Transcript Presentation title slide Verdana 32pt

Protecting the public through
professional behaviours 19th March 2014
Mid Staffordshire – the aftermath: The
impact on professional behaviour and
regulation
Care Council for Wales
Peter Watkin Jones
Partner, Eversheds LLP
Solicitor to the Mid Staffordshire NHS Foundation Trust
Public Inquiry
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The vulnerable patient in need of
protection
Extract from Trust investigation
report
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“It would appear that there were several systemic
failures and issues which caused the SUI to occur in
this particular case. Unfortunately, it cannot be said
that these failures are an isolated incident and unlikely
to re-occur. It is clear from talking to the staff (and
examining other medical records) that similar issues
are occurring regularly”
Extract from Trust investigation report
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The Government response to the Health Committee’s
3rd report – “After Francis: making a difference”
“Traditionally, the response of the Government and of
the central organisations of the NHS to failure in care
has been to acknowledge the individual failing and
then emphasise the very large number of positive
experiences and excellent outcomes that people
experience every day in the NHS”
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The public not protecting themselves
• Some of them were so stroppy that you felt that if you did
complain, that they could be spiteful to my Mum or they
could ignore her a bit more.
• There would have been a lot of little incidents that just
made you feel uncomfortable and made us feel that we
didn’t want to approach the staff. I did feel intimidated a lot
of the time just by certain ones.
• I think he felt as though he didn’t want to be a nuisance.
Because of their attitude in the beginning when he first
mentioned about the epidural, he felt as though it was a
waste of time of saying that he was in pain.
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Failure to protect the public through
professional behaviours of the staff
If you are in that environment for long enough,
what happens is you either become immune to
the sound of pain or you walk away. You cannot
feel people’s pain, you cannot continue to want to
do the best you possibly can when the system
says no to you.
A doctor who started in A&E in
October 2007
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Failure to protect the public through
professional behaviours of the staff
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“We have got to go on doing our job because we
have patients who need operations; we will
have to mend and make do. Which is the
Stafford way”.
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Keogh – “organisations trapped in mediocrity”.
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Disengagement – “not my problem to solve”
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Those who could/should have picked
up the signs of the need to protect the
public
Local “regulation”
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•
GPs
National Leaders
– Department of Health
– Commissioners
• Quality regulators
– Healthcare Commission/Care Quality Commission
– Monitor
– Health & Safety Executive
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Professional Regulators missing the
signs
• Immediate government criticism of the
regulators
• General Medical Council – 17 references
• Nursing and Midwifery Council – 3 references
• Professor Weir-Hughes – “The culture of
isolation overrode the professional
responsibility to report”
• Royal College of Surgeons – “dangerous”;
“dysfunctional”
• Universities/deaneries
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Protecting the public - the board
An absence of clinical governance - staff
• No systematic appraisal of staff
• No culture of self analysis
• Isolation and no peer review
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Protecting the public - the board
An absence of clinical governance – complaints and
information
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•
•
•
•
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Risk register outdated
Lack of knowledge of untoward incidents
No effective learning from complaints
Action plans – a reliance on assurance
Patient and staff surveys not listened to
Whistleblowing failures
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Protecting the public - the executive
• Lack of experience
• Great self confidence
• No effective clinical or professional voice on the
board
• Disengagement of medical staff from
management
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Protecting the public – the board
• Lack of openness
• Tolerance of poor practice – “The Stafford Way”
• An unwillingness to refuse to perform the
impossible or dangerous
• Finding excuses for mortality statistics – “Boards
use data simply for reassurance rather than the
uncomfortable pursuit of improvement” (Keogh)
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Protecting the public - Non executives
• Not holding executive to account
• Wrongly categorising issues of risk to patients as
“operational concerns of no strategic significance”
– a “false distinction”
• Reliance on assurances which were not checked
or challenged
• Closed culture
• An acceptance that having systems was of itself
sufficient
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Protecting the public – an isolated focus
on finance
• Focus on financial issues and targets
• No insight into import of decisions on patient
care
• Policies based on an assumption that strong
finances would equate to good quality care
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Recommendations
Categories 1-5 – all to achieve culture change – to
put the patient/service user at the heart of the
system
1.
2.
3.
4.
5.
Fundamental standards
Accurate, useful and relevant information
Compassionate, caring, committed nursing
Strong patient centred healthcare leadership
Openness, candour and transparency
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Category 1
Fundamental standards – Government
response
• CQC to create fundamental standards; improvement
is not its role
• Generalist inspection has run its course
• Inspection to involve experts and the public
• A failure regime allowing CQC to close a service or
ward without notice
• Staffing levels and fitness of directors will form part
of inspection selection criteria
• NICE to report by summer 2014
• Boards to publish actual and planned staffing for each
shift monthly and review every 6 months
• Details of skill mix
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Category 2
Accurate useful and relevant information
– Government response
• CQC and NHS England with others to make patient safety
data accessible
• Health & Social Care Information Centre to be the focal point
• Information on staffing, pressure sores, falls and other key
indicators
• Quarterly publication of never events
• Name of consultant and nurse responsible for care above bed
• Clinical outcomes by consultant being published in 10
specialities
• Data on friends and family test to be published (mental health
setting - December 2014)
• Quarterly reports on complaints data and lessons learned
• Spring 2015 – every patient can see their records online, and
book appointment
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Category 3
Compassionate Nursing – Government
response
• Care Certificate (2 levels) – Camilla Cavendish
• Pilots of 1 year pre degree experience
• Develop appraisal and development programmes
• Develop older person’s nurse post graduate
training qualification
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Category 4
Patient Centred Leadership –
Government response
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Providers to refer staff to Disclosure and Barring Service if has
harmed, or poses a risk of harm
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Fit and proper person test to also act as barring scheme for board
level by CQC
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Applies to public, private and voluntary sectors
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Appraisals; performance management; provider ratings linked to
performance
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Fast track leadership programme; a drive to attract clinicians
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Roylance
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White Paper’s envisaged role on who leads, and delivers
improvement
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Category 5
Openness, transparency and candour
– Government response
• Statutory duty of candour to report mistakes that
caused death or serious injury; possibly moderate
harm (Dalton and Williams Consultation) from 2014
on every provider registered with CQC
• Candour on care failings a pre-requisite to CQC
registration
• The CQC can prosecute providers in breach of the
fundamental standards
• Individual director can then be prosecuted if offence
committed with their consent, connivance or through
neglect
• Contractual duty of candour – NHS Constitution
(2013)
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Openness, transparency and candour
– Government response
• Separate Criminal Offence (CPS) for providers to
supply false or misleading information in
complying with a legal obligation
• “Controlling mind” applies again
• Separate Criminal Offence where organisations
or individuals are guilty of wilful or reckless
neglect or mistreatment or patients
• Trust should reimburse NHSLA compensation in
whole/part if not been open
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Professional duty of candour Government response
• Common responsibility across the professions to be candid
when mistakes occur
• Will be a duty to report near misses that could have led to
death/serious injury/actual harm
• Promptness in reporting is professional mitigation
• Duty appears to be to report to patients; default position is
to inform providers too
• New guidance required by professional regulators
• Is no duty of candour to tell patients of every error or near
miss
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Professional regulation - timings
• Cradle to grave within 12 months except in a
small minority of cases
• Improved liaison with CQC, and a proactive/
generic approach
• Parallel proceedings wherever possible (231); is
there a real, not notional, risk of serious
prejudice and injustice?
• Law Commission review – overhaul possible
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