Between 1997 and 2010 our NHS improved in terms of everything that could be properly measured, as independent studies have confirmed. Plans to continue this improvement have been overtaken by the Coalition’s wasteful and unnecessary reorganisation.
Labour invested in the service and in those who worked in it and dramatically improved access, hugely reducing waiting times to levels thought impossible. Labour’s use of targets, such as those for waiting times, met with some reasoned criticism but on balance independent observers accepted that they contributed to the improvement in our NHS.
In 2010 patient satisfaction with NHS was at its highest ever level but nobody could claim that the NHS delivered excellent care for everyone at all times. Reports of poor patient care, each telling of a personal tragedy, continued to be an unhappy reality. Anyone who has ever held a very senior management post will have had to deal with incidents of poor care in their own organisation. The most recent evidence indicates that between 5% and 8% of hospital deaths are avoidable. But these regrettable incidents should always be viewed against the complexity of what the services have to do and the sheer scale of the NHS, with millions of patient interactions which do not go wrong.
In 2009 a report by the Healthcare Commission revealed a history of poor care at Mid. Staffordshire after a lengthy investigation. Two further investigations requested by the then Secretary of State were followed by an independent inquiry chaired by Robert Francis QC into care between 2005 and 2009. These set out what had happened and made recommendations, most of which were acted upon. One recommendation was to look at how such a significant and serious history of poor care had not (apparently) been identified by the Board of the Trust, various regulators, commissioners, local GPs or the system performance managers including the Department.
It is very unlikely that emergency care at Mid. Staffs represented anything like the norm in the NHS but it remains true that some aspects of poor care found there could still be found in some parts of some hospitals even today as pressures on staffing levels and finances are as severe as ever. We cannot be certain since we still lack comprehensive real time reporting systems covering all the aspects of quality of care within one organisation let alone across the wider care system.
The consensus response to the evidence of the first inquiry was that the responsibility for the way the hospital was run rested with its board, management and staff but the framework of targets, regulatory systems and policy priorities it worked within were also very important. In response a further inquiry (also chaired by Robert Francis QC) was set up in 2010 so that there could be consideration of how “we might improve the regulatory process including the CQC and Monitor, primary care trusts and strategic health authorities, as well as the Department of Health itself”. The evidence has been published and the report will be made public early in February.
Some will try and use the sad experiences of patients and families to score political points. They will try and deny the improvements Labour made. They will claim the move to “markets” was a major factor, or that “targets” were to blame, or that the “bullying” culture of the NHS suppressed concerns. Others will claim than nobody in the system cared about patients as everything was just about finance. All such charges have some resonance within the NHS but there are still are simplistic, and not supported either by the actual evidence provided to the inquiry or by other investigations covering a wider perspective than just one trust and one period of time.
The evidence provided to the latest inquiry does make uncomfortable reading as it shows that serious issues were not identified and addressed and that, at least in respect of this trust, the systems for protecting patients simply did not work. It also starkly illustrated how various bodies failed to communicate with each other, and how the regulator of Foundation Trusts – Monitor – gave the trust the thumbs up a few weeks prior to another regulator announcing an inquiry because of serious concerns. It is still far from clear who knew what and why they did not act on what they did know.
At the end of the (second) inquiry Robert Francis set out a number of areas where he was clear recommendations would be made, especially around regulation. Regulation is hard to do. The key current regulator the CQC continues to be under criticism and it remains unclear if regulation is to enforce minimum standards or to lead improvements in quality. Who sets the standards against which regulation is carried out? What parts do information, local intelligence, patients and staff reporting play within regulation? Can we ever simply ignore costs? Can we regulate commissioners as well as providers?
It is likely many sensible recommendations from the inquiry will be acted on; changes to regulation of people and organisations being likely. Being clear about which regulator does what, and why we need so many. But better more accountable management, being far more open, giving patients a stronger voice, encouraging transparency and providing information and tools for sensible analysis are also necessary. There is going to be a lot to consider before we go too far in making additional changes to an NHS already under huge pressure, mired in controversy about the current reforms and with a demoralised and frequently demonised staff.
Our NHS is far better service than it was 15 years ago, and its improvement trajectory is continuing. The achievement of the 1.4 million staff should never be underestimated. But to get to excellent care all the time we still have a long way to go and unless we start looking at culture and behaviour instead of markets and reorganisations we will never get there. We have to be honest about trade offs between access (rationing and waits), quality and finance, about conflicts between localisation of services and quality and differences between management of performance and regulation – and much more.
PS
There is an irony that the view of the regulator Monitor is that despite every effort and all the attention; replacing the Chair and Chief Executive (twice), additional funding and sending in the best people and teams of management consultants, Mid. Staffs. is not viable in its current form. It cannot deliver the range of services expected to the appropriate levels of quality, within the financial envelope available to it; the classic small DGH problem. That was true ten years ago, but we are no nearer to facing up to the challenges posed by reconfiguration of acute services; an issue at least as important as regulation.