Monday, March 04, 2013

Our Scary NHS


The bald facts**

Two years away from blogging, and it's time to check how the NHS is doing under its current consultant Mr N.H.S Cameron.

We have to start with mid-Staffs. It ought to be old news - we started blogging it in 2009 - but last month's Francis Report has shone an even more scary light on how an NHS Foundation Hospital (yes, a Foundation Hospital!) managed to kill as many as 1200 of its patients.

I've been reading the report, intending to quote some of the many personal accounts of horrific standards of care meted out to patients: loved ones left lying for hours in their own urine and faeces - their cries for help ignored by staff - left without food and water, illnesses made worse rather than cured, and bed sores, broken bones, gashes, and hospital infections just a routine part of the grim patient experience.

But the more I read, the more upsetting it became. These are real people talking, and to use their anguished accounts merely to make a blog point feels grossly intrusive and disrespectful. So let's simply quote Robert Francis's own summary:
"I heard so many stories of shocking care. These patients were not simply numbers they were husbands, wives, sons, daughters, fathers, mothers, grandparents. They were people who entered Stafford Hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives."
As for management claims that the original press reports had been exaggerated:
"A number of staff and managers at the hospital, rather than reflecting on their role and responsibility, have attempted to minimise the significance of the Healthcare Commission's findings. The evidence gathered by this Inquiry means there can no longer be any excuses for denying the scale of failure. If anything, it is greater than has been revealed to date. The deficiencies at the Trust were systemic, deep-rooted and too fundamental to brush off as isolated incidents."
The harrowing events at Mid-Staffs highlight many of the critical NHS failings we've blogged in the past. In fact the Report sometimes reads like an excerpt from BOM:
  • target-driven priorities – a high priority was placed on the achievement of targets, and in particular the A&E waiting time target. The pressure to meet this generated a fear, whether justified or not, that failure to meet targets could lead to the sack.
  • disengagement from management – the consultant body largely dissociated itself from management and often adopted a fatalistic approach to management issues and plans. There was also a lack of trust in management leading to a reluctance to raise concerns.
  • low staff morale.
  • isolation - not as open to outside influences and changes in practice
  • lack of openness - One particular incident concerning an attempt to persuade a consultant to alter an adverse report to the coroner
  • acceptance of poor standards of conduct – an unwillingness to use governance and disciplinary procedures to tackle poor performance... incidents of apparent misconduct which were not dealt with appropriately, promptly or fairly.
  • denial – In spite of the criticisms the Trust has received recently, there is an unfortunate tendency for some staff and management to discount these by relying on their view that there is much good practice and that the reports are unfair.
The management of the Trust clearly bears a heavy responsibility for all this, and the Report shows how they made a series of ill-informed and ultimately catastrophic decisions about resourcing and organisation. It also shows how they routinely dismissed and suppressed criticism, even when confronted with the cold hard statistics of rampant death on their wards. 

Ah yes, those cold hard mortality statistics. BOM always tries to support argument with stats, but when it comes to public sector performance, the stats so often turn out to be damned lies, fabricated to hit targets and tick boxes rather than illuminate the truth. And so it seems to have been with hospital deaths.

The problem is that not all hospital deaths have been counted in a hospital's official mortality stats. For example, hospitals were allowed to exclude the deaths of those receiving palliative care (ie terminal patients who were merely being given pain relief while they died). So at the Wolverhampton Hospital, deaths recorded under palliative care were bumped up from 2% to 20%, double the national average; deaths from other causes - the ones that did count in the official stats - were correspondingly reduced. The Royal Bolton Hospital seems to have pulled a similar stunt with septicaemia deaths, which are also excluded from official mortality figures. And there are probably countless other examples around the country.

Now of course, all of this took place under the previous regime, so we can't blame Mr N.H.S. As a Conservative he fully understands the disastrous consequences of the old Stalinist regime, He's pledged to abolish targets, stop box-ticking, and enforce accountability via the criminal law if necessary.

Well, er, he kind of suggested that's what he'd do. What he's actually done seems to fall some way short.

Most extraordinarily, he has not fired the Chief Executive of the NHS - Sir David Nicholson - even though at the time of mid-Staffs disaster Nicholson was first in charge of the local Strategic Health Authority, and then CEO of the entire NHS. Long-time readers may also recall that when we first encountered him at a Public Accounts Committee hearing in 2006, we were somewhat less than impressed. He should be gone.

And then there are those targets. I've perused the Department of Health website desperately trying to pin down what's actually happened to them, but I'm blowed if I can work it out. It's possible they've largely been abolished, although I'd need to do much more digging to find out for sure. And on the ground - ie down in the hospital wards - personal experience just before Christmas suggests the nurses are still spending just as much time ticking boxes and filling in forms, rather than caring for patients.

Besides, even if the targets and the tick-boxes have gone, there's a much more fundamental problem with the NHS. And it's one that bubbles just under the surface of the entire Francis Report: the insidious effect of unaccountable institutionalised power. 

We've recently seen how corrosive this can be in other organisations, from the Catholic Church to the Liberal Democrats: powerful men abusing their positions, and even when they're discovered, continuing to enjoy the protection of an institutional cover-up. And in the case of mid-Staffs, Francis spells out how staff felt intimidated by management, making them reluctant to report problems, still less blow whistles. From the disassociated fatalism of the consultants through to the cowed cowering nurses, nobody was prepared to stand up for fear of losing their job.

But most striking of all is what Francis has to say about the complicity of patients and their relatives:
"Patients’ attitudes were characterised by a reluctance to insist on receiving basic care or medication for fear of upsetting staff."
We all recognise this. We've all been there. If you complain, are you just going to make things even worse? You or your loved one are in an extremely vulnerable position, entirely dependent on the service provided by staff. If you piss them off, who knows what might happen? You are stuck, and your only hope is to schmooze and nudge them into doing the right thing.

Being a member of the sharp-elbowed middle class, I like to think I'm fairly good at doing that. Disgusting myself, I'm prepared to use every trick in the book - crawling, sympathy, flattery, the works. Often that does the trick. But it shouldn't be necessary, and what if you're no good at it? And what if it fails? Personally, I've developed a technique of suggesting escalation to higher authority without actually threatening  to do it: more along the lines of "look, I can see you're doing your very best, but you're obviously stretched beyond the limit, and I've got to consider my sick child. I'm seriously concerned and I can't just stand by... who would I talk to?"

Of course, if this was Tesco, you wouldn't need to do any of that. You'd just take your business elsewhere - no fuss, no schmooze, no problem. Or rather, there is a problem, but it's Tesco's not yours. And either they ensure there can never again be horsemeat in their value meals, or their biz nosedives.*

The power of choice and competition. The power of simply being able to take your custom elsewhere. The power of a paying customer rather than a helpless supplicant. So much more direct and effective than hoping Mr N.H.S can somehow sort the problems before we get killed.

* Apologies to Lost Nurse for getting back on the Tesco worship so soon. We do realise that healthcare is not quite the same as groceries, and we will try to limit our grocery sermons.

** Excellent graphic from MHP Communications.

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