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What now for the NHS?

David Nicholson’s cheery goodbye to the NHS – he resigns as chief executive of NHS England on March 31 – was a step up from Liam Byrne’s parting shot as chief secretary to the Treasury (‘’I’m afraid to tell you there’s no money left.’) Not only has Nicholson’s NHS spent all the money (£110 billion a year), but he believes the government will need to spend billions more on reform or the NHS will face ‘a managed decline in the quality of care.’

Nicholson wants the NHS to ditch its reliance on expensive hospital based services, centralise  highly specialist care on a massive scale and transfer much of what is currently done in hospitals closer to the home in much better resourced community-based care. These ideas have been around as long as Nicholson has been chief executive of the NHS, and the fact that he didn’t manage to implement them and is now pleading for them as he goes through the exit door is telling.

In all Western health systems, 20% of patients – those with multiple chronic diseases (heart disease, lung disease, diabetes, cancer, depression, dementia) – use up 80% of the resources. The most successful health services (e.g. the Montefiore health system in New York) identify these patients and offer them the best possible care in the community –hour long consultations, named doctors, specialist nurses and health trainers, continuity of care based on the best available evidence –  as well as hospital care if they need it. But by investing lots of money in community care, they’ve reduced hospital admissions by nearly half and made a fat profit.

In the NHS, 90% of patient contacts occur in general practice but it gets only 8.39% of the budget. General practice is simply unsafe – with too few GPs struggling though hugely complex patients with multiple problems on multiple medications in only 10 minutes. The care is patchy and – like in hospitals – of hugely variable quality. And far too many patients go to the emergency department (ED) because they can’t get easy access to a GP, making the hospitals unsafe too and ED’s horrible to work in.

The NHS is the only safety critical industry in the world that tolerates 12.5 hour shifts for nurses. Evidence is accumulating that patients are harmed if wards don’t have adequate numbers of qualified nurses, and the best specialist care (e.g. for heart failure, stoma care or multiple sclerosis) occurs if patients have easy access to specialist nurses. Yet 4000 senior nursing posts have been lost since 2010. And around 3000 patients die every year in the NHS from avoidable error, while thousands more are harmed by substandard care. Most harm occurs because there aren’t enough well trained, well rested staff on the front line. And staff are refusing to work in unsafe wards or departments.

None of this is new, but – thanks to the Mid Staffs Inquiry – the focus of the NHS has finally shifted to providing safe, humane care rather than just crunching the numbers, hitting the targets and burying the scandals until after the next election. Without a massive up-front investment in joined up community care (rather than Labour’s profligate dumping of walk-in centres across the country), the NHS can’t keep patients healthier in their homes and prevent them going to hospital. But there is no extra money, and efficiency savings have already taken the fat off the NHS, social care and local government and are now cutting into muscle and bone. Money could come from the mass merging of hospital specialist services but no politician has yet been brave enough to advocate this. And you need good community care to already be in place.

The NHS could cease to be a provider of universal services (as the Health Bill cunningly allows) and offer a skeleton service where patients buy insurance cover to top up. Policies are already available for future dementia care or cancer drugs that NICE deem to be too expensive for the NHS. It would be a brave government to advocate mixed funding of private insurance and tax for the NHS, and there’s no evidence this would be cheaper or fairer. But the alternatives – further tax rises or more rationing and a declining, neglectful and dangerous NHS and social care system – is no vote grabber either. Simon Stevens, the new boss of NHS England, must start by being honest about the scale of the problems, even as the election looms. And Jeremy Hunt must let him.

No Surprises at Alder Hey and Morecombe Bay

Alder Hey Children’s Hospital in Liverpool as “potentially unsafe” after failing to meet four in five standards of quality and safety in an unannounced inspection by the Care Quality Commission will come as no surprise to readers of the Eye. The CQC acted after it was contacted by operating theatre staff, and found failures to report serious adverse incidents, near misses, very worrying staff shortages, and problems with essential equipment.

Alder Hey, which now has the highest risk rating the CQC can award, also had a low rate of reporting safety incidents, and its staff were uncertain which types of incidents to report, airways monitoring equipment was not in place and the emergency call alarm system in the day surgery theatre was faulty. The theatre department had a high staff sickness level, staff sometimes had to work long hours and operation schedules often overran, with ‘potentially unsafe’ staffing of the recovery area. An internal review by the trust’s own director of nursing that found “shortcuts being made to safety processes that have created high risk activity.”

The safety concerns are very similar to those outlined by the trust psychologist Dr Alan Phillips in November 2010, which were only made public after the Eye forced the trust to disclose his report by successfully appealing to the Information Tribunal. (Eyes passim) Two well-respected surgical consultants, Shiban Ahmed and Edwin Jesudason, blew the whistle on unsafe care at Alder Hey and have paid a heavy price. Ahmed remains suspended, accused of inappropriately accessing patient data when the Trust deputy Chair asked him to compile details of patient harm as part of his whistleblowing disclosure. Jesudason, who supported Ahmed and raised concerns about unethical and unsafe surgical practices,  resigned last year and has been unable to find work since.

The tactics used against Ahmed have been particularly unpleasant. The Eye has seen a letter dated 5 September 2010 from surgeon Colin Baillie which reads: “Shiban mentioned he had considered suicide. I have no doubt this was what was said because I asked him to repeat himself. I shared this with the clinical director Matthew Jones.” Ahmed knew nothing of this. The claim was made behind his back when a proper response to a genuinely suicidal colleague would have been to arrange an urgent mental health assessment. He was however suspended pending an investigation which cleared him of being any risk to himself or his patients. Yet he is still not back at work, and other charges have been made against him to keep him away at huge cost to the taxpayer.

A review by the Royal College of Surgeons found Ahmed and Jesudason are regarded as extremely gifted surgeons, which makes their senseless and expensive exclusion from the NHS all the more tragic. Alder Hey has never satisfactorily responded to the allegations made by Ahmed and Jesudason about unsafe care, and the CQC’s highest risk rating for the current service leaves little grounds for optimism. The Royal College, the CQC, NHS England and the Department of Health has no appetite for supporting individual whistleblowers, particularly if they are not white,  and they are just thrown on the NHS scrapheap. Meanwhile Jeremy Hunt’s pledge that there will be no more NHS cover ups looks ludicrously hollow.

The abuse of NHS whistleblowers needs to become culturally unacceptable in the NHS. At present, there are trusts who are serial offenders, where whistleblowers are regularly persecuted and bullied for speaking up for patients, and the harm they suffer is because they rocked the boat and therefore got what they deserved. At every level, from student nurses who don’t get their training signed off because they raised safety concerns, to senior consultants who face multiple referrals to the GMC on concocted charges for embarrassing their employer, the NHS simply isn’t a safe place to tell the truth about poor care. As the commentator Roy Lilley puts it; ‘In what sort of organization is lying about patient harm seen as preferable to sorting it out?’ Answer? The worst parts of the NHS.

No surprises at Morecombe Bay either

More than 5 years after the death of baby Joshua Titcombe, the Health Service Ombudsman this week published at scathing report which stated the trust responsible for his death failed to investigate it openly and honestly. This however, is not full story. More than 3 years earlier, the same organisation refused to investigate Joshua’s death stating that they were ‘pleased’ with the way the trust responded. The Ombudsman have now apologised to the Titcombe family for their original decision; probably a wise decision given that events at Morecambe Bay are now subject to an independent investigation by Bill Kirkup, who played a key role in the Hillsborough inquiry. One has to wonder how many other decisions not to investigate serious NHS complaints the Ombudsman has got wrong in the past?