Report from the National Advisory Group on the Safety of Patients in England

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by John Goodman,

from NCPA,

The “Final Report Of The Independent Inquiry Into Care Provided By Mid Staffordshire (England) NHS Foundation Trust”, … a 500-page report was mandated by the House of Commons and chaired by Robert Francis QC, who was quoted as saying –

“It is now clear that some staff did express concern about the standard of care being provided to patients. The tragedy was that they were ignored and worse still others were discouraged from speaking out.”

Management knew what was happening, but failed to correct it and even suppressed any discussion of the problems.

Consider this quote which helped to start the report analysis:

“…[F]or many patients the most basic elements of care were neglected. Calls for help to use the bathroom were ignored and patients were left lying in soiled sheeting and sitting on commodes for hours, often feeling ashamed and afraid. Patients were left unwashed, at times for up to a month. Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding. Staff failed to make basic observations and pain relief was provided late or in some cases not at all. Patients were too often discharged before it was appropriate, only to have to be re-admitted shortly afterwards. The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections.”

Enter Don Berwick – brought in to chair another committee — the National Advisory Group on the Safety of Patients in England, which issued another report and recommendations for action.

Berwick’s report is a complete whitewash of the situation. Here are a few of their observations and my comments.

Let’s start with Berwick’s personal letter to “Senior Government Officials and Senior Executives of the Health Service.” He writes –

“You are stewards of a globally important treasure: the NHS. In its form and mission, guided by the unwavering charter of universal care, accessible to all, and free at the point of service, the NHS is a unique example for all to learn from and emulate.”

Good grief, could he be more gushing, even in the face of glaring and criminal incompetence? No one on earth wants to emulate the NHS. Not one nation is trying to replicate the British system. It is the laughing stock of the world. The things about it that Berwick admires are the very things that made this atrocity inevitable as we will discuss below.

“Patient safety problems exist throughout the NHS as with every other health care system in the world.”

So, it’s no big deal, just the way things go. Get used to it.

“NHS staff are not to blame — in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.”

NHS staff are not to blame? Who developed the procedures, conditions, environment and constraints? Where is the procedural rule that told the staff to let people lie in their own feces and urine? Who decided to leave food and water out of the reach of the patients? What kind of monster would step over a suffering patient and do nothing? Would Don Berwick be so sanguine if these things happened in a private hospital? Of course not! Heads would roll. But since it is a government hospital, no one is to blame.

Where are the patients who are supposedly so central to the whole shebang? Not worth including, I guess.

And here is the real problem with the NHS. Like the commission itself, patients are an afterthought. They have no power, no authority in the NHS. The entire system is based upon the idea that well-meaning experts will do things for (or to) supplicating patients who get their services for free and have no choice in what they get.

But the current scandal shows that these experts are not always well-meaning or even competent. What happens to the hapless patient then? They are left to lie in their urine-soaked beds with food and water out of reach. There is no recourse, other than to “move on.”

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