Tomorrow’s Doctor’s 2009

TOMORROW’S DOCTORS 2009

Outcomes and standards for undergraduate medical education.

Mid Staffordshire – Review by Sir George Alberti

MID STAFFORDSHIRE NHS FOUNDATION TRUST – PROFESSOR SIR GEORGE ALBERTI

A review of the procedures for emergency admissions and treatment, and progress against the recommendations of the March Healthcare Commission report.

EXECUTIVE SUMMARY

“This review of Mid Staffordshire NHS Foundation Trust was undertaken at the request of the Secretary of State for Health and Monitor following a critical report published by the Healthcare Commission on 19th March 2009. The following were the key observations:

1. There have been major improvements in the A&E department with 4 new consultants, improved nursing skills and prompt, efficient handling of emergency cases, and, improved training of junior doctors. The A&E department is now providing safe, good quality care.

2. There remain problems with the flow of patients through the hospital. Suggestions have been made about improvements in bed management and patient discharge.

3. The principles underlying the operation of the Emergency Assessment Unit are correct but cannot be fully implemented until patient flows improve.

4. There are now 3 acute physicians who have improved greatly the timeliness of care of medical emergencies. The other physicians have agreed to implement a new way of working which will accelerate care and provide early consultant-delivered decisions.

5. There are highly committed, acute surgeons working at the Trust but too few in each of the surgical specialties. A system of networking with neighbouring Trusts is required.

6. Equipment deficiencies were identified by the Healthcare Commission and are still to be rectified by the Trust.

7. The medical wards have too few qualified nurses and every effort should be made to rectify this and to increase numbers beyond those agreed to date. Efforts are also needed to improve nurse training and morale and to refocus attention on the needs of each patient.

8. Care of the elderly should be enhanced at all stages of the patient pathway and a collaborative network should be established with primary and community services with more focus on care of patients closer to home.

9. A similar network or board should be established for urgent and emergency care including all partners, such as the Primary Care Trust (PCT), the ambulance trust, social services, the voluntary sector, pharmacies, patients and the public as well as Mid-Staffordshire Foundation Trust. This could and should greatly facilitate
delivery of care by the most appropriate person in the most appropriate setting in timely fashion.

10. Patients and the public have not been included sufficiently in discussions and decision-making. They should be involved at all levels and more real-time patient and family views should be sought and used to help shape service delivery.

11. The PCT should ensure that quality and safety indicators are built into all commissioning and performance management arrangements.

12. There is an urgent need for a coherent 5-year plan for the Trust with a timed action plan taking into account the changing nature of medicine as outlined in Professor Lord Darzi’s report last year. The Trust needs to see clearly where it fits into the overall health economy and should be clear about what it can do well and safely and what should be networked with others e.g. hyper-acute stroke care and some branches of surgery. The plan should be developed together with the PCT and other partners including the public. This will give the public and the staff a clear indication of how the Trust is developing and at what speed and remove much of the current uncertainty and unhappiness.

13. The Trust’s staff need to change from a “make-do” culture to a “can-do” culture. There were encouraging signs both at Board level and amongst the staff that this is indeed taking place.”

Lunar society

THE LUNATICKS – TODAY

“Today’s Lunar Society has several hundred members and includes leading practitioners from all walks of life in Birmingham and the wider region, people who are prepared to help shape the scientific, political and social agenda not just here in Birmingham and the West Midlands, but nationally and internationally.”

AND YESTERDAY

“It must have been a thrill. Something like TEDTalks with Stilton. Writes Adam Hart-Davis:

The Lunar Society believed in argument and cooperation. They had long discussions about why thunder rumbles and decided the best way to test their various theories was by experiment. Boulton made a 5-foot-diameter balloon from varnished paper, and they filled it with a terrifying mixture of air and hydrogen (”inflammable air from iron”). They lit a fuse underneath, released the balloon into the night sky on a calm, clear evening and waited for the bang. Unfortunately, the fuse was rather long, and they all assumed it must have gone out; so they began to talk among themselves, when there was a colossal explosion, and they all said, “There it goes!” and forgot to listen for the rumble! Watt was at home 3 miles away and wrote that the bang was “instantaneous, and lasted about one second.” This seems self-contradictory, but in any case, the experiment failed to produce a simple answer to the original question.

There you have it: science, explosions, debate, optimism, politics, technology, curiosity. The future started more than two hundred years ago.”

TACKLING CONCERNS NATIONALLY

TACKLING CONCERNS NATIONALLY: ESTABLISHING THE OFFICE OF THE HEALTH PROFESSIONS ADJUDICATOR

“Introduction by Sir Ian Kennedy

(i) I was asked by the Minister of State for Health to convene a working group, on behalf of all UK Health Departments, to support the establishment of the proposed independent Office of the Health Professions Adjudicator. This report sets out the draft recommendations of the Working Group “Tackling Concerns Nationally”, one of the seven Working Groups that report to the “Professional Regulation and Patient Safety Programme Board”.

(ii) Lady Justice Smith’s fifth report of the Shipman Inquiry1 recommended as regards the General Medical Council (GMC), a clearer separation of adjudication from the GMC’s other functions. In Lady Justice Smith’s view the benefits of the model she proposed were:

the absolute separation that it created between investigation and adjudication;

and

the greater confidence that the public might have that decisions were being made
purely on the merits of a case……….”

Mid Staffordshire Investigation

INVESTIGATION INTO MID STAFFORDSHIRE NHS FOUNDATION TRUST

What were the reasons for the failings at the trust?

“It is the view of the Healthcare Commission that there were deficiencies at virtually every stage of the pathway of emergency care. This can be illustrated by following the patient’s pathway.

When patients arrived in A&E, they were usually assessed by reception staff with no clinical training, before waiting in an area out of sight of the staff in reception. There was no regular check by nursing staff of the patients in the waiting room. Some essential equipment, such as cardiac monitors, was missing or not working. Assessment and treatment were often delayed.

There were too few doctors and nurses, alongside poor training and supervision, and junior doctors were put under pressure to make decisions quickly without advice and support from more senior doctors. Doctors were moved from treating seriously ill patients to deal with those with more minor ailments, in order to avoid breaching the four-hour waiting time target. Patients were moved to the clinical decision unit to ‘stop the clock’ but were then not properly monitored, since this area was not staffed. Patients had to wait for medication, pain relief, wound dressings and antibiotics. There was only a relatively junior doctor available after 9pm to give advice on surgical patients. There was no specialist trauma team. In summary, the care and assessment of patients fell well below acceptable standards.

Sometimes patients were rushed to the emergency assessment unit (EAU) without proper assessment or discussion, and without appropriate specialist care. The EAU was a large ward with a poor layout. It was busy, noisy and sometimes chaotic with too few nurses. Many of the nurses did not understandthe cardiac monitors and did not always carry out observations adequately to identify whether a patient’s condition was deteriorating. There were many instances of patients not receiving the medication they needed.

There were too few beds for patients who had had a stroke, not all patients with heart attacks went to the acute coronary unit, there was no non-invasive ventilation on the respiratory ward, and critical care beds were not always available. The medical wards on floor two were seriously understaffed and there were grave concerns about the standards of nursing care.

There were too few theatre sessions at weekends and consequent delay in getting to theatre, especially for trauma patients, and some patients did not get essential medication. Post-operative complications were not always recognised.

Surgical practice was idiosyncratic, relationships were poor and there was little multidisciplinary team work. There were concerns about the level of cover by medical staff at night and at weekends.

Across the trust, there were shortcomings in resuscitation and arrangements to avoid potentially fatal blood clots were inconsistent. There was a shortage of critical care beds and concern about access to medical advice from critical care specialists.

It is our view that all these factors would have contributed to a poor outcome for patients.

CMO Annual Report 2008

150 years of the Annual Report of the Chief Medical Officer: On the state of public health 2008

Looking back over the last year, aside from the celebration of past achievements and historical landmarks, it has been another period of major change and activity in health and healthcare.

The final report of the review of the NHS, High Quality Care for All, carried out by Parliamentary Under Secretary of State and practising surgeon Lord Darzi, is a major landmark in the development of the NHS. The work undertaken for the report was widely participative, notably involving thousands of front-line clinicians around the country. I was asked by Lord Darzi to lead the national strand of work on quality and safety in healthcare, and I reported to him in March. His final report states that quality will be the ‘organising principle’ of the NHS. This is a highly significant commitment and one that should be welcomed widely by clinicians, patients and the public.” “

Next stage review. Government’s response

THE GOVERNMENT’S RESPONSE TO THE HEALTH SELECT COMMITTEE REPORT:NHS NEXT STAGE REVIEW

“Measures to improve the leadership and workforce of the NHS

We welcome the Department’s increased focus on improving its workforce planning in the NHS. However, we note concerns that planning will be concentrated in the Department. In our recent report on Workforce Planning we recommended that SHAs have a key role in this area. The Department should ensure that regional NHS employers are given a role in identifying future workforce requirements. “

“It is widely recognised that the quality of leadership in the NHS must improve and we welcome the Department’s ambition to do this. However, we note the following concerns about its proposals:

● There is undue reliance on new institutions such as the Leadership Council; we note that previous attempts to improve the quality of management and leadership in the NHS by introducing new institutions such as the NHS University have failed;

● The Department’s approach is over-centralised; and

● The emphasis on medical leadership is important; however, we are concerned that at present many doctors are put off becoming senior managers. We therefore recommend that more training and support be given to those who wish to take on senior management responsibilities. “

“It is unfortunate that the NSR does not place more emphasis on the importance of recruiting and developing better managers. Over many years this Committee has heard concerns about the quality of management in the NHS which witnesses to this inquiry echoed. Some managers lack the analytical skills or motivation to handle and interpret the wide range of performance and routine administrative data, such as HES, that they have to deal with. With the introduction of PROMs and other quality related measures this issue is becoming ever more important. We therefore recommend that the Department address the issue of weak management skills in this area with urgency. Senior NHS management, clinical and non-clinical, should acquire analytical skills which will enable them to understand the products of expensive and increased investment in clinical and cost effectiveness data. This should be a central component of their annual appraisals, and in the case of clinicians, linked to their systems of performance related pay (Clinical Excellence Awards). The pay and promotion prospects of managers should be linked to their skills, in particular their ability to analyse and use data. “

Co-operation and Competition Panel

CO-OPERATION AND COMPETITION PANEL FOR NHS FUNDED SERVICES

“The Panel helps ensure that the Principles and Rules of Co-operation and Competition for the provision of NHS-funded services support the delivery of high quality care for patients and value for money for taxpayers.

The Panel investigates potential breaches of the Principles and Rules, and makes independent recommendations to the Department of Health and Monitor on how such breaches should be resolved. It also reviews proposed mergers, and advises on the wider development of co-operation, patient choice and competition within the NHS.

In carrying out its responsibilities, the Panel works with all parts of the NHS, non-government service providers and others to drive improvements in service delivery.”

Now we are 50

CENTRE FOR LONGITUDINAL STUDIES – NOW WE ARE 50 REPORT PUBLISHED

“The Centre for Longitudinal Studies yesterday launched a new report, published to mark 50 years of the National Child Development Study. Now we are 50: Key findings from the National Child Development Study chronicles the diverse experiences of Britons born in 1958 and considers their future prospects as they enter their sixth decade.

The publication provides a summary of 50 years of social change in Britain and explains how the study’s many findings have helped to shape decision-making in policy areas such as education, employment, housing and health.”

Release of secret USA anti-terror memos

THE REGISTER

“The Obama administration has released nine secret legal opinions penned by Bush Administration lawyers, revealing the scope of executive power the White House sought in fighting domestic terrorism.

The opinions reflect an extraordinary interpretation of presidential power used by the Bush White House to justify executive actions (some used, and some not), including use of military force within the US to combat terrorism, wiretapping domestic internet and telephone calls without a warrant, ignoring international treaties, and detaining US citizens suspected of terrorism.

Some of the Bush administration’s sweeping claims of executive privileges had been previously known, but the opinions shed new light on the legal grounds which the White House justified giving the president unilateral power over terror suspects.”

UNITED STATES DEPARTMENT OF JUSTICE – RELEASE OF SECURITY DOCUMENTS

“The opinions addressed herein were issued in the wake of the atrocities of 9/11, when policy makers, fearing that additional catastrophic terrorist attacks were imminent, strived to employ all lawful means to protect the nation. In the months following 9/11, attorneys in the Office of legal counsel and in the Intelligence community confronted novwl and complex legal questions in a itme of grea danger and under extraordiary time pressure. Perhaps reflecting this context, several of te opinions identified below do not adress specific and concrete policy proposals, but rather address in general terms the broad contours of legal issues potentially raised in the uncertain aftermath of the 9/11 attacks. Thus, several of these opinions represent a departure from this Office’s preferred practice of rendering formal opinions addressed tp particular policy proposals and not undertaking a general survey of a braod area of the law or adressing general or amorphous hypothetical scenarios involving questions of law.”