I’ve received a copy of a letter that a consultant from the Accident & Emergency Dept at Stafford hospital has sent to the British Medical Journal (BMJ). He doesn’t know whether the BMJ will publish it, but has given permission for it to be shared.
I’m publishing it, in full, here without further comment from me, in order to ensure that he gets a public hearing:
It must be made clear at the very outset that many patients suffered unacceptably in Stafford Hospital during the last decade and I sympathise with them. Some died and their deaths were considered avoidable. To their families and friends I can only extend my deepest condolences. But equally, many tens of thousands of patients attended Stafford Hospital during 2005-9 and found no cause to complain. Many of these would have been on the brink of death but were successfully resuscitated, treated and discharged. Must these patients and their families now see the hospital that saved them being maligned and prepared for closure? Do their positive experiences count for nothing?
I commenced work in Stafford Hospital only a year ago and am on the verge of retirement, with no axe to grind and little to fear in this new age of candour. Working in the A&E department, I meet local people on a daily basis and many of them recount how well they were cared for during their previous admissions. So it is with considerable angst and much concern that I watch the reputation of a locally much-liked institution being slurried in the dog-eat-dog world of the general media.
Whilst there is little I can do to encourage balanced coverage in the national press and politic, there is, surely, room for more sanguine consideration of the facts in professional journals such as this one.
1. How has it come to be that Stafford Hospital is commonly associated with 400 to 1200 deaths from 2005 to 2009? I am not being complacent when I question the derivation of these figures. It’s my training. I instinctively question ranges of 300%. And if I find even one avoidable death distressing, what do I make of a thousand? That’s carnage! People must have been dying in droves. No! As expected, the numbers are projections and estimates based on opinion, best scenario-worst scenario arguments and grossly inexpert coding. I sympathise with the view that when coding is corrected and is accurate, the death rate in Stafford during 2005-9 actually falls substantially and possibly below the national average:
“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.”
Further analysis of this subject and the fallibility of mortality ratios (HSMRs) is available here: http://skwawkbox.org/2013/02/26/the-real-mid-staffs-story-one-excess-death-if-that/
2. Unlike death, Care is a perceived quality. If people don’t feel cared for, that’s the end of the argument. It’s unacceptable. Standards of care did lapse significantly in Midstaffs. But how significantly? We don’t know, because to measure such parameters objectively we need to study an unselected sample. We need to look at representative groups, not only a group of complainants. To exclude the silent majority is to select to the point of a foregone conclusion. It’s like asking 100 patients with headache whether they have headache.
3. Many myths have grown out of the Midstaffs saga. A large section of the British population, for example, still believes that patients drank out of vases, even though Francis is clear that he heard no such evidence. ( Final report: Independent Enquiry into Midstaffs pg 48. Vol 1) And what of the more-recent mudsling about a baby who had a dummy taped to the mouth? It’s a story now known to be highly questionable, but the mud’s been slung and it has stuck. The media have walked away. Job done.
4. Is Stafford Hospital financially insolvent? Like all small Trusts Midstaffs does indeed have its back to the wall. However, its losses and rate of financial degradation are small compared to its much larger neighbours and broadly comparable to foundation hospitals of comparable size (Bolton, Kettering, Milton Keynes, Peterborough, Sherwood Hospitals) as well as non-foundation hospitals (Burton, Nuneaton and Lichfield). http://www.monitor-nhsft.gov.uk/about-nhs-foundation-trusts/nhs-foundation-trust-performance/actual-performance/risk-ratings . If the Dept. of Health acting through its henchmen wishes to close Midstaffs on financial grounds, so be it. I hope they are brave enough to be candid with the local population. To my mind it makes no sense at all because all the surrounding hospitals are in similar financial jeopardy and none has the capacity to take on Mid staffs workload.
5. Is Stafford underperforming ? After its latest unannounced visit the CQC found the hospital to be performing very well on all standard criteria. The A&E department in particular was found to be meeting all its targets satisfactorily. http://www.cqc.org.uk/directory/rjd01.
The West Midlands Deanery seems quite happy if the JEST surveys are anything to go by. Again, the A&E department, now tagged for closure, has actually received very upbeat reviews from F2 interns.
http://www.westmidlandsdeanery.nhs.uk/FoundationProgramme/FoundationSchools/Staffordshire/TraineeComments.aspx
And even when it comes to lofty work such as Research and Innovation, the hospital has received some recent accolade. ( Prof Wallwork 2010 para 13.3).Given the above, it is clear that downgrading Stafford Hospital is not going to be an easy call. Monitor has labeled it unsustainable on clinical grounds despite positive Deanery and CQC reports. It has also been labeled as ‘financially non-viable’ even though its finances are in a better state than those of many hospitals in the Midlands.
To close such a hospital will only serve to deprive good, decent, local folk of their local hospital, and it will further over-burden adjacent hospitals. It will save nothing but fools’ gold because the neighbouring Trusts have no additional capacity and are already in the red.
But allow me to embrace the new age of candour and think out loud: Perhaps all of this was avoidable. It is possible that if Midstaffs’ management had come out fighting at the outset and rejected the flawed methodology, a more balanced outcome would have prevailed. It seems to me that Management was petrified in case it was seen to be complacent and conniving.
Compare and contrast the robust defence Sir David Nicholson mounted when he felt he was being unfairly attacked. He kicked. The HSJ printed articles in his favour: http://www.hsj.co.uk/opinion/nicholson-does-not-deserve-the-mails-vilification/5055404.article?blocktitle=Opinion&contentID=141
He mobilized his support in the Civil Service and the DoH and it is possible he has prevented his own burning at the stake of pseudo-science by the popular press. In any event, he introduced a degree of balance. Should Midstaffs not have done the same?