Grenfell: There but for the grace of God goes the NHS

For the NHS, the most immediate impact will be on those acute trusts whose buildings are covered with cladding that fails safety tests.

But more significantly the focus on fire safety – as with the recent cyber-attack – will highlight how the NHS’s non-clinical resilience is skating on the thinnest of ice.

The implications of Grenfell are still emerging, but already there are some very valuable lessons to learn.

The first is that the NHS has a problem with fire safety that goes well beyond the cladding of tall blocks.

On 31 January 2013, then NHS deputy chief executive David Flory wrote to all NHS trust chief executives warning that the “apparent mismanagement and lack of governance of fire safety issues [by the NHS] gives rise to overall concerns about patient safety”. Mr Flory then listed 20 areas of action.

HSJ’s extensive research into fire safety at NHS organisations, begun before Grenfell but only published last Wednesday revealed many would struggle to satisfy these requirements four years later.

Our research exposed plenty of trusts that had no single document pulling together individual fire safety assessments of their various buildings and departments. There were many organisations that had not reviewed the issue at board level for months or sometimes years.

Boards across the country need to convince themselves they have the information to make accurate judgements about fire safety risk, just as many have done – or will be required to do – on cyber-security in the wake of the recent ransomware attacks.

The nature of the Grenfell fire means there is an understandable concentration on large acute hospitals – but the greater fire safety risk may yet emerge in mental and community facilities, which have the worst record for blazes and often run on staffing ratios well below that found in the acute sector.

Cladding is not the only problem

One result of the NHS’s uncertainty around fire safety is that trusts are reluctant to be as transparent as they should be. As HSJ collected information for its fire safety review, an internal review by Moorfields Eye Hospital Foundation Trust concluded: “We do not believe there is a public interest in wider debate about our fire safety plans.” It is welcome that Moorfields – which was by no means alone in its response – seems to have rethought its approach (see comment below).

This context makes it easier to understand the confusion that has reigned in some parts of the system post-Grenfell.

For example, the risk matrix being used to assess the likelihood of a fire plus its impact takes no account of safety precautions already in place, such as compartmentalisation, alarms and sprinkler systems. There also appears to be considerable confusion as to what actual “standard” the cladding is being tested against. Thus, attention, could focus on cladding which may be deemed unsafe, but poses relatively little danger.

Trusts are asking for further guidance on how to assess risk, but are often being left to their own devices. The capacity and knowledge in the centre on the issue of fire safety is just as compromised as it is at local level and, of course, the unusual nature of the Grenfell blaze means people are being required to check the safety of buildings against unknown variables.

There is some understandable anger at what many perceive as a knee-jerk reaction by the Department of Health to the disaster given the impact on other pressing priorities. The problems in social housing are not replicated in the NHS claim many chief executives, with some reason.

However, once councils had begun testing every tower block and concern over other public buildings gathered momentum, the DH had very little choice; and in any case, HSJ’s research suggests complacency would be inadvisable. The better complaint would be: “Are you asking us to prioritise the most pressing risks?”

There is a real concern that replacing cladding may be prioritised regardless, gobbling up scarce capital that could be better used elsewhere – including tackling greater fire risks.

It was significant and welcome therefore that NHS Improvement restated the NHS’s need for investment to “make sure all of [it’s] estate is as safe as it can be”.

A fractured system is a dangerous system

An over-emphasis on removing cladding could also be a distraction from fire issues that are much more systematic in the NHS. A case in point is the complications posed by the NHS treating patients in buildings it does not own – as they were built under the private finance initiative.

Today, HSJ reports that University Hospitals Coventry and Warwickshire Trust was undergoing remedial building works after it discovered its new PFI building was not fire safe. HSJ has also reported that Sherwood Forest and North Cumbria have experienced similar problems and hears tell of many smaller, but still significant issues with fire safety maintenance issues in PFI built premises.

The problems with PFI buildings go well beyond fire safety and the fallout from Grenfell also highlights other weaknesses that could threaten the service in a range of emergencies.

As the call went out on 24 June to accelerate the speed of the fire checks some chief executives failed to get the message. One specialist trust chief executive only picked up the instruction because they saw HSJ’s coverage on social media. Another chief executive commented to HSJ that “one of the consequences of 2012 reforms is that system resilience and cascade is much more complicated” – a factor which also alarmed the centre during the cyber-attacks.

Then there is a question of capacity once the message has been received.

Very broadly, and correctly, the NHS’s clinical staff have been protected from the worst effects of the service’s financial squeeze and care quality and access has held up reasonably well as a result.

In contrast, administrative and support roles have been cut to the quick. Estates departments are shadows of their former selves and specialist knowledge of issues such as fire safety are concentrated in an ever smaller number of individuals. The cultural issues which have seen NHS staff treat both fire and cyber risks too lightly stem as much from overwork and distraction by other priorities as bad habits.

It is only in emergencies like Grenfell that this becomes clear.

The likelihood of a catastrophic failure in NHS resilience

Of course, austerity has wreaked much greater havoc elsewhere. In emergencies and times of extremis public services rely on each other. We have already seen how cuts to social care have affected the NHS’s performance.

The struggle of the fire service to respond to the government’s desire for reassurance in the wake of Grenfell has been well documented by HSJ and elsewhere; and, no doubt, as the state of UK’s social housing comes under the spotlight the implications for the country’s health will be highlighted. Cuts in police services and education all add their strains particularly in mental health.

The lack of capability in the wider public sector significantly increases the NHS’s vulnerability at moments of crisis.

That is not to say the only answer to these problems is to reinvest in public sector resources or that outsourcing, as with PFI or at Grenfell, is always a dangerous route. Those trusts, for example, whose IT support was provided by an external supplier seemed to suffer less from the WannaCry assault.

It is often commented on how well the NHS performs in a crisis. The service has been tested severely in recent months and the response at all levels of the service has often been admirable.

But that should not disguise the fragile nature of the service’s resilience. If you need further convincing of this assertion, try this thought experiment: how would the NHS cope if Grenfell had happened while it was dealing with a widespread cyber-attack, a major terrorism outrage, a flu outbreak during peak winter pressures – or a combination of any of the three. Unlikely? That is what most of us would have said about a tower block fire killing more than 80 people before 14 June.