Following the publication of the Francis report, Mike Birtwistle considers what the future holds for Mid Staffordshire Foundation Trust

Stack of reports

It has been a long time in coming. The families of those who suffered at Mid Staffordshire finally have the report from a public inquiry. The focus yesterday was naturally on the victims, why this scandal happened and what lessons can be applied to the wider NHS to prevent it ever happening again. But what of the hospital itself?

However badly let down in the past, the local community in Stafford needs a good local hospital for the future. At present, there is no guarantee this will happen. Mid Staffordshire has been in a kind of suspended animation for the past few years.

‘Significant clinical problems also remain. This is not a hospital on the mend’

With its reputation badly and rightly tarnished, it has been unable to attract the staff required to provide a high-quality service. Agency costs have one through the roof and patient numbers have dwindled

There are also structural challenges which go beyond the scandal: the trust is very small − perhaps too small − to function effectively as a multi-site district general hospital. The result is a hospital losing money hand over fist, deemed to be financially unsustainable even by its own board.

The impact of the staffing crisis is brutally illustrated by the fact that the hospital has been forced to temporarily suspend its 24-hour accident and emergency service. This has already dragged on far longer than originally promised, demonstrating that there are no easy solutions that will enable the trust to provide a safe and effective service in these circumstances. 

Other significant clinical problems also remain. For example, the trust’s breast cancer team has been found to be “deeply dysfunctional” and compliant with only one in 10 core standards. This is not the performance of a hospital on the mend.

Political pain

It is likely the people of Stafford will not have to wait long for action to begin to address these problems. Monitor has already initiated what can only be described as a “pre-failure regime” for the trust and I can only assume this will be converted into special administration in early April − as soon as Monitor has the power to do so under the Health and Social Care Act 2012.

The question about why the powers available under previous legislation were not used is an interesting one. After all, as the people of Lewisham know all too well, the government is perfectly prepared to use these powers. 

However, there is one crucial difference: Mid Staffordshire is a foundation trust. In order to use the special administration powers available under the 2009 act, the secretary of state would have had to first deauthorise Mid Staffs as a foundation trust − something that, from April, he will no longer be able to do. 

‘The secretary of state will have far less flexibility in responding to a special administration at Mid Staffordshire’

I suspect the reason this never happened was a combination of ideology and practical politics: to strip a trust of its autonomy at a time when the government was legislating to “liberate” the provider sector and remove scope for deauthorisation would have looked and felt awkward to say the least. Whether and how this delay has affected Mid Stafforshire’s future viability is a matter for debate − and it should be debated.   

Special administration may have been delayed but it will surely come. When it does it will not be without political pain. It is hard to see how a special administration at Mid Staffordshire will not involve the painful loss of some services (will that 24-hour A&E ever reopen?). In this respect, it is a situation similar to that in south east London.

Notes from Lewisham

There are, however, crucial differences. The secretary of state will have far less flexibility in responding to a special administration at Mid Staffordshire. Under the 2009 act (used for south east London), he is able to change the trust special administrator’s recommendations almost at will.

To do so under the 2012 act, if the NHS was insistent on the changes that the trust special administrator recommended, he would be put in the position of having to sack the boards of Monitor and the NHS Commissioning Board to get what he wanted. 

The 2012 legislation does give the health secretary the power to veto administration decisions, but only at a very high cost: destroying the spirit of the entire Health and Social Care Act. That is a very high bar indeed.

‘Moving on from the scandal must surely involve ensuring that health services in Stafford are fit for the future’

The second difference is that Mid Staffordshire sits in a relatively marginal Conservative constituency. Jeremy Lefroy, the MP, will no doubt feel aggrieved if his constituency is stripped of important services such as an A&E when Jeremy Hunt is seen to have intervened to save an A&E in Labour Lewisham, even if such an intervention is effectively beyond Mr Hunt’s power. Although legally the Lewisham decision is not a precedent, it is unlikely that MPs and hospital campaigners across the country will see it this way.

Part of the purpose of public inquiries is to draw a line under past scandals, identifying what really happened and spelling out the lessons which need to be learned if the tragedy is never to be repeated. In this respect, the Francis inquiry may succeed. However, the legacy of the scandal at Mid Staffordshire lives on in the trust where it happened. 

It is impossible to right the wrongs that were done, but moving on from the scandal must surely involve ensuring that health services in Stafford are fit for the future. In this respect there is a long way to go. The pain of putting things right has only just begun.

Mike Birtwistle is managing director at MHP Health Mandate