Shocking examples of poor care are the real reason Circle withdrew from running Hinchingbrooke Hospital - they've got their eyes on easier ways to privatise the NHS, clinic anyway.
Image: Care Quality Commission's assessment of the only fully privatised NHS Trust in the country, remedy Circle Hinchingbrooke.
Last Friday private healthcare company Circle announced it was pulling out of its contract to run the Hinchingbrooke Hospital in Cambridgeshire, blaming a £5million loss and an NHS crisis including “unprecedented increases in accident and emergency attendances, insufficient care plans for patients awaiting discharge, and funding levels that have not kept pace with demand".
True enough - but the real reasons for Circle’s snap exit emerged later that day, when the hospitals inspector the Care Quality Commission (CQC) released its delayed report into Circle’s management of Hinchingbrooke Hospital.
It was damning.
Hinchingbrooke - the flagship of NHS privatisation - was given the CQC’s worst ever rating for ‘caring’. Both safety and leadership were also bottom of the heap. Circle’s cleverly branded ‘mutual’ model, far from ‘liberating’ NHS professionals to make grassroots-led improvements, had in fact replicated some of the worst hierarchical, bullying practices to be found in the NHS. And it had lost the caring and expertise that are the NHS’s strengths, principally as a result of poor leadership and financially-driven staff cuts to satisfy investors.
But Circle’s news management has always been its forte (as David Cameron knows - his health advisor used to be a Circle PR chief). By Friday afternoon, most journalists were packing up for the weekend, Paris-sickened. Their pieces were already published, based on Circle’s pre-emptive morning statement, which suggested the only real difference between the private Circle and the public NHS is how easily Circle can walk away from a hospital.
But that’s a long way from the full story.
Circle’s medical services were found to be delivering “poor emotional and physical care which was not safe or caring…people were not treated with dignity and respect… some patients were afraid of certain nursing staff”’.
Some of the examples witnessed by the CQC in their two-day inspection were chilling.
“We heard the staff member say to the patient ‘don’t misbehave, you know what happens when you misbehave’. We later asked the patient what they thought the staff member meant by this; the patient became withdrawn and was unable to provide us with an answer.”
“A patient on Apple Tree Ward, who required support during the night to go to the toilet told us that staff were ‘often too busy’. They said ‘they tell me to go in my bed and they will change me when they have time’.”
Other patients during the two-day inspection reported similar experiences, or were witnessed being left dirty and distressed, and treated rudely or roughly.
Inspectors found a patient with ‘challenging’ behaviour had been sedated without any record of a proper assessment of their mental state or best interest.
Circle’s junior doctors were often labelling patients “do not resuscitate” without discussing the decision with patients or relatives, and without any apparent oversight from senior doctors. Sometimes the failure to discuss was because the patient lacked mental capacity, notes often suggested - but the CQC “saw no evidence that a mental capacity assessment had been undertaken in any of the patient records we looked at”.
The CQC notes “We found many instances of staff wishing to care for patients in the best way, but unable to … prevent service demands from severely impinging on the quality and kindness of care for patients.” It found Circle lacking “sufficient appropriately skilled nursing staff”.
Though the details are shocking, the general picture is unsurprising to anyone except those who bought the ideological hype about private sector magic dust. Circle won the contract by promising what the Public Accounts Committee called an ‘unrealistic’ and ‘unprecedented’ level of savings - urged on by government officials. Circle’s Full Business Case said it would achieve this by altering ‘nurse-patient ratios’ but exactly how was blacked out of the plan when it was eventually published. Leaks suggested plans to cut 320 posts in total.
Within 6 months of taking over Circle had already scrapped 46 full time nursing posts, then Chief Executive Ali Parsa (an ex-Goldman Sachs banker) admitted.
Hinchingbrooke’s A&E department had over a quarter of posts vacant. Staff were particularly worried that A&E facilities and staff cover for children were unsafe, though some improvements have been made since the inspection.
“Patients were routinely triaged within the waiting room area with no consideration for their privacy and dignity…we saw patients getting frustrated that they were waiting extended periods for treatment and lack of information, however staff reported they wished they had more time to care.”
Circle loudly proclaimed its rapid improvement in the key ‘4 hour A&E waiting time’ target as evidence that privatisation had quickly turned Hinchingbrooke around’.
But the CQC discovered the hospital kept patients waiting too long in ambulances before they were allowed into A&E. And after they were seen in A&E, they then waited far too long - up to 12 hours - to be admitted to hospital. On this measure (so-called ‘trolley waits’) Hinchingbrooke had one in 5 patients waiting between 4 and 12 hours, compared to a national average of only one in 20 patients.
So much for key targets.
And whilst waiting in A&E, an unusually high number of patients (double the national average) left before being seen, fed up of waiting - and presumably unimpressed by the waiting-management computer system Circle had boasted was modelled on the Argos tills. (Circle’s senior management team had been hired from Argos, Avon, Faberge, Tesco and fashion-website Asos, bragged Ali Parsa in an article entitled “Government should not be running hospitals”).
There were pockets of good practice too. Maternity care and outpatients and diagnostics were rated as good, and the chaplain singled out for special praise.
But overall performance indicators are patchy at best - and there are enough shocking examples for the overall rating of ‘inadequate’ to be wholly justified.
Dangerously sloppy procedures were everywhere at privately-run Hinchingbrooke, the inspectors found. Incomplete patient notes, missing care plans, infected catheters, unwashed hands, broken clinical guidelines. Fluids were repeatedly out of reach of patients despite the inspectors’ intervention. On other wards, call bells were placed out of reach. Diabetic patients were left without food. Patients missed vital medication rounds. Lifesaving resuscitation equipment was not checked regularly. Many post-surgical patients were waiting over 30 minutes for a response to a call bell (Circle’s own figures claimed the maximum wait was 8 minutes).
Many patients were being moved between wards in the middle of the night. “One patient on the acute surgical and trauma ward said that they had been on seven wards in the first three days of admission, and had been moved at 12.45am, 3am and 5am on different days.”
The CQC was keen not to blame the permanent staff themselves - though it did note an over-reliance on bank and agency staff (a problem Circle repeatedly promised to fix) who were involved in many of the most worrying failings. “All nursing staff told us the trust had difficulty recruiting and retaining staff…one nurse told inspectors “we can’t keep staff”.
Staff told the CQC that shortages also meant little time for training. For example, “Staff at ward level were not competent in caring for people at the end of their life, because they had not received the training required to enable them to undertake this role.”
Of course there are similar incidents in NHS hospitals - all are operating in a difficult environment as Circle themselves point out. But many NHS hospitals are weathering the storm better than this experiment with privatisation, sold as a way of ‘saving’ a District General hospital.
As for the claim that Circle was replacing an outdated fixation on public ownership and ethos, with a supposedly more responsive, grassroots approach, the CQC report comprehensively trounces that suggestion.
The CQC report says “teams were not engaged nor felt enabled to raise concerns”. They found staff did not use Circle’s much trumpeted ‘stop the line’ process supposed to help staff raise concerns about patient safety. Staff said when they tried, “they were made to feel that they were to blame, and they have done something wrong” - a feeling shared by the CQC inspectors who witnessed this ‘blame approach’ when they ‘stopped the line’ themselves in response to serious concerns.
Whilst a few senior doctors were well informed, “senior nursing staff we spoke to said they did not feel involved in the decision-making process within the hospital.” The findings will not surprise those who have looked at other so-called “mutual” structures and found them of greater benefit to higher paid, higher status staff.
All in all, the gulf between the privatisation rhetoric and reality has never yawned wider.
The franchising model of privatisation is already dead. It’s been shelved as a supposed ‘solution’ for other struggling smaller district general hospitals like Weston and George Eliot.
But does that mean privatisation is dead?
No. Too many have staked their careers - and their fortunes - on it, for them to back off that easily.
No-one who understands the NHS has ever really expected the private sector to make profits from running full service hospitals with A&E departments.
But Parsa left at the end of 2012 for pastures new - his PR job done. And with the Act secured, and former Vice President of US healthcare giant United Health, Simon Stevens, now at the helm of the NHS, private health companies see better profits (and less brand damage) than openly taking over full service hospitals, as Circle’s statement on Friday hinted:
“We fully support the vision of Simon Stevens’ (NHS England Chief Executive) 5-year Forward View, but these potentially exciting reforms are too far into the future…if reform in the region develops fast and a new role for us becomes clear, we are happy to play our full part.”
In other words, if the entire NHS needs to be reconfigured away from providing us with local hospitals towards easier, more profitable routes for the private sector (perhaps a hefty chunk of ‘care in the community’), well, bring it on.
All of this will help companies like Circle sort the cherries from the potatoes.
And if the tariffs paid for many treatments are currently too low to squeeze a profit from, well, it's only a waiting game til the cherry picking undermines the NHS to the point the private sector providers can start flexing their muscles and demanding more money.
It's already starting.
In nearby Bedfordshire, Circle recently won a huge ‘integrated’ ‘prime contractor’ contract for all musculo-skeletal services in the area - and promptly tried to sub-contract the undesirable bits back to the NHS on Circle’s own terms. As the local NHS hospital told the BBC, “Our concern is that if we don't have the planned work coming through, then with the way the NHS is financed, we don't know whether we will have sufficient money to provide the emergency service.” Recent reports suggest Bedford Hospital is now in severe financial difficulties.
And Circle-style ‘mutual’ models are still being quietly pushed, as the government encourages nine more hospital trusts to leave the NHS - and makes clear that it would like to see all of them follow - or perhaps just their profitable cherries, leaving the NHS with the underfunded spuds.
Authors note: We asked Circle for an interview for their side of the story, but they failed to respond.
Royal College of Nursing Back Calls to Suspend NHS Closures
RCN London wants guarantees about investment in out of hospital care
The Royal College of Nursing in London has backed calls for the suspension of further hospital closures in West London, advice until guarantees can be given about investment in out of hospital care.
This message was part of the RCN London's response to a major review led by Michael Mansfield QC into the Shaping a Healthier Future programme of hospital reorganisations in North West London.
You can read the RCN London's full response to the review online here.
The RCN says it has become increasingly clear that the promised investment in out of hospital care to make up for local A&E closures has not been delivered on the scale needed to keep patients safe.
This winter the remaining A&E units in the area have experienced some of the longest waiting times in the country.
The impact of the programme for patients is now being reviewed by Michael Mansfield on behalf of Brent, Ealing, Hammersmith & Fulham and Hounslow Councils under the name “The North West London Health Commission”.
RCN London invited members working locally to contribute and among the problems raised by local nursing staff were:
Increased waits for ambulances outside hospitals and dangerous diversions due to capacity problems
A perceived lack of understanding by patients about the status of the new units. One member said “patients and particularly their carers are frightened and confused about the A&E service closures.”
Pressure on GP services, damaging the ability of practice nurses to carry out preventative health interventions – a clear driver over time of the increase in sick people presenting to A&E who should have been kept well earlier in the system.
An “unsafe and unmanageable” strain on district nursing staff.
Difficulty in transferring patients between services which have been differently arranged, creating delays for living donors and mental health patients
Registered nurses “burnt out, tired and frequently unable to get their time for the study days”, jeopardising continuing learning
RCN London Regional Director Bernell Bussue says: ' The RCN will always support service reorganisation which delivers improvements in the quality of patient care. However it is just not clear that patients have seen any benefit from these changes so far.
' The positive case for the Shaping a Healthier Future programme was based on an increase in out of hospital care to enable more patients to be kept well or treated at home to reduce hospital admissions. In practice, little seems to have been done to boost capacity elsewhere in the system to make up for the closures. Proper replacement services, transition arrangements, funding and a workforce plan should have been in place before the existing units were cut.
' Nursing staff working in the area have told us the closures have damaged patient care. The remainder of the Shaping a Healthier Future closures should be suspended until out of hospital capacity is properly expanded.'
For further information about the work of RCN London visit the website.
Hammersmith MP Andy Slaughter, who has been fighting the closure of A&E departments at Charing Cross and Hammersmith Hospitals says: ' This significant statement from one of the leading clinicians’ bodies should make the local NHS and Jeremy Hunt think twice about pushing ahead with further cuts and closures to healthcare services in west London.'
January 30, 2015
NHS tariffs for 2015-16 rejected by 75% of providers
The NHS must learn from the tariff veto and make immediate changes
Today’s veto of the 2015-16 NHS tariff by 75 per cent of NHS providers, here measured by activity, health is very significant.
It is NHS hospital, discount ambulance, community and mental health leaders saying they can no longer guarantee to provide sustainable and safe care, and meet their constitutional performance targets from 1 April unless immediate changes are made to the way they are paid for their services.‘Being forced to run a deficit is becoming normal practice’
The 2015-16 tariff proposed a fifth successive year of 4 per cent cuts to what NHS providers are paid, combined with demands for an unachievable level of efficiency savings.
A fifth year of hospitals receiving only 50 per cent of the cost of recent demand increases in accident and emergency.
And a fifth year of ambulance, community and mental health trusts not being properly funded for the emergency patients they treat.
It also proposed that providers directly commissioned by NHS England for specialised care would only be paid half the cost of any additional activity in 2015-16.
NHS Providers estimates that, taken together, this cuts £1.7bn from what trusts should be paid in 2015-16 – despite an expected 4 per cent increase in demand and cost for the fifth year in a row.
Eighty per cent of England’s hospitals are now in deficit, and most are running their accident and emergency departments at a substantial loss.
Financial deficits are rapidly spreading to mental health, ambulance and community trusts. Being forced to run a deficit is becoming normal practice.
And it’s not just about the money. You get what you pay for.
As The King’s Fund said last week: “Services are stretched to the limit. With financial problems endemic and staff morale a significant cause for concern, the situation is now critical.”
Talking to our members, vetoing the tariff is not a decision they have taken lightly. Triggering the objection mechanism has serious repercussions, creating uncertainty over the contracting round and plans for 2015-16.‘With financial problems endemic and staff morale a significant cause for concern, the situation is critical’
But after five years of unprecedented price cuts and with NHS providers helping to deliver an extraordinary £20bn of savings over this parliament, objecting to the tariff for many represents a last resort.
There is a widespread sense that politicians and many NHS system leaders simply do not understand the impossibility of the task providers are now being asked to deliver and vetoing the tariff is one of the very few ways trust leaders can raise their rapidly growing concerns.
So, what next? We believe five immediate changes are needed.
First, NHS system leaders need to clearly commit to the principle that NHS providers are fully paid for the care they provide.
NHS providers should be asked for a deliverable level of efficiency savings in 2015-16, not an impossible 3.8 per cent tariff efficiency factor which, for many, translates to a savings target of between 6 and 10 per cent due to the impact of other measures included in the tariff.
Second, all acute emergency work should be paid for at 100 per cent of tariff cost, not the current 30 per cent or proposed 50 per cent with appropriate investment across the rest of the urgent and emergency care pathway.
And the proposed 50 per cent marginal rate for specialised care should be scrapped, with providers and commissioners quickly working together to agree an alternative way to control the specialised commissioning budget.
Third, financial risk must be equally shared between commissioners and providers, so that local health and social care economies work together to address the underlying demand growth and efficiency challenges.
The 2015-16 tariff should explicitly be set to have equally sized deficits on both the commissioner and provider sides.
Fourth, we need an intense new focus on managing the risks to mental health, ambulance and community trusts who have to operate on block contracts, as they are particularly vulnerable to large demand increases.
We also need guarantees that full funding will be made available before 1 April 2015 to ensure delivery of the new mental health targets being introduced in 2015-16.
Fifth, we have to stop penalising providers for failing to meet impossible financial or performance targets. We need a new approach that supports providers, rather than the current regulatory regime that fines them for failing to deliver targets they are not realistically capable of delivering.
NHS England and Monitor need to rapidly and transparently work with the sector to find a sustainable new tariff for 2015-16.
We then need to learn from this experience to reset the way in which the national tariff is decided for 2016-17, so that we avoid a veto next year.
A month ago Circle announced it was handing back Hinchingbrooke Hospital to the NHS because it was impossible to run sustainably. NHS providers don’t have that luxury.
The tariff veto is a similar statement that it is now impossible for all but the very strongest NHS providers to cope with rising demand, meet performance targets and achieve financial balance.
We need NHS system leaders to hear this veto and we need immediate changes.
This blog was published by HSJ on 29 January 2015.
That the 50% tariff for specialised services applies also to ''pass through'' (where the provider charges what they paid) expense, such as PBR excluded high cost drugs, is particularly absurd.
This devolves the inevitable rationing decision to providers rather than commissioners. Hospitals will be blamed when patients die because the drugs they need are not funded.
Also the clause in the ''consultation'' 2015/16 Standard Contract, which increases the time frame for proposed changes to coding, from 6-months notice to 18-months, is another cynical ploy to under reimburse providers.
- See more at: http://www.nhsproviders.org/blogs/chris-hopsons-blog/the-nhs-must-learn-from-the-tariff-veto/#sthash.rNMAOMmk.dpuf
How wearable technology will keep us - especially the elderly - out of hospital - Sir Bruce Keogh
Sir Bruce Keogh, find medical director of the NHS, cheap has revealed the answer to the £120Bn question, just how will we be able to keep people out of hospital in future. The answer is ... the Apple watch or similar devices which monitor physiological readings and flag up alarming changes.
Prof Bruce Keogh: wearable technology plays a crucial part in NHS future
NHS’s top doctor believes gadgets that record heart rate and other health information will revolutionise healthcare
Devices worn on the wrist like the ones that record your heart rate, calorie intake or distance run have a vital part to play in securing the NHS’s future, the service’s medical director says.
Prof Sir Bruce Keogh believes that gadgets similar to fitness trackers, which are growing in popularity, and others resembling games consoles will revolutionise the monitoring of patients’ health, especially those with a serious condition.
“Fitness trackers are becoming increasingly sophisticated. But there are devices coming along which not only measure how much exercise you do but can also measure your heart rate, your respiratory rate, and whether or not you’ve got excess fluid in your body – quite complex changes in your physiology.
“Technology is emerging which enables those to be brought together and transmitted through mobile phones or other methods where health professionals can analyse them and act upon any warning signs,” Keogh says.
Wearable technology could easily prove useful for people with heart failure – one of the most common causes of admission to hospital – and thus relieve the strain on overcrowded hospitals.
“I see a time where someone who’s got heart failure because they’ve had a previous heart attack is sitting at home and wearing some unobtrusive sensors, and his phone goes, and it’s a health professional saying: ‘Mr Smith, we’ve been monitoring you and we think you’re starting to go back into heart failure. Someone’s going to be with you in half an hour to give you some diuretics’,” says Keogh.
Technology “enables you to predict things, to act early and to prevent unnecessary admissions, thereby not only taking a load off the NHS but, more importantly, actually keeping somebody safe and feeling good”.
Sitting in his office on the “corridor of power” occupied by the bosses at NHS England’s south London headquarters, Keogh is almost evangelical about how technology can improve health and cut NHS costs at the same time.
With a fitness tracker just visible under the left cuff of his white shirt, Keogh says in the future “people will use more wearable technology. People with conditions such as diabetes, heart failure, liver disease or asthma will wear devices, skin sensors or clothes capable of detecting deterioration and bringing this to the attention of the patient or anyone else they choose, through mobile phones.
“This monitoring will help keep people safe in their own homes rather than just waiting for serious deterioration necessitating an ambulance or GP call, followed by admission to hospital for several days.”
A polo shirt that can track the wearer’s gait, breathing and heart rate, created for tennis players, shows how quickly technology is developing that makes such monitoring simple, he says.
“The other day, on a visit to the Kent, Surrey and Sussex Academic Health Science Network, I saw a device that looks a bit like a games console. It’s much easier for elderly people to use. They hold it with both hands and a little screen asks you questions such as ‘are you breathless?’, and they just press a button that says yes or no. While they are holding the device, it is measuring their heart rate and transmitting their ECG, among other things. It can also monitor changes in bodily fluid, which is an early sign of heart failure.”
In case this all comes over as wildly futuristic, Keogh cites the results of an eight-month trial in 2013-14 of “low intensity telehealth” among 92 residents of nursing and care homes in Sussex. They had typical ailments of old age: congestive heart failure, diabetes, serious breathing problems and urinary tract infections. The local NHS community care trust gave the homes involved Android tablet computers fitted with an app devised by Docobo, a digital health company. That enabled staff to ask the patients questions regularly about how they were feeling, with the information then analysed remotely by four “admission avoidance matrons”. Anything untoward about a patient’s readings triggered an alert.
During the trial, the matrons received 252 alerts as a result of heart failure, 181 for breathing problems, 36 for a UTI and 20 for diabetes. Previously most patients whose health deteriorated ended up in hospital. But the early warning system, which cost just 90p a day per patient, led to a 75% drop in those who had to be admitted. Staff were able to intervene earlier and, for example, change their drug regime to stabilise their health.
Over the next few years the NHS will push forward with “a huge rollout” of such devices as part of “a revolution in self-care”, Keogh says.
Buy shares in Apple, Samsung, etc... The demand for their products will be huge!
The current STP is the Oct 2016 version. In January 2017 the finance spreadsheets and the Delivery Plan were obtained by FOI. They reveal job cuts of 8,000, outpatients cuts of 222K, planned admissions cuts of 50K and A&E admissions cuts of 64K cumulatively by 2020/21. 500-600 beds will be cut by end March 2021.
People's Inquiry into NW London NHS - commission chaired by Michael Mansfield QC
The Inquiry's findings have been published on Wednesday 2nd December 2015. The full report can be accessed here.
“Deeply flawed hospital plans must be halted immediately” says Michael Mansfield QC
Please click here to read the Save Our Hospitals submission.
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