Patient safety and care quality concerns must always be investigated, but the government must make sure it does the right thing and does not act first and ask questions later
There is a post-Francis nervousness about. Everyone wants to be seen to doing the right thing. This is understandable, given Robert Francis QC’s searing critique of the catastrophic failures at Mid Staffordshire and within the wider system. But there’s a danger that an unhealthy, “shoot first, ask questions later” culture is developing.
‘There has been instant alarm, confusion and intense focus on a few individuals who feel they’ve been found guilty before a court has even sat’
The problem is that avoiding another Mid Staffordshire now also means being seen to avoid another scandal. The NHS, in wanting to be seen to be doing something, is in danger of becoming capricious, arbitrary and unfair − albeit well intentioned.
The dangers of rapid response
Instant responses often lack consistency, tend to scratch the surface of concerns and run the risk of destabilising the NHS front line, which can feel exposed to random judgements it does not understand.
In the months following the Francis report we have seen three different events involving concerns over quality at NHS providers. First, Sir Bruce Keogh’s review of 14 hospitals with high mortality rates. Second, the review of mortality coding at Royal Bolton Hospital. Third, the review of paediatric heart surgery patient safety at Leeds General Infirmary.
What linked all three were: instant responses to the emergence of incomplete or partial data; a set of behaviours best summarised as “provider presumed guilty until proven innocent”; and a bunch of lurid media headlines partially driven by the need for the system to be seen to be doing something.
Before there were answers, there was action.
The initial experience of the trusts on the end of these processes has been difficult, to say the least, given how highly charged the atmosphere has become in each case. Staff morale has tumbled, patient confidence has been hit and management teams have been given the almost impossible task of keeping their trusts upright in the face of an onslaught.
There has been instant alarm, widespread confusion and intense focus on a few individuals who feel they’ve been found guilty before a court has even sat. In short, there is the feeling of being caught in the gun sights of a trigger-happy gang composed of the NHS, the government, the media and, through them, the public.
One of my most upsetting experiences of the last 12 months was seeing the anger, frustration and hurt of a senior clinician at Royal Bolton Hospital who was utterly outraged at the suggestion that their team had been deliberately falsifying mortality statistics.
“How can anyone believe that we would do such a terrible thing?” they said. They went on to outline the highly improbable chain of events and wide circle of culpability that would have been required to perpetuate such a deliberate fraud.
Clearly, none of this had occurred to the senior NHS executive who instantly tweeted about “possible criminal activity” as soon as the Bolton review was announced.
The frustration has been compounded now that the evidence has been collected, carefully considered and a rigorous, evidence-based judgement reached. Surprise, surprise: what some feared was happening wasn’t actually happening at all.
The lurid headlines were wrong. Leeds General Infirmary’s child heart surgery unit was safe and has reopened, while the Bolton hospital has been completely absolved of deliberate falsification, wrongdoing or cover up. It’s a shame that, in both cases, the absolution gained much less coverage than the original allegations. And, as we all know, it takes considerably longer to build up a reputation than to tear it down.
‘Instant responses designed to grab headlines are rarely a meaningful answer to any complex problem’
There is no question NHS trusts should be scrutinised, problems identified and solutions implemented. Sir Bruce Keogh, who deserves our full support, is right to call for the adoption of precautionary principles and the need for quick and effective investigation where there is a suspicion of avoidable harm being caused.
Careful, transparent, independent, evidence-based scrutiny is the best way of doing this. Nothing can, or should, be hidden. However, appearing to jump to early presumptions of guilt, having the media lynch mob run loose and leaving trusts with rushed, ill thought out processes are not sensible ways to proceed.
These are difficult issues. But the NHS can only navigate through them if it focuses on doing the right thing − by the trusts themselves as well as by their patients. It mustn’t prioritise being seen to do the right thing over actually doing the right thing. We need better thought out processes and a more mature reaction from all concerned, making a reality of Sir Bruce’s “no blame suspensions”.
The review of mortality outliers provides a good example: what started as a process forced on the NHS by the government’s need to be seen to be doing something has now turned into a reasonable, evidence-based process that can be understood and explained. It should generate useful findings. The fact that it’s taken time to reach that point shows that instant responses designed to grab headlines are rarely a meaningful answer to any complex problem.
Chris Hopson is chief executive at the Foundation Trust Network