The Mid Staffs Public Inquiry report was published last week. It described "appalling care" that flourished because managers "put corporate self-interest and cost control ahead of patients and their safety". Patients were "let down" by a "lack of care, compassion, humanity and leadership".
In 2001, with the company Dr Foster, our unit at Imperial College, London started publishing death rates of hospitals in England. This was a response to the Bristol inquiry into children's heart surgery, where monitoring of death rates had eventually led to an external investigation and then a reduction of the death rate from 29% to 4% within three years. The parents of the children brought to Bristol should have been told that there were much lower death rates elsewhere.
In addition to what we called the standardised hospital mortality ratio (HSMR) we also developed monthly 'mortality alerts' for specific diagnoses and procedures that were made available to people that used the Dr Foster website from 2004, and sent to the Chief Executives of Trusts from 2007.
Mid Staffordshire NHS hospital Foundation Trust was one of the trusts that had high HSMRs for years. Eventually the HSMR and several mortality alerts sent to the CE in 2007 led the Healthcare Commission to carry out an investigation of the trust in 2008/09. An 'appalling' standard of care was found. A patient group, CuretheNHS, led by Julie Bailey, whose mother died in the hospital, pushed for, and eventually got, a Public Inquiry about why the problems hadn't been detected earlier. When Robert Francis, QC, chairman of the Inquiry, presented his report last Wednesday, the Prime Minister, David Cameron, requested that hospital death rates be published. Yesterday Sir Bruce Keogh (the NHS Medical Director) announced an investigation into nine hospitals that had had high HSMRs for two years.
Although the HSMRs had been published annually in national newspapers from 2001, several Department of Health (DoH) and SHA witnesses to the public inquiry said that they were not available until 2007. The SHA said they didn't know about the mortality alerts until 2009, although NHS organisations in their area had logged on to them about 2,000 times per year from 2005.
The SHA supported the trust's application for Foundation Trust status to the DoH in Jun 2007 but the DoH say they were unaware of the high HSMRs at the trust. The briefing to Ben Bradshaw, the Minister of State for Health, on the line to take in response to the HCC investigation's findings, said "In April 2007, the Dr Foster's Good Hospital Guide classified the Trust as having a High Hospital Standardised Mortality Rate. (The Good Hospital Guide [with the HSMRs] was first published in 2001)." Also "If pushed on: DH Role: The first Dr Foster report was published in April 2007."
How did all this happen?
The Inquiry chairman said on 12 Feb 2013 "We have somewhat disempowered clinicians in favour of managers." A whistleblower emailed me "At present, if you whistleblow, you will be dismissed--it's as simple as that! . . . Once doctors are dismissed, it is virtually impossible to find employment back in the NHS." Some doctors said in a BMA survey that if they spoke out they were told their "employment could be negatively affected."
Patients don't fare much better. The complaints not resolved at the local hospital level were sent to the Healthcare Commission from 2004 but the HCC was overwhelmed and were not able to deal with them, so they were passed to the Parliamentary Health Service Ombudsman but she decided to 'accept' less than 1% of written hospital complaints. How would industry fare if they ignored their customers' complaints?
Some pressures are political. Bill Moyes, former chair of Monitor, said: "The culture of the NHS, particularly the hospital sector, I would say, is not to embarrass the minister." and Baroness Barbara Young of the Care Quality Commission described "huge government pressure" The minister, Andy Burnham, said "The impression of us all was that we would just, you know, constantly do what was meant to be the thing that Number 10 wanted or that we were all, you know, unthinkingly piling this stuff through. We weren't."
Sir David Nicholson, CE of the NHS, previously of the SHA, wrote in his evidence "The Board of Mid Staffordshire failed in its statutory duties to provide good quality care and managing within the resources provided. That no other hospital failed so profoundly and persistently in this period, serves to emphasise the singular rather than the systemic nature of this case." That seems a dangerous attitude to take if, as it seems from the Inquiry evidence, the problems are more widespread in the NHS.