Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern

After a short break, normal service from the Risk Register is resumed. This week, a selection of stories that left me wondering about the lack of common sense in some corners of the NHS.

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Shaun Lintern, patient safety correspondent

A fight worth having?

A 17-year-old girl is preparing to take her AS-Levels in maths, physics and biology in the next few weeks but has been suffering for years with severe narcolepsy, a condition which has left her with chronic sleep deprivation, fatigue, hypnogogic hallucinations and uncontrolled collapsing (cataplexy). Her clinicians argue that unlike other patients with the condition she is getting worse and the only drug available, sodium oxybate, should be provided for a three-month trial at a cost of £2,000.

Instead, NHS England decided to refuse a funding request – most recently on the grounds that it did not consider her case exceptional – even though it accepted the drug would likely be effective and offered good value. It then continued disputing a judicial review brought by the girl’s parents even though it was warned by a judge earlier this year that it should probably think again. At the High Court last week, NHS England was again urged by the judge to reconsider but it did not – with the obvious end result.

The commissioning body received a mauling from Mr Justice Collins over what he said was a “thoroughly bad decision” that was “irrational” and based on an “absurd” policy. He is expected to issue a rare mandatory order compelling NHS England to provide the drug for the three month trial.

It is another embarrassing chapter for NHS England’s specialised commissioning directorate and in particular its policy around individual funding requests. Never an easy subject and of course not everyone can get the drugs they need in a world with finite resources.

But this was not such a case – the girl was clearly in an exceptional position. The obvious question that remains is how much money did NHS England waste fighting this case all the way, and what could that have funded in the way of drugs for other patients?

Competition bites in Doncaster

Another week, and another NHS trust facing serious service provision issues as a result of the government’s heavy handed attempt to break the agency market. HSJ has already highlighted A&E departments being closed, operations cancelled and wards closed because of the impact of the agency caps on trusts’ ability to source staff.

Doncaster and Bassetlaw Foundation Trust has been forced to suspend inpatient admissions and transfer patients to other hospitals because it says other neighbouring trusts have been breaking the spending caps on staff.

Chief executive Mike Pinkerton warned the lack of locum agency staff to fill rotas “now poses an escalating continuity of services risk” to the trust.

One can hardly blame other trusts for doing what they need to ensure their wards and patients have sufficient staff and the situation is being replicated elsewhere. It’s another example of the damage being wrought by the agency caps which were implemented too fast in a desperate attempt to arrest the increase in agency pay as a result of the long-term understaffing of NHS wards going back to the previous Labour government.

While NHS Improvement trumpets its success at reducing the agency spend, the question has to be at what real cost is this spending being reduced?

An elephant in the room

According to a leaked report into the culture within Wirral University Teaching Hospital Foundation Trust’s maternity department there is a “clique” of midwives who have prevented staff raising concerns and left some feeling ostracised. Worse still, this group’s behaviour was known to senior management and reinforced. The report said knowledge of the clique was an elephant in the room for senior managers.

This is a worrying finding and is reminiscent of cultural problems that have been found in other parts of the NHS. Such problems can, if left unchallenged, lead to serious poor care for patients. While there is nothing to suggest that the cultural issues in Wirral’s maternity unit had any impact on care, the risks of such behaviour should be widely known by executives in the NHS and as such it is inexplicable that managers at Wirral allowed the situation to continue.

That said, the trust’s new nursing director deserves credit for engaging with HSJ on this story and being clear that she will take proactive steps to address the findings of the report.

It’s good to talk

As you read this, the British Medical Association will finally be sitting down once more with the government to try to hammer out a compromise on the junior doctors’ contract.

Medical royal colleges showed their value last week in intervening in the toxic dispute with the suggestion that both sides should suspend their rhetoric and talk.

Of course the inevitable happened and there was a day long to and fro between the BMA and Department of Health on Friday after Mr Hunt said the government would only talk if the BMA committed in writing to discuss Saturday pay rates.

An interesting new research paper on weekend mortality out last week also suggested the increased excess deaths was due to higher sickness and probability of admission. A worry for the government which has framed much of its argument around this – unnecessarily so.

One note of caution however. Multiple research and reports by many bodies over a number of years show that irrespective of mortality there is a clear case to improve services for patients who survive their weekend stay in hospital. This should not be abandoned.