The aims of the Conference were to identify the crucial issues which arise from a series of disasters in the NHS which have compromised public faith in the quality of care provided and to identify the way in which lay people can participate in decision making about clinical governance and quality assurance.
Intended participants
Members and staff of Health Authorities and NHS Trusts, Local Health Groups,
Public and Voluntary organisations, medical and nursing staff, patients and
their carers, Community Health Council members and staff academics and researchers.
Report of the conference by Andrew Manasse
Dr Walshe spoke about Quality Improvement.
He started with a brief history of the events at BRI with regard to paediatric
cardiac surgery and then addressed the issues of lessons to be learned.
Context: Nationally there was little formal assessing of quality before 1985. One of the earliest initiatives was 'What sort of Doctor?' from the RCGP. In 1989 Medical Audit was introduced and this underwent a series of developments culminating in Clinical Governance in 1997.
Experience at Bristol during this period: There was nothing in the audit reports to indicate that there were any problems. (Dog that didn't bark: Conan Doyle). In fact the audit activity diminished as the problems increased.
Why the (audit) system did not work there:
Leadership:
Passive, traditional doctor to doctor; little power; no links to management;
focus on conciliation, support and advice. Those on the committee were also
involved protagonists (interested parties).
Resources: Adequate - in fact lots. ? where did it go? ?wasted? No records of
how used etc.
Methods and Process: Traditional - numerous interests - but not related to quality.
Much irrelevant activity. Some directorates were good but there was no mechanism
for spreading good practice within the hospital.
Confidentiality/Secrecy: Restrictive. It was a barrier. UBHT
was uncooperative and, in fact, produced no reports.
Monitoring and reporting: Monitoring regular - but did not work. No returns.
No pursuit of non returns. Information gathered not used. RHA realised this
and reported on it.
Lessons:
· Need for strong clinical leadership - a very difficult job
· Need for clear corporate responsibility and central corporate function
i.e. ownership - being responsible.
· Need for wise (appropriate) resource use. (definition of priorities
etc.)
· Need to monitor progress
Concluding comments:
Quality of ( audit/clinical governance) programme is related to quality of
the organisation and is a good marker of wider organisational health
or
Quality improvement holds up a mirror to the organisation.
Points from her talk:
In relation to the NHS there are 3 types of stakeholder relationship:
Users
Tax payers
Voters
Good accountability leads to better services
NB re Expert patients: Expert with regard to illness etc. but also expert with
regard to local community needs.
She referred at length to the Kennedy Report and noted that the Govt. was mis/ab-using
some of the recommendations.
She spoke about the present discussion document about involving patients, said
it was an improvement on the NHS Plan but at the focus was the wrong way round:
See Para1.5 -emphasis on replacing CHCs and going on from there rather than
on starting from scratch with the emphasis on defining what is actually needed.
In this context, ACHCEW criteria for any new structures must:
· Be Independent and seen to be independent
· Have statutory powers and adequate financing
· Be accessible: CHCs are a one-stop shop and this ids very important
· Be integrated - work together. e.g. patients' forums within the same
area/city etc.
· Be accountable to lay people at all points
Here she compared the Govt. proposals in this context to the Kennedy Report
and commenting on the present document noted:
· A 6 week discussion period compared with the normal 3 months for even
far less significant changes. [NB Kennedy: 'A fait accompli gives rise to dissociation
and cynicism'].
· No lay involvement above patient forum level and these are within the
Trusts. 'Voices' ? no lay involvement - seems to have no teeth and be a talking
shop. Local 'Voices' are not local - they are at strategic HA level - a huge
area.
· Lack of integration e.g. between local patients forums. Confusing for
patients: where to go? etc.
· No mechanism for continuous scrutiny.
· LA Scrutiny currently set up to cherry pick issue on a regular basis
when what is needed is the facility for continuous scrutiny including inspection/visiting
rights.
NB Importance of (independent) Lay involvement outside the system - as made clear in the Kennedy Report and misinterpreted in the Govt. document.
One of the measures of any system is: How do the patients know where to go for their needs, questions etc.? (Mrs Archibald test).
NHS Consultants Association, of which he is chair, represents about 2% of consultants
and is at the pro NHS liberal end of the spectrum of views. BUT it was important
to realise that political/social views do not determine performance.
50% of consultants are = to or < average in their performance. It is nonsense
for people or the media to expect all consultants to be above average!!!
He spoke about the culture of the NHS in the context of managing change.
1. Tribalism: e.g. doctors; nurses; porters etc., OR clinical teams. Criticism
strengthens tribalism and makes for defensiveness.
2. Hierarchy of power: Consultants are the most powerful tribe. Also, the consultant
is the most powerful member of any group.
3. Resource shortage: Fighting for resources unites the tribe
Resource shortage is also an excuse for poor performance.
At Bristol in 1984 management was the problem; in 1995 market forces were paramount.
It is important to recognise and include business drives and needs into any
equation about change and quality.
He felt that the Kennedy Report was a good report which did fairly reflect
the situation as it was. He had surveyed all his local consultants about the
198 recommendations and most were in favour of most of them.
There were reservations over only 14 of them of which most concerned
i. Tape recording consultations and giving patients a copy of the consultant's
letter
ii. Making information about quality of care available (?related to league tables
and morale)
iii. Supervision of doctors carrying out a procedure for the first time.
Good points included
i. A single body for regulation and for quality
ii. Revision of distinction awards.
He noted that 5 things may happen to consultants who do not function properly
1. Local disciplinary action
2. (Very) Public GMC challenge
3. Risk of criminal prosecution
4. Civil prosecution
5. Trial by media (much more than happens with normal civil or criminal cases)
Points in relation to Management of Change:
i. Necessary to recognise that change is needed
ii. It is not possible, long term, to make people do what they do not want to
do
iii. Delegation is necessary and needs to be appropriate
iv. Essential to work within budgets and to have a little over (as a sweetener)
To achieve change it is necessary to
1. Identify the real problems
ii. Enable others to recognise the problems and therefore the need for change/action.
iii. Identify and support champions of change.
iv. No public confrontation otherwise the tribes just close up.
She spoke from her experience of having had an infant at Bristol early on in the period under question. Her experience showed her that one of the main issues was consultant communication failure and that others included indifference and complacency. Following this, she founded Constructive Dialogue for Clinical Accountability. She had been an NHS catering manager and had considerable experience of the management of change.
'What is needed to implement the Kennedy Report is a change of culture in the NHS'
CDCA is a charity on which are parents, health professionals and members of
the public.
The mission statement is concerned with
Creating a constructive dialogue between health care professionals
Building trust
Enabling working in partnership
Two-way communication between patients/carers and health professionals.
Key objectives:
· Balanced patient/clinical relationship including mutual respect (difficult)
· Patient safety and clinical excellence
· Clinical audit on the internet:
· Other issues: risk management, communication skills training, active
partnerships
Much of this is to be found in the Kennedy Report
The group consisted of 15 people lead by a hospital consultant
Points:
Putting patients first
Respect: them and us
Equal partnership
Welcome complaints (i.e. an opportunity not a threat)
No-blame culture - admission of failure.
Important relevant issues:
Personal responsibility
Corporate responsibility
(problems arising from) Top down pressure from Govt.
The Kennedy Report: Openness and transparency in all the NHS does.
Patient information.
Clearly understood systems of responsibility and accountability
No-blame culture essential
He then highlighted a few of the recommendations:
43. Provision of time, space and tools to do the job. Consultants work on average
55 hrs./wk. and are paid for 35 - 38 hrs./wk.
26. Informed consent. The difficulties involved in this at times in relation
to what patients want and appropriateness of describing all risks etc.
57. Training health care professionals:
· Communication with patients and colleagues
· Organisational and management skills and information
· Teamwork
· Shared learning across professional boundaries
· Clinical audit and reflective practice
· Leadership
It was a good honest meeting. There were a number of CHC chief officers and a range of others. There were many good points in amongst all the words although many of them are not new to members of Sheffield CHC.
Andrew Manasse 17th October 2001
BMA statement on improved regulatory systems
SUFFERERS of IATROGENIC NEGLECT
11/05/05