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October 18, 2010

Dr Phil’s Private Eye Column, Issue 1273 October 13

Filed under: Private Eye — Tags: GMC, Lansley, Mid Staffordshire inquiry, NMC, RCS — Dr. Phil @ 10:23 am

Preventing another Mid Staffs?

Who can say with any confidence that a similar disaster to Mid Staffs isn’t happening now in the NHS? When MD asked for a show of hands at a Tory Fringe meeting that included the Health Secretary, the president of the Royal College of Surgeons, the chief execs of the GMC and the NMC and a host of senior NHS managers and clinicians, not one arm was raised. A decade after the Bristol Inquiry and with thirty bodies supposedly scrutinising the quality and safety of NHS care, we still can’t spot and stop avoidable, repeated harm to patients occurring over a prolonged period.

Anyone doubting the scale of harm to patients at Mid Staffs between January 2005 and March 2009 needs to read the Francis Inquiry report. The debate about how useful and accurate Hospital Standardised Mortality Ratios continues, but the fact is that just about every early warning light flashed brightly in Mid Staffs for months, and yet nothing was done. The Inquiry has thus far has looked at failures within the hospital but now sets its sights on the plethora of regulatory and commissioning bodies that also failed to act. It’s likely to embarrass senior managers at the PCT and SHA, and may even finger several Labour health secretaries and the chief executive of the NHS and the Care Quality Commission. But will it prevent another disaster?

When MD gave evidence to the Bristol heart inquiry in 1999, the NHS had no proper quality control mechanisms and the questions were relatively simple. What did you know, when did you know it and what did you do? As a result of that Inquiry’s 198 recommendations, we are now supposed to have revalidation for individual clinical staff to guarantee their competence (still hasn’t happened), clear whistle-blowing policies backed by legislation to protect those who speak out (ha, ha), regulation of managers (no action taken), a national reporting system for unexplained death and serious physical or psychological injury (voluntary), effective local and national monitoring of performance and very clear guidance on involving the trust board, purchasers and regulators when things go wrong. So Robert Francis, QC, can now ask: what should you have known, when should you have known it, what should you have done?

We already know the answers. The current Bristol Pathology Inquiry suggests that NHS management in the city is still deeply dysfunctional and regulators are unable or unwilling to step in, the Oxford Heart Inquiry has shown how we have failed to safely reorganise child heart surgery eighteen years after the Eye blew the whistle, and the Bristol Inquiry chair Ian Kennnedy has just reported on the continued widespread failures in the treatment of children in the NHS.

As the NHS is now facing £20 billion cuts, it’s hard to see how systemic failures of care can be stopped. Most participants at the fringe meeting accepted that some hospitals and units may need to be merged or closed to keep them safe, but ‘asset-stripping’ hospitals is complex and can have knock on effects on other services. The seeds of Mid Staffs were sewn by Labour’s earlier boom and bust in the NHS – John Reid as health secretary spent all the money, leaving Patricia Hewitt to pick up the debt and some hospitals felt obliged to balance the books irrespective of the effects on patient care.

Lansley hopes that getting rid of SHAs and PCTs will at least remove a lot of the top down bullying and suppression of whistleblowers in the NHS, but it remains to be seen whether the alpha GPs who take up the mantle of commissioning have the balls and skills to act on the poor care they discover both in hospitals and GP practices on their patch. For the White Paper to work, doctors have to stop whingeing about management, and start doing it. Clinicians should manage clinical services, but it might be an idea to train them for the task. If we simply transfer the ‘see one, do one, teach one’ mentality of medical training to NHS management, we’ll be courting more avoidable harm.

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July 23, 2010

Dr Phil’s Private Eye Column Issue 1268, July 21, 2010

Filed under: Private Eye — Tags: Lansley, Oxford heart inquiry, White Paper — Dr. Phil @ 2:20 pm

OXFORD HEART INQUIRY LATEST

Just had a phone call from a very reliable source about the Oxford heart inquiry, due to report on Thursday, I believe. Apparently big failures in clinical governance and oversight at trust level, lessons not learned from Bristol etc but despite that, the Oxford unit has asked to be allowed to continue paediatric cardiac surgery. I strongly believe it should remain suspended pending the findings of the latest paediatric cardiac services review. Decision rests with the SHA. Who will take these decisions when there’s no SHA?

Medicine Balls: The White Paper

How does Andrew Lansley’s Equity and Excellence: Liberating the NHS compare to White papers past? Frank Dobson’s 1998 bestseller, ‘A First Class Service – Quality in the new NHS’ gave us 191 mentions of ‘quality’ and promised to ‘publish outcomes to end unacceptable variations in health care.’ A decade later, Lord Darzi gave us ‘High Quality Care For All’ with 359 exhortations of ‘quality’ and a warning that the ‘unacceptable variations that have grown up in recent years must end.’ Lansley is also a firm believer that the way to achieve ‘quality’ (110) and to end ‘unacceptable services’ is to publish ‘outcomes’ (85). But after 13 years of Labour, we have precious little access to robust and valid comparisons of different clinical services. And without outcomes, offering patients ‘choice’ (Darzi 62, Lansley 84) is pointless, and you can’t ‘commission’ (Lansley 184) excellent services.

There will always be variation in healthcare, and collecting and analyzing outcomes to try to understand which variations are due to chance and which to unacceptable practice is both complex and expensive. Labour made little headway and most commissioning was done on the basis of cost. So various PCTs gave Out of Hours Services to a company called Take Care Now because the price was right and they sounded as if they cared. Alas, they employed overseas doctors who didn’t know the patients, didn’t know how the NHS worked and didn’t understand how to use drugs like diamorphine. Dr Daniel Urbani killed David Gray by injecting him with ten times the safe dose because he was exhausted, had poor English and the drug was not routinely used in Germany. Prior to his death, two other German doctors had made similar errors (without causing death) but despite warnings from one of its own doctors that ‘it was only a matter of time before a patient is killed’, Take Care did not take note.

One way to stop doctors giving ten times the dose of diamorphine is to not allow them to walk around with it in their bags. I’ve only ever carried one 5mg ampoule, so why Dr Urbani had 50mg or more on him is a mystery to most GPs. Lansley said before the election that he was going to put GPs back in charge of commissioning out of hours care, and it makes sense that clinicians should help commission and manage the services they know most about. Indeed Lansley is very big on services being ‘clinically commissioned, credible, approved, led and justified.’

But just who are these clinicians? Midwives get 1 citation in Liberating the NHS, nurses 2, pharmacists 2, consultants 5 and GPs….. 75. ‘Manage’ gets 43 citations but ‘manager’ only 3. GPs, apparently, can do it all by organizing themselves into ‘consortia’ (new entry, 64). Lansley has picked up the Tory baton from where it was discarded 13 years ago, just as fund-holding GPs were pooling themselves into multifunds, only to be scrapped by Labour and replaced by PCTs. In seven years as shadow health secretary, Lansley has had his ear bent incessantly by GPs complaining about the control-freakery and lack of clinical understanding of PCTs. So he’s calling their bluff, taking out the Strategic Health Authorities and the PCTs, and giving GPs the responsibility for commissioning nearly everything, while saving £20 billion and making sure the mighty Foundation Trusts don’t hoover up what’s left.

GPs have always seen themselves as NHS gatekeepers, managing as much illness as possible in the community to present precious NHS resources being squandered in expensive hospitals. But emergency admissions to hospital are up by 12% and unless GPs can put a brake on this, they’ll be taking on an impossible job. It’s a bit like being handed the steering wheel just as the runaway coach approaches the cliff edge. And amidst all the financial pressure, it’s hard to see who will find the money to collect and analyze comparative outcomes in a meaningful way to guide commissioning and choice. Lansley’s catch phrase of ‘no decision about you without you’ sounds great for patients (217). But when they ask me which of my local hospitals is best for, say, hip replacements and which is ‘unacceptably poor’, I haven’t got a clue. And I’m supposed to be in charge. Now I must find out which consortium I belong to.

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July 9, 2010

Dr Phil’s Private Eye Column Issue 1267, July 7, 2010

Filed under: Private Eye — Tags: Conservative health policy, Lansley — Dr. Phil @ 2:39 pm

Tory Health Policy

‘Health secretary Andrew Lansley has just spoken to more NHS managers than he will ever do again’. So observed the Health Service Journal after he told the NHS Confederation conference that management costs (i.e. jobs) would be ‘shaved’ by a minimum of £220 million this year. Redundancy packages and Brazillians all round.

According to Lansley, we’ll need fewer managers because targets will be abolished, GPs will be in charge of the money and an independent NHS board will ensure fair play. If only it was that simple. Targets per se are not a bad thing. If you can prove they improve outcomes for patients and the staff are given a degree of flexibility in implementing them intelligently, they work. If you enforce them with a rod of iron, irrespective of the clinical context – as Labour did too often – then they lead to bullying and disillusionment, and harm as many patients as they help.

Too many targets are inevitably counter-productive, like squeezing a tube of toothpaste in ten places at once. Labour’s failing was to believe that the NHS was a linear system, easily controlled by central levers. Doctors have never have been easy to control but any central dogma that clearly isn’t helpful to patients breeds resentment. Lansley is right to focus on outcomes but to improve these, he will need some targets, whatever he chooses to call them. They just need to be relevant and evidence-based.

As for GP commissioning, Lansley wants a ‘full system roll-out’ rather than the patchy adoption of budgets under the previous Tory administration, where GP fund-holders negotiated much better care for their patients at the expense of patients who’s GPs weren’t interested or able to hold their own budget. This year’s model will require 500-600 ‘consortia’ who will be held accountable for £60 billion of spending money by ‘fiscal control and proprietary mechanisms’ of the yet to be established NHS board. And most of this should be up and running by 2012.

Theoretically, it might work. The NHS is a clinical service and clinicians (not just doctors) should be in charge of it, rather than bleating about the management from the sidelines. GPs are generally good with budgets and can hire the cream of the redundant crop of NHS managers to help them spend it wisely, but they’ll also need to involve their hospital colleagues. Some GPs aren’t remotely interested in commissioning, so will need to be herded into consortia with some ‘can do’ enthusiasts, otherwise we’ll end up with the winners and losers of fund-holding.

The Treasury is understandably twitchy about handing so much money over to one clinical specialty, and Lansley’s vision isn’t helped by ‘no-can do’ NHS chief executive David Nicholson, who closed the Confederation conference by saying he doubted the Tory reforms would be ‘anywhere near ready for full implementation by 2012.’ Hardly the rousing call to arms Lansley was hoping for, but perhaps realistic given Nicholson’s failure to introduce GP commissioning under Labour. This was launched in 2005 with a target of ‘100% voluntary coverage’ by 2007, but there has only been sporadic interest. Overall, Nicholson’s commissioning regime was rated ‘poor to mediocre’ by the common’s health select committee. Clearly something needs to be done and Nicholson possibly isn’t the man to do it.

What the NHS needs more than ever was nailed in the Bristol Heart Inquiry 10 years ago: a change of culture. Lansley already has a public inquiry at Mid Staffs in his in-tray and private inquiries into the sacking of Cornish chief executive John Watkinson and Bristol’s dysfunctional pathology service. And there are strong calls for inquiries in East Midlands from allegations by Professor David Hands and Gary Walker, a former boss of United Lincolnshire Hospitals NHS trust. What appears to link all these allegations is a defensive, power-obsessed management culture that bullies whistleblowers into submission. Health care is complex and mistakes inevitably happen. But if we keep hiding them, we keep making them. Perhaps Lansley is right. Time to transfer the power to GPs. We may not have all the answers, but at least we won’t beat them out of you.

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June 21, 2010

Letter to Andrew Lansley

Filed under: Bristol Pathology Inquiry — Tags: Bristol Pathology Inquiry, Carruthers, Havercroft, Lansley, Verita, Watkinson — Dr. Phil @ 5:49 pm

Andrew Lansley has said that “all service changes he NHS must be led by clinicians and patients and not driven from the top down”. This letter to him from patient advocate Daphne Havercroft should test whether he means it.

20^th June 2010

Dear Mr Lansley,

NHS South West – Fitness to be a Pilot Site for recommendations of the Carter Review of Pathology and concerns about transparency of the Bristol Histopathology Inquiry

Patient Advocates in the South West welcome your commitment for NHS service changes to be led by clinicians and patients.

http://www.publicservice.co.uk/news_story.asp?id=13045

“all service changes must be led by clinicians and patients and not driven from the top down”

In the Bristol area, we are surprised and disappointed to find ourselves being subjected to a review of Pathology Services imposed from the top down that has been instigated by NHS South West and NHS Bristol without proper and full involvement of clinical users of the service and patients.

NHS Bristol has produced a review initiation document that states “There is a requirement on Strategic Health Authorities (SHA’s) (sic) to ensure that all PCT’s (sic) develop plans for establishing the consolidation of services into managed pathology networks in the annual Operating Framework for the NHS in England in 2009/10. By 2011/12 the review recommends that consolidated networks should be fully established and performing to the revised quality standards. The South West Strategic Health Authority is to be one of the two national pilot sites to deliver the Carter review recommendations and savings”

Local patient advocates fully support a review of local Pathology Services to modernise, improve quality and safety and deliver cost efficiencies. However the top down imposition of the Carter Review recommendations looks depressingly like a variant of the same top down dogma that people in the South West have endured, without appropriate consultation, by the way in which Cancer Improving Outcomes (IOG) reconfigurations have been implemented.

There is an urgent public debate to be had about the fitness of NHS South West to be one of the two national pilot sites to deliver the Carter review recommendations in the light of the following:

1. Your ordering of an Inquiry into the part played by NHS South West in the dismissal of John Watkinson by the Royal Cornwall Hospitals Trust, including consideration as to whether the SHA “acted appropriately, proportionately, in keeping with its role and within its statutory responsibilities”.

2. Public calls for the suspension of SHA Chief Executive Sir Ian Carruthers, and other implicated South West managers while the Inquiry proceeds.

3. The resignation of a highly respected and experienced patient advocate from a Cancer Group in Cornwall, alleging “bullying and intimidation” by the NHS in the South West.

4. The poor quality of the IOG driven Bristol/Bath Gynaecological Cancer Services Review, where local patient advocate opinion is that clinicians were intimidated and bullied into silence, and similar attempts were made to do the same to patients. We believe local NHS Organisations, including NHS Bristol, tried to avoid their statutory responsibilities to consult and this was because the SHA clamped down on proper consultation, as it did for Upper GI service reconfiguration in Devon and Cornwall. Fabian Richter, Conservative Prospective Parliamentary Candidate for Bath at the 2010 Election, saw for himself the injustices that took place with the Gynaecological Review, including NHS Bath and North East Somerset repeatedly trying to mislead patients and clinicians into believing that implementation of IOG is a legal requirement, when it clearly isn’t, being guidance. We are very grateful to Fabian for publicly articulating the concerns of local people and clinicians.

5. The fact that NHS South West has officially known about the UH Bristol (University Hospitals Bristol NHS Foundation Trust) Histopathology misdiagnosis allegations (now the subject of a UH Bristol commissioned inquiry) since at least August 2008, and has not shown the public that it acted promptly and responsibly to protect those who raised the concerns, protect patients and ensure the allegations were properly investigated. According to a Freedom of Information Response I received from NHS Bristol on 19th June, it is alleged that the SHA knew about the serious allegations before July 2008, a year before they were reported by Private Eye Magazine.

6. The question as to whether NHS Bristol and other local NHS organisations within the NHS in the South West, acted appropriately and responsibly when they first became aware of the Pathology concerns. In NHS Bristol’s case, this was in October 2007 and may even have been before.

7. The extremely disappointing start to the Bristol Pathology Review where it appears that the NHS has tried to appoint a lay representative to its Project Board behind the backs of local people and without giving them any say in patient and public involvement in the Review. NHS Bristol appears to have used this extraordinary incorrect and patronising statement as a reason to exclude patient representation from the Pathology Review:

“We must recognise that patients have little direct contact with pathology services and therefore cannot contribute their own experiences of using the services”.

It seems that NHS Bristol will only allow patient views to be represented through local LINks Local Involvement Networks) organisations. Although I am a LINks member, I believe this is an inadequate substitute for the direct involvement of patient advocates who have actually used pathology services and have a good, basic understanding of the science of pathology and how it is central to diagnosis, treatment decisions and research.

At the root of the Bristol Histopathology Inquiry are these and similar allegations “misdiagnosis of patients with thoracic, gynaecological and breast disease whose histopathology specimens have been reported by pathologists at the Bristol Royal Infirmary. Some of these have had fatal outcomes, and other patients have been treated for malignant disease (e.g. mastectomy and node clearance; intrapleural chemotherapy) when subsequent review showed benign disease.”

In two of the cases the BRI admitted liability and settled with the families. Yet astonishingly, NHS Bristol appears to claim that patients have no useful contribution to make to the pathology review and will only allow tokenistic representation via LINks organisations. In our opinion, based on all the evidence of lack of consultation in the South West mentioned previously, Sir Ian Carruthers is behind this exclusion of patient advocates from direct involvement and decision making in the Pathology Review. The South West has highly experienced, well educated patient advocates and we suspect that Sir Ian fears their ability to best represent patient interests by questioning and challenging the NHS and demanding good evidence and quality assurance to support decision making.

Following the Bristol Histopathology Inquiry, managed by Verita since December 2009, and widely perceived as heading for a whitewash because of secrecy and lack of confidence in the way it is being conducted, Bristol’s Pathology Services urgently need to be reviewed. It is looking increasingly unlikely that patients and the public can entrust such important work to local NHS organisations while they display obvious resistance to allowing the Pathology Review to be led by patients and clinicians, in defiance of Government expectations, and when the fitness of NHS South West, under Sir Ian Carruthers, to be a pilot region for the top down Carter Review, is highly suspect.

South West patient advocates support the recommendations of the Carter Review in principle. However, we fear that in Sir Ian Carruthers’ South West, they will be imposed on us and clinicians without full, open and transparent consultation that meets statutory requirements. We believe that this may lead to less safe and lower quality Pathology services in the South West.

We ask you to consider and advise whether, with its track record of suppressing patient and clinician leadership of NHS service change, and with a Chief Executive widely regarded as fostering a bullying and intimidatory culture, NHS South West is an appropriate and safe site to be a pilot for the Carter Review recommendations.

We would also appreciate knowing the coalition Government’s position on the importance and validity of the Carter Review recommendations in respect of local pathology service reconfigurations. As it is a top down recommendation it is unclear to the public whether it can be easily reconciled with the requirement for all service changes to be led by clinicians and patients, not imposed from above.

As you have asked Verita to conduct the Inquiry into the circumstances surrounding the John Watkinson Industrial Tribunal, we suggest that you may also wish to inquire into public concerns I mentioned earlier about the Bristol Histopathology Inquiry, which is managed by Verita. One of the reasons for the concerns (there are others) is that the Terms of Reference of the Inquiry do not include investigation into role of NHS South West, NHS Bristol (and other local Primary Care Trusts) and the Avon, Somerset and Wiltshire Cancer Services (ASWCS) Network in respect of their response to the allegations. A lesson learned from the Bristol Royal Infirmary Heart Inquiry is that it is important to know from the organisations and individuals responsible for patient safety and quality of care the answer to these questions:- what did you know? when did you know about it? what did you do about it? It appears that NHS South West, NHS Bristol and ASWCS will be protected from being accountable to the public to answer these questions. This is not right.

We also request your intervention to protect our rights and those of clinical users of pathology services to be fully involved and consulted by insisting that NHS South West and the organisations that report to it ensure that any Bristol area Pathology Review is led by local clinicians and local patients, without intimidation and bullying by NHS South West and other local NHS organisations.

Yours sincerely,

Mrs Daphne Havercroft

Consumer Member, National Cancer Research Institute, Breast Clinical Studies Group

Trustee, Independent Cancer Patients’ Voice www.icpv.org.uk

Member, South Gloucestershire LINks

Member, Breakthrough Breast Cancer Campaigns and Advocacy Network

Member, Bristol & Weston Breast Care Services Review Project Board

Independent Patient Adviser, Bristol & Bath Head and Neck Cancer Services Review.

Graduate, Project Lead & Project Lead Clinical Trials http://www.stopbreastcancer.org/index.php?option=com_content&task=view&id=395

copied to:

Steve Webb, MP for Thornbury and Yate

Jack Lopresti, MP for Filton and Bradley Stoke

Fabian Richter

Paul Burstow, MP, Care Services Minister

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