Come back community health councils, all is forgiven
- Nigel Hawkes, freelance journalist
The Department of Health has announced that NHS organisations have a new target: proving they listen to patients. Instead of star ratings, they will be awarded “ears”—one ear for poor listeners, two for those who are at least trying to hear, three for those who can tune in to even the most distant bat-squeaks of disquiet.
OK, I made that up. But I bet you half believed it. In response to the failings at Mid Staffordshire Foundation Trust, the NHS has suddenly rediscovered that customers may have something to tell it about the service it delivers. It wants their views listened to.
This, from a government that abolished community health councils, invented a half hearted replacement called patient and public involvement forums, abolished those, invented another replacement called local involvement networks (LINks), and imposed on foundation trusts a preposterous form of governance with members, governors, and all the trappings of a pseudo-democracy.
To make this machinery function, targets have to be imposed. Trusts will in future have to publish an annual statement about how they are fulfilling their legal duty to involve patients in decision making, publish the number of complaints they get, improve support for LINks and “raise their profile” (above knee height, presumably), and get strategic health authorities to talk to the Care Quality Commission occasionally.
This announcement, in its short journey between the Department of Health and the waste paper basket, tells us so much. Were LINks asked what improvements they needed to enhance their role? No. Instead, the department decided that what they needed was extra support, a “how to be heard” guide for the general public, and a national publicity campaign to promote awareness. We know best what is best for you.
Meanwhile, the Mid Staffs shambles is being categorised as a freak event, unprecedented and never to be repeated. Listen to David Nicholson, NHS chief executive. “While this was an awful case, it was highly unusual that such poor quality care and patient complaints could go undetected in the NHS for so long and we will make sure this will never happen again.” Both parts of that statement are false. First, how does he know it was highly unusual? There is no basis for such a claim. And second, how can he make sure it will never happen again? He can’t. Even now, somewhere in the system, equally bad care is almost certainly being provided for some patients by some trusts. Which are they? I have no idea. But nor does he.
Did he know, for example, that the NHS had failed so miserably to protect the life of Baby P, the 17 month old boy abused to death by his mother, her boyfriend, and their lodger, in Haringey, north London? The Care Quality Commission last week blamed systemic failures and a catalogue of errors by the NHS. If Nicholson knew and failed to act, he shouldn’t be in his job. If—which is far more likely—he had no idea, then how can he possibly claim that it is “highly unusual” for poor care to go undetected?
A straw poll by Health Service Journal suggests that about half of NHS managers believe that elements of the failings at Mid Staffs exist in their own trusts—including one case of receptionists in A&E acting as triage nurses. Attention to waiting lists at the expense of care, poor communication, poor board use of benchmarking, and a lack of board focus on care quality were all cited by respondents.
The NHS believes it can get away with categorising every failure as a freak and scapegoating the managers involved. Each time, new targets are set up. You can require people to meet goals—as John Kay remarked in the Financial Times apropos the financial crisis—but that is not the same as encouraging them to meet the obligations behind the goals. The more targets there are, the more managers become demotivated and the less they are able to focus on achieving these fundamental underlying goals.
At Mid Staffs, the targets that managers cared about were those needed to achieve foundation status. The result was neglect of some of the basic principles of health care. So what is the answer? More targets. This way madness lies.
Trusts are also being instructed to measure patient experience as it happens, in an endeavour to identify those trusts that are failing. The initiative, announced by Alan Johnson in September before the Mid Staffs report was published, aims to achieve “fast-turnaround feedback.” I think this means that what patients say will be acted on without delay. The initiative is hobbled by having no standard collection methods, questions, or measures, which means that trusts cannot be compared with one another.
If a trust’s management cannot see that it is failing its patients by walking the corridors and watching, what difference are a lot of new statistics going to make? The NHS drowns in statistics, but gathering them is often a substitute for action. I guess we might all draw the line at the actions of the Mayor of Foz do Iguacu in Brazil, who set up cameras in a health centre to monitor how staff treated patients, and how patients behaved towards staff, but Paulo MacDonald (for that is his name) at least didn’t hide behind figures or “measures.” He wanted to see for himself.
That used to be the job of the community health councils, staffed by public spirited volunteers who had the right to stick their noses in. I used to think it slightly sad that people with nothing better to do would endure public meetings in draughty halls listening to other people making decisions about their local hospital. They were, I thought, the NHS equivalent of Sid and Doris Bonkers, the sole supporters of Private Eye’s cod football team, Neasden FC, and its ashen-faced manager, Ron Knee.
I take it all back. I was wrong. I never expected to feel any nostalgia for CHCs, but I do. Every change in patient and public representation since then has been a change for the worse. And by now, even Sid and Doris are beginning to lose heart.
Cite this as: BMJ 2009;338:b2023