Do you believe in the Care Quality Commission?

Do you believe in the Care Quality Commission? Health Secretary Jeremy Hunt clearly does, pronouncing that a “good” or “outstanding” rating is now the “single definition of success” in the NHS. This implies that something as complex and fast moving as health care can have a single definition of success, and the over-stretched CQC – which often only produces its reports many months after it has inspected a hospital – is up to the task of measuring and monitoring it. The previous badge of excellence for NHS hospitals in England was the prestigious ‘Foundation Trust’ status, but this lost credibility after Mid Staffordshire hospital became an FT despite appalling failings in the care it provided, and it has lost further credibility after the CQC rated 33 FTs as “inadequate” or “requires improvement”. FT’s are rewarded for balancing the books, whereas the CQC rewards the quality and safety of the services provided. So a highly rated CQC trust could be a basket case financially, and a financially prudent trust could be hiding appalling care.

The CQC inspects hospitals, GP practices, ambulance services, care homes, clinics, dentists, community services, mental health services and home services in both the NHS and private sector. It’s a massive and very expensive undertaking. – of its most recent inspection ratings, 20 services were judged outstanding, 646 good, 334 require improvement and 74 were inadequate. Hunt is doubtless keen for patients to shop around and take their custom to the outstanding trusts but choice is hard in healthcare, particularly when care is needed urgently. A further complication for patients is that a single large hospital may contain a mixture of outstanding, good, inadequate and unsafe services. For example, on 17 August, Homerton University Hospital in Hackney recently received an overall rating of ‘Good’ from the CQC. It’s urgent care centre was deemed outstanding, and all of its other services were judged as good apart from Maternity and Gynaecology, which ‘Requires Improvement.’

‘The maternity unit reported a high number of serious incidents including two maternal deaths in 2013, two in 2014 and a further one in January 2015. The service was not consistently learning from all these adverse incidents and implementing all the necessary improvements. Woman and their babies were not always being adequately monitored. The environment and equipment were not appropriately cleaned. Equipment was not consistently maintained or checked…. We found the majority of issues identified at our first unannounced inspection, such as the environment, documentation and patient safety, which the trust stated they had taken action to address, had not been resolved when we returned one week later for an announced inspection.’

Read further and the CQC report gets even more unsettling. ‘Not all incidents in maternity service were reported. There were unacceptable levels of serious incidents and never events. Reported incidents were investigated but the response was slow resulting in continued potential risks to mothers and their babies. Staff were not proactive in maintaining a safe environment and both the environment and equipment were not appropriately cleaned. Resuscitation and emergency equipment had not been consistently checked to ensure it was ready for use. Drugs were not administered or stored safely in the maternity service. Midwifery staffing levels were less than the recommendations of Birthrate Plus. Some shifts on the labour suite were staffed predominately with bank and agency staff.’

None of this is news to readers of the Hackney Gazette, where an anonymous whistleblowing group called ‘the unhappy midwives’ have been raising concerns about the quality of maternity care for some time. A separate petition was set up to investigate neonatal deaths. The Eye received an allegation of a delivery where a baby’s head became separated from its torso. In response the trust stated that ‘Legally we cannot discuss details of individual cases. We can confirm that on that day there was a delivery of a non-viable foetus and this was reported to the Coroner’s Office who felt that this did not require further investigation.’ The CQC appear not to have been told about this.

Homerton provides maternity services for 252,000 people in Hackney, and its maternity unit delivered over 5,500 babies in 2014. It’s caseload is huge and extremely complex, and yet for the maternal death rate to be so high and the service to be judged unsafe on so many measures suggests it is not a unit you would choose to have a baby in. And yet the vast majority of people who use its services have no choice, whatever Jeremy Hunt or the CQC says. So how will Homerton improve? Or Addenbrooke’s?

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

A leadership crisis

On paper, running the NHS seems relatively straightforward. You have to provide universal healthcare (or at least the treatments NICE deems are both effective and value for money), you have to do it a standard that is both safe and effective, and you have to stick to your budget. Yet in the battle to achieve access, safety and affordability, very few NHS leaders succeed, or are given the time to succeed.
The average job span of an NHS chief executive is two and a half years and only one in 10 trusts has had the same chief executive for a decade or more. One-fifth of trusts have no substantive director of finance and one-sixth have no substantive chief executive. It is the same picture for directors of nursing and medicine. The jobs are so tough, and the culture of fear and blame so prevalent, that very few clinical staff want to do them. And yet the NHS will collapse if they don’t.

Between 1948 and 2011, NHS annual funding growth averaged 4%. From 2011-2015 it was 0.9%, and the target growth 2015-2020 is 1.5%. The current budget requires another £22 billion of ‘efficiency savings’ in the course of this Parliament, and yet demand for care is rising. I in 3 people can now expect live to a hundred and half of those diagnosed with cancer live well over 10 years. For dementia alone, there are currently 850,000 people in the UK who have been diagnosed, costing the UK £26 billion a year. According to the Chief Medical Officer’s latest annual report, almost two in three adults in England weigh more than they should: 37 percent are overweight, and a further 25 percent obese. Over the next 20 years, the number of obese adults is set to rise to 26 million with a huge impact on the NHS. Many illnesses (cancer, diabetes, kidney, liver, heart and vascular disease, stroke, dementia, depression) are more likely if you are obese, and many treatments are higher risk and more expensive.

There clearly is no easy answer, but encouraging the brightest clinicians to take up senior leadership roles in the NHS is vital. This makes the government’s threat to impose rushed new contracts on consultants and junior doctors all the more nonsensical. A decade of austerity it tough enough without alienating the staff who are best placed to keep the NHS afloat. In a brilliant letter that has been shared 175,000 times on Facebook, intensive care junior doctor Janis Burns vents her frustration on David Cameron. She is part of a team, including consultants, that provides a 24 hour, 7 days a week, 365 days a year service.

Having worked 11 hour overnight shifts on Friday, Saturday and Sunday ‘on Monday night I did something Jeremy Hunt has openly chastised. I worked another night shift as a locum in another hospital. Why did I do this? Because I, 34 years old, did not want to have to borrow money, yet again, from my elderly parents. As a student, my student loans did not even cover my rent. I accumulated £20,000 professional studies loan and £7000 of credit card debt. Over £1000/month of my salary is used for debt repayment and I still have 26 more months to pay before I am only left with my student loan repayment. Living in London, my rent is £926/month. Will ever be able to afford to buy a one bedroom flat in London?’

The staffing time bomb in the NHS is as much of a threat as diabetes and dementia. Young doctors are leaving the NHS to work abroad, and many doctors and nurses are choosing to work for locum agencies because they need the money. The BMA’s junior doctor committee has now voted not to re-enter contract negotiations with NHS Employers following the government’s insistence it accepts all of the recommendations on a new contract without question by mid-September. The new contract would extend routine working hours from 60 hours per week to 90, and deem that working at 9pm on a Saturday is the same as working at 9am on a Tuesday. Junior doctors may be bounced back into working dangerously long hours and their pay would not match the experience junior doctors’ gain through their training. Doctors on 1A banding face a 15-20% pay cut, those who spend 4 years on a research PhD get no pay increase, and a hospital doctor who retrains as a GP may get a big pay cut. None of which will inspire recruitment and retention in the short term or the loyalty needed to develop the leaders of the future. It’s time for the government to listen to and collaborate with NHS staff.

The petition for a vote of no confidence in Jeremy Hunt has garnered enough signatures to be debated in Parliament on September 14 – but it probably wont be

MD’s book – Staying Alive – How to Get the Best from the NHS – is available here