Select Committee on Health Written Evidence


Memorandum by Mr Arthur Briggs (PS 22)

PATIENT SAFETY—A LOW PRIORITY OF ACUTE TRUSTS, PCTs & HEALTH AUTHORITIES

  My submission is a personal one, though I am a member of AvMA. My background before retiring was as a Project Engineer working in the Oil Exploration and Production Industry. Though living in Scotland, my experience is related to the Hertfordshire NHS bodies.

  My submission is centred on:

    —  the failure of the WHHT to put into effect a Risk Management system, despite the number of related policies issued by the DoH, CMO & NAO;

    —  the complacency and ineffectiveness of the various regional bodies in ensuring patient safety in the WHHT; and

    —  the need to change the culture of the NHS Management from the Trust level up to and including the DoH.

1.0  EXECUTIVE SUMMARY

  1.1  Patients admitted to some Acute Hospitals are exposed to an unacceptably high risk of HAIs and untoward incidents. Some die unnecessarily—These incidents could be reduced considerably—see statistics sections 2.1 & 2.2.

  1.2  The policy "Risk Management in the NHS" was introduced in 1994 as a guide to reducing these incidents. Sir Duncan Nichol, Chief Executive of the NHS, stated in the foreword that Risk Management was no longer an optional extra. Unfortunately, it was only a recommendation.

  Despite this and subsequent policy documents, Risk Management is not universally implemented by NHS Trusts. In sections 2.3 to 2.5 I have discussed the advantages of having a Risk Management Policy based on the CNST Clinical Risk Management Standards.

  1.3  In 1999 the West Herts Hospital Trust (WHHT) was at level Zero of the CNST Risk Management Standards. My complaint about the lack of a Risk Management system, QA and auditing was ignored. It has still only reached level 1. Not a reassuring record in terms of patient safety and confirms that enforcement is required rather than guidance.

  1.4  My submission sets out the history of Patient Safety events in the WHHT against the Patient Safety related national policies issued over the same period. Compare the reality of Patients Safety in the WHHT section 3.2 against the objectives of Policies section 3.9

  1.5  During this period the PCTs and Health Authorities in their various forms failed to take remedial action. These bodies ignored complaints about the problems in the WHHT and their complacency. Protecting incompetent managers was considered more important than protecting Patients. Their ineffectiveness is covered in sections 3.4 to 3.8.

  1.6  I have concluded with proposals for improving Patient Safety in section 4.—ie

    —  A Clinical Risk Management System to be put in place within an agreed timetable, say 2/3 years.

    —  A Complaints System that is Operated Independently of the NHS Trusts where harm or death has occurred.

    —  The identification of Incompetent Trust Managers who should be retrained or made redundant

    —  The introduction of a set of core standards which are guaranteed.

    —  PCTS & StHAs to be accountable for ensuring Patient Safety policies are met in Acute Trusts.

2.0  RISKS TO PATIENT SAFETY—DEFINITION

2.1  Statistics for Patients Admitted to Acute Hospitals in England.

    2.1.1  a)  1 in 10 patients suffer an untoward incident and

    b) 1 in 11 patients acquire a Hospital infection

  2.1.2  1 in 3 of 1800 deaths investigated in 2005 by the National Patient Safety Agency were unnecessary—ie at least 600 patients died unnecessarily.

  There is estimated to be at least 34,000 deaths / annum in the NHS caused by errors.—Some authorities believe this is an underestimate but the exact number is not known (A Safer Place for Patients Key Facts)

2.2  Are these Incidents & HAIs Avoidable?

  2.2.1  These untoward incidents and high infection rates are due to a combination of human and system failures. While all failures cannot be avoided, there is a lot that can be done to reduce the numbers of failures, including learning from failures.

  Referring to A Safer Place for Patients -Learning to improve Patient Safety NAO 2005 30% to 50 % could have been preventable

  There is no reason why these reductions cannot be achieved if given a higher priority.

  2.2.2  Essential to reducing incidents and infection rates are the changes set out in paragraph 1.6 and section 4.

2.3  Risk Management—Definition

  Risk Management covers all the processes involved in identifying, assessing and judging risks, assigning ownership, taking actions to mitigate or anticipate them, and monitoring and reviewing progress. (Definition from Standards for Better Health).

  The more effective the risk management system, the higher the standard of patient Safety.

2.4  CNST Clinical Risk Management Standards—Introduced 1995

  2.4.1  A summary of the CNST Clinical Risk Management General Standards 2005 issue is attached

 (appendix 1). Even a layman can understand the benefit of being treated in a hospital which is compliant with levels 2 & 3 rather than level 1. eg using Standard 1: Learning from experience

  2.4.2  An Acute Trust in which incidents and near misses are reported in 100% of all specialities and can provide examples of how that information has been used to improve patient safety will be inherently safer than a Trust at Level 1 which only reports incidents and near misses in 50% of all specialities.

  2.4.3  Reporting some incidents ( a level 1 requirement) is not much good if the Management takes no action and does not learn from experience.

  2.4.4  A Trust progressing from level 1 to level 3 will increase the level of Patient Safety. The NHSLA authority actuaries would be able to provide detailed evidence of the benefit of such a system in terms of improving Patient Safety and reducing negligence claims.

  2.4.5  A measure of the improvement in Patient Safety is that for compliance with each level, there is a 10% reduction in the contribution to the CNST scheme up to a maximum of 30%. For the WHHT, paying a gross contribution of £4.2 million in 2004, there would be a financial saving and considerable improvement in Patient Safety if operating at level 3.

2.5  Consequences of No Risk Management System

  2.5.1  Conversely, without an effective Risk Management system, an integral part of governance, patients will be at greater risk. Managers will not be in a position to manage and optimise their use of limited resources.

  2.5.2   A Clinical Risk Management System is not considered by the NHSLA to be to be in operation until level 2. Unfortunately for patients 45% of Acute Trusts are still at level 1

  2.5.3  As the CMO has stated, Patient Safety needs to be a core non-discretionary activity. CNST standards are measurable and so are the benefits in terms of Patient Safety.

3.0  NHS BODIES INEFFECTIVE IN ENSURING PATIENT SAFETY

3.1  Acute Trust Boards—Accountability for Patient Safety

  Accountability rests with the chair and board of each NHS organisation. Following the NAO report on "Health and Safety in NHS Acute Hospitals", HSG (97) 6—Annex A—Managing Risk, stated that the Chief Executive of the organisation has the overall statutory and operational responsibility for managing Health & Safety. Ideally an executive Director should be allocated clear responsibility for Health & Safety Risk Management across the whole organisation.

3.2  WHHT since 1999—History of Major Safety Failures.

  3.2.1  Some Trusts, such as the WHHT, will be more risky than the general statistics indicate. I would not want to undergo treatment in such a hospital except as a last resort.

  3.2.2  The low standards of Patient Safety of the WHHT have been confirmed over the years by a series of events including:

    a)  In 1999, the number of women patients (300 to 400) damaged by Drs. Kane & Rosenberg became Public. This was followed by an "Independent Inquiry" into these incidents and the "Effectiveness" of the WHHT Complaints system. The report was issued in 2002.

    b)  The HSE in April 2001 issued a warning letter to the WHHT, (and the Herts Partnership Trust and the St.Albans PCT) concerning their failure to train clinical staff in Infection Control (including MRSA).

    However, in August 2001 Mr.S.Eames, Chief Executive of the WHHT, advised me that collecting data on HAIs was unreasonable & too expensive.

    c)  The Public Health Laboratory Service MRSA League table for 2001—2002, placed WHHT 6th from top.

    d)  The HSE issued several Improvement notices in December 2002 one of which required the Trust "to provide executive and non-executive directors and divisional managers with adequate Health and Safety training to enable them to discharge their responsibilities"

    ie Board members did not realise they were not competent to fulfil their statutory duties.

    e)  The HSE in 2003 issued 3 Improvement Notices because of the Trust's failure to maintain water systems and prevent Legionella, a potentially lethal failure.

    f)  CHI awarded the Trusts zero stars for 2003/2004. Simultaneously, the Trust was operating at Level 0 Maternity standards.

    g)   The DoH who in November 2003 "imposed" a three year comprehensive Modernisation/ Improvement Plan

    Mr. John Bacon, Group Director, Health and Social Care Delivery, would be able to provide details

    h)  The Healthcare Commission in 2003/2004 reported that for the second year running, the WHHT did not provide or did not have data for:

    —  Emergency re-admissions following discharge (adults)

    —  Deaths following selected non-elective surgical procedures

    —  Emergency re-admissions following discharge for a fractured hip.

    and

    —  Infection control rated at level 2, as was hospital cleanliness

    This was despite or because of the study into the high rate of MRSA infections and deaths in the Hemel Hospital issued in March 2001.

    i)  The Audit Commission commented on dodgy data and other matters.—B&H StHA Annual Audit Letter 2004/2005.

    j)  A&E problems which were evident for several years, requiring 3 reports and another major incident before there was a significant improvement. On several occasions the Trust had ambulances queuing at doors.

    k)  The Trust operated between 2003 & 2006 without a capacity plan.

    l)  In January 2006 the HSE prosecuted the WHHT for failing to maintain hospital water systems and dispose of clinical waste safely. (amongst numerous other matters)

    m)  The HC in October 2007 awarded the WHHT a double weak rating.

    n)  The Trust in 2007 was awarded a position 17th from the top of the Clost. Difficile League,

    o)  In Jan 2008, the Healthcare Commission graded the Trust's Maternity Services the worst in England

    p)  PEAT teams in the past classified Trust Hospitals as Double Red, rarely green. The WHHT Trust managers blamed the problems of dirty hospitals on the cleaning contractors. The Hertfordshire Health Authority Performance Director, Mr.A.Morgan, would not or could not explain why the Trust managers continued to pay the contractors for sub—standard work.

    q)  The low standards of Care of the Elderly wards continued over several years, confirmed by NHS staff, the CHC and the Public & Patient Forum.

3.2.3  DoH Inspection 2007

  The basic hygiene & problems identified in 1999 and subsequent years should be history. In August 2007 the DoH inspectors confirmed they were not. The following actions were implemented after the visit:

    —  two isolation wards were opened;

    —  a rolling programme of deep cleaning with hydrogen peroxide nebulisers has been implemented, in line with the Secretary of State's proposals;

    —  restrictions have been placed on the use of cephalosporins, quinolones and protein pump inhibitors;

    —  the antibiotic policy has been revised and new flash cards for use by doctors issued;

    —  the hand hygiene policy has been reviewed;

    —  levels of general cleaning have been increased;

    —  the 24 hour rapid response cleaning team has been re-established;

    —  there is a zero tolerance policy on hand hygiene with dismissal for those who repeatedly fail to comply with hand hygiene policy;

    —  the bowel management system has been continued from an earlier trial;

    —  root cause analysis for Clostridium difficile positive cases has been implemented; and

    —  roles and responsibilities of individuals from board to ward have been clarified.

3.2.4  Conclusions

  3.2.4.1  This brief history confirms that simply issuing Patient Safety policy documents to such Trust Managers is not effective in improving Patient Safety.

  3.2.4.2  Using the CNST General Standards as a measure of Patient Safety, the WHHT is still at Level 1, another indicator that Patient Safety is not a priority.

  3.2.4.3  This series of events is not comprehensive and more detailed information was available to the various bodies with responsibility for ensuring WHHT delivered services that were Safe for Patients. Quite clearly, the bodies listed below did not.

3.3  PCTs Role in Patient Safety in Acute Trusts

  3.3.1  South Hertfordshire PCTs Prior to merger—Direct Involvement

The PCTs in the 2000 Service Level Agreements with the WHHT specified standards for the commissioned services including a requirement to have joint audits. It took almost 3 years to persuade the Dacorum PCT to carry out a half hearted audit of the WHHT Care of the Elderly Wards, although there were ongoing complaints.

Evidence that Patient Safety was not a priority.

3.3.2  West Herts PCT—After the merger of the Hertfordshire PCTs

Direct Involvement

  The West Herts PCT was awarded a double weak grading by the Healthcare Commission for 2006/2007. Not surprising as managers from the Beds and Herts St.HA and the old PCTs were simply shuffled across to the Board of the new PCT.

  When such levels of incompetence are accepted as the norm, their inefficient management of both Clinical and Financial Risks obviously reduces the funding available for patient care. One example is the allocation of approximately £20 million to the Beds &Herts St.HA authority for the increase in Intermediate Care Beds. ( see HSC 2000 / 001)

3.4  Indirect Involvement—Impact of Reduction of Intermediate Care Beds

  3.4.1  The NSF for Older People included a programme, with dates, for meeting the standards including the provision of additional Intermediate Care Beds to reduce the problem of bed blocking in Acute Trusts.

  The West Herts PCTs:

    —  were given money to increase the number of Intermediate Care Beds, (see HSC 2001/001 Intermediate Care)

    —  Planned in 2003 to increase Intermediate Care Beds by 90.

  Instead, PCTs

    —  By 2006, reduced the number of Intermediate Care Beds by 35%—without carrying out Risk Assessments of the impact of bed closures

    —  Complained in the Acute Services Review that shortage of Intermediate Care Beds was resulting in payments to the WHHT and E&NHT Acute Trusts of £22 million/ annum

    —  After taking 12 months to "unpick" PCT could not explain where money allocated by HSC 2001/ 001 had been spent.

    —  As part of the same "efficiency" exercise, increased Acute hospital bed occupancy to 95% +

  3.4.2  In the WHHT, this contributed to an increase in premature discharges, readmission rates & hospital infections. As Ms. A. Walker, Chairwoman of the Herts PCT, eventually admitted, the impact on Patients Safety was not considered.

3.5  Strategic Health Authorities Role

  3.5.1  According to Shifting the Balance of Power issued in 2001, SHAs were supposed to performance manage Acute Trusts.

  Mr.I.White, Chairman of the Beds & Herts StHA despite the history of problems in the WHHT, refused to find out what the Clinical Risk Management Department had been doing for the previous 10 years.—I asked the question in August 2002.

  Unfortunately, he refused to investigate, advising it was more important to look to the future. Confirmation that he considered protecting incompetent staff more important than protecting patients' health.

  3.5.2  A response to another Patient Safety question, raised at a Board meeting, was that Patients had a choice at which hospital to have treatment & could therefore decide which was safest.

3.6  CHI / Healthcare Commission

  The Healthcare Commission can carry out reviews and investigations but only makes recommendations which the Trusts can ignore eg the Stoke Mandeville C.Diff. disaster where 33 patients were killed and 334 infected in two separate outbreaks.

  The HC report stated that "The Trust failed to demonstrate that it took the necessary steps to identify risks and implement changes to protect the interest of patients"

  A bigger C.Diff. disaster occurred in the Maidstone & Tunbridge Wells Trust—Demonstrating that the HC is unable to take effective actions to prevent these disasters

3.7  Effectiveness of PCTs, St.HA and Healthcare Commission in Ensuring Patient Safety—Conclusions:

  3.7.1  As the DoH Inspection confirms, Patient Safety is not a priority of either the PCTs or the St.HA.

  3.7.2  The Healthcare Commission can only make recommendations and take limited action (the issue of improvement notices related to hygiene) but cannot take enforcement action.

  3.7.3  The NHSLA assessment also confirms that in terms of Clinical Standards, a Risk Management system is still not in place in the WHHT. Further evidence that these bodies are ineffective in improving Patient Safety even where Trusts have long term problems.

  3.7.4  These bodies did not consider it their responsibility to ensure policies contained in the Documents listed below were applied.

3.8  National Policy Documents—Effectiveness in Improving Risk Management & Patient Safety

  3.8.1  Some of the policy documents issued before and during the period of the WHHT events are listed below:

    1994 Risk Management in the NHS

    1999 Governance in the new NHS—HSC 1999/123

    2000 An Organisation with a Memory—DoH / CMO

    2003, Achieving Improvement through Clinical Governance- A NAO progress report noted "that progress in implementing clinical Governance is patchy, varying between Trusts, within Trusts and between components of Clinical Governance.

  There is, not surprisingly, scope for improvement inter alia improving processes for managing risk and poor performance.

  Overall, key features of the organisations that have been better at improving Quality of care are quality of leadership, commitment of staff and willingness to do things differently."

  3.8.2  There followed another series of Policy Documents

    2005—A Safer Place for Patients : Learning to improve Patient Safety—NAO Report

    b) 2006—A Safer Place for Patients. Learning to Improve Patient Safety: HC Public

    A Accounts Committee:

    2006—Safety First—CMO's Report:

  3.8.3  A series on Hospital Infections was also issued by the NAO including

    2000—The Management and Control of Hospital Acquired Infections in Acute NHS Hospitals in England

    2004—Improving Patient Safety by Reducing the Risk of Hospital Acquired Infection: A progress Report

3.8.4  Safety First—Extract

  3.8.4.1  In foreword to "Safety First: A report for patients, clinicians and healthcare managers" the CMO outlines four major themes, first being,

    "We need to redouble our efforts to implement systems and interventions that actively and continuously reduce risk to patients." Recommendation 1 of his report dealt with this concern

3.8.4.2  Recommendation 1

  As the next round of national goals, priorities and targets are being established from the period from 2008, it is important that the NHS takes steps to ensure that patient safety is further deeply embedded as a core principle that underpins those priorities.

Rationale

  Patient safety needs to be a core, non-discretionary part of the agenda for 21st-century healthcare in this country. The setting of national priorities should explicitly take this into consideration and be informed by overall analysis of NRLS (National Reporting and Learning System) data linked to existing safety-related targets and drawing on other relevant national information sources through the National Patient Safety Observatory.

  3.8.4.3  Unfortunately the report does not include a set of mandatory clinical standards. Nor does it set out a timetable for change, only a date for starting talks about change. What will this achieve?

3.8.5  Conclusions

  3.8.5.1  These policies demonstrated that those who were producing them had identified the problems and solutions.

  3.8.5.2  Relating the issue of these policies to the events in the WHHT demonstrates that the policies were not being put into effect and Patient Safety was still a low priority.

  3.8.5.3  The disparity between the Policies and the situation in the WHHT highlights the need for a change in the NHS Management culture up to and including the DoH. "We" need to take action instead of simply issuing further policies. The WHHT is not the only Trust with Patient Safety problems.

4.0  What the NHS should do next regarding Patient Safety

  The steps referred to by the CMO in Safety First need to be set out in a timetable & monitored as closely as waiting list targets have been. These should include :

  4.1  An Effective Clinical Risk Management System must be Non—Discretionary

  4.1.1  The 2005 CNST Risk Management System was developed over a period of 10 years and is administered by a relatively independent organisation. A short programme of 2 or 3 years to get all Trusts to level 3 would improve Patient safety. While not comprehensive it could be further developed.

  4.1.2  Trust managers that have not complied with Levels 2 & 3 CNST at the end of programme should be considered incompetent and retrained or made redundant. Managers have to realise they are no longer managing cottage hospitals of the 1940s.

4.2  An Independent Complaints System

  4.2.1  I made a complaint in 1999 about incompetent management and an absence of QA and auditing to Mr.Eames (at time Chief Executive). The very people I was complaining about were those who were dealing with my complaint and took no action about incompetent management.

This complaint was based on several other problems my mother experienced including filthy wards and poor staff hygiene. Matters criticised by the DoH Inspectors in August 2007

  4.2.2  Obstruction and corruption of the complaints system is quite prevalent and a third change is underway. This is another example of changing the system instead of removing the cause of the problem. ie the incompetent Managers who obstruct and corrupt the complaints system.

  4.2.3  Until the basic problems of having incompetent NHS managers investigate their own incompetence is resolved, learning from mistakes when caused by system failure or other matters for which the Chief Executive is responsible, will not happen.

  4.2.4  A complaint system independent of the NHS is required for instances where death or harm has been caused to a patient. The body dealing with these complaints must also be given the power to enforce changes should recommendations be ignored, as with the HSE.

  4.2.4  Patients and Public should be involved in the auditing of the complaints system, whatever form the new system takes.

4.3  Selection & Regulation of NHS Chief Executives and Managers

  4.3.1  Unfortunately there is no body for regulating NHS Managers. Therefore incompetent managers can and do float about the system adding nothing to Patient Safety.

  4.3.2  The main cause of the major disasters that have come to light in the last three years has been the incompetent managers of the Stoke Mandeville and Maidstone & Tunbridge Wells Trusts.

  4.3.3  In general, the problems of the WHHT have also been caused by management failures over the years. The damage caused by Kane & Rosenberg was extended by several years because the Trust's management ignored complaints and failed to take remedial action resulting in harm to hundreds of patients.

  4.3.4  To resolve this problem, it is necessary to check the performance of the Trusts Managers, which existing regulatory bodies cannot do, and either retrain or make them redundant.

  4.3.5  The WHHT is now on the 5th Chief Executive since I became involved which indicates there is also a problem with the selection of Chief Executives. Good management skills should be considered more important than PR skills and years of service in the NHS when selecting managers.

4.4  Introduction of Guaranteed Standards

  4.4.1  Ms Hewitt in September 2006 stated that a regulatory system to guarantee standards was one of the 4 key elements of NHS reform.

  These standards need to be set out, incorporated into a timetable and enforced. Patient and Public Forums must be involved in the auditing of these standards.

  4.4.2  The CHRE is in place with a review of Health Professionals Regulators already complete. However, the Self Assessment Process needs an auditing procedure to ensure that assessments are accurate.

  The auditors should include members of the public & patients

September 2008






 
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