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Editor’s blog 26th March 2009: On blame for Mid-Staffordshire, and the Second Horseman of the NHS Apocalypse

Good morning, and apologies for the short interruption in normal service. I have been “out in the field” (see Edge Of Darkness for an explanation).

Anyway, I am now back from the field, and I hope you are well. I am fine, thanks for asking.

Since my last post, there have been various helpings of new Maynard Doctrine on here, and a plethora of other events.

Today I want to talk specifically about the events of Mid-Staffordshire NHS FT, and about the second horseman of the NHS Apocalypse. Not to be dramatic …

I will also be updating this blog later today, as I’m en route to the Simon Stevens session at the Kings Fund. Which should be interesting, to put it mildly.

Declaring an interest
Which reminds me that before I start doing so, I need to declare a conflict of interest: I’m currently doing an acting press officer job for NHS Alliance for a month or so to cover a maternity leave.

So I’m getting paid. So treat my comments about NHS Alliance with caution during this period – and I shall try to remind you (though I’m sure you treat my comments with caution anyway, if you have sense).

The Mid-Staffordshire blame game
One of the functions of the press is to “name the guilty men”. The response to the Healthcare Commission’s report into Mid-Staffordshire FT’s fatal A&E practices has been, at best, wildly disappointing and at worst an almost complete absence of wit, thought or analysis in virtually all of the press.

Among the rather under-reported issues was the Healthcare Commission having issued the Trust with respectable, pass-level ratings during the whole period in question. HC chair Ian Kennedy responded to this in a letter to =”http://www.guardian.co.uk/society/2009/mar/23/letter-healthcare-commission-nhs> The Guardian, rather spectacularly missing the point.

The Healthcare Commission is on stunningly shaky ground, because it was the regulator. Kennedy’s assertion that “Everyone bought the story, except us. The degree of risk to patients was not clear, but we were suspicious … We exposed what was happening” begs the question of why it took until March 2009, when the data were emerging in 2007.

It is also given the lie by dint of a quick look in to the February 2006 minutes on the Trust’s own website. These state, under the always-to-be-examined-first ‘Any Other Business’, “PTB(06)31 Any other Business - Mrs Brisby expressed concern regarding a report in the Staffordshire Newsletter relating to the views of Mr Terry Deighton on the cleanliness of the Accident and Emergency Department at Staffordshire General Hospital, based on a visit made by the PPI Forum. Mr Deighton had since resigned as a member of the PPI Forum Staffordshire.

“Christine Woodward from PPI Forum Staffordshire emphasised that the PPI Forum had no knowledge of this story being published, and in no way endorsed the remarks made. She said that the Trust had been open and accommodating towards the needs of the PPI Forum in undertaking inspections or visits to Trust premises, and had always been extremely co-operative. Over the period of time they have been visiting the Trust, significant improvements had been noted, and a high standard of cleanliness has been maintained.

“Following discussion, it was agreed that a joint statement between the Trust and the PPI Forum would be prepared for inclusion in the next edition of the Staffordshire Newsletter ACTION: A CRAWSHAW / C PLANT”.

Step forward and take a well-earned solo bow on behalf of the media, the =”http://www.staffordshirenewsletter.co.uk>Staffordshire Newsletter. Sir Ian has been a distinguished public servant, most notably in the Bristol Inquiry, but sadly he is simply talking defensive bollocks in this letter.

The Healthcare Commission did not cause the problems. But its job was to notice them, and act. It took far too long to do so, and the appalling organisational behaviour that the HC has modelled during its ‘fight to the last minute’ handover to the new Care Quality Commission does it little credit.

Neither does the open secret of the Healthcare Commission's reputation among its former staff and within the wider NHS as a dysfunctional and somewhat internally incompetent place to work.

The Care Quality Commission’s chief executive Cynthia Bower was, of course, the chief executive of West Midlands Strategic Health Authority, which was notionally in charge of the patch in the later, post-2006 spell of the period until it achieved FT status in February 2008.

Prior to Cynthia Bower’s tenure, the SHA chief executive was none other than NHS chief executive David Nicholson.

It has become clear that part of the Trust board’s avoidance of the quality issues related to the need to return to financial balance in order to achieve foundation trust status.

There are issues for Monitor to address here too. The new sharing of information about trusts under investigation is the correct move, but has of course come too late.

The guilty men and women
So who should be blamed?

The senior management and board of the trust are of course highly and principally culpable. If they knew and did not act, then they are criminal. If they did not know, they are incompetent and negligent.

It will be interesting to see whether the Crown Prosecution Service breaks the habit of a lifetime and actually seeks to press some charges. Of course, they failed to do so after Maidstone and Tunbridge Wells, so, much as this stinks, holding one’s breath is inadvisable.

I have unsuccessfully sought to find out from the National Patient Safety Agency whether they shared with the Healthcare Commission or even with the SHA data on adverse patient safety incidents from the National Reporting and Learning System. They have promised to come back to me with some details on this and of when Mid-Staffs went on the system. I will update on receipt.

But there is another group who cannot totally escape some element of responsibility. The trust, and especially its A&E department, were staffed by clinicians who have professional bodies and royal colleges, membership of which requires them to sign up to some form of ‘primum non nocere’ – first, do no harm.

I would say that any clinician who stood by while their trust implemented a Mid-Staffs-style ‘Clinical Decision Unit’ – translated, a room to dump people to avoid target breaches – needs to have a bit of reflection on what they might have done. And the medical director of the trust should do likewise.

It is a sorry story. Off to Simon Stevens, so second horseman to follow.

Steve Bundred – the Second Horseman of the NHS Apocalypse
During recent weeks, the Second Horseman of the NHS Apocalypse rode into town.

He is Steve Bundred of the Audit Commission, and his warning, in The Times that “the dark years of the mid-1970s and the early 1990s may look like days of wine and roses quite soon. This year net public sector borrowing will comfortably exceed 10 per cent of GDP.

“Next year, according to credible forecasts published by the CBI, it will be about 12 per cent. Others have suggested that it might be as much as 15per cent, more than double the figure reached in 1976”.

The next thing you’ll be asking me is who was The First Horseman of the NHS Apocalypse? I’m afraid you did need to spot that one for yourselves.

But this is not intended as a criticism of Second Horseman Bundred – unlike the very uncharcteristic comments of Professor Chris Ham to Health Service Journal comparing the Co-operation and Competition Panel’s edicts to the work “a neoliberal economist on speed”.

Ham told Sally Gainsbury of HSJ, "It's mind boggling. A body that ought to be an appeals committee is actually setting some key principles of reform, which goes beyond its brief," warning that the panel's "one-eyed" approach risked undermining moves towards integration and its position against "price fixing" also apparently conflicting with DHpolicy to set a national tariff. Ham was reported to ask, "is the panel going to take the DH to court for fixing prices?"

Hey! You! Get off of my cloud cuckoo-land
No, Bundred is stating nothing but fact when he points out that “tax increases and spending cuts are inevitable immediately after the election, assuming that there are signs of economic recovery by then - and why any managers of a public service who are not planning now on the basis that they will have substantially less money to spend in two years time are living in cloud-cuckoo-land”.

There is a worrying lack of a sense of urgency among many in the NHS managerial community about the financial slowdown, which repeatedly reared its head in the Simon Stevens / Chris Ham session this morning at the Kings Fund.

There is of course a certain irony in Bundred’s comments quoted today by BBC News Online, that "there is no doubt that the circumstances leading up to the collapse of Icelandic banks were highly exceptional but the potential loss of nearly a billion pounds is of great concern," said Steve Bundred, chief executive of the Audit Commission - which itself deposited £10m in Icelandic banks - my emphasis.

The story suggests that Icelandic banking by councils highlighted the "variable standards" within finance departments when it came to managing council investments.
"Good treasury managers recognised those risks and managed them appropriately," Mr Bundred apparently added. "Others either did not appreciate the risks or underestimated their significance."

But there you go: that’s the first Two Horsemen of the NHS Apocalypse who've done the long, Omar Sharif / Lawrence Of Arabia tracking shot into view. Two down; two to come …