Andrews Report — A failure of trust

Quality of care Wales

The Andrews Report (Trusted to Care) into concerns at two hospitals in Abertawe Bro Morgannwg University Health Board (ABMU HB) was published at the beginning of May 2014. The NHS Confederation in Wales rightly said “ “We are shocked and saddened by the findings ….. into the quality of care for older people at (the) two hospitals. It is terrible that patients and their families have suffered such distress and it is absolutely right that all failings in our health services are laid bare. “

After reading the report “….no one should be in any doubt that there are aspects of the care of frail older people which are simply unacceptable and must be addressed as a matter of urgency through action by the Board of ABMU and by the Welsh Government.” (Andrews Report)

In the face of the this damning verdict the immediate priorities must address the failures that have been highlighted and provide redress to the patients and families who have been affected. The Welsh Government has committed itself to doing this with the Minister, Prof Mark Drakeford, promising “.. that nothing of this sort will be tolerated in Abertawe Bro Morgannwg University Health Board or indeed anywhere else in Wales in the future.”
The Minister outlined a range of detailed actions which he expected to take place and underpinned this by a clear pledge to undertake follow-up inspections to see that improvement is taking place. But as we welcome these assurances, we must also step back and reflect on how things could deteriorate to such an extent in a key public service which embodies the highest humanitarian principles and commitments to care.

In responding to the Report the local Assembly Member, David Rees, pointed out that our response must be measured. The seriousness of the situation should not be devalued by efforts to make opportunistic political capital from a sickening situation. Despite efforts for opposition parties in Wales to suggest otherwise, the Report clearly states “ABMU has not at any point been another Stafford “ .
Attempts to portray the specific failures as being more generalized are both alarmist and unacceptable. Such opportunistic, politically motivated scare tactics not only frighten patients unnecessarily but also undermine the good work that is undertaken by staff at the affected hospitals. The ABMU Health Board recent “Friends and Family” ward feedback questionnaire showed satisfaction levels well about 90%. This confirms the Andrews’ Report finding that the unacceptable failures that it revealed were not to be found in all instances all of the time.

But fact that such sickening practice happened at all must raise questions as to why they occurred and were allowed to continue for too long. The Andrews Report states that there were insufficient corrective processes in place to tackle bad practice as it emerged and consolidate itself.

There was a lack of professional and clinical leadership. Those who might have responded did not do so because they did not feel it was their problem or because they felt they could do nothing about it. This led to culture in which low standards were tolerated and perpetuated. The Health Board’s own clinical governance and audit processes were found wanting. Clinical concerns from staff, patients and their families were either unspoken, unseen or unheard. The actual patient experience was buried underneath a surfeit of information, reports and conflicting priorities.

The nature of Board Membership and how it works must be part of the problem. Following the latest re-organization the Boards are more similar to those of disbanded Trusts than the previous community based LHBs. While there is some community, third sector and trade union representation on the present boards they have a decided technocratic bias. This can provide a specialist expertise in holding the local health service to account but the NHS experience of Board members is unlikely to be typical of the community they serve. Better off and better educated people tend to get a better service from the NHS in terms of access and outcomes. In view of this, our Health Boards need to be better at capturing the experience of those who have the greatest need for and have the greatest difficulty in using the service.

The Report makes clear that individual health care workers must have a collective and an individual responsibility for standards of care. Health bodies and managers must recognize this. Clinical care is a partnership between the patient and their clinician. As part of this relationship the clinician or carer must see advocacy and being a champion for their patient as part of their duty. Those who raise concerns must not be seen as “an awkward squad” but must be listened to and taken seriously.

The complaints process for patients is not only a key way to raise concerns and seek redress, it can also provide an important warning light that all may not be well in the way services are being delivered. But the Andrews Report said the ABMU process was slow, bureaucratic and failed to highlight the deep problems which under-pinned legitimate concerns. The complaints process is being reviewed in Wales and this Report provides important pointers as to how it could be improved.

But we cannot just depend on a complaints process to highlight patients’ concerns. The personal experience of patients’ use of the NHS has to be monitored much more effectively. ABMU’s use of concern clinics is a step in the right direction but they should become an everyday part of the NHS work. The use of surveys of patients’ experiences must also become routine. Lessons can be learned from the English NHS from its experience with NHS Choices and Family and Friends questionnaires.

Getting this information together is not enough. The Andrews Report pointed out that parts of the NHS are being overwhelmed by a mountain of indiscriminate and poorly organized information. Getting this information together must not become box ticking exercise. It should tell a story and give a clear message on how well people are being treated as patients and as human beings.

External bodies also failed in their duties to under-pin governance arrangements. Healthcare Inspectorate Wales (HIW) has been subject to particular criticism. It had visited ABMU in 2012 and its report highlighted some areas which could, in retrospect, have been seen as warning signals of deeper problems. But the seriousness of the situation was not recognized by either HIW or by ABMU and the response to the inspection action points failed to achieve the necessary improvement. This has led to calls for a review of how HIW undertakes its work and its overall fitness for purpose but any such review cannot look at the regulators operation in isolation.

The Report was also critical of the Community Health Council (CHC) in failing to identify concerns or to work with ABMU to address them. CHCs have been in place since1974 in Wales with the mission to be the patient’s voice. Despite their 40 years existence they continue to have a very low profile and public recognition. Much of its volunteer members’ time is spent in meetings with papers in excess of 100 pages at times for consideration. As well it undertakes inspections of health care facilities though how productive this is debatable. It does have a complaints advocacy service which is generally valued. It supports about 10% of NHS complaints which could be a source of valuable intelligence on local health service performance though how effectively this information is used is not clear.

This is not to say that there is no role for CHCs. There clearly is but how their functions can best be delivered needs further thought. There have been repeated recent reviews of CHCs and how they perform but the Andrews Report provides little reassurance that we have gotten it right.

The Andrews’ Report highlights a lack of transparency in and accountability for health service performance. There is a democratic deficit. At a national level in Wales the National Assembly carries out an important role in holding the Minister and Welsh NHS to account. But this does not extend beyond Cardiff Bay. This was not always the case as local authorities played a key role in the delivery of public and community health services up to the mid-1970s when they gave way to health authorities.

The Beecham Report in 2006 proposed the concept of a single public service in Wales and since then greater public service partnership and co-operation has been at the heart of public service delivery. At a local level our councils are our key democratic forum for most public services, with the exception of the NHS. This can be seen to be an anomaly.  If 60 Assembly Members are involved in most public service delivery in Wales at a national level, then there is no reason in principle why something similar should not take place locally.

Local elected representatives are well recognized as being local advocates for users of public services. Indeed how well they do this is frequently how their electorate judges their performance. They can therefore be an important barometer of the quality of local services though at the moment this role does not include the NHS.

However this is not straight forward. The recent Williams Commission showed that there are continuing weaknesses in local government governance arrangements. Too often elected members have struggled to use their case working and local advocacy role as a platform to effectively fulfill their role in the wider scrutiny of the services for which they are responsible. Furthermore the 2012 Longley report on CHCs showed that local government representation at that level leaves a lot to be desired. However these failures are not just down to the performance of individual councillors. They are, in part, a cultural legacy as to the role of an local elected representatives but they also stem from a lack of proper support and training.
The routine experience of patients in the Welsh NHS is that they get high quality, compassionate care.  But  the Andrews Report shows it is not universal. The legacy of this Report must be that it provided a fresh impetus for a renewed culture of accountability for standards across the Welsh health service.