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The real Mid Staffs story: one ‘excess’ death, if that

mstaffsqmark
Mid Staffs: was it what we’ve been told?

What I’m about to write is likely to make me very unpopular with some people. While I’d prefer to avoid that, the issues and the truth about them are too important not to write it. I have no axe to grind, no personal connection to the events or people (that I know of) – but I am passionate about the NHS and about truth.

A couple of weeks ago, I wrote a couple of articles about the Mid Staffs NHS (MSNHS) report by Robert Francis, and about David Cameron’s reaction to it. These articles focused on the political implications of the events and the report, and on setting the reported death figures in context, rather than on the veracity of the figures themselves and the story behind them. Although I touched on the fact that the wide range of the figures given – 400-1200 – showed how uncertain they were, like everyone else I assumed there must be some truth to them, because they were so widely reported and so seemingly uncontested.

Not only the more lurid newspapers like the Sun, but also the ‘respectable’ press and media have reported the 400-1200 figure as fact – and continue to do so, the relevance of which we’ll see toward the end this article. Only a couple of weeks ago, a politics round-up programme on BBC Radio 4 included these figures as simple fact in their comments on David Cameron’s Commons speech on the Francis Report – and none of their guests there to talk about the issue raised even a murmur of contradiction.

The idea that 400-1200 ‘excess’ deaths took place during a period from 2005-2009 has been repeated so often, with such a complete absence of dispute (unless you knew where to look), that in the public consciousness it has become, to all intents and purposes, a fact.

But it is an idea without any basis in fact.

If you’re a regular reader of this blog, you will know that I believe in research – in drawing together facts and making conclusions based on them. I am no stranger to research and to the effort and time that have to go into an article to be able to make credible statements. But the preparation for this article has taken that investment of time and attention to another level.

My research for my earlier articles on Mid Staffs had led to some even more fundamental questions in my mind that I had to investigate. If you’ve noticed that this blog has been quieter than normal for the past couple of weeks, it has been because almost every spare moment over that period has been spent in researching this post – reading transcripts of witness statements to the Francis Inquiry, investigating the comments and opinions of others on the MSNHS issue specifically or the issues around the use of statistics in general.

What was starting to become apparent to me about the whole Mid Staffs issue was so deeply at odds with the prevailing perception that I had to read more widely and deeply than ever before in order to make sure that I was perceiving correctly.

Because the issues are so complex, and the evidence I could use so abundant (I’ve read well over 1000 pages over the past couple of weeks and will leave out of this article far more than I can put in), that even my best efforts to distill them into conciseness will still leave a post that will take patience and attention for anyone to work through, I’m going to break from the normal ‘good form’ that would mean putting the reasoning and evidence first and saving the conclusion until last.

Instead I’m going to state the conclusion first, and then list the evidence and narrative around it, so that those who wish to and who have the patience to can read through it and satisfy themselves that the conclusion is justifed. So here is that conclusion, along with a very brief justification:

There were no ‘excess’ deaths at Mid Staffordshire NHS during the 2005-2009 period in which the news media and anti-MSNHS campaigners claim there were 400-1200 of them – or, in the words of the independent clinical expert who led the ‘Independent Case-Note Review’ (ICNR) into each individual, contentious death at the Trust:

maybe one

This information has been in the public domain since at least 2010 – but I doubt if you could find a single reference to it in the mainstream media. “One person might have died!” does not sell newspapers, or gain viewers, in the same way that “400-1200 unnecessary deaths!!!” does, I guess.

You’re quite possibly thinking to yourself, “What?! How can that possibly be correct?” Here’s how.

In 2009, Dr Mike Laker was asked to conduct an independent review into the detailed case notes of every contentious death at MSNHS during the period in question. To identify which cases needed reviewing, the Trust offered all patients who had been treated by the Trust, or their families, the opportunity to ask for a detailed case note review – and ‘detailed’ is the right word: each review would take 5-6 months to complete, so a large number of expert, independent clinicians were needed to complete the process within a reasonable timeframe.

60 such requests were received – which already puts a massive question mark against the figures of 400-1200 ‘excess deaths’. In the course of the review, Dr Laker eventually interviewed 120 families and edited the case notes of 40-50 cases. He was asked by Tom Kark, Counsel to the Francis Inquiry, how many ‘excess deaths’ had occurred among the cases he had reviewed. Mr Kark related Dr Laker’s answer in his ‘final submission‘ to the 2010 inquiry:

lakerkark

‘Perhaps one such death’ – so maybe not even one. People die in hospitals every day, of course – but as far as unnecessary, avoidable deaths caused by negligence or malpractice, the detailed, intensive reviews of all the deaths where relatives were dissatisfied enough to ask for one uncovered ‘perhaps one’.

Dr Laker is no ‘stooge’. His comments, which you can read about in the ‘final submission’ link just above, also included strong criticisms of the organisations overseeing the ICNR. He successfully had the overseeing body changed from the Trust itself to the responsible Primary Care Trust (PCT), to ensure independence, and also stopped the Trust from accessing the case review findings before they went to the families. His findings were not those of a man trying to court favour from, or minimise embarrassment for, the establishment – yet he still could only find ‘maybe one such death’.

In terms of demonstrating that the media portrayal of the story and the underlying reality bore no relation to each other, I could ‘rest my case’ here. But in order to understand why and how the false story that has so permeated the public consciousness came to do so, we need to look in more detail at other aspects of the background, the witness transcripts and the advice/opinions of other experts.

What this examination will reveal is a story of:

  • overstretched and struggling hospital staff unable to provide the ‘basic care’ that any health professional would wish to, but managing just about to hold things together even though things weren’t pretty (and a ‘drinking from vases’ claim that appears to have been almost entirely fabricated)
  • commercial conflicts of interest and over-stated claims
  • statistics that could never say what they were made out to say, even if the data-input was perfect
  • data input that was anything but perfect, creating an even more false picture
  • bereaved relatives lashing out understandably but excessively
  • most critically, collaborating political and media interests spinning a story in a wholly false way for their own ends

The (very truncated but still lengthy) details follow. You may prefer to skim the headings and choose the areas of immediate interest to you to read in detail, and then come back later for other sections as required. I leave that to your preference, but please make sure at least to read section 6, which examines the reasons why the misleading figures have been propagated and exploited – and by whom and why.

1. Even in an ideal world, HSMR is no ‘Ronseal’

The public furore over Mid Staffs began as a result of a set of statistics called ‘Hospital Standardised Mortality Ratios’, or HSMRs which – it appeared – showed a significantly higher ratio of deaths at MSNHS compared to the national average. At no point did the statistics or any report on them name a number of avoidable deaths, either in the 400-1200 range or any other figure. Robert Francis stated this unequivocally on the first day of hearings for his second report.

The reason for this is simple: even working perfectly, the HSMR system is neither designed nor intended to identify ‘unnecessary’ or ‘excess’ deaths, nor is it a measure of quality and safety in a particular hospital (the owners of the system did claim the latter, but backtracked on the witness stand). Chapter 5 of the 2013 Francis Report states the following (which again you will struggle to find in any media reports referring to Mid Staffs:

to this day, there is no generally accepted means of producing comparative figures, and unjustifiable conclusions continue to be drawn from the numbers of deaths at hospitals and about the number of avoidable deaths.

In the context of the careful, neutral wording used in official reports as well as the commercial sensitivities around the HSMR method and the vociferous and aggressive tendencies of the anti-Stafford campaigners, Francis might as well be putting up in neon lights: “HSMRs do not say what you’ve been told they say!

Or take this exchange between Mr Kark and Roger Taylor, the Director of Research and Public Affairs for DFI, the company that supplies the HSMR data:

K: Can I just ask you this, we’ve heard a lot in this inquiry about how HSMRs might be used as no more than an indication of risk or a need for further attention in a particular area. Did the 2007 publication put the significance of HSMRs too high, calling it an effective way to measure and compare clinical performance safety and quality?

T: No, I — I don’t believe it did. I think it is an effective way to do exactly that. However, I will add to that comment the point that it’s really important to remember that in measuring clinical outcomes and clinical performance there are no perfect measures..

K: Does that mean to say that when the HSMR is above a certain level, and that is to say, if I can get my terminology correct, above certain control limits, it’s not just a tool to identify risk, but it is an effective measure of safety?

T: I’m saying an effective measure of safety is one that helps you identify the risk of something being wrong.

Kark asks Taylor about how the HSMRs can legitimately be used and Taylor fudges initially – but when he is asked directly whether HSMRs can provide an effective measure of safety, he backtracks and says it can only identify where there is a risk that something might be wrong.

Professor Brian Jarman, the creator of the HSMR system, made a statement in his evidence that demonstrates that quality of care and HSMRs are by no means automatically linked:

Now, you’re not going to measure the quality of care of pacemaker insertion by measuring the mortality because, you know, that’s – they are very low.

Similarly, the 2010 inquiry put out a ‘Joint Statement’ on the usefulness of HSMRs which included the following statement:

Along with other indicators, they can usefully help us to understand comparative information about in-hospital deaths. But they have limitations, and should not be used as a sole indicator of patient safety. To do so could potentially give a misleading interpretation of a hospital’s safety record. They should be used with other relevant indicators as a tool to support the improvement in the quality of care.

And the clincher comes (again) from Roger Taylor, as he is asked by Counsel about the link between HSMRs and the media claims about the numbers of ‘excess’ deaths:

Q. Where does Dr Foster stand on the portrayal of the figures about Mid Staffordshire as indicating or showing that there were 400 to 1,200 unnecessary deaths?

A. ..that is a misuse of these data.

Some 300 different indicators are used to assess hospital safety and quality. Even in perfect circumstances, with everything functioning as it should, HSMRs can only perform a small role in this assessment – effectively a signal to say ‘take a look, just in case something is wrong’. Using them to state anything beyond this is ‘misuse’.

1,2,3,4..

Another important indicator lies in the guidance provided by the company that owns the HSMR system to Trusts that find themselves with a high mortality ratio. This guidance takes the form of a list of recommended actions:

  1. Check to see whether incorrect data has been submitted, or whether an approach to coding which differs from other organisations’ approach has been adopted
  2. Consider whether something extraordinary has occurred which explains the result
  3. Consider whether their healthcare partners work in ways which are different from those in other areas
  4. Consider whether there are any potential issues with regard to the quality of care

The 2nd Francis Report criticised MSNHS for focusing first on whether the high HSMRs were caused by coding issues – but DFI’s own guidance to Trusts on what to do in the case of high HSMRs puts ‘check coding’ at number one in the list of actions. By contrast, checking whether there are actually any issues with care standards is down at number 4.

If even the owners of the system consider that there are 3 factors more likely to affect high HSMRs than actual poor care, can anyone seriously consider that the system is accurate, robust and reliable enough to provide an actual number of ‘excess deaths’ – even in perfect circumstances?

And yet the media continue to report the figures as fact. Since they can’t be unaware of all the above statements and factors (and many more that I’ve had to choose not include for the sake of some semblance of readability), then one has to ask ‘Why?’ – what is the real agenda?

A moving target

One of the key weaknesses with the HSMR system is that it is based around a ‘standard’ score of 100 – which is ‘rebased‘ every year. In simple terms, the statistics take an average score for all the hospitals in England and call that ‘100’. Hospitals scoring worse than average get a score above 100, while hospitals scoring better get below 100.

But what ‘100’ means moves every year. In the words of Professor Jarman:

we do for the simple — simple-minded English, if you like, adjust it so that the English value was every year.

(That Prof Jarman considers the English simple-minded and unable to handle a figure that isn’t simplified every year is interesting, given Roger Taylor’s testimony that DFI considers the public to be savvy enough to realise what you can’t do with its figures, even if the media are all screaming ‘Excess Deaths!‘)

This ‘rebasing’ means that a hospital can have exactly the same performance in a given year that it achieved in the previous one, and still show a worse HSMR because the overall average moved down. Similarly, if some hospitals are ‘gaming’ the system to improve their score (a possibility that the creator of the system, Professor Sir Brian Jarman acknowledged in his testimony to the 2nd inquiry), they will bring down the average so that ‘honest’ hospitals appear to be doing badly.

But even if nobody cheats, a hospital can be doing well, as well as it’s ever done, and still appear to be sliding down the performance table.

[EDIT: if you’re struggling to see why this rebasing to 100 is so misleading, please look here for some additional information that might help]

2. Rubbish in, rubbish out

We’ve just seen that, even if everything around the HSMR system is functioning perfectly, HSMR cannot be used to identify a number of ‘excess’ or avoidable deaths. But as a reading of the inquiry transcripts will quickly show, things were about as far from perfect as they could possibly be in terms of the data that was entered into the system – both nationally and, especially, in the case of Mid Staffs NHS.

One fundamental thing needed for any correct understanding of the issues surrounding MSNHS’ HSMR scores is the knowledge that, for most of the ‘problem’ period at the Trust, it had no coding manager.

The data on which HSMR scores are calculated are based on codes that have to be entered for each patient treated. These codes relate to the condition from which the patient is suffering, and an ‘expected’ death rate is allocated to each condition measured for HSMR purposes. If a hospital shows a higher rate of deaths for a particular condition than the expected rate, this pushes up the overall HSMR score for that hospital. If it shows a lower rate, that helps bring down the HSMR score.

Let’s take a simple example. ‘Fractured neck of femur’ (FNOF) is a fairly common result of falls in elderly people – and a serious one. Out of every 10 people, nationally, who go into hospital with this condition (which in layman’s terms might be called a ‘broken hip’), on average one will die as a result of complications arising from the initial condition. If a hospital loses more than 10 patients with FNOF for every 100 it treats, it will have a relatively high HSMR for that condition. Each condition has its own rate of expected deaths.

But there are serious problems with both the basic principles of the coding and with how it was done at MSNHS – and remember, Mid Staffs’ coding manager was on long-term sick leave for most of the period in question.

First or primary diagnosis

The rules of HSMR coding state that the first ‘non-vague’ diagnosis – sometimes referred to as the ‘primary diagnosis’ – for any patient when they enter hospital for an ‘episode of care’ must be used to determine the coding. But this is full of dangers in terms of measuring mortality rates.

If a patient enters hospital with, for example, a broken tibia (shin-bone), you would expect this to have a low death-rate – dying from a broken leg is pretty rare. The ‘first non-vague diagnosis’ is obviously going to be ‘broken tibia’. But if it is subsequently discovered that the bone broke because it was eaten through by an aggressive, spreading cancer, the expectation of death would clearly be completely different.

But, following the rules of HSMR coding, the code that is entered is the one for a fractured tibia – and the death will seem very unexpected and so will worsen the HSMR score.

Junior doctors

Junior doctors work long hours in an intense environment. They are often the first medics to assess and diagnose a patient, and they are unlikely – unless the importance is hammered home to them very hard – to consider it too important to put the right code down for a patient they are treating. Being junior, there is also a higher likelihood of them misdiagnosing or missing a condition when a patient is first examined.

MSNHS’ investigation of its coding, once it had a new coding manager in place, showed that there was a major problem with the coding entered by junior doctors.

POA

In his testimony to the 2nd inquiry, Prof. Jarman confirmed that his system did not ‘adjust for’ secondary diagnoses unless they were ‘present on admission’, or POA. In other words, if a condition – no matter how serious – isn’t either spotted by the doctor or otherwise known about when a patient is first treated, it’s ignored for the purposes calculating HSMRs. But Prof. Jarman made a key admission:

70 per cent of PMA (sic) — present on admission diagnoses are the same as the primary diagnosis.

In other words, in 30% of cases there is a discrepancy – 30% room for the figures to be skewed by a primary diagnosis of one thing when a serious condition might be present that would push the expected death rate much higher. So even if everything goes as planned, there is a known potential for variation in the system of as much as 30%.

C0-morbidities

‘Co-morbidities’ is the medical term for ‘other stuff that’s wrong with you’. So if you’re in for treatment on an ingrown toenail, for example, but you also suffer from congestive heart-failure and lung-disease, there’s a much higher chance you’ll die while you’re in hospital – and it wouldn’t mean the hospital did anything wrong. But the ‘episode of care’ is for treatment of an ingrown toenail – which would have a very low expected death rate.

The HSMR system does allow co-morbidities to be entered (based on the ‘Charlson Index‘)so that they are taken into account – but if these are wrongly entered or not entered at all, the figures will look as though you died from an ingrown toenail.

The investigations into coding at MSNHS showed that there were substantial problems with the coding of co-morbidities, probably because of the absence of the coding manager combined with problems of under-reporting of co-morbidities by consultants.

Z51.5 and the ‘parade ground’ effect

One the major problems with Mid Staffs’ HSMR scores that I found in my reading of the transcripts was in a change that was made to the coding system to include code Z51.5 – a code to indicate ‘palliative care’. A patient receiving palliative care is suffering from an incurable, terminal condition and is being treated to relieve pain, make him/her comfortable etc. At some point he or she is going to die from the condition – so the expected rate of death during any given ‘episode of care’ is going to be relatively high.

For the sake of brevity, I won’t go into every detail, but when the change to include Z51.5 was made, Mid Staffs’ coding did not change to include it. Since other Trusts were now using a code with a high expected death rate that would lower their HSMR score, and because this would affect the ‘rebasing’ and move the ‘100’ benchmark, this had the same effect as a rank of soldiers all stepping back at the same time except for one – he would appear to be standing out in front without having moved at all.

‘Zero stays’ and 30 days..

Another thing that came out during Prof. Jarman’s evidence was the effect of two particular peculiarities in the way that Mid Staffs was coding its patients. The first of these is the ‘zero days’ stay’ category (which actually includes stays of up to 1 day).

MSNHS was not including in its coding any patient who came for treatment and either didn’t stay in hospital at all or only stayed one day. Since the vast majority of patients who come into hospital and leave again in a day or less will be there for treatment of mild conditions (or mild manifestations of potentially serious conditions), the rate of deaths among such patients would be very low. This would have the effect of ‘concentrating’ the death rate at Mid Staffs (by reducing the total number of codes and taking out almost exclusively patients with good outcomes). Since all or almost all other Trusts were including these patients, their death rates would be ‘diluted’ by the ‘zero stay’ patients – again causing, or accentuating, the ‘parade ground’ effect and making MSNHS look worse without necessarily being worse.

Conversely, Mid Staffs was also negatively affected by the lack of ’30 day coding’ in HSMRs – codes allocated according to the outcome 30 days after discharge from hospital.

If a hospital discharges a patient early, who then dies outside the hospital, this is not reflected in the HSMR. But if a hospital keeps a patient longer to make sure he/she is fit for discharge, or is unable to discharge an elderly or infirm patient because of the lack of non-hospital care facilities, and the patient then dies, the hospital effectively suffers in its HSMR because it did the right thing.

The 30-day effect might not only occur because of irresponsible discharge of patients. If a hospital has a hospice nearby and can discharge terminally ill patients for palliative hospice care, the patients will die in the hospice and this will improve the hospital’s HSMR even though the patients still die.

Professor Jarman repeatedly claimed that the effect of correcting codings for co-morbidities and palliative care would be very small, but this claim appears highly questionable.

Firstly, the ‘parade ground’ rebasing effect when the Z51.5 palliative coding was launched in other hospitals caused Mid Staffs’ HSMR to rise by 13 points, from 114 to 127 – a serious change.

The group ‘Straight Statistics’, a “pressure group whose aim is to detect and expose the distortion and misuse of statistical information, and identify those responsible”, wrote an article examining the reliability of HSMRs and particularly the effects of errors/corrections in coding. The article included an examination of the relationship between ‘depth of coding’ (how many co-morbidities were recorded alongside the main diagnosis), which varies widely across Trusts, and HSMR.

Quoting a response from Prof. Jarman’s organisation ‘The Doctor Foster’s Unit’, the article says:

a hospital using only 2.5 codes per patient would show an HSMR about 15-20 points higher than one using 5.5 to 6 codes per patient

15-20 points is not ‘very small’. The number of codes per patient at Mid Staffs is not stated – but with no coding manager in place and proven issues with uncoded co-morbidities, it is certain that it was at the low end during the period of high HSMRs.

When the new coding manager joined MSNHS, she carried out a re-coding exercise (apparently 2, in fact, since the first one over-corrected). According to evidence given by acting Chair of the Trust David Stone in 2009 to the Health Scrutiny Committee, once the correct re-coding was done, Mid-Staffs’ HSMR score was:

88

Just in case there is any lingering doubt on the fact that coding can have a massive effect, we’ll leave the last word to Professor Jarman. Just 8 days ago, he sent the following message on Twitter:

Prof Jarman's telling tweet.
Prof Jarman’s telling tweet.

PwC is PricewaterhouseCooper, a huge firm that carries out detailed audits and analyses – and it found a 25-30% difference in Mid Staffs’ high HSMR code due to incorrect coding.

Rubbish in, rubbish out..

3. Conflicts of interest and exaggerated claims

The HSMR system is run by Professor Jarman’s Doctor Foster Unit (DFU), which is part of the faculty of medicine at Imperial College. DFU receives the majority of its funding, confusingly, from Doctor Foster’s Intelligence, or DFI. DFI is a commercial, profit-making company (although 47%-owned by the Dept of Health). DFU calculates the HSMR scores for hospitals free of charge.

There is no suggestion, that I can make out from the transcripts, that DFI or DFU deliberately skewed any figures in the HSMR index for commercial gain. However, DFI does publish an annual ‘Good Hospital Guide‘ that includes a ‘league table’ of HSMR rankings. Based on these rankings, DFI attempts to sell to Trusts its ‘Real Time Monitoring’ (RTM) service for the sum of £35,000 per year. This service provides ‘alerts’ to customer Trusts about areas where HSMR is poor or starting to slip, so that the Trusts can take corrective action – and can optimise their position in the Good Hospital Guide. From Roger Taylor’s evidence to the 2nd inquiry:

Walsall hospital was named as the hospital with the highest death rate in the first hospital guide in 2001, which they were not very pleased about..Walsall subsequently became very enthusiastic and started using the RTM tool.

An email from a senior DFI director in 2011 stated:

we ran a consultation on the indicators used before they went into the hospital guide in 2010..We alerted hospital trusts to this by writing to them and letting them know and through the Health Service Journal. We will do the same this year. Providing access to them in the tools we sell is the obvious next step.

The fact that DFI stood to gain financially from the creation and publication of league tables based on HSMR must cast serious doubt on the use of HSMR as a tool for assessing quality of care – especially since the information is made public – even if DFI were not deliberately exploiting the opportunity. Despite the fact that Roger Taylor stated in his evidence that he did not think this represented a conflict of interests, an impartial observer must recognise that there was indeed potentially such a conflict.

The fact that Mid Staffs knew that their HSMR position was going to be made public in this way must also have contributed to their focus on coding, which was criticised by the Francis Report – especially when DFI’s own guidance on how to respond to poor HSMRs put ‘check coding’ as number 1 on the list of actions.

Overstated claims

As was revealed during the testimony given by Roger Taylor, DFI’s 2007 publication had massively overstated the usefulness and significance of its HSMR data, calling it:

an effective way to measure and compare clinical performance safety and quality. Deaths in hospital are important and unequivocal outcomes.

As we’ve already seen, HSMRs are nothing of the sort, and the information that they give on deaths is anything but ‘unequivocal’. Mr Taylor initially denied that this was claiming too much – but under further questioning he eventually said, when speaking about focus groups made up of members of the public, that they show a

general scepticism of the ability to accurately measure quality of care. In which regard they are being, I think, pretty smart, actually.

If the public are being ‘pretty smart, actually’ to be ‘generally sceptical’ of the system’s ‘ability to measure quality of care’, then I think that calling the HSMR measure ‘unequivocal’ as a measure of ‘clinical performance safety and quality’ is without question an exaggeration – and a pretty big one. Especially when Mr Taylor also acknowledged that the output of the system is only as good as the data that’s put into it – and when, as Prof. Jarman put it in his testimony,

it depends how the coder codes it.

Such an exaggerated claim can only have fanned the self-fuelling flames of misleading publicity about the ‘400-1200 unnecessary deaths’.

4. The top 3 factors in poor care at Mid Staffs: understaffing, understaffing and understaffing

There is no doubt that there was poor care in some parts of MSNHS. Various inspections that followed the initial public furore found that care in some departments was ‘appalling’. However, Robert Francis’ recommendation that individuals should not be pursued for events at Mid Staffs strongly suggests that the failings at the Trust were systemic rather than resulting from malice or neglect on the part of any one person or group of people, particularly front-line nurses and doctors.

This is supported by the statistics provided in Annex 1 (part of Volume 3) of the 2013 report which show that, over the 5 years covered by the report, the number of ‘serious untoward incidents‘ which were recorded at the Trust and ascribed to lack of staff was a massive 1,756 – an average of 351 ‘serious’ incidents per year attributable to short-staffing.

However, these ‘untoward incidents’ mostly represented failures of ‘basic care’ – cleaning, comfort and so on – rather than life-threatening incidents. Remember, the review of the 60 incidents (and interviews of 120 families) that were serious enough during this period for the families to accept the offer of a full case-note review resulted in ‘perhaps one’ avoidable death.

Patients were left in their own waste etc, which is a horrendous indignity that no one should have to suffer – but which is very, very rarely life-threatening. If staff numbers were too low, as the stats suggest, then nurses inevitably faced times when they were simply unable to do everything and had to prioritise.

I know from my many conversations with nurses from various hospitals that there can often be times when a patient’s ‘basic care’ needs have to wait – because all the available nurses were trying to help another patient breathe, or to keep him/her alive through a heart attack, or deal with sudden and serious haematemesis (vomiting blood) and so on.

At this point it’s worth addressing one of the most persistent myths of the ‘Mid Staffs phenomenon’: that ‘neglected’ patients were so thirsty, and so ignored, that they had to drink the water from flower vases.

Appalling if true – but flower vases were banned from the two MSNHS hospitals from the late 1990s, presumably for hygiene reasons. I’ve heard anecdotally that there may have been one incident in which a (probably confused) patient was allowed a vase as an exception, and did drink from it – but the idea that this was more than a one-off appears to be entirely unfounded. Instead it appears that the media spun out a one-off into a regular incident for the sake of lurid headlines.

Nurses feel terrible about those who have to put up with indignity or discomfort – and relatives of those patients frequently fail to understand that their loved ones are only suffering ‘neglect’ because nurses had to choose between that and allowing someone to die or suffer horrible fear and pain.

It’s awful and it should never happen – but it will, as long as wards are not fully staffed according to not only the number of patients but also the severity of their conditions and the level of their dependency. And under this government, it will happen more and more.

Which leads me on to my final sections – which I’ll try to keep brief because this post is already more than long enough.

5. The viciousness of grief, the cynicism of politicians and the collaboration of the media

Just last weekend, the Guardian’s online edition carried a call from a relative of someone who died at MSNHS for ‘heads to roll’. This same lady – to whom my heart goes out for her loss – was also heard, at a public meeting of anti-MSNHS campaigners, to call

Let’s shut the hospital, let’s sack all the staff!

Losing a close family member is a horrible experience – I lost my mother after a long and gruelling battle against ovarian cancer 9 years ago. But surely, someone who would rather have no hospital and see thousands of doctors, nurses and other health staff, most of whom she can never have met, made unemployed because of her grief and rage is not thinking straight.

One can understand and sympathise, certainly – and I do. But it must be a foolhardy decision indeed to allow someone who is in such a state of mind to influence policy and to invite him or her frequently to influence public opinion via media interviews and articles. When deciding the fate of health services that about a quarter of a million people rely on, ‘cool heads’ surely have to prevail and decisions made must rest on logic and fact, and not emotion and grief.

And a person or entity that would exploit the grief of such a vulnerable person would be reprehensible indeed.

Which leads me to my final section:

6. Politics, media and exploitation

In my opinion, it’s extremely telling that the ‘media mentor’ of the anti-MSNHS group was the Conservative MP for Stone in Staffordshire, Bill Cash. Mr Cash’s testimony to the inquiry makes perfectly plain that he understood absolutely none of the detail of what was happening at Mid Staffs and why. However, he evidently understood a political opportunity when he saw one, and he set up meetings for the group to promote its calls for a public inquiry.

Mr Cash was also associated with the first ‘leak’ of the supposed ‘unnecessary death’ toll of 400-1200 people to the Daily Mail. Mr Cash, it must be said, has denied being responsible for the leak, and there is nothing to prove that he was. The fact that the figures appeared alongside quotes from Mr Cash must at least raise the question – but the article also included quotes from the leader of the relatives’ group, so the provenance of the figures is uncertain.

It’s all political

At various points throughout his testimony, Prof Jarman refers to negative attitudes from the (Labour) government toward HSMRs – but then (from p.171 of the record) he reports a sudden change:

There has been an improvement, it seems, in [the Dept of Health’s attitude to the value of HSMRs.

In his view, this might be linked to the publication of the first Francis Report on Feb 2010. However, he is very specific about the point when the real change occurred:

But the statements in the White Paper of 12 July 2010 were very positive.

The white paper of 2010 in which the government published its outline plans that eventually led to the Health and Social Care Act 2012, under which they are decimating the NHS and at this very moment are trying to force through undebated, unvoted measures to force accelerated privatisation.

A Tory government takes power. Two months later it launches it’s ‘here’s one we made earlier’ blueprint for the destruction of the NHS – and ‘coincidentally’ it starts to take a ‘very positive’ attitude toward a tool that can make hospitals look as if they’re killing people even when they’re not.

A positive attitude in spite of the fact that Mr Francis’ first report contained the ‘Joint Statement’ that we’ve already seen about the weaknesses and limitations of HSMRs.

It doesn’t take a great deal of imagination to ‘put two and two together’ in a far clearer and more reliable way than the HSMR method.

What the papers say..

It’s also very significant that one of the most enthusiastic users of the spurious figures has been the Daily Telegraph – a ‘newspaper’ with a proven track record of NHS attacks for political purposes. The paper is on record as having co-ordinated articles on behalf of private health interests to help the passage of the invidious 2012 NHS Act and has even instructed sub-editors to leave anti-NHS material in an article to which it was irrelevant.

As recently as a few days ago, the Telegraph was still hammering the MSNHS issue – and just yesterday ran an article tarring the whole NHS with the Mid Staffs ‘brush’.

The desire for eye-catching headlines, improved circulation and journalistic laziness have all contributed to the spread of the myths about ‘excess deaths’ at Mid Staffs and the distortion of the public perception of what really went on there. But, without question, at its core lies yet another unholy alliance between the Tories and the right-wing media for the advancement of their multi-fronted, ideologically-driven assault on the NHS of which most of us are rightly proud.

In this context, it’s perfectly plain why David Cameron found it expedient to ‘eat humble pie’ and apologise on behalf of the country for the “horrific pain and even death” suffered by “many” (again propagating the myth). The recommendations of Robert Francis’ report include the closure of hospitals found to have similar problems to MSNHS; by accepting the report with crocodile tears and in sackcloth and ashes, Cameron has positioned himself to be able to exploit those recommendations as another excuse to close hospitals – alongside ‘rationalisation’, creating ‘centres of excellence’ and the financial problems of neighbouring Trusts (as the people relying on the successful Lewisham Trust have already found to their cost).

And, of course, to tarnish the image of the NHS in the eyes of a public that still considers the NHS the crowning achievement of our country.

The moral is clear:

Don’t believe everything you read in the papers – especially when it involves Tories and the NHS.

310 comments

  1. Just on the subject of finance and Doctors pay,yes we got a significant payrise from the last Labour government. The deals were negotiatedby the DoH. When I first became a Consultant I was paid for a 40 hr week. I did about 56 hours, so the NHS got 16 hours for free. A survey of Consultants at the time showed I was typical. The DoH didn’t believe this and opted to pay us for hours worked. Not surprising then that our salaries went up. Should I feel guilty about this?

    The DoH also negotiated with GPs a reduction in their pay in exchange for no longer having to workout hours. Again, the DoH wanted this.Is it the fault of GPs that Out of Hours services are a shambles?

      1. I think we are paid too much for what little we offer. Doctors thrive on gratitude, any one who say they need more money must certainly find an alternative profession.

      2. When you consider the amount that bankers, chief executives and others of their ilk get paid, doctors and nurses receive nothing and offer far more!

  2. Reblogged this on paurina and commented:
    This excellent research demonstrates that the hoo-hah about Mid-Staffs Hospital Trust is mainly right-wing propaganda

  3. Private Eye, issue1334/7.2.13 ” . . . Another way to reduce mortality alerts [over a certain limit of deaths an alert is registered for the hospital to have checks on mortality causes and potential problems] is to change the diagnosis. Patients come in with a fractured hip, and the longer the delay in operating, the more likely they will die, often from pneumonia. But if they have the pneuimonia longer than the fractured hip, their primary diagnosis can be recorded as the former, and they vanish from the hip fracture mortality alerts. Using this method, the number of people dying after fracturing their femur at Mid Staffs fell from 87% to 40 percent, even though the number of people dying didn’t change. This entirely legal recoding was overseen at Mid Staffs by Texan coder Sandra Haynes Kirkbright. She had a philosophy degree and had learned how to ‘code’ patients in the American insurance model of care.” The article covers two pages and goes through the years of evidence from whistle-blowers and other sources Private Eye have presented since the early 2000s on NHS dodgy patient care. Several previous issues in recent months have much more detailed articles about the same subject.

    1. Of course they have. But if the system can be ‘gamed’ it can also be just wrong. Stafford’s re-coding has been independently checked and appears to be correct, which means that their first efforts were way out – 25-30% according to PwC.

    2. Private Eye in suggesting that ‘gaming’ was taking place actually exposed one of the flaws in HSMR. As you say, if a patient with a fractured neck of femur and heart failure and kidney failure and pneumonia was coded as dying simply from fractured neck of femur, Fosters quite rightly says this is an unexpected (or ‘excess’) death. If they are coded including all the other health problems, Fosters regards this as a high risk patient in which the chance of dying is very likely. This does not count as an ‘excess’ death. Same patient, same health problems, more accurate coding and a completely different response from Fosters. HSMR can only be useful if the depth of coding for all patients across the country is the same. As this is unlikely to happen there will always be Hospitals with ‘excess’ deaths according to their methodology.

  4. May I apologise for incorrectly calling you Skywalker in my first comment – I was so pleased to read some intelligent thoughts about the Mid Staffs affair that I didn’t read your name correctly and attributed you Jedi knight status!! Sincere apologies but I think that the work you are doing is worthy of a Jedi and so perhaps it was a freudian slip.

    1. Thank you lol. Don’t worry about the slip – almost everybody does it at some stage. I even considered renaming the blog, but then everyone would think it was a Star Wars one!

  5. Jarman says that coding has a negligible effect on HSMR but then tells the press that other companies are working for NHS Trusts to help them improve their coding. Why would they do this? Well one reason is that coding relates closely to income and another is that everyone (except Jarman it seems) accepts that the deeper you code the lower your HSMR. If it doesn’t matter, then why is everyone doing it?

  6. Just another thing on rebasing. This has the effect that there will always be Hospitals above the 100 mark about which questions can be asked. It would be interesting to find out if there were always the same number of Hospitals over 100 year on year.

    The advantage of NOT rebasing is that you draw a line in the sand e.g. say at 2005 and set the average mortality at 100. Those above the line know that they have to improve and as their mortality comes down this would be a sign of REAL improvement. Those below the line must continue to stay there i.e. continue to provide good quality care.

    If one was to give a time period of say 3 years for those above to improve then at that time action could be taken to look at why some might have failed.

    Rebasing every year simply means that even if Units improve they may still be above ‘the line’. As a mathematical simpleton even I recognise that if you have an average, there will be numbers above and below it – thats how averages work!!!

  7. The official press release puts it very clearly:
    “The Inquiry concluded that it would be unsafe to put a figure on the number of avoidable or unnecessary deaths at the Trust. Robert Francis QC has recommended, given the lack of understanding surrounding mortality statistics and their use, that the Department of Health set up an independent working group to urgently review the gathering and use of mortality data in the NHS.”
    So let’s hope there will be no more misuse of Dr Foster-type “facts”.

  8. The point that is being missed: NHS trusts have to buy the DFI RTM tool to get an accurate understanding of how exactly coding changes will affect the all-important HSMR. Yes, the methodology is transparent and yes HSMRs are published but that is quite different from being able to replicate it accurately. Bizarrely DFI lost out on the contract to produce HSMRs for NHS Choices when it was first awarded and the company that won the bid (IMS Health) could not replicate the HSMR – so they had to go back to DFI to do this for them. In his evidence to the Mids Staffs Inquiry Brian Jarman says:

    “At their request I had given two presentations to IMS Health regarding the calculation of HSMRs on 16 Jan 2009 and 16 April 2009. They were given the B coefficients from our regression model that we publish that would have enabled them to do the necessary calculations. However, I think that Dr Foster currently still does the calculations for IMS Health.”

    1. Oh, that’s not being missed – the article looks at the commercial conflict of interest and the fact that DFI would benefit from the pressure applied on hospitals in poor positions in the ‘Good Hospital Guide’.

  9. Excellent piece. Keep going – we need people with intelligence and determination to fight the demonisation of the NHS

  10. Congratulations for a wonderful piece of research. Your report has the potential to shock even more than the original Mid-Staffs ‘revelations’.

      1. You right and the BBC and other media all wrong? I expected nothing else in reply!

      2. Argue with the facts rather than with me. BBC and other media are ignoring massive and hugely significant facts – distorted reporting is inevitable.

        Checking the facts and getting the story right is a hugely time-intensive job, as I can testify. Most journalists will be happy to base their stories on how others have reported it, rather than on a proper analysis of the facts.

        There are some others who’ve done the same work on it as I have, but not many. All have come to the same conclusion – even Francis, although none of the media are highlighting that he said HSMRs do not indicate numbers of avoidable deaths.

      3. No idea, since it’s the first I’ve heard of it and I make a point of commenting only once I know the facts.

        Doesn’t change that I DO know the facts regarding Mid Staffs – and most of the journalism on that is definitely shoddy.

  11. Why would anyone believe Professor Jarman implicitly when he cannot be said to be impartial due to his involvement with Dr Foster the organisation supposedly measuring hospitals’ mortality outcomes. Try reading a letter from Professor Nick Black from the London School of Hygiene in today’s Guardian newspaper which in my view presents a much more balanced view.

    1. Well of course his letter presents a much more balanced view – it’s published in the Guardian, that bastion of independent journalism!

  12. Sarcasm very rarely wins an argument – I at least read the article that you cited from the Telegraph – a paper not completely independent of political bias – did you proffer me the same courtesy. There is obviously no point in debating with you since you have a closed mind.

    1. Of course I read the article. For a self-appointed researcher you sure do jump to conclusions.

      1. You clearly don’t read very carefully – since it was another commenter making the comment you’re replying to, and not the ‘self-appointed researcher’.

  13. Good point comrade. Actually I was distracted at the time – browsing an intriguing web site, labourleft.co.uk

    1. ……it kept me amused for quiet some time. If that’s the best team that can be put together and be called “labour’s largest think tank” I don’t think people need worry about ethical socialism getting a foothold to be honest.

      1. Well, I could say the same about the ‘team’ on the other side – from government down to commenters on this blog, the right wing seems largely bereft of insight, intellect or integrity. I could count on the fingers of one finger the number of commenters from a right-wing perspective who’ve presented cogent arguments.

        I guess the old saying is true: ‘Not all right-wingers are stupid people, but most stupid people tend to be right-wingers’..

      2. …and Marxists under cover of champagne socialism are just a “mob of dupes”.

      3. Nonsense response – doesn’t seem to relate to anything. You’re starting to just sound like a troll, Andrew – and still signally failing to actually refute anything I’ve said.

  14. I did respond to be part of the Independent review and was told in a letter from Robert Francis QC that the inquiry received hundreds of letters and emails. Not 60.
    The Mid Staffordshire NHS Foundation Trust Inquiry letter stated that the purpose of the Inquiry was “to consider the views of patients and staff about the care given to patients at Stafford Hospital, not about deaths at all.
    Other reasons that there may not have been 400-1200 respondents would be due to the overwhelming shock and grief felt by family members who may feel that they cannot cope with anything more at that time.
    Another reason would be that people believe that it will be a fruitless exercise; that nothing will come out of it nor can bring it the deceased back. Both are right.

    1. The total (as one of the articles says) was around 200, of which Dr Laker personally reviewed 50 – presumably the most questionable 50, since he was the review leader.

      People die avoidably in every hospital in the world – the nature of healthcare is that it’s risky, and it’s delivered by people, who are fallible.

      The fact – difficult and unpalatable to some – is that Stafford’s death rate was below the national average. So whatever the failings in basic care in some parts of the hospital, they weren’t resulting in a higher mortality rate.

  15. Professor Brian Jarman, statement “you’re not going to measure the quality of care of pacemaker insertion by measuring the mortality” is very true and very relevant.

    Your research does highlight few points but it looks as if you are (1) 20 years younger than me (2) May not have worked as a doctor working in acute and intensive care setup (3) Not been victimised and harassed because you have identified the problem that caused is embarrassment in the NHS.

    The first and the most important duty of a doctor is to identify the cause of an illness. This I call as the “Clinical Diagnosis” because we must alleviate pain and suffering . Every doctor in the universe knows this and often do the correct treatment based on knowledge and experience. This can also be treated as a “Therapeutic Diagnosis”, in other words, we assume the symptom occurred due to some infection and so offer the right treatment, patient gets better, so you can document this as “The diagnosis”

    Case Example:

    A teenager presented with breathlessness, sore red tongue and mouth ulcers. He has a history of ear infection few days ago. The doctor or nurse following the guidelines will diagnose this illness as “Tonsillitis, URTI or Scarlet fever and prescribe “Penicillin”.

    Clinically I diagnosed this as “Atypical Pneumonia” based on history and the age of the patient. I would treat him with “Erythromycin” and
    if the boy gets better, I would label this as “Atypical Pneumina, caused by Mycoplasma”. This is “Therapeutic Diagnosis”. I may request blood test, X Rays and other investigation to confirm my Diagnosis and not use this to help me diagnose the illness.

    As a doctor (hands on as the registrar, staff paediatrician) I was the one who slept in the hospitals and managed very sick children as soon as they were brought into the A&E or ward. My head was between two sharp swords. If my clinical diagnosis was right the child lived but if the child died my career would come to an end because the consultant, the hospitals and the nurses would blame me for the mistake. Being a “Foreign Trained Doctors” the media would highlight this too.

    To survive, as a “underling”, I had to be fast with good clinical examination technique, clinical approach to diagnose and update my knowledge.

    In twenty years I have only been criticised twice (minor) and survived with no mistake. How can this be possible? True, I learnt my job often by seeings others mistake and not acquired any by reading books or publications. The reason I can say this is because I know how research is conducted in hospitals, and how some data are cooked up to deceive you and me. After the “Swine flu” I do not trust even “Cochran Database”.

    So what is the Problem in the NHS?

    As doctors we were forced by “Labour” to start auditing our management. This was not in the interest of improving the quality of patient care nor in the interest of medical profession but only in the interest of the politicians who wanted statistics to help them save money. This was not in the interest of doctors, why because the so called guidelines and protocols which was developed helped them “Systemisation”.

    If all the symptoms and disease follow a “Starlight path”, yes we could use this protocol or may be a computer to offer diagnosis and treatment. The politicians used nurses because the doctors who are well trained clinicians, refused to follow these guidelines meticulously. The nurses are “Trained to Flow Guidelines” and are not allowed to be innovative or creative in their approach.

    Going back to my example, the teenager treated by a nurse or a doctor, with no knowledge of “Atypical Pneumonia” and knowing it is important to treat early with a specific antibiotic will miss the boat. A poorly trained doctor or a nurse following the protocol or guidelines will assume the breathlessness of the teenager as ear and chest infection and will prescribe “Penicillin”. This wrong diagnosis and treatment will not only prolong the illness, suffering and death.

    It is true, we must make sure every patient who access healthcare will expect the best care, unfortunately the politicians approach claiming as “Modernisation of Healthcare” has acutely back fired. I identified this problem would occur and published a letter (Critisisng Preprinted assessment sheet) in the medical journal in1996. Identified numerous problem as soon as I stopped working in the hospitals (2003) and became a GP.

    I must tell you that no doctor or nurse will come forward and accept they did a mistake but defend themselves using the document “The Guidelines” provided by the NHS. This is the reason the patients are right, “The Quality Of Care” offered in the NHS is poor.

    Doctors like me who collected data and identified the problems are the victims because these people in power have harassed, humiliated and are still desperately trying to stop me from making my findings public.

    Please download my FREE Apps (www.appcat.com/maya) to help protect you, watch my video “Medical Ethics, Do No Harm” and please eave your comments.

    1. Thank you. Every doctor who is working to help patients has my respect. I have no idea how old you are, but I doubt we’re that far apart.

      The example you outlined is very interesting – but those same pressures and risks of error are surely present in every healthcare system the world over. Nobody running a hospital wants their hospital to have a bad reputation – and this would be even worse in a commercially-driven health system.

      I’m sorry you had a bad experience, but for quality of care compared to cost the NHS is one of the best healthcare systems in the world. Far from perfect – but the way to improve it is not to cut billions at the same time as conducting a massive reorganisation – as the current government has done and continues to do.

  16. Thank you for allowing me to share my experience. The same pressures and risks of errors do not not occur in other countries because the patients do not trust doctors and nurses as in UK.

    I have observed how patients treat nurses in the hospitals and used to wonder why. You may not believe this but it is true “As the registrar in Paediatrics, I struggled to save the life of dying children for hours and often days but not one said thank you. It was always the nurses who received a card and a box of chocolate.

    After reading the history of medicine, I realised the hype of nursing profession has always been the media because of Florence Nightingale. Her achievement has been subject to some debate. The fame and influence Nightingale gained from the Crimean war would never have happened without the actions of the press. (Reappraising Florence Nightingale, BMJ
    Keith Williams) http://www.bmj.com/content/337/bmj.a2889

    These problems and wrong doings do not happen in other countries ( I have worked in 3 countries) because the senior experienced doctor (not nurses or junior doctors) will first examine the patients. As I said before, It is very important to first “Clinically Diagnosis” before offering any treatment or advice. As doctors trained for almost 10 years “Under Supervision” do often make trivial mistakes but rarely develop serious complication or death.

    Junior doctor working in the hospitals see a patient in A&E or as a Gp Trainee in the surgery. They will discuss their finding with the registrar, consultants or the Gp Trainer. This 5 years training will help junior doctors learn and master diagnostic skills required to diagnose and mange patients in hospitals or the community.

    The problem started in the NHS since they used nurses as the front line staff (to help save money), mistakes occur and I have seen serious complications. This is similar to you asking me to repair your car using a manual using the tools you provide. How will I know how to use the tools? One of my teachers, Dr Haliday Smith, Paediatric Cardiologist, Hammersmith Hospital (1980s) thought me the most important part of a stethoscope in the part between the two ear pieces and I know it is very true.

    NHS pandits claim the quality of care is brilliant but I have not found one publication that satisfy me the diagnostic skill and management of patient’s illness or disease is in par with doctors.

    The Nursing professionals have conducted studies and published data to prove “Patients are happy”. This does not prove the care offered is safe and the best quality in the world. I would call this “Licences Quackery”

    As a doctors, we spend all our life “Perfecting clinical skills” and avoid complications. Our duty is not to prescribe but to identify the cause of an illness and offer a solution.

    As foreign trained doctors (7 years training) we have to pass examinations to prove that we are safe and competent to work as a doctor (Under supervision) in the NHS. A nurse who sat with me for 12 days (ie., once a week) is allowed to work as a independent doctor in the NHS, so please tell me how can you expect these nurses to offer a service that you can trust and claim to be the “Best in the World”?

    1. The nurses are the ones who clean up the waste, the vomit, who hold hands as people cry, suffer, fear and die. They’re there every minute and doctors come and go – as their job requires them to do.

      Doctors are hero-worshipped in this country and many others – but nurses are adored, and rightly. This government is trying to undo that.

      The variants of ‘consultant nurse’/’nurse practitioner’ may not be the best way of delivering the right care (or they may be), but that’s not their fault – they step in to fill a gap the ministers and executives decide needs to be filled. They shouldn’t be blamed for that – any more than it’s a healthcare assistant’s fault that the bosses at her hospital change the skill mix to save money and put more HCAs on a ward than nurses.

      You sound as if you’ve been eating too many sour grapes – you may well have a justified cause for grievance, but you’re directing it at the wrong people, at least in part.

      1. I do apologise for not making it clear, I am not blaming the nurses but am blaming the system and authorities who licensed nurses to work like doctors.

        The World Medical Association makes it very clear “A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician’s fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose.

        People in power have the responsibility to help support doctors do their duty in the interest of fellow human. They have no right authorise nurses or any person to use the skills we are trained for and allow them to inflict injury, pain or suffering to fellow human. When a doctor (junior, senior or a professor) who has sworn to protect fellow human (Hypocrites oath) identify wrong doings and informs authorities, I think they have a moral duty to protect the doctors and patients and not just shoot the messenger.

        I went through your blog and and the comments and found them all interesting. To tell you frankly statistics and data cannot be substituted for human being before you; they embody averages and not individuals. Numbers help us and compliment our decision and certainly do not help us deliver the care. Coding is not necessary to offer the best care, this is not so straight forward as you think because every patient’s story and expectation is different. Please read my comment published in medical journal in 1996. http://qualitysafety.bmj.com/content/5/2/121.2.citation

        You may not know this but the “Trained nurses” are not expected to clean up the waste, the vomit, who hold hands as people cry, suffer, fear and die. This role has been passed on to “Care Assistants” (not a nurse but men and women paid minimal wages and are often foreigners. Its not comfortable but the doctors are expected to be in three places at the same time and so they do pop-in and out.

        About me, to tell you frankly, it is more than sower grapes. It would have been happier for me to walk into a gas chamber and not live the way I am living now.

        Please watch my video published in youtube and am sure you will find this interesting.

      2. I couldn’t agree more with most of what you say. I do think there can be room for nurses to do certain ‘medical’ tasks, but to be a doctor is a very specific skill that requires years of training.

        The ‘sour grapes’ comment was based on a misunderstanding of your comment about nurses and I’m now happy to withdraw it.

        I do need to correct you on something, though – my wife is a nurse and she routinely cleans up patients from their waste, vomit and blood. There is a phenomenon of some nurses trained under the new ‘degree qualification’ system who do not like working ‘hands on’ in that sense, though (but only ‘some’) and that needs to be corrected.

        I suspect we’re on the same page in most things, and I would wish you and improved situation!

      3. Thank you. Nurses who qualified before 2000, were simply great to work with but certainly not the new qualified ones. Sorry if I have offended your wife.

      4. She’s not party to the discussion! But you haven’t offended me, either – I’m just concerned for a clear and balanced picture to be presented.

  17. I forgot to tell you, I read your profile and so I know your age. After passing PLAB in 1983, I worked day and night in hospitals all over UK. Yes NHS is trying hard to block my story published, the ministers have not replied and media is silent because they still believe nurses save lives in the NHS.

    1. Of course they do. They may not save some they could have, but they save many – but those never make the headlines.

      Are there bad nurses? Of course, as there are bad practitioners of any job – but the vast majority want to give good care, and are often prevented from doing so by cuts and shortage of staff.

      1. After I passed my final examination, one of my teacher asked me a simple question “What is the duty of a doctor?”. As any junior doctor, passing out from medical school, I also said, “Save lives”.
        He stopped, looked at me and asked me “What is God’s Duty?”
        Its true, we have the skill to alleviate pain and suffering and can only postpone death because ono God or some super power has the abilty to save lives.

    1. How does this in *any* way challenge the facts about *how* the poor care arose? If anything it reinforces it.

      In his speech this week Hunt tried to put the blame on Labour:

      “On staffing levels and nursing numbers, I remind the right hon. Gentleman that the problems at Mid Staffs happened when Labour was in power, when budgets were going up quite significantly, and when numbers were going up.”

      This is utterly disingenuous. FT status and restrictions created a microclimate of underfunding and understaffing at Stafford regardless of the bigger picture.

      That the Tories are turning the microclimate into the prevailing one should worry everyone, GPs included.

      1. I’m back on here AGAIN!!!! but this is something I would like to share with you all. I am completely behind the NHS and as an employee of Stafford Hospital fully support our cause, however today I feel I am in a predicament to say the least and see the point from a patient relative side. My dad was taken in to hospital on Wednesday with a lung and chest infection, this has worsen due to the fact he has lung and mouth cancer. Yesterday I went to visit him and he complained about a member of staff being very rude to him during the night because he had asked for a couple of things and she got quite arsey with him. His chest flares up during the night and he finds it difficult to breath. I know how demanding my dad can be so brushed it off and told him he had to be patient because the staff can be overworked during the night. He also said that the call bell is a waist of time because no one ever comes or when they do its to late by then.

        This evening I went to see him and he told me he had asked for some cream in the morning and again several times during the day with no prevail. He also complained that his bottom was extremely sore and that one of the staff had broken the air mattress first thing and he had told staff AGAIN and AGAIN numerous times during the day that his mattress was flat. On close inspection his mattress had no air inside and he was lying on hard metal. 🙁

        He also pressed his buzzer because he needed the toilet yet three nurses sitting at the desk did nothing. I kept thinking to myself “please don’t prove me wrong about nurses” 10 mins later still no sign of anyone. My dad begged me to get the commode, so I decided to grab a member of staff myself, still being my lovely apologetic self but by then it was to late, he had already done it. 🙁

        The final straw came when I was due to go home and my dad looked at me and said ‘that’s the nurse’ I looked up and she was setting up my dads suction. She looked at me and said “You can go now. Goodbye” I was speechless to say the least. I retaliated by mentioning the FLAT mattress. Her reply was, ‘yes well a new ones on order so it really isn’t a problem is it’. Did I really just hear this or was I imaging the whole thing?????

        I’ve come away feeling angry upset and genuinely worried for my dad.
        He asked me if he could go home before I left because he didn’t like the way he was being treated.

        Visiting times are very limited at this particular hospital, so I worry what happened’s when the doors are shut to relatives.

        As an NHS employee I am in disbelief.

        What do I do???? 🙁

      2. I’m sorry to hear about your troubles!

        There are without question some ‘bad apples’. Insist that nurse doesn’t treat your dad any more and put in a formal complaint. Some people just aren’t suited to being nurses, and the disciplinary process needs to kick in.

      3. The only problem I have with identifying bad nurses is when people try to extrapolate that to an attack on nursing and the NHS in general!

      4. How does this in *any* way challenge the facts about *how* the poor care arose? If anything it reinforces it.

        True, I collected the evidence to prove what and why these problems have occurred and happened but the institution and politician in UK have turned a blind eye and ignored this. The immoral and unethical medical practice has only destroyed the human face of medicine .

        It is very obvious these people in power are supporting and the wrong doings to continue to help them dismantle the NHS. There is now way we can help bring in chafes because people who complaint or raise concern will be ostracised.

  18. Skywalker, it was more than one nurse in the horrific episodes described by Sally- another factual error. Also, not surprised by Sally’s epiphany – check with curethenhs.co.uk Sally, they have many similar current instances in spite of claims to the opposite from the current regime there at mid staffs. They will be able to assist you should you need help. Also email your story to Anne Clwyd at Westminster.

    1. ‘Cure’ are very destructive and irrational, sadly – and listened to far too much because people are scared of seeming callous.

      Sally’s issue seemed to be primarily with one nurse – and such problems should be addressed at a disciplinary level, not by attacking the wider NHS, which does incredibly considering the challenges it faces. It’s very fallible, but any big organisation inevitably is.

      1. Hi guy’s.

        I may have not made myself clear on my last post. My father is NOT a patient at Mid Staffs. He is in a midlands based hospital. Also it was one particular nurse on that ward that I have issues with. She was VERY rude and condecending to both my dad and me. Some staff could have done more but am I comparing them to how I would have dealt with that situation? 🙁

        My dad has been in and out of hospital for many years and we have never had any problems with the level of care.

        I’m back there tomorrow, so we shall see. Like any working environment you get good and bad employees. I’m just up against a bad one in this case.

      2. Oh, I understood that – whichever hospital he’s at, I’d recommend the same course of action. Good luck with everything – let me know how it works out!

      3. I agree there are without question some ‘bad apples’ in every basket that must be removed. In the NHS the rotten apples were supported by their superiors and even the NMC. Unfortunately, people like Sally thinks of the past and try to defend this organisation. Even I tried to defend this institution for almost three years because I have worked as a doctor for almost 25 years and believe this as the best healthcare system in the world. If similar problem had occurred twenty years ago, I would have stopped working and moved on.

        This problem going on in the NHS is not likely to get better because the doctors are too scared to step in and start acting in the interest of their patients. I believe it is our duty to make sure they are responsible for physical and mental wellbeing of their patients and so acted in the interest of patients. Now I will not advice any doctor to do what I did and people like Sally must act and not chicken out.

        Formal complaint may have worked in the past, but now this is simply a waste of time because there are too many rotten apples that are in control and they do not see this as a problem.

        Whoe ever reads my comment, please act and do not shy away, if not its you, your family and loved ones that will suffer in the future.

  19. Can the independent sector do better than the NHS?
    Independent sector dominates top ten for improved quality of life following elective hip and knee replacement
    19/03/2013
    Independent sector organisations which carry out elective hip and knee replacement surgery for the NHS dominate the top ten providers for improving patients’ quality of life following the procedure, according to an analysis of PROMS data published today.

    Patient reported outcome measures (PROMS) assess the ‘health gain’ for patients who undergo hip and knee replacement surgery, as judged by the patient.

    Analysis published today by the NHS Partners Network (NHSPN) suggests that NHS patients who had surgery in an independent sector facility are more likely to enjoy greater improvement in quality of life following the procedures.

    Top ten

    Of the top ten providers for hip replacement surgery, seven are from the independent sector. In the top five, four are independent sector providers.

    In the bottom 25, only one provider is from the independent sector.

    For knee replacement surgery, eight of the top ten are independent sector providers, and in the top five, three are independent sector providers.

    No independent sector provider appears in the bottom 25.

    Elective procedures

    The independent sector now carries out almost a fifth (19 per cent) of all elective hip and knee replacement surgery in the NHS and is increasingly treating more NHS patients across a range of elective procedures, both in independent sector treatment centres (ISTCs) and private hospitals.

    Although the sector is only permitted to undertake certain types of cases, usually excluding the most complex, the data is adjusted for key aspects of case mix.

    The data also suggests that the case mix differences are not as significant as is sometimes claimed.

    High-quality care for NHS patients

    David Worskett, chief executive of the NHS Partners Network, said: “This data clearly shows that independent sector providers deliver some of the highest quality orthopaedic care for NHS patents.

    “Hip and knee replacements are two of the most commonly performed orthopaedic procedures and they can significantly improve the quality of life for patients. It is important that this data is available so that patients and their GPs can make informed decisions about where to go for treatment.

    “The quality of clinical care is crucial, and this data, drawn from the NHS PROMS database, clearly shows that the independent sector delivers very high standards NHS care, seen from the patients’ perspective”.

    Contribution to modern NHS

    NHSPN is also today publishing a briefing note, compiled from various official sources, which in addition to the PROMS results, shows that:

    almost all independent providers – 98 per cent in hospitals and 96 per cent in community services – are meeting the required standard on dignity and respect.
    independent sector readmission rates for hip and knee surgery are significantly lower than the NHS average and comparable with specialist orthopaedic hospitals.
    Mr Worskett added: “Taken together, all of this provides a full and well-rounded picture of the care NHS patients receive from the independent sector, and demonstrates the great contribution the sector can make to the modern NHS.

    “It is clear from the newly published Civitas research that 83 per cent of British people are entirely happy to use independent sector NHS services as long as they come up to standard – as they clearly do – and are free at the point of need.”

    1. Hip & knee replacements, and similar treatments, are ‘production-line’ stuff that can be done cheaply and profitably – the government is setting Lewisham up for privatisation by downgrading it to a joint-replacement centre.

      The fact remains that ‘independent sector’ (if not non-profit) are taking money out of the NHS as profit that could otherwise be used for more treatment. If the same treatments are offered, it means lower pay or fewer staff, which is bad for the wider economy.

      And NHS hospitals need to offer care for chronic illnesses, A&E etc, which are not profitable – to take out the ‘easy’ bits and give them to money-makers is insanity.

    2. You need to be in my shoe to understand the role of healthcare professional. NHS was created to offer a healthcare, a service (mental and physical well-being) and not dish out tablets or perform practical procedures.

      If every person patient with hip pain consulting their GP had one of these conditions (Arthritis, Dislocation, Fractured head, infection or osteoporosis or tumour) then Independent care providers is a good choice and my job would have been very easy. I would say only 5%-10% of adults presenting with one symptom may have one of the disease that can be treated by specialised unit and their quality can be assessed.

      The problem we have is because majority of patients presenting with one symptom often have primary problem in another organ or they could be hypochondriac and classified as “Psychosomatic”.

      I don’t think and independent care provider will offer a screening tool or service because they will require, paediatricians, surgeons, psychiatrists, gynaecologist, Radiologist, MRI Scan and CT Scan experts. This is not cost effective, practically possible nor will it benefit patients.

      The problem in the last ten years was because the nurses and staff working in call centres were screening patients (Frontline staff). They are not properly trained to examine, diagnose nay illness based on history, clinical diagnosis or tests. The protocol was developed by nurses (observation) helped by medical students. When the “Front line staff” make a basic mistake, the delay in getting the right treatment is delayed by minimum 3 weeks. Any thing can happen during this three weeks.

      When complication occurs, the patient is brought into hospital patient presents with different symptoms and so the statistics will say the patient died because of …….. but this does not tell you the reason this patient died was because the initial diagnosis and management was wrong. The only person who will know why the patient died is the doctor who goes through the notes. I am one such doctor who raised concern but would never do this again if I returned to work in the NHS and do not expect any doctor to come forward and complaint.

      No person on earth will invest in a primary care that help patient get the best care because it is very complicated and will never generate “Profit”.

    3. I expect that a lot of this can still be explained by ‘cherry picking’. My experience is that independent/private sector treatment centres are allowed to impose restrictions on the patients they treat, based not only on the nature of the condition but also on the age, weight and general health of the patient. In addition, none of the non-NHS facilities would be accepting emergency admissions or trauma. Comparing these is therefore manifestly misleading, and encouraging the cherry pickers will inevitably, and rapidly, destabilize the NHS services picking up the pieces.
      There is little money to be made from universal health care, and no universal benefit from extracting what little there is from the system. As a GP I run a private business providing NHS services, no cherry picking, no case selection, universal access and no shareholders. That model can coexist with the NHS and still get very high patient satisfaction ratings. Profit driven models can never join this health ecosystem on a large scale without destabilizing it

    1. Following my recent post regarding a particular member of staff. I am please to confirm the matter has been dealt with and the nurse in question has spoken to my dad and myself regarding our concerns towards her. She has apologised for her actions and my dad seems to be a lot happier with his level of care. It just goes to show, they do listen and act on your concerns. 🙂

      1. That’s great to hear – that’s how such issues should be addressed, rather than trial by media! Well done, I’m really glad it worked out so well for you.

  20. “Doctors thrive on gratitude”

    Really ?

    Gratitude doesn’t pay my bills.

    Or pay for my children’s tuition fees.

    Let’s not kid ourselve; money is VERY important.

    D

    1. True, you may be after money but I am not.

      The main reason doctors like me lived and worked in the NHS is because I treated every one the same and was paid by the NHS and not paid by rich people. If I was not thriving on gratitude, I would have been a working in USA and been a millionaire long time ago. I did have a job to go and work in USA and Canada in 1984 but I did not because I do not believe in private healthcare.

      It looks as if people have not understood what private healthcare is all about. You need to read this publication in American College of Physician Executive state 80% of doctors do not accept un-insured patients and 79% perform tests, investigation and refer jut to boost income. “This is private healthcare”, people do not realise how easy it is to advice tests and investigations knowing it is useless.

      I am sorry if some of you think every doctor on earth chase money, majority of the doctors working all over the world are thriving on gratitude. I would have also trained to be a plastic surgeon and not opted to work in Paediatrics if I was keen on earning millions.

      By the way, sending your child to private expensive school do not make your child smarter and clever. I went to a school in a village, borrowed books from British Council and from friends. Please read “How Doctors Think” by Jerome Groopmen. I stopped working in UK because I think the NHS is offering sub-standerd care and this is against my principal.

      No person on earth could have paid me any thing for the work I did and I so am proud of what I did…Money can’t buy what I have. Bill Ghat or other earned a lot but what are they doing with it, trying to bribe doctors like me to find a cure… can he buy me…certainly NOT.

  21. The above article is a very interesting response to the hysteria around this issue. I was always a bit surprised that given such large numbers of supposedly horrific episodes there were only a very small number of stories put forward as ‘evidence’ of calamity. I work at a hospital in a different trust and I remember thinking ‘Thank god no one is checking us out!’

    That isn’t meant to be cynical, just a reflection of the fact that in these times of austerity the new maxim for the NHS is ‘more for less.’

    More work is expected from fewer members of staff. A single first year doctor might find themselves covering several hundred patients for 12+ hours on a weekend night. An equally new nurse might be responsible for 12+ unwell patients some of whom are actively trying to hurt themselves by mobilising despite being pathologically unsteady on their feet. That same nurse might suddenly find herself caring for a whole ward of 28 patients at 3 o’clock in the morning, especially if there are 1 or 2 particularly disruptive patients requiring increased supervision.

    In times like that, and times are increasingly always like that, you can’t drop everything to refill a water bottle, or ensure that all 28 people have said bottle readily to hand – and a sad factor in this is that most patients are remarkably stoical so don’t actually point out that they can’t reach things as they know how tough things are for the staff looking after them, it’s only when a family member arrives and sees a shattered nurse seemingly ignore patients as she’s doing some irrelevant task like writing things down (which is a legal requirement) that people get upset.

    This isn’t to condone neglect or justify everything that’s happened at Mid Staffs, but it is to offer some perspective from the other side, a side that is legally barred from discussing issues relating to specific patients.

    So the next you read of some ‘horror on ward’ please take a moment to think about all you’ve read here and, if you really are still too horrified to let it go, I have one suggestion…

    Volunteer. Hospitals are desperately short of help. If you were to spend one half day a week helping out you’d do the power of good, and may even find yourself defending your local hospital and the NHS before they’re both shut down for good!

    I only hope there aren’t too many bureaucratical nightmares, like manual handling or background checks, waiting to stop you joining us and helping out!

    1. I agree what James is saying but do not accept the problem in the NHS is because of understaffing. Yes, it is not fair to allow a single junior doctor or nurse to manage inpatients and emergencies in the hospitals.

      As doctors we must think like a patients to understand what patients expect and why so many people are angry, blaming doctors, nurses but defending the NHS ?.

      The World Medical Association makes it clear we must not provide any premises, instruments, substances or knowledge to facilitate the practice any form of cruel, inhuman or degrading treatment or to diminish the ability of the patients to resist such treatment.

      The doctor shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal. Doctor shall not be present during any procedure during which torture or any other forms of cruel, inhuman or degrading treatment is used or threatened.

      Doctors working in the NHS do not have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The fundamental role of a doctors is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose

      If we cannot do what we promised, then we have failed to provide the care and so have no right to be claim to be members of a “Nobel Profession” any more.

      I do think the senior doctors, nurses or the Consultants have failed to provide the care they are paid and expected to offer by allowing junior doctors and nurses to manage patients. The senior doctors must be made to stay in the ward or A&E when on call and not allowed to go home and sleep at night or attend meetings.

      As a junior doctor, I have been on call for three days and nights and never found it hard nor had any problem. Each speciality was managed by 2-3 consultants and 1 or 2 registrars and 3 SHOs. Doctors and nurses knew one another and worked as one family.

      In the past ten years, the number of consultants and junior doctors has quadrupled but patient satisfaction has declined. The number of complaints, litigations and compensation payment has sky rocketed, WHY?

      The reason is simply poor communication, lack of enthusiasm, culture of blaming one another and not thinking or listening to what patients are saying or expecting. Blaming understaffing, low pay and working conditions and high patients expectation.

      The administrators and the mangers (people in power) removed the atonamy of doctors by introducing guidelines and protocols resulting in wrong doings that can lead on to minor or serious complications and even death.

      It looks as if the doctors have forgotten their role is not to harm but provide a service that is safe and makes patients feel as if they are at home and comfortable. This will not only reduce pain and suffering but also make patients get better sooner and go home happy.

  22. Dear Skywalker,
    Intereesting article, but you didn’t expect that a nurse practitioner would read this? I am disappointed in your attitude towards specialist nurses. Times have changed, in the western world you will find specialist nurses all over and they do a great job, often advicing even middle grade doctors. Why on earth does it mean once you qualified as a nurse you will have to clean vomit for the rest of your life? Every profesion has a way up, be it a carpenter, electrician, medical, nurse, we all progress. Some nurses choose to stay on lower levels, and are very happy. But I think some doctors seem to have a problem with that, which is unfortunate, I am getting on very well with all my medical collegues, they value me and I value them. And I am going up, enjoying learning more and more, what’s your problem with this?

    1. Good comment duo, you have to be a patient or a doctor to understand the difference between how a doctors and nurses are trained. Nurses knew they are getting trained to work as a nurse and not as a doctor in the hospital or community. No one forced them to go to nursing school. If they wanted to work as doctors, they must have joined a medical school.

      Making a nurse work like a doctor after 6 moths of training is like make a plumber work like a structural engineer using a computer programme?. Just because a nurse sat with me for 12 days in 6 months and observed me examining and prescribing antibiotics does not mean to say she is an expert and can be licensed to work like me. This is what NHS did. I raised concern about this in 2003 but the mangers continued and established more clinics and walk-in-centers managed by nurse practitioners. I am a doctor and so my concern is only “You” who trust doctors. http://www.bioscilibrary.com/resource/EndocrineNurseCourse/ent04/ent04_wil.htm

      As a doctors we study every branch of medicine and then work under supervision in a hospital for 5 -7 years after graduation. We are aslo constantly updating information and reading medical journals. As SHOs or registrars we are criticised, humiliated when we diagnose illness wrong but complimented for getting it right. We also know it takes years to master the art of clinical medicine.

      What will you do if a practice nurse who does not even know how to place the earpiece on her ear has the audacity to tell me that you must prescribe only Penicillin and not Amoxacillin. She does not know the difference between the two other than the cost and defends herself saying the protocol say so.

      I have seen patients (young adults and children) brought in because they developed septic shock (blood poisoning) and almost dying. The nurse practitioner in the local walk-in-clinc had prescribed Penicillin for a skin rash. This was the wrong diagnosis and treatment but defended her action because “the protocol to say she must prescribe Penicillin”. If the patient died, she is well protected because she has followed the guidelines.

      As doctors we know bacteria develop resistant very rapidly when and also become very aggressive and will kill the patient. http://www.healthline.com/health-news/policy-combining-antibiotics-increases-bacterial-resistance-042313.

      The duty of a doctor is to “Do No Harm”. Prescribing antibiotics was not a major problem in the past but now “This can Kill” and so more harmful than not treating infections.

      Think what will you were the patient with a skin rash? We can be emotional, passionate and support nurse practitioners, but when its your life in their hands, I am sure you will setback and do what it takes to survive.

      I have asked GMC to define “Doctors” because these nurse practitioners are allowed to diagnose, advice and prescribe drugs like me but not governed by medical ethics and guidelines stipulated by GMC. I would call them licensed quacks – or bogus doctors employed by the NHS.

      Please click on my name and watch my video in you tube and tell me if I am wrong….

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