Spicer’s report in this issue of IJCP should make you stop and reassess how you perceive the quality of care within the English National Health Service (NHS). It provides a striking counterpoint to the claims by the incumbent government that quality of care has improved substantially since 1997 when it took office, not least that the NHS has managed to hit a series of centrally imposed targets relating to access and waiting times. No one reading Spicer’s report can fail to be concerned that some patients, children in this case, have been and are being failed by the NHS. Doctors, nurses and patients know that the reality of care, when assessed across the continuum, often falls short of what is claimed, yet Spicer’s report is valuable because it offers a rare insight into a problem that is invisible to routine measures of quality.
Spicer’s account might be dismissed as an isolated experience if it were not for a number of other recent tragedies; collectively, these might well indicate a disturbing underlying trend in the way healthcare is delivered, but it is hard to generate evidence about how widespread these incidents might be as they involve exploration of what is not routinely measured. It is particularly significant that the mainstream media have been the ones to highlight these issues. In a sign of how far removed medical journalism is now from frontline clinical issues despite widespread coverage in the mainstream media, there has been little coverage within medical journals – the Lancet ignoring the issue completely.
The Healthcare Commission, the independent regulator of health care, has a remit to investigate allegations of serious failings in the NHS in England and Wales: it has the resources to conduct in-depth explorations of quality that probe well beyond the routine data. In 2007, it released a damning report into the quality and safety of care received by patients who became infected by Clostridium Difficile when treated at a Kent hospital, known as the Maidstone and Tunbridge Wells NHS Trust. It found that patients had received abysmal care despite the apparently normal functioning of the hospital over several years. The report highlights many factors: poor hand washing practices by clinical staff, extended periods of high bed occupancy, poor systems for monitoring infection rates and understaffing of nurses. Particularly worrying was a style of leadership, according to the Healthcare Commission, that placed overall patient care secondary to achieving financial balance and meeting government targets. Around 1200 cases were investigated and 90 deaths were reported as being the cause or probable result of infection by Clostridium Difficile.
A closer look at the report reveals that misleading data on infection rates had been submitted before and a previous investigation had been carried out for this reason. Nursing staff described a culture where they were in some instances, discouraged from reporting their concerns. Consultants were left to communicate the concerns of patients who were unable to see their relatives because they were frequently being moved around the hospital. The leadership style was described by many, including senior management, as autocratic or in other cases dictatorial.
In 2009, another tragedy was reported in the media, this time resulting from an investigation by the Healthcare Commission into another hospital, Mid Staffordshire NHS Trust. In this hospital, from 400 to 1200 deaths were estimated to have resulted from gross failings in the operation of the Accident and Emergency department over a 3-year period. As in the case of Maidstone and Tunbridge Wells NHS Trust, targets and cost cutting were implicated in the failure and the views of patients and staff were not taken seriously. Disturbingly, the report found there was not ‘an open culture where concerns were welcomed’. The report went onto say that ‘the board appeared to be insulated from the reality of poor care for emergency patients’. This, and its other findings were virtually identical to the failings at Maidstone and Tunbridge Wells NHS Trust, yet they were occurring when the earlier investigation was taking place.
A slavish devotion to targets at the expense of other priorities by managers and hospital leaders is clearly a feature of both cases and was identified by staff at both hospitals, even though such concerns were angrily dismissed by the then Secretary of State for Health. The government argues that by meeting the targets, the NHS has benefited patients through speedier access and that the vast majority of hospitals have achieved this without apparently compromising other dimensions of patient care. Yet, although in these cases targets can certainly be blamed for obstructing the NHS’s view of its real responsibility – actual patients – several other factors were also identified. It would be unfair to stereotype NHS managers as being the only group vulnerable to target myopia or to deny that there are benefits to targets if used appropriately.
Doctors too, can embrace targets with zeal. Anyone with knowledge of the rules guiding the treatment of heart disease or diabetes will know how ideological debates around clinical targets distort the need to offer individual patient care not only for a single medical condition but across multiple areas. Often emanating from academic clinicians who are insulated from the reality of every day care, the unintended consequences of ‘one size fits all’ clinical targets can disadvantage patient groups with ‘Cinderella’ conditions or marginalised groups such as the elderly, in the fight for resources. ‘One size fits all’ performance measures that are targets in all but name, have received similar criticism although because they do not explicitly specify a time frame their benefits and harms are muted.
Contrast this with the comments of the newly appointed Chair of the Care Quality Commission, a body that has now replaced the Healthcare Commission, who described a legal vision where doctors might face legal action for not following guidelines developed by the National Institute of Health and Clinical Excellence (NICE). In order for her vision of a patient sitting in front of their GP or consultant interrogating their healthcare provider with NICE guidance to be consistent with her legal vision, the pressure for the doctor to interrogate the patient with the guidance is obvious. It ignores the fact that there are multiple ways is which equally valid guidelines can be drafted and that their recommendations cannot be prescriptive as autonomy rests between the patient and their care giver. Moreover, guideline recommendations are rarely ever definitive.
Is Spicer’s claim credible that other tragedies are inevitable? Reliance solely on the quality paradigm, a limited number of measures and a target driven culture indicate that similar tragedies on a hospital scale can easily occur. Smaller scale, ‘micro-events’, occurring below the hospital scale, are not only possible but probable, happening now and measured only by personal experience. Larger, ‘macro events’ or crises are the black swan phenomena of quality improvement i.e. unforeseen because they do not lie within accepted dogma that rests on the limited information afforded by a narrow measurement windows, yet puzzling, high impact and serious when they occur.