In the wake of multiple healthcare scandals involving the ill-treatment of patients, the Coalition government is determined to promote ‘harm free’ care within the NHS. Bob Hudson explores the implications and omissions of new proposals aimed at improving patient safety.
Responding to scandals in healthcare treatment must rank as one of the hottest policy issues of 2013. Following on from the first Francis Inquiry into the ill-treatment and death of patients in Mid-Staffordshire Foundation Trust in 2010 (which looked at what had gone wrong) the second report (into why this happened) appeared earlier this year. This was followed in quick succession by the Keogh Report into higher than expected mortality rates in 14 NHS hospitals and a report by President Obama’s healthcare advisor, Don Berwick into improving patient safety.
The government published an interim response to the second Francis Report earlier this year and has now brought out its final response to all 290 of the Francis recommendations. This runs to almost 400 pages over two volumes. What have we got to show for it? The answer is a raft of solutions largely modelled upon a marketised view of healthcare provision – one in which ‘consumers’ are ‘empowered’ and a failure regime is in place to deal with ‘imperfections’.
Listening to and supporting patients, and widening the information base to help them exercise choice are all prominent themes. Much of this was already in train such as the extended use of the Friends and Family Test (whereby patients are asked if they would recommend a hospital or ward to friends or family), more prominence for the hitherto ignored NHS Constitution, and publishing clinical outcomes by consultant for ten specialities.
There are also new proposals. The government will act upon the recommendations of the recent report by Ann Clwyd MP on strengthening the complaints system and create a new army of 5000 ‘patient safety tsars’ within five years. In order to help patients exercise choice more wisely there is to be a new hospital safety website – ambitiously aimed at ‘putting the truth about care at the fingertips of patients’. Indeed, Health Secretary Jeremy Hunt says in his foreword that the measures will ‘ensure people know what the system knows’.
However the thrust of the new measures are in a different direction – the regulation of activity and the criminalisation of breaches of behaviour. Here there is a wave of proposals including:
- A new ‘duty of candour’ on provider organisations (but not individuals) to tell patients about medical errors, and a threat to remove government indemnity cover if the rule is broken.
- More robust inspections by the inspectorate – the Care Quality Commission – led by three newly appointed Chief Inspectors for hospitals, primary care and adult social care respectively.
- New barring regimes to determine if board directors of NHS provider organisations are ‘fit and proper persons’ and to prevent unsuitable persons working as untrained Health Care Assistants.
- New criminal offences of ‘wilful neglect’ and the provision of ‘false or misleading information’.
Spurred on by lurid and misleading headlines in the tabloid press of ‘50,000 too many people’ dying under Labour governments, all of this will doubtless strike a chord with the public. It also fits in with the wider political narrative developed by the Coalition government of blaming individuals for shortcomings in the system – people without jobs failing to look for work, people with disabilities holding the wrong mindset, people with too many bedrooms who are selfish. Now we can add NHS staff who simply don’t care enough.
The other problem here is not so much what is in the government’s response but what is left out. The key omissions are around participation and support. The Francis Report had much to say about the miserable record of the NHS in its relationship with local people, observing that the high tide of public participation had been reached with Community Health Councils – created by Barbara Castle in 1974 and abolished by a Labour government in 2003. The proposals in the Francis Report on strengthening the role of Foundation Trust Governors (most of whom are elected rather than appointed), improving public and patient participation in the Foundation Trust regulator, Monitor, and strengthening the role of the new Local Healthwatch bodies have all been downplayed. Notwithstanding recent guidance from NHS England on improving public and patient engagement, the reality is that local people – individually and collectively – have little or no say in how their healthcare is commissioned and provided.
The greatest omission, however, is an offer of support to NHS staff. The government seems to have largely turned its back on Don Berwick’s advice to ‘abandon blame as a tool’ and ‘make sure pride and joy in work, not fear, infuse the NHS’. The registration of untrained Health Care Assistants as recommended by both Francis and the Health Select Committee is rejected, as is legal protection for whistleblowers – people who currently put their careers on the line by exposing failures in care. More significantly and predictably the government has sidestepped the need for adequate levels of nurse staffing, both in terms of volume and skill-mix. Rather than set legal minimum staffing requirements, hospitals will be told to use evidence-based tools to decide for themselves what staffing levels to use, and to publish twice yearly figures to show they have met these standards.
Even the measures that are being proposed will have considerable cost implications. Hospitals will be saddled with more targets and reporting requirements at a time when much of their administrative infrastructure has been dismantled. Around 7000 nursing posts have already disappeared since 2010 but somehow hospitals will be urged to meet new evidence-based staffing levels. Failure will be laid at their door. In the meantime most trusts are being financially crucified by 4% per annum ‘efficiency savings’, Private Finance Initiative repayments and crippling tariff rules on delayed discharge, emergency readmissions and accident and emergency services.
What we are left with is an imbalanced response to the issue of harm free care, one that prioritises blame and recrimination over learning and support, inspection over participation and the imparting of information over accountability to local people. Failure will be perpetually in the spotlight, successes rarely exposed and celebrated.
It is possible this will suit a government that seems keen to undermine the idea of a publicly provided NHS. The thrust of the 2012 NHS and Social Care Act was to embed competitive tendering into the NHS and this has already resulted in an increase in private sector engagement. By continually profiling failure the public may well take the view that the traditional public sector NHS can no longer be trusted. But bad publicity is a two-edged sword. The more people believe their healthcare system to be failing the greater the likelihood they will blame the incumbents of political office. The government is playing a dangerous political game.
Note: This article gives the views of the author, and not the position of the British Politics and Policy blog, nor of the London School of Economics. Please read our comments policy before posting.
About the Author
Bob Hudson is Visiting Professor in Public Policy, Durham University. Prior to this he held posts at the universities of Leeds and Glasgow. He has written and researched widely on health and social care issues and is currently undertaking work on public and patient engagement in the NHS.