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Mid Staffs and the dangers of medicine by numbers



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
colleagues?

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?