Developing Labour Health Policy Birmingham 2006

10am – 3pm Saturday 11th November 2006

Birmingham and Midland Institute Margaret Street, Birmingham, B3 3BS

Notes of the discussion:

1. Medical negligence – what happened to the NHS Redress Bill? – It has just been passed by the Lords. The DoH website says “The detail of how the scheme will work in practice will be set out in secondary legislation, and there will be consultation with stakeholders on the detail of how the scheme will operate as we develop this, within the scope of the broad powers taken in the Bill.” We think that there are sound ideas in this Bill and they should be developed and implemented, possibly in conjunction with the proposals for reform of systems for Regulating Health and Social Care Professionals, because issues relating to negligence litigation have a huge impact on the complaints system. They impact greatly on the first issue the Policy Forum want to address – “How do we do more to empower patients?”

2. The establishment of the National Patient Safety Agency is an important achievement of the Labour Government, but its intention to “promote an open and fair culture in the NHS, encouraging all healthcare staff to report incidents without undue fear of personal reprimand” is a long way from achievement, and this is partly because of failure to deal with problems resulting from the litigation system and the weaknesses of the complaint system. Patients who have been damaged by the NHS want truth, justice, restitution, and closure. They don’t get these very often from our present systems, but a lot of mostly public money is spent by lawyers arguing about whether they are going to get compensation. We are very much in favour of “creating an environment in which staff are able to report incidents openly and honestly without recrimination”. That should include open and honest disclosure to patients regardless of legal liability’. We would like to see more progress towards a situation where patients and carers could benefit from a similar environment, and they too could report incidents easily. The present system assumes that the staff will know that something has gone wrong, but sometimes only the patient knows that. At present patients who complain are at risk of retribution, victimisation and denial of healthcare.

A study of 4000 patients in 1995 found hospital acquired infection resulted in an extra 14 days in hospital, a 10% chance of dying, an extra £3154 spent on healthcare and six extra days off work. The study concluded that the economic burden of hospital acquired infection was about £1 billion a year for the NHS in England and affects 1 in 10 patients. The total number of bed days consumed by hospital acquired infection was then estimated at about 3.6 million a year, or equivalent to about 27 400-bed hospitals working at 90% capacity.

3. Health acquired infections are a very serious concern to patients but it is not clear that their concerns are always taken as seriously by healthcare staff. These costs will have risen considerably in the last ten years. Although there is now a great deal of guidance available it is apparent that this problem is a good deal worse in the UK than in most other European countries. The reduction in numbers of cleaners in hospitals does not yet seem to have been made good everywhere. We would like consideration of whether further measures, such as screening of staff and use of face masks in certain situations, would be appropriate. Furthermore, if this problem proves intractable, we may have to contemplate major changes in the way we deal with people vulnerable to infection – which of course includes most hospital patients.

4. The handling of complaints needs to be much improved. There are far too many different processes for handling complaints and they are not joined up. Most PALS services (with some honourable exceptions) are transparent public relations services for their trusts with insufficient status to challenge poor practice. Concern for confidentiality has been used as an excuse to prevent any useful monitoring of complaints. We want to see detailed information about services which are subject to complain made available to the public.

5. The introduction of more choice for at least some patients may make hospital managers more sensitive to the concerns of patients, including those which they traditionally belittle, such as food and parking. But without the provision of much more useful information than is currently being made available it will not achieve much. Unless assistance is provided then informed choice will only be available to those who have the advantages of literacy, numeracy, access to the internet, and their own transport. Choice at present is still generally confined to the question of where and when planned operations take place. Planned surgery is a small part of the NHS budget. Patients are much more interested in choices about managing chronic conditions, where they have a more informed view. We are glad to see some progress on choice in mental health and maternity.

6. It now seems clear that it will be necessary to close or reconfigure quite a large number of hospitals, typically those serving towns with population between 80,000 and 150,000. This is likely to arouse fierce opposition. These issues have not been handled well in the past, and part of the problem has been that the NHS has not been as open about the dangers of ineffective hospitals as it could be. Hospitals, even the best of them, are not safe places to be. It is hard to think of any other industry where a 1% chance of death resulting from a service would be tolerated. Of course the public has immense attachment to local hospitals (more than patients who will be more knowledgeable about their failings). If we are going to manage the process of reorganisation successfully then the processes of public consultation and involvement need to be strengthened considerably. We will need to demonstrate that distance to the nearest casualty department is not as important as the time taken for the paramedic to arrive and that travelling further to a centre of excellence is more likely to keep us alive than going quickly to a place where there is less expertise. At the same time we need to be much more aggressive about moving services like outpatient clinics, diagnostic testing and monitoring out of hospitals into local health centres. We will need more, bigger and better equipped health centres to be in place before hospitals are closed or downgraded. This may well mean the end of the small General Practice. And we need to be able to demonstrate that sick and vulnerable people can be cared for effectively at home.

7. The computerisation of health records has the potential for considerable benefits to patients, but those benefits are not yet apparent, leaving the IT programme vulnerable to criticism. We have still not achieved a culture where information in medical records is accessible to patients, and there is plenty of evidence showing that many medical records are inaccurate and that in cases of dispute they are tampered with. Computerisation has the potential to improve this situation. It also could improve the delivery of what is supposed to be a joined up service with continuity of care. In fact at present every NHS organisation keeps its own records and few have access to records of other organisations. In a more mobile society this is both dangerous and wasteful. We do not want to see any retreat from the computerisation programme and we would like to see a more robust exposition of the benefits to patients. See Patient Record Access Fisher et al 2006

8. It will always be necessary to ration healthcare. The introduction of NICE was an excellent initiative, and needs to be defended. The increased funding for the NHS over the past few years considerably reduced pressure to pay for new drugs and procedures, but increases on that scale are not sustainable. Difficult decisions about priorities will need to be confronted. Many health professionals feel that the government is encouraging unreasonable expectations in the public which cannot be delivered on any conceivable budget. In fact most patients’ expectations are modest. They can cope with more information than they are given, and they are usually realistic about heroic interventions. Most of us do not want to expire in an intensive care unit full of tubing. We would rather die quietly at home. Given that most NHS expenditure goes on our last year of life there has been little public debate or information about priorities in this area. Patients are very keen to take up any opportunity for a cure when they are well, but they be more open to discussions about withholding invasive treatments with little chance of success than most professionals give them credit for. If we are going to deliver more care at or close to home then this must include end of life care which is the most resource intensive.