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Not good enough: Mid Staffs was no one's fault, apparently

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I do not work in a hospital. I do not work in Stafford. I’m a GP from elsewhere.

This small city and its local hospital are now at the eye of the hurricane, and the ramifications will be as important as Dr Shipman and the Bristol Children’s heart scandal. It will affect all doctors in the UK.

We have now had five reports on what went wrong at Stafford, including the latest, which is a second bite of the cherry for Robert Francis QC. I have not read the report (three volumes and 290 recommendations), and only know what I know from the prism of what others have read, and the edited extracts I have seen.

There are some early lessons here for those of us working in primary care. The first thing to know is that it is a process that is deeply set in the Establishment. It was requested by the coalition Government (because the events occurred under the previous Labour government), and it had a long opportunity to see it before everyone else did and prepare its response. The terms of reference can be set by those ordering a public inquiry, and they can pick who to do it as well. These are caveats, but important ones.

The overriding sense of the report is that it has gone into the evidence and the analysis of that evidence in great and appropriate detail. Where I feel it becomes less robust is in some of the apportioning of blame, and recommendations for change.

I just want to remind myself of what happened: at least 400 people, and possibly up to 1,200, died in a smallish hospital in the middle of England. People’s mums and dads, their nans, grandads, uncles and aunts. People whose deaths were avoidable or postponable. That is horrific.

Many will look for reasons why this happened, and ask why nobody is being brought to task about this. Some 400 or more deaths and nobody’s fault? Not good enough.

Many should take a share in this disaster. They should include nurses and doctors, managers and directors, supervisors and regulators, policy analysts and journalists, and lobbyists and politicians.

Having worked in the NHS since 1975, I have seen changes come and go, and my judgement is based on nearly 40 years of experience of being at the sharp end of medicine.

The origin of this process lies with Margaret Thatcher and her ministers. It was she who decided to commodify health and try to give it a value - so that it could be changed, using a market.

The development of the internal market in health is the start of the process which ultimately ended with the death of someone’s mum, unnecessarily, in Stafford General Hospital in 2006.

Equally, Mrs Thatcher’s successors continued with the process of marketisation, egged on by lobbyists, think tanks and special advisers. This was a consistent policy down the years, and followed by politician after politician, with civil servants facilitating it,

So, as we have seen the apotheosis of the policy - writ large in Stafford - we must ask ourselves who was responsible for this end result? Who actively promoted these changes down the years, and how many people were asleep at the wheel when all this was going on?

I am not a hospital doctor. I do not work in Stafford. Today, I am ashamed of how the service I joined as a young man has changed so much. And killed so many people.

And, apparently it’s no-one’s fault.

Not good enough.

Readers' comments (6)

  • "And, apparently it’s no-one’s fault.
    Not good enough."

    Hear hear

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  • I agree that the rot started with government interference, but our weak leaders did not help.
    retired GP

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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 even bigger than this fiasco where the authorities also failed to listen to similar concerns raised.

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  • (With apologies to Christopher Marlowe)

    FRANCIS: Thou hast committed -

    EVERYONE RESPONSIBLE: Negligence: but that was in another organisation; And besides, the patients are dead.

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  • Ever thought of sending this blog (including comments) to the newspapers? The Mail wouldn't publish as they are known haters of the NHS but the Mirror? Criticises Mrs Thatcher as the initail catalyst so they may be interested.

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  • I agree the internal market was a key driver but we shouldn't forget that it was Patricia Hewitt who first introduced the requirement for PCTs to live within their budgets in 2006. I believe that was a key factor in Mid Staffs - managers had little choice but to cut front line services to reduce their deficit, and they appear to have had no support from the centre on how to do it without compromising patient care. There are many lessons to be learned but we should be aware that CCGs are still being required to put money before anything else, for example they have to achieve financial balance before they become eligible for the Quality Premium. What message does that send? Personally I think Francis was right to avoid the temptation to blame individuals in his report - this was primarily a failing of the system and finding a few scapegoats would distract attention from that. Which isn't to say that individual cases of neglect shouldn't be pursued and the professionals involved held to account, but this should be through existing processes.

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