Our Scary NHS - 3

Maybe he should have a crack at the NHS

According to government health adviser Professor Sir Brian Jarman, ministers and officials could have saved at least 20,000 lives had they listened to his warnings over dangerous NHS hospitals.

Jarman is the co-founder of the Dr Foster company, which provides comparative information on health and social care services. Among other things it produces statistics on hospital mortality rates (Hospital Standardised Mortality Ratios - HSMR) that flag up hospitals with significantly higher levels of mortality than the average. Jarman says their stats identified the problem at mid-Staffs long before any official action was taken, and similar issues at other hospitals now finally being reviewed by the government. He says:

“Those hospitals which had persistently high death rates over all those years and have now been listed for investigation should have been investigated earlier, because it’s quite possible we would have had fewer deaths in those hospitals... [there] must be at least tens of thousands of avoidable deaths in those hospitals alone, when we should have been going in and we should have been looking at them”.

In just the 14 hospital trusts* now being reviewed by the government, he reckons excess deaths number "a bit over 20,000".

This is bad enough. But even worse is the fact that even when Jarman flagged up his concerns directly to Labour Health Secretary Andy Burnham, nothing was done. In March 2010 he sent Burnham a list of hospitals with significantly high death rates and nothing happened. Nothing.

It's not hard to see why. Because March 2010 was just two months before the last election. No way would Burnham - or any other Health Secretary - have wanted that blowing up during the campaign. With politicians at the controls, patient safety must always come second to political imperatives.

Not that Burnham ignored Jarman outright. According to Burnham's own account, he referred the matter to the Care Quality Commission, who "did not find that there was anything to worry them". Further, Jarman's HSMR data was "new" and "the government could not put it's full weight behind it".

Hmm. Here we have an officer of the state, warned that his state owned industry is going seriously off the rails, and relying on his own state commission and own state statistics to check it out. Does that sound like a recipe for customer safety?

Now, nobody's saying Burnham's a bad man. True, he's a politician, but just like every other Health Secretary in living memory he found it impossible to manage our huge NHS to deliver as he (and his customers) would have wished. He found himself as one against one-and-a-half million staff, staff who know far more about their business than he could ever hope to find out. And if his managers choose to tell him there's nothing to worry about, how can he possibly hope to find out what's actually going on down at ward level? As always, information is power.

Which is why the current Health Secretary, Jeremy Hunt, is now making it a criminal offence to fiddle NHS stats. In future, anyone cooking the figures for hospital mortality, or waiting lists, or anything else in the NHS, will face a jail sentence and their employing trusts will be fined millions. Hunt says:

“This is about a transparent, honest and accountable NHS. Patients and the public should be confident that they can trust information about how hospitals are performing, and a culture of honesty and accuracy will help those organisations drive up standards of care."

A new culture, yes, that's what we need all right. But can criminal sanctions deliver it? Out East, they have plenty of criminal sanctions to support the right culture - and we're talking sanctions that are a tad more bracing than three months in Ford Open Prison. Yet their new management team inherits a state behemoth with all the NHS problems plus a few more besides.

"President Xi Jinping told the nearly 3,000 delegates gathered at Beijing’s hulking Great Hall of the People that his government would “resolutely reject formalism, bureaucratism, hedonism and extravagance, and resolutely fight against corruption and other misconduct in all manifestations.” Shortly afterward, freshly appointed Premier Li Keqiang said the central government would slash its payroll and freeze spending on overseas trips, guest houses, office buildings and new vehicles in response to falling revenues. “The central government will lead by example and all local governments must follow suit.”

Formalism, bureaucratism, hedonism, extravagance, corruption, and other misconduct in all manifestations. Well, maybe the NHS hasn't quite ticked all of those boxes yet, but on my count it's done at least four out of six.

Good luck to the reformers, both out East and here in the NHS. But meaningful reform in big organisations whose customers have no choice is next to impossible.


*Just so you know, here are the 14 hospital trusts now under review for having significantly higher than average death rates:

• Basildon and Thurrock University Hospitals NHS Foundation Trust
• Blackpool Teaching Hospitals NHS Foundation Trust
• Buckinghamshire Healthcare NHS Trust
• Burton Hospitals NHS Foundation Trust
• Colchester Hospital University NHS Foundation Trust
• The Dudley Group NHS Foundation Trust
• East Lancashire Hospitals NHS Trust
• George Eliot Hospital NHS Trust
• Medway NHS Foundation Trust
• North Cumbria University Hospitals NHS Trust
• Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
• Sherwood Forest Hospitals NHS Foundation Trust
• Tameside Hospital NHS Foundation Trust
• United Lincolnshire Hospitals NHS Trust

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Our Scary NHS - 2

Postponing our appointment

"The UK has had universal free health care and public health programmes for more than six decades. Several policy initiatives and structural reforms of the health system have been undertaken. Health expenditure has increased substantially since 1990, albeit from relatively low levels compared with other countries.... However, the UK performed significantly worse than the EU15+ for age-standardised death rates, age-standardised YLL rates*, and life expectancy in 1990, and its relative position had worsened by 2010."

Today's report in the Lancet is a timely companion to yesterday's blog. Not that it tells regular BOM readers anything particularly new about the under-performance of our nationalised healthcare system, but the facts need to be known much more widely, and this Lancet study has certainly grabbed the headlines.

The study focuses on premature death, and as we've blogged many times, compared to its counterparts just across the Channel, the NHS is pretty poor at keeping us alive. In the BOM book we summarise the key figures on premature death, including our low survival rates for cancer and heart disease. In fact, every year around 50,000 of us - the population of Salisbury - die from diseases which should in theory have been treatable (so called Mortality Amenable to Healthcare). Of course, no healthcare system manages to prevent all such deaths, but the European social insurance systems do much better.

And although our life expectancy has increased hugely under the NHS, nobody can seriously argue that's down to the NHS itself. While life expectancy has increased by around 13 years since the NHS was founded, in the previous five decades it had increased by 20 years. These are worldwide trends, and they reflect improvements in medical knowledge and diet much more than the efforts of our underperforming NHS.

However, despite the headlines, the Lancet article did not set out to be an NHS hatchet job. Rather, it puts the blame for our poor showing on our own unhealthy lifestyles - too many horse burgers and not enough press ups. And the report's authors clearly want more state intervention to control our unhealthy lifestyles. More public health programmes, more booze taxes, more fat taxes, more sugar taxes, more indolence taxes, etc etc.

You can certainly see how you get there - if we could all be hassled or forced into living healthier lives, we'd almost certainly live longer and probably save the NHS a shed-load of cash. It's exactly the kind of thinking that drove Labour's anti-obesity programme, although somehow they never did get round to fat and sugar taxes.

Except of course, that's not how the better performing countries do it. Although France, Spain, and Italy all outperform us in this study, my own extensive research suggests that their booze taxes, at least, are an awful lot lower than ours. The issue is rather more complex than comparative tax rates and public education campaigns.

What this study really highlights is that when it comes to health, we have a lot to learn from our neighbours. None of them have a nationalised health system, yet most of them enjoy longer healthier lives than us. Instead of pretending our healthcare system is the envy of the world, we should have the humility to look and learn.

PS I've just been listening to Sir David Nicholson being grilled by the Health Select Committee. I must say I admire the guy's sheer nerve. Yes, he says, terrible things happened at mid-Staffs while I was in charge of the regional health authority, but I knew nothing about it. Barclays tried that one, but Diamond still had to walk the plank. And even if Nicholson didn't know, he surely should have done. As we've said many times on BOM, you can delegate authority, but you can never delegate responsibility.

*YLL is Years of potential Life Lost

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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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Oink

With a cheep-cheep here, an oink-oink there, and a total confusion everywhere

For reasons we needn't go into, Tyler is what the NHS describes as immunocompromised. No, it's not what you think, but it does mean he received a call today from Sharon at his GP group practice.

Sharon informed Tyler he was in an at-risk group, and therefore needed to come in for the Swine Flu jab.

"Wha!" said Tyler. "The new experimental quatermass vaccine... but, but... is it safe?"

"Oh, yes," said Sharon, "it's under the government vaccination programme. It's all been tested and it's perfectly fine. And actually I see you haven't had the normal seasonal flu jab - we'd better do that at the same time."

So what to do?

Clearly, you'd be mad to say yes just because the government wants you to.

For one thing they're a bunch of serial incompetents, and for another, they are proven liars.

Why would they lie about the safety of swine flu vaccine? Well, because this is one of those public health issues: the more people they can get vaccinated, the less likely it is that we'll have an epidemic. And as we've blogged before, when it comes to public health, governments follow traditional Stalinist principles: "one death is a tragedy, a million is a statistic". In other words, they're not bothered if a few dozen Tylers go down under the needle, as long as the herd gains immunity.

This calls for an urgent consultation with Dr Google.

Now let me see... "swine flu vaccine"... yikes! Google immediately suggests "swine flu vaccine deaths" with 13.1 million results.

So... "Swine flu jab link to killer nerve disease: Leaked letter reveals concern of neurologists over 25 deaths in America... The letter from the Health Protection Agency, the official body that oversees public health... tells neurologists that they must be alert for an increase in a brain disorder called Guillain-Barre Syndrome (GBS), which could be triggered by the vaccine. GBS attacks the lining of the nerves, causing paralysis and inability to breathe, and can be fatal." (Daily Mail)

Gulp.

In Sweden there have been four vaccine-related deaths. Or is it six? Accounts seem to vary. And come to that, how do we know the deaths don't run into hundreds, and there's been a cover-up? The bodies could easily be stored in a cordoned-off frozen fish factory - they must have loads of them up there. Obviously they'd keep that pretty quiet, so how are we supposed to find out?

Or what about this in Time Magazine - Time Magazine! - "...the vaccine is tainted with antifreeze or Agent Orange, causes Gulf War syndrome, has killed U.S. Navy sailors... the vaccine is an "evil depopulation scheme."

Jeepers! That's it! No way is Tyler getting pumped full of Agent Orange.

Oh, wait. Time goes on to say "these claims are nearly pure bunk", and that "the crop of falsehoods about the H1N1 vaccine... are potentially... dangerous, since they encourage the credulous to avoid vaccination at all costs."

Hmm.

OK, so what does the NHS itself say about vaccine safety?

"The swine flu prototype vaccines have been clinically tested and shown to produce good immune system responses, and have an acceptable safety profile. The insertion of the H1N1 strain into the vaccine should not substantially affect the safety of the vaccine in the same way that annual modifications to the seasonal flu vaccine do not."

There they go again. What exactly is an "acceptable safety profile"? Acceptable to whom? Stalin's Commissar for Collectivised Health?

In a complete muck-sweat, Tyler finally turned to the one man he could trust to cut through the doublespeak - the good Dr Crippen. What should Tyler do?

Unfortunately, the Doc is himself now under heavy medication, having gone down with a nasty bout of H1NHS gravis.

Apparently he was exposed to a whole series of confusing and largely incomprehensible circulars from the Chief Medical Officer at the Department of Health, believed to have been triggered by the recent outbreak of swine flu vaccination fever.

So at the Doc's suggestion, and suitably masked up, Tyler examined the latest of these circulars, the one that gave the order for Sharon to ring Tyler. Under the Stalinesque identifier of Gateway 12870, it orders NHS operatives like the Doc "to maximise the level of uptake of the vaccine amongst the priority groups". Operatives are further instructed to access further vital campaign plans at Gateways 12241 and 12781.

Unfortunately, when you actually try to access those vital further Gateways, all you get is this:

"Error page

We are sorry but the page you are looking for cannot be found. It may have been removed, had its name changed or be temporarily unavailable."

Is it any wonder the Doc is a wreck. After months of trying to follow this kind of gibberish, the poor fellow's immune system is shot. Jabwise, he has no more idea what the Commissars are asking him to do than you or I. Only Sharon seems sure.

Although, now we come to think of it, what about Sharon? Is she going to have the jab herself? According to recent polls, roughly half of nurses (and GPs) are going to refuse. They obviously know something the rest of us haven't been told.

Which leaves Tyler in a quandary.

You see, although now immunocompromised, Tyler is old enough to have picked up some of the natural immunity oldies seem to have to this swine flu. For example, he got very ill in the 1957 Asian flu epidemic.

So is it worth risking a shot of Agent Orange now?

Tricky.

But one thing's for sure: all the guff so expensively pumped out by the Department of Health is not going to help him decide one jot.

PS What will the vaccine cost the NHS? Needless to say, the government refuses to tell us, but according to the World Health Organisation, the cost per dose is $20. So if, as the government apparently expects, three-quarters of us get the jab, it will cost $900m, or around £0.5bn.

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