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Six Lessons for CCGs from Mid Staffs

Recommendations from the Mid Staffs public inquiry will be published later this year, but the counsel's summing up last month already provides fundamental lessons for CCGs

Mid Staffordshire NHS Trust hit the headlines in 2009 when the Healthcare Commission reported that more than 400 patients had died ‘needlessly' at Stafford Hospital.

Although the trust was monitored by a PCT, SHA and patient safety agencies, none had picked up the shocking catalogue of failures cited in the report.

Perhaps the most important lesson from Mid Staffs, however, came in the public inquiry summing-up last month, where counsel Tom Kark QC concluded Mid Staffs was not an isolated case: ‘The Department of Health failed in the period 2005-09 to secure sufficiently universal implementation of the principles of clinical governance in the NHS.

‘This was demonstrated most starkly in the case of Mid Staffs, but reports produced in 2008 for the purposes of Lord Darzi's review demonstrate that key features of the trust's failure were replicated to a significant degree across the NHS. The tendency within the DH to view Mid Staffs as an isolated example is dangerous.'

1. Track complaints

What went wrong at Mid Staffs

The complaints process at the trust failed to value and use complaints and to treat complainants with the respect they deserved.

What Mr Kark QC said

‘Complaints must be embraced by trusts (and supervisory bodies) as a valuable source of feedback and investigated quickly, efficiently and objectively.'

Dr Mike Dixon (MD), NHS Alliance chair  Commissioners must see all complaints – and the answers to them. And we must remember that GP commissioners will be clinical commissioners, rather than admin people, and will be better able to understand their implications.

Dr Jocelyn Cornwell (JC), King's Fund, Point of Care director CCGs do need to know about complaints made to trusts, but I'm not sure if they can take the place of SHAs in this respect. Some acute trusts get hundreds of complaints every year. Providers should be responsible for handling complaints and they must do it well, but CCGs will need to have a decent grasp of what patients are complaining about and what's being done about it.

Jeremy Taylor (JT), National Voice's CEO My view is love all feedback. You've got to learn from the good stuff, too. When you make it easy for people to give feedback, you get positive as well as negative.

2. Patient engagement is about more than creating a patient group

What went wrong at Mid Staffs

The predecessor PCT and South Staffordshire PCT (SSPCT) failed to engage the public in a discussion on the quality of services prior to 2008. The patient forum's members were not able to understand the trust's complexities, and the inquiry found little evidence of a concerted attempt to find out about patients' experiences.

What Mr Kark QC said

‘The clear lesson is that public and patient involvement in the affairs of a body such as the trust is unlikely to be ensured merely by forming a committee of members of the public who have occasionally been patients.'

JT The culture we have surrounding collecting feedback is a ‘research' culture. It tends to mean a lot of effort and then it's entirely unclear what happens as a consequence.

The approach instead should be much more about the ‘customer' relationship. Ask small questions often – and then do something about it.

MD Since community health councils went, we haven't really had proper public engagement. Clinical commissioning offers the possibility of much more granular local involvement and should ensure that individual patient experience gets a look-in.

The second element will be practice patient participation groups, which nearly half the practices in the country already have.

Elizabeth Wade (EW), NHS Confederation's head of commissioning policy and membership This absolutely has to be at the core – patients' experiences and the way they feed back into commissioning are very important.

3. Stats matter

What went wrong at Mid Staffs

The trust failed to understand mortality statistics.

It latched onto the most convenient explanation for its high hospital standard mortality ratio (HSMR) in 2007, without proper consideration of the underlying quality of care, and promulgated it in a misleading way to a number of outside organisations that accepted the trust's analysis without rigorous scrutiny. 

What Mr Kark QC said

‘A system of trusted, routine, quality measures and information flow that ensures commissioners are able to assess the standard of service they are commissioning, without having to rely on voluntary disclosure, is required... The chair [of the public inquiry] may wish to consider whether recommendations can ensure the embedding of a mindset that treats the risk of such indicators being right as more significant than the risk they might be wrong.'

MD The statistics were there all along, but people just accepted the explanations they were given. The difference now will be that with GPs as commissioners, they will use all the information – not ignore it.

JC The idea of voluntary disclosure is just ridiculous when you are looking after people. The flow of statistics needs to be regular and not just once a year. There is a lot of information around that needs to be better analysed, and there has been a lack of analytical expertise in the NHS.

Our research into trusts showed the annual national patient survey wasn't enough. Trusts might use patient experience trackers in A&E or maternity, but not everywhere or systematically. We concluded they needed more manpower to do it right.

JT You need good data. People ask what we can learn from Tesco or John Lewis – they're good at understanding customers. CCGs need to segment their market to a very fine level of detail and then use that data.

4. Connect with hospital clinicians

What went wrong at Mid Staffs

Clinical engagement from consultants with management at the trust was extremely poor.

A vicious circle of marginalisation from decision making and withdrawal from engagement created an environment in which it was easier for the interests of clinical care to be ignored and in which positive efforts to implant effective clinical governance fell on stony ground.

What Mr Kark QC said

‘Clinical engagement between commissioners and acute trusts should be enhanced, so that there can be a better flow of information between clinicians and problems can be aired and solved together.'

JT Clinicians and managers have to work together. Polarisation is dangerous. Clinicians have to take an interest in management and management have to take an interest in the quality of care.

MD This was very dangerous. Neither side should have been prepared to play that game.

It's also important for clinicians within a hospital to have a connection with clinicians outside it – not just locally, so there can't be collusion within a trust.

5. Connect your GPs with quality – even if they are not engaged in commissioning

What went wrong at Mid Staffs

SSPCT's emphasis on PBC to provide clinical engagement between GPs and the trust and a strong basis for commissioning for quality did not work.

The trust's clinicians failed to communicate problems to GPs, and despite having their own concerns GPs failed to pass them on to the PCT. 

What Mr Kark QC said

‘There must be a reliable means of capturing GPs' concerns and the concerns of their patients. There is a danger that as commissioning groups get smaller, the

co-ordination of such information is lost. This must be avoided. Do not assume others will act on poor-quality care at the acute trust.'

JC This is very important. My own GP might not be directly involved in the CCG, but through her daily contacts with patients she builds up a lot of knowledge about providers.

It ought to be up to CCGs to glean that knowledge. That's part of the value of having GPs doing the commissioning.

EW GP intelligence from patients is a useful source. But it needs some real thought to make it work. We should not put too much onus on the individual practice. Even a large practice doesn't have a lot of patients seeing the same consultant and feeding back.

MD GPs' concerns didn't get related to PCTs because they were, effectively, foreign bodies. Hopefully, within a CCG there will be real joint responsibility. I think we need to reinstate something like the old yellow-card system so someone can collate all the individual issues that arise.

JT The views of GPs ought to be the low-hanging fruit in all this. The theory of CCGs is that GPs will feel more ownership. But will they engage?

6. Actively monitor providers

What went wrong at Mid Staffs

SSPCT and NHS West Midlands failed to detect the poor quality of care provided by the trust because their monitoring of it was limited to little more than an assessment of compliance with financial and activity targets.

There were a number of earlier indicators – such as the patient and staff surveys, the review of children's services in 2006 and the review of medicines management in 2006 – which might, if given sufficient consideration, have triggered concerns earlier than those upon which the Healthcare Commission acted.

Despite the fact that three acute trusts in Staffordshire were among the top 10 with the highest HSMR in the country in April 2007, a number of outside organisations accepted the trust's explanation without rigorous scrutiny.

NHS West Midlands investigated care at the trusts with high HSMRs in April 2007. But having met trust executives and received documents from them essentially refuting the connection between their high HSMR and quality of the care, the SHA chose to commission an academic response to Dr Foster's statistical methodology instead of scrutinising the trusts.

What Mr Kark QC said

‘Clarity about which organisation is responsible for monitoring and ensuring acceptable levels of safety and quality, as well as who will act when an organisation is failing, is necessary.

‘Duplication of effort and regulatory burden must be avoided. Regulators should share information and co-ordinate their actions. Commissioners must now be given the guidance, tools and data to be able to play their part in improving standards.'

JT This is all about the transparency agenda. The more transparency, the more likely someone will spot any problems. There are two components: whose job it is to raise concerns, and whose job it is to do something about it.

They're both important. Everyone should feel they can raise concerns. One of the imponderables of Mid Staffs is that there were a lot of fail-safes – but they all failed.

The more we move to a transparent system where we can see data, the less we'll have to rely on trusts' assurances.

MD In general practice, we talk about the ‘collusion of anonymity' where everyone's involved but no one does anything.

If it's clear that commissioners have to take responsibility for monitoring then they will, but this still needs to be clarified as there are all these other bodies – Monitor and NICE, for example – involved.

The crucial thing here is that GPs are actually empowered. Nobody in Mid Staffs felt responsible or empowered. That was the fundamental cultural problem.

If GP commissioners can get the right information and find out the common themes, disasters can be avoided. But we may need an ally in that. Monitor needs to ensure that foundation trusts are listening.

Clinicians are trained in critical appraisal and are fairly independent thinkers. They won't get taken in by corporate lines.

EW It's not going to be entirely clear – particularly with a large trust (who will monitor acute providers) – with numerous different local commissioners and the NHS Commissioning Board. The commissioners will have to work it out between themselves.