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.

 MD