Tuesday, 22 September 2015

What really went wrong at Addenbrooke’s

The commentariat have issued a torrent of bullshit on the decision to put Cambridge University Hospitals into special measures. Most explanations are misleading nonsense that don’t match what we know. Seeking the right explanation is an essential first step to fixing anything in the NHS.

The decision to put the hospital into special measures has been controversial. Senior people have resigned. And far too many commentators have responded by rolling out clichéd explanations that pander to their prejudices and don't fit the specific facts of the case. Roy Lilley blames the regulatory environment. Polly Toynbee agrees and adds another explanation: the funding crisis (which, despite the flat NHS budget, apparently consists of “savage cuts” though that might just be a cliché obsessed sub editor). Another Gruaniad story claims problems in social care keeping people stuck in beds. Others have blamed unsustainable surges in emergency demand. Many bemoan the loss of a highly regarded CEO and blame the government, the CQC, Monitor and just about every other central body in the NHS for making hospital leadership roles impossible.

While many of these supposed explanations are real problems in the NHS, none explain what went wrong at Cambridge or why it happened so quickly. In leaping to conclusions without checking the facts commentators are creating a fog of distraction that seriously inhibits identifying the real issues and fixing them. And the real issues are pretty important for the whole NHS so we really should be paying attention and trying to learn something that will help in the future rather than contributing to the miasma of ignorance.

The thing that seems to cause confusion among the commentariat is that a hospital with motivated clinicians which recently had a top rating for care quality has fallen over. The thing they don’t seem to understand is that motivation, vision and general worthiness of intent are not adequate to run a hospital: you also need good operational management. All the good will in the world won’t compensate for dysfunctional operation processes and data.

And this is the real explanation for what went wrong. The hospital tried a big-bang implementation of a visionary new eHospital system and (i’m guessing a little) botched the implementation process or seriously underinvested in it. The result was that the basic information operational managers needed to actually run the hospital was missing or corrupted. So basic processes no longer happened the way they should. Patients in A&E couldn’t be tracked so the 4hr target wasn’t met; surgical activity wasn’t correctly recorded so the PbR payments due from commissioners were wrong; appropriate matching of staff with activity couldn’t be done…

I can’t be sure of all the details because I haven’t visited the hospital to check. But I know that the clinicians thought the implementation was a catastrophe and were concerned that top management didn’t want to know their visionary system wasn’t working. I know that A&E performance fell off a cliff the week the system was started up. I know that the financial situation deteriorated very suddenly at the same time.

Roy Lilley blames the regulators. But they were just recognising the emerging catastrophe and did nothing to cause it.

Polly Toynbee blames cuts to social care and general government policy. But they affect everyone and impact only slowly. They don’t explain why things happened so fast in Cambridge.

A&E performance didn’t suddenly fall because of a surge in attendance. There was no surge. And attendance has no effect on performance anyway.

200 beds were not suddenly blocked by social care problems outside the hospital. Chances are that number is the same this year as last when the hospital was performing well. reports the following:
The introduction of the eHospital programme, which included a major infrastructure upgrade by HP, and the first implementation of the Epic electronic patient record system in the UK, may have contributed to the deficit, but the CQC report shows it may have impacted patient care as well.

In its key findings, the CQC says that the introduction of Epic, which is in common use in the US, has “affected the trust’s ability to report, highlight and take action on data collected on the system.”

This includes the ability to access information from diagnostics tests such as electrocardiographs, while agency staff are not always able to access information about patients they are supporting.
In other words basic operational processes couldn’t be done properly and this started to affect the quality of care. This explanation explains the facts, the timing and the speed with which the problems arose. Other explanations don’t.

Too many commentators have focussed on general distractions and pressures rather than the specific issues at Cambridge. Roy Lilley, for example, highlighted a radio interview given by Keith McNeil just after his resignation as chief executive. Early in the interview McNeil blames general system pressures (which is what Lilley wants us to see as the cause for losing a good chief executive). But immediately afterwards McNeil argues that he was a “vision and strategy” person lacking the “granular detail” about management and the hospital now needed someone with operational “grip”. This is pretty much an admission that the problems were about a failure to get to grips with the detail of how the operations would be affected by his grand vision.

There is a really important lesson here. Operational management matters. Hospitals don’t spontaneously organise themselves to give quality care, they have to be organised. You have to know what is going on inside your hospital or the efficiency and quality of care will suffer badly. Grand visions of how new IT will make things better are fine but if you neglect the detail the vision won’t happen. If you don’t spend enough effort to implement the new system and make it useful for and usable by the doctors and nurses who will have to work with it every day, your grand plan will fail and the clinical care will be worse.

Too many commentators believe the foolish idea that management consists of a bunch of bureaucrats who just get the way (I’ve ranted about this before). The idea that management doesn’t matter is a pervasive and damaging idea widely believed (though implicitly and unquestioningly) by commentators about the NHS and many of the staff inside the system.

Effective operational management needs good information about the activity in the hospital. And doctors need good information to deliver the right care to their patients. An effective hospital needs good information, good operational managers and good clinicians to do a good job for its patients.

Cambridge is a perfect illustration that good clinicians and a grand vision do not lead to great care: you also need good information and good operational management. The torrent of misleading commentary on the situation in Cambridge has distracted from this critical lesson. We need to ignore the commentary and pay attention or we won’t be able to make the NHS better.