NHS and Social Care need to be a single, joined up system. And the Ombudsman needs to own up, learn and apologize to the Titcombes.

The annual conference of the NHS Confederation is where politicians of all sides present their big ideas for health and social care. In the one before an election, there is usually tedious point scoring but this year Jeremy Hunt, Andy Burnham and Norman Lamb all agreed that the service faces massive challenges, that health and social care need to be joined up as a single system and – having just gone through the biggest reforms in NHS history – it will require further massive reforms to do this.

When the NHS was founded in 1948, half the population died before the age of 65. Now, the average life expectancy is 80, with the rich living 15 years longer than the poor and having 20 more years of healthy living. Inequalities in health and truly staggering. One in three children born today will live to 100, but one in four boys born in Glasgow still won’t make it to 65. One in three people will get cancer, one in three will get diabetes and nearly everyone will get heart disease. Obesity appears unstoppable. Liver disease, kidney disease, musculoskeletal disease, depression and anxiety are all on the increase.  Mental illness currently costs the UK over £70 billion a year and one in three people over 65 will die with dementia. Many people with dementia live for many years, even if they haven’t been properly diagnosed and treated. Dementia alone already costs the economy more than cancer and heart disease put together. Some patients have three of more incurable diseases, and are on multiple medications the combined effects of which are unknown.

The NHS and social care system is crucially dependent on millions of  unpaid carers and the round-the-clock pressures and responsibilities they face are huge. If carers went on strike, the NHS and social care service would collapse overnight.  Already the NHS is unable to provide safe staffing levels and care around the clock. Staff recruitment and retention is critical in some areas and some specialties. Your ability to access care and the standard of care you get across the NHS is hugely variable as are the outcomes for just about every disease. Your chances of survival even depend on what day, and time of the day time of the day, you get sick.

Every other western country is facing similar problems and the NHS at least has the potential to properly coordinate care in one single, joined up system had it not been forced down the route of marketization.  Burnham has said Labour will repeal the competitive element of the Health and Social Care Bill, and make the NHS the preferred provider of services. Both he and Norman Lamb spoke of a single health and social care system with a single budget, with patients having ‘whole person care’ delivered by single team. Burnham believes this will be ‘a 10 year journey’.  Lamb wants immediate action now to legally oblige health and social care commissioners to pool their budgets. The theory is that elderly patients with high medical needs also have high social care needs, so there is currently a lot of duplication of effort, miscommunication and patients falling down the cracks between services.

Nobody is promising extra money, despite the ever increasing demand, and it’s likely the NHS may hit a wall before the election. Hunt is hoping to kickstart integration with ‘a better care fund’, which transfers £3.8 billion of existing NHS money to social care services in the hope that it will pay for itself by reducing emergency admissions. However, cuts in existing social services have been so savage it may only just keep social care afloat and not keep patients out of hospital. And it seems inconceivable the NHS could lose so much money without affecting patient care. Hunt has publicly promised an end to NHS cover-ups and to support whistleblowers and carers who speak up, which could come back to haunt him before the election were it not for the monstrous back log of unresolved tragedies still awaiting truth and reconciliation.

At Morecambe Bay, the role of the Parliamentary and Health Service Ombudsman (PHSO) has at least moved a step closer to proper scrutiny. The PHSO have been subject to wide spread criticism following the revelation that they refused to investigate the death of Joshua Titcombe in 2008(Eyes passim). The PHSO stated at the time that there would be ‘no worthwhile outcome’ in pursuing an investigation. Years later, in 2011, Joshua’s death was eventually subject to an inquest which revealed serious failures in his care and triggered a review by Monitor which found 119 serious risks to mothers and babies in the unit.

Information obtained under the Data Protection Act by Joshua’s father shows that the case advisor at the time had recommended an investigation but the former Ombudsman, Ann Abraham declined to investigate  following non documented meetings with Cynthia Bower, the former CEO of the Care Quality Commission (CQC), in months before the  last general election. Mr Titcombe wrote to request an internal review of these circumstances in July 2013 but the new Ombudsman, Dame Julie Mellor refused the request. The events at Morecambe Bay are now subject to an independent investigation led by Bill Kirkup, but the Ombudsman initially refused to participate in this process too. The Eye has learned that Mellor has now made a u-turn and agreed to ‘fully cooperate’ with Dr Kirkup’s investigation. But why have the PHSO gone to such lengths to avoid proper scrutiny of its actions at Morecambe Bay? All eyes are now on Dr Kirkup to provide the answer. Hopefully before May.

Witness Statement from Dr Phil Hammond

I have been both a general practitioner and journalist for twenty years, breaking the story of the Bristol Heart Scandal in Private Eye in 1992 and giving evidence to the eventual Public Inquiry seven years later. Much of my journalistic work involves supporting and protecting NHS whistleblowers, while allowing their concerns to be made public in a way that could help protect patients from avoidable harm. One of the saddest elements about the high rates of death and brain damage for babies undergoing complex heart surgery in Bristol was that the problems were well known within the heart surgery community and regulatory authorities, and yet no-one – save for whistleblower Stephen Bolsin – saw fit to act.

Despite legislation to protect those who blow the whistle in good faith, I am not convinced that the lot of the NHS whistleblower has improved much over 20 years, nor that we have got any better at stepping in to protect patients from harm when concerns are raised. This is well documented in the recent Private Eye supplement, Shoot the Messenger. The Francis Inquiry may well find that NHS staff are now even less likely to blow the whistle, rather than more.

Staff that do blow the whistle are frequently marginalised, counter-smeared and suspended, and many subsequently agree to a modest pay off with a gagging clause to protect themselves from personal and professional ruin. The gagging clause is counter to DH guidance and technically not enforceable under PIDA, but few whistleblowers have the strength and legal resources to risk breaching it, and so their legitimate safety concerns are never made public and there is no evidence that they have been addressed.

Gagging clauses seem to occur in all walks of life for all sorts of reasons, and it may be that some are used by staff themselves to hide their own failings when they move jobs. However, the wider point remains that public money should never be used to suppress information that may be in the public interest. Gagging clauses provide management with a powerful tool to suppress stories of medical harm and cover up management wrongdoing (particularly the failure to act swiftly and appropriately when concerns are first raised).

I believe that many doctors who have previously been silenced would welcome the opportunity of openness and it might ensure action is taken on long standing safety problems. To maintain trust in the NHS, we need to explain why and how public money has been used to silence doctors. It would not harm the profession for this information to be released, and it may even improve it. In future, I would hope the CQC will assess the culture of the NHS by asking hospitals to provide evidence of how they responded to whistleblowers’ concerns, and whether the whistleblowers  were happy with that response, rather than unable to comment.

Signed……………….

Dated………………..

18th June 2014

Rt Hon Jeremy Hunt MP
Secretary of State for Health
Richmond House
Whitehall
London

Dear Secretary of State

Thank you for meeting with us today to hear from whistleblowers across the NHS.

We were heartened to hear your praise for our courage, and how you saw us as being at the ‘vanguard’ in showing how the NHS culture is still intolerant of whistleblowing.

We are looking to help you achieve the cultural change that is overdue, in order that NHS staff feel safe to report their concerns about harm to patients.

At present, we have the opposite of a witness protection program, where staying silent is rewarded by payoffs and relocation, whereas speaking up gets you ‘buried in the woods’. Until this changes, and NHS staff can see for themselves clear examples of restorative justice, NHS workers can never feel safe to raise the most serious concerns about patient care.

Our position is that a public inquiry is now required to reveal the whistleblower’s journey in full and show how the ‘middle’ – that complex interaction of Boards, Unions, Colleges and Legal gaming of PIDA (PIDA avoidance) – puts patients and staff in harm’s way.

The call for a public inquiry already has wide expert support from a number of leading figures, ranging from Sir Brian Jarman to the President of the Royal College of Physicians.

Without a substantive inquiry, the top of the NHS will again fail to get to grips with the powerful culture of the ‘middle’, while the sharp end of the NHS will continue to suffer.

Inquiries can take time and may be expensive. But the 13-year Mattu case shows how the NHS can spend £20M on a single whistleblower, over a clear and neglected matter of patient safety. And patient harm is very expensive in every sense.

‘Plebgate’ revealed the police union culture – now courageously critiqued by Theresa May. Similarly, an inquiry is needed to reveal how health unions and others, help to suppress concerns and manage whistleblowers out of their posts. Please bear in mind that the latter experience was shared without hesitation by every whistleblower in the room today. Roger Kline has worked for eight unions and he too agreed. Only a public inquiry will have the powers to ensure that these organisations that operate in the midst of the NHS are held accountable, and required to reform.

Without this inquiry, the best intentions at the top of the NHS will be frustrated. Having an ombudsman for whistleblowers is supportable, but we know from Clywd-Hart it is not sufficient. Reform to professional codes will not help if culture does not change. After all, Raj Mattu is a whistleblower and yet one of the doctors most investigated by the GMC. In contrast, Harold Shipman was investigated once, but the GMC missed his lethal intent.

We appreciate that your consideration of these matters may take time. Therefore, in the near term, we wish to engage with your teams via working groups, to flesh out interim proposals required urgently to protect staff and patients at risk now.

Finally, we also wish to work again within the NHS to support the culture change and to protect patients. This would be the most positive form of restorative justice being urged by Ann Clywd.

Yours sincerely

Ms Loo Blackburn
Ms Sharmila Chowdhury
Dr David Drew
Ms Jennie Feccit
Dr Edwin Jesudason
Professor Narinder Kapur

cc Mr Simon Stevens, CEO NHS England

Ms Fiona Bell, Cure the NHS North East
Dr Kim Holt, Chair, Patients First
Mr Roger Kline, Director, Patients First
Dr Raj Mattu, formerly Consultant Cardiologistwe

Urgent Investment Needed in Young People’s Mental Health Services

The British Medical Journal’s erroneous over-egging the risks of side effects of statins lead to former heart surgeon Sir Magdi Yacoub pronouncing that everyone over 40 should be on a statin to lower their cholesterol. Whilst statins can be life saving for those at high risk of heart disease and stroke, there is no evidence that the mass medicalisation of those at low risk and with no symptoms, would do any good. Making everyone pill-dependant, anxious and ‘at risk’ at the age of 40 is hardly a recipe for happiness, and the money would be much better spent on mental health services which are failing badly in the NHS.

A report by NHS England leaked to the Observer has found that only a quarter of children with mental health conditions receive the treatment they need, but this is hardly news. Multiple previous reviews have found the same problems, but the current budget cuts and increasing demand is tipping the service into crisis. Only 6% of spending on mental health goes on services aimed at children and young people, yet 50% of lifetime mental illness starts by the age of 14. MD’s own experience of trying to access mental health services for young patients it that they have to be very severely ill before they will be seen in many parts of the country. So young people with moderately severe anxiety and depression are left to deteriorate with no specialist care until they get bad enough to warrant it, often by self-harming or suicide attempts. NHS England  found that whilst 35% of adults with anxiety or diagnosable depression are not in contact with mental health services,  this rises to 76% for those aged five to 15.

There has also  been a sharp rise in the number of young people needing assessment for complex conditions such as attention deficit hyperactivity disorder (ADHD) and autism, and many face severe delays or are not seen at all. The report echoed MD’s experience that many services were unable to offer early intervention and we’re becoming ‘urgent only.’ In England there is only one mental health specialist per 30,000 young people under 20, compared with one per 5,300 in Switzerland, 6,000 in Finland and 7,500 in France.

A recent survey by YoungMinds, a mental health charity, found that two-thirds of local authorities had cut their budgets for young people’s mental health. Sarah Brennan, chief executive of YoungMinds, told the Observer: “It is verging on inhumane for children and young people to end up, as they do now, being shipped hundred of miles across the country for the nearest bed, held in police cells or placed on unsuitable adult wards. We should be ashamed of the paltry support and care we assign to the mental health of children and young people in this country.”

The government is investing a modest £17.4m to try to improve earlier intervention, diagnosis and treatment of mental health problems in under-18s, and the hope is that technology in the form of ‘e-Therapies and computer based-applications’ will work for the prevention and treatment of less every mental health problems and substance misuse in this group, to take the strain off frontline services. A recent systematic review of these services by the  National Collaborating Centre for  Mental Health found that the evidence of their effectiveness was limited. ‘When considering  e-Therapies collectively, the treatment delivered shows promise and may be beneficial for improving the mental health of some  children and young people.’ It also stressed that ‘e-Therapies are not a replacement for face-to-face therapy and, if used, should form part of a child or young person’s overall therapeutic plan.’

Clearly more research is needed, as is current data on the numbers of children and young people with mental health problems. The last national study was done 10 years ago and so commissioners are either ignoring the problem or ‘buying blind’ which is unlikely to result in a rational, cost-effective service. There is good information for young people with mental ill health and their carers, such as the MindEd website launched by the Royal College of Psychiatrists in March. It helps parents identify mental illnesses in their children at an early stage when early intervention could stop it progressing. GPs manage most mental health problems, often very effectively, but if referral to a specialist service is needed, it’s a long wait to get the right care. Mental health services are  much less sexy than, say, those for cancer and heart disease, but those with mental illness are at far higher risk of physical illness too and the impact on the whole family is huge. And the later the illness is picked up, the more damaging and costly it is. To deny proper care is a false economy as well as inhumane.