Patient Diagnostic Services
Debate between Keith Vaz and Barry Gardiner(10 years, 6 months ago)
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Barry Gardiner (Brent North) (Lab)
As it is the first time I have had the pleasure of speaking in the House since your election to the Chair, Madam Deputy Speaker, may I congratulate you and say how pleased I am to be speaking this evening under your guidance?
The doctors and consultants in Brent, like those in the rest of the country, are highly respected members of our community. Their work is part of the glue that keeps our society together and enables people to function and get on with their daily lives. Doctors, though, would be the first to admit that they are not omniscient—well, some of them would. Their work depends upon the work of many others in the health care sector—in particular, the work of laboratory and radiography technicians who provide the evidential base for diagnosis and treatment. The quality of patient outcomes will always depend on the quality of diagnostic services because a diagnosis delayed is a treatment delayed, and an incorrect diagnosis is potentially fatal.
This evening, I wish to detain the House and suggest to the Minister that the structural changes that his Government have introduced in the national health service have had a seriously adverse and dangerous impact on patient care.
In May 2012, the decision was made to outsource pathology services in Brent and Harrow. Previously, it had been provided by the NHS at a facility at Northwick Park hospital. The decision was taken because the hospital wanted to invest in improvements to the system. Rather than incur those financial costs, it was considered more efficient to outsource the contract to TDL Ltd—otherwise known as The Doctors Laboratory. That was a mistake.
The first indication that there was a problem came when a GP identified a serious technical flaw in the way patient test results were presented through the computerised system. The GP had received a list of multiple test results in respect of a patient. When looking at one set of results on the list and closing it or archiving it to the patient file, the GP realised that it was possible inadvertently to apply that same action to all the other test results returned on that list. Pathology results that required urgent action could be accidentally archived owing to an error in the TDL reporting system. Critical patient test results could be missed altogether or inappropriately actioned.
The GP reported that as a serious incident and immediately flagged up the issue to the North West London Hospitals NHS Trust, on the assumption that pathology services were still being carried out there. In fact, the service has been provided by TDL since May 2012. The hospital trust passed the concerns on to the Brent and Harrow clinical commissioning group, which was now responsible for managing the contract with TDL. At that time, the matter was not thoroughly investigated and was deemed to be a single incident and not a cause for concern.
However, GPs began to talk to each other about their concerns and realised very quickly that they were not alone in seeing a sudden change in the quality of results they were receiving from the service that had, up until 2012, been carried out adequately at Northwick Park hospital. At an emergency meeting with representatives of NHS Brent and Brent CCG, the GPs were led to believe that steps were being taken to resolve the matter.
The problem got worse. GPs across the borough were receiving many more abnormal results than they would ordinarily expect: test requests were ignored or the results were never reported back to them; other tests were being returned incomplete with only partial results and data omitted; and some samples were being incorrectly marked as complete and being discarded without being tested.
This alarming downward trend in the quality of the results finally prompted NHS Brent and NHS Harrow to launch a proper investigation, which commenced on 20 December 2012. Let me quote this root cause analysis investigation report, which finally reported in March of this year and found
“spurious results, missing results and samples not processed...reference ranges had changed and...the presentation of the results into groupings that did not make sense”.
One GP wrote to me to say:
“In the new year the scale of serious anomalies and problems had become so great that individual practices started to send out e-mails to each other to see if the problems were as isolated as we were being led to believe…The response was shocking. Our patients are at serious risk. Unless we have these basic services reliably we cannot diagnose and treat our patients.”
Keith Vaz (Leicester East) (Lab)
The situation in north London is clearly shocking. Does my hon. Friend know whether any of the tests that were outsourced relate specifically to diabetes, which is a huge problem for people who live in Brent? About 10% of the population is thought to suffer from diabetes.
Barry Gardiner
I am grateful to my right hon. Friend for his intervention, and he is absolutely right that diabetes is a major problem in the Brent area. Given that many of the tests related to phlebotomy, I would assume that some of them might have related to diabetes, but I do not have that specific information to hand.
I was explaining that GPs across the borough were receiving many more abnormal results than they would ordinarily expect, that the downward trend in the quality of the results had prompted an investigation and that the GPs had expressed their own concerns by exchanging information among themselves to ascertain the extent of the problem.
The interim deputy director of quality and safety for Brent, Ealing, Harrow and Hillingdon CCGs reported
“many incidents of patients attending for repeat blood tests at both the practice and within the hospital and some patients…referred to A&E Department because of high potassium levels.”
Many consultants began to experience similar problems with the service and were also having to carry out further unnecessary tests. One consultant, when pressed, scribbled a note setting out a variety of issues:
“Immunology—assay results; Calcium results—change in calculations; Change in reference ranges; Potassium—delays in transfer and refrigeration”.
I am sure the Minister will agree that such failings in service are wholly unacceptable.
The question then arises how any competent company of qualified health professionals could come to make such errors. After all, its website states that it is
“providing quality accredited pathology services to the UK and worldwide”.
I trust the Minister will be as surprised and as disappointed as I was to learn that, at the time the service was outsourced, TDL was
“not currently registered with Clinical Pathology Accreditation (UK) but is working towards this”.
The words “working towards this” should be accompanied by some degree of scepticism, given that the final report on the root causes of the problem identified that TDL was so incompetent that
“There was an operational issue with the new robotic sorter which resulted in a number of samples being filed incorrectly as ‘analysis complete’ and subsequently discarded. There was also a problem with one of the lines in the calcium analyser as a result of which samples were transferred to another laboratory, and a number of issues were attributed to human error.”
Compounding the confusion, when the service was transferred, TDL used different reference value ranges to assess and analyse results in order to fit in with its own IT systems. Unfortunately, it failed to communicate this change to the GPs or consultants who were now expected to interpret results that they did not understand, based on reference ranges with which they were not familiar. TDL was found to have not followed its own procedures, which required it to flag up to its service users when systems were changing. Owing to this transition, GPs and consultants were effectively left blind about the difficulties they might experience with pathology reports.
Of course, the quality of any test results will always depend on the quality of the samples received. Just as in the world of computing, “garbage in leads to garbage out”. One would imagine that when the decision was taken to outsource the pathology courier service that delivers samples to the pathology laboratory, clear and appropriate clinical advice was sought about precisely how this contract should be specified—and it was. In fact, GPs suggested that a courier service carrying samples for potassium tests must be refrigerated in order to avoid the impact of temperature change on the quality of the sample. However, the terms of the contract failed to specify that, and the eventual service that was commissioned did not provide for temperature control.
I have also received complaints about delays in delivery, as well as allegations that damage to samples in transit has made it difficult to record and analyse them properly. Indeed, the NHS Brent CCG noted in a report to the Brent health overview and scrutiny committee that issues of transportation quality and service delays on the part of the courier service, Revisecatch Ltd —trading as Courier Systems—
“appear to play a seasonal role in the variation of potassium levels; in that they add to the instability of the samples due to fluctuation in temperature during storage at the GP practice and/or during transportation to the laboratory in both summer and winter”.
Another privatised diagnostic service, the London NHS Diagnostic Service, is provided by InHealth. It is designed to enable London GPs to make direct referrals for their patients so that they have already had tests before being referred to specialist consultants. The tests might include ultrasound, echocardiography, audiology, cardiac physiology, magnetic resonance imaging, X-ray, endoscopy or phlebotomy scans. The intention was to reduce the CCG’s consultant costs by referring only patients who really needed their attention. In other words, GPs would filter patients to avoid unnecessary and costly referrals.
GPs have objected that that practice has simply introduced a middleman to the process, and that delaying a diagnosis from a specialist consultant may put patients in danger. I am told that the problem is compounded because the scans received from InHealth are often themselves delayed, and are frequently found to be of such poor quality that the patient must be referred to a specialist consultant in any event. My office has also been given anecdotal evidence that staff at diagnostic centres do not possess the necessary skills or understanding to handle complex diagnostic services.
General practitioners are not specialists. They are not consultants, and they are seeing scans which they cannot decipher or which are in a format that they cannot use. The patients are sent for another scan, or often are simply referred to the consultant whom they would have seen under the old system, who then usually orders a further scan at his or her own site. What started off as a way of saving money and freeing consultants to focus on clear cases of need becomes a bureaucratic process that puts patient outcomes at risk and costs more money as a result of duplication and delay. I should like to know from the Minister whether it is still the case that a patient has a statutory right to see a consultant, and whether a patient can insist on a direct referral from his or her GP without the interposition of additional diagnostic tests.
However, it is not just those diagnostic support services that are being privatised; front-line diagnostic services are being outsourced as well. I am, of course, referring to the NHS 111 service. The service was designed to ease pressures on accident and emergency departments by providing telephone-based triage, but many criticisms have already been made of it. Reference has been made to patients’ calls being answered by medically illiterate staff and to failure to meet targets to transfer calls to a clinician or nurse within 60 seconds or return them within 10 minutes, and there have been stories of patients simply being referred to A and E departments because call centre staff do not know what alternative facilities are available.
I do not wish simply to add to that catalogue of failings. My concern is more specific. In Brent and Harrow, we have an NHS 111 service that was awarded to Harmoni. That in itself was cause for some concern, as the company’s shareholders included the majority of the Harrow clinical commissioning group board that had decided to award it the contract. However, that is not the potential conflict of interest on which I wish to focus.
The urgent care centre at Central Middlesex hospital happens to be owned by Care UK, the company that also now owns Harmoni. Let me make clear that I am not accusing Care UK of encouraging its NHS 111 staff to make referrals to Central Middlesex in the knowledge that they will benefit from the treatment of any patients at the urgent treatment centre there, because I have no information to suggest that that is the case. Nevertheless, it is clear that there is a serious conflict of interest that any contract must monitor and guard against.
The interests of Care UK are clear, but its performance is not. I wrote to the Secretary of State for Health asking how the service in Brent had performed relative to the service specification. I asked,
“how many calls have not been (a) answered, (b) referred to a clinician or trained nurse within the appropriate timescale or (c) in receipt of a call-back from an appropriate clinician within 10 minutes”.
I received the following response:
“Local commissioners are responsible for performance management of NHS 111 services, and set their own performance targets for services…Data…is not available in the format requested.”—[Official Report, 23 October 2013; Vol. 569, c. 213-4W.]
In other words, the only people responsible for policing such conflicts of interest are the very people who have stood to gain from them.
The final issue I wish to raise with the Minister is that of the National Clinical Assessment Service. In many respects, this could merit an Adjournment debate all of its own. NCAS was established to undertake performance assessments of GPs and clinicians when primary care or hospital trusts had expressed concern that their clinical results or statistics appeared to have been outside normal parameters. There are more than 1,000 referrals a year, and in the vast majority of cases NCAS will assist simply by advising the trust in order to return the clinicians to safe and effective practice. However, in 50 or 60 cases each year an extraordinarily detailed and intensive process of assessment and remediation is required. Only about 60% of those who undergo that process make it back into safe and effective practice, while 40% never return to work in the NHS. NCAS is therefore one of the key guardians of patient safety.
In 2010, it became clear that NCAS would be restructured as part of the reconfiguration of the NHS. Its budget was cut by 20%, and it was told that it would have to become self-funding by 2013. In 2012, Deloitte was asked to conduct a review of the service, but it is due to publish its report only on 14 November, 10 days from now. In April this year, NCAS was joined to the NHS Litigation Authority, which has since consulted on a new structure prior to publication of the Deloitte report.
I understand that senior clinicians in NCAS are deeply worried that the head of the NHSLA has simply dismissed the very serious concerns that senior and experienced practitioners fed into the consultation about the proposals and the impact they might have on patient safety. NCAS is now haemorrhaging junior staff, whom it is allowed to replace only with agency people. The advertisement for a replacement for the senior assessment adviser specifies that the person concerned must be someone on secondment, and for one year only. The restructuring proposals dispense with the post of the director responsible for the “back on track” service, but no one else in the service has the clinical capacity to perform the role.
For some 50% of those who come for assessment, previously unidentified patient safety issues are revealed, often involving the cognitive impairment of the clinician himself or herself. I believe that before the proposed changes are allowed to proceed, the Minister must provide satisfactory answers to two questions. First, how will those patient safety concerns be discovered under the new model? Secondly, how will doctors who present a risk to the public be remediated and returned to safe and effective practice, given that the proposal specifically does not replace the key post with the clinical capacity to carry that out?
The problems and failings I have outlined this evening are not a series of unfortunate but unrelated events, but the logical consequence of a restructured NHS that has put competition and cost, rather than patient care and patient safety, at the heart of the health service. There has been a failure to ensure quality commissioning of the services being provided. In fact, one GP has written to me noting:
“It perhaps raises an interesting learning point for the future; that being if GPs are going to commission services and deal with private providers, what mechanisms are in place to stop patients being harmed by”
our
“negotiating a less than water tight contract? We are GPs not lawyers.”
Certainly with respect to the takeover of the pathology laboratory by TDL, no risk assessment was carried out to predict the potential problems that might arise from a change in both system and process, and no suitable performance measures were implemented, nor was a structure of monitoring put in place to ensure that a good quality of service was maintained. The Health Secretary has been keen to argue that privatising these services is on the basis of improvements to patient welfare and sound clinical evidence. It is not.
The awarding of the contract to Revisecatch Ltd shows that the clinical advice was ignored on the basis of cost, despite the clear implications for patient safety. The irony is that the subsequent change in contract specification almost always results in much higher costs, to the benefit of the private provider.
Patient care and patient safety can only be prioritised in a system where transparency thrives. Only in such a system can mistakes be learned from and become the basis of better future practice, but it is not in the interest of private companies to disclose any aspect of failing service. The root cause analysis report notes:
“The report provided by TDL on 08 March, was light on detail in parts and so it was difficult to identify lessons learned. TDL enjoy a good reputation and it is understandable that they would wish to protect this. However, in light of the requirements to put patients first and the duty of openness, transparency and candour, as recommended by Francis, it is felt that all involved could have been more open throughout the process.”
This issue of transparency and openness will remain a serious challenge for as long as private companies compete for contracts on the basis of cost.
Too many medical professionals are having to discover to the detriment of their patients that, for all their clinical expertise, they were never trained in the dark arts of commercial contract law, contract specification, negotiation and monitoring. It is the dogma of this Government that has put competition at the heart of our national health service, where patients should rightly be.
Public Confidence in the Media and Police
Debate between Keith Vaz and Barry Gardiner(12 years, 9 months ago)
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Barry Gardiner (Brent North) (Lab)
We heard yesterday from people who said that they did not know about hacking and that they did not authorise payments for it. It is extraordinary that those executives did not take their responsibilities for corporate governance seriously enough to determine who did know about hacking, who authorised it and who paid for it. This question is not just for the House, but for the shareholders of News Corp and News International. How can those shareholders have confidence in a management who, six years on, have failed to find out those simple facts and to hold people to account?
The £500,000 settlement to Gordon Taylor was discussed at the time by James Murdoch and Rebekah Brooks in a meeting with other officers of News Corp and News International. They were discussing a payment to someone who was the victim of the company’s illegal practices, so the House must consider whether it is at all credible that at that meeting James Murdoch did not put one simple question: why do we have to pay this money? Any chairman would want to know the full details of why he was being asked to make such a payment, so of course he was told the details of the breaches of privacy suffered by Gordon Taylor and others. However, any semi-conscious corporate lawyer would ask a further question: what is the full extent of our liability? When James Murdoch asked that question, it is inconceivable that he would have accepted anyone answering, “We don’t know,” or, “We haven’t bothered to find out,” yet in effect that was the response that he and his father gave to the Culture, Media and Sport Committee yesterday. Had he received such a response, I think that his answer would have been swift and sharp.
If the House accepts that that question must have been asked and then fully and honestly answered, it follows that James Murdoch knew that Jon Chapman and Daniel Cloke had full knowledge of the extent of the phone hacking because, of course, they reviewed the files given to Harbottle & Lewis. James Murdoch told the Select Committee that he did not tell his father about the £500,000 payment to Gordon Taylor until after it had been made in 2009. He did not explain why he had failed to tell his father that he knew what Chapman and Cloke knew, namely that widespread hacking and illegality had taken place, and that that was why they had to buy Gordon Taylor’s silence.
The files at Harbottle & Lewis are crucial. Yesterday, James Murdoch told Parliament that the actions of News Corp did
“not live up to the standards that our company aspires to…and it is our determination to put things right”,
yet News Corp has refused to allow Harbottle & Lewis to release those documents to the police. Being determined “to put things right” starts with releasing those files.
Why, in 2009, did Deputy Commissioner Yates decide that there was no new evidence in The Guardian’s revelations about the hacking of Gordon Taylor? Mr Yates has been at pains to insist that this was not a full-scale review. I accept that, but it takes not even eight minutes, never mind eight hours, to appreciate that the reason there was new material evidence was that a royal correspondent—the subject of the original investigation—would not have been doing an investigative story on the chief executive of a football association. In other words, that gave the lie to the widespread assumption that this was just one rogue reporter.
Barry Gardiner
I am grateful to my right hon. Friend the Chair of the Home Affairs Committee, who has carried out excellent work on this, for that comment. My point is that Mr Yates did not need even eight hours. He needed eight minutes, because all he had to consider was the central fact that the latest information in The Guardian revealed that there was not one rogue reporter, but more than one.
Paul Stephenson, in his resignation statement, made a distinction between his appointment of Mr Wallis and the Prime Minister’s appointment of Mr Coulson. A distinction has repeatedly been made in the House by the Home Secretary and others, who have tried to say that an important line has to be drawn between the investigated and the investigator. I agree: that is absolutely right, but it is equally right and it is of fundamental importance in our debate about public confidence in the media and the police that we should consider public confidence in the Government and in the Prime Minister. If there is a proper line between the investigator and the investigated, there should be a proper line between the law maker and the law breaker.