My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Mid Staffs: What I might have done better to improve the policy and culture of the NHS.

Filed Under (Failure regime, Francis Report) by Paul on 20-02-2013

Part 2: The failure to create a failure regime

One of the long term mistakes has been the failure of policy to clearly develop, publish and use a failure regime for the nation’s hospitals. Whatever else we learn from Mid Staffs, we must recognise that a considerable number of local people felt that this hospital was failing them. Yet I am still not clear if, several years later, Mid Staffs is labelled a falling hospital or not.

That fact it has failed is clear. Whether anyone has had to nerve to categorise it in this way is less clear.

This has been a policy area that has been fraught with political failure. Several governments, including the one for which I worked, have failed the public by failing to develop, publish and use a regime that clearly and consistently uses the label ‘failure’ to describe a hospital.

In 2000 the NHS plan made it clear, not only that there should be a simple red amber and green rating system for the nation’s hospitals, but that there should also be a regime which clearly labelled a hospital as ‘failing’ and had a policy to deal with that.

But in fact the development and application of this policy over more than a decade has been weak.

Compare this to education – where the first school was labelled as failing 20 years ago.

Let’s look at where we are today.  South London Healthcare Trust had the administrators sent in because it had failed economically. But the point made by the Public Accounts Committee was that we don’t know the criteria that determined that administrators should be sent into this hospital – and not to any of the others that can only pay their staff because money is stolen from the rest of the NHS to subsidise them.

In quality and safety terms we don’t really know what the failure regime looks like.

Two weeks ago this led the Prime Minister, in his statement in reply to Francis, to ask Monitor to develop what he described as a ‘unified’ failure regime.

We all know why there has been a decade-long failure to construct a failure regime. It is a collective failure of nerve by the political class (including me in my time in Government).

Most of the public believe that all NHS hospitals provide a similar standard of service. As far as they are concerned the NHS brand is a badge which guarantees both quality and their safety.

ALL of us in the system have long known this is not true.

But it took a catastrophe like Mid Staffs to acknowledge this.

It’s true that some Government policy helped patients at Mid Staffs. In the past they would have had to keep going to the hospital because they had no choice. Developing the policy which gave patients the choice to go to a different hospital was hugely controversial. It took row after row with the various aspects of the NHS to say that the public had the right to choose where to go.

This is one area where I don’t have to apologise because we faced down that opposition and implemented a policy of choice.

What did this mean for people at Mid Staffs?

On February 10th BBC news carried an interesting report on a Freedom of Information request. This had been published on the BBC Stoke and Staffordshire web site.  This showed that the current CEO of Stafford hospital had found that the number of patients who had chosen to go there through the ‘choose and book’ system had fallen from 15740 in 2007/8 to 6513 in 2012/13.

This is a really significant statistic. Because people could choose two third chose not to go.

It is the case that many outside the NHS may find it very odd that as many people as 6513 are choosing to go to a hospital which has been so systematically labelled as bad.

This is the first time I have seen a set of figures which so powerfully demonstrate the choice of the public not to go to a certain hospital. 2 people out of 3 are choosing not to go to Mid Staffs compared to 5 years earlier.

These choices are costing the hospital £3.7 million a year and will be one of the reasons why Monitor has had to look carefully at whether the hospital has a future.

The policy of choice enshrined in the NHS constitution gave people the right not to go to a certain hospital, but because we did not have the nerve to develop and implement a failure policy, we left it all up to the individual.

I am pleased that we gave people choice. But I am ashamed that we didn’t clearly say that failure was failure and decisively act upon it wherever and wherever it took place.


7 Responses to “Mid Staffs: What I might have done better to improve the policy and culture of the NHS.”

  1. It is difficult to understand the clearly parallel world that people like you live in, Paul. You had a golden opportunity to develop and enhance the NHS by attempting to fund it up to EU average. The mistakes that were made were mostly policy ones (Internal Market, Re-organisations, Performance-related pay, privatisation of services – starting with OOH, Darzi Centres and PFI): the list is a long and inglorious one of spectacular policy failure. The blinkers are on and you have no idea what it has been like to be a Jobbing Doctor in a deprived area of the UK.

    I was hoping for an insightful analysis of policy failures: all we are getting here is an apologia pro vita sua.

    Disappointing analysis.

    PS When I started in GP I could refer anywhere in the country if I chose. Who stopped that? Policy makers. Now you tell me it was one of your achievements. Small beer indeed.

  2. Choice has been welcome, but we shouldn’t assume that real choice is actually possible. An example from my own experience. My wife recently gave birth, and during the pregnancy we moved into South London Healthcare Trust near Farnborough Hospital. Having looked at the figures and so forth online we were clear that we did not want to have the baby in that hospital, and wanted to choose St Thomas’ or Kings. However all the midwives and doctors we consulted insisted there was no other option for us due to distance, and so we were forced to ‘choose’ the hospital we didn’t want.

  3. Choose & Book covers only a small part of the referrals to Mid Staffs.

    When you check the Monthly Hospitals Activity Data, GP Referrals to Mid Staffs (covering both Cannock Chase and Stafford Hospitals) show only a small decline from 60804 in 2008/09 to 56640 in 2011/12, ie about 7%, which appears to be continuing through 2012/13.

    Perhaps it is more disturbing that GPs continued to refer patients to Mid Staffs despite its reputation.

  4. There is a disconnect here. Choose and book is predominantly foot outpatient and elective clinical episodes. The death rates were for whole Trust and the failures in care described were mainly for acute clinical episodes. It demonstrates that the public cannot distinguish the complexity of the data presented to them.

  5. The reforms of this government will only further confusion. Already private ambulances operate with the NHS logo on their sides, preceded in small letters by ‘working in partnership with’. The NHS is at risk of becoming a franchise which will make a unified policy for such failure even harder. It also runs the possibility of making institutional failure more likely as economic factors domiate competition, and institutional memory and learning across the whole NHS is lost.

  6. Second point:

    “This is the first time I have seen a set of figures which so powerfully demonstrate the choice of the public not to go to a certain hospital. 2 people out of 3 are choosing not to go to Mid Staffs compared to 5 years earlier.”

    To use that statistic the way you have you have to assume that people in the area are being referred at the same rate, the same proportion are doing so through choose and book and it would be nice to see some evidence that people from the same catchment area were actively choosing to go elsewhere. A simple drop in C+B referrals tells us nothing.

    Also was there a 66% dropped in outpatient new referrals to match this astonishing drop in C+B activity?

    Was it not that C+B was being enforced as the only way to refer, and that many GPs simply don;t use it now.

    It makes for a great headline but I am not convinced by the relevance of it as presented.

  7. A failure regime for hospitals doesn’t work because you can’t close a hospital in the way you can a school- there isn’t the spare capacity in the system. In trying to fix a broken health economy you get into the kind of complexity with unintended consequences we have seen at South London. And then the story becomes much more difficult for the public- because hospital A has failed, hospital B has to lose its A&E.

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