A damning Healthcare Commission review of emergency care at Mid Staffordshire foundation trust last week found that money was put before patient care. Dave West investigates what went wrong

The question of when care for emergency patients at Mid Staffordshire foundation trust became so shockingly poor is one of several exposed by the Healthcare Commission’s most critical report on a hospital trust to date.

The organisation’s high whole-hospital mortality ratio dates back to 2003 and there is “some evidence” of problems beginning even earlier, says Heather Wood, the commission investigations manager.

A clinical governance review by the Commission for Health Improvement in 2002 raised concerns about nursing numbers, privacy, dignity and clinical data quality, but not on the scale of the report’s revelations. An acute hospital portfolio review in 2004-05 exposed a high rate of complaints, particularly about nursing care.

The investigation into standards at the trust going back to 2002, ordered last week by health secretary Alan Johnson, will ultimately shed some light on the case but, as the health service awaits the findings, managers and patients are divided.

Some people associated with the hospital believe its most serious problems began before 2005.

David Denny, who stepped down after nine years as a non-executive director in January and who rejects some of the commission’s findings, said the trust was aware of problems as early as 2002-03, when it was awarded a three-star rating by CHI. “The board were somewhat puzzled about that, because we didn’t believe the standards were as high as they needed to be,” he recalls.

Trust governor and Stafford borough councillor Joyce Farnham claims sky-high figures for deaths caused by poor care - 1,200 by some estimates - are “utter rubbish”, as, she says, are reports of patients drinking from vases and sinks.

Ms Farnham says: “I think 2004, 2005 and 2006 were pretty bad years. There was a slight improvement in 2007, a little more in 2008 and [since] then the organisation has shot up.”

A strong view remains among some people close to the trust that Martin Yeates, the now suspended chief executive, and the team he enlisted in late 2005 made important improvements. The commission report acknowledges: “We were told that, since the arrival of the chairman [Toni Brisby] and the current chief executive [Mr Yeates], the board had become much more effective, particularly in having a clear strategic direction and receiving the information on performance to help deliver this.”

Big shock

Mr Yeates and his board were well respected and thought to be addressing the trust’s problems, a senior acute director in the region said. “There are some very good people over at Mid Staffs, so the report is a big shock [for the NHS in the West Midlands].”

Mr Denny believes 2005 was a “turning point” and insists Mr Yeates and Ms Brisby, who resigned ahead of the report, do not deserve to be castigated.

This view is in stark contrast to the Healthcare Commission narrative, which devotes much attention to how Mr Yeates’ board at best exacerbated, and at worst brought about, the problems it highlighted. That account correlates with that of Stafford campaign group Cure the NHS, which first identified the problems in late 2007. Founder member Samantha Bailey says it began receiving large volumes of complaints in 2005.

The Healthcare Commission says, at Mr Yeates’ first board meeting in August 2005, he declared “marginal closures [already underway] were not enough and radical moves were needed” to recover a £2.2m deficit and become sustainable.

The board oversaw a 150-head redundancy programme and a significant reorganisation of wards designed, the commission suggests, to cut costs. Nurse numbers - linked closely by the regulator to quality of care - dropped by 129 in 2006-07 and a further 32 in 2007-08. There were 103 vacancies in July 2007 and 104 in September 2007. Discussion at the time, the report says, was “dominated by finance, targets and achieving foundation trust status”.

Mr Denny states, as do board minutes, that most job cuts were planned to come from non-clinicians. He insists the board was seeking to improve care, but his explanation of its behaviour reflects the weight being given to costs.

“Every trust in the country was looking at the [financial] problems. We had to take radical action. It was proposed to reduce staff, because in a hospital that is the only way you can make savings.”

The trust saw financial stability and foundation status as a route to improving care, he maintains.

“There was also the imperative that everybody would become a foundation trust and if we didn’t we would be closed or taken over.”

The Healthcare Commission paints a picture of a leadership at Mid Staffordshire which was so intent on achieving a budget surplus it was blind to terrible standards of care.

The trust’s commissioners and NHS West Midlands have found it difficult to explain why problems were not identified earlier. Both investigated the high mortality ratios - albeit only from 2007 - but were satisfied the main problem was bad coding (see below).

Even a fortnight ago, few people close to the trust realised the scale of the criticism that was coming. Public governor Margaret Reeves admits: “We all thought it would just go away - that [the complaints] would be found to be from people who had lost someone dear to them and they were very distressed; and when everything had been explained… it would settle down.

“We thought there had been problems and it was all being corrected. Nobody expected a report like this.”

Regulators forced to question their own role

In publishing its most critical report yet, the Healthcare Commission has raised questions for its successor, the Care Quality Commission, for Monitor and for itself - about its own procedures.

Mid Staffordshire foundation trust was rated “fair” for quality of services and resources in its 2005-06 annual health check, “fair and good” in 2006-07, following a risk-based assessment, and “double good” in 2007-08. The commission notes the last health check was “based largely on the trust’s assessment” because of the ongoing investigation.

Asked about its failure to identify problems earlier, the commission chair, Sir Ian Kennedy said: “I don’t think anybody would welcome groups of people wandering through their hospital, just in case.

“Everyone else was fobbed off by arguments [from] Mid Staffordshire [blaming coding and other causes]. We were not. You needed the tools to get under those explanations. What we did was develop those tools.”

The Healthcare Commission pointed out that NHS West Midlands “was assured” by the trust’s response to its mortality rates. Its report also said there was no “formal or comprehensive handover of information from the predecessor organisations” to the merged strategic health authority.

Before taking up her current post in August, Care Quality Commission chief executive Cynthia Bower was the first chief executive of NHS West Midlands, and from June 2006 was interim chief executive at Birmingham and the Black Country strategic health authority. Ms Bower told HSJ: “From my point of view this wasn’t a trust that was on my radar.”

She said the SHA had spoken to primary care trusts, GPs and MPs to ask about high hospital standardised mortality ratios for six trusts, published by Dr Foster Intelligence in 2007.

She pointed to the Healthcare Commission’s inspection for the annual health check during 2007.

“This trust was also, post the Dr Foster data, inspected. There was an assessment of the trust that said it met the standards. I believed, and I believe now, that as an SHA I was doing what I needed to do in order to understand what was going on in that trust.”

Ms Bower said if the foundation trust regulator Monitor had been aware of the situation, it would not have authorised the trust’s foundation status in February last year. There was a lesson for regulators and SHAs, she said. “If they had shared that information earlier we could have worked together to look at what the issues were.

“By doing the detailed investigation that frankly only the regulator can do, issues emerged that didn’t emerge through other things we were doing. The regulator had another range of tools and when it sat in accident and emergency it did something we didn’t have the capacity or remit to do. We should have been working together on that.”

Monitor executive chair Bill Moyes has said his organisation had expected the commission to highlight concerns about applicants. Now it specifically asks for the information, he said.