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Mid Stafford Hospital report

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Mid Stafford Hospital report

Post by blueturando on Thu Feb 07, 2013 4:07 pm

The 1,700 page report has been released into the serious lack of care & compassion at Stafford Hospital that resulted on 1,200 premeture or unnecessary deaths between 2005 and 2008.

My questions is......Why has no one been sacked or prosecuted over these deaths?

My other query is......I would expected a big expose on cutting edge on this issue from the likes of Skywalker or Ivan as they usually do on such matters of importance, in particular the NHS. An expose out lining where the blame lies and what should be done to stop this happening again......... but the silence is deafening......Not a single mention, not even a faint whisper
My conclusion (which I knew already) is that the 'Left' has no concerns for the people/general public, only for political power. Subject are only worth discussion when there is an opportunity to slander the Tories, but as this was on Labours watch then the subjust and all those unfortunate people and grieving families must be ignored.

My hope is that the less militant posters on here will recognise the hypocrisy and total lack of 'giving a sh*t' from the left and realise that all Labour and their supporters desire is power and the people of this country will always come a distant 2nd to that need.

I await the lack of serious response to this charge

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Re: Mid Stafford Hospital report

Post by Ivan on Thu Feb 07, 2013 5:24 pm

blueturando. I’m disgusted that you seek to use what is a tragedy and a scandal as a weapon with which to attack the staff of Cutting Edge. You’ve been told before to put any complaints in PMs – is that so hard to grasp?

Unlike you, some of us have other things to do than just post messages when we come to Cutting Edge. Our security concerns are heightened at present because a maniac who stalked me across the internet for six months in 2011 has surfaced again, someone has been posting rumours that Cutting Edge has closed down, and one or maybe two members have been impersonated. Furthermore, an attempt has been made to hack into my computer and my e-account has been flooded with filth. That’s why I haven’t been very prominent this week.

As to Stafford Hospital, what do you want us to say? “It’s all Labour’s fault”? Just like it was all Labour’s fault when Lehman Brothers collapsed and when it snowed last week? Labour trebled spending on the NHS, brought back matrons to hospital wards and gave us 85,000 more nurses and 32,000 more doctors. Clearly that wasn’t good enough for at least one of the hundreds of hospitals in the country. Politicians can trot out the usual platitudes about “lessons being learned” and “we must ensure this never happens again”, but we all know that in a country of 63 million people we can never guarantee that things won’t go awry.

Between 400 and 1,200 extra deaths are thought to have occurred at Stafford Hospital. It didn’t definitely result in 1,200 extra deaths, but trust you to quote the maximum figure as a cast-iron fact. If you want to politicise the Stafford scandal, perhaps you can tell us how the Tories reducing the number of nurses in the NHS by 7,000 will help to prevent anything from like this happening again?

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Re: Mid Stafford Hospital report

Post by oftenwrong on Thu Feb 07, 2013 5:25 pm

Does anyone else believe that supporting Tory dogma can best be achieved by constant reference to the Opposition?
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Re: Mid Stafford Hospital report

Post by boatlady on Thu Feb 07, 2013 7:49 pm

I'm still waiting for a convincing argument in favour of right wing political ideas.

Meanwhile ---
In re the recent hospital scandal, surely the neglect and abuse of patients was carried out by hospital staff and not in fact by the ministers of any government?

I've never held to the view that government ministers should be held responsible for failures of individual workers in the public sector - only for ministerial decisions which starve public sector organisations of the resources to do a proper job (e.g. HMRC, currently woefully understaffed as a result of the absurd 'austerity' measures put in place by this government).

I haven't yet read the report on Mid Staffordshire, but, having worked in hospitals and other care based settings, I am aware that staff morale is vital to good outcomes for service users, and staff morale is affected by a very complex range of factors, which can include the impact of misguided government policy, but can also include the impact of really very reasonable government policy that has been incompetently presented by a management team not in tune with the concerns of the workforce.

Working practices that are unprofessional can remain unchallenged in an environment where individuals are working in roles that exceed their competence, working long hours, working without appropriate equipment and guidelines, and most importantly, working without adequate and effective supervision.

Within a particular establishment staffing and supervision practices may need review, and we may want to deplore the growing (since the '80's) practice of using unskilled and unqualified staff for hands-on care, while pulling back skilled experienced and qualified staff to management and supervisory posts for which they may lack the aptitude or skills. The way this breaking down of the work is managed has a significant impact on the quality of the eventual service outcomes. Individual managers may or may not have been helpful to the process; management structures may or may not have been fit for purpose. It would be difficult, if not impossible to ascribe responsibility to any individual for the structural factors within the hospital that have contributed to a bad outcome; however, lessons can be learned, structures can be changed, things can be done differently in future.

I share your frustration Blue - many people have died and suffered because inappropriate, dangerous and uncompassionate care was allowed to become the norm - however, unless there are clear grounds to ascribe responsibility to an individual for a particular crime of omission or commission, in which case that individual ought of course to be disciplined and possibly prosecuted, I fail to see what benefit a few random sackings will have. The process of the enquiry will have been punishing in the extreme, and the lessons learned will not easliy be forgotten by those involved.

If you cast your mind back to the Nuremburg Trials, I think I'm right in saying that was the approach taken to the arguably much worse actions of the Nazi regime - the appropriate punishment only when a crime could be proved to have taken place.
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Thu Feb 07, 2013 9:26 pm

I've been given a copy of the official parliamentary summary - not the full report as it's in 4 volumes and weighs a ton, apparently. Even the summary is half an inch thick.

When I've had chance to work my way through it, I'll post some thoughts.
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Re: Mid Stafford Hospital report

Post by oftenwrong on Thu Feb 07, 2013 10:23 pm

Management bullying manifests itself in all sorts of employment situations, and arises from people being concerned to keep their own particular jobs. Whether the pressure is applied from Government or from shareholders is somewhat academic.
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Re: Mid Stafford Hospital report

Post by blueturando on Thu Feb 07, 2013 10:58 pm

blueturando. I’m disgusted that you seek to use what is a tragedy and a scandal as a weapon with which to attack the staff of Cutting Edge. You’ve been told before to put any complaints in PMs – is that so hard to grasp?

Ivan.....I do not have a complaint, i made an interesting observation. The health board on cutting edge is littered with hyped up semi-truths, semi-lies about the tories and the NHS...Almost to frenzied levels, so given the level of worry from many posters on here on the NHS I was a little surprised that there was no mention at all on this tragedy.


I am NOT attacking Cutting Edge staff, I am attacking the hypocrisy of the LEFT....and as this is a left inclined forum headed by you and others like Skywalker, I was surprised neither of you had any thoughts on this tragedy....until I realised that maybe this was because the tragedy was not another stick you could bash the Tories with, so the issue is 'irrelevent' and not worthy of discussion here. So if I have a complaint its against the motives of the LEFT and not on a personal level

Does anyone else believe that supporting Tory dogma can best be achieved by constant reference to the Opposition?.

OW....Most Labour supporters only ever make references to the opposition. Please see 9 out of 10 threads on cutting edge for evidence

In re the recent hospital scandal, surely the neglect and abuse of patients was carried out by hospital staff and not in fact by the ministers of any government?

Agreed Boatlady....and that's why I haven't pointed any fingers at the last Labour government on this, but I have asked why no one has been called to account for the failings at Stafford. That would be staff members, hospital managers and the head of the Hospital Trust at the time. I am sure that amonst a report that is 1700 pages long there can be clearly defined examples of individual failure, neglect and incompetence


Skywalker....I look forward to your thoughts when you have the chance to wade through the documents. I am always impressed by the way you tackle issues in such detail

Lastly....Ivan, I am not apportioning blame to any particular politician or party for this tragedy, but I think this is a subject worthy of serious discussion because I am sure that Stafford hospital is not an isolated case and I fear similar failings have...and are still happening in some hospitals. Believe it or not most Tories love the NHS and I have been lucky enough to receive excellent care in the past...My concerns are genuine

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Re: Mid Stafford Hospital report

Post by blueturando on Thu Feb 07, 2013 11:04 pm

Unlike you, some of us have other things to do than just post messages when we come to Cutting Edge. Our security concerns are heightened at present because a maniac who stalked me across the internet for six months in 2011 has surfaced again, someone has been posting rumours that Cutting Edge has closed down, and one or maybe two members have been impersonated. Furthermore, an attempt has been made to hack into my computer and my e-account has been flooded with filth. That’s why I haven’t been very prominent this week.

I am sorry to hear this Ivan and I genuinely hope you can flush out and get rid of this 'nutter'. My first thoughts were Brownboots...just a gut instinct

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Re: Mid Stafford Hospital report

Post by astradt1 on Thu Feb 07, 2013 11:17 pm

As some one who still works in healthcare, all be it in a private care home, I have seen how PCT and CQC inspections are carried out and what the result of their 'findings' are.......

Inspectors come in and look at records..in detail and pick up on what is not written down, they very rarely speak to patients or relatives, but as a result it usually ends up in yet another set of paperwork to be completed by staff, I will not say nursing staff, as normal practice within the unit I work on it is one nurse on duty working a 13 hour shift looking after 13 patients with dementia, supported by anywhere between two and four care staff....

The nurses are under constant pressure to be aware of everything that is going on and at the same time ensure that every part of care is carried out...

The current prime minister has said that he wants nurse to hourly ward rounds, check on each patient this is all well and good but can you imagine how that would be carried out with the unit I work on?...

Each patient, would in theory get just under 5 minutes of 1 to 1 time per hour but that excludes other routine jobs such has medicine rounds, where it can take more than 10 minutes to get just one patient to take their medicine and then there are dressings..etc

It is all to easy to blame ward staff for failing to care and I agree that what happened at Stafford should never happen but nursing has become a paper based activity, you know that RED TAPE which this government has said it will cut but no red tape in health care is a growing business...Our care plans have 18 sections per patient and there is a requirement to write something in each section everyday........ on each 13 patients.

I like to think I care, I like to think I work hard and to do the my very best for the patients I look after and I have always done so during my nearly 40 years of nursing...But I find it harder at the end of each shift to believe I have been totally successful....
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Re: Mid Stafford Hospital report

Post by oftenwrong on Thu Feb 07, 2013 11:28 pm

"Inspectors come in and look at records..in detail and pick up on what is not written down, they very rarely speak to patients or relatives, but as a result it usually ends up in yet another set of paperwork"

Inevitably, because paperwork is what audit teams and Inspectors understand, and actual conversation with workers might reveal their ignorance of the specific task.
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Thu Feb 07, 2013 11:54 pm

blueturando wrote:I was surprised neither of you had any thoughts on this tragedy....until I realised that maybe this was because the tragedy was not another stick you could bash the Tories with, so the issue is 'irrelevent' and not worthy of discussion here. So if I have a complaint its against the motives of the LEFT and not on a personal level

The matter puzzling most of the MPs I talked to yesterday was why Hunt was so circumspect in his speech on the matter, when he could have used it as a club to beat Labour. I think it's fairly straightforward - he's aware that there are another 5 or 6 hospitals whose CQC assessments since the coalition took over show even worse indicators than those which led to the exposure of Mid Staffs. And for the same reasons: chronic understaffing and craven management. If he's too belligerent on the issue now, he knows he's only making a rod for the Tories' own backs, and given the time these inquiries take, probably just in time for the next General Election.

Incidentally, all the MPs I talked to were horrified that 'it happened on Labour's watch', so nobody is taking it lightly. But under Labour it happened at one Trust. Under the coalition, it threatens to happen in several - and saying that Trusts must ensure patient welfare at all costs is meaningless unless you're prepared to pay what it costs, which the government is plainly not.

Skywalker....I look forward to your thoughts when you have the chance to wade through the documents. I am always impressed by the way you tackle issues in such detail

Thank you. I have strong opinions, but I believe if you want to convince others, you have to be prepared to put in the effort to support your arguments and conclusions.
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Re: Mid Stafford Hospital report

Post by tlttf on Fri Feb 08, 2013 6:30 am

Part of the problem is the CEO of the health trust is employed for his/her economic skills and has no understanding of the clinical requirements needed. Perhaps if one of the top people had to defend themselves in a court of law, the future would look brighter for the patients.

I agree with both blue and Steve on this, in as far as no minister (irrespective of the lib/socialist party is in control) would know as all he/she would see is a report handed to them by the inspectors.

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Re: Mid Stafford Hospital report

Post by oftenwrong on Fri Feb 08, 2013 11:21 am

blueturando wrote: ....

OW....Most Labour supporters only ever make references to the opposition. Please see 9 out of 10 threads on cutting edge for evidence ....

I'm not sure whether that sentence conveys what you intended. However, the obvious difference between "The Government" and "The Opposition" is that only Government can make changes in the Law. Opposition's only power is to comment, so supporters of the opposition are never going to have much to say beyond agreeing or disagreeing with those comments.
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Fri Feb 08, 2013 11:32 am

astradt1 wrote:I like to think I care, I like to think I work hard and to do the my very best for the patients I look after and I have always done so during my nearly 40 years of nursing...But I find it harder at the end of each shift to believe I have been totally successful....

I hear exactly the same kind of comments from my wife. The system is set up wrongly, with it being more about what you can prove you did (even if you didn't) from the written record than about actually providing the best care - perverse incentives and CYA. Making nursing a degree-based profession hasn't helped in this regard, even though I understand the RCN's motives in pushing for it, to enhance the standing of nurses - in many ways it's done the opposite, by letting loose nurses with more 'book-smarts' than practical intelligence. My wife qualified in the old days, attending nursing school and spending most of her time on wards, and she's a natural - always bringing home cards from grateful patients and families, but I doubt she'd qualify for the degree course these days.

It seems like the real training in 'proper' nursing now starts when a newly-qualified nurse arrives on a ward - but some arrive who really aren't cut out for it and are expecting to sit at a desk while the health-care assistants do the dirty work and the patient interaction, while others who'd make natural, vocational nurses fail to get onto the course in the first place because of a lack of good exam grades. Of course you have to have certain knowledge and competencies to nurse well, but those aren't enough or even the most important thing.

There's no easy solution, because 'you wouldn't want to start from here', but here's where we are - I think the first step would be to re-work the nursing degree so that at least 50% is ward-based and grades are achieved on practical competence and compassion, not just theoretical learning.

All that said, I think 'angels' still predominate in nursing - but it's seen as too much of a career now rather than a vocation, and that attracts some of the wrong sort of people to it.
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Re: Mid Stafford Hospital report

Post by oftenwrong on Fri Feb 08, 2013 11:57 am

The Peter Principle is a belief that, in an organization where promotion is based on achievement, success, and merit, that organization's members will eventually be promoted beyond their level of ability. The principle is commonly phrased, "Employees tend to rise to their level of incompetence." In more formal parlance, the effect could be stated as: employees tend to be given more authority until they cannot continue to work competently. It was formulated by Laurence J. Peter and Raymond Hull in their 1969 book The Peter Principle, a humorous treatise, which also introduced the "salutary science of hierarchiology".

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Re: Mid Stafford Hospital report

Post by skwalker1964 on Fri Feb 08, 2013 12:00 pm

oftenwrong wrote:The Peter Principle is a belief that, in an organization where promotion is based on achievement, success, and merit, that organization's members will eventually be promoted beyond their level of ability. The principle is commonly phrased, "Employees tend to rise to their level of incompetence." In more formal parlance, the effect could be stated as: employees tend to be given more authority until they cannot continue to work competently. It was formulated by Laurence J. Peter and Raymond Hull in their 1969 book The Peter Principle, a humorous treatise, which also introduced the "salutary science of hierarchiology".

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Oh, the number of times I've seen this in action! It's why I've always resisted promotion, preferring (hopefully) to enjoy being very good at what I'm very good at.
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Re: Mid Stafford Hospital report

Post by boatlady on Fri Feb 08, 2013 3:39 pm

Of course, in a profession like nursing, often you have to take the promotion to maintain a decent standard of living
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Mid Staffs: why Cameron was circumspect and we should worry

Post by skwalker1964 on Sun Feb 10, 2013 12:07 am

As promised, a preliminary analysis of the Francis report. Original including links at: [You must be registered and logged in to see this link.]

Mid Staffs: why Cameron was circumspect and we should worry

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I had the privilege of spending a couple of evenings in Parliament this week, including Wednesday evening, after David Cameron’s announcement – and apology – on the ‘Francis Report’ into the disastrous failings at Mid Staffs NHS Trust.

The question a number were asking was: ‘Why didn’t Cameron go for the throat?’ There was, rightly, a sense of dismay on the part of Labour MPs that Mid Staffs ‘happened on our watch’ – but there was also a puzzlement about the apparent humility of Mr Cameron’s speech.

David Cameron and his government are not exactly strangers to finger-pointing, or to attempts to use past events to undermine their opponents. Even when it’s completely unfounded and they supported the measures that led to it, they’ve shown neither shame nor hesitation about using something to hammer the Labour party in the eyes of voters. The constant ‘inherited mess’ accusation that is trotted out routinely in every interview or Prime Minister’s Questions is the classic case in point.

And yet, presented with a genuine opportunity to attack Labour, Mr Cameron chose the opposite tack. First, he acknowledged that Labour had already apologised for what happened:

The previous Government commissioned the first report from Robert Francis. When he saw that report, the former Secretary of State—now the shadow Health Secretary, the right hon. Member for Leigh (Andy Burnham)—was right to apologise for what went wrong.

Then he went on to add his own and his government’s:

I would like to go further as Prime Minister and apologise to the families of all those who have suffered for the way the system allowed this horrific abuse to go unchecked and unchallenged for so long. On behalf of the Government—and, indeed, our country—I am truly sorry.

But not a word of attack on Labour. I have no reason to doubt that the Prime Minister’s regret about deaths at Mid Staffs was genuine – but the lack of attack was out of character in a way that goes beyond mere political astuteness dictating that it wasn’t the right moment for an attack. There were other reasons that he chose the approach he did – reasons that should worry anyone who truly cares about the NHS.

I believe Robert Francis’ introductory letter to the Health Secretary as part of his report holds part of the key to the Prime Minister’s stance – and some elements of this letter were touched on in Mr Cameron’s own speech. These key phrases and passages were written about Mid Staffs and its board in particular – but they apply equally or even more to this government’s policies and actions on the NHS as a whole.

Mr Francis’ letter highlights the following causes for the Mid Staffs disaster which could equally be describing the failings of the government toward the NHS:

- Failure to listen to patients and staff
- A culture of denying negative information while embracing the positive
- Disruptive re-organisations damaging ‘corporate memory and focus’
- An over-emphasis on numbers and finance
- A lack of openness, transparency and candour

Failure to listen

This was primarily caused by a serious failure on the part of a provider Trust board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention.

Just like the Mid Staff’s board, the government has consistently failed to listen to key people if they were not saying what it wanted to hear. From its very inception, the government’s Health and Social Care Act was vehemently opposed by almost every body of health professionals. Yet it pressed ahead regardless – clearly following another, less public agenda.

The RCN and unions have repeatedly called the government’s attention to the increasing pressures on staff caused by short-staffing, and the risks to patients that it presents – yet nurse numbers have consistently reduced over the course of this government, with over 7,000 nurses lost.

Most recently, the people of Lewisham have protested vigorously against the downgrading of their local hospital because of problems at a completely separate Trust. Local clinicians agreed that the facilities were vital to the wellbeing of the people they served. The government’s response? Find other clinicians to agree with its plans and plough ahead regardless, even though there are more than enough funds to solve South London Health Trust’s problems many times over without any need to touch Lewisham’s services. Again, there’s clearly another agenda the government finds more compelling than the wishes of patients and clinicians.

Denying the negative

An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern.

Let’s take the RCN example above. Over 7,000 fewer nurses and counting, while the professional body of those on the front-line regularly call attention to the problems this causes. Yet, when challenged on the matter in the Commons, the government uses weasel words to avoid conceding the point. Look at this exchange between Ed Miliband and David Cameron from PMQs in November last year:

EM: First of all, there are 7,000 fewer nurses in the NHS than when the Prime Minister came to power, according to the figures published this morning..the president of the Royal College of Ophthalmologists said recently..“Half of health commissioners are restricting access to cataract surgery..Can the Prime Minister tell me why, for the first time in six years, the number of cataract operations actually fell last year?

DC: What I can tell the right hon. Gentleman is that, under this Government, the number of doctors is up, the number of operations is up, waiting lists are down and waiting times are down.

Confronted by uncomfortable facts, Mr Cameron chose not to address the issues raised, but to cherry-pick a couple of points on which he could say something positive. And even those were wrong – in September 2012, the number of people on NHS waiting lists was the highest since 2008.

Disruptive reorganisations damaging ‘corporate memory & focus’

A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation.

‘Corporate’ here doesn’t mean to do with businesses, but the collective memory, experience and expertise of a hospital or the NHS as a whole – which means that lessons learned in one part, or in one period, can be of benefit in another. Robert Francis found that this applied to Mid Staffs. But the government’s own risk assessment – which it fought hard to avoid releasing and only disclosed in a redacted form – said that the introduction of the Health and Social Care Act would lead to fragmentation and loss of clarity.

Yet it was forced through anyway, in complete disregard of its own warnings. The process of allowing ‘any qualified provider’ to bid for NHS service provision inevitably leads to greater and greater fragmentation of the NHS – and this fragmentation will cost lives because of the lost collective memory, and the inherently less efficient communication among disparate organisations. But there’s profit in it, and that’s apparently enough justification for the Tory-led coalition. Which leads us to the next failing highlighted by Francis’ introductory letter.

Over-emphasis on numbers and finance

This failure was in part the consequence of.. a focus on reaching national access targets, achieving financial balance and seeking foundation trust status

The Nicholson Challenge, which requires ‘efficiency savings’ of £20 billion by 2015, and a total of £50 billion by 2020, is driving the approach and decisions of both the Department of Health and NHS executives. This imperative to cut cost leads to:

- closure of Accident & Emergency departments in spite of the known risks of delay in receiving urgent treatment during the ‘golden hour’ (a term emphasising the importance of high-quality intervention as soon as possible after trauma).
- reductions in staffing, in spite of the risk to patients and the strain on remaining staff
- widespread rationing of treatments such as cataract and joint replacement operations

and many other consequences which cannot in any way be said to be in the best interests of patients.

As Mr Francis points out, as well as financial goals and national targets, one of the key things which distracted the management of Mid Staffs from its primary task of providing high-quality healthcare was the push to achieve ‘foundation trust’ status – semi-autonomy from the national structures governing ordinary NHS trusts. The Health & Social Care Act 2012, which the Tories forced through Parliament last March in spite of massive opposition from professionals, public and Labour politicians, requires every NHS Trust to achieve foundation status by no later than April 2014. There is no realistic doubt that this imperative has been distracting the executives and managers of other Trusts since the Act became law.

Lack of openness, transparency and candour

The essential aims of what I have suggested [include]:.. Ensure openness, transparency and candour throughout the system about matters of concern.

We’ve already seen above how the government routinely avoids admitting any problems or giving a direct answer to questions about areas of concern raised in the Commons (or the media). But it goes much further – if any of Mr Francis’ conclusions about the failures at Mid Staffs captures perfectly the government’s behaviour on the NHS, it’s this one. We’ve seen how, challenged on reductions in nurse numbers, the Prime Minister and his ministers will answer about increases in numbers of midwives or doctors, and how challenges about patient care are met with misrepresentations of waiting list times and numbers. Here are more:

Real-terms spending on the NHS has increased across the country
(Health Secretary Jeremy Hunt, House of Commons 23/10/2012)

On the basis of these figures, we would conclude that expenditure on the NHS in real terms was lower in 2011-12 than it was in 2009-10.
(Andrew Dilnot, Head of the UK Statistics Authority)

or

It will improve the quality of care the NHS delivers while making up to £20billion of efficiency savings by 2014-15, which will be reinvested in frontline care.
(Department of Health website, QIPP section)

£1.4 billion of NHS surplus was clawed back by HM Treasury.
(Evidence to Commons Health Select Committee, Nov 2012)

No one trusts the Treasury and we have already seen it steal carry forward money built up to help the NHS over the years ahead.
(NHS Finance Director Malcolm Cassells)

Why we should be worried

The government’s culpability and ‘form’ in all the areas condemned by the Francis Report explains why Cameron and his government have been so apparently humble and careful in their statements about Mid Staffs – why they haven’t chosen to use the Francis Report as a club to try to beat Labour over the head in front of voters. That and the fact that another 5 Trusts are to be investigated for similar warning scores to those that flagged Mid Staffs as a problem.

If the Tories tried to do so, it would be a straightforward matter for Ed Miliband and his health ministers to show how the failings in a single Trust under have been copied, propagated and worsened by the Tories – and, given the time the investigations into the 5 other Trusts will take, the results of those will come out just ahead of the next General Election, the worst possible time for Tory electoral hopes. So it makes tactical sense for Cameron to play it humble for now.

However, I don’t believe that’s all there is to it – and if I’m right we have cause for concern. The Tories are not known for letting an opportunity for some posturing to pass by, even if its wisdom is obviously questionable. So there’s another agenda here.

What could it be?

I believe the answer to that question lies in Jeremy Hunt’s recent decision to downgrade services in Lewisham because of financial problems in a neighbouring Trust. While he could have decided to set a common-sense precedent that funds from across the NHS can be used to rescue struggling Trusts, Mr Hunt instead chose to set another: that successful, well-run Trusts can be carved up to rescue their struggling neighbours.

I believe that this methodology now represents a Tory ‘plan A’ – one which means that they can afford to be very cautious and careful about their previous modus operandi of starving Trusts of funds, resources and staff. They won’t give up on that tack – but they can be circumspect about it, because when they need to ‘lie low’ on that, they can press ahead with closures and downgrades anyway.

For all Mr Cameron’s words about treasuring the NHS and wanting the best for it, the evidence suggests otherwise – and that serious concerns should be entertained about his current, seemingly-modified stance.
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Re: Mid Stafford Hospital report

Post by Shirina on Sun Feb 10, 2013 7:14 am

My conclusion (which I knew already) is that the 'Left' has no concerns for the people/general public, only for political power.
Right-wingers here in the States say the same thing. It's a bogus argument, one I've heard ten thousand times and one I instantly dismiss as incredulous. Why, might you ask? The first reason is also a response to this little gem:
My hope is that the less militant posters on here will recognise the hypocrisy and total lack of 'giving a sh*t' from the left
Blueturando's statistics assert that 1,200 unneccessary deaths have occurred over a three year period due to, ostenisbly, the inefficiency or corruption of NHS. Well, wrap your brain around THIS statistic. Here in the States, over 100,000 people ... let me spell that out for you: one hundred thousand people ... die EACH YEAR, not over a three year period, but EACH YEAR because they cannot get adequate health care. Also keep in mind that those 100,000 people die from easily preventable or easily treatable conditions - we're not talking about an 80 year-old with congestive heart failure. No, I'm talking about a 13 year old boy who died of a goddamn tooth ache. I'm NOT kidding. This is the kind of "care" you receive in a nation without NHS. More than ten times the number of Americans die needlessly in a single year than the number of Brits who die in three years under NHS.

To insinuate that the left only cares about power simply because Ivan or skwalker didn't write up a post about death statistics is utter rubbish. The cold, harsh reality is this term called "acceptable losses." No health care system is perfect. People are going to die, some of them needlessly. I hate that it happens, I really do, especially knowing that I or someone I care about could end up as one of those statistics. But to demonize NHS and the left because of 1,200 deaths when Britain could EASILY see 100,000 needless deaths WITHOUT NHS ... well, what can I say other than to adivse you to rethink your position. Go ahead and privatize your health care system and see what happens. Go ahead. I dare you. Trust me as someone who suffers from a disability without insurance - I wish to God Almighty that America had NHS because I'd rather take my chances as being one of 1,200 over a three year period than one of the 100,000 who die each year in the States - where your worthiness to receive medical care is completely contingent upon your net worth.

"The price of everything, the value of nothing" as your MP Tony Benn said. Yeah, that sums up the medical system here in the USA. A human life has no intrinsic VALUE ... only an intrinsic COST.

And if my post comes across as, well, mildly aggressive? Well, ahem, that's because this staunch leftist actually DOES "give a sh*t" about human lives, not dollar, pound, or euro signs. If you think the right-wingers in either of our nations gives a big sh*t about human life, come here to America and see how well the right-wingers' idea of health care works. Some hospitals even paid debt collectors to harass patients who were still in recovery with tubes down their throats about how they were going to pay. Yeah ... nice, huh? Unfortunately, a lot of these poor patients were so stressed out over the payment that, while half-dazed with meds, strapped down with IVs, and not even out of recovery, they paid for procedures on their 20% interest credit cards instead of brokering a payment plan through the hospital. Turning health care into a for-profit business means that money comes first, actual care comes in a very distant second.

Right-wingers in America haven't offered up any solutions to the barbarity of our system. In fact, the right-wingers in this country rallied around the idea of repealing the Affordable Health Care Act, otherwise known as "Obamacare" ... the ONLY sweeping change in our system in decades. In other words, even though right-wingers know that our system is an unmitigated disaster, they wanted to deny tens of millions of Americans access to health care so that it could continue being one of many cash cows of capitalism.

The left doesn't care, you say? I'll leave you with a final thought on that. Here it is: lol!
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Sun Feb 10, 2013 8:16 am

Shirina, great stuff. Can you point me to a source for the 100,000 figure?

I wrote this some time ago which bears on your points - there are a lot of source-links in the original, so (anyone) please take a look at if you want to verify anything:

A horror short: if the UK lost the NHS and looked like the US

I and others have written at length about Health Secretary Andrew Lansley’s catastrophic Health and Social Care Act and the disastrous effect it’s having on the NHS. I’ve written variously about the BBC’s near-criminal silence on the matter, the blackmail tactics the government has used on the BBC to force it to collude in this way, and on the BBC’s indolence and arrogance if anyone complains about it.

I’ve also written about the Tories’ real feelings about our National Health Service and their determination to break it up and sell it off along with the rest of the welfare state, and the origins and history of their ideological motivations for doing so.

And yet I still get a steady stream of Tweets, comments on this blog and email messages from people who’ve fallen for the government’s (and its media mates’) propaganda that the NHS is inefficient and wasteful (it isn’t!); that NHS doctors, nurses and other workers are lazy, selfish, and not worth the pay they receive especially if they live in a poorer area; that the NHS is in need of radical reform to get it working properly (the government isn’t interested in reform – ‘reform’ is simply an excuse for initiating its destruction); that the government genuinely wants to improve the NHS (its determination to cut spending by an impossible £50 billion shows the lie of that). If I had hair, I wouldn’t have hair – I’d have torn it out by now.

The Tories want to remove the NHS and even dismantle the welfare state completely. Some of them have even been caught saying so. They claim to admire the US system of private healthcare provision, and continue (in spite of G4S!) to insist that private provision is more efficient than a public system could ever be, and that this justifies opening up the NHS to ‘competition’, even though adding a profit layer can’t possibly be cheaper unless you ration care and strip the wages and conditions of health workers.

So, just in case you’re still on the fence on the matter, let me paint you a couple of very quick word-pictures based on a couple of very simple comparisons of US and UK statistics – word pictures that amount to horror stories:

Horror Story 1: Cost

The government keeps claiming (a clear example of the ‘Big Lie’ principle in action) that the NHS is inefficient and needs reform to ‘save’ it. That reform means allowing private companies to carve up the NHS (according to Eoin Clarke’s ‘Green Benches’ blog, if the latest sale of 3 hospitals in London goes through, the value of the NHS sell-off/give-away under the coalition government will reach £7 billion), with the result that in a few short years the treasured NHS principle of ‘care free and at the point of need’ will be gone (see also [You must be registered and logged in to see this link.]

But, as referred to above, the US spends more than twice as much per health per head of population as the UK does - an additional 128%! So what would it mean here if the UK followed the US pattern?

The UK currently spends about £120 billion a year on the NHS. If we were as ‘efficient’ as the US, that £120 billion would increase to a whopping £273 billion. That’s where the Tories are taking us. But because they’re destroying ‘free at the point of need’, that incredible cost would have to be borne by you, me, my loved ones, your loved ones, instead of being paid for via taxation so that nobody’s health is dependent on their ability to pay. Which leads us to horror story #2:

Horror Story 2: bankruptcy

In the US, cost of medical care accounts for an incredible 62% of bankruptcies. Figures vary each year, but in the UK as a whole, among England, Wales, Scotland (haven’t found figures for Northern Ireland yet), there are around 130,000 insolvencies every year.

If we followed the US, that 130,000 would only equate to 38% of the total. Add in another 62% for insolvency related to medical bills, and the UK would be facing – at horrendous cost both fiscally and socially – a staggering total of 342,000 insolvencies every year. When the government talks about the NHS being inefficient, what it’s really referring to is ‘inefficient for the super-rich’ – if you earn multiple millions a year, it’s much more efficient for you personally to pay for your healthcare yourself rather than through taxation. But it would be a disaster for pretty much everyone else – even if you’re pretty wealthy, you’d only be a diagnosis away from losing your job, losing your income and finding your house and your savings drained to nothing by the cost of treatment – and then finding yourself bankrupted by the cost of trying to live.

The title of this post says ‘short’, so I’ll round up now. I haven’t even mentioned the obvious horror story that under a US-style system anyone who can’t get insurance and can’t afford to pay for treatment would be turned away by the vast majority of hospitals and would be forced to hope that a charity hospital might give them some kind of basic care.

Even without that, what the two comparisons above show is that even if you don’t think the NHS is something we can be proud of, something to be saved, treasured, lauded – you should still be campaigning with every fibre of your being to save it. Unless you’re super-super-rich, pure self-interest dictates it. The alternative is a pure horror story.
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Re: Mid Stafford Hospital report

Post by Shirina on Sun Feb 10, 2013 9:28 am

Shirina, great stuff. Can you point me to a source for the 100,000 figure?
Okay, I poked around looking for the exact statistics. I remember reading that it was 102,000 deaths annually from preventable illnesses caused by lack of insurance. Ironically, this figure came from the Cancer Research UK site. However, just to be fair (and perhaps more reputable) I'll go with the figure of 45,000 annual deaths issued by a study published by the American Journal of Public Health. This study was conducted by the extremely prestigious Harvard Medical School and the Cambridge Health Alliance. I tend to go with the most conservative estimates to avoid hyperbolizing the scenario.

However ... 45,000 annually? That's still intolerable and a far greater risk than the 1,200 who die every three years under NHS.

Here is the link: Click Me

Another issue concerning NHS vs. for-profit health care is the ease in which costs can rise. In the case of a tax-funded NHS, taxes must be raised for the costs for the patient to be raised. Not so with a for-profit system whereby costs skyrocket constantly without votes, without parliamentary procedure, without public debate. In other words, NHS is democratic while a for-profit system is fascistic and totalitarian. Take this recent article as an example:

Health Insurers Raise Some Rates by Double Digits

Health insurance companies across the country are seeking and winning double-digit increases in premiums for some customers, even though one of the biggest objectives of the Obama administration’s health care law was to stem the rapid rise in insurance costs for consumers.

In California, Aetna is proposing rate increases of as much as 22 percent, Anthem Blue Cross 26 percent and Blue Shield of California 20 percent for some of those policy holders, according to the insurers’ filings with the state for 2013. These rate requests are all the more striking after a 39 percent rise sought by Anthem Blue Cross in 2010 helped give impetus to the law, known as the Affordable Care Act, which was passed the same year and will not be fully in effect until 2014.

In other states, like Florida and Ohio, insurers have been able to raise rates by at least 20 percent for some policy holders. The rate increases can amount to several hundred dollars a month.


Click to See Source

How many goods or services do you receive that ever increases by 20% to 36% in a single fell swoop? That's right ... none. Yet one of the most important necessities in life - health care - has seen these massive over night increases more than once. A family of four already spends almost $15,000 per year for health insurance. A 20% markup will increase that cost to $18,000 per year. The average household income in 2011 is $51,000 per year. Note, that is HOUSEHOLD income, not individual income. This means that the cost of insurance alone (not including all other taxes paid) is 35% of the household's entire income. Now, if you also pay 20% of your income to taxes, Americans are paying 55%!! That is more than most citizens pay in total taxes where heath care, university costs, and job training are absolutely free!

Oh oops, my bad. I was being WAY too generous. Look at this ...

Healthcare Costs for Insured American Family Top $20K in 2012: Milliman

The average cost of healthcare for a typical American family of four in an employer- sponsored health plan in 2012 is $20,728. That is a 6.9 percent increase over the 2011 total but the lowest rate of increase in the 10 years that actuarial firm Milliman Inc. has been doing its study. It is also the first time that the total dollar amount has gone above $20,000, according to Milliman’s index.

Click here for Source

LOL! How embarrassing. The cost has actually increased by $5,000 per year since the last time I checked those figures. Golly gee, doesn't THAT tell you something like, for instance, just how fast the rates are increasing? I suppose now when you count taxes and insurance cost, Americans are paying around 60% of their income. Heh, even the Scandinavian countries don't pay that much for their taxes and health care costs.

And the Tories think that privatizing health care will SAVE people money? What ridiculous tripe. The math is irrefutable. Oh sure, it may save the filthy rich a few pennies and certainly make others even filthier rich as the profits born of privatization begin to roll in. But the price of creating a handful of new billionaires will come at the cost of many more British lives ... perhaps around 45,000 of them each year.

Anyhow, the point is that taxes must be raised only slowly and sporadically. What do you think would happen in Britain if the citizens there were suddenly told they would face a 20% increase in their taxes starting ...now! Yep, remember those riots last year? Well ... But that's precisely what we Americans have to put up with every year, and an ever increasing number of families are being priced out of insurance altogether. Right-wingers would have you believe that most of the uninsured are actually illegal aliens. Yeah, that was true ten years ago. Not so now.

Here in the States, the most common refrain you will hear over and over ... and over and over from right-wingers is this: "Why should I have to pay for someone else's health care?" Now, perhaps that's not the attitude right-wing Brits have adopted, but somehow, I just don't believe that the right-wingers there are all that different from the ones over here. Therefore, how on earth can any right-winger talk about hypocrisy when they say with their own mouth, lips, tongue, and larynx that they don't care about the plight of others when there is a penny or pence to be saved? It really does grind my gears to the point of insufferable anger when I hear this ... and you can see from my posts how EASY it is to refute.

Oh yeah, I almost forgot this very important point. Taxes are generally progressive. In other words, you pay what you're capable of paying, usually as a percentage of income. Therefore, even in a nation that charges a 50% tax rate on income to pay for all of those free services, no one will ever find themselves owing more taxes than they can pay and then being denied services. This means that even the poorest among those citizens can still walk into any doctor's office or hospital and receive the care they need, not just the care they can afford. When health care costs are a product of market forces rather than taxation, sick citizens are faced with a flat fee which, by its very definition, is regressive. The result is that health care services costs X, and if you can't afford to pay X, then you're essentially screwed. That, if nothing else, justifies NHS.

There is absolutely NOTHING about our system that is superior to yours in Britain unless you're sitting in the higher echelons of the executive food chain. To those fat cats counting their money, a for-profit system is utterly brilliant ... but not so brilliant to the 13 year-old who died because of an infected tooth. Did I mention that America's health care system is horrifically inefficient, too? A massive chunk of the expenses incurred by patients are due to administrative costs. Yeah, that's right ... the cost of shuffling papers around. If you want a job in America, become a medical biller. There is such a huge demand for people who write and send bills to the patients that patients have to pay extra for their care in order to pay for the huge numbers of people employed to ... wait for it, wait for it ... bill you!! I mean, seriously, how stupid is that? And you think NHS is inefficient? Words cannot even begin to express ... well, okay, I've ranted enough. Hopefully I've made my point by now. Very Happy
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Sun Feb 10, 2013 10:04 am

Shirina - or should I say 'Night-owl?! - that's fantastic information, thank you so much. I feel my fingertips itching for a 'horror short' part 2.
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Re: Mid Stafford Hospital report

Post by Ivan on Sun Feb 10, 2013 11:32 am

Shirina. Thanks for opening our eyes to the horrors of a privatised health system. I wish that everyone in the UK who votes for the Tories and Lib Dems - or doesn't bother to vote for any party - could read your excellent posts, along with that brilliant analysis of the Francis Report by skwalker1964.

....the 1,200 who die every three years under NHS.
The claim is that there were between 400 and 1,200 extra deaths between 2005 and 2008 in just one hospital in Staffordshire. This issue was raised on another thread (and predictably, distorted) by tlttf, who tried to claim that 1,200 extra people died in that hospital in just one year, 2006:-
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Re: Mid Stafford Hospital report

Post by boatlady on Sun Feb 10, 2013 11:40 am

Steve and Shirina - I am in awe!
So much hard information and expert analysis in less than 12 hours!
You've really frightened me
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Re: Mid Stafford Hospital report

Post by oftenwrong on Sun Feb 10, 2013 12:16 pm

If, as seems to be the case, David Cameron and Jeremy *unt are intent upon dismantling the NHS and reforming it in a semi-privatised form, can we expect them to have similar plans for the creaking Parliamentary process?
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Sun Feb 10, 2013 6:45 pm

oftenwrong wrote:If, as seems to be the case, David Cameron and Jeremy *unt are intent upon dismantling the NHS and reforming it in a semi-privatised form, can we expect them to have similar plans for the creaking Parliamentary process?

If they can find any profit in it! They're working on education, too.
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Sun Feb 10, 2013 6:46 pm

boatlady wrote:Steve and Shirina - I am in awe!
So much hard information and expert analysis in less than 12 hours!
You've really frightened me

It's amazing what the internet combined with an obsessive mind can do! Smile
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Re: Mid Stafford Hospital report

Post by oftenwrong on Sun Feb 10, 2013 7:05 pm

skwalker1964 wrote:
oftenwrong wrote:If, as seems to be the case, David Cameron and Jeremy *unt are intent upon dismantling the NHS and reforming it in a semi-privatised form, can we expect them to have similar plans for the creaking Parliamentary process?

If they can find any profit in it! They're working on education, too.

Quite so! Ever since the 1980s, Tory policy has been to denigrate Teachers and Health-service workers.

A strange idea until you realise the intention is to enfeeble any and all Organisations which might present a united front against Central Government, if not kept firmly in their place.
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Sun Feb 10, 2013 11:48 pm

Ivan wrote:Shirina. Thanks for opening our eyes to the horrors of a privatised health system. I wish that everyone in the UK who votes for the Tories and Lib Dems - or doesn't bother to vote for any party - could read your excellent posts, along with that brilliant analysis of the Francis Report by skwalker1964.

....the 1,200 who die every three years under NHS.
The claim is that there were between 400 and 1,200 extra deaths between 2005 and 2008 in just one hospital in Staffordshire. This issue was raised on another thread (and predictably, distorted) by tlttf, who tried to claim that 1,200 extra people died in that hospital in just one year, 2006:-
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The fact is that we're not quite comparing apples with apples, because Shirina's figure is people who died because they couldn't access healthcare at all, while the Mid Staffs figure is thought to be somewhere between 400 and 1200 across that 3-year period. But they accessed healthcare - it was just poorer than it should have been. The number of people who die in the UK because they don't have access to healthcare is as near to zero as you can get in a country of 60-odd million. There will be a number of people in the US - 10,000, 50,000, 100,000, more? - who died from poor care in the same period to be added to those who couldn't access care at all.

But the 40-100k figure is still very useful context for a proportionate understanding of Mid Staffs, because it shows that no matter the problems the NHS might have, we're still better off with it than without it, even when it's poor. Lots of people were treated perfectly well at Mid Staffs during the same period, and the hospital has strong support from the local community, with some 20,000 signatures on a statement of support - and none, or very close to none, died because they couldn't get treatment at all.
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The Mid Staffs lesson you won't hear from Francis or the Tories?

Post by skwalker1964 on Mon Feb 11, 2013 7:25 pm

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I wrote on Saturday about the Francis Report into the Mid Staffs NHS (MSNHS) ‘failings’ and tragedy, and the reasons why David Cameron was remarkably circumspect in his statement in the Commons on Wednesday. Robert Francis’ lengthy investigation into the events at the Trust have identified a number of contributing causes, and recommends a number of measures to reduce the chances of a repeat of them.

The government’s circumspection is partly because it would be easy for the opposition to accuse it of exactly the same attitudes and failings that Mr Francis identified at the Mid Staffs Trust, but even more because the precedent set by the recent Lewisham downgrade decision allows the Tories an alternative route to erode NHS services in preparation for privatisation.

They can therefore afford to eat a little ‘humble pie’ now, in order to soften the impact of any fallout from the continuing investigations into 5 other NHS Trusts that have achieved similar quality scores to those that raised warning flags over Mid Staffs, in the knowledge that they can continue the progressive dismantling of the NHS via their alternative route when necessary.

However, the scope of Tory ambitions against the UK’s greatest social achievement is such that they won’t make merely passive use of the Francis Report, and will be busily making plans to actively exploit the report and its recommendations.

Conversations I’ve had with NHS campaigners over the last 24 hours or so have revealed deep concerns over the extent of these plans and the ways in which the Francis Report might be used against the NHS. These concerns are various, but all centre around the ways in which the lessons of the report might be twisted to accelerate and extend the assault on the NHS and its founding concepts.

I’ll look at some of those ways in a separate post shortly, but for now I want to examine the underlying public feeling about happened at Mid Staffs, and to provide some context for understanding what went on that will, if understood widely, help to counteract the Tories’ inevitable attempt to misuse the undoubted tragedies at Mid Staffs as a weapon against the NHS as a whole.

The Mid Staffs deaths

It is estimated that the number of ‘additional’ deaths (people who died who otherwise wouldn’t have) because of poor care at Mid Staffs was somewhere between 400 and 1200 – over a 3-year period, not per year as some have misapprehended. The media – and politicians – have been trying to use these figures to stoke a sense of public horror, and to cast a bleak light on the NHS in general.

The wide gap between the minimum and maximum numbers should ring a warning bell – as should the word ‘estimated‘. It’s impossible to know how many of the people who died at Mid Staffs during that 3-year period would have died anyway. The official estimate reflects that high level of uncertainty.

Some context

Any death is a tragedy, and an avoidable death even more so. If the official estimate is correct, somewhere between 133 and 400 people a year died avoidable deaths, so without question the events at Mid Staffs were a terrible tragedy. But to appreciate it properly, neither underestimating nor overestimating the scale of the poor care at the Trust, we need to understand how many people were treated by the Trust in that period.

Mid Staffs treats around 250,000 people a year, with around 63,000 being admitted as patients. That means a rate of avoidable deaths of 1 in every 158-474 (0.2-0.6%) patients admitted or 1 in every 626-1,880 (0.05-0.15%) of the total people treated. Looked at another way, hundreds of thousands of people were treated in each of the identified ‘failure’ years with good outcomes.

This is not in any way to minimise the consequences for the people who died, or for their families, but simply to set in context statistics which, in isolation, might seem even worse than they are.

It’s also worth noting that the local people still seem to offer Mid Staffs strong support, and to understand these nuances. A petition of support for MSNHS organised by a local pro-NHS campaigner was signed by over 20,000 people.

A comparison

The big risk is that the government will use the failure at Mid Staffs, and the ensuing report, to justify sweeping changes in the NHS as a whole, even though the report stresses that yet another reorganisation is not the answer.

I’ll go into detail in a separate article on some of the likely ways they’ll do this. But to judge correctly on any measures the government proposes, and the justifications it puts forward for them, it’s necessary not only to understand MSNHS in the context of the wider NHS, but also the NHS itself in a global healthcare context.

Many senior Tories are known to be admirers of the (pre-’Obamacare’) US healthcare system and others funded via private health insurance. Because it would be cheaper for the wealthy to pay for their own healthcare than to pay toward a National Health Service that cares for everyone, free at the point of need, this is an attractive option if you’re extremely well-off and don’t care too much about what happens to those who are not.

Even a cursory look at the details shows that any move toward a US-style system would be insanity – for the vast majority of us.

45,000 (at least)

The people who died at MSNHS died because they received poor care - but they received care. People are fallible. They make mistakes – sometimes very bad mistakes. Even the best nurse in the world, or the best doctor or surgeon, can make an error that costs someone’s life – and there is no system of oversight in the world that can prevent this completely.

But in the US, 45,000 people a year die because they could not access care at all. Unable to get insurance for a specific condition, or to afford health coverage at all, as many people die in the US because of lack of health insurance as MSNHS treats in total as in-patients in 9 months.

And the Harvard estimate is cautious – many estimates put the number of deaths through lack of health insurance as high as 100,000 a year.

Not only that, but with health insurers in the US putting up their premiums by 20% or more, the number of people who can’t afford health insurance (already 44 million!) is going to rocket and so is the number of deaths – without any statutory checks and balances to control the greed and callousness of health insurance providers.

And all this happens in spite of the fact that the US spends more than twice as much per head on its health system as the NHS costs us even before President Obama’s attempt to launch a socialised medicine programme.

The lesson

So, what is the lesson that’s missing from Robert Francis QC’s report and the impression that is being carefully, cautiously but insistently cultivated by government ministers and spokespeople?

Winston Churchill is famously quoted as saying that democracy is the worst of all systems of government – except for all the other ones.

The unspoken lesson of Mid Staffs is similar: the NHS is flawed, imperfect and sometimes lets people die avoidably. Its care is, inevitably, imperfect – but we can all access it when we need it, no matter what our personal circumstances.

Of course we should always do everything we possibly can to help the NHS minimise deaths and maximise good treatment – and every death is a tragedy.

But if we allow the government to erode our affection for this great institution, for the doctors, nurses, healthcarers and others who provide care ‘free at the point of need’, and to continue with their stealthy, piecemeal dismantling of our health protection – then we risk losing a treasure because we were persuaded that a blemish on it meant trashing it rather than cleaning it up.

For all its flaws, and even with the avoidable deaths that happen – every year, in every Trust because they happen in every hospital in the world – the NHS is incomparably better than any alternative the Tories want to foist on us.

It may not make as sensational a headline, but even at its worst we’re far, far better off with the NHS than with anything else – and we must fight tooth and claw to resist any attempt to use the MSNHS tragedy or any other to weaken it further or spread it more thinly.

Because that’s what the Tories plan to do – and it’s what they’ll continue doing even while they wring their hands and shed crocodile tears about avoidable deaths.
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Re: Mid Stafford Hospital report

Post by oftenwrong on Mon Feb 11, 2013 7:40 pm

Something like the NHS is by its nature open-ended. (Define "Perfect Health").
But regrettably the resources required to sustain such an ideal are inevitably limited.

The situation can readily be resolved, however, by the National Health "Service" being extended to include voluntary euthanasia. At a stroke, all those people who prefer not to be a burden are released from a pointless existence, and the insupportable provision for geriatric facilities greatly relieved.

Now which Political Party will be brave enough to embrace such an obviously realistic philosophy?

Oh we don't want to lose you, but we think you ought to go!
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Re: Mid Stafford Hospital report

Post by skwalker1964 on Wed Feb 13, 2013 9:00 am

From my reading of the report and researches around it, it turns out that the '400-1200 avoidable deaths in 3 years due to poor care' figure appears to be entirely unfounded - and known to be so in expert circles.

Very few people died avoidably at Mid Staffs, and probably no more than will happen in even the best-run hospital. In fact, Mid Staffs' corrected mortality rate was lower than the national average.

More to follow once I have all my ducks lined up..
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Re: Mid Stafford Hospital report

Post by tlttf on Sun Feb 17, 2013 8:12 am

Strange how a bit of a nag turning up in a burger has knocked a real crisis from the news?


Mid Staffs crisis: No one wants to talk about the real scandal of our time
The horse meat affair matters not a jot. The interesting question is why the deaths of more than 1,000 people in an NHS hospital have been ignored .

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Re: Mid Stafford Hospital report

Post by skwalker1964 on Sun Feb 17, 2013 10:33 am

'T' - I wouldn't go quite as far as to say that nothing you've seen in the media about Mid Staffs is true. But I'm not far from it! I'm not too far off being ready to write a proper article, but I can already say with certainty that the "400-1200 excess deaths" figure is a nonsense that even the various official reports say (diplomatically) is completely unfounded.
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Re: Mid Stafford Hospital report

Post by tlttf on Sun Feb 17, 2013 12:18 pm

I hope your right Steve otherwise scrapping and rebuilding is the only option left. As is, somebody should be in court pleading their innocence!

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Re: Mid Stafford Hospital report

Post by skwalker1964 on Tue Feb 26, 2013 4:13 am

Finally, finally finished my research and investigation into Mid Staffs. I'll upload it tomorrow as I can barely see straight now - but if anyone's up and watching, and wants to see it early, it's at:

The real Mid Staffs story: one 'excess' death, if that - [You must be registered and logged in to see this link.]

Night all!
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Re: Mid Stafford Hospital report

Post by boatlady on Tue Feb 26, 2013 8:37 am

This seems to be an excellent and much-needed piece of work - just on my way out the door so I have only read your conclusion, which, based on everything I know about hospitals (having spent some years working within them) seems right on the money.
I look forward to reading the rest later.
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Re: Mid Stafford Hospital report

Post by bobby on Tue Feb 26, 2013 10:41 am

The statistics for Mid Stafford hospital are probably no more Accurate than many other statistics. We are constantly bombarded with the cost of everything, but just how accurate are these figures. An example is the cost of a war. We kept hearing the Afghanistan war costs this and the war in Libya cost that. And I guess in a way they did. But what is not shown in those costs are the basic costs that would have to be met without a war. The Military’s wages still have to be paid as do the cost of weaponry (other than that which will need replacing) Vehicles and of course the subsidy for the officers mess.
If you take out the basic running cost of a peacetime military from the overall costs you will find these wars do not cost anywhere near the amounts claimed. What they need to do for the sake of honesty is to publish the extra cost of the war, leaving the running cost of a standing army out.
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Re: Mid Stafford Hospital report

Post by oftenwrong on Tue Feb 26, 2013 12:30 pm

In a Hospital Theatre, a principal expense - loss of human life - is impossible to compute.

In Theatres of War such as Iraq and Afghanistan, "The West" has never even pretended to count the enemy's dead. With God on our side.
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Mid Staffs: one 'excess' death, if that

Post by skwalker1964 on Tue Feb 26, 2013 4:01 pm

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Mid Staffs: was it what we’ve been told?

(Many links to sources in this article - for those please visit the original at [You must be registered and logged in to see this link.]

What I’m about to write is likely to make me very unpopular with some people. While I’d prefer to avoid that, the issues and the truth about them are too important not to write it.

A couple of weeks ago, I wrote a couple of articles about the Mid Staffs NHS (MSNHS) report by Robert Francis, and about David Cameron’s reaction to it. These articles focused on the political implications of the events and the report, and on setting the reported death figures in context, rather than on the veracity of the figures themselves and the story behind them. Although I touched on the fact that the wide range of the figures given - 400-1200 – showed how uncertain they were, like everyone else I assumed there must be some truth to them, because they were so widely reported and so seemingly uncontested.

Not only the more lurid newspapers like the Sun, but also the ‘respectable’ press and media have reported the 400-1200 figure as fact – and continue to do so, the relevance of which we’ll see toward the end this article. Only a couple of weeks ago, a politics round-up programme on BBC Radio 4 included these figures as simple fact in their comments on David Cameron’s Commons speech on the Francis Report – and none of their guests there to talk about the issue raised even a murmur of contradiction.

The idea that 400-1200 ‘excess’ deaths took place during a period from 2005-2009 has been repeated so often, with such a complete absence of dispute (unless you knew where to look), that in the public consciousness it has become, to all intents and purposes, a fact.

But it is an idea without any basis in fact.

If you’re a regular reader of this blog, you will know that I believe in research – in drawing together facts and making conclusions based on them. I am no stranger to research and to the effort and time that have to go into an article to be able to make credible statements. But the preparation for this article has taken that investment of time and attention to another level.

My research for my earlier articles on Mid Staffs had led to some even more fundamental questions in my mind that I had to investigate. If you’ve noticed that this blog has been quieter than normal for the past couple of weeks, it has been because almost every spare moment over that period has been spent in researching this post – reading transcripts of witness statements to the Francis Inquiry, investigating the comments and opinions of others on the MSNHS issue specifically or the issues around the use of statistics in general.

What was starting to become apparent to me about the whole Mid Staffs issue was so deeply at odds with the prevailing perception that I had to read more widely and deeply than ever before in order to make sure that I was perceiving correctly.

Because the issues are so complex, and the evidence I could use so abundant (I’ve read well over 1000 pages over the past couple of weeks and will leave out of this article far more than I can put in), that even my best efforts to distill them into conciseness will still leave a post that will take patience and attention for anyone to work through, I’m going to break from the normal ‘good form’ that would mean putting the reasoning and evidence first and saving the conclusion until last.

Instead I’m going to state the conclusion first, and then list the evidence and narrative around it, so that those who wish to and who have the patience to can read through it and satisfy themselves that the conclusion is justifed. So here is that conclusion, along with a very brief justification:

There were no ‘excess’ deaths at Mid Staffordshire NHS during the 2005-2009 period in which the news media and anti-MSNHS campaigners claim there were 400-1200 of them – or, in the words of the independent clinical expert who led the ‘Independent Case-Note Review’ (ICNR) into each individual, contentious death at the Trust:

maybe one

This information has been in the public domain since at least 2010 – but I doubt if you could find a single reference to it in the mainstream media. “One person might have died!” does not sell newspapers, or gain viewers, in the same way that “400-1200 unnecessary deaths!!!” does, I guess.

You’re quite possibly thinking to yourself, “What?! How can that possibly be correct?” Here’s how.

In 2009, Dr Mike Laker was asked to conduct an independent review into the detailed case notes of every contentious death at MSNHS during the period in question. To identify which cases needed reviewing, the Trust offered all patients who had been treated by the Trust, or their families, the opportunity to ask for a detailed case note review – and ‘detailed’ is the right word: each review would take 5-6 months to complete, so a large number of expert, independent clinicians were needed to complete the process within a reasonable timeframe.

60 such requests were received – which already puts a massive question mark against the figures of 400-1200 ‘excess deaths’. In the course of the review, Dr Laker eventually interviewed 120 families and edited the case notes of 40-50 cases. He was asked by Tom Kark, Counsel to the Francis Inquiry, how many ‘excess deaths’ had occurred among the cases he had reviewed. Mr Kark related Dr Laker’s answer in his ‘final submission‘ to the 2010 inquiry:

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‘Perhaps one such death’ – so maybe not even one. People die in hospitals every day, of course – but as far as unnecessary, avoidable deaths caused by negligence or malpractice, the detailed, intensive reviews of all the deaths where relatives were dissatisfied enough to ask for one uncovered ‘perhaps one’.

Dr Laker is no ‘stooge’. His comments, which you can read about in the ‘final submission’ link just above, also included strong criticisms of the organisations overseeing the ICNR. He successfully had the overseeing body changed from the Trust itself to the responsible Primary Care Trust (PCT), to ensure independence, and also stopped the Trust from accessing the case review findings before they went to the families. His findings were not those of a man trying to court favour from, or minimise embarrassment for, the establishment – yet he still could only find ‘maybe one such death’.

In terms of demonstrating that the media portrayal of the story and the underlying reality bore no relation to each other, I could ‘rest my case’ here. But in order to understand why and how the false story that has so permeated the public consciousness came to do so, we need to look in more detail at other aspects of the background, the witness transcripts and the advice/opinions of other experts.

What this examination will reveal is a story of:

- overstretched and struggling hospital staff unable to provide the ‘basic care’ that any health professional would wish to, but managing just about to hold things together even though things weren’t pretty (and a ‘drinking from vases’ claim that appears to have been almost entirely fabricated)

- commercial conflicts of interest and over-stated claims

- statistics that could never say what they were made out to say, even if the data-input was perfect

- data input that was anything but perfect, creating an even more false picture

- bereaved relatives lashing out understandably but excessively

- most critically, collaborating political and media interests spinning a story in a wholly false way for their own ends

The (very truncated but still lengthy) details follow. You may prefer to skim the headings and choose the areas of immediate interest to you to read in detail, and then come back later for other sections as required. I leave that to your preference, but please make sure at least to read section 6, which examines the reasons why the misleading figures have been propagated and exploited – and by whom and why.

1. Even in an ideal world, HSMR is no ‘Ronseal’

The public furore over Mid Staffs began as a result of a set of statistics called ‘Hospital Standardised Mortality Ratios’, or HSMRs which – it appeared – showed a significantly higher ratio of deaths at MSNHS compared to the national average. At no point did the statistics or any report on them name a number of avoidable deaths, either in the 400-1200 range or any other figure. Robert Francis stated this unequivocally on the first day of hearings for his second report.

The reason for this is simple: even working perfectly, the HSMR system is neither designed nor intended to identify ‘unnecessary’ or ‘excess’ deaths, nor is it a measure of quality and safety in a particular hospital (the owners of the system did claim the latter, but backtracked on the witness stand). Chapter 5 of the 2013 Francis Report states the following (which again you will struggle to find in any media reports referring to Mid Staffs:

to this day, there is no generally accepted means of producing comparative figures, and unjustifiable conclusions continue to be drawn from the numbers of deaths at hospitals and about the number of avoidable deaths.

In the context of the careful, neutral wording used in official reports as well as the commercial sensitivities around the HSMR method and the vociferous and aggressive tendencies of the anti-Stafford campaigners, Francis might as well be putting up in neon lights: “HSMRs do not say what you’ve been told they say!

Or take this exchange between Mr Kark and Roger Taylor, the Director of Research and Public Affairs for DFI, the company that supplies the HSMR data:

K: Can I just ask you this, we’ve heard a lot in this inquiry about how HSMRs might be used as no more than an indication of risk or a need for further attention in a particular area. Did the 2007 publication put the significance of HSMRs too high, calling it an effective way to measure and compare clinical performance safety and quality?

T: No, I — I don’t believe it did. I think it is an effective way to do exactly that. However, I will add to that comment the point that it’s really important to remember that in measuring clinical outcomes and clinical performance there are no perfect measures..

K: Does that mean to say that when the HSMR is above a certain level, and that is to say, if I can get my terminology correct, above certain control limits, it’s not just a tool to identify risk, but it is an effective measure of safety?

T: I’m saying an effective measure of safety is one that helps you identify the risk of something being wrong.

Kark asks Taylor about how the HSMRs can legitimately be used and Taylor fudges initially – but when he is asked directly whether HSMRs can provide an effective measure of safety, he backtracks and says it can only identify where there is a risk that something might be wrong.

Professor Brian Jarman, the creator of the HSMR system, made a statement in his evidence that demonstrates that quality of care and HSMRs are by no means automatically linked:

Now, you’re not going to measure the quality of care of pacemaker insertion by measuring the mortality because, you know, that’s – they are very low.

Similarly, the 2010 inquiry put out a ‘Joint Statement’ on the usefulness of HSMRs which included the following statement:

Along with other indicators, they can usefully help us to understand comparative information about in-hospital deaths. But they have limitations, and should not be used as a sole indicator of patient safety. To do so could potentially give a misleading interpretation of a hospital’s safety record. They should be used with other relevant indicators as a tool to support the improvement in the quality of care.

And the clincher comes (again) from Roger Taylor, as he is asked by Counsel about the link between HSMRs and the media claims about the numbers of ‘excess’ deaths:

Q. Where does Dr Foster stand on the portrayal of the figures about Mid Staffordshire as indicating or showing that there were 400 to 1,200 unnecessary deaths?

A. ..that is a misuse of these data.

Some 300 different indicators are used to assess hospital safety and quality. Even in perfect circumstances, with everything functioning as it should, HSMRs can only perform a small role in this assessment – effectively a signal to say ‘take a look, just in case something is wrong’. Using them to state anything beyond this is ‘misuse’.

1,2,3,4..

Another important indicator lies in the guidance provided by the company that owns the HSMR system to Trusts that find themselves with a high mortality ratio. This guidance takes the form of a list of recommended actions:

1) Check to see whether incorrect data has been submitted, or whether an approach to coding which differs from other organisations’ approach has been adopted

2) Consider whether something extraordinary has occurred which explains the result

3) Consider whether their healthcare partners work in ways which are different from those in other areas

4) Consider whether there are any potential issues with regard to the quality of care

The 2nd Francis Report criticised MSNHS for focusing first on whether the high HSMRs were caused by coding issues – but DFI’s own guidance to Trusts on what to do in the case of high HSMRs puts ‘check coding’ at number one in the list of actions. By contrast, checking whether there are actually any issues with care standards is down at number 4.

If even the owners of the system consider that there are 3 factors more likely to affect high HSMRs than actual poor care, can anyone seriously consider that the system is accurate, robust and reliable enough to provide an actual number of ‘excess deaths’ – even in perfect circumstances?

And yet the media continue to report the figures as fact. Since they can’t be unaware of all the above statements and factors (and many more that I’ve had to choose not include for the sake of some semblance of readability), then one has to ask ‘Why?’ – what is the real agenda?

A moving target

One of the key weaknesses with the HSMR system is that it is based around a ‘standard’ score of 100 – which is ‘rebased‘ every year. In simple terms, the statistics take an average score for all the hospitals in England and call that ’100′. Hospitals scoring worse than average get a score above 100, while hospitals scoring better get below 100.

But what ’100′ means moves every year. In the words of Professor Jarman:

we do for the simple — simple-minded English, if you like, adjust it so that the English value was every year.

(That Prof Jarman considers the English simple-minded and unable to handle a figure that isn’t simplified every year is interesting, given Roger Taylor’s testimony that DFI considers the public to be savvy enough to realise what you can’t do with its figures, even if the media are all screaming ‘Excess Deaths!‘)

This ‘rebasing’ means that a hospital can have exactly the same performance in a given year that it achieved in the previous one, and still show a worse HSMR because the overall average moved down. Similarly, if some hospitals are ‘gaming’ the system to improve their score (a possibility that the creator of the system, Professor Sir Brian Jarman acknowledged in his testimony to the 2nd inquiry), they will bring down the average so that ‘honest’ hospitals appear to be doing badly.

But even if nobody cheats, a hospital can be doing well, as well as it’s ever done, and still appear to be sliding down the performance table.

2. Rubbish in, rubbish out

We’ve just seen that, even if everything around the HSMR system is functioning perfectly, HSMR cannot be used to identify a number of ‘excess’ or avoidable deaths. But as a reading of the inquiry transcripts will quickly show, things were about as far from perfect as they could possibly be in terms of the data that was entered into the system – both nationally and, especially, in the case of Mid Staffs NHS.

One fundamental thing needed for any correct understanding of the issues surrounding MSNHS’ HSMR scores is the knowledge that, for most of the ‘problem’ period at the Trust, it had no coding manager.

The data on which HSMR scores are calculated are based on codes that have to be entered for each patient treated. These codes relate to the condition from which the patient is suffering, and an ‘expected’ death rate is allocated to each condition measured for HSMR purposes. If a hospital shows a higher rate of deaths for a particular condition than the expected rate, this pushes up the overall HSMR score for that hospital. If it shows a lower rate, that helps bring down the HSMR score.

Let’s take a simple example. ‘Fractured neck of femur’ (FNOF) is a fairly common result of falls in elderly people – and a serious one. Out of every 10 people, nationally, who go into hospital with this condition (which in layman’s terms might be called a ‘broken hip’), on average one will die as a result of complications arising from the initial condition. If a hospital loses more than 10 patients with FNOF for every 100 it treats, it will have a relatively high HSMR for that condition. Each condition has its own rate of expected deaths.

But there are serious problems with both the basic principles of the coding and with how it was done at MSNHS – and remember, Mid Staffs’ coding manager was on long-term sick leave for most of the period in question.

First or primary diagnosis

The rules of HSMR coding state that the first ‘non-vague’ diagnosis – sometimes referred to as the ‘primary diagnosis’ - for any patient when they enter hospital for an ‘episode of care’ must be used to determine the coding. But this is full of dangers in terms of measuring mortality rates.

If a patient enters hospital with, for example, a broken tibia (shin-bone), you would expect this to have a low death-rate – dying from a broken leg is pretty rare. The ‘first non-vague diagnosis’ is obviously going to be ‘broken tibia’. But if it is subsequently discovered that the bone broke because it was eaten through by an aggressive, spreading cancer, the expectation of death would clearly be completely different.

But, following the rules of HSMR coding, the code that is entered is the one for a fractured tibia – and the death will seem very unexpected and so will worsen the HSMR score.

Junior doctors

Junior doctors work long hours in an intense environment. They are often the first medics to assess and diagnose a patient, and they are unlikely – unless the importance is hammered home to them very hard – to consider it too important to put the right code down for a patient they are treating. Being junior, there is also a higher likelihood of them misdiagnosing or missing a condition when a patient is first examined.

MSNHS’ investigation of its coding, once it had a new coding manager in place, showed that there was a major problem with the coding entered by junior doctors.

POA

In his testimony to the 2nd inquiry, Prof. Jarman confirmed that his system did not ‘adjust for’ secondary diagnoses unless they were ‘present on admission’, or POA. In other words, if a condition – no matter how serious – isn’t either spotted by the doctor or otherwise known about when a patient is first treated, it’s ignored for the purposes calculating HSMRs. But Prof. Jarman made a key admission:

70 per cent of PMA (sic) — present on admission diagnoses are the same as the primary diagnosis.

In other words, in 30% of cases there is a discrepancy – 30% room for the figures to be skewed by a primary diagnosis of one thing when a serious condition might be present that would push the expected death rate much higher. So even if everything goes as planned, there is a known potential for variation in the system of as much as 30%.

Co-morbidities

‘Co-morbidities’ is the medical term for ‘other stuff that’s wrong with you’. So if you’re in for treatment on an ingrown toenail, for example, but you also suffer from congestive heart-failure and lung-disease, there’s a much higher chance you’ll die while you’re in hospital – and it wouldn’t mean the hospital did anything wrong. But the ‘episode of care’ is for treatment of an ingrown toenail – which would have a very low expected death rate.

The HSMR system does allow co-morbidities to be entered (based on the ‘Charlson Index‘)so that they are taken into account – but if these are wrongly entered or not entered at all, the figures will look as though you died from an ingrown toenail.

The investigations into coding at MSNHS showed that there were substantial problems with the coding of co-morbidities, probably because of the absence of the coding manager combined with problems of under-reporting of co-morbidities by consultants.

Z51.5 and the ‘parade ground’ effect

One the major problems with Mid Staffs’ HSMR scores that I found in my reading of the transcripts was in a change that was made to the coding system to include code Z51.5 – a code to indicate ‘palliative care’. A patient receiving palliative care is suffering from an incurable, terminal condition and is being treated to relieve pain, make him/her comfortable etc. At some point he or she is going to die from the condition – so the expected rate of death during any given ‘episode of care’ is going to be relatively high.

For the sake of brevity, I won’t go into every detail, but when the change to include Z51.5 was made, Mid Staffs’ coding did not change to include it. Since other Trusts were now using a code with a high expected death rate that would lower their HSMR score, and because this would affect the ‘rebasing’ and move the ’100′ benchmark, this had the same effect as a rank of soldiers all stepping back at the same time except for one – he would appear to be standing out in front without having moved at all.

‘Zero stays’ and 30 days..

Another thing that came out during Prof. Jarman’s evidence was the effect of two particular peculiarities in the way that Mid Staffs was coding its patients. The first of these is the ‘zero days’ stay’ category (which actually includes stays of up to 1 day).

MSNHS was not including in its coding any patient who came for treatment and either didn’t stay in hospital at all or only stayed one day. Since the vast majority of patients who come into hospital and leave again in a day or less will be there for treatment of mild conditions (or mild manifestations of potentially serious conditions), the rate of deaths among such patients would be very low. This would have the effect of ‘concentrating’ the death rate at Mid Staffs (by reducing the total number of codes and taking out almost exclusively patients with good outcomes). Since all or almost all other Trusts were including these patients, their death rates would be ‘diluted’ by the ‘zero stay’ patients – again causing, or accentuating, the ‘parade ground’ effect and making MSNHS look worse without necessarily being worse.

Conversely, Mid Staffs was also negatively affected by the lack of ’30 day coding’ in HSMRs – codes allocated according to the outcome 30 days after discharge from hospital.

If a hospital discharges a patient early, who then dies outside the hospital, this is not reflected in the HSMR. But if a hospital keeps a patient longer to make sure he/she is fit for discharge, or is unable to discharge an elderly or infirm patient because of the lack of non-hospital care facilities, and the patient then dies, the hospital effectively suffers in its HSMR because it did the right thing.

The 30-day effect might not only occur because of irresponsible discharge of patients. If a hospital has a hospice nearby and can discharge terminally ill patients for palliative hospice care, the patients will die in the hospice and this will improve the hospital’s HSMR even though the patients still die.

Professor Jarman repeatedly claimed that the effect of correcting codings for co-morbidities and palliative care would be very small, but this claim appears highly questionable.

Firstly, the ‘parade ground’ rebasing effect when the Z51.5 palliative coding was launched in other hospitals caused Mid Staffs’ HSMR to rise by 13 points, from 114 to 127 – a serious change.

The group ‘Straight Statistics’, a “pressure group whose aim is to detect and expose the distortion and misuse of statistical information, and identify those responsible”, wrote an article examining the reliability of HSMRs and particularly the effects of errors/corrections in coding. The article included an examination of the relationship between ‘depth of coding’ (how many co-morbidities were recorded alongside the main diagnosis), which varies widely across Trusts, and HSMR.

Quoting a response from Prof. Jarman’s organisation ‘The Doctor Foster’s Unit’, the article says:

a hospital using only 2.5 codes per patient would show an HSMR about 15-20 points higher than one using 5.5 to 6 codes per patient

15-20 points is not ‘very small’. The number of codes per patient at Mid Staffs is not stated – but with no coding manager in place and proven issues with uncoded co-morbidities, it is certain that it was at the low end during the period of high HSMRs.

When the new coding manager joined MSNHS, she carried out a re-coding exercise (apparently 2, in fact, since the first one over-corrected). According to evidence given by acting Chair of the Trust David Stone in 2009 to the Health Scrutiny Committee, once the correct re-coding was done, Mid-Staffs’ HSMR score was:

88

Just in case there is any lingering doubt on the fact that coding can have a massive effect, we’ll leave the last word to Professor Jarman. Just 8 days ago, he sent the following message on Twitter:

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Prof Jarman’s telling tweet.

PwC is PricewaterhouseCooper, a huge firm that carries out detailed audits and analyses – and it found a 25-30% difference in Mid Staffs’ high HSMR code due to incorrect coding.

Rubbish in, rubbish out..

3. Conflicts of interest and exaggerated claims

The HSMR system is run by Professor Jarman’s Doctor Foster Unit (DFU), which is part of the faculty of medicine at Imperial College. DFU receives the majority of its funding, confusingly, from Doctor Foster’s Intelligence, or DFI. DFI is a commercial, profit-making company (although 47%-owned by the Dept of Health). DFU calculates the HSMR scores for hospitals free of charge.

There is no suggestion, that I can make out from the transcripts, that DFI or DFU deliberately skewed any figures in the HSMR index for commercial gain. However, DFI does publish an annual ‘Good Hospital Guide‘ that includes a ‘league table’ of HSMR rankings. Based on these rankings, DFI attempts to sell to Trusts its ‘Real Time Monitoring’ (RTM) service for the sum of £35,000 per year. This service provides ‘alerts’ to customer Trusts about areas where HSMR is poor or starting to slip, so that the Trusts can take corrective action – and can optimise their position in the Good Hospital Guide. From Roger Taylor’s evidence to the 2nd inquiry:

Walsall hospital was named as the hospital with the highest death rate in the first hospital guide in 2001, which they were not very pleased about..Walsall subsequently became very enthusiastic and started using the RTM tool.

An email from a senior DFI director in 2011 stated:

we ran a consultation on the indicators used before they went into the hospital guide in 2010..We alerted hospital trusts to this by writing to them and letting them know and through the Health Service Journal. We will do the same this year. Providing access to them in the tools we sell is the obvious next step.

The fact that DFI stood to gain financially from the creation and publication of league tables based on HSMR must cast serious doubt on the use of HSMR as a tool for assessing quality of care – especially since the information is made public – even if DFI were not deliberately exploiting the opportunity. Despite the fact that Roger Taylor stated in his evidence that he did not think this represented a conflict of interests, an impartial observer must recognise that there was indeed potentially such a conflict.

The fact that Mid Staffs knew that their HSMR position was going to be made public in this way must also have contributed to their focus on coding, which was criticised by the Francis Report – especially when DFI’s own guidance on how to respond to poor HSMRs put ‘check coding’ as number 1 on the list of actions.

Overstated claims

As was revealed during the testimony given by Roger Taylor, DFI’s 2007 publication had massively overstated the usefulness and significance of its HSMR data, calling it:

an effective way to measure and compare clinical performance safety and quality. Deaths in hospital are important and unequivocal outcomes.

As we’ve already seen, HSMRs are nothing of the sort, and the information that they give on deaths is anything but ‘unequivocal’. Mr Taylor initially denied that this was claiming too much – but under further questioning he eventually said, when speaking about focus groups made up of members of the public, that they show a

general scepticism of the ability to accurately measure quality of care. In which regard they are being, I think, pretty smart, actually.

If the public are being ‘pretty smart, actually’ to be ‘generally sceptical’ of the system’s ‘ability to measure quality of care’, then I think that calling the HSMR measure ‘unequivocal’ as a measure of ‘clinical performance safety and quality’ is without question an exaggeration – and a pretty big one. Especially when Mr Taylor also acknowledged that the output of the system is only as good as the data that’s put into it – and when, as Prof. Jarman put it in his testimony,

it depends how the coder codes it.

Such an exaggerated claim can only have fanned the self-fuelling flames of misleading publicity about the ’400-1200 unnecessary deaths’.

4. The top 3 factors in poor care at Mid Staffs: understaffing, understaffing and understaffing

There is no doubt that there was poor care in some parts of MSNHS. Various inspections that followed the initial public furore found that care in some departments was ‘appalling’. However, Robert Francis’ recommendation that individuals should not be pursued for events at Mid Staffs strongly suggests that the failings at the Trust were systemic rather than resulting from malice or neglect on the part of any one person or group of people, particularly front-line nurses and doctors.

This is supported by the statistics provided in Annex 1 (part of Volume 3) of the 2013 report which show that, over the 5 years covered by the report, the number of ‘serious untoward incidents‘ which were recorded at the Trust and ascribed to lack of staff was a massive 1,756 – an average of 351 ‘serious’ incidents per year attributable to short-staffing.

However, these ‘untoward incidents’ mostly represented failures of ‘basic care’ – cleaning, comfort and so on – rather than life-threatening incidents. Remember, the review of the 60 incidents (and interviews of 120 families) that were serious enough during this period for the families to accept the offer of a full case-note review resulted in ‘perhaps one’ avoidable death.

Patients were left in their own waste etc, which is a horrendous indignity that no one should have to suffer – but which is very, very rarely life-threatening. If staff numbers were too low, as the stats suggest, then nurses inevitably faced times when they were simply unable to do everything and had to prioritise.

I know from my many conversations with nurses from various hospitals that there can often be times when a patient’s ‘basic care’ needs have to wait – because all the available nurses were trying to help another patient breathe, or to keep him/her alive through a heart attack, or deal with sudden and serious haematemesis (vomiting blood).

At this point it’s worth addressing one of the most persistent myths of the ‘Mid Staffs phenomenon’: that ‘neglected’ patients were so thirsty, and so ignored, that they had to drink the water from flower vases.

Appalling if true – but flower vases were banned from the two MSNHS hospitals from the late 1990s, presumably for hygiene reasons. I’ve heard anecdotally that there may have been one incident in which a (probably confused) patient was allowed a vase as an exception, and did drink from it – but the idea that this was more than a one-off appears to be entirely unfounded. Instead it appears that the media spun out a one-off into a regular incident for the sake of lurid headlines.

Nurses feel terrible about those who have to put up with indignity or discomfort – and relatives of those patients frequently fail to understand that their loved ones are only suffering ‘neglect’ because nurses had to choose between that and allowing someone to die or suffer horrible fear and pain.

It’s awful and it should never happen – but it will, as long as wards are not fully staffed according to not only the number of patients but also the severity of their conditions and the level of their dependency. And under this government, it will happen more and more.

Which leads me on to my final sections – which I’ll try to keep brief because this post is already more than long enough.

5. The viciousness of grief, the cynicism of politicians and the collaboration of the media

Just last weekend, the Guardian’s online edition carried a call from a relative of someone who died at MSNHS for ‘heads to roll’. This same lady – to whom my heart goes out for her loss – was also heard, at a public meeting of anti-MSNHS campaigners, to call

Let’s shut the hospital, let’s sack all the staff!

Losing a close family member is a horrible experience – I lost my mother after a long and gruelling battle against ovarian cancer 9 years ago. But surely, someone who would rather have no hospital and see thousands of doctors, nurses and other health staff, most of whom she can never have met, made unemployed because of her grief and rage is not thinking straight.

One can understand and sympathise, certainly – and I do. But it must be a foolhardy decision indeed to allow someone who is in such a state of mind to influence policy and to invite him or her frequently to influence public opinion via media interviews and articles. When deciding the fate of health services that about a quarter of a million people rely on, ‘cool heads’ surely have to prevail and decisions made must rest on logic and fact, and not emotion and grief.

And a person or entity that would exploit the grief of such a vulnerable person would be reprehensible indeed.

Which leads me to my final section:

6. Politics, media and exploitation

In my opinion, it’s extremely telling that the ‘media mentor’ of the anti-MSNHS group was the Conservative MP for Stone in Staffordshire, Bill Cash. Mr Cash’s testimony to the inquiry makes perfectly plain that he understood absolutely none of the detail of what was happening at Mid Staffs and why. However, he evidently understood a political opportunity when he saw one, and he set up meetings for the group to promote its calls for a public inquiry.

Mr Cash was also associated with the first ‘leak’ of the supposed ‘unnecessary death’ toll of 400-1200 people to the Daily Mail. Mr Cash, it must be said, has denied being responsible for the leak, and there is nothing to prove that he was. The fact that the figures appeared alongside quotes from Mr Cash must at least raise the question – but the article also included quotes from the leader of the relatives’ group, so the provenance of the figures is uncertain.

It’s all political

At various points throughout his testimony, Prof Jarman refers to negative attitudes from the (Labour) government toward HSMRs – but then (from p.171 of the record) he reports a sudden change:

There has been an improvement, it seems, in [the Dept of Health’s attitude to the value of HSMRs.

In his view, this might be linked to the publication of the first Francis Report on Feb 2010. However, he is very specific about the point when the real change occurred:

But the statements in the White Paper of 12 July 2010 were very positive.

The white paper of 2010 in which the government published its outline plans that eventually led to the Health and Social Care Act 2012, under which they are decimating the NHS and at this very moment are trying to force through undebated, unvoted measures to force accelerated privatisation.

A Tory government takes power. Two months later it launches it’s ‘here’s one we made earlier’ blueprint for the destruction of the NHS – and ‘coincidentally’ it starts to take a ‘very positive’ attitude toward a tool that can make hospitals look as if they’re killing people even when they’re not.

A positive attitude in spite of the fact that Mr Francis’ first report contained the ‘Joint Statement’ that we’ve already seen about the weaknesses and limitations of HSMRs.

It doesn’t take a great deal of imagination to ‘put two and two together’ in a far clearer and more reliable way than the HSMR method.

What the papers say..

It’s also very significant that one of the most enthusiastic users of the spurious figures has been the Daily Telegraph – a ‘newspaper’ with a proven track record of NHS attacks for political purposes. The paper is on record as having co-ordinated articles on behalf of private health interests to help the passage of the invidious 2012 NHS Act and has even instructed sub-editors to leave anti-NHS material in an article to which it was irrelevant.

As recently as a few days ago, the Telegraph was still hammering the MSNHS issue – and just yesterday ran an article tarring the whole NHS with the Mid Staffs ‘brush’.

The desire for eye-catching headlines, improved circulation and journalistic laziness have all contributed to the spread of the myths about ‘excess deaths’ at Mid Staffs and the distortion of the public perception of what really went on there. But, without question, at its core lies yet another unholy alliance between the Tories and the right-wing media for the advancement of their multi-fronted, ideologically-driven assault on the NHS of which most of us are rightly proud.

In this context, it’s perfectly plain why David Cameron found it expedient to ‘eat humble pie’ and apologise on behalf of the country for the “horrific pain and even death” suffered by “many” (again propagating the myth). The recommendations of Robert Francis’ report include the closure of hospitals found to have similar problems to MSNHS; by accepting the report with crocodile tears and in sackcloth and ashes, Cameron has positioned himself to be able to exploit those recommendations as another excuse to close hospitals – alongside ‘rationalisation’, creating ‘centres of excellence’ and the financial problems of neighbouring Trusts (as the people relying on the successful Lewisham Trust have already found to their cost).

And, of course, to tarnish the image of the NHS in the eyes of a public that still considers the NHS the crowning achievement of our country.

The moral is clear:

Don’t believe everything you read in the papers – especially when it involves Tories and the NHS.
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