The must-read stories and debate in health policy and leadership.

A case of desperation

HSJ’s exclusive on the latest accident and emergency data fiddle – this time involving several hospitals trying to artificially boost their four-hour performance data by exploiting a loophole opened up by the introduction of new emergency day care units – generated a lively debate in the comments section. 

The story concerns the mandated rollout of same day emergency care units, which are designed to treat patients judged to require several hours’ worth of treatment, tests or observation, avoiding the need to admit them to an overnight bed.

Concerns have been raised to HSJ that trusts are simply rebranding part of their emergency department as an SDEC unit and saying, “these patients no longer count in the four-hour data”.

However, one staff member at a large A&E department pointed out: “But there’s no actual change in clinical practice – it’s just an exercise designed to game the system.” They were not alone in raising the concern. 

News trusts are gaming the system will come as little surprise to many. Stories about hospitals fiddling their figures have been around for as long as hospitals have had to report their figures.

So, why should we take note of this latest not-that-cunning wheeze?

Firstly, a large chunk (between 20 and 30 per cent) of emergency admissions are set to be triaged into SDEC units – so, this is not a case of tinkering around the edges.

Secondly, such behaviour could threaten the credibility of the whole SDEC programme, which is a flagship policy of the NHS long-term plan. While it is not without its critics, it has broad clinical support from all the major royal colleges.

Finally, and perhaps most importantly, it begs the question, “why are trusts doing this?” HSJ would argue the vast majority of managers do not want to cheat or cover up poor performance. It is more a case of desperation: overstretched and understaffed A&Es simply cannot cope with the rising demand and no number of telling offs from the centre – even those of the highest quality – will shift the dial. As the saying goes: you can put lipstick on a pig, but it’s still a pig.

Fit and proper regulator?

For the second time, the Care Quality Commission’s handling of fit and proper person test regulations has been found to be wanting by the Parliamentary Health Service Ombudsman in a new report.

This time, the PHSO has looked at the way the regulator handled a complaint by former paediatrician David Drew against now retired NHS CEO Sue James in 2015.

At that point, Derby hospital commissioned an independent investigation costing taxpayers £200k. It cleared Ms James but now lies tainted by the PHSO’s findings that the CQC was guilty of maladministration for failing to pass on Dr Drew’s evidence and concerns to the trust and preventing him from taking action to tackle criticisms of him in the report before it was published.

Why does any of this matter? It underlines the weaknesses in the fit and proper person test regulations, including poor drafting and implementation. In this case, the CQC did not follow its own guidance and policies in relation to Dr Drew, which seriously undermines the regulator’s reputation for handling whistleblowing concerns from external sources. The CQC has consistently argued it does not have the power to take action against unfit directors, even though it has the ability to impose conditions on organisations that can require individuals to not sit on trust boards.

The entire fit and proper person test regulations have been a mess – a failed experiment to avoid proper professional regulation of senior NHS managers. Tom Kark QC’s recent proposals have again raised the need to both better support managers as well as hold them more to account for their actions.

It is time the nettle was grasped and the sooner the better.