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Editorial Tuesday 26 March 2013: On the Government's response to Francis 2 and Monitor's Fair Playing Field review

In his classic essay 'Fear And Loathing At the Superbowl', Hunter S Thompson famously said, "when the going gets weird, the weird turn pro".

The Government has not issued its full response to the Francis Public Inquiry in detail, but has issued this document 'Patients First And Foremost: The Initial Government Response To The Mid-Staffordshire NHS Foundation Trust Public Inquiry Report', with this statement to the Commons by Health Secretary Jeremy 'Bellflinger' Hunt.

First thoughts: what a lovely title! Now we have this initial response, can we expect 'On Second Thoughts: Response To The Health Policy Twitterstorm' and 'Third Time Lucky: Stealing Good Ideas From Newsnight Guests And Comment Pieces In The Next Day Nationals'?

There is a curiously broad assertion in Hunt's foreword that "patients and service users, and their families, friends and advocates ... know immediately if something is not right". On certain levels, it's spot-on: it wouldn't have taken a genius to work out that the degrading situations at Mid-Staffs and no doubt elsewhere were wrong.

But all generalisations are dangerous. Patients and their friends and families are generally not trained medics, and do not instantly know if clinical care is not right. There is a risk of teetering close to demagoguery if this rhetoric becomes policy.

Bring me your poor and huddled chief inspectors
The foreword also pledges, "We will start immediately by the Care Quality Commission appointing a new Chief Inspector of Hospitals to champion the interests of patients and make judgements about the quality of care. We will make hospital performance more transparent and easier to understand through a clear system of ratings. We will have a single failure regime that drives a coordinated and time limited response to unacceptable care. We will do this in a way that rationalises rather than adds to the bureaucratic burdens on frontline staff and on hospitals, and we will look to reward those organisations and individuals who deliver the highest quality care. We will also take steps to apply that approach beyond the hospital setting to other parts of the health and care system. The Care Quality Commission will appoint a Chief Inspector for Social Care.

"We will take further action to improve safety and learn the right lessons when things go wrong. We will create a system that is much more responsive to feedback from staff, patients, service users and their families, and as part of this we will ensure that everyone is able to say whether they would recommend the service they received to their family and friends. We will foster a climate of openness, where staff are supported to do the right thing and where we put people first at all times".

A few thoughts on this: chief inspectors all round is this decade's knee-jerk policy equivalent of bringing back matron. It comes devoid of analysis of why the regulators - CQC and Royal Colleges - and clinicians' own professionalism failed to spot, raise and stop the scale of Mid-Staffs' problems.

There is no definition of what "the right lessons" are.

Nor is there an exploration of why "a clear system of ratings" under the Healthcare Commission's star ratings system was found to be unhelpful to the point of being abandoned.

Nor is there any detail about how the climate of openness will be fostered. The "Actions for cultural change" section at 1.25 doesn't actually feature any action. Section 5.32 comically says, "Cultural change is not something that can be undertaken lightly or half-heartedly. It is one of the hardest things that leaders can do, and needs their wholehearted commitment. It is vital that attempts to change culture do not simply focus on surface-level observable behaviours. Meaningful change is only possible if deeply ingrained beliefs and assumptions are brought into the light and discussed. This is necessarily an uncomfortable process, and requires courageous, authentic leadership".

Fine. But how?

In a touch of Pulp-inspired "let's all meet up in the year 2000" nostalgia, pages 11 and 12 give us a The NHS Plan-style signed-up statement of common purpose.

The report is themed around a five-point plan:
A. Preventing problems
B. Detecting problems quickly
C. Taking action promptly
D. Ensuring robust accountability
E. Ensuring staff are trained and motivated

All fair enough, and we are told it "will drive coasting hospitals to improve and it will give greater freedom to care for the good and the excellent".

The document pledges that "the Chief Inspector will ensure that there is a single version of the truth about how their hospitals are performing, not just on finance and targets, but on a single assessment that fully reflects what matters to patients". Mmm. Clearly the authors of the text have never seen Kurosawa's Rashomon.

Fortunately, it goes on to add, "In line with the Nuffield Trust recommendations, information about hospitals will not be limited to aggregated ratings but it will be possible to drill down to information at a department, specialty, care group and condition-specific level. As a starting point, the NHS Commissioning Board will extend the transparency on surgical outcomes from heart surgery, which has been hugely successful, to cardiology, vascular surgery, upper gastro intestinal surgery, colorectal surgery, orthopaedic surgery, bariatric surgery, urological surgery, head and neck surgery and thyroid and endocrine surgery".

In a thoroughly sane move, it also states that "the Care Quality Commission, the NHS Commissioning Board, Monitor and the NHS Trust Development Authority will be required to agree together the data and methodology for assessing hospitals".

'Lying is bad' shock
The document also says, "Mortality data must be interpreted with care, but it must also be accurate so that the public and patients can trust that they are hearing an honest and fair account. So there will be tough penalties and we will consider the introduction of additional legal sanctions at corporate level for organisations that are found to be massaging figures or concealing the truth about their performance.

"A statutory duty of candour on providers to inform people if they believe treatment of care has caused death or serious injury, and to provide an explanation, will reinforce the existing contractual duty ... the NHS Standard Contract for 2013/14 will include a contractual duty of candour on all providers to be open and honest with patients when things go wrong with penalties for breaching the duty.".

It also heralds "a new time-limited three stage failure regime, encompassing not just finance, but for the first time quality, will ensure that where fundamental standards of care are being breached, firm action is taken until they are properly and promptly resolved".

Employment lawyers will be interested in the proposal to have a register of struck-off NHS managers. (The standard of proof for this will need to be pretty high.) But at least they'll be able to get new MBAs and fast track entry from world-class universities first.

Nursing training extended by a year
Nurses who want their university tuition fees funded will have to first work for "up to a year" as a healthcare assistant. Apparently, this will indelibly rework their DNA to make them eternally compassionate. There's no evidence for this whatsoever, but it's a fact.

Nurses will be revalidated, and healthcare assistants can be struck off too.

And in a hog-whimperingly insane move, within four years, DH civil servants will need to have front-line experience of delivering care. Cleaners, IT staff, data analysts, policy advisers. (That'll make public health work really effectively.) But will they be revalidated? And can they be struck off?

We learn that "The Government has asked Don Berwick to lead a National Patient Safety Advisory Group to advise on a whole system approach to make zero harm a reality in the NHS". Erm, didn't there used to be an agency for doing that? Also that "if the Chief Inspector finds a potential breach of health and safety requirements, the Care Quality Commission would refer the matter immediately to the Health and Safety Executive, which in serious cases could use its existing powers to prosecute".

There's another good bit: "From April 2013, Quality Accounts will also include comparable data from a set of quality indicators linked to the NHS Outcomes Framework. This will include the summary hospital-level mortality indicator, infection rates and levels of patient safety incidents".

HR departments may quietly panic when they read that 5.11 warns "We will also ensure that medical pay rewards current excellence, rather than historical performance".

Journalist Camilla Cavendish's name appears five times, which is nice.

Oh, and in a real Windscale / Sellafield moment, the NHS Commissioning Board is henceforth NHS England. (This is the name Comrade Sir David Nicholson always wanted it to use.)

Monitor's Fair Playing Field review
The big news from Monitor's fair playing field review is that third sector and independent sector providers will be subject to the Freedom Of Information Act. This won;t please The Bellflinger, who responded with Lansleyite querulousness on this topic in the last session of Commons health questions. It'll be worth watching if this is accepted.

Monitor's review "found three types of material distortion:
1. Participation distortions. Some providers are directly or indirectly excluded from offering their services to NHS patients for reasons other than quality or efficiency. Restrictions on participation disadvantage providers seeking to expand into new services or new areas, regardless of whether the providers are public, charitable or private. Participation distortions disadvantage non- incumbent providers of every type.
2. Cost distortions. Some types of provider face externally imposed costs that do not fall on other providers. On balance, cost distortions mostly disadvantage charitable and private health care providers compared to public providers.
3. Flexibility distortions. Some providers' ability to adapt to the changing needs of patients and commissioners is constrained by factors outside their control. These flexibility distortions mostly disadvantage public sector providers compared to other types"

It also "found two cost issues that affect patients and which are not currently being addressed: differences in access to rebates for Value Added Tax (VAT) and the variation in cost of capital faced by different types of provider. On these issues we recommend changes to remove the distortions, subject to some further work.

"VAT. Current VAT rules represent a material playing field distortion. Under the ␣Contracted Out Services␣ scheme, public sector providers claim VAT rebates worth a substantial amount in total on contracted out services, such as legal or laundry services. However, it appears that they may no longer be eligible for all of this rebate because of changes in the health care sector. Private and charitable providers cannot claim VAT rebates on any of their contracted out services and this sometimes affects their decisions about supplying services. We recommend the Government reviews whether certain public providers remain eligible for VAT refunds and considers extending rebates to services provided by the charitable sector, where they would be eligible. We recommend that the Government re-invests any resulting net saving in the NHS.

"Cost of capital. Many providers raised the differential cost of capital faced by different providers. Private and charitable providers borrow (and in the case of private providers, raise equity) at rates that reflect the lender's risk of not recovering the capital. Public providers, however, do not. We recommend that risk is priced into the cost of capital for all providers".

That has just made capital more expensive for the NHS. It would be a good thing interest rates are so low, were it not for the ongoing commitment to using PFI / PF2 for capital spending.

And with thanks to a sharp reader, it is well worth noting that the document also suggests that "Monitor should issue a call for evidence by June 2013 to help determine the extent to which the commissioning and provision of general practice and associated services is operating in the best interests of patients".

A message for GPs as a tribe ... and for NHS England, which holds their contracts.