Thursday, 16 May 2013

Waiting for the Administrators.

For all of us who are concerned about the future of Mid Staffs and the health service for our future this is an anxious time.

We are waiting, because at this moment there is little else that we can do.

I know that many people feel frustrated that they are not doing something now. Lots of people have sent in lots of documents to the administrators, and received back lots of letters that effectively tell us very little. The Administrators have had many meetings with key people aimed at helping them to work out where the solution lies. The expressions of interest from a number of different bodies are in and are being scrutinised.

Within a matter of days now we will have a much clearer idea of where the administrators are pointing this process and the public consultation can begin in earnest.  

People will be aware of a number of things in the background that do have a real bearing on what will happen here.

Bruce Keogh from DoH  is coming to the end of his review of the first wave of 14 hospitals who were identified as having potential problems. (they are looking at over 50). He will be publishing this soon and it is likely to make interesting reading.  I would expect to see indications that that the underlying problems that gave rise to the pressures at Stafford are pretty widespread. The TSA certainly understand this clearly already.

There is recognition that the A&E system throughout the country is on the verge of collapse. The descriptions of what is happening and why mirror what we saw in the detailed evidence to the public Inquiry here, so there is now much clearer understanding that the problems we saw here are part of a much wider problem.

There is a lot of talk about integrated care. The Staffordshire Partnership trust is playing a pioneering role in trying to make integrated care a reality. We need to understand more about what they are doing, why it matters, and what the difficulties are.

Integrated care is being seen as the best way of relieving pressure on the Health service and making it affordable, whilst at the same time improving the quality of care for patients. Everyone agrees with the principle, but there are real difficulties in making it work in practise. There is potential for making Stafford the blue print to make integrated care work.

An interesting article from David Rose who works for the Mail on Sunday, and has been one of the leading writers on A&E downgrades raises serious questions on the effects that A&E downgrades may have on mortality with his report on Newark As it says a minister has ordered an investigation, and I am sure that the results will not be as clear cut as indicated here, but it does raise the question has anyone really done an effective impact assessment on the unintended consequences of A&E downgrades.

I have been asked to be one of the people in the HEIA team (Health equality impact assessment) Once I have a clearer idea of how this will operate then I am sure I will be looking for guidance from many people.

Another couple of comment pieces.


Wednesday, 15 May 2013

Everyone is now talking about A&Es - It is a relief!

It is a relief.

Finally people from all over the country, people who understand the issues, are talking openly about the very serious difficulties that the country is facing with Accident and Emergency services.

The openness we are seeing here now can be seen as one of the positive side effects of the Francis report into Mid Staffs. Here hundreds of people were pilloried for not having noticed anything unusual at Stafford Hospital

What Clinicians saw in Stafford was a run of the mill hospital suffering run of the mill problems. For a while I think it was worse than that and there were reasons why the impact of an ageing population which is now being blamed for the national crisis in A&E was felt particularly strongly in Stafford. I will explore these reasons in a later blog.

Now nationally clinicians and NHS Managers, perhaps mindful of the way their colleagues were attacked for not telling us about the pressures they were under, are speaking out. They are telling us loud and clear that the system faces collapse, and they have identified the key matters of the ageing population, how acute care is funded, the lack of viable alternatives to Acute Care, and the way in which Primary, Secondary and community care currently fail to work together.

It is good that we are finally hearing these voices. Finding the solutions to the huge problems they are telling us about is going to be a major challenge to the fragile and imperfect systems that we have for making decisions.  It is also going to be a huge challenge to the media. We do absolutely need the media to help get across to people the complex challenges, and the difficult choices we may need to make.

Stafford is again going to find itself at the centre of a very important story as over the next few months we move towards a conclusion to the Administration process that will decide the future of our hospital. For those of us who are deeply involved in this we know that any structural solution that is hammered out is really only the very beginning of a long process that will aim to work out how to deliver the right care in the right place, and how to manage rising demand with shrinking budgets.

I hope that Stafford will attract the support of many people who have the expertise to try to make an integrated care system happen. We are the forerunners. What happens here will matter across the country.

Here is some of the mainstream media coverage of the A&E crisis.

I am also going to make an exception to my normal practice and include a video from @chunkymark.  Please do not click on this link if you are easily offended, because it does contain a staggering amount of swearing. 

I have included it because it really does indicate the fury that is felt by so many people in the country about the perceived threat to the NHS.

I think that the government has a choice, It can work with the people of Stafford who are trying quietly to express their needs, and their fears, or it can wait for the wrath of @chunkymark and the many who feel as he does.

Tuesday, 14 May 2013

Is the Administration process for Mid Staffs a done deal?

Earlier today I saw a letter that one of the Support Stafford Stafford campaigners had from the Department of Health attempting to explain the administration process.  It appeared a bit confusing, so I thought I would have another go at explaining what I think is going on.

In September Monitor raised concerns that the hospital may not be sustainable, and they sent in the Contingency Planning team to check this out.

The CPT did loads of work into looking at the whole health economy of the area, but they then had to follow their remit, which was to make a judgement about whether Mid Staffs in isolation and in its current form is “sustainable”. They came to the conclusion that it is not.

As part of the CPT process they had to define what was at that time called “protected services” but is now called “location specific services”.  This means the services that really do have to be delivered locally. It is not the same as the services that we feel that we want. There was informal consultation on this, but in the end it was the Clinical Commissioning Group who determined the very limited list of Location Specific Services.  This exercise seemed important at the time, but will probably not be in the end.
The CPT prepared a report to monitor, which concluded that the trust is not Clinically or Financially sustainable (we dispute some of the reasoning behind this) and that an administrator should be sent in. Their recommendations, based on Mid Staffs alone, were to close A&E, ICU and maternity, and essentially take away all acute services.  I am not sure if anyone expected us to meekly accept this, but of course we did not. 

It may have taken 50,000 people on the streets, and a unanimous motion from the borough council to convince the administrators, but they now see the wisdom of finding a more acceptable alternative.

The Administrators do not have to accept the CPT recommendations.. They are now looking for solutions that are right in terms of the whole health economy. This is necessary because all the neighbouring hospitals have trouble of their own. None of them have the capacity to take on the acute patients form Mid Staffs. The expressions of interest are in, and as I write this I know that the administration team is working through the night to scrutinise the bids.

I believe that what the administrators are looking for is a proposal that gives the option of bringing together at least two hospitals, which will allow cost sharing and skill exchange, but would allow acute services, maybe at different levels, to be delivered on both sites.

The Administrators will be coming up with their proposals and presenting them to the community within the next couple of weeks, and this will then form the basis for the consultation process.

Up to now it has been very difficult for the public to work out how best to communicate with the administrators. When the proposals are made public then there will be a great deal of engagement.

Speaking personally I have always been very clear that this must be genuine consultation, with the public being given very good quality information on what is being proposed and why.  I also think it can become the start of a much longer process where the public becomes an active player in designing the services we need for the future.

In Stafford we have been learning a thing or two about ourselves over the last few months, or years, and I think it is now very important to us that we are not seen to be passive recipients of what someone else tells us is “good for us”.

Speaking personally, I am very very weary with Stafford being seen as a problem.  I want the country to start seeing Stafford as the forerunner. Somewhere that is getting things right against the odds, and somewhere where we can set out to build a positive future for the NHS. 
I think we can do this!

Monday, 6 May 2013

Why would a downgrade to Stafford Hospital matter nationally?

Why would a downgrade to Stafford Hospital matter nationally?

What is happening in Stafford now will set the pattern for hospitals nationally in the future. It is ingenious the way that hardly anyone nationally knows the extent of the threat to their services.

What we are seeing here is a battle about what the health service should look like in the future. The responsibility for finding the way has been delegated to a team of administrators, led by Ernst & Young, but the conditions which determine what is possible are set by the government and the department of health.

Most people nationally will have had their perception of Stafford coloured by years of bad publicity, some based on highly questionable material. They will assume that whatever is happening here is just about Stafford. They would be wrong. In Stafford we have seen this coming for the last 4 years, and we know that we are being used to set a precedent.

Why did 50,000 people march in Stafford?

When 50,000 people took the streets of Stafford on April 20th for what was probably the largest ever march to save a hospital. We marched to demonstrate our support for the staff of the hospital, to show that we value this service and wish to keep it, and to blow the whistle on the threat to the future of the NHS. We marched because we know we are in a unique position to see this threat.

You will not have heard that whistle blowing, because frankly none of us expected the demonstration to be quite on that scale, and the press gave minimal coverage to this story, which many of them would have found inexplicable.

It is worth taking a look at some of the photos of the event to get an idea of what this means to a town the size of Stafford.  If you have seen them all before then take another look – just for inspiration!

The group who organised the march and run the Support Stafford Hospital campaign are unusual. It is a community led group that has the active support of all major political parties who are choosing to put aside their differences and work together. The borough councillors voted unanimously to reject the Monitor proposals on the Hospital. The campaign has the backing of all major organisations in the town including the churches which are playing a key role. If you take a look at the extensive video coverage of the march you will see Middle England marching! Many people in their 60s and 70s were taking part in their first ever protest. Stafford will never see anything like this again!

The question.of Sustainability

The Administrators after their first bruising public meeting with 600 residents have been at pains to make it clear that they are here not because of the supposed “history” of the hospital, but because of “future sustainability”.

This is the argument that is putting the future of around 60 hospitals throughout the country in doubt, and will change the way in which health care is delivered in every hospital in the country. There are genuine questions here. We should be having this debate, but we need to do so openly, honestly, and nationally.

Financial sustainability.

The key reason why the administrators are here is because the hospital is in deficit. It is deemed to be “not financially sustainable”.  With Stafford there are a number of unique reasons for that.

·         The two site hospital is currently running with empty wards that are a drain on resources.

·         Recruitment and retention of staff has been expensive because of the reputational damage.

·         A one off grant authorised by Andrew Lansley to help the hospital meet the unique costs of the years of public attention, and to regain public confidence, was later re-designated as income, which had a major impact on break even plans.

·         Patient choice and GP recommendations have been artificially suppressed by the reputational damage.

There is also another major reason which applies nationally. The Tariffs for acute care are set at a level where they do not cover the cost.

The role of tariffs

This use of Tariffs is deliberate. The DoH wants, probably quite rightly, to minimise the admissions to A&E and to focus on preventative care and care in the community, so they have used the Tariffs as a lever. The only trouble is that the community care is not there, and A&E admissions keep on climbing, with the result that more and more hospitals are getting into deeper financial trouble and are struggling to meet the demands on acute care with insufficient funding. The newspapers are full of stories which illustrate this problem.

The Hidden costs of downgrades

The pressure to close A&Es, which are the most unprofitable part of the NHS, is growing. The “temporary” overnight closure of A&E in Stafford in 2011 (it is still closed) has been accompanied by pressure on the ambulance service, which is now starting to give us some leaks from Ambulance service staff who know they are not coping well with this pressure. There is pressure on neighbouring A&Es where breaches of waiting times, trolley waits and ambulance waits are regular occurrences, pressure on ICU beds, which led to one lady being transported to Hereford where she died. The Hospital reports daily blips in admissions, with large numbers coming in in the morning when A&E opens, and just before the closing deadline at night. There are reports of people who delayed calling ambulances, rather than be sent to other hospitals, and sometimes these decisions have been fatal. The anxiety that many families feel, especially elderly people and families that have to rely on public transport, is considerable but hard to measure. For many people who moved to Stafford the presence of hospital services was a consideration. Businesses fear the knock on economic effects if we lose acute services, there are consequences to the entire economy of the town which we do not know how to calculate.  

There is a genuine question here. The accountants who are making the decisions on the future of Stafford are taking an accountants view. How do we know that they have added in all the hidden add on costs, such as the increased costs to the ambulance service? How do we know that they are giving the right weight to all the quality of life and quality of service issues that concern the people who will use the hospital? These people have no connection with the town. They are here to make a quick decision and move on, probably to the next hospital on the list. They are almost certainly acting in good faith, but this is complex stuff. There is plenty of room for miscalculation. They will have no accountability for the unintended consequences of their actions. 

The Myth of Local Decision making

Whilst the government would like us all to accept that “financial sustainability” is a matter for local Clinical Commissioning Groups, and local choice, the reality is that the choice is rigged. The commissioning groups have to live within means that does not cover the costs, and are therefore in the unenviable position of making unpalatable choices on the behalf of the government.

The fact that we are not talking about this nationally shows us just how ingenious the restructuring of the health service has been.  These “local decisions” are dismissed as nothing to do with the Government or the Secretary of State. Whilst they may get some column inches in the local press they are currently remaining invisible nationally. This needs to change!

With Stafford we have seen that the “local” bodies cannot come to a decision, so we have the Administrator instead. Potentially they could play the role of making the preferred solution of the community clear and work out how to make it happen, but will they do this?  

The power of the Clinical Sustainability arguement

Any policy maker who accepts the arguments for re-configuration of the health service and who has read what the national press & media has to say on Stafford Hospital over the last half decade could be forgiven for believing that this was going to be pretty straightforward. Any objective scrutiny of standards at Stafford must surely demonstrate that conditions at Stafford Hospital, and by extension other hospitals of a similar size would be poor, and that the people of Stafford would be only too happy to have their services removed and have safe services from bigger and better neighbouring hospitals. Once such a precedent has been set then of course other hospitals that can be seen as comparable could then be lined up for downgrade too.

This may reveal the dangers of policy built as a response to the media. The reasons why much of the press coverage of the last five years has been quite seriously misleading is a subject for much more detailed explanation at another time.

The 50,000 people who marched for Stafford, even those who accept press coverage at face value, clearly do not accept that whatever trouble there may have been seven years ago should be the basis for decisions about the services that we need now and for the future. People who used their vote to call for a public inquiry in 2010 did so because they expected answers and improvement. Not because they wanted to lose services.

Standards in Stafford Now.

From 2007 when the concerns about Stafford’s supposedly high mortality rate first surfaced the hospital has been focused on turning the problems around. Under the three different CEOs that have been in place since 2007, and despite the obsessive interest of the media and of the regulatory bodies (14 unannounced Care quality Commission (CQC) inspections in 9 months – all good to excellent) the hospital has reformed. It has learned the lessons of the Francis inquiries in the way that few other hospitals will yet have done. Mid-Staffs is now deemed to be one of the safest 20 hospitals in the country. The systems of governance that are in place are robust. Recruitment has been challenging but the hospital is up to strength. On virtually all measures the performance of the hospital is “better” than in the surrounding hospitals.

Clinical Sustainability. 

So the arguments about clinical sustainability take as the starting point that what is being offered by the hospital now is of high quality.
The question mark over clinical sustainability is essentially about size. These are some main factors which all apply nationally:

·         A small hospital remains vulnerable to small changes in staffing levels. In A&E or ICU the loss of a consultant or middle grade doctor, for holidays, sickness or changing job may tip the department from having an adequate staffing level to one which is below optimum levels.

·         The flow of patients in A&E is always unpredictable, and this will be more marked in smaller hospitals.

·         There is a national shortage of Consultants and Middle grade doctors which means that small hospitals will always struggle to keep numbers up to strength.

·         In a small hospital the volume of cases passing through the hospital may not be sufficient to ensure that the clinician has experience of the problems they will see and can deal with them in the best possible way.

·         There are some conditions where better results are achieved by hospitals with specialist staff and equipment, and the expense of these services means that they need to be delivered in a limited number of sites. 

·         Clinicians value the support of colleagues that they can call upon in larger hospitals.

·         In an increasingly litigious society having second opinions on hand is reassuring for clinicians.

·         There is a proliferation of different sub specialisations. There are fewer and fewer generalist consultants, who are capable of dealing with a mixture of different medical needs, and the increase in the number of “experts” means we need larger and larger catchment areas for hospitals to be able to support the growing numbers of specialists. This trend is now actively under question, and there is a strong argument for reversing it and recruiting more generalists, which would help to make the future of District general hospitals  far more secure. 

Balancing Clinical and Financial sustainability. – can it be done?

The difficulty is this. Mid Staffs is now one of the safest hospitals in the country because it has stopped doing some of the processes that need to be delivered in specialist hospitals, it has invested in staff, and it has invested in quality. By doing all of this Mid Staffs is now safe, but not financially sustainable, and if it takes the measures to make it financially sustainable then it may become clinically unsustainable.

The margins under which the NHS is currently required to operate means that most hospitals most of the time are walking this tightrope.

When the numbers of hospitals in declared financial or clinical difficulties began to rise into double figures I felt we had to try and understand the reasons for this.

·         The tariffs are set to deter acute admissions and to encourage integration.

·         It is only possible to make the tariffs work by radical change of the way the health service is delivered.

·         Integration is the right direction of travel but is not in place.

·         Making Integration work means improving communication between organisations.

·         It could take ten years to get this right.

The aspiration of Integration.  

When you study the transcripts of what when wrong in Mid Staffs the matter is pretty clear. When staffing cuts and bed cuts were carried out in Stafford, at the same time as cuts in Community care was happening then there was a build-up of patients in Stafford Hospital, who probably should not have been there in the first place and could not be discharged. The expensive care that they needed was not met by the tariff system that was designed to prevent such admissions. With squeezed budgets the costs did not meet the care needs. Care suffered.

The reports coming out of Stafford, and others from age concern, the Kings fund, the Alzheimer’s society, and the ombudsman all pointed in one direction. It is important to find better alternatives to acute care beds for frail elderly people. It is important to find ways to make primary, secondary and community care work effectively together.

Everyone accepts the need for the integration of services, but most people are concerned that the cuts to acute care are being carried out before the necessary preventative and re-enablement care is in place. It appears that the right thing is being done in the wrong order.

The Stafford Blue Print.

The recommendation to the administrators was to downgrade Stafford to the status of a “local hospital” which would offer no acute services. This is not acceptable to the 50,000 people who marched on 20th April.

The Administrators have indicated that the recommendations were based on the remit that the Contingency planning team were set, looking at Mid Staffs in isolation. The administrators are not bound by this, and are now looking at solutions which fit the needs of the wider health economy. This means looking at the demands and capacity of the neighbouring hospitals and suggests the creation of a networked solution.

There is currently active consideration of the amalgamation of Stafford and UNHS to create a hospital where the size will give economies of scale, and which could relieve some of the capacity problems currently being experienced at UNHS. The plan preferred by the community would mean keeping a level of A&E, ICU, Acute care and maternity at Stafford.

It needs to be considered that amalgamating Stafford and Stoke would bring together two trusts, each with their own financial challenges. Whilst amalgamation would bring about some economies of scale it should not be assumed that this will be adequate in the longer term.

Building sustainability means investment in making integration work. Initially double funding may be necessary in order to make this happen. 

We have been used in Stafford to being seen as the “NHS problem”. In Stafford we would prefer that it should be seen as an opportunity. Stafford can be the testing ground, to build a blue print for the future for district general hospitals.

The 50,000 that marched in support of Stafford hospital are an asset. They are people who understand a lot about the pressures on our health service. They take a realistic view, and if invited to do so will assist with the design of a health service that works for the future. It would be crazy not to make good use of this extraordinary resource.

It’s your turn next.

Just remember, whatever happens here is Stafford has implications for people all over the country. The changes that are happening, driven by the accountants in the Treasury, the DoH, Monitor, Hospital Board rooms, Health scrutiny committees, The Management consultants and the CCGs are bringing change to your health service. If you live in a small town like Stafford your hospital services may be obviously threatened. If you live in a community with a large hospital the threat will be less obvious, but the change is happening whether you see it or not.

Many people will watch from the side lines to see what happens. In Stafford we know that the Support Stafford Hospital Campaign is being fought on behalf of the whole NHS. You can help us by pressing for open debate on “sustainability” and what it means for your services.