25 February 2010

Foundation, finance and *uck-ups

The alliteration was too good to miss. It's a shame about the asterisk but Dr Grumble does not want to attract inappropriate traffic. So why these three F-words? It is because Dr Grumble thinks they might just be connected.

If you are in charge of a hospital your main focus should be on providing a high quality, safe service. Everything else should be secondary. If you have to overspend to obviate a disaster you should do it. It actually used to be like that. Everybody understood that safe care was paramount and sometimes the balance sheet but not the patients would have to suffer.

Where do you think this paragraph comes from?

The minutes of the executive team suggested that the main focus of the executives was also on finance, the PFI, service reconfiguration, service level agreements and, latterly, foundation trust status. (pdf)

Could it be from some inquiry into the Mid Staffordshire Foundation Trust? Perhaps it could. But it isn't. This is from the Mid Stafforshire Inquiry:

If there is one lesson to be learnt, I suggest it is that people must always come before numbers.

The very interesting thing is that Dr Grumble had not read the Mid Stafforshire report as he started this post. He just somehow knew what it was going to say. And amazingly on the second page in the covering letter there it was. People must come before numbers. Which is a pithier way of saying what Dr Grumble has always known.

But the question Dr Grumble would really like to ask is whether the creation of Foundation trusts has created this problem. It seems it has. Which means that the problem has been of the government's own making. Yet it seems they are powerless to undo it. Worse still, the opposition want to speed up this flawed process. Is there no hope of some sanity?


Pondering Practitioner said...

Dr Grumble you've absolutely nailed it. Yours is a simple message which strikes at the very essence of why privatisation of the NHS must be stopped.
For at the end of the day, are we to believe that a private company will put people before numbers....?

The Shrink said...

I'm not sure it's the existence FTs themselves. Our FT turns over a healthy profit (erm, surplus) of over a million a year, and has done every year for over a decade, so being/not being an FT really hasn't made/lost us cash.

It's stopped the SHA clawing it off us to pay off the deficits of other Trusts in the region, so although our balance sheet's good, I'll concede that the system's less balanced.

I agree with Pondering Practitioner that privatisation can be bad, but I think FTs within the NHS (and the accountability and flexibility it can generate if done right) are good.

Your quote that resonates is, "If there is one lesson to be learnt, I suggest it is that people must always come before numbers."

It's the culture of business that can be malign, not the local orchestration of service delivery that FTs freedom generates. We have to evidence "quality" to oodles of folks far more as an FT than we ever had to before FT status.

In or out of an FT, in any system, if it's pounds not patients you look at, you're doomed.

Andy Cowper said...

Disagree, Dr G. Agree with The Shrink.

Dangerous, dreadful and uncaring care is nothing directly to do with whether you're a foundation trust (see, for example, Maidstone and Tunbridge Wells, or Stoke Mandeville (both for C Diff deaths), or Kingston for the patient with learning difficulties - none is an FT).

It is clearly all about putting numbers - whether financial numbers or national target numbers - before people.

An FT could get that wrong. So could a non-FT. We have evidence of both.

Someone should compare casemix-adjusted excess deaths between FTs and non-FTs.

The real question, still unanswered, is why nobody took any notice of what was going on, when there was a big public outcry, for so very long.

the a&e charge nurse said...

Andy - hospitals are not awarded coveted Foundation status without convincing the powers that be that they are up to the job.

In fact, once successful, such organisations might be considered the creme de la creme of the NHS?

But if Staffordshire was deemed good enough what does this say about the entire process of deciding how hospitals become worthy of such an accolade?

One worrying possibility is that the standards delivered at Staffordshire are, in fact, not such an exception (providing the paperwork looks good), or put another Foundation status can be awarded to any old shit?

As long as the movers & shakers remain far enough away from the shop floor, there is NO prospect of the kind of mindset that proved such a critical factor in the Stafford debacle, ever changing.

The Shrink said...

". . . such organisations might be considered the creme de la creme of the NHS?"

No, I don't think so. An FT has to evidence financial stability to Monitor and that's the main thing, really.

Oh, there's a Business Plan that (for our Trust) when printed out stood was 8 inches high, that waffles on about whatnots that keeps the Care Quakity Commission sweet, but everyone knows it's Monitor that decide if you become an FT or not.

This does slant things, so managers in Trusts know it's the financial regulation that's critical to the process, skewing energies into positive financial positions rather than in leading in clinical excellence.

Button Ginger said...

It was the headlong rush to save money here, there and everywhere to become a Foundation Trust and then to maintain that financial performance that was the root of the Staffordshire scandal.

I work in Walsall with people who know staff at Stafford and they are still worried for their jobs, patient safety and their sanity.

There are still too few nursing/nursing auxilliary staff for the number of patients being treated.

The fact that Stafford still retains Foundation Trust status after everything that's happened is a scandal in itself.

Andy Cowper said...

Hi A&E Charge Nurse,

My point is really that the esteemed Dr G was asking "whether the creation of Foundation trusts has created this problem. It seems it has". Correlation is not causation: to suggest that 'Mid-Staffs delivered awful care, therefore FTs created awful care' is to over-state the case massively.

There is ample evidence that non-FTs can provide equally bad care, as I've said.

What quality measures we have (with all their imperfections) show FTs to perform significantly better than non-FTs, year after year.

The quality of care at Mid-Staffs is an issue for:
the Care Quality Commission (whose chief executive Cynthia Bower was in charge of the strategic health authority for Mid-Staffs during most of the period in question; before her, the SHA was led by NHS chief executive Sir David Nicholson);
the National Patients Safety Agency;
Mid-Staffs' own board of directors - executive and non-executive directors;
and the staff of the trust.

The report makes it explicitly clear that staff tried to speak out, and were ignored.

Mid-Staffs was approved for FT status because Monitor (independent regulator and authoriser of FTs) was not told by the Healthcare Commission (CQC as was) that it was investigating quality concerns there.

Monitor's remit is financial viability and governance arrangements of applicant FTs. Quality was the Healthcare Commission's remit, and is now the CQC's.

the a&e charge nurse said...

Thanks, Andy - I would only quibble with one point.

You say, correctly, that "Monitor's remit is financial viability and governance arrangements of applicant FTs".

Now correct me if I'm wrong but isn't clinical governance equated with "the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish" (to quote the DoH)

Shrink has already emphasised the significance of financial credibility but having participated in our Trust's bid for Foundation status it was my impression that financial plans only make sense in the context of their affect on clinical services - so, for example, an important plank in our bid was to attract more money by increasing A&E attendances by 3% (see A&E tariff map).

If we translate this increase in A&E attendances to Stafford (3%) how many additional untoward incidents would this have accounted for?

Andy Cowper said...

HI A&E Charge Nurse,

My impression is that the clinical governance is a matter for the Healthcare Commission (as was) and the CQC (as is). Monitor's thing is financial governence.

I accept that bad financial decisions - to do something evidently unsustainable medium-term, like plan for income based on higher A&E attendances - can impact on clinical care. It is wholly clear from the Mid-Staffs report that their financial decisions caused them to make decisions that were bad for patient care, including staff reduction and service reconfiguration. These were inappropriate and unsafe.

I see your point about rising A&E use causing SUIs or worse. Rising A&E use seems to have been caused by the 4-hour waiting time target in A&E; inadequate access arrangements to primary care; and a relatively decent tariff rate, which taken together with the presumption to admit, can create a 'double-bubble' of income.

[One of the solutions to A&E access is to put a GP 'front door', staffed by very experienced triage staff, on every A&E. You can then quickly get the real A&E patients in to a system of your choice ('see-and-treat' or other), and meet the primary care needs appropriately.]

I'm very unclear whether Mid-Staffs' business plan was about rising A&E admission. Are FT business plans treated as 'commercial in condifence'?

Dr Grumble said...

I think it was right to ask the question. I asked it because I remembered that preparation for foundation status was implicated in the Maidstone/Tunbridge Wells outbreaks. But the main reason was that I have witnessed how managers can appear hell-bent on foundation status. That is fine provided they do not take their eye off the ball. I think some do.

It's gratifying to know that there are good performing FTs but presumably these are organisations that are selected out to be better in the first place.

I remain suspicious that the frenzy that can accompany an application for foundation status can turn poor managers into dangerous managers.

The thing about the old system (despite disasters within it) was that the managers knew that if they focussed on low risk strategies and ensuring at least adequate clinical care then they would be safe in their jobs. It seems that sometimes today's managers can be distracted by different priorities. But it is just a hunch.

Andy Cowper said...

Good evening Dr G,

I believe that there are no questions that are not worth asking.

I am sure there are temptations to cut corners to achieve anything. Whether it is FT status, hitting a P-45 national target ... you get the picture.

Once anyone in healthcare loses the plot (that they are working for the taxpayer and the user; for that is the broadly-agreed social contract that creates the NHS), they are indeed likely to do bad things.

I'm just not convinced this misbehaviour is more prevalent in the FT sector (or aspirant FTs) than elsewhere.