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Editor's blog 1st April 2009: Not The NHS News - The meaning of March

Hello, and what a nice day. And welcome if you've come from OnMedica, with whom I will be sharing a 'review of the month' feature on an ongoing basis. Look around and enjoy yourselves. Let us know what you think - editorial@healthpolicyinsight.com

There are a couple of good April Fool Stories over at the excellent E Health Media. But below is my review of March 2009.

Not The NHS News March 2009: Wait loss, a capital carve-up, money matters and ironic quality regulation

In the first instalment of 'Not The NHS News', a new collaboration with OnMedica, Andy Cowper, editor of  Health Policy Insight (www.healthpolicyinsight.com) reviews the month in policy.

March 2009 was packed with incident: every one of its credit-crunch-busting 31 days! The NHS achieved the 18-week referral to treatment (RTT) waiting time target, a mere three months after the December 2008 deadline. So will there be a cost-effectiveness analysis of how many millions have been spent on this and for what health gain, did I hear you say? Don’t hold your breath; just feel the symmetry – 18-month waits in 1997; 18-week waits in 2009. Oh, and former acting chief executive of the NHS Sir Ian Carruthers is burning through his PCTs’ budgets beautifully in his NHS South West SHA fiefdom, as they stay on track to hit their eight-week maximum RTT target.

Capital-ism in crisis?
South-east London will finally get its super-trust with the merger of Bromley Hospitals, Queen Elizabeth Hospital and Queen Mary's Sidcup. The new South London Healthcare NHS Trust will be able to run up exciting new deficits, building on the Bromley legacy – the major contribution to its legacy debt of £187 million.

On other London-related matters, the capital’s 31 PCTs have now seen the writing on the wall from the comically dysfunctional NHS London SHA, who have ‘zoned out’ responsibility into six sectors. The sectors and chief executives are: south east London - Bromley PCT chief executive Simon Robbins; inner north east London - Tower Hamlets PCT CE Alwen Williams; outer north east London - Redbridge PCT CE Heather O' Meara; north central London - Islington PCT CE Rachel Tyndall; north west London - Westminster PCT CE Michael Scott; and south west London - Wandsworth PCT CE Ann Radmore.)

These Super Six will be fired at the drop of a hat – sorry, held responsible for acute commissioning, strategic change and service redesign, ensuring clinical engagement and leadership and continuing to improve commissioning in their sector. Mmmm. There’s a proud tradition of bottling out of London NHS reform which goes back decades. Capital-ism is clearly in crisis. Good luck, guys!

Oh, and do look at NHS London’s magnificent statement about this change, which insists that it “will not diminish local accountability as each one (sector) will be required to operate on behalf of, be performance managed by and responsible to, its constituent PCTs." So NHS London SHA – the intermediate tier – has created six new intermediate tiers, which are going to be performance-managed by their constituent bodies? How is that going to work?

Money talks
And the dear old doddery DH confirmed that it will be giving a Happy New Financial Year present to everybody’s favourite rationing body, NICE. Rawlins The Reappointed and company will take over the DH’s responsibility for setting the clinical indicators for the quality and outcomes framework (QOF). Except it won’t really be NICE work as such: the final say over these remuneration-related indices will be decided with the traditional naked mud-wrestling between the BMA and NHS Employers. Rumours that this will be a pay-per-view download available on NHS Choices could not be confirmed at the time of going to press, but if so, N3 bandwidth could be sorely tested.

GPs and managers’ pay also hit the headlines in the new Era Of Austerity. PM Gordon ‘Saviour Of the World’ Brown personally intervened to cap the 2009-10 pay review body recommendation for a 2.8% increase for senior NHS managers (and 2.4 for less senior NHS managers) down to 1.5%. Their bonus pot is also frozen.

GPs, in contrast, have lucked out, getting the whole 1.5% recommended. So, were the BMA happy? Were they buggery. Chair Dr Hamish Meldrum GP grumbled, “while we appreciate that tough decisions have to be taken during this period of economic difficulty, holding back on doctors' pay is not the answer. Health services will be under intense pressure as the recession takes its toll on people's health. NHS frontline staff will be required to work at an even greater pace and intensity and it is vital that their hard work and dedication is recognised. This award does nothing to support that view”.

Ooookay. Doctors’ jobs are safe in a recession; their market is fairly steady; they enjoy a government-backed pension scheme to die for; and overall as a group, they are - quite rightly - pretty well-paid. Would any treatment be (cost-)effective for the BMA’s tin ear for the popular mood?

Staffordshire bull
It is more difficult to make jokes about what has emerged over the scandalous patient care at Mid-Staffordshire NHS Trust. Fortunately, the departed Healthcare Commission did it for me, ironically lauding their own genius for spotting the incidents through their magnificent analysis of the data.

What do you mean, they weren’t being ironic?

The Healthcare Commission have performed an invaluable function over the past six years. Seriously. Any time people in NHS management have felt bad about their jobs (15.7 times a day, on average), they’ve been able to comfort themselves with the thought, “well, things might be tough just now - I might have a £7 million deficit, DH nappyrash (they’re on my arse and full of shit) and the media baying for my blood … but at least I don’t work for the Healthcare Commission”.

Sir Ian Kennedy wrote to The Guardian, “Our surveillance techniques got under the skin of the story. We went in. We exposed what was happening”.

Er, no you didn’t, Sir Ian. Nor did others fail to notice what was happening. The local paper, the Staffordshire Newsletter ran articles in early 2006 from Terry Deighton, a disgruntled member of the Trust’s PPI Forum (remember them?). This is covered in the Trust’s board minutes, and I’ve written about it in more depth here.

This material was in the public domain in early 2006. Yet only in 2007 did the Healthcare Commission start to analyse the data for problems – probably prompted by their receipt of a dossier from Julie Bailey of a local campaign about Mid-Staffs’ poor care standards, ‘Cure The NHS.’

The Healthcare Commission was meant to be the quality regulator. It rated Mid-Staffs as one-star; then fair; and then last year, ‘good-good’. It failed to do what it was paid to do – to notice the problems as they built up from 2004-5 onwards. The self-congratulatory tone with which it issued its report, lauding its “intelligent information”, was nauseating. The failure of almost every part of the media to call them on it has been appalling.

What was the PCT who commissioned care from Mid-Staffs doing? Did nobody there read the local paper? What about the SHA? Well, latterly, the Trust was in the West Midlands SHA, whose chief executive, Cynthia Bower is the chief executive of the Care Quality Commission, whose work starts today. Prior to the July 2006 reorganisation, it was in the patch of David Nicholson, who is currently enjoying a spell as chief executive of the NHS.

The blame for what happened in Mid-Staffs is widely distributed. Most obviously at fault are the Trust’s senior management team and board – and critically, the medical director and director of nursing. It was not exactly Monitor’s finest hour to fail to consider asking whether FT applicants such as Mid-Staffs were under investigation by the Healthcare Commission – though hindsight is always the best way to spot these things. More broadly, there is a significant question as to why the whistleblowing avenues – to the SHA, the National Patient Safety Agency, the royal colleges, the GMC and NMC (or even the media) – do not seem to have been used by clinicians working at the Trust.

The NHS is, unsurprisingly, the spiritual home of the TLA (three-letter acronym), and a good motto for clinicians with serious concerns about the quality of care in their trust might be CYA – Cover Your Arse. At least 120 people died because of shitty healthcare at Mid-Staffs. It might be a fitting memorial if clincians report safety concerns more – internally and externally; on and off the record.

Primum non noscere? CYA.