Government’s initial response to Mid Staffordshire reportBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2209 (Published 09 April 2013) Cite this as: BMJ 2013;346:f2209
All rapid responses
The devil is in the detail:
The preliminary response of the government merits careful reading. Embedded in the text strewn with words such as 'compassion' and 'courage', are some worrying caveats. Some have been already been pointed out in this journal, but there are others. For example, whistleblowing is severely proscribed, but then we read: ..."where confidentiality clauses are used, they should go no further than is necessary to protect matters such as patient confidentiality or commercial interests". Commercial interests? One can imagine a number of examples where 'commercial interests' will be damaged by exposure of poor practice - take for example the for-profit out-of hours company Harmoni or Hospital Trusts with private patients.
Secondly, the plan to enforce nurses to undertake another added year of 'training' working as healthcare assistants is to be 'cost neutral'. This implies that student nurses will potentially work alongside poorly paid, poorly trained healthcare assistants without receiving high quality support, teaching or supervision. They then enter their second year with their morale and professionalism eroded and have to endure another year without earning a semi-decent salary. Good wheeze.
Thirdly, the Chief Inspector of Hospitals, aside having a huge and potentially unworkable remit, will not have the executive powers to make a hospital shape up if found unsatisfactory. This is left to Monitor (a government appointed quango) and the NHS Trust Development Authority (yet another body). If these fail in their mission, the Chief Inspector has the unenviable power to put a hospital 'into administration'. What happens to patients and staff in this scenario is not made clear - the catastrophic effect this could have in a rural or other area where there is limited or no choice of hospitals is ignored.
Finally, although the report does in principle accept a barring mechanism for poor managers, it remains silent about barring those leaders under whose watch were allowed some of the most egregious examples of inhumane care.
Competing interests: No competing interests
The subtitle to your Editorial perceptively includes the words ‘some things worryingly missing’. But it then misses a huge omission. Death certification and inquests.
Francis regarded this as sufficiently important to award it an entire chapter (14). He praises the reforms in the Coroners and Justice Act 2009, and recommends some minor improvements. He assumes that the reforms in the 2009 Act will be implemented. So ‘Implement death certification reform’ is not actually one of his recommendations. Is that naïve?
The reforms would (amazingly, for the first time) require that someone with a degree of independence asks the bereaved whether they have concerns relating to the death. That was intended to catch the next Harold Shipman, but it’s equally well designed to catch the next Mid-Staffordshire.
The reforms would improve the quality of death certification. The pilot sites have reported that local coroners see an increase of up to 30% in the number of deaths that need investigation by inquest (with a similar decrease in unnecessary referrals to the coroner).
So at the moment, at least 6,000 deaths p.a. that ought to be investigated by inquest are being certified by doctors as ‘natural causes’, with no inquiry at all. Is that not an outrage? How can mortality-based measurements of hospital performance be trusted if the input data is so incomplete?
Will these reforms be implemented? The legislation was passed in 2009; it’s now 2013. The Government response to Francis makes no mention of reforms that could easily have been played in a positive light. Recently the Chief Coroner has been openly critical of the reforms, even though they would stop his service from missing 30% of the deaths that it really ought to be investigating. One hopes that money is not the problem? It should be regarded as a trivial cost in comparison to the benefits.
Far from omitting any mention of death certification reform, the Government should publish (and stick to!) a detailed timetable and appoint a team to make it happen, with scheduled public progress reports.
As the Shipman Report mentions, successive Government reports since 1910 have called for reform of death certification, all to no avail. To fail when we are so close would be tragic. To fail in the aftermath of Mid Staffordshire and the words of the Francis report would be bizarre.
Competing interests: The author is Chair of the RCPath Medical Examiners Committee