David Oliver: Are we recreating the conditions that led to the Mid Staffs scandal and Francis inquiries?

david_oliver_2015I am worried that we are heading right back to the very conditions that led to the Francis inquiries, losing any progress we have gained on the back of them. In health, as in many industries, it often takes a major incident or scandal to prevent more from occurring in the future. But let’s not go back to it.

It’s now six years since the report of the independent inquiry by Robert Francis QC into events at Mid Staffordshire NHS Foundation Trust from 2005-9. It’s still a powerful testimony of a hospital whose culture was broken. The report described leaders more interested in finance, targets, achieving foundation status, and strategy than operational performance; losing sight of their very human business of caring for patients and their families and becoming disconnected from the clinical shop floor.

Concerns repeatedly flagged from complaints or safety incidents were minimised and not seen as key business for the executive. The stories from patients and especially their families remain harrowing. How could anyone be oblivious? As a career NHS clinician, the accounts of frontline patient facing staff—either inured to poor care and poor leadership or feeling powerless to speak out—still shock me.

Although Mid Staffs was probably an extreme case of such failure at scale, I have never kidded myself that examples of equally poor care couldn’t have been going on in other areas of other hospitals, nor that poor leadership and values were unique to Staffs. Still it was a long time ago, wasn’t it?

The second, public, Francis inquiry reported in 2013. Its focus was on wider factors in health policy, leadership, training, values, regulation, and accountability. Francis focused strongly on recommendations to change the climate in which hospital trusts operate and on the responsibilities of hospitals themselves.

Most of his 292 recommendations were accepted by the government in their response “Patients First and Foremost.” Those not accepted were telling. No compulsory registration for NHS managers akin to that for health professionals, nor for the healthcare assistants who deliver so much daily hands-on care. No mandatory safe staffing and skill mix levels for nurses.

I know that Francis came in for some criticism; notably, for providing legalistic solutions to clinical and organisational problems, and for saying that hospitals needed freedom from endless regulations, performance management, and “initiativitis” burden, while making so many recommendations. As a frontline clinician, also involved in national leadership and advisory roles, I will stick my neck out: I think far more good than bad has come from Francis.

In my view, we now have far more dialogue about quality and safety. We have far more public facing information—for instance on incident rates, staffing numbers, performance indicators such as mortality or readmission rates, and patient feedback. The “fit and proper persons” test and safeguards for whistleblowers aren’t working well in practice yet and are still attracting deserved criticism. But at least they exist.

I have been a fierce critic of the Care Quality Commission, its methods and attitudes, but at least there is more rigour and transparency to the process and a rebalancing of what is inspected.

Yet for all my cautious welcomes, I can see us recreating the same conditions for failure that Francis identified.

For starters, there’s the money. Mid Staffs happened at a time of relative plenty in the NHS after year on year of increased investment during the Blair years. Outside the government spin machine, all serious commentators agree that the acute sector now faces major unbridgeable funding deficits. Mid Staffs’ leaders wanted to cut the hospital’s pay bills to get foundation status. But the end result is the same.

Social care, meanwhile, has suffered swingeing cuts since 2010, with consequent impacts on preventable admissions to hospital and the ability to discharge patients home or tackle delayed transfers of care. And remember, Francis highlighted the care of frail and vulnerable older patients as the biggest problem at Mid Staffs—the very group hit hardest by these cuts.

New NHS England workforce numbers have shown how much we were underestimating the true extent of current workforce problems. There are actually 15 000 fewer nurses, midwives, and health visitors and 3000 fewer doctors than government ministers were claiming in 2015. Nine in 10 acute hospitals in England are short of their own target nursing establishment. While in England, Wales, and Northern Ireland there are more than 23 000 nursing vacancies. We have major rota gaps in much needed acute medical specialties and workforce problems in allied health professions.

Against this backdrop, the government claims to have an electoral mandate to stretch the service even further to provide “the first fully seven day health service in the world” with hospitals “staffed to deliver services over seven days.” This despite performance now slipping not just on finance but in key waiting time targets, such as the four hour waiting time in emergency departments, two weeks for cancer referrals, or 18 weeks for planned surgery. Now is not the time to exert yet more pressure on a flagging system.

Francis’s call for safe staffing guidance has also gone awry. After saying a firm “no” the government then commissioned the National Institute for Health and Care Excellence (NICE) to review the evidence linking numbers, training, and skill mix of nurses to patient outcomes (there is plenty by the way) and produce national safe staffing guidance. However, not long after this work was given to NICE it was announced that it would be taken over by NHS England, raising fears that NHS England lacked NICE’s objectivity and would be susceptible to pressures to prioritise cost over safety.

Francis called for transparency. Jeremy Hunt, in a speech setting out his vision for the NHS, also called for intelligent use of transparent data. However, not only have we got the national workforce numbers and workforce planning wrong, the government refused to release the risk register for Andrew Lansley’s disastrous 2012 Health and Social Care Act. And we still aren’t allowed to FOI private contractors for health services due to commercial sensitivity.

We had months of an industrial relations dispute over a draft junior doctors’ contract that noone had seen, and which was only put on the NHS Employers’ website and leaked to the media on the eve of the first strike. The Department of Health press office has also relentlessly spun information regarding the contract. And Jeremy Hunt has repeatedly refused to be corrected, even by authors of studies on weekend mortality or the journals publishing these papers, about misinterpretation and over-claiming of the data.

Finally, Francis criticised the heavy handed “command and control” culture—focusing excessively on finance and “targets and terror”—prevalent in the NHS at the time of events in Mid Staffs. The Lansley Bill, in its stated aim to “reduce bureaucracy,” disbanded strategic health authorities and primary care trusts, thereby removing operational NHS leadership from the Whitehall Department of Health to the “arm’s length” of NHS England.

Lansley wanted organisations to focus “on outcomes that matter to patients,” not “clinically irrelevant, politically motivated process targets.” He also wanted the secretary of state for health removed from operational interference with NHS matters—delegating authority to the commissioning board.

As the real scale of NHS austerity has hit, with the £22bn funding gap completely undeliverable by efficiencies, NHS leadership has now inevitably reverted to type. There is huge pressure from the centre to reduce and contain costs (most of which are on staff salaries—hence “headcount”) and a whole new bureaucratic apparatus to ensure this.

The pressure of the same old targets we had back in 2005-9 is still there—even more so. And the current secretary of state has further subverted the Lansley vision by clearly involving himself in a series of operational matters, not least those concerning seven day services and doctors’ contracts.

I will leave you where I started. These are just the conditions in which the next Mid Staffs type scandal is almost bound to happen. It might come to light sooner. It might be going on right under our noses as we speak.

No wonder King’s Fund chief executive Chris Ham, generally an inscrutable, impartial figure not prone to hyperbole, said in a recent Guardian Column that Mr Hunt now faces his “Iain Duncan Smith” moment. Having set out his vision for an NHS focused on safety, quality, and transparency, yet lacking the finance or workforce to deliver on this and having caused completely avoidable crises in morale, recruitment, and retention in the medical workforce, it may be time for him to go.

If we do have another public inquiry into another scandal there will be no reputational hiding place for him or his government or for those in national NHS leadership bodies.

David Oliver is a consultant physician at the Royal Berkshire NHS Foundation Trust.
He was seconded to Whitehall until 2013 as national clinical director for older people.
He is currently president of the British Geriatrics Society and writes the weekly “Acute Perspective” column in
The BMJ.

Competing interests: None declared.

  • Stephen Bolsin

    I admire David’s optimism but the reality check is that Ara Dharzi believes <5% of NHS incidents are reported and it is now estimated that in the US systemic healthcare error is the 3rd largest cause of death after heart disease and cancer (1)(2). Solutions to this uncomfortable state of affairs have been suggested including feedback of outcome data and professional performance monitoring (3,4). More radical remedies have also been suggested including moving beyond the 'principlism' of medical ethics (5)(6). Using modern management speak to frame the issues, while appearing drastic in scope such transformational approaches may be the ‘disruptive’ solutions required to deal with what is a truly ‘wicked’ problems in healthcare.

    References

    1. N. Yu, A. Flott, K. Chainani, G Fontana DA. Patient Safety 2030. London; 2016. Available from: http://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/centre-for-health-policy/Patient-Safety-2030-Report-VFinal.pdf

    2. Makary MA, Daniel M. medical-error—the-third-leading-cause-of-death-in-the-US. London: BMJ Publishing Group Ltd.; 2016. p. i2139. Available from: http://www.bmj.com/content/353/bmj.i2139

    3. Bolsin S, Chan D. Measurement of competence: achieveable goal or “holy grail”? Br J Anaesth. 2015;114(6):867–9.

    4. Stephen N Bolsin, Cawson E, Colson ME. Revalidation is not to be feared and can be achieved by continuous objective assessment. Med J Aust. 2015;203(3):142–4. Available from: https://www.mja.com.au/journal/2015/203/3/revalidation-not-be-feared-and-can-be-achieved-continuous-objective-assessment

    5. Bolsin S, Faunce T, Oakley J. Practical virtue ethics: healthcare whistleblowing and portable digital technology. J Med Ethics. 2005;31(10):612–8.

    6. Bolsin S, Saunders K. Evolving medical ethics. Trends Urol Men’s Heal 2012;3(3):22–4. Available from: http://dx.doi.org/10.1002/tre.264 DO – 10.1002/tre.264

  • david oliver

    Thanks for the thoughtful and informative contribution Stephen and thanks for your ongoing leadership in this area. I am not sure i would describe a blog in which i tell the world we are heading for more Mid Staffs type disasters thanks to funding, demand, workforce and confused regulation as “optimistic” though. God knows what a pessimistic or dystopian blog might look like!

    David