Kids First?

Health and Social Care Secretary Jeremy Hunt has been busily briefing that the NHS will get a substantial funding settlement for its 70th birthday, but how should any extra cash be prioritised for maximum benefit? Hunt is fond of saying that patient safety is ‘paramount’, and yet has singularly failed to enforce legally mandated safe-staffing and skill mix levels that are essential to patient safety. Patients, and members of staff, are avoidably harmed every day in health and social care because of staff shortages right across the service. So where should Hunt and NHS England start to reverse this wholescale avoidable harm?

The law, as enshrined in the 1989 Children’s Act, made it clear that “the welfare of the child is paramount”. Adopting this legal principle would mean that in any situation the right of children to be both protected from avoidable harm and to live healthy lives should override all other concerns in health and social care. So how is England complying with this law? Even if in its narrowest interpretation, protecting children from the risk of abuse, services are struggling. A recent survey by the National Network of Designated Healthcare Professionals for Safeguarding Children (NNDHP) found that there was huge variability across Clinical Commissioning Groups in England in their commitment to resource their statutory obligations, with no logical explanation.

Safeguarding children is highly complex and stressful, and to do it competently costs money that many CCGs are unwilling to commit, even though it is supposed to be their paramount obligation, overriding all others. Doctors, nurses and social workers working is safeguarding are covering populations up to ten times greater than the agreed safe standard. Unsurprisingly, recruitment and retention of staff has become a big problem. CCGs are about to get a big wake-up call as the Children and Social Work Act 2017 kicks in. The Act puts duties on three ‘safeguarding partners’ – the local authority, CCGs and the Chief Officer of Police – ‘to make safeguarding arrangements that respond to the needs of children in their area.’ If they don’t, and failures ensue, all will be held to account for missing child abuse.
Paramountcy for childcare also requires adequately resourced services for children to access. Last year, an angry Justice Munby was forced to blow the whistle to the media to get care for a 17 year old at acute risk of suicide, saying the nation would have ‘blood on its hands’ if a bed could not be found, and that he was ‘ashamed and embarrassed’ at the lack of provision. As the NHS’s longest serving health secretary, Hunt too should be ashamed at embarrassed at the state of child health and welfare.

One in five children in England live in poverty, it’s highest since 2010, and there is clear evidence that the future health of adults is clearly defined by the number of adverse childhood experiences they endure. UK child mortality is not only higher than many other countries but is on the increase, both for the neonatal period and for children under 5. As an excellent review by paediatrician Neena Modi paints a depressing picture. About a third of 10-year-old children are overweight or obese; a quarter of 5-year-olds have tooth decay, self-harm among girls aged 13–16 has risen by two-thirds in the last 3?years and compared with 2015–2016, there has been a decrease in 2016–2017 in coverage of four of the six routine vaccinations at age 1 and 2 years, and coverage for Measles, Mumps and Rubella decreased for the third year in a row, following previous annual increases over 9?years.

Over 80% of obese children will remain obese as they grow older, and this will lead to them losing about 15–20 healthy-life years as adults. Teenagers, even if only at the upper end of normal body weight, have a substantially increased risk of premature death in adulthood. Air pollution experienced in fetal life, infancy and early childhood scars lungs for life, increasing the likelihood of chronic respiratory conditions in old age. As Modi puts it: ‘these are classic examples of societies fouling their own nests, by failing to see the destructive consequences for everyone of not safeguarding child health.’ If child welfare was truly paramount, it would receive ring-fenced funding and all the resources it needed from keeping children safe and secure in the home to providing adequately staffed emergency services when they are admitted with sepsis or meningitis. Hunt, who has overseen the worst decline in NHS performance on record in nearly six years in office, celebrated his longevity (and brass neck) by declaring ‘judge me on my results.’ If he wants to leave a positive legacy, he should ensure the legal paramountcy of child welfare is matched by paramountcy of funding. All our futures depend on it.

We’re Scamming

Many older people resent being called vulnerable, but to scammers they can be easy prey. Whilst car theft and house burglary have become harder due to improved technology and security, there has been a massive growth in relieving older people of their money, secure in the knowledge that they may be considered unreliable witnesses under fierce cross-examination. Professor Keith Brown from Bournemouth University leads research for the Chartered Trading Standards Institute in the field of financial fraud and scams prevention. He estimates that £10 billion a year may be taken from citizens without their full understanding and consent, and not always by criminals.

Brown cites clear evidence of legitimate companies targeting and repeat selling to vulnerable individuals. He highlights the gap in the protective measures offered by the current definition of mental capacity. People in the early stages of dementia have some form of cognitive impairment, but do not lack capacity as defined by the Mental Capacity Act. Yet they are clearly more vulnerable than the average citizen. Brown cites his own mother, who paid over £3000 for unnecessary vitamin D supplements, and £600 to have her front drive spray-cleaned with a pressure hose, leaving sand all over the road. The law states that an unwise decision is not a reason for intervention if a person has capacity, and is foolish enough to pay way above the odds for something. Governments can legally bankrupt hospitals by signing up to overcharged PFI schemes, just as scammers can charge your mum £500 for gutter clearing.

There are plenty of organisations who charge different rates for the same service or product, simply on the basis that they can get away with it due to the customers’ age, gender, cognitive ability, wealth or relative social isolation. The pension industry runs on differential charging, and many care homes rely on self-funding clients to make up for a shortfall in state funded care. Charities and fundraisers may phone an older person every week for a donation, and it is given each time because the person cannot remember that they already donated last week and the week before. Over 300,000 names have now been identified as circulating on so-called ‘suckers lists’, of predominantly older people who are considered an easy touch. Many of these lists are derived from data shared or sold on by charities and other bodies.

And then there are the sophisticated postal scams driven by criminals. Again, many of these scams rely on people forgetting that they have already bought or contributed, and so respond when asked to pay again. More depressing, a few older people admit to enjoying the social interaction that scamming brings, because it’s the only contact they get. Health and social care services are ideally placed to spot the signs of scamming, but since 2009 the number of people with unmet care needs has grown to 1.2 million. Left alone, people are desperate for company. Professor Brown describes poignant examples of older people pulling out their call blocking device because the only phone calls they get are from scammers. Another man had three garden sheds full of products he’d bought through scamming, and freely admitted that the 10 or more items he received every day by special postal delivery was the highlight of his day. He spent many hours a day responding, believing he was connecting to the outside world in a meaningful way.

The cost of scamming is not just the immediate loss of money. Most people do not enjoy finding out they’ve been scammed, often of their life savings and the loss of confidence and dignity that follows can mean they are no longer able to live independent lives. This has a huge impact on the state in terms of social care provision especially if they can no longer help fund their care if they have been relieved of their wealth. It is currently trading standards who are supposed to prosecute and stop scamming. However, like other local authority services, they have experienced huge cuts in their budgets, with a total spend reduced from £213 million in 2009 to just £124 million now. Five trading standard services have a budget of less than £200,000 a year. Many feel they cannot afford to risk a prosecution that relies on the evidence of a vulnerable older person. And most local authorities lack the forensic capability to submit items for analysis including fingerprinting and DNA, to assist with the identification of offenders. Unsurprisingly, the average number of prosecutions per local authority in England and Wales for scamming has remained at one prosecution per local authority per year.

West Yorkshire Trading Standards have bucked this trend and used a ‘suckers list’ of 4500 people from their area. By supporting these individuals, they have saved over £900,000. They estimate that if scam involvement leads to only 10% of victims in West Yorkshire requiring residential care a year earlier than the average person, this would save the local authority £29 million. Time for a war on scamming and loneliness.

Breast Screening – Is it worth it?

Choosing whether to have breast screening is a complex decision for any woman, balancing the risks of benefit and harm. The program was introduced 30 years ago for those aged 50-70, using 3 yearly mammograms, which use X-ray imaging to find breast cancer before a lump can be felt. However, it wasn’t until a review in 2012 that women were given proper information about the downside instead of the patronising ‘have screening, it’s good’ government line. The Marmot review found that for every 1,000 women screened over 20 years, about 5 breast cancer deaths are prevented at the expense of around 17 women being diagnosed and treated for a cancer that would never have caused them any problem. Furthermore, more than 200 women will experience significant psychological distress, anxiety and uncertainty because of false positive findings. And to make matters more confusing, the overall death rate from ‘all causes’ does not improve with screening. The lives saved from screening are balanced by the lives lost through overtreatment from X-ray exposure, surgery, chemotherapy and radiotherapy. In addition, screening doesn’t pick up all cancers and some women die at the same age of unrelated causes whether they had screening or not.

In 2017, the Nordic Cochrane Centre published a cohort study that found that screening did not reduce the number of late stage tumours (those bigger than 2 cm) and that screening is unlikely to reduce breast cancer mortality or lead to less invasive treatment. It found 1 in 3 breast cancers detected in women by screening are likely to be over-diagnosed and over-treated, which costs the NHS a significant sum but makes private practice very lucrative. Independent expert groups in Switzerland and France have recommended that breast screening be stopped or reduced substantially. And the American Cancer Society recommends less frequent screening of a narrower age group. In England, the NHS was planning to extend the screening age range from 47-83 but has inadvertently cut it by failing to send out 50,000 final mammogram invites a year for 9 years. Could this have done more good than harm? And should women queue for their missed screen or let it be?

Health Secretary Hunt rightly apologised but then claimed that 135-270 lives may have been shortened by the screening recall failure. Medical negligence lawyers such as Leigh Day are licking their lips but – when the evidence is forensically dissected – it will be near impossible for any woman to prove that her life may have been shortened by the error. For a start, there is no current evidence that missing a single screen at age 68-70, at the end of a 20 year screening programme, will harm you. Hunt’s guess comes from the most optimistic estimate that 1 in 1400 women has an early death from breast cancer prevented per screen. Hunt and Public Health England (PHE) appear to have divided 450?000 by 1400 to get 321, then factored in the fact that 30% of women decide not to be screened so 225 lives may have been shortened, but make it a range (135-270) to make it clear it’s a guess and individual harm is hard to prove. However, given that the government has spent 30 years simplistically telling women that ‘screening saves lives’, it would be hard to perform a volte farce and argue that not screening doesn’t shorten lives, even if the evidence – particularly for older women – is lacking.

The initial error may have been in computer programming, setting the wrong age parameter, but the fact that it wasn’t acted on for 9 years, despite some hospitals raising concerns, has led PHE and Hitachi to blame each other. 50,000 missing mammograms a year sounds a lot, but given there are 79 screening units in England, only a dozen women a week in the older age group were not being screened. The NHS has gone into full panic mode. The emergency phone line (0800 169 2692) had more than 8000 calls on its first day and PHE has promised to contact the 309?000 women they think are still alive by the end of May, with the aim of providing mammography to all who want it by the end of October. Breast screening units across the country may have to arrange thousands of additional appointments and many are already stretched to the safe limit due to staff shortages. This could be a recipe for more errors and more litigation. As the Nordic Cochrane website observes, the tremendous advances in breast cancer treatment make early diagnosis through screening less important to survival; ‘It no longer seems beneficial to attend for breast cancer screening.’ By opting out of screening, a woman will lower her risk of being labelled and treated for early breast cancer with no benefit to her quality of life, or life expectancy. Many women will still choose to be screened but for the 800 or so who would have been over-diagnosed, the NHS error may have been a blessing in disguise.

More Privates on Parade

The NHS has always had an awkward relationship with doctors who also practice privately. Unlike schools, where teachers choose state or private, consultants can serve two masters simultaneously thanks to the ‘stuff their mouths with gold’ compromise agreed by health secretary Nye Bevan in 1948, to try to win around the 85% of doctors who had voted against joining the NHS in a BMA plebiscite just 5 months before the new service was due to launch. Bevan – and the consultants – preferred option was to have NHS pay beds which allowed doctors to stay ‘on site’ and not bugger off to Harley Street leaving their junior staff to fly by the seat of their pants. And it also gave private patients the benefits of NHS facilities and emergency care if their treatment went badly awry.

In the event, the creation of the NHS and the provision of universal healthcare made private practice much less popular, with fewer than 100,000 people having private medical insurance in 1950. In the sixties, it made a comeback as a company perk for rewarding workers who couldn’t be paid in cash and by 1974, 2.3 million people were covered (4% of the population). Half of them were treated in NHS hospitals, a much safer option that being stranded in the upgraded nursing homes that masqueraded as private hospitals but had no emergency cover. Only consultants benefited financially from private practice, which led to resentment from junior doctors and other NHS staff who were often roped in to look after precious patients. There was also evidence of consultants using NHS equipment for private patients without reimbursing the NHS and manipulating waiting lists – keeping them artificially long to tempt patients to go private, or to allow private patients to jump NHS queues when they had run out of money (see John Yates book ‘Private Eye, Heart and Hip’ – Eyes passim).

In 1974, ancillary workers “blacked” private patients at Charing Cross Hospital, and Labour health secretary Barbara Castle legislated to phase pay beds out of the NHS completely but ‘only when alternative private provision was available locally.’ This lead to a massive increase in private hospital building – an 80% increase in beds up to 1979 alongside widespread industrial action and lengthy NHS waiting lists. By 1980, 26% of the population had private health insurance and Barbara Castle was dubbed ‘the patron saint of private medicine.’ The danger for patients of this new arrangement was that although many private hospitals had plush rooms and nutritious food, they still didn’t have cardiac arrest teams or intensive care. MD’s only foray into private practice was to be the only on call doctor covering an entire hospital over a weekend in 1988. There was no hand over, I didn’t know anything about any of the patients and the cardiac arrest trolley consisted of a bottle of port and the death certificate book. The only hope of survival if something went wrong was for someone to spot you were ill in your private, secluded room and call 999 to transfer you back to the NHS safety net.

How safe are private hospitals today? Last week, the Health Service Journal reported that assistant coroner for Manchester West Simon Nelson has written to Jeremy Hunt warning about poor processes for emergency transfers, the lack of responsibility private companies have for consultants they use, and junior doctors working alone for 24 hour shifts with a lack of training and monitoring. He has given Hunt until next month to respond, following his investigation into the care of 77 year old Peter O’Donnell. Mr O’Donnell, who was an NHS patient, died in January 2017 after hip replacement surgery at BMI Healthcare’s Beaumont Hospital in Bolton. His hospital-acquired pneumonia was not promptly recognised by staff, who dialled 999 to rush him to the Royal Bolton Hospital four days after his surgery, where he died from a cardiac arrest, organ failure and sepsis. The coroner cited an excellent report by the Centre for Health and the Public Interest, which is also investigating the rogue breast surgeon Ian Paterson (Eyes passim). CHPI points out private hospitals are likely to have profited handsomely from his malfeasance. ‘The 750 patients who underwent breast surgery and numerous other unnecessary procedures will have generated a very large amount of revenue stream for Spire Healthcare, which employed him as freelance surgeon. This large income stream could have meant that there was no strong incentive for the hospital management to look closely at the nature of Paterson’s work’. CHPI recommends consultants be directly employed by private companies who should have responsibility for monitoring performance, and the coroner agrees. Whether Hunt will agree remains to be seen, but with a substantial number of NHS operations now outsourced to the private sector, the safety holes in private hospitals could trap anyone. FFI www.chpi.org.uk

Whistleblowers Seldom Win

Do NHS whistleblowers have any meaningful legal protection if they take safety concerns to the media? In 2012, Edwin Jesudason –a highly regarded consultant paediatric surgeon and researcher – went to the media because he believed Alder Hey Children’s Hospital (AHCH) failed to address serious concerns about harm and risk to children, and the smearing of the mental health of a fellow surgeon-whistleblower, Mr Ahmed (Eyes passim). Jesudason hoped he would be protected by the Public Interest Disclosure Act (1998), which was introduced to protect whistleblowers after the appalling treatment of anaesthetist Steve Bolsin, who became unemployable in the NHS after exposing the Bristol heart scandal, and saving dozens of babies from brain damage and death (Eyes passim).

In July 2012, Jesudason won a temporary high court injunction with costs against AHCH, which was seeking his “no fault” dismissal after certain surgical colleagues refused to work with him. However, in trying to make the injunction permanent and to improve whistleblowing protection for other NHS staff, Jesudason lost at a second high court hearing after his union, the BMA, withdrew their legal support for him. The BMA often represents doctors on both sides in whistleblowing disputes, hardly an ideal situation. AHCH have since claimed that all Jesudason’s concerns were unfounded and had been dealt with, but it heavily redacted an investigative report into safety by the Royal College of Surgeons, and Jesudason believed it was misrepresenting the report to defend its reputation and hide failures of care. Jesudason was particularly concerned that avoidable deaths were not learnt from openly, a view supported by the mother of Caitlyn Parry, who died after surgery at AHCH in March 2010. Sian Parry had to take legal action against AHCH to get to the truth – seven and a half years after Caitlyn died because major arteries had been cut in error by a surgeon who had just returned from sick leave and was supposed to be overseen by another surgeon.

In the same year as Caitlyn’s death, on learning Jesudason (now on secondment in America) had reported safety concerns, AHCH surgeon Colin Baillie wrote ‘It is imperative that our legal position is solid should trust wish to terminate the employment of Jesudason… The allegations of patient harm go beyond the cases mentioned in this document, so we can expect more damaging revelations. There are only two possible outcomes; major departmental restructuring (on the quiet) with Jesudason returning… or a very dirty fight, fully in the public eye, with the organisation’s chief weapon being to bring Jesudason (who remains a talented surgeon and researcher) before the GMC for sanction.’

‘Weaponising the GMC’ is a standard procedure for punishing whistleblowing doctors. Raj Mattu, a brilliant cardiologist lost to the NHS after raising patient safety concerns at University Hospitals of Coventry and Warwickshire (UHCW) had to endure absurd and invented allegations of sexual misconduct, fraud and over 200 spurious referrals to the GMC (Eyes passim). Mattu eventually won a record payout but not before the trust, under the ‘leadership’ of CEO David Laughton has squandered over £6 million of public money in trying to shut him up or discredit him. Loughton is now CEO at the Royal Wolverhampton and the proud owner of a CBE for services to the NHS. Meanwhile, Jesudason and I submitted a poster about his concerns to a paediatric meeting. AHCH’s Medical Director and former BMA Place of Work Representative, Mr Rick Turnock responded: ‘I think the first priority is the poster. Then we turn our attention to Dr Hammond GMC number 3257087.’

Jesudason wanted his concerns to be investigated fully, but the BMA wanted him to accept a pay-off and compromise agreement, their standard mo when making awkward situations disappear. When Jesudason went public, they not only withdrew legal support, causing his case to collapse, but pursued him – and are still pursuing him 6 years later – for costs in the case – estimated at £250,000. The BMA knows Jesudason lost his house and surgical career and has no chance of making any such payment. Jesudason had to represent himself against the BMA in October 2016, and judgment is still awaited 18 months later. Why the doctors’ ‘union’ would want to inflict such a punishment beating is unclear, but its later discrediting of junior doctor whistle-blower Chris Day continues this pattern (Eyes passim). Jesudason lost an initial Employment Tribunal in Liverpool after it refused to grant him whistleblowing protection and excluded important evidence against AHCH. He now has an Employment Appeal Tribunal in London on April 17-19. It’s an important test of whether workers, in good faith, are legally protected when they take legitimate concerns outside their organisation when they are not being addressed internally. You can support his case at: https://www.crowdjustice.com/case/whistleblower-seeks-protection/