Notes on an informal Socialist Health Association discussion 8/5/13

This is still work in progress.  We haven’t decided anything, and we would particularly welcome constructive comments on what we might say which would be helpful.

We don’t think more regulation will avoid future problems.  In fact we are not very convinced about the Care Quality Commission or its predecessors.  Registering providers is worth doing, but is there good evidence that the inspecting and monitoring regimes delivers results?  Ofsted style ratings and Chief Inspectors are meaningless gimmicks. Local monitoring of standards based on more transparency is a more productive way forward.  In particular we think Commissioners should take more responsibility for the quality of services they are paying for.

We need the Secretary of State for Health to be held responsible to Parliament for the NHS, but this on its own is clearly not sufficient.

Much of the reporting of Mid Staffs is inaccurate and heavily spun – we should avoid knee jerk reactions to sweeping generalisation.

The official channels for patient and public involvement and for dealing with complaints and the people within the various bodies in Stafford had no credibility.

What works with clinicians – and indeed managers – is peer pressure.

We can learn from two features that unite almost all the clinical scandals over the last 50 years which have been:

  1. Patients who are unable to complain, have few friends or visitors and are largely invisible.  Stafford was very unusual in that much of the dreadful stuff happened in and around the casualty department, the most public part of the hospital.
  2. Clinical isolation –usually accompanied by geographical isolation.  Stafford is a small hospital in a small town.  Clinical practices were tolerated which would not have been survived in a more fluid environment.

There has been a lot of talk about protecting whistleblowers, but staff can commit professional suicide by causing trouble.  Junior doctors regard it as risky to mention things to their own consultant. The idea of involving anyone outside is largely unthinkable.

National clinical audits are a key driver to increase quality and encourage peer comparison. There are a number of successful examples of this, including stroke and hip fracture.

There are useful lessons from the experience of some of the better Community Health Councils. In particular:

  1. The funding and management of CHCs was controlled at Regional level, insulating them from political pressure locally.
  2. Their operation was very publicly transparent – all meetings were held in public.
  3. They built up relations of trust with local organisations and their staff, so benefited from a great deal of what would now be called whistleblowing. Staff could contact the local CHC suggesting that they might like to visit a particular area of their hospital and telling them what they might like to look for.  As the CHC visited regularly this was quite safe for the staff.
  4. The informal role taken by many CHCs in assisting complainants was helpful in alerting them to problem areas that needed investigation.
  5. CHCs were stable organisations, with experienced staff who built up relationships of trust over long periods.  Since they were abolished the successor organisations have been transitory with short term funding and repeatedly reorganised.
  6. CHCs grew in confidence, particularly in dealing with the media, over the years.  Healthwatch needs to be encouraged in this area.  In particular the new rule that Healthwatch must not campaign for changes in local or national policy needs to be repealed.

Healthwatch could be strengthened to take account of this experience. Funding must be separated from the local authority which will have a larger role in the organisation of the NHS.  It is already clear that some local politicians regard their local Healthwatch as a threat and are doing their best to suppress any independence. 

The organisation which represents the patients’ voice must be insulated from political pressure.  It needs long term financial stability so that it attracts and keeps experienced staff.  Healthwatch England needs to be charged with providing specialised expertise, technical, clinical and legal.

Local Healthwatch already has the power to “enter and view” premises from which health and social care are provided if publicly funded.  This includes unannounced visits, so long as it doesn’t “compromise the effective provision of care services”.   Royal colleges are increasingly publishing quality standards, which set a benchmark- for example that acute medical units should have 12 hour 7 day consultant cover. These benchmarks are very useful for lay assessors. Lay people need some support in understanding what they are looking at, and if such standards are comprehensible they are useful for patients too.  But not everything is susceptible to lay inspection.  Peer review is also needed.  But the NHS should define and commission what minimum standard of service must be provided (eg on hip fracture, a theatre slot within 36 hours and ortho-geriatrician review as standard), and wherever possible in terms that patients can understand.  The most effective monitoring of services is that provided by the people at the receiving end.

We also need to rethink our ideas about Foundation Trusts. Over the last 10 years their independence has centred on a rather nebulous financial autonomy to make then behave like “businesses. Accountability to members or to the elected governors is weak and unconvincing, even to those directly involved, and such accountability as there is centres on financial, not clinical, performance.

Labour’s vision for health and social care needs to include ideas about how we can redistribute power in healthcare.  This needs to include much greater transparency and local accountability.

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  1. Hannah Cooke says:

    I think that this broadly covers the things that we discussed although I thought that the discussion of regulation and inspection was a little more nuanced. I personally think that the routinised annual checks carried out by the CQC were of little value but there may be a role for a troubleshooting body to inspect organisations where concerns have been raised. I did not feel that we have reached consensus on the issue of regulation.
    > I think that more needs to be said about whistleblowing. Your piece is rather pessimistic and I think that a more constructive approach to whistleblower protection is needed which perhaps ties up with the role of a new local Health Watch (which as you note needs to be strengthened and given more independence).
    It seems to me that the laws, charters,guidelines etc which have been put in place to ‘protect’ whistleblowers since ‘Working For Patients’ (starting with Virginia Bottomley’s misnamed whistleblower’s charter) have actually made it more difficult for individual staff to blow the whistle. ‘Raising concerns’ policies within the NHS now require staff to escalate concerns through several layers of management before speaking to anyone external to the organisation. This is likely to defeat most staff. .
    For example the nursing regulator (NMC) requires nurses to raise concerns with their line manager and then escalate through 2 further levels of internal management before then going to a health regulator. Nurses ‘going public’ without following this daunting procedure could find themselves referred to the regulator for professional misconduct. Whistleblowing policies need reform and staff need the right to go directly to nominated outside bodies if they feel intimidated by management. This could include local HealthWatch, their professional body, maybe their MP etc.

  2. Martin Rathfelder says:

    I am very pessimistic about whistleblowing, It’s hard enough for senior staff. Junior staff are so vulnerable, they will never go through several layers of management without jeopardising their careers. Any policy that requires them to involve their superiors will not work. They need the protection of anonymity.

  3. dilys greenhalgh says:

    sorry to be late in replying but have been sampling present NHS as patient .I can say as having visits from CHC as a ward sister and after retiring visiting hospitals as CHC worker, IT did work and Stafford would NOT have occurred if CHC s were still used

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