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A faulty production line

Mid Staffs and the dangers of medicine by numbers

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How did it happen? The Francis report into the Mid Staffordshire hospital scandal is at best uncomfortable, at worst, horrendous. People died needlessly, because of poor care. Why?

There has been some debate recently about just how useful HSMRs – hospital standardised mortality statistics – really are. But it is clear that the rates at Mid Staffs were higher than expected as far back as 2001.

There are multiple problems in pulling reliable data from existing coding systems. The trust spent time and money investigating mortality statistics, making changes to coding practice, which was thought to have errors which were responsible for the apparently high rates. Eventually, in 2008, the Healthcare Commission launched a full investigation into mortality at Mid Staffs, and a succession of inquiries followed.

But look again. In 2001, the chief executive of South Western Staffordshire PCT warned the hospital leadership was not competent. In January 2002, a clinical governance review recommended urgent action over a range of concerns. In 2003, another review noted inadequate medical and nursing staffing. Junior doctors had been removed from position because of concerns over poor quality training. Staff were ‘utterly demoralised’ and ‘facing a chronic lack of manpower’. The medical director said in his evidence to the inquiry that ‘a quick walk around the wards would have shown…there was cause for concern.’

Evidence-based medicine is in my blood. I like numbers, I like robust proof, I want statistical confidence before I act. But the problem is that no matter what the HSMR had been, the story on the ground remained there to be heard. If patients are left to soil themselves or go unfed, if staff are demoralised and distressed - this is what we should have been hearing. That evidence was there. But who was listening?

People tend to go into medicine or nursing because they have a desire to do something useful. So what happens when the professional culture goes sour? I was thinking about this today when I caught myself worrying about all the contract indicators I was missing. I instantly felt guilt. I was torn between what would tick boxes and what, instead, would be best for my patients.

What would happen if we decided that targets please politicians more than patients? What would happen if we ditched the QOF, and made all our appointments 15 minutes long? What if we collected the data we thought clinically useful, and peer reviewed each other, supporting and helping ourselves and our

What if asked our patients to help us to do what we said we wanted to do in our interview to medical school - deliver our work as a vocation?

As the QOF drives its fingernails under the skin of the consultation, we get further away from centering what we do on patients. We chase targets instead. We look at the computer instead of the patient and faithfully tick boxes. I hate it. We have less time to listen, and less time to hear. This was at least part of the problem in Mid Staffs: numbers mattered more than responsive listening.

The skill of general practitioners is being squeezed out by the demands of the contract. We are being pushed harder to meet tighter targets. But what are we doing? And who is it for?

Readers' comments (21)

  • Mark Struthers

    A very perceptive article! Well done.

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  • Mark Struthers

    Margaret Thatcher once said: "there is no such thing as society, there are only individuals and families". I suspect that this was when the rot set in.

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  • Let common sense prevail

    Another excellent column Dr McCartney. I can hear GP's all round the land saying 'hear,hear!'.
    So what is the next step? How do we ditch QOF whilst retaining those parts of it which are valuable, and the income for delivering the holistic care we desire for our patients?
    Is it time to launch an all out campaign, on the back of the Mid-Staffs furore, stating "We know what is best for our patients - give us the time and resources we need to get on with it". I'm not convinced GPC could make that happen - have the RCGP got the muscle necessary? Perhaps a grassroots protest/campaign might be more effective.

    All ideas welcome!

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  • Scandals like this will happen more often in the future as this government is gagging NHS staff by preventing whistle blowing.

    The worst example of this is the requirement now for doctors to revalidate their licence to practice every 5 years for which they will need appraisals from their employer. Doctors will now be discouraged from highlighting patient safety concerns as they will not want to loose their licence to practice medicine due to an unfavourable employer appraisal.

    With the increasing likelihood of doctors working for cost cutting private sector employers in the future, one shudders to think of the potential dangers to patients if doctors cannot highlight safety concerns for fear of loosing their licence to practice medicine.

    These revalidation requirements and other similar NHS staff gagging measures must be scrapped to prevent future patients deaths and scandals such as this where the authorities also failed to listen to similar concerns raised. I hope that this warning also does not fall on deaf ears.

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  • I have been thinking for some time that the pendulum has swung too far away from professionalism towards mangerialism and control. The Francis Report provides much food for thought, not least around what are the most effective working models for clinical professionals. Is now the time to set GPs free to be the expert generalists they are trained to be?

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  • Mark Struthers

    A doctor, has recently written a remarkable response to the BMJ about the disaster at Stafford.

    The sentiments echo those of Dr McCartney, with some added colour in the language. I've selected the best bits:

    "The fact that this appalling routine mistreatment of inpatients in an NHS needed years of examination of abstract data on death rates before it became a matter of public discussion tells us almost all we need to know about the culture of psychopathic insouciance among some managers and politicians in British hospitals."

    "How have we reached this dreadful state of affairs? The answers are not simple, but I fear they are not to be found in the output of spreadsheets and statistical calculations. At least part of the answer must lie in the culture of corporate management which has been applied to the NHS."

    "Managers spend their time poring over spreadsheets and preparing reports and presentations, when all they need to do is to stand up from their desks and walk into the wards of the institutions for which they are responsible. If they spot a patient who is starving or lying in filthy bedding or a filthy toilet then they should insist that the matter be remedied instantly. We used to have such managers, they were called matrons."

    "We have been robbed of our simple professional moral compass and are being guided by those who have no satisfactory substitute."

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  • Vinci Ho

    I still stick my point : concentrate what the report criticised of DoH.
    Who created this culture of tick boxes?
    Do you really believe politicians care about the health of people more than the health of their political well being?
    This constant interference in the way we practise medicine , whether primary or secondary care , has clearly backfired . In fact , it is logical the compassion of care could gradually fade up because your priority of caring somebody was completely changed . Face it ,managers are toy soldiers of the government(s). Look what happen in this scandal.
    If those with power and leading authority involved in the crisis STILL have some conscience , come out to face those families .........

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  • I can still remember a prominent consultant surgeon rounding up her colleagues and summoned the managers to protest about the state of the HDU

    "We are not going to compromise patient care, and you'll do as we say or we'll all walk out"

    The manager turned as pale as ghost and the Demand was met. Immediately. That was over 10 years ago.

    I can't see any consultant I know now who has the balls or the leadership to do this today. Not the consultant's fault, it's the result of years of deprofessionalizing medicine by the labour/coalition governments.

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  • Mark Struthers

    It's humiliating! GPs have sold their souls, their professionalism, for a blessed crock of QOF.

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  • Mark Struthers

    Dr Smith, former editor of the BMJ, has recently said,

    "Every defect is a treasure in that it provides a way to reform.”

    Sadly, the NHS reforms about to be instituted, will not correct the defects that made Mid Staffs possible; the reforms will make matters worse, much, much worse. We need a different reform. A book that could help generate those caring effects needed to prevent such disasters in future is: 'Intelligent Kindness: Reforming the Culture of Healthcare' by John Ballatt and Penelope Campling.

    “Intelligent Kindness is a powerful new approach to healthcare reform. Ballatt and Campling argue that the NHS is a system that invites society to value and attend to its deepest common interests; it is a vital expression of community and one that can improve if society, patients and staff can reconnect to these deeper values. To do so will improve quality and patient experience, as well as morale, effectiveness, efficiency and value for money.”

    Could kindness heal the NHS? In June 2010, I had some words to say about the matter,

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