Amidst all the shocking evidence about failures of staff, regulators and managers, there's a subplot to the Mid Staffordshire Inquiry that's received less attention. This is the failure of the vehicles supposed to convey patients' voices beyond the hospital, to the local public, patient and representative bodies.
Evidence to the Inquiry exposed how the arrangements for responding to complaints within the hospitals failed to deliver: many patients complained to PALS (the Patient Advice and Liaison Service), the first port of call for most patients in hospitals.
PALS however, were not empowered to act. Given what has now emerged about the ingrained failures in managerial and clinical culture that had taken place within the hospital, it is not surprising that all efforts to complain internally were doomed.
The evidence from those involved in the local overview and scrutiny committee painted a picture of a tardy response, complicated by confusion about the purpose of scrutiny
But the patients’ voices were also not heard by the local bodies that should have been representing them, including the patient and public involvement forum (PPIF) and the overview and scrutiny committee of the local authority.
The failure of these bodies adds a truly Orwellian flavour to the sense of hopelessness described by campaigner Julie Bailey and others when they attempted to flag up failures using the very systems designed to help patients and relatives faced with uncooperative hospital clinical staff and managers.
Witnesses from the local patient and public involvement forum told the Inquiry about a lack of training for them in basic issues (for example the nature of hospital acquired infections) and, more importantly, some asserted that the Forum had an essentially deferential attitude towards the hospital, with an emphasis on cooperation at the expense of challenge.
These witnesses alleged that this did not change with the creation of the Local Involvement Networks (LINKs) – which inherited many of the same people and were not confident that the new Healthwatch would be any better.
The evidence from those involved in the local overview and scrutiny committee painted a picture of a tardy response, complicated by confusion about the purpose of scrutiny. Despite voices of complaint reaching local councillors, there was a lack of clarity about which committee had responsibility over the hospital (borough or county) or what the role of the committee was.
One witness commented that ‘it’s not our job to micromanage’ the Trust, and there was no attempt to find out about the content of formal patient complaints. There was also a similar deference shown by the Patient Forum, along with failure to challenge the account given by the Trusts’ leaders.
The final Inquiry report is blunt about the performance of these arrangements for public and patient involvement and the scrutiny role of local Government: they were ‘a conspicuous failure’.
Putting the apparent personality clashes that emerge from the witness accounts to one side, the evidence raises an important question about the role of local bodies that are supposed to represent patients and the public.
There are strong local instincts to protect and preserve the local hospital: Cure the NHS, the campaign group set up in the wake of the scandal, has stirred a great deal of local controversy, not least from people with positive experiences of care. There is also an active, parallel campaign to restore a full A&E service to the hospital.
Effective lay scrutiny of an institution as complex as a hospital will require an independent mindset: to question always the quality of the care, regardless of how convincing the leadership seems or how impressive the performance indicators appear to be.
It will also require resources: individuals need to be trained to understand this complexity and spot failure as well as access to data (particularly complaints).
The bulk of the recommendations put forward by the Francis Inquiry are professionally focused: better inspection, better data, clearer, nationally defined standards of care and much sharper enforcement of those standards.
But they leave some unanswered questions about how patients’ voices should be heard. But in recent years, Government policy has emphasised the importance of local patient and user voice and accountability. Since 2003, there have been three reorganisations in the search for effective vehicles for local public and patient voice.
There is scepticism about whether the latest incarnation – Healthwatch – will be effective and some argue for the restoration of Community Health Councils, which remained unchanged from 1974 to 2003 (sheer durability is an important part of their reputation).
In the light of the Francis Inquiry (and the Government’s immediate reaction), local patient, user and other representative bodies may now be wondering about their role in improving hospital care and whether the Inquiry’s recommendations for more support and training will be forthcoming in such a constrained financial environment.