Thursday, February 07, 2013


My UK colleagues have had two reactions to the horrors revealed in the recent report about Staffordshire Hospital.  Some have said that, while terrible, it was an isolated and unusual set of circumstances.  Others have said, that while less extreme, the conditions underlying the degradations of clinical services at Staffordshire exist throughout the country.  From here in the US, it is hard to judge, but I'm guessing that both views are correct.  The degree of harm to patients at Staffordshire was, indeed, appalling.  The level of more subtle, but real, harm at other hospitals remains.  Let's look at two quotes:

The New York Times reported:

The report into what has been called the biggest scandal in the modern history of the health service found that many of the problems were due to the efforts of the hospital to meet health-service targets, like providing care within four hours to patients arriving at the emergency room. It also said that in its efforts to balance its books and save $16 million in 2006 and 2007 in order to achieve so-called foundation-trust status, which made it semi-independent of control by the central government, the hospital laid off too many people and focused relentlessly on external objectives rather than patient care.

The Huffington Post UK reported:

Robert Francis QC, who led the public inquiry into Mid Staffordshire NHS Foundation Trust, uncovered failings at every level of the NHS and said the culture among healthcare staff must change. His comments come as it emerged there were 3,000 more deaths than expected at another five NHS trusts between 2010 and last year.

Mr Francis, speaking ahead of a public meeting with the families of former patients at Stafford Hospital, said: "What we need to avoid is yet another wholesale reorganisation of abolishing organisations and creating new ones.  This is about how people behave when they go to work and their ability to raise concerns and be honest about what's going on in their hospitals."

He said the change would only happen when NHS managers, clinicians and staff started to address the failings "rather than waiting to be told what to do from Whitehall, or by the top of the NHS".

I can almost hear many of my US colleagues say, with self-satisfaction, "This kind of thing could never happen here."  But I can hear my more thoughtful colleagues saying, "It is happening here."

In the US, we start with a baseline of about 100,000 people being unnecessarily killed each year in hospitals, and many more suffering from unnecessary complications, infections, and other morbidities.  In the US, we have introduced a set of metrics about clinical care, generated by bureaucratic forces, that are often arbitrary and have the potential for unintended consequences.  Our accreditation process encourages "teaching to the test" as opposed to evaluating systemic issues within institutions.  Likewise, our review process for graduate medical education programs fails to enforce standards of competency that ostensibly are required for residents.

In the US, we have engaged in a restructuring of the industry that shifts financial risk to doctors and hospitals and that encourages consolidation and reduces competition.  Repeating our failures in investment markets, we fail to regulate providers to see if they are financially capable of absorbing risk.  We celebrate the expanded role of private equity firms in owning and operating hospitals, with an ostrich-like approach to understanding how such firms create profit.  The potential for short cuts and under-treatment and degradation of clinical equipment and hospital infrastructure arises in these circumstances.  Meanwhile, we fail to provide the kind of real-time transparency of clinical outcomes, pricing, and financial results that would help hold institutions accountable to themselves and to the broader community.

All in all, it sounds like a setup for the kind of problems experienced by our friends across the Pond.  So, let's not be so self-satisfied.  There is at least one Staffordshire in our midst, and there are hundreds of other hospitals that do not make the grade for the kind of quality, safety, and transparency that you would want for members of your own family.


The Medical Contrarian said...

Where is the Joint Commission?

Paul Levy said...

The question answers itself.

richard.blogger said...

I am an elected governor of a Foundation Trust (recently re-elected for a second three year term). Mid Staffs provides a lot more lessons than the superficial treatment the Press have given to this, the Second Francis Report.

The Press want retribution, Francis does not offer scapegoats. (Let's be clear - and Francis said this in his first report - it is unsafe to accurately attribute any number of deaths to the elevated standardised mortality rates seen at Mid Staffs. It is important that the figures of 400 to 1200 deaths were disputed by Francis, and it is important to note that there were no additional coroners' inquests, or any criminal investigations during the period of these ascribed deaths. If people insist on giving absolute numbers of 'additional' deaths then they need to be prepared to criticise the coroner process that failed to investigate them. From my perspective, poor care is unacceptable, period. You do not need an extra "unnecessary" death to say that.)

Mid Staffs is two hospitals - Stafford and the smaller Cannock Chase - and the trust covers a rural area with (in UK terms) large distances for patients to get to hospital. When the trust was created there were many doubts as to whether its income was large enough to be financially viable. Clearly it wasn't because the trust generated a debt and in attempting to clear this debt (so that the trust could achieve Foundation Trust status) undoubtedly led to fewer than needed staff and poor care. The organisation that authorises trusts as Foundation Trust, Monitor, has now declared that Mid Staffs is too small to be financially viable and there are now measures to break up the trust and merge the hospitals with other trusts. This decision was a decade too late.

Was Mid Staffs isolated? Well, if you look at tables of HSMR then you would say "yes". But HSMR is a statistical measure and it is not save to say a 1 point increase over 100 means that a specific patient's death was unnecessary (neither is it possible to say that a one point decrease from 100 means that some how the trust is "unnecessarily" keeping people alive).

There are several small trusts that cover rural areas, and have as poor finances as Mid Staffs did. One example is George Eliot Hospital in Nuneaton (which, coincidentally, has high standardised mortality rates). However, rather than making a rational decision about whether this trust is financially viable, the current government is keen to use the largely untested franchise model and allow a private company run the hospital for a ten year period. The government believes that however small a trust's income is, it is management that is the issue. Will George Eliot be the next Mid Staffs? No one can say for sure, but forcing the franchise model onto the trust will not help.