NHS: Standards of Care and Commissioning

Baroness Murphy Excerpts

Thursday 31st March 2011 Lords Chamber

[Baroness Murphy]

My Lords, I shall hark back to much of what the noble Lord, Lord Turnberg, said in his admirable introduction to this topic. The stories in the ombudsman’s report are so shockingly familiar to us, yet we still find it very difficult to take in that they reflect the norm. The National Confidential Inquiry into Patient Outcome and Death in surgery for elderly patients found that only 38 per cent got good care. It is not just that care is neglectful to the point of cruelty, but that families that try to intervene are actively discouraged and largely ignored and the denial by managers is a cultural norm. I found that I could not save my own mother-in-law from truly appalling care in a suburban London hospital, and my own mother’s recent care in a Midlands teaching hospital was pretty variable, too, depending on the team that was on duty.

I have heard people minimise the significance. Apparently the NHS has improved over the past few years and patients say that they are very satisfied with the care that they get. It may well have improved, but the very aged do not respond to these patient surveys, and in any case it is their distressed kith and kin we should be surveying to get an accurate picture. My mother would not let me complain because they fixed her hip, did they not? The Patients Association has been flagging up the truth for years and the majority of senior managers know that Mid Staffordshire Hospital was not an outlier on the graph by any means.

The usual response to a scandal is to launch an inquiry, and I have sat on many myself. Typically they make vast numbers of recommendations that are then translated into points for action with a monitoring schedule for ticking off the boxes. Schedules will be cascaded and all will get a bit better. There are marginal improvements locally, but nothing really changes. What is the answer? More inspection? I do not think so. The CQC knows that the self-monitored standards of dignity that hospitals claim to have reached are often a fiction. Inspection never picks up more than a snapshot. Unannounced visits are helpful, but they are too infrequent and superficial to be realistically helpful. Regulators simply cannot substitute for caring staff. More training that treating old people appallingly is wrong? I do not think so. We all know it is wrong, but we learn by example from our seniors. If that counts as training, then perhaps training is needed. More geriatricians and psychogeriatricians like me? We need champions in medicine and nursing—but no, this is every clinician's business, not a specialty.

I agree with many colleagues who have spoken before that getting the teamwork and ward processes right might help a bit. It is noteworthy that these episodes of poor care do not occur on specialist wards where unified teams work together under good leadership. We have tended to undermine teams on general wards in the misguided and counterproductive chase for efficient turnover. I harp back to Professor John Yates’s earlier studies, which show that it is vulnerable patient groups, local ward staff left to their own devices and staff not included in team support who fail.

My recipe comes back in part to unannounced regular inspections by HealthWatch and the regulator and to surveys of family carers. However, hospitals reflect the wider attitudes of society. We should look properly at the price of care, and we should stop commissioning specialties such as cardiac, cancer and renal at a higher tariff on the care price compared with medicine for the elderly and general surgery. The funding imbalance is profound and reflects the poor value which society puts on the everyday care of the most vulnerable. Therefore, the commissioning sensitivities that GP consortia will have will be crucial. We know from studies in the States that commissioning cannot be the whole answer; it is the providers who are important. However, we should not necessarily ignore commissioning. It is vital, but ultimately it is the care design in hospitals and structures that really count.