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.

Good for the L&D hospital: leading the way again...

It does the heart good to find your local hospital doing really rather well.

The L&D: glad it's my local hospital

More than once, I’ve commented on the silent ward initiative being pioneered at the Luton and Dunstable hospital just up the road from me. It has the merit of focusing nursing effort on nursing – as opposed to answering phones, completing paperwork or dealing with administration generally. Equally admirable was the investment it was making in Discharge Planning (where my wife worked for a while): hospital nurses, district nurses and social workers worked out of a common office in the hospital, to ensure that patients could be discharged quickly but safely, with all the necessary support services in place.

Now it seems that the L&D is leading the way in another key area. I wrote the other day about the work being done by University Hospitals Birmingham, under the leadership of Chief Executive Julie Moore, on keeping up permanent staff numbers. So I was pleased to see a report on ITV about how the L&D is at the forefront of this kind of work too.

It quoted Chief Nurse Patricia Reid:

It doesn't matter how good an agency [nurse] is – and some of them are absolutely brilliant. The fact is the way they work they are in different hospitals some days, on different clinical wards, and that impacts on the continuity of patient care and undoubtedly impacts on long term quality.

Much the same point as Julie Moore was making: she reported that their own studies found that as soon as there were two or more temporary nurses on a ward, care quality suffered. You need your own people, used to working in your own teams, who know the patients and the processes on specific wards.

In addition, and the ITV report makes this clear, interviewing Jeremy Hunt, Health Secretary, on the subject, expenditure on agency nursing is far too high – twice expected levels. It must be cut for financial reasons, which makes it all the more satisfying that the result is likely to be an improvement in quality, not a loss.

That’s a real case of win-win.

Like University Hospitals Birmingham, the L&D is working deliberately and resolutely to cut its dependence on agency staff.

Now, I’d rather not have to go there if I possibly can. But just in case I really can’t avoid it at some time, I’m delighted to know that my local hospital – alongside Julie Moore’s – is right up there in the forefront of enlightened thinking.

Let’s hope that all the other hospitals soon follow in their wake.

Bad arguments about healthcare: if you can't stop them, at least give as good as you get

Marc de La Val had built an enviable reputation for complex cadio-thoracic operations on babies, at Great Ormond Street Hospital, the most prestigious children’s hospital in Britain. But then things started to go wrong. 

The always fascinating David Spiegelhalter, Professor of the Public Understanding of Risk at the University of Cambridge, recently told the BBC what happened:

‘A cluster of his babies died when he was doing these really difficult operations for transpositions of great arteries, and then he actually wrote a paper about how he stopped and retrained and changed the way he did the operation, and after that he was very successful, but he had this real blip, this real cluster of failures, and he nearly gave up...’

Spiegelhalter: well worth listening to

Spielgelhalter maintains that it was careful analysis of the data that showed that de Laval hadn’t just been unlucky, that there really did seem to be something going wrong with his surgeries, something he had to fix.

That was one surgeon. Outstanding, a practitioner to seek out, then dangerous, a surgeon to avoid, and then outstanding again.

And no doubt many of the other surgeons at GOSH were achieving excellent results, even at that time. When de Laval was struggling, the department might well have been fine overall. It was only he who was having bad outcomes.

But sometimes it isn’t just individuals. Whole departments can be in trouble. I worked at one time with the Bristol Royal Infirmary, when there were terrible problems in paediatric cardiac surgery that led to a major scandal and the closure of the department; but much of the rest of the hospital was performing more than adequately.

In fact, I’ve spent 30 years working with healthcare information, and if it’s taught me anything, it’s that there’s no such thing as good or bad hospitals; there are often good or bad departments in hospitals; more often still, there are good or bad practitioners within departments within hospitals; and as de Laval’s case shows, there can be good and bad moments in the career of an individual surgeon within a department within a hospital.

So I look on with wry displeasure when I see yet another scandal about bad hospitals in England. A report has just been published into fourteen hospitals that were giving cause for concern. It had been extensively leaked before publication, and we were softened up for hearing of 13,000 avoidable deaths across the 14; we were told that heads would have to roll.

In fact, the report was much more intelligent than that. It identified failings and errors that needed correcting, but it pointed out that these hospitals were already correcting many of them. In addition, the heads that could be made to roll were in many cases new people in post for a relatively short time, brought in to put right what had gone wrong under predecessors who had resigned or been forced out.

But that didn’t stop Jeremy Hunt, the Health Secretary, making a real meal of the report – and, in particular, using it as a stick to beat his opposite number, Andy Burnham. He’s an unusual opposition spokesman, Burnham, in that he had been Health Secretary at the end of the previous government: most shadow ministers can’t be attacked for their own track record in the post, because they don’t have one. Burnham can.

And Hunt went for the gullet. The problems at these hospitals had arisen under the previous government and so they were Burnham’s responsibility. He should take the blame, resign his position and slink off into obscurity.

Burnham fortunately wasn’t having any of it. For instance, in connection with one of the hospitals, Basildon and Thurrock, he pointed out it was one ‘on which I placed a warning before the last Election. The news that this hospital has cut 345 nursing job from its front-line workforce should be greeted with real alarm.’

In other words, the present government has had three years to fix the problem. Instead it’s pursued policies that have led to serious cuts in staffing levels. That’s likely to have made the problem far worse.

Hard to see how Burnham’s to blame.

These exchanges do prove one thing, though. However inappropriate it may be to try to judge the quality of an entire hospital, it’s a brilliant way of turning healthcare into a political football between the major parties. And there are serious electoral points to be made from doing so.

Moreover, the attitude that says that heads have to roll is likely to be particularly out of place, as de Laval’s story shows. Sometimes, the people responsible for poor performance are actually excellent practitioners, they’re as devastated as anyone over the failures, and they only need the opportunity to improve again. But calling for retribution is much more effective with voters.

So it’ll go on happening. The mere fact that the argument is based on flawed premises doesn’t make it less effective politically. Which means the recriminations will go on being hurled.

Pretty miserable stuff. Which leaves me with only one consolation: at least Burnham gave as good as he got.

Not before time. This is a government that specialises in handing out low blows, few lower than trying to blame problems it’s failed to address on a man who's been out of office for three years. It was good to see him hitting back. 

It’s been one-way traffic for far too long.

A worried NHS fan, as young as his heart but older than his lungs

It’s not the cough what carries you off, runs the Cockney saying, it’s the coffin they carry you off in.

My cough, with accompanying wheezing, has lasted on and off for the whole summer. I use the word ‘summer’ here in the calendar sense. A cough that lasts two weeks is neither here nor there, really, and that’s the summer we’ve had by the weather. But I’ve had this recurring irritation pretty well since June.

So today I decided it was time to follow my wife’s advice and visit my GP. Or rather not the GP, but the nurse practitioner, a wonderful institution: people with great wisdom rather than learning who can deal with the minor conditions effectively, efficiently and with great affability.

I got tests galore. From my height and weight to my lung capacity. Over a couple of visits it must have taken two to three hours. And apart from the kindness and professionalism I met, one of the striking features of the whole experience was that it was all free. No-one asked me to produce an insurance document. No-one asked me to provide evidence that anything had been pre-approved by some bureaucrat somewhere. Above all, no-one asked me for a credit card.

It always amazes me when friends or colleagues look at the States, where healthcare costs twice as much, and tell me how much better things are over there. Yeah, right.

Not that things over here are all that safe. The poor old NHS has been put through the wringer over the last couple of years by Andrew Lansley, one of the most inept Health Secretaries it’s been my misfortune to come across. He’d had five years as Opposition spokesman beforehand, which suggested he might know what he was talking about, but it was obvious as soon as he got into office that he didn’t have the faintest idea.

We’ve just had a cabinet reshuffle, the opportunity for a competent prime minister to replace dead wood by fine new brains. Unfortunately, instead of a competent prime minister we have David Cameron. I couldn’t think of anyone who might make a worse Health Secretary than Lansley, but Cameron is unbeatable: he’s found just the man.

I’d forgotten about Jeremy Hunt, Culture Secretary, who gave a lamentable performance before the Leveson enquiry into press standards (for which read lack of standards). He’d revealed himself to be entirely a pawn of the Murdoch family interests, with no control of either his department or his advisers. Basically a walking disaster area. I’d written him off as a man whose career was over and who would be returned to the back benches at the first opportunity.

That was to reckon without Cameron. Step forward our new Health Secretary: Jeremy Hunt. If you want an accurate assessment of the man, just remember that Cockneys like to use rhyming slang.

However, if things don’t look too good for the NHS, so far the results of my own tests have been encouraging, to the point that I’m beginning to be concerned that the condition will turn out to be mostly psychosomatic, a kind of man-wheeze, if that’s the pulmonary equivalent of man-flu.

The best finding was that produced by some little testing machine (so it must be true) that I have the lungs of a 55-year old. If you’re not impressed by that, well it’s because you’re too young. From where I’m sitting, that’s satisfactory news.

Except that I’m worried about the 55-year old. Whose lungs has he got?

Great if they're in good shape. But whose are they?

And it must be time my mother came clean with me. She never mentioned the double-lung transplant I had at four. I think I should be told.

Spads, Spuds, a Hunt and a skinned Prime Minister

Those who have been following the Hunt saga with bated breath won’t need any introduction to its salient points. Just in case, however, there are readers in some remote and benighted corner of the world like the United States, who haven’t been enthralled by this edifying tale, here is the gist of it.

Firstly, it has nothing to do with pursuing a fox to extinction. That activity has been banned in Britain for many years, a matter on which we liberals congratulate ourselves with great satisfaction even though the practice continues unabated, with the police turning the kind of blind eye towards it that they reserve for the misbehaviour of the ruling classes.

No, in this case the quarry is the Hunt himself. More specifically, it is Jeremy Hunt who is our Minister of Culture. If you tend to think of ‘culture’ as the kind of thing a life scientist produces in a lab in order to grow large numbers of unpleasant bugs, then you’ve probably got a pretty accurate picture of the man.

It has recently been revealed that he, or at any rate his office, had been far too close to Rupert Murdoch’s empire, at a time when Hunt had to adjudicate over an acquisition which the Murdochs were keen to make and which would have been very lucrative to them.

It has to be said that Hunt has shown all the honour we expect of him, and allowed a special adviser to fall on his sword on his behalf.

I didn’t get much further with this story because at about this point the article I was reading began to refer to this special adviser as a ‘spad’. I’d forgotten that this was the familiar term for these characters. My problem is that I can’t see the word without thinking of ‘spud’, the humble potato that naturally bears so little resemblance to the noble spad.

But then, on the other hand, perhaps they’re not that different. We used to have a chain of shops int this country, and possibly in others (perhaps including the benighted States), called ‘Spud-U-like’. It used to serve jacket potatoes which you could take with any of a wide range of toppings. They always smelled mouthwateringly good and turned out to be rather disappointing: once the topping, the superficial attraction, was gone all you had left was a mushy pile of starch with little flavour and even less nutritional value.

Which, come to think of it, isn’t that different from a spad.

Meanwhile, the hunt for Hunt goes on. Yesterday Members of Parliament summoned the Prime Minister to come and talk to them about the affair. David Cameron looked deeply upset at being treated this way.

‘Me? They dare to summon me? To appear in front of them?’ He looked like Charles I, the last British monarch convinced of his divine right to rule, a delusion Cameron probably shares.

Playing the role of Cromwell to Cameron’s Charles was one of the great institutions of the House of Commons, Dennis Skinner. Despite being eighty, Skinner can still wield a mordant wit as sharp as any executioner’s axe. He asked the Prime Minister whether he was protecting Hunt out of a sense of self-preservation, knowing that if Hunt went he, the Prime Minister, would have to face the ‘bullets’ himself.

‘Well, the honourable gentleman has the right, at any time, to take his pension and I advise him to do so,’ Cameron quipped back.

Oh dear, oh dear. I’ve always thought that the saying ‘the truth never hurts’ revealed particularly limited understanding of life. Didn’t Cameron prove the point? If Hunt goes, he certainly is the next in the firing line. And that truth has got him so rattled he can no longer control his temper. Not even in Parliament.

Perhaps he ought to remember what happened to his illustrious predecessor who believed he ruled by the grace of God. Charles I also treated parliament and certain hard-hitting parliamentarians with contempt.

Look where that got him.

The moment Charles I realised he could have
chose his tactics more judiciously