data, but in being seen to have put safety first so publically, Keogh has conveniently holed Leeds below the waterline before the final decision on closures is made.

Perhaps, with the derailing of the Safe and Sustainable review, this was the only way to get the specialty to see sense and force through the centralisation of surgery. Keogh will swat away the calls to step down by Leeds MPs, but the lack of trust in NHS England under David Nicholson remains. Keogh has pledged his loyalty to Nicholson, despite his role in the Mid Staffs scandal, and has now said he would allow his own child to have heart surgery in Leeds. Meanwhile, Professor Sir Roger Boyle, director of the National Institute for Clinical Outcomes Research, has said he would not. Keogh called on Boyle to resign, and he has. NHS England is already   committed to publishing outcomes for individual consultants in ten surgical specialties by the end of the summer. NHS staff are not convinced this will be done fairly, and without risk of media crucifixion. Such sensitive data data needs to be explained to the public and staff by gifted communicators who are trusted. Nicholson is beyond repair, and Keogh has much work to do.

Listen to my interview on Radio 4’s PM programme, 13.4.13

Radio 4 PM 13.4.13 Child Heart Surgery Interview

MD

Here’s the report Sir Someone leaked to the BBC. It actually shows all units are performing within safe limits, with outcomes as good as anywhere in the world and better than most. So huge congratulations all round. Let’s start praising our child heart surgery teams for the incredibly difficult work they do under huge stress, rather than abusing them. But we still need to reorganize. Why? Read next week’s Private Eye, out on Tuesday

CHILD HEART SURGERY MORTALITY REPORT

Unaccountable accountants

More bad news is on its way for NHS chief David ‘no accountability’ Nicholson.  The report of the joint health overview and scrutiny committee (JHOSC) for six south west London councils into financial mismanagement at Croydon Primary Care Trust is imminent.  It will show how the buck is passed when financial disasters happen, and question what ‘grip’ Nicholson really has on the money.

When is an accountant not an accountant?  When he is not qualified.  This fact escaped Croydon’s director of finance Stephen O’Brien and chief executive Caroline Taylor (Eyes Passim) when they appointed former nightclub owner Mark Phillips as interim deputy finance director.  Under lax supervision and failure of both Deloitte and the Audit Commission, Phillips was able to report a £5 million surplus in the 2010/11 accounts when there was at least a £22m deficit.  Ernst and Young were called in by NHS London when Croydon insiders, including director of public health Dr Peter Brambleby, and managers from surrounding PCTs, raised concerns.

Ernst and Young’s inquiry cost the NHS £1m and went into considerable detail.  A summary with recommendations was published by NHS London and discussed at its board, but when JHOSC asked for authorship and for someone to come and explain it to them, both NHS London and Ernst and Young declined, each claiming it was the other’s report. In Nicholson’s NHS, no one has to be personally accountable. It’s always the system’s fault. The version of Ernst and Young’s report discussed at NHS London’s Board concluded that no-one was personally responsible for any failing, no-one gained personally, and no patient services were adversely affected.

Given that the last of these was not even in the terms of reference for Ernst & Young, and they had no epidemiologist or clinician on their team to test it, Brambleby asserted that none of these statements could be true and blew the whistle to then Secretary of State, Andrew Lansley, and Chief Medical Officer Dame Sally Davies.  He observed a systematic culture of dishonesty and bullying in the NHS, and cited personal experience from other posts (Eyes passim).  He also retracted the relevant chapters of his last two annual reports on the grounds that he could no longer trust the finance data on which they depended. This is unprecedented.  Lansley and Davies simply asked the SHA for its opinion and wrote back to state the matter investigated and closed. Whistle-blowers are not heeded in the NHS.

In Croydon, the accountable officers were particularly hard to call to account. The JHOSC was frustrated by non-appearances from Phillips, O’Brien and Taylor, as well as no-shows from PCT chair Toni Letts, PCT audit committee chair David Fitze, and NHS London’s director of finance Paul Baumann.  So where were they? Taylor had been promoted to run the North Central PCT cluster and O’Brien secured a post with a Trust in Essex.  Phillips was taken on by Baumann to be NHS London’s interim financial controller, before moving on to join Taylor. Baumann was promoted to Nicholson’s NHS Commissioning Board. The only serving NHS officer to appear before JHOSC was the SW London cluster chief executive, Ann Radmore, but she brought a lawyer along and refused the JHOSC access to any Croydon finance staff who had served under Phillips.  She has been promoted to run London’s Ambulance Service.

Croydon is one of London’s largest boroughs in terms of population and NHS budget.  The PCT scored above average in most performance indicators.  It had been entrusted with hosting the budget of London’s specialist services.  No-one took notice when former audit committee chair John Power (a former parachute regiment colonel with public and private finance experience) was pressured out for asking awkward questions.  Alarm bells failed to ring when Professional Executive Committee chair, Dr Ravi Sondhi, absconded with money borrowed without authorisation from the out-of-hours service (and is now suspended by the GMC).  If PCTs like Croydon can fail to report truthfully up the line, what assurance is there that Nicholson has any grip? The JHOSC report will make uncomfortable reading for the local population and for Nicholson, who recently mislead the Public Accounts Committee over the Gary Walker case (Eyes passim). Walker raised safety concerns as a whistleblower in a letter to Nicholson, Nicholson told PAC he didn’t. When the letter was shown to the press, Nicholson retracted. His next appearance before PAC should be revealing. But Nicholson can always claim he knew nothing about Croydon. It’s always the system’s fault.

Unaccountable accountants

More bad news is on its way for NHS chief David ‘no accountability’ Nicholson.  The report of the joint health overview and scrutiny committee (JHOSC) for six south west London councils into financial mismanagement at Croydon Primary Care Trust is imminent.  It will show how the buck is passed when financial disasters happen, and question what ‘grip’ Nicholson really has on the money.

When is an accountant not an accountant?  When he is not qualified.  This fact escaped Croydon’s director of finance Stephen O’Brien and chief executive Caroline Taylor (Eyes Passim) when they appointed former nightclub owner Mark Phillips as interim deputy finance director.  Under lax supervision and failure of both Deloitte and the Audit Commission, Phillips was able to report a £5 million surplus in the 2010/11 accounts when there was at least a £22m deficit.  Ernst and Young were called in by NHS London when Croydon insiders, including director of public health Dr Peter Brambleby, and managers from surrounding PCTs, raised concerns.

Ernst and Young’s inquiry cost the NHS £1m and went into considerable detail.  A summary with recommendations was published by NHS London and discussed at its board, but when JHOSC asked for authorship and for someone to come and explain it to them, both NHS London and Ernst and Young declined, each claiming it was the other’s report. In Nicholson’s NHS, no one has to be personally accountable. It’s always the system’s fault. The version of Ernst and Young’s report discussed at NHS London’s Board concluded that no-one was personally responsible for any failing, no-one gained personally, and no patient services were adversely affected.

Given that the last of these was not even in the terms of reference for Ernst & Young, and they had no epidemiologist or clinician on their team to test it, Brambleby asserted that none of these statements could be true and blew the whistle to then Secretary of State, Andrew Lansley, and Chief Medical Officer Dame Sally Davies.  He observed a systematic culture of dishonesty and bullying in the NHS, and cited personal experience from other posts (Eyes passim).  He also retracted the relevant chapters of his last two annual reports on the grounds that he could no longer trust the finance data on which they depended. This is unprecedented.  Lansley and Davies simply asked the SHA for its opinion and wrote back to state the matter investigated and closed. Whistle-blowers are not heeded in the NHS.

In Croydon, the accountable officers were particularly hard to call to account. The JHOSC was frustrated by non-appearances from Phillips, O’Brien and Taylor, as well as no-shows from PCT chair Toni Letts, PCT audit committee chair David Fitze, and NHS London’s director of finance Paul Baumann.  So where were they? Taylor had been promoted to run the North Central PCT cluster and O’Brien secured a post with a Trust in Essex.  Phillips was taken on by Baumann to be NHS London’s interim financial controller, before moving on to join Taylor. Baumann was promoted to Nicholson’s NHS Commissioning Board. The only serving NHS officer to appear before JHOSC was the SW London cluster chief executive, Ann Radmore, but she brought a lawyer along and refused the JHOSC access to any Croydon finance staff who had served under Phillips.  She has been promoted to run London’s Ambulance Service.

Croydon is one of London’s largest boroughs in terms of population and NHS budget.  The PCT scored above average in most performance indicators.  It had been entrusted with hosting the budget of London’s specialist services.  No-one took notice when former audit committee chair John Power (a former parachute regiment colonel with public and private finance experience) was pressured out for asking awkward questions.  Alarm bells failed to ring when Professional Executive Committee chair, Dr Ravi Sondhi, absconded with money borrowed without authorisation from the out-of-hours service (and is now suspended by the GMC).  If PCTs like Croydon can fail to report truthfully up the line, what assurance is there that Nicholson has any grip? The JHOSC report will make uncomfortable reading for the local population and for Nicholson, who recently mislead the Public Accounts Committee over the Gary Walker case (Eyes passim). Walker raised safety concerns as a whistleblower in a letter to Nicholson, Nicholson told PAC he didn’t. When the letter was shown to the press, Nicholson retracted. His next appearance before PAC should be revealing. But Nicholson can always claim he knew nothing about Croydon. It’s always the system’s fault.

The dead Samaritans

ON 5 March, NHS chief executive Sir David “no accountability” Nicholson told the Commons health select committee that he always takes the concerns of NHS whistleblowers seriously and has always acted appropriately to investigate them when brought to his attention. Strange then that he should promote Dame Barbara Hakin to be his interim deputy when she is the subject of an ongoing GMC investigation triggered by the Eye (see Shoot the Messenger, Eye 1292) to ascertain whether she acted appropriately on the whistleblowing concerns of former Lincoln hospitals chief executive Gary Walker.

Walker raised concerns that enforced targets for routine care were harming emergency admissions to both Hakin and Nicholson, and was later sacked. Walker is due to reveal all to the health select committee on 19 March; but in appointing Hakin, Nicholson is putting two fingers up to whistleblowers everywhere in the NHS, safe in the knowledge that the GMC moves at the speed of a glacier, usually bottles important cases and that Hakin can simply remove her name from the medical register at any time to avoid accountability.

Nicholson claims he did not know that Walker had been gagged until recently, despite a whole Eye column being devoted to it in September 2012 (Hint – It was titled ‘The Mother of All Gags’). He also claims that he did not know about the high death rates at Mid Staffordshire prior to the Healthcare Commission report in 2009, even though they had been significantly high from 2001-02 to 2007-08, and published in the Torygraph. The Department of Health is either wilfully blind or wilfully incompetent.

As no one in the DH was apparently aware of these problems or indeed able to read, here is a pretty picture. It shows how trusts can disguise high death rates by recoding those that die as palliative care (code Z51.5). They are then ‘expected to die’ and disappear from the published death rates.

The graph clearly shows, even to Nicholson’s untrained eye, that while the rest of the NHS adjusted their palliative care recoding modestly (dark blue line, David), the hospitals in his former parish of West Midlands – Mid Staffs (red), Walsall (green) and George Elliot (light blue with circles David), all dramatically increased their palliative care coding. Was there a genuine, massive increase in the admission of terminally ill patients? Was this a correction of previous massive coding errors?  Or where they trying to hide poor care and high death rates? I think we should be told

Daily Mail journalists do at least read the Eye and have done a very proficient job of repackaging all our whistleblowing stories (Gary Walker, Raj Mattu and last week Ed Jesudason). The Mail rejoiced with the headline “Victory for NHS Whistleblowers” as Jeremy Hunt announced an end to gagging clauses.  Fine work from the Mail, and a campaign started long ago by the Eye, but Hunt’s stunt has been done before. In 1999 a Health Service Circular prohibited gagging clauses in compromise agreements.  The circular cited “employees too scared to speak up” and “powers that be… doing nothing about it”.  Fast forward to early 2012 and Nicholson wrote to all hospitals referring to a “small number of instances” where confidentiality clauses had been used. Will Hunt persuade local NHS managers desperate to avoid scandal to uphold the law? Lawyers will find easy ways around this, and no mention has been made of whether those already gagged are now free to speak up without getting the kind of unpleasant legal threat dished out to Walker.

Denial is a strategy beloved by Nicholson and his underlings. On 8 March 2013, Alder Hey told the Eye that it had “never issued a ‘gagging clause'”. Unfortunately the Trust may have forgotten that it has provided a compromise agreement to the Eye under freedom of information legislation, and the Trust confirmed that one corresponds to Mr Marco Pozzi a senior paediatric cardiac surgeon who gave evidence to the Bristol Inquiry.  The Eye had received information that a sum of £156,000 was paid for the silence of Mr Pozzi from a source (not Mr Pozzi) within the trust.  That agreement contains the following clause, “[Mr Marco Pozzi] shall not at any time, whether directly or indirectly, make, publish or otherwise communicate any adverse, disparaging or derogatory statements or announcements… [this agreement] prohibits all communications with Press, TV, radio and in any other media.” That looks suspiciously like a gagging order.

Alder Hey has also provided the Eye with mass redundancy agreements as part of disclosure to the Information Tribunal, which similarly contain an identical gagging clause (drafted by the same firm of solicitors).  One has been applied to Dr Alan Phillips, the trust psychologist who wrote the highly critical report into stress in the theatres department (see below).

The Eye has been unsuccessful in getting Alder Hey to investigate allegations by its former paediatric surgeon Ed Jesudason that surgeons were carrying out procedures on vulnerable children that were unnecessary and experimental, without any research approval and without informed consent or proper audit.

The Eye asked specifically for data about stomach surgery called fundoplacation with pyloroplasty and vagotomy carried out by surgeon Mr Matt Jones.  The data should be easily accessible through the Payment By Results system, together with morbidity, complications and outcome data. No response as yet.

After much effort, the Eye did get hold of the Phillips report, a victory acknowledged even by the Mail. In November 2010, Dr Alan Phillips the trust’s psychologist, studied the culture in the operating theatres and found “extremely high levels of sickness absence” and “staff reporting ‘coercion’, ‘bullying’, ‘emotional blackmail’ from NHS managers, Dr Phillips concluded: “As well as concerns expressed for patient safety, the human cost, as observed in the participants’ levels of distress, the quality of their work/life balance; the impact on their families and the quality of work is incalculable, as is the potential reputational cost to the trust, if changes to the existing status quo are not seriously considered.”

The full report was kept a dirty trust secret until the Eye won at the Information Tribunal.  Even theatre staff had been denied their own report, and the trust had prepared a doctored two page summary removing any criticism of NHS managers.  Dr Phillips had refused to sign the doctored version and left the trust under retirement and yes…  a gagging clause.  These factors might have influenced the Information Judge.

Whistleblower Ed Jesudason refused to take a gag but lost his case in the High Court after admitting passing information to the Eye. The Public Interest Disclosure Act is supposed to protect whistleblowers who share serious concerns with the media in good faith, but clearly not in the court of Justice Haddon-Cave. On December 17 2012, he entered Manchester High Court  and waved a copy of the Eye – concerned that some of the material appearing before the trial would prejudice him.  This showed the pisspoor attitude of the judiciary to the press and necessary exposure when other agencies have done nothing, been misled or at worse covered-up.  Jesudason resigned, with costs against him that have forced him to sell his house. His marriage has ended and he is struggling to find work as a surgeon. But at least he is not gagged.