Cut To The Chase

The best thing, by far, that I've read on events surrounding the Mid Staffordshire hospital scandal - is the following piece by Philip Collins which appeared in The Times the other day.

In my view Philip Collins gets straight to the heart of the matter - instead of indulging waffling on in management speak or wallowing in sentimentality about the NHS - and its place in public life.

I read another article by Polly Toynbee in the Guardian on the same subject - which I thought was truly ghastly - because it placed the NHS on a pedestal, inviting readers to agree that anyone criticising standards of care in our hospitals - is somehow an enemy of the NHS.

What a load of old bollix.

Because all Philip Collins is saying - quite rightly in my opinion - is that far too much power lies with the people who run the NHS - and far too little rest with the people whom it purports to serve.             

The NHS is run for the staff, not the patients

By Philip Collins

It’s not heresy to demand that hospitals treat people like customers. More listening would have meant fewer deaths

It is safe to say now, after Mid Staffs, that even at the time I found Danny Boyle’s Olympic celebration of the NHS cloying and complacent. But for anyone who didn’t and who reads the devastating report by Robert Francis, QC, into the treatment of patients at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009, the sentimental view is no longer available.

The Francis report tells the stories of incontinent patients left to lie unattended in soiled bed linen. Many of them testify that it wasn’t the dirt that hurt so much as the shame. To be humiliated in a ward in which nurses never called anyone by their name, to be visible to passers-by while in a state of undress was to be deprived of dignity, irrespective of the presence or absence of physical pain. The most touching testimony to the inquiry was from patients who complained that what most hurt them was that nobody ever thought to wash or brush their hair. The duty of care, which is almost always the wellspring of motivation for nurses, somehow dissolved in a rigid application of bureaucratic rules.

It is an appalling story and many similar tales will now surface. But there is, nevertheless, a difference between those things that happened in Mid Staffs and the general lessons that can be drawn. Francis runs to 455 pages and the right verdict is definitely in there but only because every verdict is in there. Perhaps Mr Francis has written a long report because he did not have time to write a short one. But by the time we get to the recommendations for weekly multidisciplinary meetings and a revamping of managerial accreditation, we know we have wandered far away from the main point. It is a rule of thumb that anyone demanding “culture change” has no order of priority among their hundreds of half-relevant suggestions.

The sheer range of recommendations has two malign consequences. The first is that responsibility is assigned to the abstract “system” rather to anyone in particular. But it is not the “system” that fails to feed anyone. The “system” doesn’t leave filth in the bathroom. The estimable Julie Bailey, who established the campaign group Cure the NHS after the death of her mother Bella in Mid Staffs, has asked why Sir David Nicholson, now the chief executive of the NHS but at the time the boss of the local health authority, should stay in post. It is never pleasant to demand a resignation but she is surely right. Nobody has resigned over Mid Staffs and nobody has been struck off. The only people who have gone are those who went there and never came back.

The second consequence is that Mr Francis has a prize for everyone. The disaster at Mid Staffs is variously attributed to the effect of trying to hit an A&E waiting time target, staffing cuts forced by the need to save £10 million, poor professional development, a weak hospital board and unclear regulation. In other words, he has supplied an alibi for every professional blame-shifter. Lo and behold, here is the man from the British Medical Assocation to say that the doctors should be in charge, even though Mr Francis explicitly criticises the Staffordshire consultants for refusing to engage with management. And here is the General Medical Council representative to say that this shows the malign effect of targets and financial incentives, even though every other hospital managed to reduce waiting times, on budget, without killing people.

Mr Francis gets close to an essential point in his repeated assertion that there were too few staff, especially nurses, on the wards. A more telling way of making the same point would be to say that there were too many patients. Lots of the old people who were abused in Staffordshire should not have been there in the first place. They should have been at home or in respite care. The reason they were still in hospital, being treated expensively and inhumanly, is that there was nowhere else for them to go.

The best thing the Prime Minister might have said in response was that he would ensure that he fixed the mess that is this country’s social care system. Instead, David Cameron proposed to create a Chief Inspector of Hospitals. This could be a useful reform but episodic inspection is no substitute for the regulation provided by professionals observing a duty of care and vigilant patients who know what is happening in the NHS because it is happening to them.

This, finally, is where Mr Francis gets to the point. Shrouded in guff about multidisciplinary meetings, the report cites the words of the current medical director of Mid Staffs: “Our job is to treat patients. That is all there is to it.” These words should be carved into marble ten feet high and placed in the foyer of every hospital. For the most shocking revelation of the Francis report is in the written and oral evidence from patients and relatives.

For years they had been telling the hospital that it was a disgrace. But the hospital management didn’t count personal stories as real knowledge. They were treated with arrogance and disdain. Instead, managers preferred the carefully collected benchmarks and star ratings that came with the imprimatur of the Healthcare Commission. The hospital’s chief executive dismissed its high level of mortality as a coding error.

In a system that is currently run by the staff for the staff, the NHS needs to let the public in. People want their hair washed as well as their pain abated, and quite right too. They are paying for it, after all. The hotel industry is now subject to online review from paying customers. So is the travel industry. The NHS will have to put aside its hostility to learning anything from the private sector and follow suit. The satisfaction of patients needs to be built into the judgment of hospitals and the pay of chief executives. Patients should have easy access to their own records and it should be simple to find out where a hospital ranks, both in the area and the country.

Boiled down to its essentials, the Francis report says that NHS staff are hoarding power and they have to be made to listen. It is often said airily that British people have a mystical relationship with the NHS. It has never been more evident that the metaphor is misleading. Nobody has a real relationship with an institution. We have relationships with each other, patient to doctor, patient to nurse and, as Mr Francis says in his first recommendation, it is always the patient who should come first in those couplets. As the American writer Henry David Thoreau once said: “The greatest compliment that was ever paid me was when one asked me what I thought and attended to my answer.”