In 2001 the learning from the largest public inquiry in the history of the NHS reported its findings.
According to Dr Phil Hammond, GP, Broadcaster, Journalist and PATIENTSTORIES contributor, despite years of discussion and debate little has really changed in the culture of the NHS.
In this article (first published in Private Eye) Phil explores how and and why change has been so slow to come.
Why are most inquiries into NHS failings still held in secret? Without scrutiny of the process, there is no way of establishing their independence and we’re forced to rely on blind trust in the integrity and competence of experts, which is generally why NHS scandals occur in the first place. And given that inquiries are paid for out of public money, it’s absurd that patients should be excluded from hearing the evidence and cross-examination, and giving their own evidence.
The Bristol Pathology Inquiry was run by Verita, cost £700,000 and the report was published 18 months after the Eye first published allegations of serious errors in pathology reporting at University Hospitals Bristol (UHB). These had been circulating around the city for some years, and the hospital management, Bristol PCT, South West Strategic Health Authority and Royal College of Pathologists all knew about them without properly investigating. As the report conceded: ‘This Inquiry was only established because of the articles in Private Eye and, had it not been for them, the issues would have continued to be ineffectively addressed.’
The report found that: ‘The culture in the histopathology department at UHB veers towards the opposite of what is required. We have observed a culture which is at times defensive, responds aggressively to criticism, is sometimes unwilling to acknowledge, let alone learn from, mistakes, and which is based on overconfidence bordering on arrogance.’ However, it concludes that: ‘Overall there is no evidence to lead us to believe that the department provides anything other than a safe service.’
Given that mistakes inevitably occur in all histopathology departments, where complex tissue samples are analysed under pressure, the key factor in making it safe is a culture of openness where the staff accept criticism and scrutiny of their work, and work together to ensure patients get an accurate diagnosis and the best possible treatment. As one senior consultant told the inquiry: ‘I would urge you to ensure that the money invested in this review (money that could have been spent on patient care) is responsibly spent on an in depth investigation into what many believe, but are too frightened to admit in public, is a dangerous histopathology service.’ This failed to make the 264-page final report.
The report’s length belies an adequate analysis of the safety of the reporting. Detailed allegations were made in five areas of tissue reporting – breast, skin, lung, gynaecology and paediatrics. The inquiry should have invited those who made the allegations to present their tissue evidence for independent analysis. They were excluded from this process and have no way of knowing that the 26 samples analysed by the inquiry adequately represented the errors they had observed. There are concerns that nine cases were missed completely. And the paediatric pathology slides weren’t analysed at all.
An audit of the five specific areas is necessary to establish proof of safety but instead, UHB ordered an expensive audit of 3,500 slides in all areas. As the inquiry put it: ‘There is no doubt that the final selection has to some extent diluted the effectiveness of assessing competency in the specific specialist areas of concern.’ So in one area – paediatrics – slides weren’t examined at all, and in four others they were done in a very limited manner in conditions of extreme secrecy. Some serious errors were acknowledged but no patients or relatives who had been harmed were invited to give evidence. On that basis it’s hard to know how safe UHB’s pathology department is. Not great value for £700,000, though it does protect the reputations of senior NHS managers and doctors who knew about the allegations for years but failed to adequately investigate them.
Getting rid of John Watkinson, the whistle-blowing former chief executive of the Royal Cornwall Hospitals’ Trust may cost the NHS over £2 million, after an employment tribunal – held in public with rigorous cross examination – judged that he was substantively and procedurally unfairly dismissed in a ‘travesty of anything approaching basic concepts of fairness’. An inquiry ordered by Andrew Lansley and run by Verita (in secret), has completely absolved South West SHA of any wrong doing, and Verita has threatened legal action against local campaigner Graham Webster who gave evidence and concluded that the inquiry “hasn’t given us the independence and integrity that we were looking for”. Promoting a culture of openness and transparency in the NHS, and re-establishing public trust, is impossible while its inquiries are so non-transparent and defensive.
A detailed critique of the Bristol Pathology Inquiry is at http://drphilhammond.com/blog/category/bristol-path-inquiry/
and the Watkinson Inquiry at http://www.healthpolicyinsight.com/?q=node/903