Category Archives: Stafford hospital

Insulin, badly drafted law, & the threat of No win No Fee claims.

An increasing amount of time at the Stafford Hospital inquiry is being spent on looking into the circumstances surrounding one individual case.
A press report of the inquest of this case is here.
Last week we heard from the Health and Safety executive who unexpectedly found himself at the centre of the Stafford Hospital mess. He came under astonishing pressures from a number of different directions to use a legislative loophole and open up a legal case.
The HSE took the best advice it could get and backed away from this action, for reasons that were very thoroughly explored in the evidence.  The HSE may have had a theoretical power to act, due to a very loose piece of legislative drafting on an old bill, but taking action in this particular case would set precedents that would have had major implications for all of us. 
The main function of the HSE is to protect the health and safety of people at work. Their 500 inspectors cover the entire working environment for the entire country. They have to prioritise their work. Within hospitals they are often concerned with matters like safe lifting, techniques, they also have some requirement to look at the safety of the premises and equipment.  Here are examples of work that they have done in a hospital setting. The delivery of treatment is not normally considered to be within the remit of the HSE. This is covered by other regulators, and therefore the HSE is instructed to avoid duplication of effort.
The arguments for using this legislation to take this particular case are highly unusual. The case might potentially be winnable, but the effects of this would potentially to a huge increase in the numbers of health and safety claims in all manner of working environments. It would require a massive increase in the numbers of HSE inspectors, and it would mean taxpayers and insurance payers channelling a lot of public money through No Win No Fee lawyers.      
We frequently hear from the press about the unintended consequences of over use of Health and Safety legislation. Here is the most recent example.

This quote is in relation to school trips but does flag up the worrying impact of a claims culture

The people behind unreasonable rulings were often “well-meaning but misguided jobsworths” who go too far, said Hackitt, adding that many organisations imposed restrictions not out of concern for people’s safety but due to fears of no-win no-fee lawsuits for personal injury. Other bodies used the guidance as a cynical excuse to cut services, she added.

This government is keen to reduce red tape and the number of burdensome insurance claims.

The particular case at Stafford is about the failure to give insulin at the right time. This is clearly wrong, The Coroner is clear that it did contribute to the death of a very sick lady, and the family have every reason to be hurt and angry.  

I was certain that I had heard that this is in fact an extreme example of what is a very common occurrence.

I found this study from the US.

The Patient Safety Alert follows a review of 16,600 patient safety incidents involving insulin, reported to the National Reporting and Learning System (NRLS) over a six year period between 1 November 2003 and 1 November 2009. Six deaths and 12 incidents resulting in severe harm were reported. Of the 16,600 incidents, 26 per cent were due to the wrong insulin dose, strength or frequency and 20 per cent were due to omitted medicine. Patients being prescribed or dispensed the wrong insulin product accounted for 14 per cent of incidents.
The NPSA analysis shows the main categories of failings.
administration of a wrong dose,
● administration to the wrong patient,
● use of the wrong insulin type,
● administration via the wrong route,
● wrong timing of doses,
● omission of doses,
● failure to properly adjust insulin therapy, and
● improper monitoring, timing, and assessment
of blood glucose (BG) results.
One of the main things that many families want when their family member has been involved in a tragedy of this nature is to ensure that lessons are learned and that other families should not suffer in the same way. They often have a very generous wish that other people should benefit from the mishap that they have suffered. If we look at the actions being taken by NPSA we can see there is now a detailed programme to improve the care of patients with diabetes in hospital. This will involve a widespread training programme for staff and new safety protocols.
I have no way of knowing if all this was triggered by this individual case, but if it was then it is a major achievement for the family. If this has the effect of reducing the very substantial numbers of insulin related incidents that take place in our hospitals all the time, then they can have the satisfaction of knowing that they will have made a substantial difference to health care.  
It would be good the think that this knowledge, in addition to the great many apologies the family have received may go some way to healing the hurt.
As to taking the case through the courts, maybe for some families there does need to be a way to do this.  It is clear that there was at the time of this incident a real gap in the powers of the Health Care commission. The Inquiry evidence shows us that the clear focus of the HCC was to learn from things that went wrong, and work to improve matters. It was not their remit to focus on individual cases.  That goes a long way to explaining the very real frustration suffered by the families. I am sure that Robert Francis will be ensuring that in the future there are simpler and more effective ways of a addressing the needs of families who feel that the problems they have suffered crosses the line into injustice.
The HSE would certainly see it as preferable that this should not be done through the legislation that they have to operate. They do not believe it would be in the public interest, and I think the figures I have quoted on insulin related cases above indicate that they may well be right.  Cases related to insulin would just a tiny proportion of the potential cases that no win no fee lawyers could seek to bring if this particular legislation was to be used.
The local and national press have been campaigning for justice for the individual family. I am sure that Robert Francis will be taking a great deal of trouble to find a solution that is good for this family and good for the wider public interest.
When we do campaign for a particular course of action it is I would suggest always worth listening very carefully to those individuals who have detailed knowledge of what this would imply; People who can show us the unintended consequences of the actions we take. We need to be careful what we wish for.

What the Ombudsman said.

When I first heard about what would become Cure the NHS, right at the end of 2007 it became immediately apparent to me that there had been a failure of the complaints system at Stafford Hospital.  This raised big questions for me then, and it continues to do so now.
The ombudsman matters.  This is the end of the road for complaints. It is our guarantee that if someone has suffered injustice or hardship as a result of failure of the service, or failure to provide a service or, maladministration, that their case can be examined.  You will find more about the service here
Ann Abrahams is clear that the ombudsman is very much a last resort. People only come to her when they have exhausted other possibilities. For some people this works, and for other people and Julie Baileys evidence shows that this includes her, the process is frustrating.
The ombudsman has to work within the clear confines of a act.
what the ombudsman is empowered to investigate is a complaint that a person has sustained injustice or hardship in consequence of service failure or maladministration.
The case has to satisfy both of these requirements.
Often the cases are not cut and dried. Here is an example that Ann Abrahams used to illustrate the problem
So it may be that somebody comes to us and says: there was a delay in diagnosis and as a consequence, my loved one is no longer with us, and if that diagnosis had been done when it should have been done, because, you know, the referral time for — for tests had been adhered to, then my husband wouldn’t have died. And — and we can look at that and we can, with the benefit of expert advice from our clinicians, we may well be able to say that: yes, there should have been a referral and there should have been a diagnosis, you know, six months previously; but we may also be advised by our professional advisers that it would have made no difference; and therefore that the consequence in terms of injustice as the complainant, you know, quite reasonably believes it to be the case, actually isn’t sustained as a result of one of our investigations. So, you know, the — the two legal concepts of service failure and injustice have to be both present and the injustice has to be as a consequence. That’s what the law gives me to work with.

THE CHAIRMAN: But presumably in a case such as the one you mention, an injustice might be identified in terms of the distress caused by the late diagnosis, even if it has no physical causative effect. 

A. Absolutely, chairman, and I can think of a number of cases in — in which what we’ve concluded is that the – the outcome in terms of the person’s death may not have been any different, but that doesn’t mean there has been no injustice.

There was a discussion on the concept of “worthwhile outcome”.  This is something which is not defined in law, but has been used by the ombudsman’s office as an internal measure to test if anything meaningful can be achieved by pursuing a complaint. There is a clear meaning for this within the office, but this can be less clear to other people.
Ann Abraham says that this has been flagged up by the parliamentary select committee as a concept that can cause offence to some complainants, and they are going to review the use of the language.
For Ann Abrahams what she is trying to identify is if the ombudsman’s action can achieve what the complainant wants. If it can’t do that then is it in the wider public interest? If the complaint has specific wishes like seeking the disciplining of an individual doctor then this is best pursued by other means.
 if somebody is really concerned about the professional conduct of an individual clinician, and that’s what’s eating away at them, then there really isn’t any point in the ombudsman taking that case on for investigation, because at the end of that, we might, if we felt there was sufficient concern about the professional conduct of an individual, make our concerns known to the relevant professional regulator, but it would be a very indirect way of supporting the outcome the complainant was looking for.
There may be cases where there is no point in trying to do more than has already been done in other ways.
And in a case where something may well have been seriously substandard, but the NHS body has acknowledged that and accepted that and apologised for that, and there has been an appropriate remedy for the individual, and there has been an appropriate systemic remedy put in train, and there’s been learning, and the regulator is on the case in terms of follow-up action, then I would say, and I think my staff would say: what is to be gained by an ombudsman investigation for this individual and for the wider public interest in these circumstances?
Ann Abrahams feels strongly that the right way is to aim for local and immediate response to complaints. This shows some of the work being done to establish better complaint handling. They have been supporting the process of improving the complaints process at a local level by visits and training sessions with the 50 trusts with the highest complaints level. With the first of these there has already been a major drop in complaints to the ombudsman.
( I will add my own suggestion here, It may be that the process they are trying to bring about here needs to mirror that of the NSPA, where the aim is to increase the level of low level reporting – which could here be comments or concerns – with the aim of raising issues before they ever reach the stage of being complaints )
She Reacts to Health Select Committee’s report
I suppose I’m always concerned with recommendations which seek a change in the law, when actually what people want is a change in behaviour and it may well be that my office needs to behave differently and we needto use some different language, but I don’t think there’s anything in the legislation which stops us doing that.
She is keen that there should be no major structural changes. It has taken from 2002 to 2009 to get the system to current 2 stage process and she is certain this is the right solution
Previously there was a three stage process, starting local – then going through Health Care commission and then ending up with ombudsman.  The fatigue of dealing with this cumbersome system could well have deterred people from complaining.
The new system is working faster. Ann Abrahams sees complaints coming through now within 6-12 months. Previously it was much longer.
The Inquiry wanted to know why are there so many more complaints?
in 2010 to 2011 you received 13,625 enquiries.
The Healthcare Commission during its time as the second stage received roughly 8,000 referrals  a year.
Ann Abrahams did not have an answer to this.  (I would personally suggest that this may be to do with greater prominence of these issues in the press we have seen that the patients association had to increase its staffing levels from 2 to 6 following the publication of the HCC report, and that there have been a stream of high profile reports, which will all have had the effect of increasing the likelihood of people complaining.
Ann Abrahams was asked if this might reflect worse handling of complaints at a local level. She does not think this is the case. Her caution is that we should try to understand the story, rather than try and deduce the story from the numbers.
The inquiry looks at numbers of contacts, and the numbers that were pursued to investigation . in 2009-2010 there were 15,579 contacts, and only 219 interventions and 349 accepted for full investigation. Ann Abrahams was at pains to say that the presentation of the is data may be a little misleading, and there may be an element of double counting, but she agreed with Robert Francis that investigations were a tiny proportion of total complaints.  This is useful to know as it puts Julie Baileys disappointment that her case did not proceed to investigation into a wider context. The most likely reason why her case did not proceed was that by the time a decision was made she had already been very heavily involved in the healthcare commission report. and the David Colin Thome report and Alberti Report had already taken place. The steps to learn from and remedy the issues her case raised had already been taken and it was unclear that any further benefit could be gained from pursuing an ombudsman’s investigation.
There was some discussion about if it is right that the numbers should be so small? Ann Abrahams thinks that it is. The priority should be to improve the quality of local complaints handling, so that complainants are not subjected unnecessarily to long, drawn out processes.  She feels that the NHS has a long way to go before it can be said to be offering a good complaints service.  In the 2010-2011 year only 2 trusts did not have a complaint to the ombudsman.  
if the NHS is doing the sort of job it should be doing, in resolving complaints locally, and the ombudsman is the last resort in that; well, what size should the ombudsman’s office be? What sort of numbers of complaints should it review and should it investigate? And how much public money, you know, should go into that part of the system? So they’re all, you know, perfectly proper questions. And it has always been my overriding objective to work in a way that drives improvements in the way the NHS handles complaints and delivers healthcare, rather than to suck huge volumes of complaints into a — a national ombudsman’s office.
Ann Abrahams was at pains to add
I’m not for a moment suggesting that everything’s okay out there, because we all know it’s not.
She was asked to look at the reasons why some people will remain  dissatisfied with the system? What are the causes for dissatisfaction
·         outcome of their complaint,
·         no one to help them make their complaint, so the advocacy services were poor.
·         People may be unhappy with how long it took.
·         Is it about the culture in the NHS which provides defensive responses?
She told us that  I can’t shed much light, if any, on the events at  Mid Staffordshire NHS Foundation Trust between  January 2005 and — and March 2009. the pattern of complaints that we received  didn’t provide any information to distinguish  Mid Staffordshire from any other NHS trust, and we had  no other information that would have led us to do so.
With regard to the Health select committee she strongly argues that there should be no major changes to the service. It needs time to settle into the new structures set up in 2009
I spent the five years in this job arguing for reform, and then I spent the following two years working to implement reform, and to achieve a smooth transition and we did that. And what I said in my evidence to the Health Select Committee earlier this year was that the two-stage NHS complaints system introduced in April 2009 is quicker, simpler and more effective than the previous system. And that the new system is already demonstrating its potential and needs to be given time to prove its worth. So the design is good.
But that doesn’t mean that everything is working as well as it should be, and it doesn’t mean everything is working as well as it could be. It doesn’t mean the NHS is performing as well as it should be, it doesn’t mean that there’s no scope for my office to improve the service it provides. But it does mean that we don’t  need to redesign the system.
Her recipe for a  better complaints system  includes
·         Advocacy
·         Information
·         Leadership
·         Time.
Both Robert Francis and Ann Abrahams were concerned about the effect that the complaints process can have on the complainant.  This exchange shows a little of this.
 THE CHAIRMAN: What is the answer to the problem of the complainant who makes a complaint in which they believe and have very strong feelings, which can then, of course, be exacerbated by the system that they have to go through, but you find, as perhaps others in the organisation have found, that there is no actual justification for the particular subject matter of the complaint, but the individual remains firmly of the belief that there is some substance to it?
I mean, in a sense, by definition that’s an impossible problem, but it seems to me from my previous inquiry, and generally my experience, that there is a diaspora of complainants who are damaged by a process, whether or not their original complaint had any foundation to it?
A. Well, I think, you know, your experience and mine is the same. And I think what my office tries to do is ensure that — that we give proper consideration to — to complaints, that we make a decision which is fair to both sides in this dispute and that’s our job, and that we explain the reasons for our decision, if it’s a decision that the complainant’s not going to be happy with, we do this for everybody, but if — if somebody’s not going to be happy with our decision, then our challenge is to explain that with the proper combination of analysis and empathy for what’s happened to them. And we have in place a review process which is my safety net, so that if people think we have — have got it wrong, that somebody who has not had any previous involvement can have a look at it, and — and if we still think that there’s nothing more that we can do or, you know, our analysis of these events is very different, then we will write a final letter and we will usually say that we will look at anything else that the person sends us, but we may only acknowledge any further correspondence, because we have to draw a line. And we try and do that as sensitively as we can.
Here is some more information from the Ombudsman website.

End of life care: some straws in the wind.

It is clear that we are not doing end of life care well.
We have powerful medicines and wonderful delicate surgery which can do things that would have been seen as impossible even 10 years ago. These mean that the conditions which people were dying of just a few years back are treatable. People survive, and that often means surviving in a very frail and dependant state for many years.
During John Major’s government we saw a big shift. We had already begun to see the extending of the “twilight years” and at that point many people were ending up in Geriatric wards in hospitals. It was seen as a problem then, and the cost was crippling the NHS.  The solution put forward by John Major’s government was the community care act which encouraged the creation of private nursing homes, and meant that the burden of costs passed to the individual, with the safety net of means tested payments from Social Care once a life time of savings had gone.
The fact that many people were likely to lose their life savings to pay for care was quickly recognised by the Labour Party and it was one of the issues on which they stood in 1997.
Resolving the question of how we pay for care has proved very difficult. A series of commissions and reports all recommended that we needed major surgery, but offered sticking plaster options. In the face of resistance to anything that looked as if we needed to spend more on the issue we got the sticking plaster. My family was one of the many casualties of this period, with care costs for my mother close to the £100,000 mark.
I recognised that this was not acceptable and spent five years working quietly with my MP to find a fairer solution. I think it is partly because of his quietly insistent work on this that we got the major rolling consultation led by Caring Choices, followed by a well publicised green paper.  We also held a seminal conference here at Stafford University which the MP organised to answer some of my questions. This brought together all the key players from Whitehall, the insurance industry, Health and social care, the voluntary sector and many representatives from our community.
It was not until the white paper of 2010 that we finally had a brave solution offered. For a brief period there was real hope offered on this, with the health spokesmen from the three main parties working secretly together to talk about the solutions. Then the lure of electoral advantage was seized by the Conservative party who broke away from the talks and got the tabloid press into a frenzy with the now infamous “death tax” posters.
My husband’s humorous suggestion that it is all my fault, that I brought down the Labour Government, is I think going a little too far, but I accept that it has at least a few grains of truth in it! Sorry!   
So where are we now?
The Stafford Hospital inquiry has show us that a hospital, especially a busy hospital with chronic staffing shortages and the wrong kind of ward layout, may not be the most restful or dignified place for people to come to the end of their life. The very effective media management methods used by the Stafford pressure group have been successful in forcing many people who would rather not have seen, to face the uncomfortable fact that some of what is on offer as elderly care is simply not good enough.  The media and the press are also completely tied in to this issue. People throughout the country are now being vocal about failures of care in a way that would never have happened before Stafford. The extent to which the Conservative party have aligned themselves with this sentiment means that failures in care under their leadership will not be tolerated. It is now a political imperative to find good solutions.
From the point of view of my interest in the press and elderly care, I am wondering about the press and media stories that will affect the difficult decisions ahead, and wondering if the media can this time play a positive role in allowing all the arguments to be clearly heard.
So how can we do elderly care better at a time of austerity?   Here are a few of the straws in the wind.
The Alzheimer’s society recommendations.
There will be a lot of anxiety that the decisions taken by this government about end of life care . Many people will believe – fairly or unfairly – that cost will be the deciding factor.
It is worth putting a counter argument. The Alzheimers society report “Counting the Cost” showed clearly that people are ending up in hospitals because of failures of primary care, and they are staying too long because good social care options for re-enabling after a period of acute illness do not really exist.
The prolonged hospital stays are a huge and potentially avoidable expense for the NHS. Confused but mobile patients can completely wreck the running of otherwise viable wards as we have seen at the Stafford Inquiry, so the cost and efficiency arguments matter, but long hospital stays for confused elderly patients is something that can be distressing, undignified, at times life threatening, and can destroy future quality of life.
It is a priority to get people out of hospitals if they do not need to be there. We need to recognise that. We need to create the right pathways.
Making the NHS cost effective  
Cost cutting in the NHS and the move towards the GP commissioning is aimed to concentrate minds and stop people passing the problem from one budget to another. It will be in the financial interests of commissioners to ensure that no one ends up in hospital because of lack of support from primary care, and that people do not stay in hospital too long because of lack of good options for helping people return home or to more appropriate care settings.  These priorities fit with the Alzheimers report and also with the Alberti report on Stafford Hospital.
The increased focus on quality.
The NHS has been talking about quality and the ways to improve it and measure it for at least the last decade. Many improvements have been made. The Stafford Inquiry has spent a lot of time looking at this issue, and has ensured that quality will remain high up on everyone’s agenda. This will happen not least because the Stafford Hospital case, coupled with the ubiquitous presence of mobile phones has now made speaking up against poor care fashionable. The media now notices these issues in ways which it never did in the past.  
We need to start asking the deeper questions. What do we actually mean by quality for end of life care. What is a good death and how can we create the conditions for more people to experience this.
Dilnot comes at the end of a decade of commissions and reports on the vexed question of how to pay for Care costs. It will have taken as a starting point the Labour White Paper on social care from 2010. Dilnot will report very soon.  All the indications are that this is going to be very stormy 
It sounds as if there is a preference from some parts of the cabinet for an insurance based care funding solution. This is bad news. It is what John Major tried. It did not work, and that is why by 2009 people were being offered an insurance package by only one remaining insurance company that still thought there was any point in this at a cost of £80,000.
For those who are very rich, too rich to worry about care costs, there is clearly an interest in voluntary insurance packages to fund care risk. For everyone else the best option is for universal risk sharing.  The “Death tax” is only one way of doing this – there are many possibilities.  We need to understand the options better. The media have a major part to play in this.
Southern Cross
The problems with Southern Cross have helped focus our minds. This is the kind of company set up in response to John Major’s Community Care legislation, and fostered under New Labour. Many people feel a great distaste at the idea that this business which is now in real financial trouble, and threatens the security of many very frail elderly people, has been the source of major profits to big business through maximising the profits from property speculation.
There is a need to do things differently. People do not like the sense that their misfortune is the source of profit for other individuals. We should remember Southern Cross and start thinking seriously about community ownership of the care of our elderly.  
The media and local press could be playing an important part in helping promote discussion on these issues.
Steve Field Future Forum.
Steve field has completed his listening exercise for the NHS “pause”.  One of the roles for competition, choice, and other providers that he identified is for better options for end of life care.
Communities have a clear interest in understanding this. If we come together there is an option for community led and community owned solutions. If we do not there will be plenty of big businesses willing to come in and give us “choice” of Southern Cross mark 2!
It is the Job of NICE to lay out guidelines for Cost effective options for the NHS and care systems. They will research and issue guidelines on ways of delivering the best quality we can achieve at the price we are willing or able to pay. They are now beginning a consultation on end of life care which will end in November.  It would be very useful of the Media can share with us the opinions that are feeding into this consultation. The results of it may be rather important.
Terry Pratchett
Terry Pratchett matters. He is doing a wonderful job of presenting the dilemmas that face Alzheimer’s sufferers. He wants us to talk about the right to die. He has made this an issue that far more people have thought about.
A conversation about better ways to die
There are many taboos in this country. One of them is about dying. We have shied away from this. When I was a child many people died at home. They died quietly and peacefully with their family around them and a little reassurance from visiting doctors and nurses.  Perhaps we were less afraid of it. Now for all sorts of reasons death has become a “medical issue”. The incredibly frail elderly people that we are now seeing often need experts working in pairs to move them, and we are frequently looking at families where the person dying is in their 90s and the person caring is in their 70s.
Many people believe that they need the full range of feeding tubes, drips, help with breathing, and pain relief in order to die a good death. This need not be the case. In the case of my own mother, after having seen three distressing deaths with a lot of medical intervention, and after having read up on some of the more modern approaches to death, I chose minimal intervention. In her case at least it was a very peaceful and positive way to die.
We have lost the art of the good death. Maybe it is now time for the media can tackle this taboo and help us to understand the options more fully.
Over the next few weeks I predict an outbreak of discussion on Death Taxes. Death and Taxes are the two certainties in life. Let us hope that we use this opportunity to ensure we all have the comfort of knowing we are creating the conditions for ourselves and all the people we care for to die well.

A focus on Patient Safety: Stafford Hospital Inquiry. NPSA

MidStaffs Public inquiry Day 102.
Suzette Woodward  is Director of the National Patient Safety Agency.
The NPSA is a small organisation working quietly in the background to try and understand issues which affect patient safety and to try and see what lessons can be learnt, and ways of changing practice for the better.  The existence of this organisation and the amazingly detailed work that it does goes some way to disprove the allegation that the Health service has not had sufficient emphasis on Quality and Safety. The output on their website is impressive. I would advise taking a look. Many safety issues have been identified and directed back the health service for action to be taken. A lot of progress has been made. One could perhaps argue that greater resources would have brought greater results, but funding is always an issue. The organisation is now set to close as a result of the “health reforms”, though some of its functions may be retained.
Dr Woodward worked with the agency since 2003 and became director in 2010.
The perception that people in Stafford may well have formed over the last few years is that adverse incidents quite rare and we have had an unusually high level of them in our hospital. I was of course interested to see if the evidence of Dr Woodward would support this perception.
She tells us that the NPSA now has data on over 7 million incidents.  These incidents are reported to the NPSA at the rate of around 3000 a day; Over 1 million every year.  Dr Woodward says this was initially a surprise to the organisation. They of course knew that “adverse incidents” do occur to around 1 in every 10 people who are treated in hospital, but they had initially been told that the culture of the NHS would be too defensive, and that people would not come forward on a voluntary basis to report things that go wrong.  They expected very small numbers of reports, and Dr Woodward thinks it is a measure of success that people came forward with reports from the beginning and the level of reporting has become steadily higher and more open.
It is probably worth saying that these incidents are graded. They vary from an incident in which there is no harm done, through to actual harm, severe harm and death.  We saw charts of how the pattern of reporting has changed over the 7 years.
As part of the task of bringing about an open and learning culture and moving away from an environment where staff are afraid to own up to mistakes  staff have been asked to get in the habit of reporting very minor incidents, as well as more worrying severe events.   In the open culture that Dr Woodward would like hospitals to foster there tends to be an increasing reporting of No harm and Low harm events, and a very much smaller number incidence of severe harm and deaths. This is where Stafford now is, though it is clear from Dr Woodward’s evidence that they did take time and training to get to this level.
One of the minor issues she picked up on was a matter of Coding. (The legal team are now correctly interested in how the hospital copes with coding whenever we see it, because we know that this was such a major contributor to the concerns about the mortality rates.)  We heard that the hospital initially was misunderstanding the coding requirement. They were coding a number of incidents where there was the potential of severe harm, as severe harm, when in no actual  harm or low harm had resulted. This is of particular importance with issues like falls which are one of the most common kinds of adverse incident.  
Dr Woodward indicated that coding anomalies are quite common with many smaller hospitals, and it did cross my mind that bigger hospitals may be able to support more specialist staff who can handle more of the paperwork and reporting systems. – this is just a thought – I do not know if it is accurate, or if anyone has done any research on this.  What do we know about the way in which different hospitals handle reporting and coding?
At the coffee break in the inquiry a number of people indicated their surprise about the numbers of severe harm and death related incidents for this hospital.
If there really had been unusually high numbers of people dying in Stafford Hospital it might be expected that we should see significantly high numbers in these categories.
Deaths related to an adverse incidents in 6 month swathes from April 2006 – to Sept 2009 came up as 0, 1, 0, 0, 4, 4, 5
Severe Harm incidents for the same period came up as 9, 23, 23, 28, 51, 68, 11
The System does rely on voluntary reporting so it may not give us a full picture, but with the more severe incidents and death it is reasonable to assume that reports would have generally been filed.
What we are seeing here is of course only those deaths and severe harm related to something identifiable that went wrong. Every one of these cases is clearly awful for the families involved. A real tragedy, and it is the job of the NPSA to try to find ways of learning as much as possible from every tragedy like this and to help the NHS to avoid such tragedies in the future.  But the pattern of reporting of adverse incidents for Stafford is something that does not stand out within the NHS.
If there have been unusually high numbers of deaths in Stafford, (which is of course an open and hotly disputed question) it does not look – at least on the evidence we saw- as if the explanation lies in terms of an unusually high level of adverse incidents.
Dr Woodward pointed out that there is a pattern across the NHS that nurses are far more likely to file adverse incident reports than doctors.
Dr Woodward explains that they had different levels of success with different kinds of problems, and there was a tendency to pick the low hanging fruit. If you have a tiny organisation it makes sense to do things that actually make a difference.   If you have a procedure that people were doing wrongly, then it was a simple matter to put out an analysis with this and advice, and work with the locally based advisors to change the procedure. If is something bigger, and she cited the matter of being more open with patients – something we all see as desirable – then this actually entails a massive cultural change, and Dr Woodward felt that you were looking at a minimum of 7 to 10 years to bring this kind of change about.
They had three and a half staff members to cover the 1 million reports they received each year. They had to prioritise, and they concentrated on the Deaths and Serious harm cases. These key cases picked on important things that had gone wrong with serious effect. They then drilled down into the huge data base to bring out evidence of how widespread the problem behaviour actually was within the NHS and to research ways of remedying the problem.
The Big issue of Staffing Levels
We saw some of the reports that had been sent in from Stafford internal Safeguarding system. Most  related most strongly to staffing levels. Some were clearly being written by nurses who were at the end of their tether, had just been doing a really difficult shift, and felt that the staffing levels had made it impossible for them to do their job properly. They read as if the nurses involved were “letting off steam”. They were using this avenue to emphasis the simple point that they did not have enough staff, and using it (as we know from previous evidence) with the clear knowledge that the reporting would increase the evidence in the ongoing staffing level review to argue for an increase in resources.
What we have heard from many witnesses to the inquiry is that during the period 2006 to 2007 staffing shortages were present throughout the NHS. More money had been spent on the NHS than was politically acceptable to the electorate. Money was tight everywhere, and there was no simple formula which would allow a hospital to demonstrate that it did not have the level of staffing it needed to cope with the kind of case load it was carrying.
With no formula to prove need and financial cut backs hospitals all over the country were struggling. For those nurses who were suffering and felt their patients were suffering because of this the reports which reached the NPSA leave us a powerful record of what it felt like to be there at that time.
There is a lengthy section on staffing starting at page 40 of the transcript.  This is worth reading in full. Here are some of the points I picked up on.
·         Staffing levels would not be seen as an issue that NPSA could focus on.
·         It would be seen as a local issue.
·         Royal colleges should be the lead bodies in ruling on staffing level needs.
·         THE CHAIRMAN: So if all trusts happen to be suffering the same sort of staffing shortage/safety issue, they’re not  going to stand out? A: Correct.
·         940 incident reports relating to staffing levels at Stafford  between 2005 and 2010
Three reports from nurses given verbatim.
A report from a nurse: “For 18 bedded acute ward only one trained nurse and
6 one untrained on duty. Most of the night shift I start
7 with lots of outstanding jobs from previous shift.
8 Two/three confused patients who climbs out of bed. Some
9 patients who needed one to one care. 2200 hours
10 medications patients are getting at midnight or after.
11 Leaving the ward an going around to ACU/ward 2 to ask
12 for help. Checking IV antibiotics. This staffing level
13 at night shift particularly in ward 2 seriously
14 dangerous and this incident form I have done many times.
15 No action no feedback. I am very unhappy about patient
16 care.”
“During the late shift there was no allocation of
21 staff to the four bedded CDU. Upon transferring
22 a patient from minor injuries to the CDU I found one
23 elderly a very distressed patient shouting for help.
24 Another patient said she had been shouting for hours.
25 When I assisted the patient on to the commode her bed
1 was soaked in urine which had started to dry. None of
2 the patients had nurse call buzzers. None of the
3 patients had been given any food or drink.”
Yet again the experience and quantity of the
8 trained staff is not adequate to cover the floor safely.
9 There were only two trained staff who have experience to
10 do three jobs …”
There is a lengthy exchange detween the Chairman and Dr Woodward on P49 of which this is part
THE CHAIRMAN: But if we look at the period during which
11 this was happening, what look on occasions to be quite
12 distressed members of staff are reporting distressing
13 incidents saying nothing has been done about it. If we
14 assume for the moment that the trust management was not
15 listening or capable or for whatever reason doing
16 anything about it, who else was?
17 A. Those types of incidents would not, unless the patient
18 had died, been generally reported as serious untoward
19 incidents. So it’s unlikely that the PCT or the SHAs
20 would have been looking at those incidents. So it is
21 highly reliant on a good local risk management system.
This all raises some very difficult issues. It raises a stream of questions in my mind.
If it is something as fundamental as the level of staffing required to run the service well, then this is essentially like the elephant in the room.  You cannot see it in comparative data, because it is something that is happening across the board.  You cannot resolve it because there is neither the money nor the political will to do so. People will vote to protect the NHS, they will not vote for the taxes necessary to carry this through!
It is virtually impossible to agree a formula for staffing levels, because there are so many different vested interests. It becomes increasingly difficult as we shift to Foundation Trusts where staffing levels becomes commercially sensitive.
If the staffing levels are too low either in some or in all hospitals, then I think it is reasonable to assume this will increase the likelihood of adverse incidents.  As we heard in the evidence from the HPA a hospital operating under great stress is much more likely to suffer problems with infection.
People are not superhuman. If you put them under too much pressure individual staff will either work themselves to a standstill or standards will slip.
Mortality Rates
Dr Woodwards statement makes mention of the HSMR mortality rates, she has been asked to comment on why the NPSA did not pick up on the increased mortality rate identified by the Dr Foster Figures. Perhaps the underlying assumption behind this question is that if there were to be unusually high levels of mortality in a hospital then one might reasonably expect that some of these additional deaths would have to be accounted for by adverse incidents.
Dr Woodward points out that the NPSA does not rely on HSMR. The NPSA is looking at actual incidents and will only be notified of those  deaths which have been caused by an incident.
Dr Woodward does make reference to the need for a hospital to understand the systems for coding mortality, and especially co-morbidities well, in order to be able to gain reliable data from their mortality rate systems. 
The Seven Steps to Patient Safety
This is a simple way in which the NPSA has tried to bring about a safer culture within the NHS. You will find all the documentation related to this on their website.
The steps provide a simple checklist to help NHS organisations plan their activity and measure performance in patient safety. Following them will help ensure that the care they  provide is as safe as possible, and that when things go wrong the right action is taken. They will also help NHS organisations meet their current clinical governance, risk management and controls assurance targets.
The steps are:
1. Build a safety culture.
2. Lead and support your staff.
3. Integrate your risk management activity.
4. Promote reporting.
5. Involve and communicate with patients and the public.
6. Learn and share safety lessons.
7. Implement solutions to prevent harm.
 Looking to the Future.
Like many organisations in or close to the NHS, the future is uncertain. The NPSA will cease to exist, some of its functions will be taken up by the Commissioning body.  It remains to be seen what effect this will have on peoples willingness to report adverse incidents. Will this improve or threaten the desire to create an open culture.
There are many things that Susan Woodward would like to be doing now, but the re-organisation is taking its toll. Many new projects cannot now begin until after 2012. At the moment the priority is to  write legacy documents. I suspect these will be the matter of many future academic studies where we look back to see what we have lost.
Here are a few items off the NPSA website. Take a look! Nil by mouth study and recommendations never events

The C Diff outbreaks at Stafford Hospital: Role of the HPA.

On Day 101 we heard from the health protection agency. This body, which is soon to be abolished, and have some of its functions assimilated into the DoH exists to guard the health of the public. They have dealings with GPs surgeries, Care Homes, a wide range of aspects of public health, Mental hospitals and hospitals. They were at pains to point out not regulators. They have no direct authority over any of the organisations that they deal with. Their role is to offer expert advice and support.
The Chairman asked on a number of occasions if they felt It would help if they had greater powers to ensure that their advice is headed, but they believed quite strongly that this would be counter productive. They work on a collaborative basis. They want hospitals to feel free to come to them for advice, without fearing any adverse consequences, and they believe that this very unthreatening way of working makes them effective in what they do.
Dealing with hospitals is only a small part, maybe 10% of the work that they do, and each member of the HPA will have a large number of hospitals in their area, so it is clear that they can have only a small part to play in this story, but I feel that it is a significant one.
The line of questioning was largely about C Diff. MRSA and C Diff became a huge issue across the NHS in the period 2005-2008. It was claiming lives throughout the country People were genuinely frightened of headline stories of hospital super bugs, and the idea that antibiotics which we have depended on for so long are powerless to help in some cases.  This level of justified fear made it a  major political issue. Dealing with these infections, and reducing the number of cases became the number one priority for hospitals at that time. Stafford did have great concerns about MRSA and the deep cleaning programmes introduced at this time, together with a much greater awareness of proper prescribing of antibiotics worked with considerable success to greatly reduce the incidents of this infection.  
The HPA had a role to play as they were experts that could be called in to give Advice and Support. They would have been I think a very comforting presence for hospitals at a time when an outbreak occurred, when the hospitals needed to take action quickly
The Chairman asked about their recommendations for reducing the incidence of C diff. MRSA patients are now routinely screened when they go into hospital and he wondered if it would help to screen for C Diff as well. Dr Azfa patiently explained that this would not serve any useful purpose. She wanted us to understand the nature of C Diff. Many of us carry the bacteria for C Diff in our bowel. It only becomes a problem if the immune system is compromised or if the patient has been over prescribed antibiotics. So many people will find that because of other conditions that the C Diff which they carry will become active during a period of ill health.   C Diff cannot be prevented. It can only be controlled.
Keeping CDiff under control is a matter of having the right nursing techniques, right antibiotics, right hygiene and being able to isolate people if needs be.
Preventing it is a much more difficult matter. There are some recent articles  and here  which clearly link the rise in the incidence of hospital infections with the way in which our food, especially meat and chicken is being produced. This is something that we should all rightly be concerned about. The bugs are often described as Hospital Superbugs That is a misnomer. They are clearly a huge challenge when they do appear in hospital, but if they are arising from problems in the food chain, as well as from over prescription of antibiotics to us as individuals, then this is a much bigger problem.
Dr Azfa was I think keen to tell us more about the nature of the bacteria that we all carry in our guts and the factors that affect them, but the Lawyer under time pressure curtailed the discussion.
In terms of the timing of events there had been a significant outbreak in 2006 at the time when CDiff outbreaks were occurring throughout the country.  This came before Dr Azfa’s time at the HPA, but she was there for Clusters in 2008 and an outbreak in 2009.
A major problem that Stafford faced if an outbreak occurred was how to effectively isolate the patients. Dr Azfa felt that the hospital did not have enough side rooms, and therefore the next best thing would be to have a special cohort.  She had raised this issue at the time of the 2008 events and was still bringing it up at the meeting where she first became aware of the January 2009 outbreak.  The hospital needed to devote time energy and money to sorting this out. It may not have had any of these.
I was advocating it fairly strongly and consistently,
20 and hence you see it appearing in the minutes of
21 26 January meeting, at which point we were not aware of
22 this 2009 C.difficile outbreak beginning, because it’s
23 through this meeting and subsequently formerly on
24 27 January meeting notes that I became formally aware of
25 it. So even before that knowledge, I am trying to — to
Page 166
1 make it quite clear to the trust that, “You need in your
2 own mind to distinguish what isolations facilities you
3 need, you need isolation facilities for other reasons,
4 besides C.diff and MRSA. And you need to — you know,
5 you need to clearly demonstrate within the breakdown of
6 cases that these are the breaches which has happened
7 because of MRSA patients not getting isolated, these due
8 to C.difficile, these are due to immuno-compromised
9 patients taking priority”. when you
10 have limited isolation facility, the clinicians need to
11 prioritise who gets that first room first.
Her involvement in the 2008 and 2009 episodes was very interesting. I felt that it gave us a snap shot in to a time in the hospitals history when they were under very real stress.
In July 2008 the Healthcare commission was already well into the process of its investigation. Dr Azfa did not know any detail of this at this stage.  There was a meeting at which she was present and there was a prolonged discussion about whether the cases of CDiff which were occurring at that time amounted to an Outbreak or if they were Clusters. There is a distinction, a cluster is when the infection is arising from individuals, an outbreak is when it is being transmitted.   Dr Asfa felt it would have been helpful to think of the two distinct clusters that were occurring at that time as an outbreak, and felt that if this had happened it may have persuaded the PCT to find the money that the hospital needed in order to set up an adequate isolation facility.  The hospital was reluctant to declare an outbreak.  The Chairman asked her to offer an opinion about why they felt this way, and Dr Azfa speculated that it could be because the hospital was concerned about the reputational damage.  
Another reason that Dr Azfa would have favoured the declaration of an outbreak is that it makes it possible to involve the public in a much more open and informative way. She said that if you announced it as an outbreak then you would have signs and screens and taped off areas, and clear instructions to every member of the public to use gel and to stay away from the hospital if they themselves were unwell.  Her message was that infection is everyone’s responsibility.
Dr Azfa was a pains to point out that it is not possible to prevent C Diff occurring, for the reasons I have indicated. The emphasis has to be on helping hospitals to deal with the outbreaks that do occur as well as possible. She did not feel that the hospital was as well prepared for the outbreak as it might have been, and she mentioned about carrying out an audit of commodes and finding that they were all dirty.  A report flashed up on the screen mentioned  that infection control had not been made any easier by a confused patient with profuse diarrhoea wandering about in the ward and having accidents.
Sick patients with Diarrhoea, in a time when the hospital was already short of staff, can of course easily be compounded by staff becoming sick.  It is very easy for things to run out of hand. At times like this calm and authoritative leadership can make a positive difference and can help to guide a hospital through what will always be a difficult experience.  I think it is important to remember what else was going on in this hospital at this time. The leaders of the trust will have been very much distracted by the Investigation process, and all the adverse publicity that accompanied it.  I think it is fair to assume that the Hospital was probably not functioning at the optimum level.
The intervals between the 2008 and 2009 outbreaks should ideally have been used to set up an isolation facility but things calmed down, the resources were not forthcoming from the PCT and other things, including dealing with the ongoing HCC investigation took priority.
. If — if you look at the interval between the number of
15 cases — in July 2008 were eight to nine at any one time
16 in the — in the context of that outbreak. The trust is
17 demonstrating continued reduction in the number of
18 C.difficile cases and meeting all the targets, so
19 they’ve — it’s not as if there were alarm bells going
20 on
Mr McCraken was asked if he thought that infection would be more likely to occur or spread in a hospital that was experiencing pressure. He had no hesitation in answering “Yes!”
The second Outbreak, this time clearly described as an outbreak, occurred in Spring 2009.
By this time the hospital was awaiting the publication of the HCC report and there were a whole series of increasingly bitter rows going on in the background.  Dr Azfa refers to the level of chaos that this was bringing to the hospital at that time.
In 2009, again, what information was in the public
18 domain that the Healthcare Commission inquiry report was
19 imminent, was something I was aware of and in fact it
20 became quite — how do I put it? — quite a significant
21 issue for us who were trying to deal with the problem of
22 the outbreak as it was unfolding, in February —
23 February and March 2009, to — to be, you know, to be
24 mindful of the fact that the — that the trust was under
25 quite a lot of pressure at the time, because the
Page 174
1 Healthcare Commission report was coming out.
2 And it was evident from, you know, the way — you
3 know, particularly with Helen Moss, she was having to
4 rush into the meeting and leave early, although she was
5 meant to be chairing those meetings. And another
6 something which I did not get the opportunity to tell
7 your learned — learned selves is that in March — early
8 in March — late February/early March 2009, when
9 I raised my concerns with my line manager, the unit
10 director and the regional director of HPA at the time,
11 we were — we asked to meet the chief executive, myself
12 and my unit director. And that meeting — and as well
13 as the medical director, Dr Val Suarez, at the time.
14 That meeting actually did not happen, because both of
15 them stepped down on roundabout 3 March, which was the
16 date when we were supposed to meet them.
It is certainly the case that people died in the C Diff outbreaks of 2008 and 2009. It is an unpleasant and undignified way for people to come to the end of their life and the relatives who experienced these sad events will always carry the burden of this.  Could any of these deaths have been prevented? I am not sure that anyone can say. 

I attach for interest the coverage of the HPA evidence from one of the local papers, who clearly do not have the opportunity to go into the kind of detail that is possible on line.

The Health Protection Agency desperately tried to get managers at the hospital to change the way they handled clostridium difficile infections after two outbreaks in 2008.
But managers at the scandal-hit trust refused to follow their advice and a much larger outbreak erupted in 2009.
It spread to several wards at both Stafford and Cannock Hospitals, killing 10 and infecting many more.
Yesterday the Francis Inquiry heard evidence from Justin McCracken, chief executive of the Health Protection Agency, who revealed the hospital repeatedly refused to act on advice and was reluctant to declare outbreaks – possibly due to a fear of bad publicity.
There was an outbreak of c.diff in July 2008 with eight cases on one ward, then in September and October there was another outbreak with four cases in 19 days.
Mr McCracken told the inquiry the HPA had “serious concerns” about the lack of an isolation ward, a shortage of staffing and cleaning of hospital wards.
He told the inquiry: “We felt we were banging our heads against a brick wall.
“It is clearly a matter of deep regret that our advice was not followed.”

How bad could the coding really be?

Listening to the evidence of Roger Taylor from Dr Foster Intelligence on day 99 of the Mid Staffs Public Inquiry the last piece of the jigsaw that I needed to see how we got into a hopeless mess about Mortality information at Stafford fell into place.  I had had it all the time, but just had not seen that this is the piece that counted!
There was a happy time back in early 2009 when I had never heard of HSMR or the Hospital standardised Mortality Rates.  But since 17th March 2009 the matter has never been far from my thoughts.
The reason I know this date, when I have difficulty remembering family birthdays is that this is the day when the press and TV brought a media hurricane to Stafford.
We had known for 18 months before that there was a band of relatives who had suffered real tragedies at Stafford. There were demonstrations in the town square and outside the hospital, they were working closely with the press to tell their stories and had already forced the resignation of the Chief Executive officer and Chair of the trust. What no one had reason to suspect that we would see press headlines that 400-1200 people had died as a result of poor care in Stafford.
The problem with the mortality rate figures in Stafford were known to a relatively small number of people – I knew of them, but did not even know the name “Dr Foster Intelligence”at that time. What I did know is that a considerable amount of research had been carried out which showed that there were serious problems with the coding of the data which was producing the apparently high mortality figure.
I was not directly involved in the chaos that followed the arrival of the world’s media in Stafford so what I did was I sat down and read the Healthcare commission report from cover to cover 4 times. It took that many times to convince myself that the “excess death figures” which appeared in every press item and every TV interview were not there, and that there was no other material contained within the body of the report that could imply these figures. This was clearly a hospital with problems, a hospital where lots of people would have had an uncomfortable time, I could imagine that there will have been some people who will have died, I found an interview with Sir Ian Kennedy who said it is likely that “some people may have died”. This seemed to me to be a completely fair balanced and reasonable statement. The rest looked like media induced hysteria.  
There are clear caveats in the HCC report about the limitations of what the data can tell us.
For the data to accurately reflect hospital
activity, there must be clear, accurate and timely
information recorded in the patient’s notes;
accurate and consistent clinical coding; and
clear procedures for collecting and processing
the data. There also needs to be appropriate
training and accreditation of staff.
This is the passage which came to dominate my reading of the report.
The highlighting is mine. This seems to me to be the very simple human story at the heart of this chaotic chain of events.
We were told by clinical staff and managers
that the trust had a long history of poor quality
information about its services. ..
A report by CHKS was commissioned by the
trust in early 2007, due to concerns about the
coding of clinical data. The report identified
deficiencies in the clinical coding entered in
the Patient Information Management System
(PIMS). This was manifested by inaccuracies
in coding and under-reporting of co-morbidities
(that is, patients’ other health
The coding manager at the time
had been on long-term sick leave and the rest
of the team were working part-time. Contact
with clinicians was also poor, with coders
being reluctant to approach them about
unclear notes. Clinicians had little
understanding of the need to make notes
clear for the coders.
The trust recruited a new coding manager in
July 2007, when the previous post holder
retired. More investment was put into the
department and new members recruited to
the team. Staff told us that the new coding
manager had had a positive impact on the
quality of coding. The new manager built
better relationships with clinicians and
motivated her staff to attend training courses
and gain accreditation. Examples of positive
developments included having consultants on
the clinical coding and data quality group, and
systems that the coders could use to crosscheck
information, such as radiology and
pharmacy reports.
The coding manager told us that she still had
concerns about some of the clinical input to
coding. It was reported that junior doctors
could present a problem because of their
frequent job rotations. They were often
imprecise about diagnoses, whereas the main
problem encountered with senior consultants
was the tendency to under-report comorbidities.
The trust had a history of poor performance on
mortality. The data from Dr Foster showed that
the three-year HSMR for 2003-2006 was 125.
This was the fourth highest ratio in England.
The trust had only begun to monitor clinical
outcomes after the publication of Dr Foster’s
Hospital Guide in 2007, and had relied on the
use of the Dr Foster ‘real-time monitoring
tool’ to identify areas of concern (‘red bells’).
This tool was used by the trust’s lead clinician
for clinical governance.
In response to its apparently high mortality
rate identified by Dr Foster, the trust initially
focused on the poor quality of the clinical
coding of the cases involved. It also
established a group to consider mortality
outcomes. The group’s follow-up of high
mortality rates had focused on reviews of
individual case notes of patients who had died.
This was conducted by clinicians at the trust
over a period of time. The general conclusions
of the follow-up were that the deaths were
predictable and that no problems with care
were identified.
There is further on in the report the description of the work of the mortality report – which carried out a limited case review of deaths, and found that around 80% of these had been miscoded. ***** I have still to find this reference.
As the story has moved on and the press headlines have kept on coming I have watched for every bit of information which might help to explain what happened here. How is it that the world in general has accepted this mysterious assertion that 400-1200 people died unnecessarily in Stafford when this information does not appear in any official document and there is clear evidence that the coding on which the information was based was of exceptionally poor quality.
Here are some of the pieces of the jigsaw.
My Attitude to HSMR
I am not a statistician though I have had some experience of using statistical systems. I have only learnt about any of this because of the truly dreadful experience that the people of Stafford have suffered. I am a fan of statistical information and believe that where people understand how to use them and use them well that they can often give a really good way of seeing what is happening. I accept that HSMR and some of the newer systems that Dr Foster are developing in partnership with other organisations are of considerable value, but they are, as Roger Taylor himself has clearly stated very vulnerable to misuse. Rubbish in will result in rubbish out.
No one left to fight the story.
When the story broke the only people with enough knowledge to contest the story had already gone. Everyone else was in a state of severe shock.
25 out of 75
It would be easy to assume from all that we have heard about HSMR that this is a universally used and accepted system, tried and tested, the single measure for comparing Quality of care and performance on Mortality in the country.  This is not the case. We now have a definitive statement signed by many prominent names within the NHS including DFI which clarifies the limits of what HSMR can do.  It is a system used by some hospitals. It would like to be the dominant system accepted by all hospitals. Maybe one day it will be, but it is not there yet. It has not won universal acceptance, and the huge amount of controversy surrounding the Stafford Hospital story has not helped it to win this.  I would suggest there is a real opportunity now for DFI to mend some fences and put the matter right!
All hospitals have to try and set systems in place to monitor quality. Stafford was using a whole raft of systems. For whatever reason – and this is lost in the mists of time, they did not regard HSMR as a high priority. They had bought into it but were not enthusiastic supporters.  On their prioritised list of indicators I believe (this information was given at one of the hospital board meetings) that the HSMR was ranked 25 out of the 75 indicators that they used.
I suspect that this means that staff were going through the motions of making returns rather than giving it any kind of priority.  A hospital which was seriously understaffed, and where admin staff had been cut, and the coding manager was off on long term sick leave will not have had the time, training or motivation to do this tricky job well.  
Lack of understanding.
Professor Jarman was shown a report by Helen Moss which showed her understanding of the function on Primary coding. She was struggling with the reality that they often did not know what a patient was admitted for, they were there for investigation, the diagnosis would come later, and she would then wish to code it with the dominant condition.  He was clearly very puzzled by this. Robert Francis asked him to clarify – if you get a case with admission for a broken hip and the person later develops CDiff, then what is the right code. Professor Jarman would not give an answer to this. It was clear that Helen Mosses understanding did not match with his, so there was confusion right at the centre.
Counter intuitive coding.
What a hospital would want this system to do is to give a clear indication of the overall health of the patient, so that it is possible to spot if a death occurs unexpectedly.
Roger Taylors very clearly stated example, of a diabetic being admitted for an in-growing toe nail and being coded by the in-growing toe nail is very helpful, but I can see that it would really be of serious concern to a clinician. 
Reflecting the state of health.
DFI in their analysis of the coding for Stafford say that the Primary coding seemed ok and that therefore the results are valid.  I would suggest that for a hospital with the kind of case load Stafford actually has, with many elderly patients suffering from 5-10 chronic conditions, that if the system does not clearly reflect this and weight it adequately then HSMR based largely on primary coding will give highly misleading results.
Poor recording of Co-morbities.
The evidence in the HCC report shows us that recording of co-morbidities was completely inadequate, it had been for years, and it continued to be so for some time after 2007.
(follow up – I would say that Dr Foster has work to do to satisfy hospitals that it can pick up on cases of people dying when they come in with a broken toe nail – but also accurately represent people whose general health makes death a likely outcome. The “information revolution” probably gives the way forward on this. I am certain that Roger Taylor left the Inquiry with the clear understanding that there is work to be done to ensure people understand the system better, and that it is responsive to their needs.)
The PCT investigation
The PCT carried out its own check – comparing the coded cases to the GPs notes. They thought it was the coding.
Carried out an investigation and thought it was the coding.
The SHA investigation
through Birmingham university thought it was the coding.
Who thought what?
In the run up to the HCC report all the health experts close to Stafford were confident that  though there were clearly some problems at the hospital that so far as the mortality problems were concerned they were looking at a coding problem. Doctor Foster, Some elements of the HCC, Bill Cash, The pressure group, elements of the local press and possibly the Conservative central Communications team though that there had been huge numbers of deaths.
The piece of paper with the figures.
We learn from the evidence of Bill Moyes what happened at the meeting held in Alan Johnsons office immediately before the release of the HCC report.  The HCC appeared at the last minute with a piece of paper with the Excess deaths. None of this had been discussed fully with other parts of the health service before.  There was a huge row and a consensus view was formed that the material could not be released because the foundation of the figures was insufficiently sound and because it would cause widespread misunderstanding and concern.
The leak to the Daily Mail
We still do not know who leaked this figure to the Daily Mail. Bill Cash was asked directly about this by the BBC and said that he would not talk about it. The figures appeared with quotes from Bill Cash and from Julie Bailey.
Promotion of the figures
Whoever chose to put these figures into the public arena, they have been heavily used by the press, the Conservative party (including David Cameron, and Andrew Lansley)  and the Pressure group.
Why the numbers changed
One of the mysterious facts about these figures only became clear to me through the evidence of Professor Jarman and Roger Taylor.  The Hospital had been expecting their HSMR figure to come out as 114, when in fact the 2007 figures it came out as 127. This was a huge shock to them. There are two explanations for this, as Brian Jarman made clear.
The base line for HSMR shifts. The general trend is downwards, and so hospitals are “re-benchmarked” each year. To do this they have to get returns in and Stafford failed to do this. The other big element was that a new code for Palliative Care had been brought in, and that this had entirely escaped the notice of the people struggling with the coding in Stafford.  They had not used the palliative care core, but lots of other hospitals had, so there was a major shift occurring at this point. The 2007 League table quickly highlighted this problem and brought about action to recode cases.
The Palliative care recoding first pass
What really exited the press from the Professor Jarman evidence is that he clearly took the view that a group of hospitals in West Mids, under the guidance of the SHA had set out to game his system by recoding loads of people as palliative care. So we have again had lurid headlines involving many thousands of deaths!  
Roger Taylors evidence under careful questioning has I think helped us to get to the bottom of this. I am sure that there was a concerted action to get the coding sorted out. I think that the hospitals will have taken the immediate action of switching primary codes. This was sometimes the wrong thing to do. It certainly made an impressive graph!
Getting the coding right
Once the understanding of the system improved then I think what happened is that the hospitals recoded again, doing it the hard but right way in entering all the co-morbidities to give a balanced view of the health of the patients.
David Stone
David Stone was acting Chair after March 2009. He gave evidence to the Health scrutiny committee indicating that the coding at that time was robust – with an HSMR of 88 at that time. with the implication that it may not have been previously.
The 80% miscoding and Roger Taylors surprise.
What made a real impression on me was that Roger Taylor gave the bulk of his evidence with the conviction that though there were some real areas where the HSMR figure could be a little misleading, that there was no way that it could be very far out. He is used to thinking that everyone always says “it’s the coding”.
He was visibly shaken by the idea that the coding could be 80% wrong and clearly thought that if this was the case then the admin must be pretty chaotic. I could see him thinking  (of course this is just my impression) if the coding is really out by that much then the implications would be major!
Today I spotted a tweet about the Titanic being designed by professionals.  I think that the HSMR system is designed by very clever professionals and is an elegant system capable of being really helpful to the NHS. I think it is also vulnerable to being holed under the water line as comprehensively as it was by the unique series of events in Stafford.
I hope that if anyone from DFI gets to read this that they will think about this.
After looking very closely at this issue for three years, I think it is the coding!   

Professor Jarman. First impressions.

This is a preliminary and perhaps impressionistic account of Professor Jarman’s  evidence. There will be much more in the way of important evidence this week, so I wanted to make an attempt to capture first impressions.  I hope that other people with a much more detailed grasp of the statistical systems involved will also choose to analyse the case that he has made.
Professor Jarman has played a very prominent role in the course of the Midstaffs Inquiry. It is the use – or possibly abuse of the statistical systems that he created that led to the highly contested “excess death figures”. These figures, which were set to be included in the health care commission report at the very last moment and then were withdrawn after a major row, have completely dominated the press and media coverage of the Midstaffs story, and are the reason why I am now involved in a campaign for press reform.
With me there are key witnesses that I needed to see in person. Professor Jarman was one of these. I needed to see the person in order to see what his system means to him. This may sound like a strange approach to a matter of Statistics, but been discovering from the Inquiry is that it is the statisticians who are most passionately involved with what has happened here, and that the different systems for monitoring and regulating are always built on a very individual approach. People and personalities matter!
Like everything else in the Midstaffs Inquiry this is not as simple as it might seem!
First – what did we learn about Professor Jarman’s personal history.
It is clear that Professor Jarman’s career is both long and distinguished. One of the things that he is most committed to now is his involvement with the Institute for Health improvement in Cambridge and Boston Massachusetts USA. Since 2001 This is a body of people who are deeply committed to improving the quality of health care. His work with them is a reflection of his own deep commitment.
Professor Jarman’s early background is interesting – He did not begin medical training until the age of 31 after early training as a geologist. His first PHD was in seismic wave propagation.  He then went on to develop an interest in Socio economic indicators and has developed computer systems for CAB and Social services.
He became a GP in 1970. He was a member of the Community health council for Bloomsbury in the 1970s, and thinks they managed things very well.  When visiting a hospital he witnessed a serious untoward incident, which he believed could have led to a death. He does not think this was reported. This may have led to his wish to look for ways of improving quality of health care through better training.
He talked about the unintended Impact of the Griffiths report in 1983, which he believed divorced the health service from control by the clinicians and put it into the control of Health service managers. He clearly feels that this was a mistake.
He was involved in the Bristol Inquiry, where his statement gives us an interesting insight into his relationship with the government – He believes he would not have been the Government’s first choice for this task!  He set up the Dr Foster Unit as a response to what he saw at Bristol.
 He has been working on Mortality rates since 1990 so this forms a very significant part of his life’s work.
It became clear as he gave his evidence that this is something about which he feels very very deeply, and that he sincerely believes that he has developed the tools that have the potential to save many lives.

A little of the detail.

Because I am rushing to get to today’s inquiry I am now going to focus on the points that stood out from the evidence – all of which I will try to come back to later. I would of course advise people to read the transcripts for themselves. Do not take it from me! I am not objective, and neither is anyone else who is reporting this matter!
There was discussion about the Doctor Foster Unit and Dr Foster Intelligence. The Inquiry tried its best to clarify this difficult distinction. Dr Jarman is keen to emphasise that there are points of real difference between them, and that he is often at pains to point out where he thinks they are going wrong.
There was a long discussion about HSMR and the basics of coding. What struck me from this is Professor Jarmans emphasis on the importance of Primary coding. The system depends on people getting this right. It was made clear that this was a matter of clinical judgement – often by junior Doctors working under stress. Professor Jarman sees this as a simple matter- the question which is still unanswered from my point of view, and I think from the point of view of Robert Francis is how simple is this in practice.
The discussion got bogged down in “primary coding” actually meant. It was clear from board minutes in Midstaffs that the hospital did not have the same understanding of this as Professor Jarman. He seemed genuinely surprised by their degree of incomprehension.
Robert Francis asked a hypothetical question about how you could code a case where a person was admitted with a broken Hip and then developed CDiff. Professor Jarman’s answer was that it was a matter of clinical judgement how this would in fact be coded.
What was I felt notable by its absence was any prolonged discussion on Secondary coding. We know clearly from the Health care commission report that this was something that was being done entirely wrong in Stafford. The coding manager had been off sick for a long time, the stand-ins found difficulty getting information about co-morbidities. They therefore had to rely on Primary coding (which may or may not have been accurate).
To my mind, and I am of course no expert on this, any system which sets out to tell us if a death is “expected” or “not expected” has to reflect the total medical condition of a patient. Let’s take a case study from my own family. My mother in law was admitted to hospital (in Scotland) because she had had a massive stroke, brought on by the medication for the rheumatoid Arthritis which she had suffered from for 15 years. The Stroke left her immobile, and she was in acute pain whenever staff had to move her because of the arthritis and eventually needed morphine to enable her to cope with being moved. Her breathing patterns became very irregular, and she needed heavy medication to cope with this. She had kidney infections and needed antibiotics. Her condition stabilised.  She at one point was told that she would be fitted with a peg feeding tube and discharged to the only nursing home that could cope with her complex conditions. She did not want this and went down hill rapidly at this point. She then got C Diff. She eventually died from heart failure.  I do not think she died of “a primary cause” I think she died of all these reasons combined.  I have no idea how her case was coded.
To form any judgement of how well the HSMR system works, I think we need to look at a large number of case studies and understand the variation of coding that occurs in practice.
There was a lot of discussion about a factor that came as complete news to me after three years of looking at the Stafford Case.  Professor Jarman makes it clear that he is always open to suggestions about how to improve his system, and as a result of concerns from some of the users he changed the statistical model in 2007.
The “customers” for the system had pointed out the need for a palliative care code, which would make it easier to show cases where a patient was essentially just being kept comfortable, and was unexpected to survive. The introduction of this code came in 2007 and this along with the failure of Stafford to “rebase” their coding explains why there was a huge jump in their HSMR. The Hospital had been expecting to see HSMR at 114, High but not alarmingly high, It in effect came in as a result of their failure to use the new palliative care code at 127. The figure that sparked all the fuss.  
It is clear that West Mids hospitals as a whole had missed the introduction of the Palliative care code, and that therefore those hospitals which had a high case load of elderly patients – with complex health problems, who were not expected to survive, were being wrongly coded. This may – and I repeat may – be the explanation for the higher than usual HSMRs on the 6 hospitals in the West mids region.
A slide which drew a lot of attention from the Inquiry, and very much pleased the press, related to the work that the SHA did with its hospitals at this point to sort out their coding problems. The three hospitals that Professor Jarman pointed out began using the palliative care code extensively and their HSMR consequently fell rapidly. 
What Professor Jarman clearly felt, and the press picked up on was that this was “gaming” the system.  I think it is perfectly possible that there was some overcorrection going on, but I think it is also very important to view this in the light of the genuine undercoding that had been going on previously.  This was not discussed and I think it should have been.
There was quite a lot of discussion of the way in which the SHA had commissioned the Birmingham university group to carry out research into HSMR. Dr Jarman clearly interprets this as a personal slight. His anger about this was tangible.
He also feels immensely strongly that the DoH have not valued his work in the way that they should and that if they had done so thousands of lives would have been saved.  He puts out the HSMR data to all hospitals now, not because he is paid to do so, but because he feels it is his moral duty.
One thing which did impress me is that he described work which he had done with a hospital to help them study their processes and help them bring down mortality.  I think this may be in contrast with the work of DFI where the emphasis is on offering training and consultancy to hospitals to help them use the system better.
Dr Jarman is a physician. He wants people to do things better, and what his system can do at its best is to help people identify areas of concern. It is only at that point that the work begins. People have to analyse what is happening, and work out how to do things better.
Dr Jarman’s system can help people begin this intellectual journey. So can all the statistical systems that have been shown to us by the Trust, The SHA and the CQC.  It is also clear from the work highlighted by Ben Goldacre, that systems that this government has wished to scrap – involving the Targets, can also help people begin this journey very effectively.

Getting beyond the politics.

To my mind the big problem that all of us are struggling with is how statistical systems, which need to be carefully evaluated, and carefully used, have found themselves at the heart of what is essentially now a political battle.
The Conservatives took a political position on this. Targets were out, Outcomes were in, and Professor Jarman’s system, alongside his belief in the importance of a GP led Health care system would do the job.  This annexation of professor Jarmans work may have been damaging to him. He clearly expected that his work would finally now be recognised, but yesterday he expressed his disappointment with the contents of the Health bill.

Could the press act as regulators for the health service?

I have been thinking about this article from Health Policy Insight
I was alerted to it by a twitter exchange between the outgoing chief executive for Midstaffs and one of the journalists who has spent what must seem like a high proportion of his life covering the Midstaffs story.
The Health Policy Insight blog makes the point that regulation does not always do what it says on the tin, and given that in a series of recent NHS scandals the press have got to the problem before the regulator, he wonders if we should just forget about regulation and give the money to the press to do it for us.
Here is his solution.
Having read many of the witty and incisive pieces written by this writer, it is quite likely that this is a piece of kite flying, but it is interesting that both the CEO and the journalist were very taken by the idea.

Abolish poorly-functioning national quality regulation, and give the money as a subsidy with a range of conditions to local newspapers. A small sum needs to be paid to some independent regionally-based staff, to monitor and follow up on the output.

Regulation and the Stafford Inquiry
Like the Journalist and the CEO I have also devoted a lot of my time to days at the inquiry, or reading transcripts. I do so because I am interested in the challenge of regulation, and also because I have become fascinated by the many important issues that this case has raised about the press, and the real difficulties the press may sometimes face in painting a fully rounded picture. I have learnt a lot about the many sided and often un-graspable nature of “truth” in this process.
In my opinion the impetus for the public inquiry at Stafford came from four different directions.
·         Obviously there is the hurt of the individual campaigners and their need to make sense of their experience. This need quickly became enmeshed with the needs of politicians.
·         There is the press and their sense of duty and financial commitment to a  powerful public interest story
·         Then there is the political impetus. The story was an apparent opportunity to prove the “failure of the NHS“ and to prove the need for the Government’s now teetering health reform package.
·         And then there is the question of how to regulate the health service. It became abundantly clear that regulation, as it was at 2006-2007 was not doing its job. Regulation should either have been able to flag up problems, or give the health service a clear defence against disproportionate criticism. It could do neither. We are not looking back to a golden age of regulation in the past. Regulation has been developing for decades, partly as a response to political need, but this slowly evolving art has not yet reached a stage where we know it can do the job.
How Regulation is developing
What is clear to me is that the health service has learnt a huge amount about regulation as a result of the complex but demonstrable regulatory failure at Stafford. The service has responded with quiet reforms so that the regulatory systems and tools that we now have are unrecognisable from the systems as they were in 2007.  I am not sure that these major changes are yet widely understood. I would advise reading the evidence and statement of Richard Hamblin who served in both the Healthcare commission and the Care Quality commission as a good starting point on this.

The new tools are promising, but a crucial element of this new approach to regulation, is the recognition of the limitations of the statistical systems. The systems matter, and matter a lot, because they are the way in which we can build a framework to keep NHS standards national. It is clear from David Cameron’s recent speech that the government is depending upon them for this purpose. The practitioners, those who understand the systems best, know that what we have is at the very most a warning system. The data is subjective, quality of coding matters, there are few people with the skills to do this well, and human error occurs. As investment in “non essentials” is squeezed then this is an area of the health service performance that may well suffer.  What the statisticians tell us plainly is that simple statistics cannot be used to demonstrate that a hospital is “failing”. The League tables so loved by the press for their simplicity and dramatic effect should now be a thing of the past.

The CQC new philosophy of regulation combines use of the indicators that may flag up potential problems with skilled people on the ground to delve into areas of concern and to help hospitals begin to be able to identify clearly where they can do better. The weakness that the CQC has now, and I think this is demonstrated by the Winterborne case, is that there are simply not enough skilled inspectors to do the job. There is a serious recruitment problem.
The role for the press and the public.
The thing which I think appealed to the CEO and the journalist about the idea of the press as quasi regulators, is that the CEO has said there is a need for thousands of pairs of eyes. It is everyone’s responsibility to take care of the health and care services. We all need to raise concerns. The question that remains is what is the best way to be able to do this effectively?
One thing that was abundantly clear from the Midstaffs case is that the complaints system within the hospital was dysfunctional. It was quickly reformed and is or course being reformed again now.
Complaints directed outside the hospital were effectively useless, as many different people ended up with one or two pieces of paper on their desk. -Never enough to form a pattern.- None of this connected.
The need for an effective patient participation vehicle was of course completely recognised and the LINks system was in the process of forming as a replacement to earlier vehicles for participation when the Midstaffs problems kicked off. This small group of willing and well meaning volunteers was not in any way equipped to deal with the huge problems the Stafford Campaign group brought with them. Having witnessed some LINks meetings at this period the volunteers who might well have done a good job in other circumstances were paralysed by the truly astonishing level of animosity that these meetings generated. It is perhaps useful to mention that the LINKs system, which was crying out for more public involvement received virtually no support at all from the local press, and did not become visible until the press were in a position to criticise them.
So the channels which should have led to constructive engagement between the public and the hospital over the problems that existed failed, and we were left with a situation where the press perhaps rightly saw it as their job to side with the pressure group against the hospital. The hospital found itself on the receiving end of literally thousands of negative articles, ( I have boxes of them) which may arguably have contributed to the loss of staff morale, patient confidence and to the financial problems of the hospital. Energy that could have gone into resolving the problems that existed was diverted into simply surviving the barrage.
Changing the game
The public voice needs to be heard –but how?
I think there are a number of ways in which this has already been tackled:
·         The Hospital pioneered comfort checks, which means that potential “complaints” are tackled before they ever reach that point.
·         The hospital brought in simple boards for patients and families to raise suggestions.
·         The board meetings are all held in public, and actively encourage public engagement.
·         Training for staff brings the patient experience to the forefront.
·         The Trust holds meetings on a range of issues which are all designed to help the public make their voice heard.
·         NHS Choices was set up by the DOH and SHA and already functions as a way of channelling complaints and concerns  through to CQC and presumably to the hospitals.
·         LINks  in Stafford got adopted by County Council, Not sure what impact this has had, but it removed the temptation to use it as a political football.
·         Healthwatch will have a clearer integration path to CQC which will assist to ensure all problems channelled into a place where they can be collated.
·         One element of the CQC system which is still very new, but potentially game changing is the QRPs. Hard data, particularly hard data that tells you what you think it does, is hard to find. For it to be of any value it requires skilled people spending time collecting data, Some of this is essential, but it is at least for the time being politically unpopular. The QRPs will make it possible for many sources of “soft data“ such as patient complaints and press stories to be logged in a way that would give some idea of patterns or clusters of complaints.  If this takes off then the press will find that there is potentially more of a response to their efforts than was ever possible in the past.  This would help everyone. If low level complaints can be heard there should no longer be the necessity for vocal and potentially divisive and delaying campaigns. So with or without a “quasi regulatory” role the press should be able to play through the QRPs  a more effective role in helping to express people’s concerns. Richard Hamblins evidence is again helpful on this matter.
Could the press do more?
To go further, to actually direct public money at the press to help regulate the NHS and other services is a genuinely interesting proposal, but I think this raises some rather serious questions about what the press is actually for and how far the press is willing to modify their role.
If you had asked me this question 20 years ago I would have said that the local press was there to serve the good of its community, but 20 years of observing the press in practice has made me question this.  
What the press perhaps has to offer is the skills of individual journalists in assisting individuals to make their points. Many journalists would be able to do this job very well, and the community would be better for it. But does this sit comfortably with the role of the press?
A regulator – and anyone who would want to perform a regulatory role has to be accountable. Their first priority is to see clearly the truth of a situation from all sides. This will generally mean slow, careful research, the checking of facts, and making it possible for different people to give their side of a story.
The press – at least the press as we know it does not do this. The role of the press is to tell interesting stories and to sell papers and advertising space. We are dealing with businesses trying to make a profit in a market that is under some fairly extreme pressure.
Journalists do not have the luxury of time to research carefully. They must tell their story in the required number of words, in time to get the paper to press.
Papers belong to wealthy men, who have friends and have political allegiances. Running papers means attracting advertising revenue, and people who pay well are obviously important to any proprietor. Public services, and especially the NHS is deeply political. Journalists are hired and fired for a variety of reasons, and unless journalists acting as “regulators” can be protected from the subtle pressures to say “the right thing” they could not carry out this role objectively.
Beyond that there is the whole way in which the press sees the world. The press likes stories where people are shocked or disgusted or angry. They like stories of distress and human suffering. They like blame and retribution. These are the stories that set the tills ringing. Other stories, less dramatic but equally important do not have the same weight.
Just as an example, I spent 5 years trying to interest the press in the complex issues that were addressed in the Labour party White paper on social care, and are now going to be addressed by the Dilnot report.  These are issues that cause very real hardship and distress to thousands of families, but because I was interested in seeking solutions to the problem, and was working with people to do so, this was not really a very interesting story to the press. I was not prepared to blame anyone for the problems that I had personally encountered, and therefore there was no conflict to make this important story entertaining.
If we were to direct public money at the press it would need to carry the requirement for them to deal with stories, sometimes, complex stories, in which they might not actually be very interested.
So is the whole thing impossible?
Perhaps not.
Papers as we know them are at the end of their life. All journalists accept this. When papers go the influence of the powerful men who run them will go too. This influence is already waning as the internet continues to bring together clusters of individuals who work together to make their voice heard. Papers are already losing their monopoly of “the truth”.
But this is not enough. In five to ten years the press and the internet will have changed beyond recognition, but the skills that good journalists have to offer will still matter.
If we do go down the road of GP commissioning and shadowy new providers then it could be that the press really will have a vitally important role to play   When providers are not open, then real investigative journalism will be needed.

“The advantages for local papers are that a subsidy to deliver adequate health coverage would reinforce their curiosity about local provider (and indeed commissioner) performance. There are many good stories to be had.”

The internet is bringing a quiet revolution, the democratisation of information. NHS Choices is a part of this. But more need to be done to make this quieter more collaborative approach work for people. This kind of development is a tool for a healthier democracy.
Journalists have a role to play here. If everyone is helped to use their voice, if we get beyond the paternalism of the press in its current form, then there will be thousands of stories that at present we simply never hear.  Good journalists could help with the task of making these visible. If they really help to give people a voice they can play a part in transforming our communities.
The Problem of “Truth”
The writer makes the assumption that the libel laws we currently have are enough to ensure that the truth will generally be told by the press. My perceptions of the Stafford Story show why in this particular case – which may well be unique I would have deep reservations about this. Truth is not always a simple matter. That is why many millions of tax payers money are now being spent to find out what really did happen at Stafford, and even when we have with of hundreds of hours of clear evidence and witness statements to go on then we find that there is still some surprisingly radical differences in the interpretation of the “truth”. 
For the press to be able to play the part that I would like it to play in our communities, either as a “quasi- regulator” or simply as good newspapers I think there are some simple changes which need to happen.

This is perhaps most easily illustrated by looking at a single element of the Stafford Story.

The single biggest problem with the reporting of the Stafford Hospital story comes from the fact that the excess death figures were presented as authoritative fact, when in my favourite euphemism of the moment, they are “not an entirely uncontested version of events.” They were something which came from a document that has been deleted, under circumstances we now clearly know, leaked by a person who has not been identified, based on data acknowledged by virtually all informed opinion to be seriously flawed, and using a calculation which the creator of the data system has clearly stated to be inappropriate. If this is fact it is certainly not fact as I recognise it. – but due to the extreme complexity I am not yet satisfied that the PCC would see it as a clear infringement of the editors code.
I am very easily satisfied. All that I ever required from the press is clear attribution. If they had begun with the premise all “facts” must be traceable back to their source, I do not believe they would have been tempted down the road they travelled. Repeated quotes of “hundreds of deaths” would be so much less appealing if it was immediately followed by the details of what was known and not known about this “information”.
Health policy insights says
There are also the pitfalls of bias, grudge-settling and other such drivers – but the press are used to dealing with these motives, and to presenting both sides of a story. More to the point, the British press knows that it is subject to some of the world’s most stringent libel laws, in which absolute truth and the public interest are key defences.
This Is something that I would really like to be able to rely on, but at the moment I do not genuinely believe that I can do so.
The press is in the dock now, over a growing range of different abuses. All institutions must now come under scrutiny and it is the turn of the press. Maybe now is the time to set the ground rules for giving us the press reform that I believe both most good journalists and the public want and need. The Stafford Hospital story gives us valuable pointers to the reforms we should be looking for.
 I could be reassured if
·         journalists would always produce their source material if requested for it,
·         in the event of serious disagreements over the interpretation of “truth” that one could call upon an impartial expert tribunal to act as an “appeal court”,
·         in the case of science based stories these tribunals would be expected to call in people who understand the material in question,
If this were done then I would genuinely welcome the major improvements that this would bring to journalistic practice, and would welcome an appropriate role for the press in helping people hold public services to account.  

Is Stafford Hospital the Last Big Hospital Scandal?

We are reaching the end of the Health reform listening exercise, something that has been forced on the government by their recognition that many people within the health service do not accept their reasoning for major health reform.  There are still big questions, Does the health service need major reform? Do we understand well enough the reforms that have already taken place from within the health service? Are the reforms proposed by the government taking us in the right direction.
Because I live in Stafford and have lived with the impact of the Stafford Hospital story over the last three years I think that understanding what happened at Stafford or because of Stafford gives us some clues on these questions.
The truth about Stafford is many sided, and we are still learning what this truth may be, but I think that many people now agree that the prolonged process of investigation and inquiry has been costly, damaging to the hospital, staff and patients and relationships the NHS and also very damaging to political relationships.
As the process of “learning the lessons of Stafford” plays itself out, significant lessons have already been learnt about how to monitor health care, but people have also been very keen indeed to ensure that nothing as destabilising as the Stafford Hospital Scandal can ever happen again.
So the question I am asking in this post is “has enough been done to ensure that Stafford will be the last of the big hospital scandals?”
What do I mean by this question? Do I think that “learning the lessons of Stafford” will ensure that there will be a magical overnight improvement in the delivery of health care? No, Not at all!
The evidence from all those who are skilled observers of the health service tells us a similar story. This is a service which ultimately depends on people. I think that the assessment of Peter Carter from the RCN was pretty accurate. Hospitals are made up of a series of micro climates. The quality of the patient’s experience of hospital health care will continue to be dependent on the unique mix of individuals present on an individual ward on an individual day.
What I mean is that the unique set of circumstances which made up what Robert Francis describes as the “perfect storm” for Stafford can now never occur again.
For those who have not already seen it, it may help to look back at the short video in which I describe the anatomy of this perfect storm. 

Here in a little more detail are some of the key elements.

·         The story has to begin with Julie Bailey, the creator of the pressure group, who has been described by so many people including herself as the reason why we have the Public inquiry. Julie Bailey is unique in her determination and in her distinctive approach to the problems she found in 2007, but many people around the country have learnt from her experience about effective ways to use the media in furthering their campaigns. There is the potential for many more pressure groups to form.
·         A central reason for her discontent was that the complaints system and also the forums for patient participation were both dysfunctional. All parties are united in their recognition that this had to be improved. The Labour government brought in a reform of the complaints process, created NHS choices, and carried out work on patient and public participation, There is interesting work underway to be able to pick up “soft intelligence” A stronger framework for listening effectively to the concerns of patients and families at an early stage should mean that it is never again necessary for dissatisfaction to get out of hand in the way it did in Stafford.
·         Creating a really effective way of finding out what patients feel and responding to it is always going to be challenging but Stafford hospital has made a number of changes. It has pioneered ideas like the two hourly comfort checks which will cut of potential problems before they ever reach that point. It has carried out restructuring of the hospital to ensure that there are easier ways of monitoring high dependency patients, and it has created an ethos of openness which brings patient stories into the heart of the board room (the CEO has now started tweeting board meetings) and makes patients the clear focus of the service.
·         The funding squeeze in the NHS in 2006 was of course not unique to Stafford. This lay at the root of many of the problems of understaffing that did occur. It will have affected many other hospitals in 2006-7. The financial pressures which caused the staffing shortages and care problems are of course present again now, so we should expect that hospital front line staff may at times find themselves under intolerable pressures, and may still deliver care which they know to be less than perfect.
·         The Dr Foster Intelligence Hospital Standardised Mortality Rates HSMR, which came to the national attention through the publication of a league table in the Telegraph in 2007 has as a result of the eruption of the Mid Staffs scandal come under very serious scrutiny by politicians, Health service managers and statisticians. It is perhaps unfortunate for Dr Foster intelligence that the press coverage by the Daily Telegraph greatly over claimed what it is possible for these figures to show us. Different parts of the Health service have now looked at the use of these figures in detail and there is now clear agreement by the experts in the field that the figures are a tool which have a value as part of a range of tools. It will often produce misleading results, and it cannot meaningfully be used to demonstrate the quality of care in a hospital (the Statement by Richard Hamblin is the clearest expression of this). ·         There will never again be the publication of the HSMR figures as a league table, and the HSMR system has now been superseded by SHMI  which was created by experts working together as a response to set of problems identified by David Kidney in his Westminster hall debate of April 2009  and the recommendations of the Independent inquiry.
·         The reason why Stafford Hospital performed so poorly in the HSMR league table is due to a mix of circumstances. Stafford deals with a very high number of elderly patients, who have a complex mix of illnesses. If the co-morbidities (which reflects the total risk to a patient) are not recorded accurately for hospitals with this kind of case load then there will be an elevated HSMR figure
·         There is only a very small hospice provision in Stafford so most people will die in hospital. This will lead to an elevated HSMR figure.
·         Coding of co-morbidity was being done badly in most hospitals throughout the country, because it was not seen as a priority until the 2007 league table. It was being done particularly badly in Stafford due to the long term sickness of the coding manager (See HCC investigation report)and cuts in administration support staff.(highlighted by the evidence of Dr Singh. The repercussions from poor coding at Stafford have been so major that the health service as a whole is now fully aware that whatever else you might cut in times of financial difficulty, that you cannot afford to cut the time given to code information accurately.
·         The publication of the Dr Foster league table by the daily telegraph in 2007 is a fairly typical way of how the press operates. They took the simple but flawed and misleading figures to build a story which damaged the reputation of Stafford and a number of other hospitals. I see no prospect of this changing unless the press is ready to learn the lessons that they should learn from the Stafford story. This irresponsible use of information by the press is the central reason why I am personally fighting a campaign for #pressreform . The press problem remains, but we can be certain, that in the case of the HSMR figures at least that these will never again be presented to the press in the same damaging way.
·         Here are a few references on the statistical row sparked by the use of the Dr Foster figures. It will be seen that the statistical world splits into different camps on the issue of how you can measure quality in the health service. Professor Jarman and the Dr Foster unit end up on one side of this divide, and Dr Mohammed from Birmingham university ends up on the other side.  
These different philosophical approaches to how you measure quality become politically important as a substantial part of the Conservative parties claims on the NHS is that their “outcome” measures would be a good way of measuring quality, and that the “targets” and “process” tools which were available to the NHS during the “noughties” were now a thing of the past. The Daily telegraph helps us with an outline of the conservative led philosophy here

I suspect that few of the politicians espousing one side or other of this argument actually understood the intricacies of the argument. They just wanted a system that would give them reliable information on how the health service was doing and help to drive up standards.

Management systems and statistical methods evolve over time. They are getting better, but this is something that all political parties should welcome and none should try to claim the credit for! I have put together some information on how I see the philosophical approach to monitoring developing here. (to follow)
·         The Strength and ultimately the weakness of the Cure the NHS campaign is that they drew the conclusion that the poor care they witnessed was part of a pattern of high mortality “proved” by the Dr Foster Figures. Because of this firmly held belief they had no hesitation in calling for heads to roll and pointing out the errors of large numbers of people within the community. This has put Stafford through an extraordinary experience. the best analogy is probably found here. The effort which perhaps could and should have gone into bringing the community together to address the genuine concerns raised by Cure the NHS may have been dissipated because of this.
·         All of this is just a prelude to the HCC investigation. The unique factors about this are that the HCC was about to be disbanded and the style of investigation favoured by the investigation team, something of which they were naturally proud, was about to be discontinued. A strong theme in the evidence given by the HCC investigation team is that they do not believe the Stafford Hospital Scandal could have been “discovered” in any other way. This may well be correct – but what is that they actually discovered? And how can we assess the scale of the problem? After years looking intently at this matter I cannot answer that question. Richard Hamblin’s joke is an interesting insight into why this is so tricky (to follow)
·         There are other factors that make the position of the HCC unique at that particular period of time. They were just beginning to see the very first alerts from a new statistical pilot scheme to identify “outliers”. They had no way of knowing how reliable these new untested figures might be. Their investigation at Stafford was in part a live test to see if the new figures were telling them anything useful.
·         Because the outliers system was so new, and so controversial the HCC deliberately did not share any information about it with the rest of the health service.
·         Because the rest of the health service was unaware that the HCC had already discounted the value of HSMR and was working secretly on the new outlier system the SHA focused its attention on looking at the Dr Foster figures and the impact this had had on 6 hospitals in the west midlands region. They commissioned Prof Mohammed from Birmingham University to look into HSMR, other mortality systems and other ways for measuring quality.
·         Over the course of time the operational basis of the HCC investigation team had shifted. Previously they would only “investigate” if they had clearly identified that a problem existed. In the case of Stafford this was quite different. They had figures. They did not know what these figures were telling them, and they did not know if there was anything to worry about or not. The “inspection” at Stafford happened because they did not receive the answers they were looking for when they were looking for more information on the areas identified by the outliers.
·         When the HCC asked for information to help with their concerns on the outliers Martin Yeates would have been completely in the dark. I suspect that he would have assumed that this was simply an extension of the problems he was having with the Dr Foster league table, and that the response to this by Prof Mohammed would cover the questions that were being raised. This would have been the wrong assumption. What the Stafford Hospital scandal has firmly impressed on Hospital managers all over the country that if the CQC is asking for further information then it is absolutely in the best interest of the hospital to comply with their requests!  
·         In practice coding problems could, and I believe did play a part in the alerts being triggered by the Mortality outlier system, just as they did with the Dr Foster system. This is recognised in the evidence from Martin Bardsley, but the investigation team saw the coding issues for the two systems as completely separate matters.
·         Martin Yeates will have believed that the research being conducted for the SHA by Prof Mohammed would answer all the points being raised by the HCC. The HCC did not explain adequately why this would not satisfy them, and in addition the use of Prof Mohammed will have appeared to the sensitivities of the Dr Foster Unit to be a direct and calculated insult with political overtones.(blog to follow on the sensitivity of statisticians).  In the fog of confusion created by all of this the effective communication between the HCC investigation team and the Trust broke down in a fairly dramatic fashion.  Martin Yeates, for reasons completely beyond his control found himself the unfortunate pig in the middle of a statistical spat.
·         The combination of the Mortality outliers that no one but the HCC knew about, the sensitivities of the investigation team, the different philosophies about monitoring, the lack of clarity about the roles of the different organisations and perhaps also some clashes in personality meant that Monitor did not step in to take action to support the hospital,  because they were reluctant to tread on the toes of the investigation team. This led to substantial delays in taking action to rectify the problems that were found. One substantial lesson that the health service has thoroughly learned from Stafford is that there has to be better communication between the different sections of the NHS. This problem should not occur again. Investigations if they occur will go hand in hand with steps to rectify the problems.
·         There is now much greater openness about the statistical underpinning of health service monitoring systems. The Dr Foster HSMRs are no longer considered as sufficient basis for investigation by any sector of the NHS and this source of misunderstanding has therefore now been eliminated.
·         All of this was coming to the boil at the start of 2008 which coincides with the time that Julie Bailey shifted from being a one woman band, to being the head of Cure the NHS. Cure the NHS began a forceful campaign to draw attention to the HSMR league table and its supposed implications. This was a campaign that was taken up by the local press and spread further as the Campaign group began systematically contacting and putting pressure on an extensive list of organisations which are listed in Julie Baileys evidence to the inquiry.
·         It should be remembered that because of the changing nature of HCC investigations and because of the “testing” of the new mortality outlier system the decision to inspect the hospital was not taken because the HCC had clearly identified a problem at Stafford. It was taken because they could not rule out the possibility that there might be a problem, and because the hospital was not providing the answers they were looking for.
·         There is one single incident which tipped the HCC into the decision to carry out a full investigation. This came when members of the investigation team, including Heather Wood, carried out an unannounced visit to the hospital, and Heather Wood saw one elderly lady about to fall out of bed in the Emergency Admissions Unit. (This is of course an issue which faces all hospitals and all care homes every day. I can vouch for this. My own mother suffered a broken hip when she fell over the cot sides aimed to protect her in a care home in Stafford. Short of having one to one 24 hour care which is of course impossible, I suspect these accidents will always happen).
·         Once the investigation began this sparked huge interest from the local press, and saw the beginnings of what is perhaps an unusually close relationship between sections of the local press and the pressure group. It is of course inevitable that the personal stories of the bereaved relatives, which formed a regular part of the local media coverage, will have made a strong impression on the minds of the journalists involved, and will have created a real bond between the journalists and the pressure group. This is quite a common phenomena when people find themselves at the centre of a tragedy. It can appear that the press are the only ones who understand, but the press always have their own agenda.
·         The level of press interest and the growing self confidence of the pressure group will have left the investigation team in no doubt that they needed to clearly identify “the problem” at Stafford. Their credibility depended on this. There was no middle way.
·         In the last few months before the issue of what was to be the last major report from the outgoing HCC investigation team, we also have the additional complication of growing political interest. At a local level this was interesting. The two MPs involved were David Kidney the Labour MP in Stafford, and Bill Cash the prominent Euro sceptic Tory MP in Stone. David Kidney was the first to become caught up in the matter. The pressure group experimented with a form of direct action that they subsequently used against a number of prominent people. They turned up at David Kidney’s surgery en mass, with placards, and with a hidden video camera. They were not interested in dialogue, but in making a point. Their “film” was then posted on Youtube.
·         David Kidney’s response to this difficult encounter is characteristic. He listened, identified things that he could do to help them follow up their complaints and set the wheels in motion. He then kept them informed of progress. He was in regular contact with the hospital trying to understand the concerns that were being raised.
·         In the summer of 2008 he made the decision to spend a number of days at the hospital on work experience in order to see more clearly what conditions were like. He worked in various areas of the hospital. It is of course true that he, like the governors, and councillors who have some responsibility for the hospital, was a lay person, without any specialist skills in inspection, and it is also true that he was instantly recognisable by staff who might well behave better in his presence than normally, but this was nevertheless a very serious attempt to see what was happening, and to make it possible for staff to talk very informally with him. He actively took part in the in deep cleaning which was part of the national efford to tackle the very serious issue of hospital acquired infections, which was killing people throughout the country at this time, and he saw nothing during this work experience to cause him any serious concerns. This is in line with the impressions of every lay person and every health professional who visited the hospital during this period. If what was happening in Stafford was in anyway unusual there was nothing that would be immediately apparent to most people on most days in most wards.
·         David Kidney’s report on his work experience was taken as a gross insult by the pressure group who formed the idea that he was undermining their position.
·         What we can say clearly about David Kidney is that he went to very considereable efforts to inform himself about the hospital, he visited regularly, he read reports in detail, he talked to the different agencies involved, and he also knew from his dealings with these agencies that the Mortality Statistics had their limitations, and that they should not be taken at face value. This meant that he could not simply accept some of the less accurate assertions of the pressure group.
·         With Bill Cash, we see an entirely different approach. Mr Cash’s evidence  to the inquiry tells us that he had no contact with the hospital since before 2003, he never met Martin Yeates, He took no direct action in any complaints involving the hospital, but simply sent copies of complaints to the department of health, He had no understanding of the statistical systems or the systems for monitoring the quality of the hospital. He had not accepted a series of invitations to attend briefings. His information about the hospital came from the newspapers, and when Julie Bailey made contact with him in winter 2008 he simply accepeted her version of events unchallenged and took steps to assist her to  gain wider media coverage.
·         From the local perspective this will have looked to the Conservative party like a godsend. David Kidney had, for very good reasons, the reputation for being one of the most trusted and competent politicians in the country. Finding someone who believed that he had let them down, and was prepared to say so as publically as possible, and who was essentially unassailable because of the genuine sympathy with their suffering, will have seemed like a gift from heaven.
·         In the months before the publication of the HCC report major battles broke out between the different parts of the health service involved. Drafts of sections of the reports circulated to interested parties were actively contested by people who felt that the report misrepresented them. There was a major discussion on an appendix which included “excess deaths”. I can give you no reliable information on what this appendix contains, because it was removed from the report on the authority of Sir Ian Kennedy, who was Chair of HCC, after discussions with Bill Moyes, from Monitor. What I can say about these figures is that Richard Hamblin, who has to be seen as the expert on what these figures mean, is firmly of the opinion that the figures should not be used, and that there could be no proof about how many people might have died as a result of poor care without a full case note review. The case note review which did take place found it was also impossible to give any estimate of numbers. The coroner could not help with this either. 
Cure the NHS on the other hand see the “excess death figures” as completely central to their case against the hospital. They have used them extensively, they appear in hundreds of press articles, they have been quoted by David Cameron on their behalf in PMQs, and they are now a firmly embedded “fact” in the minds of thousands of people in Stafford, as well as many millions beyond Stafford. It should be noted that Cure the NHS have been directly told of the weaknesses of these figures by David Colin Thome, and by Robert Francis, but they still continue to use them. 
·         The day before the publication is highly significant. An article appeared in the Daily Mail, Using the excess death figures, and quoting Cure the NHS and Bill Cash, This article formed the background of understanding with which the press took in the information from the HCC press conference.
·         The coverage of the release of the report was entirely dominated by the excess deaths which do not form a part of the report to the exclusion of many specific problems identified by the report which had already been resolved.
·         Once these figures were out, in a way that no one could contest because they were not in any printed material, they dominated headlines not just in Stafford, or Britain, but across the world. They played a significant part in the republican election campaign for Massachusetts where they were used successfully to persuade American voters that they should not back health reform.
·         In this country the prominence if the story in the tabloid press meant that it was inevitable that Andrew Lansley and David Cameron should grasp this opportunity to show that the NHS had “failed” under labour, and that there was a need for major reform of the NHS. Videos and press coverage of David Cameron with the Cure the NHS fulfil many different functions. ·         The HCC report left many lose ends and raised as many questions as it asked so since then we have had the Alberti Report, The David Colin Thome report, The report into the conduct of Martin Yeates, and the Independent inquiry by led by Robert Francis. All of these which provided significant pointers for action, were belittled by the Conservatives who declared, as Bill Cash had always insisted, that a Public Inquiry was the only possible answer. Locally and nationally the demand for a public inquiry was the sound bite response of the pressure group, press and Conservative politicians to the hospital issue.
·         As we moved towards the 2009 elections the eruption of the MPs expenses scandal through the Daily Telegraph expose formed a climate in which “the voice of the people” became increasingly powerful and more rational voices amongst MPs were effectively silenced. 
·         This hospital story, alongside indiscriminate coverage of the expenses scandal dominated the press in the run up to the local elections in this area in 2009, where they played a part in unseating a number of Labour councillors. The issue of NHS “failure” then moved to centre stage for the Conservative election campaign in 2010, where images of Stafford, and the perception of failure still firmly in most peoples minds were skilfully used by the Conservative party to overcome deep rooted distrust in their relationship with the NHS.
·         The Conservatives very wisely took the public position that there would be no top down reorganisation of the NHS, which is something that would have resonated with many people, including many health professionals who had lived through the upheavals of 2006-2007.
·         The Election of 2010 brought us a Conservative MP in Stafford and a Conservative led government, which meant that the hospital issue no longer had to play a part as an election winning tool , though it has continued to be used by the Conservatives as a means to “sell” their proposed reforms, with a totemic appearance of the pressure group on the platform for Andrew Lansley as part of the 2010 conference.
·         Throughout all the period from 2007 with the first release of the Dr Foster league table, until now the Health service has been effectively healing itself from within. The relationships between the different tiers of management, which the Health reforms now threaten, have been worked through and new systems of communication worked out. A significant coalition formed to reform the statistical basis for Monitoring health care as a result of the Robert Francis Independent inquiry and alongside these new and robust systems of monitoring there is a complete new philosophy on how to manage the health system, of which the essential element is that hospitals are not left to sink or swim through periods of difficulties.
The unique mix of ingredients which created the perfect storm over Stafford Hospital will never occur again. There are massive and growing problems in the delivery of a health service, poor care will continue to be an issue in hospitals, care homes, and in private houses throughout the country, This needs the co-operation of all regardless of political affiliation to resolve the problem, but Stafford could be the last of the big hospital scandals, because the NHS has recognised and acted on the real problems which did exist and has removed some of the triggers which made it possible for the media and politicians to turn a limited local problem into an international scandal.
The Health Reforms which this government – or more precisely the Conservative element of the government- wishes to put forward are based on a false idea of the failings of the NHS, and on an attempt to solve problems that the NHS has already resolved organically from within.

The road to a new philosophy of health regulation

I have raised the question, was Stafford Hospital the last of the big hospital scandals? One of the reasons that I think that it could be is because there has been a complete change in both the tools available to regulate the health service and the philosophy and structure of regulation.
It may help to look at what has happened in Stafford in historical terms.
I think that what we have seen in Stafford is a major milestone in the journey towards effective regulation of the NHS, and perhaps to complex systems in general.
Let us think back.
In the days before the National Health Service, the provision of health within a town was down to individual doctors, and to worthy citizens playing a role in governing their hospital. I perhaps have an unusual insight into this time, because my own family, Russell of Hitchin, combined two interests. Some of this small mafia were chiefly interested in running the town’s leather factory; others ran a chain of chemists which locally gave Boots a run for their money. All of them had a strong social conscience and were prominent players in local politics and in the running of the local hospitals.
This involvement in the health service persisted after the establishment of the NHS, something in which my own father played a part.
I suspect that the regulation my father would have been involved in at the numerous committee meetings that I remember from my childhood was pretty rudimentary. They would have heard reports from the Matron and hospital administrators, but also, because they were so well known in the town they would have been approached by local people who had any concerns. Maybe at that time this was enough.
The world I am describing here bears a closer resemblance to “Middlemarch” than it does to anything we would recognise now. Regulation is small scale, local, personal, and subject to variations in the quality of the individuals involved. 
The next point at which I pick up the thread of what was happening to regulation comes with the advent of the Labour government in 1997.
It is clear that what was happening in health was one of the major themes that contributed to Labours Landslide victory. We had the long trolley waits, and people dying on waiting lists, and the general sense that there was a great deal that the best of the rapidly developing world of health care could offer that was not being shared evenly across the country as a whole. Postcode lottery was becoming unacceptable.
I think there is a fundamental difference in the way that Labour and the Conservatives view regulation of services, which has its roots in how our different political parties evolved.

For Labour, providing good public services is central. It is why they exist. It is about the mutual good. For the conservatives the provision of public service is something they choose to do because it is necessary to maintain a productive workforce, and perhaps also because it is “right”.

The differences in attitude go deeper than this. For Labour public services are about ensuring that everyone has the chance to make the best of their life, for Conservatives, there is the additional driving motivation to use the provision of services to create entrepreneurial opportunities.
For Labour, because public service matters so much the state of the regulatory system as they found it must have been pretty disturbing. There was no effective way of comparing the quality of care across the country, and there was no way of identifying hospitals which needed help to improve.
We saw the emergence of systems to try and measure and drive up quality.
The simplest of these, which draws a very mixed response from practitioners and people with political views, is Targets. At their worst these are box ticking exercises and things that administrators with a mind to get round them will “game”. It is clear that in Stafford the hospital struggled to honour the targets in the “spirit” and found ways of working round them which were not good for patients.  Despite the problems with targets it is now widely admitted that they did work, they drove down waiting times in A&E and in waiting to see a specialist to a remarkable degree. It is clear that some powerful sections within the health service found this onerous, and these persuaded Andrew Lansley, during his 7 years as shadow secretary of state for health that we would be better off without the burden. We are now getting a chance to see how this experiment works. Waiting times are again growing, and perhaps as a consequence of this I am certainly noticing prominent adverts for Bupa and other health insurance companies cropping up in my daily papers with greater regularity.
A second development was Standardised Mortality Rates. This is an attempt to measure the very marked discrepancies in life expectance throughout the country and to relate that to the various factors which affect the health of the population. These variations are huge and shocking. If we take a local example then people in Stafford are on average dying more than ten years older than ten miles up the road in Stoke.
A minor factor, and it is only a minor factor in looking at mortality rates as a whole, is concerned with hospitals and hospital care. The Hospital Standardised Mortality Rate or HSMR is – or more accurately was – an honest attempt to look at the how good different hospitals were in keeping patients alive. This runs into all the kind of problems that you have with Stats in school. It is only telling you something useful about the performance of the hospital – crudely the value they are adding –  if you know what the condition of the patient when they are admitted.
How good HSMR could have been is something we will never now know. It did not work because admission coding throughout the country was almost universally poor, and because there were factors like the complexity of medical conditions, and options on places to die all skewed the results. HSMR effectively shot its bolt by the publication of the Dr Foster Intelligence league table in 2007. This was presented simplistically by the press as showing a whole lot of hospitals as “failing”. The furious response of many people within the health service to this league table was sufficient to prompt academic research into the system. The result of that is that HSMR, though it still exists as one tool in the hospital managers tool box, has been downgraded in its importance, it will never again be published in this league table form. A new system SHMI has been put in its place. The details of how this will work are still a little unclear.
Part of the controversy over HSMR was that it appeared as in the case of Stafford to be in total contradiction to the findings of other parts of the regulatory system, which included the annual health check. So you have the Health care commission carrying out its Annual health review and saying that the hospital is good followed by the Dr Foster HSMR indicating that mortality is amongst the worst in the country.
What you are effectively getting is some systems that are producing false assurances that everything is fine, and systems producing false alarms that things are dramatically and disastrously wrong.
Perhaps the best indicator of the effect of this comes in the extraordinary Westminster Hall debate led by David Kidney in April 2009 to look the Stafford Hospital question. I think it is widely known that I am a friend of David Kidney, and I am glad that I was able to give him some support in the dreadful days that followed the release of the Health care commission report, and the media hurricane that it brought to Stafford. Everyone in Stafford was traumatised by this, and David was thrust unwillingly into the spotlight. After weeks of seeing him under unbelievable pressure it is still remarkable to me that he could in this Westminster Hall debate clearly identify many of the points and conflicts which are only now emerging through the Inquiry, slowly, painfully and at very great public expense.
Many of the people who have been pilloried for “failing to see” the problems at Stafford have been perhaps correctly accused on not looking closely enough. No one could possibly accuse David of this. He is a man who has a rare capacity to see detail and to also see the broader picture (see blog on Granular still to follow) The problem that David faced at this point is that there were conflicts within the information he was being given. In the weeks that followed the HCC report he was hearing directly from patients about their experiences, and therefore knew definitively that there were some things that had gone wrong, he also knew that the blanket statement that hundreds of people had died was based on very shaky foundations.
He knew that the information that was available to him had not helped him to see clearly. He had actively wanted the tools to be able to measure the quality of service in his constituency and the tools that existed had failed him.
The evidence that I have seen through the Inquiry does give me reassurance that many of the issues he so clearly identified have now been tackled.
I have further blogging to do on this but as an interim would recommend reading the evidence and statements from Rashmi Shuckler, Peter Blythin, Steve Allen, Martin Bardsley, and Richard Hamblin,  
The limitations of the Dr Foster Intelligence system have now been recognised.
The Strategic health authority has developed clinical dashboards which bring together in one place a wide range of indicators that anyone with the ability to read this kind of information can understand and benefit from.
The creation of the SHMI system marks a major achievement in bringing together a range of Statisticians who might previously have seen themselves as rivals, to create a robust new approach.
The development of the Mortality outliers has got past the tentative beginnings, and is now giving CQC a real tool for raising questions about care in individual hospitals, a tool that can also be used by hospital managers themselves to help ensure that their performance is as it should be.
An important development of the philosophy of health service management that has occurred as a result of Stafford and as a result of the movement from the Health care commission to the Care Quality commission is that the way in which the regulator operates has completely changed.
In the Stafford case, we had a centrally placed investigations team spotting a potential problem, which its own locally based teams were not aware of, waiting months for supporting evidence, which no one understood how to give, and then sending in someone to look and starting what appeared to be a highly punitive form of investigation. This nature of this investigation process in itself made it very difficult for other agencies to support the hospital through the problems and created real divisions between the different “arms” of the health service. The investigation built in a year of delays as Monitor felt unable to take decisive action.
Everyone I think now accepts that the investigation process was not as it should have been and there is a radical change. We saw this in action with the recent CQC reports on the first 12 of 100 hospitals where they have carried out investigations. The CQC if they suspect a problem now directly involves their local teams at the earliest possible time to go into the hospital and work through the problem with them. They are not being left to sink or swim. This is a partnership approach.
The Outliers system is just one small part of the changes prompted by the response to the Dr Foster league tables and to the failure of complaints monitoring in Stafford.  One of the major themes within the Inquiry is that there have been lots of individual people who each had one or two clues that some things may have been going wrong, but there was no possible way of bringing this evidence together. No one saw the patterns and it has taken the Inquiry to bring this complex picture of who was able to see what to bring all of this together.  
There is an entire new arm of monitoring which is based on picking up the soft intelligence which forms the basis of much of the evidence to the inquiry. These QRPs are outlined in Richard Hamblin’s evidence. (will try and blog specifically on this evidence later) These systems, which are still developing, will allow us to aggregate “soft information” from complaints, websites such as NHS choices, Press reports and other sources, and will give the local regulators and managers an effective way of seeing how they are doing in a way which would have been completely unthinkable when Labour first came to power in 1997. The software to analyse text, and help draw out patterns and clusters will really help us to compare the quality of service between different hospitals, and trends over time, in a way that would never before have been possible.
This may seem an abstract discussion, but it is central to the questions which are now being asked about health reforms. Few people have yet seen or understood the fundamental importance of the evidence given by people like Richard Hamblin.
If we do not see or understand what is being done here there is a real danger that we are carrying out disruptive reforms, which will damage the health service, in order to find a solution to problems which have already substantially been solved.