The Good,the Bad and the Ugly
These are my conclusions about the report.
The Ugly
The 14 Trusts were failing 10 years ago, failing now and
likely to be failing in 10 years time unless real changes are made.
A number of the trusts, despite prior warning of inspection,
were still unsafe or not properly staffed when Keogh came calling.
If management couldn’t get its act together to sort
everything out before an inspection, when would it? Unless the management changes it is going to
happen again, as soon as the Keogh spotlight has moved on.
The report doesn’t identify management or managing clinicians
as a problem and it should have spelt that out. The problems start at the top
even if they don’t finish there.
The managers get the big rewards, they should pay the price
when things go wrong.
The Bad
Because it was so quick, the report does little except
highlight areas of concern and raise good intentions for the future. These
include;
The need to listen to patients.
Staff morale – every study indicates that low morale or
alienation leads to increased mortality rates for patients.
Inadequate staffing levels – a danger for staff.
Too much reliance on agency staff or a high staff turnover to
fill the gaps and ignoring the problems that forced staff to leave in the first
place. Long service is a sign that people are happy. Happy people make happy
patients.
Not enough consideration given to junior doctors and nurses –
to tap their enthusiasm and idealism.
In short – too many question marks and too few answers.
The Good
As reports go, it was quick and decisive and Keogh identified
the safety problems, taking action quickly.
As he says, after taking emergency action it’s time to debate
what was going wrong and then check up on how the Trusts have acted following
the review.
Plainly, managers need to be losing their jobs if it doesn’t
improve – however much you argue about numbers, people have been dying. From
the tone of the report, it is implied that there will be follow up action.
He wants Junior Doctors and Nurses to be involved far more
than they currently are. The implication is that they are likely to be more up
to date, more modern in their outlook, more committed and more concerned than
their older, worn down colleagues.
He wants hospitals to listen to patients.
It gives every indication that Keogh wants to change things
for the better. Let’s keep an eye out on what happens next.
My say;
For what it’s worth, my view is that there was too much time
spent on whether the mortality figures are helpful or not – it’s a red herring.
Mortality figures have proved to be a very useful indicator of problems, up
till now. Unfortunately managers have realised that and have been massaging the
figures, ‘gaming’ the codes. You can go on expensive courses to learn how to do
it.
However, there are many other indicators and they are all of
value.
Here’s three lists that the report took account of:
In-patient, Cancer survey, PEAT – privacy and dignity,
Complaints about clinical aspects, Ombudsmans Rating, PEAT Environment, PEAT
Food, Friends and Family test, Patient voice comments.
Then they looked at;
Harm incidents, ‘never events’, patient safety incidents,
medical error, MRSA/ C-Diff infection rates, litigation, coroners concerns.
Then they looked at indicators of staff dissatisfaction and
alienation;
Ratio of Nurses to beds, periods of working, vacancies
unfilled, sickness rates, staff leaving rates.
As I found when I was analysing the never events, when you
look at any one indicator it doesn’t obviously have much relation to any other
indicator.
As I also found when I was comparing never events with
mortality rates, a trust can succeed on some indicators, but failing on others
can still be an indication that the trust is failing.
We need to be looking at the widest possible range of
indicators, for patient outcomes, for staff alienation, for clinical excellence
and pro-actively look for areas of concern.
The more indicators the better, the less likely they can be
fixed. Broadly, if hospitals are failing on several indicators, its time to
take a close look at everything else.
And that, I think, is what Keogh’s report is saying.
But;
My big problem is that nowhere is there any mention of
democracy – of democratic control. Once upon a time, we paid the taxes, the
government ran the NHS and was responsible for any failures. When things went
wrong a minister had to resign. Now, Foundation Trusts are independent, the
government is off the hook and we have no control. Neither do the local
authorities, whose elected representatives used to have some influence. It
seems that all we have left is to stand protesting at the hospital gates. Or
Blogging!
You don’t have to be very political – ‘No taxation without
representation’, cuts across left and right. At the very least, we need to take
back control and ownership of our NHS, because we could have done a better job.
Then;
There is no mention of democracy in the workplace.
No mention of the Trades Unions and professional bodies
representing staff – they should have a role.
There’s no breakdown of the workforce and the role that
inequality, prejudice and bullying plays in creating alienation.
As I keep saying;
1) The majority of NHS staff are working class.
2) The majority of NHS staff are women.
3) The majority of NHS staff are from ethnic minorities.
But this report does not discuss equal opportunities and
fairness at work or the climate of fear and division that there is, right now.
Then;
There are managers, often with little or no experience of
running hospitals - ordering clinicians about. Once upon a time, Doctors ran
hospitals, helped by administrators, who ‘administered’. I know which I’d
prefer.
It’s not just Doctors – there are nurses, care assistants and
all kinds of specialists. A hospital is a whole collection of competing
specialisms and interests fighting for scarce resources.
And that’s not even taking account of healthcare outside of
hospital, fighting over the same money.
What Keogh has done is lay down a marker – a brand new start.
He’s opened a debate and we need to
dictate the form that debate takes. Because if we do nothing the agenda will be
set by NHS bureaucrats, hospital managers, a biased press, Big Pharma, private
finance initiative rip-off merchants, and private healthcare.
Then we really will be left standing at the gates.
Neil Harris
(a don’t stop till you drop production)
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