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.