Austerity? Not good for your health

In 2008, the Healthcare Commission, the body then charged with monitoring and improving care quality in England, published a report into lamentable failures in Stafford hospital, run at the time by the Mid Staffordshire NHS Foundation Trust. Mid Staffs, as it’s familiarly if not affectionately known.

The scandal that ensued revealed shocking levels of poor care which certainly caused great suffering to many patients, and a certain number of deaths. Just how many deaths is difficult to determine. Headlines at the time of “400 to 1200” excess deaths were deeply misleading, as was the report that established that number, by Dr Foster Intelligence, a healthcare analysis company.

Insofar as the number means anything, it is that there were that many more deaths than would have been expected given the levels of illness recorded among the patients treated. That figure does, therefore, depend on the records kept by the hospital, which weren’t necessarily as comprehensive or accurate as they might have been. Besides, no one has ever established that the “excess” deaths were actually avoidable, which would have been a truly devastating finding.

Indeed, Robert Francis who wrote the report into failings at the Trust, would comment, “…it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care.”

Nevertheless, in November 2015 Mid Staffs pleaded guilty to four charges of causing the death of patients, so it’s clear that there were deaths as a result of the poor performance of the Trust, whether or not we can set a reliable figure on the number.

Incidentally, by the time of the guilty plea, Mid Staffs Trust had been dissolved more than a year and the Stafford Hospital, now the County Hospital, was being administered by the University Hospitals of North Midlands NHS Trust.

In his report, Francis identified a number of causes for the failings. Prominent among them was one that had been broadly acknowledged in the general debate: poor levels of staffing, especially among nurses. In its sometimes desperate quests to be granted the status of NHS Foundation Trust that gives hospitals greater autonomy in managing their affairs, Mid Staffs had gone too far in slashing staff numbers to meet financial targets. The Francis report recommended an action on the National Institute for Healthcare Excellence (NICE):

The procedures and metrics produced by NICE should include evidence-based tools for establishing the staffing needs of each service. These measures need to be readily understood and accepted by the public and healthcare professionals.

After the report was published, the government commissioned another, from US Healthcare analyst Don Berwick. It echoed Francis’s views on staffing:

NICE should interrogate the available evidence for establishing what all types of NHS services require in terms of staff numbers and skill mix to assure safe, high quality care for patients.

Admirable idea. What should determine staff numbers is quality and safety of care. Certainly not financial considerations. Nothing could matter more for us: if we’re seriously ill, and admitted to hospital, it would be nice to know that the level of service provided is based on what we need, not on what the hospital can afford.

Or, put another way, if the choice is between an increase in public spending, or the kind of dangerous care that gave Mid Staffs such a bad name, few would choose the dangerous care.

Except, sadly, that too many of us nonetheless vote for people who will make precisely the opposite choice. Those people won’t, themselves, suffer from that choice. The Camerons and Osbornes of this world don’t have to depend on the NHS for healthcare: they can pay for what most of us have to hope will be provided free. So they choose to prioritise money over care.

It was obvious from the beginning, from when Berwick make his recommendations in August 2013. Health Minister Jeremy Hunt rejected the notion that there should nationally backed standards for staffing:

If you start mandating things from the centre you create an artificial target and hospitals and trusts say: well if we meet that national minimum we’ve done our job as far as staffing’s concerned when actually they haven’t – because you’ll find there are places that need a lot more help and a lot more care.

This is a neat argument: it says we’re not accepting a recommendation because we don’t think it goes far enough – but then you don’t do anything at all.

Two and a half years on, few recall the Berwick report. Even the Francis report and Mid Staffs has become a bit of a vague memory: wasn’t that the hospital that did so badly when Labour was in power?”

NHS Nurses: much applauded at the Olympics 2012 opening
But have we now decided we have too many?

So now’s a great time to put the squeeze on, when people aren’t watching that closely any more. And that’s just what’s happening. Faced with a £2.2bn deficit, NHS hospitals are being told to cut staff to get their finances under control. The Guardian quoted Richard Murray, director of policy at the King’s Fund healthcare consultancy, saying:

If trusts do begin to reduce headcount the impact on patients would be swift, through either rising waiting times or reduced quality of care or both. Three years on from Robert Francis’s report into Mid Staffs which emphasises that safe staffing was the key to maintaining quality of care, the financial meltdown in the NHS now means that the policy is being abandoned for hospitals that have run out of money.

The government has long since decided that its overriding aim was reducing the deficit, and ultimately cutting public debt. It’s achieved some reduction in deficit but debt has grown like topsy, making George Osborne Britain’s first ever trillion-pound Chancellor. So austerity has failed.

I don’t know how anyone dependent on the NHS might feel about healthcare being sacrificed for the sake of a failed economic policy. I don’t know how anyone dependent on the NHS might feel about generalising the standards that fuelled the Mid Staffs scandal. I don’t know how anyone dependent on the NHS would want to risk giving that lot another chance in power.

Bad hospitals: a convenient myth

There’s no such thing as a bad hospital.

When I made that statement a couple of weeks ago, it was met with some derision. That’s hardly surprising, particularly in the light of yesterday’s news that the Mid Staffordshire NHS Trust is to be wound up: as well as Cannock, it runs Stafford Hospital which has become a healthcare horror story, the hospital we all love to hate. That’s all of us except, strangely enough, the population of Stafford itself, who have been running an increasingly active campaign in support of their hospital.

Stafford Hospital: notoriously run by Mid Staffs NHS Trust
now about to be dissolved.

The scandal broke back in March 2009. A report gave a catalogue of shameful failures of care. But, more specifically, the press focused on the finding that between 2005 and 2008, between 400 and 1200 more people died there than might have been expected. Now that really set the alarm bells ringing. Up to 1200 excess deaths? A place of healing seemed to have turned into a killing field. No other judgement about the hospital could possibly have been as devastating.

So it’s curious that when the Francis report into the shortcomings of Mid Staffs was published in February 2013, it made no mention of this devastating statistic.

The figure came from Sir Brian Jarman, a professor at Imperial College London and one of the founders of healthcare information service provider Dr Foster Intelligence (DFI). It was based on DFI’s vaunted ‘hospital standardised mortality ratio’, the flagship of the indicators the company has developed to evaluate hospital care.

Why wasn’t it included in the final report?

Because it is extremely difficult to interpret in practical terms. It seems to be saying that there were up to 1200 avoidable deaths in the hospital, but it decidedly does not mean that. Studies since have shown that a great many of the ‘excess deaths’ reflected factors entirely unrelated to care quality, such as including in the hospital’s mortality figures patients who were already dead on arrival, or not making allowance for the terminal patients who were there for palliative care only and were simply being nursed to a humane death with no hope of recovery.

A 2009 study of 50 questionable deaths in the hospital revealed that just one of them might have been preventable.

So the Francis report detailed many completely genuine instances of poor care but dropped all mention of the mortality figures that caused so much noise in the first place. The failings identified led to departures and even, recently, to two nurses from the particularly criticised Accident and Emergency area being struck off. The new management has made major efforts to correct shortcomings, efforts vindicated when the Care Quality Commission (the body that monitors hospital performance) officially declared that all its concerns had been addressed.

Dr Foster has also given the hospital a clean bill of health.

Oddly enough, though, that  last statement doesn’t suprise me. It’s not the first time DFI has given a favourable judgement on Stafford. Hunting through my old posts recently, I came across one from December 2009. It mentioned that Dr Foster had published a new study and again created quite a stir by identifying the ‘dirty dozen’ of ‘worst’ hospitals in England.

In that study, Dr Foster used fifteen metrics to evaluate hospitals. All of them were tightly defined, even in some cases narrowed to a single operation. For example, one concerned a particular technique for gall bladder removal. So a hospital whose General Surgeons used that specific technique well would score highly on that measure; with only fifteen being taken into account, that would probably have a major impact on its overall standing too.

Equally, a hospital with general surgeons who were not particularly competent in that approach might find its rating seriously depressed. And yet General Surgery is just one of the 25-30 specialties in even a small hospital like Stafford. The gall bladder indicator tells you nothing about any of the other specialties.

More generally, just fifteen metrics are far too few to give a clear view of performance across all specialities, or by the whole body of staff, which at Stafford is nearly 3000 strong.

That didn’t stop DFI publishing its performance ratings of hospitals based on fifteen indicators. Poor old Stafford, I can imagine you saying, being castigated again. But have no fear: it wasn’t. Far from it. On that terribly narrow range of DFI indicators, Mid Staffs, far from being one of the dirty dozen, was categorised ninth out of 146 around the country.

And that was based on data up to March 2009, the very period for which Stafford Hospital was being crucified for appalling performance.

Excellent confirmation, if any were necessary, that trying to define good or bad hospitals is an impossible task, especially if you use a highly limited range of indicators to assess them.

In fact, to get a real idea of performance across the whole range of services within a hospital would take many dozen indicators, far more than any organisation such as DFI, other companies or even the health service have the means to measure. And even if the full range were available, how could they be combined into a single value reflecting whether the hospital as a whole is ‘good’ or ‘bad’? How does one weight poor performance in cancer care (very serious) against excellence in delivering babies (huge volume)? How long must patients wait in Emergency services to cancel out the benefit of having an enviable record in avoiding hospital acquired infections?

No-one can answer those questions. Which is why I maintain there’s no such thing as a good or bad hospital: there’s no way of saying that one hospital, taken as a whole, is either particularly bad or particularly good. It’s much more likely that it will be under-performing in some areas and doing well in others.

That’s why when the dust settled, the people of Stafford became upset that in the aftermath of the original scandal, the hospital’s Accident and Emergency services were cut down to daytime only (8:00 a.m. till 10:00 p.m.) At any other times, people requiring emergency hospital care travel to Stoke (20 minutes by car) or Wolverhampton (25 minutes). Alternatively, they hang on for the local service to open and join the massive queues that now form at the entrance: Stafford, like most places around the country, has seen a big increase in Accident and Emergency attendances.

As a result of yesterday’s decision, Cannock hospital is now to be brought under the management of Wolverhampton, and Stafford hospital under Stoke’s. Will that make things any better? Only if management by executives remote from the place where services are being delivered is likely to lead to better performance than was achieved by local control.

Why have we reached this position?

Because life’s a lot simpler if we can identify a whipping boy and vent our animosity against it.

Because Stafford Hospital is synonymous with bad quality and there is mileage for politicians in running it down, and no mileage at all in defending it.

Because, in short, there’s nothing easier or more likely to generate good press coverage, than to attack a ‘bad hospital’.

Even though we all ought to know there’s no such thing.

Among all the noise about the NHS, a little quiet should be a great improvement

There’s been a lot of noise in Britain recently about the failings of the National Health Service.

Popular anger, or at least anger in the media, has focused above all on the Mid Staffordshire NHS Trust. The scandal has its roots in a study by hospital information company Dr Foster Intelligence, which found that 400 more people had died in the hospital over a three year period than might have been expected given how ill they were. A public enquiry revealed a harrowing string of cases of appalling care: patients suffering dehydration because they weren’t given anything to drink, patients left in their own faeces, patients left to suffer in pain as buzzers rang wildly throughout the wards with no nurses answering.

There’s been less talk about the people who sent flowers and chocolates to the hospital, to thank the nurses for the care they or their relatives had received, though some of those making the gifts have been among the most outspoken in their criticism since. Equally, not a lot is said of the encouragement the Trust was given to opt for the much vaunted status of a ‘Foundation Trust’, even at the cost of economies that left too few nurses to ensure adequate coverage. Nor is much said of the findings, again from Dr Foster, which classified the hospital ninth in the country for quality.

Instead, those orchestrating the media noise seem to be intent on directing outrage against nurses, once universally seen as angels, now increasingly portrayed as fiends.

The truth is that in a professional body of 370,000, there are bound to be a few rotten apples. But, overall, the vast majority of nurses are deeply committed to caring for patients, just as nurses always have been: it is after all the overriding motivation for choosing the profession in the first place. But the government chooses to proclaim that nurses have lost their compassion and demands, for example, that in future nurses have more hands-on care of patients – washing them, feeding them – as part of their training, to teach them the compassion it’s alleged they have lost.

This from a government that has just imposed the deepest cuts for a generation in benefits for the poorest people in Britain. But then I suppose we don’t all have the same notion of compassion.

It should also be said, in passing, that the government has launched a programme of reform of the NHS which seems destined to fragment it and undermine its public service commitment. That will encourage the government's friends in the private sector, who want to take over apparently lucrative parts of healthcare, although few of those who’ve tried so far have made any money from it and the scandals about quality from private providers have already begun.

Against this background, I was fascinated to hear of an initiative in my local hospital, the Luton and Dunstable, or ‘L&D’ as we fondly call it. 

Instead of responding to the problem of patients ringing buzzers to no avail by demanding that nurses answer them more quickly, the hospital is planning to do away with buzzers altogether. Rather than giving nurses more non-nursing duties, as the government seems to favour, they’re recruiting more clerical staff to free up qualified staff to concentrate on nursing.

The L&D: quietly improving where others just shout

The hospital has been piloting the idea of a ‘quiet ward’. The approach is widespread in Germany, which is where the L&D came across it. I believe something similar was tried in Gwent, in Wales. In England, however, it’s an innovation.

On a quiet ward, there are no buzzers, phones or faxes. There is a nurse and a healthcare assistant for every ten patients. Nurses are freed of tasks such as cleaning, ordering x-rays, coordinating discharges, answering phones or making beds. Instead, that work is carried out by support staff. 

This means that the nurse and healthcare assistant can devote far more of their time to nursing, including simply walking the ward and checking on patients’ welfare. So patients can expect to see a nurse far more quickly now, without a buzzer, than was ever possible by ringing one before. And without buzzers, phones or faxes the ward is quieter so the patient's experience better.

The pilot at the L&D went so well that the hospital is now rolling out the approach to other wards, and recruiting 105 ward clerks and other staff to support it. 

Without all the recriminations and impassioned debates that surrounded Mid Staffs, the L&D is quietly making radical changes in its approach to nursing, with the profession’s enthusiastic support. The pilot suggests the new arrangements will greatly improve healthcare quality.

It remains to be seen whether our ‘compassionate’ government will support this pioneering initiative by a hospital in the old, public and much-maligned NHS.


Postscript. On Mid Staffs, I was amused to see that 40,000 local people – or possibly 50,000, depending on who you believe – turned out to march through Stafford to try to save the hospital, now slated for closure. The difficulties the hospital experienced were always on the front pages, but the support march  received very little coverage. The march is just boring old news; the high death rates, on the other hand, were a story.