IF EVER there was overwhelming evidence that performance targets and foundation trust status have no place in the National Health Service it is the case of Mid Staffordshire NHS Trust. Senior managers were apparently so obsessed with meeting Department of Health targets, ticking the right boxes and winning freedom from Government control – which foundation trust status gives hospitals – that they did nothing to correct serious failings in the care of patients in the accident and emergency department.
They were apparently so keen not to miss waiting time targets that A&E doctors were ordered to leave the most urgent patients, including those with suspected heart attacks, to treat those who had waited the longest – however minor their condition. Prioritising patients to treat the sickest first had to be abandoned in order to give way to overpowering pressure to make sure patients didn’t stay a minute longer than four hours – which meant targets were missed and points lost.
There was even an unstaffed “clinical assessment unit” where A&E patients were put to avoid missing waiting targets. This resulted in between 400 and 1200 more patients dying at the Stafford Hospital than would have been expected in the three years to March 2008.
In the words of the Healthcare Commission’s chairman, Sir Ian Kennedy, the situation at the hospital presented “appalling standards of care and chaotic systems for looking after patients. There were inadequacies at almost every stage.”
However, in the eyes of the Department of Health, failure to meet targets is the most serious offence a hospital can commit. The pressure is to treat patients within a strict timescale. It has turned the NHS from a service based on professional pride and duty of care to patients into a market force based on the speed of patient turnover.
Incredibly, while this “complete failure of management to address serious problems and monitor performance” was going on, to quote Sir George Alberti, the national clinical director for emergency care, the Mid Staffordshire hospital was in the process of achieving foundation status “for outstanding hospitals based on financial sustainability and good governance”.
Even more incredibly, Monitor – the regulator for foundation trusts – gave it that approval, signifying it was rated one of the leading NHS hospitals in the country and considered to be what the Government describes as the elite of hospitals – at the cutting edge of the NHS, a status to which every other should aspire.
Yet concern about the running of the trust had been growing over the previous months. The Healthcare Commission, the NHS watchdog, had received 11 alerts about high death rates. Just a month after the hospital became a foundation trust, the Healthcare Commission launched a major investigation.
How can this happen? How can a hospital that is failing its patients so badly that many of them die unnecessarily be approved as one of the best in the country? Isn’t there any co-operation or collaboration between the Healthcare Commission and Monitor? Doesn’t anyone in these high-powered bodies speak to each other? Isn’t there any way of sharing this information? Didn’t the Healthcare Commission know Mid Staffordshire NHS Trust was close to being elevated to foundation status? Didn’t Monitor know there was an investigation pending?
This scandalous situation raises very serious questions about the regulating and approval of foundation hospitals. Monitor admitted using “independent” analysis of safety issues provided by the trust itself to help decide whether it should give its approval. Yet it was totally misled by the trust. This vitally important analysis was later shown to be inaccurate. Shouldn’t independent analysis of safety issues be truly independent?
But the really serious questions are: why were the bosses at North Staffordshire NHS Trust so terrified of missing targets? Why were they so desperate to get away from the Department of Health rules and regulations? Is the big stick which the DoH wields so threatening that hospital managers are too frightened to stand up for themselves? Is the intimidation and bullying so severe that managers are too scared to put quality of care before performance targets?
Foundation status for hospitals may not be an outright privatisation, but it is certainly denationalisation. It gives them independence and makes them unaccountable to the Health Secretary. Bosses have greater freedom over decision-making and are able to determine their own future. It allows financial freedom, allowing them to keep surpluses and borrow money from the private sector.
In return for this freedom, foundation trusts are supposed have high clinical standards, top-quality leadership, sound finances, a high level of patient responsiveness, sound safety standards, and evidence of staff and community support.
But how many of them actually achieve these criteria? How many hospitals have gained foundation status, like Mid Staffordshire, when they have misled Monitor, hidden their failures and lied about patient outcomes? How often have these things been overlooked in a bid to meet yet another Government target of all hospitals becoming foundation trusts?
Health Secretary Alan Johnson has insisted the scandal is not being repeated at other NHS hospitals. But in this climate of fear of reprisals for missing targets how can we, the public, be sure? Was this an isolated disaster, a one-off instance of bureaucracy gone mad, or is it a sign of the future of the health service as the Government encourages every hospital to achieve foundation status?
How many NHS bosses are brave enough to speak out and risk saying that patients are paramount and quality of care must come before meeting targets? How many are fearless enough to admit that targets are harming the delivery of good service in the best interest of patients? How many are courageous enough to declare that targets have no place in the NHS where goodwill, professionalism and patient outcomes cannot be measured?
