We are on the eve of an earthquake in the National Health Service. On 6 February, Robert Francis QC, will present his report into what Health secretary Jeremy Hunt has described as "perhaps the most shocking betrayal of NHS founding values in its history".
The betrayal happened at the Mid Staffordshire NHS Foundation Trust where, according to an initial investigation, up to 1,200 people died unnecessarily between 2005 and 2008. Robert Francis's report will attempt to explain why such shocking standards of care were allowed to exist at the hospitals. The report will no doubt end some careers. Many in the health service are hungry for a 'scalp', a high profile resignation or the abolition of one or more incompetent regulatory body. Even the Chief Executive of the NHS himself - a survivor if ever there was one - has faced calls to resign over the scandal.
An earlier inquiry established the facts of what happened. It makes for grueling but essential reading for anyone working in healthcare. Here is an extract chosen almost at random:
On one occasion, when Mrs B11 went to visit her father she found the rails at the sides of his bed were down and his leg and arm were hanging over the side of a soaking wet bed. She told the Inquiry if she had not visited, her father would have been left and probably have fallen out of the bed completely. There were no staff to assist so Ms B11 helped her father and changed his bed herself. [The patient's wife] also told the Inquiry that she had to beg the staff to provide her husband his pain relief.
Tragically, there's nothing unusual about this tale. Hundreds of similar stories have emerged of the treatment of patients in Mid Staffordshire during the three years in question. I find it impossible to read them without feeling powerless, growing angry, vowing never to let anyone I know go near a place like this.
Here's another representative story: 96-year-old 'F11' was referred to the A&E by her nursing home as she was screaming and had a water infection. When she arrived she was very distressed, in tears and dehydrated. A fluid drip was brought to ease the dehydration, but it wasn't actually connected until the family had asked several times. Even then, during F11's stay in the hospital her daughter said they would often find the fluid bag empty. Once, a nurse half-fixed it and then left, saying her shift was over. The family said they couldn't remember anyone ever coming to check on F11 while they were there. A patient in the next ward told them no-one ever did when they weren't there either. F11 was diabetic, but was left without anything to eat or drink for several hours.
At one point the daughter visited and found F11 with no clothes on and her door open, meaning that anyone walking through the ward would have been able to see her. She was covered in dried faeces, which were also in her hair, nails and bedclothes. The daughter had to persuade a nurse to clean her. No-one apologised. F11 died six weeks after her hospital stay.
The worst thing about all of this is that no-one in the health service believes that Mid Staffordshire is the only place in the UK in which there are cases of shocking care. On the contrary, many more accounts have emerged from other hospitals, other organisations.
This is why Robert Francis' report is so important. Not just because it's essential to understand what happened in Mid Staffordshire. Not just because this understanding might affect several high profile careers. But because there is plenty of evidence that what happened at Mid Staffordshire is still happening, in its own way, today.
Inevitably, people see whatever they want to see in a healthcare crisis. The diagnoses of the problems in Mid Staffordshire have predictably followed party lines. Too much market competition in healthcare. Not enough market competition in healthcare. Too much performance management. Not enough performance management. The wrong kind of performance management.
That debate is an essential one to have. But there are also some relatively apolitical measures that it should be easy to all agree on and begin working towards immediately. Here are three:
1. Vastly better governance from Boards. Board members need to be activist, critical, curious. They need to acquaint themselves with multiple sources of patient feedback, wander around the organisation, speak to patients, get to know workers on the front line. Too often, sitting on a hospital board is seen as little more than a prestigious hobby, rather than as a sacred duty. In education, there has been a transformation in the attention paid to Board governance in the past couple of years. The same now needs to happen in health.
2. Transparency of data and outcomes. We shouldn't have had to rely on a special investigation to discover that up to 1200 more people than expected died at Mid Staffordshire. That data -ideally ward level, clinician-level - should have been available in near-real time. I like health veteran Roy Lilley's suggestion that staff should push a button on their way home, with hospital results published in real time on the internet. My own healthcare organization publishes real-time feedback, unedited, via our Twitter feed. But we can all do more, and the Department of Health should be leading the way.
3. Reflection on staffing levels, especially nurses. Nursing shortages are a common theme throughout the stories emerging from Mid Staffordshire. Nursing levels at the Trust were cut to the bone, and then cut again. But there is a limit, no matter how efficient you are, to how far you can cut back on caring staff. Every Board member (them again!) in every healthcare provider in the country should satisfy themselves that their organisation has made good local decisions about how many nurses they genuinely need for safe care. They should look for any evidence that the level is too low. If nothing else comes out of the Francis report , a thousand worried conversations on 7 February would be a good start.
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