How did Stafford happen?

Stafford happened because of local, regional and national failures and a failure of corporate governance, Professor John Caldwell, Chair Mid Staffordshire NHS Foundation Trust told the HSE Masterclass. Maureen Browne reports.

Prof. John Caldwell
Prof. John Caldwell

What happened at Stafford Hospital between 2005 and 2009 was a systematic failure of the provision of good care, far more than can be ascribed to personal failings of a few staff, Professor John Caldwell, Chair Mid Staffordshire NHS Foundation Trust told the HSE Masterclass.

He said many patients “suffered horrific experiences that would haunt them and their loved ones for the rest of their lives”, and both the Trust’s Board and the system as a whole failed to protect patients from unacceptable risks of harm and from unacceptable, and in some cases inhumane, treatment.

Prof. Caldwell was speaking on “Learning from the Experiences of the Mid Staffordshire Trust.”

He said the great majority of complaints related to basic nursing care rather than clinical errors leading to morbidity or mortality.

There were inadequate numbers of staff to deal with the challenge of elderly and confused patients; staff were not adequately trained to meet these needs, there was no proper system of nursing and ward management, staff morale was low and there was disengagement from management, notably by the consultant body, who took a “fatalistic approach” to management issues.

Unacceptable standards were tolerated for a significant number of patients, there was a lack of openness and transparency, overall staff numbers were reduced during the period of deficiency, higher level committees were focused on finances with no priority given to clinical matters and there was an isolation from the wider NHS community.

The hospital was not open to outside influences, lacking management, focussed inappropriately on target‐driven priorities, with pressure applied to achieve these, notably the A&E waiting time target.

“Staffordshire had been an NHS backwater for many years and the hospital was not open to outside influences, lacking management, focussed inappropriately on target‐driven priorities, with pressure applied to achieve these, notably the A&E waiting time target.”

Prof. Caldwell said that financial drivers led to a significant reduction in overall staff numbers and changes in skill mix during the period of deficiency.

Changes in staff numbers were not properly risk‐assessed and not evidence‐based. There was inadequate clinical governance and lack of board oversight. Clinical staff were too distant from board with several layers of management between divisional groups and the board.

He said Stafford happened because:

  • Locally there was loss of individual responsibility, failures of line management, failure of board governance
  • Regionally there was failure of commissioning
  • Nationally there was failure of oversight
  • And there was failure of corporate governance

“The Mid‐Staffs as I found it in November, 2011 was a very small trust – 300 beds, turnover £ 160M/year, vulnerable as result of the scandal but also due to configuration. It had a marginal existence at best, was inward looking and with no prospect of using the freedoms of a Foundation Trust.

The financial deficit was a permanent situation, it was a terminally damaged brand, with a fatal impact on patient choice, staff recruitment and commissioning intentions, there were strong opinions pro and con in the local community and a huge need for an organisational development overhaul, with minimum management capacity.

Changes in staff numbers were not properly risk‐assessed and not evidence‐based, there was inadequate clinical governance and lack of board oversight.

Prof. Caldwell said that the findings of Francis 2 were largely anticipated ‐ CQC concerns removed, performance deficiencies largely remedied, the Trust “operationally sustainable,“ by late 2012 community (re)engagement opened, MSFT was not sustainable in the longer term and the option appraisal was to seek a long‐term future for services for the community.

The present position was that it was in administration since April 2013, MSFT not wound up until October 2014 and long term service configuration would not be finalised before Summer 2015 at the earliest, but would closely resemble the board’s preferred options from May 2012. The bill to consultants was > £ 17 M thus far.

He said patients must be the first priority, they must receive effective services from caring, compassionate and committed staff, working within a common culture, and they must be protected from avoidable harm.

Prof. Caldwell said there were fundamental standards of behaviour, healthcare standards, the promotion of a culture of openness, which required transparency and candour and promotion of a culture, competence and conduct through effective leadership.

Fundamental standards of behaviour:

  • Organisations must be committed to fundamental standards of behaviour which needed to be applied by at levels by all those who worked and served in the healthcare system.
  • Standards of service needed to be formulated to enable services to be delivered safely and effectively, informed by an evidence base and to be readily measurable
  • Professional groups had specific responsibilities which needed to be advanced without recourse to self‐interest
  • Fitness to Practice issues must be tackled vigorously
  • As much attention must be paid to the lowest grades of staff as to the highest

Healthcare Standards:

  • The system must accept responsibility for and demonstrate the effectiveness of healthcare standards
  • Boards must exercise effective governance according to standards set and scrutinized nationally
  • Commissioning arrangements must be a driver for higher standards
  • There must be effective scrutiny of safety and standards of care by local communities.

Promoting a Culture of Openness, required transparency and candour

  • Openness – enabling concerns and complaints to be raised freely without fear and questions asked to be answered
  • Transparency – sharing performance and outcome data in a timely fashion with staff, patients, the public and regulators
  • Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked
  • Effective complaints handling
  • Timely, sensitive and accurate handling of complaints, with effective communication of the complaint to those responsible for providing the care
  • Demonstrate the features of a listening organisation

Promoting Culture, Competence and Conduct through Effective Leadership

  • Provide a training system to facilitate training in management and leadership to potential senior staff
  • Promote healthcare leadership and management as a profession with appropriate accreditation
  • Build an evidence base for best leadership practice in healthcare

He concluded that the management of major change post‐Stafford required that “changes must be properly planned and once a provisional plan has been formulated, widespread consultation is essential. If properly done, this should lead to engagement and ownership by concerned staff groups. Proper risk assessment essential. New process must be managed with purpose and consistency. There must be regular monitoring with dissemination of results and adjustments as appropriate.”