Catholic Medical Quarterly Volume 63(4) November 2013

Scandals and inquiries:
Can the NHS spot bad care?

Dr Adrian Treloar FRCP, MRCPsych, MRCGP

Mid Staffs and bad care

2013 has seen the publication of three truly scandalous reports into the NHS . The first was the Francis report into the Mid Staffs NHS Trust [1]. In Mid Staffs, appalling care delivered in the context of a very badly managed trust led to deaths, patients so thirsty that they drank the water from flower vases, and staff who (under pressure from management to reach NHS targets), falsified key performance indicator targets. Although patients and staff knew of and spoke about the difficulties, management hid them, failing to follow through inquiries and falsely reporting excellent quality. The Care Quality Commission (CQC), whose job is to inspect hospitals also failed to spot the difficulties.

Interestingly, Mid Staffs was excellent in terms of implementing quality targets, and in response to a specific quality target for which payment was made to Trusts which “hit the target” Mid Staffs saw 50% of its patients dying on the Liverpool Care Pathway. And yet the stories of poor care, severe dehydration and excess death rates exposed by the Francis report were truly harrowing and shocked the world. But neither Mid Staffs nor the CQC had spotted the problems. Key recommendations of the Francis Report included a duty of candour and specific measures to improve care and compassion.

The Keogh Report

In the wake of the Francis report, Keogh was asked to investigate 14 Trusts which were “outliers” as judged by mortality rates. Keogh [2] found that “these organisations have been trapped in mediocrity”. Keogh used a variety of methodologies but he tells us that “Unconstrained by a rigid set of tick box criteria, the use of patient and staff focus groups was probably the single most powerful aspect of the review process and ensured that a cultural assessment, not just a technical assessment, could be made.” Keogh emphasised that NHS data can be "hard to analyse and understand.” For example he points out that “two different measures of mortality to determine which Trusts to review generated two completely different lists of outlier Trusts”. Also “The reported data did not provide a true picture” with multiple “green” pre-visit indicators not being matched by experience upon the ground during inspections.

But then he also saw clearly “the limited understanding of how important and how simple it can be to genuinely listen to the views of patients and staff and engage them in how to improve services". Most of all the Keogh report pointed out that the difficulties at Mid Staffs are reflected elsewhere in many other NHS Trusts. Indeed the Keogh report was triggered by the Secretary of State for Health and the Prime Minister’s concern that issues were not only relevant in Mid Staffs.

The Neuberger Report into the Liverpool Care Pathway

Finally, following deep public concern, the Neuberger report into the Liverpool Care Pathway was published [3]. Concerns about the LCP were so grave that the report recommended that it be phased out and replaced. It was too often associated with poor or appalling care and the report found that it had been used as an excuse for bad care, dressing up that care as the application of a “model of good practice”.

Neuberger found that “Unsurprisingly, this Review has uncovered issues strongly echoing those raised in the Mid Staffordshire Public Inquiry: notable among the many similar themes arising were a lack of openness and candour among clinical staff; a lack of compassion; a need for improved skills and competencies in caring for the dying; and a need to put the patient, their relatives and carers first, treating them with dignity and respect.”

The LCP will be discussed elsewhere in this journal as indeed will palliative care in the future. But it should be noted that less than a year before the Neuberger Report, twenty two national bodies ranging from the Royal College of Physicians, through key palliative care organisations and right through to the voluntary sector (but not including the CMA or Medical Ethics Alliance) signed up to a consensus statement on the LCP [4]. The Consensus Statement gave the LCP a huge affidavit and (more-or- less) a clean bill of health. It asserted that the LCP was safe, did not shorten life and was an excellent pathway in which all should have confidence. Any concerns about it were seen as being caused by poor clinicians and poor training with the LCP affirmed as being excellent.  And yet, so soon after the consensus statement was published, Neuberger required that the LCP be abandoned because of the shocking stories of its use and misuse. The LCP “can provide a model of good practice” but it is clear that, in the wrong hands, the LCP has been used as "an excuse for poor quality care.”

Linking together the scandals

There are therefore, clear links between these three scandals. In Mid Staffs, the initial response was that the difficulties must be around bad clinicians. And yet it is very hard to believe that clinicians in any one trust are vastly different from others. In truth, the Trust failed to spot the issues, and carried on reporting good quality measures to the NHS regulatory bodies.

And the Keogh Report showed clearly that the inability to spot difficulties affected many Trusts and not just Mid Staffs. With the LCP, vast numbers of national bodies did not see the real issues. And in each scandal it was, first and foremost, patients and carers who drove the outcry.

Failing to spot difficulties

Put simply, the NHS, the Care Quality Commission and multiple National Healthcare Bodies all now have a track record of failing to identify serious problems until patients and carers cause an outcry. So it is not just Mid Staffs that has missed the point, throughout the NHS key national bodies have shown that they too missed the obvious problems of poor care that were associated with the LCP. How can the NHS be so blind?

Quality structures in the NHS

Lord Darzi, in his review of the NHS required the setting up of quality boards and quality assurance systems throughout the NHS. Each trust must have a quality board with boards in each directorate and a focus upon Clinical Effectiveness, Patient Safety and Patient Experience. These are laudable aims indeed, but in the modern NHS all of this is monitored and key targets must be “green”. CQuIn (Commissioning for Quality and Innovation) targets enable quality initiatives to produce real change in the NHS by linking payment to the achievement of targets. With  the intention (and effect ) of promoting the LCP, CQuIn payments required Trusts to assure that over 30% of patients who died were on the LCP. Mid Staffs managed this as did many others, but we all know how targets can corrupt care. Little wonder that financial incentives to ensure that people die on a “Death Pathway” were so toxic in the National Press. As well as CQuIn targets and QuIP (Quality Improvement Programme) targets there are other dire penalties for failing to report good quality care.

Monitor (the regulatory body for Foundation Trusts) can and will also deduct income for poor quality. The Care Quality Commission has stringent penalties that can be applied to Trusts that provide poor care. The legion of quality measures are closely linked to Trust performance and Trust pay. To  fail  a CQC inspection every  bit as damaging to  the organisation as a failed Ofsted is to  British  Schools. Trusts are therefore required to report excellent performance on measures of quality

Reporting quality

However all of these measures of quality can be misused and toxic. If payment is linked to the reporting of good quality, Trusts will move mountains to ensure that they report green targets. In Mid staffs (and doubtless elsewhere) staff lied so that measures were reported a green [5]. And underneath a sea of targets reported as “green”, dreadful care happens and scandalises more now than ever before. And national bodies, seeing the need to defend a pathway that was associated with bad care and whose use could cause death [4], felt obliged to rush to defend it while finding themselves unable to see the gravity of problems associated with it.

A Catholic response

We must ensure that Health Care sees the unique worth of all individuals for whom it cares. Care which affirms the dignity and worth of each individual is essential and that care must be excellent, safe, skilled and well delivered. Catholics should be in the vanguard of leading excellent and honest health care. Learning as we all must from the grievous failures of good governance within our Church, we must re- emphasise the fundamental principles of honesty, openness and diligence in care.

We must never cover up, and must be open and willing to seeing our human failings and weaknesses as well as celebrating the huge successes we have in delivering the care we do in challenging circumstances. The same must be required of the NHS.

So the Church has a real lesson to teach the NHS. Truth, open honesty and willingness to be audited, investigated and held to account is essential if the NHS (or the Church) is to be truly respected by the world at large. Even more importantly, if we fail to be open, honest and self critical, we betray our patients by providing bad care. That honesty must be based upon listening to patients and carers and a willingness to see when things are not as they should be. 

There is much to do. The principles of quality assurance in the NHS are centrally important. But at the present time there is real cause to worry that the NHS is structured in such a way that incentivises the inability to spot serious quality failings. Many will worry that the current system encourages dishonesty.

Listening to patients and carers, reinforced by a willingness to truly reflect and learn from quality concerns are central to safe and effective care . As Keogh says, it is simple to genuinely listen to the views of patients and staff.