The pursuit by NHS trusts of flagship status can mean dire consequences for patients, writes David Batty
Staffordshire General Hospital Staffordshire General Hospital. Photograph: Christopher Furlong/Getty Images Damning reports this week on failings at two supposedly flagship NHS trusts pose grave questions over one of New Labour’s most significant and controversial healthcare reforms. The inquiries into Mid Staffordshire and Birmingham children’s hospital foundation trusts have raised concern that their semi-autonomous status has led to financial targets being prioritised over patient care and safety.
When the first foundation trusts, which enjoy greater freedom to raise and spend money, were established in 2004, critics expressed fears they would lead to a two-tier health system. One major concern was they would be able to poach more staff by offering higher salaries.
But the two investigations into the Mid Staffordshire and Birmingham foundations has revealed quite the reverse – that trusts have cut staff and clinical budgets in order to gain flagship status, with dire consequences for patients. During the three years to March 2008, at least 400 more patients died at Mid Staffordshire than at comparable hospitals, the Healthcare Commission found.
The prime minister, Gordon Brown, told MPs this week that the failings at the trust were unique. But the commission’s report into the Birmingham foundation, plus anecdotal evidence from clinical staff, suggest otherwise. The common thread is medical and nursing jobs being cut in order to meet financial targets to gain foundation status, and the continued prioritising of these targets over clinical standards once that status has been achieved.
In 2006-07 Mid Staffordshire set a target of saving £10m and more than 150 jobs were lost, contributing to a shortage of 120 nurses. Budget cuts and nursing shortages were also found to have undermined care at Birmingham.
A senior doctor told the Guardian yesterday that trusts trying to achieve foundation status were “forbidden from hiring new staff”. The pressure group Health Emergency warns many trusts applying for foundation status are “looking at cuts in the tens of millions”, including St George’s, south-west London, planning “a £30m-plus cutback”, which it predicts will lead to widespread staff shortages. With ministers pushing for all trusts in England to gain foundation status, and more than 100 already in operation, the implications are profoundly worrying.
One of the most puzzling aspects of the Mid Staffordshire scandal is that the trust’s status as a supposedly flagship foundation will not be reviewed. If failings leading to the deaths of 400 patients aren’t reason enough to be stripped of foundation status and the benefits it brings then what is? Can anyone now seriously claim the trust provides a better standard of care than non-foundations? As Karen Jennings, head of health at Unison said this week: “It is time Monitor was held to account and made to raise the bar regarding the standards it is sanctioning when awarding foundation status.”
Perhaps William Moyes, chief executive of the foundations regulator Monitor, might care to reconsider his claim that the trusts have proved their mettle. Senior NHS managers privately question whether he is behaving more like a shop steward for the foundations rather than a dispassionate regulator.
This view seemed to be supported by his row with David Nicholson, the NHS chief executive, after the Department of Health gave orders to the foundations on how they should improve hospital hygiene. Moyes said the instructions broke the law. His objection appears inappropriate given there was a doubling of the rate of the potentially lethal Clostridium difficile infection in Mid Staffordshire in early 2006, which was not reported to the trust board or public. Moyes might do well to ensure that a sizeable chunk of the £2.4bn surpluses accrued by foundation hospitals from trading profits and the sale of assets are now spent on hiring more doctors and nurses to improve care standards.
But the scandals brought to light this week raise wider concerns about the monitoring and inspection of NHS care. As policy expert Allyson Pollock notes, not only did Monitor find “no regulatory concerns” with Mid Staffordshire, awarding it four out of five for performance, but the Healthcare Commission rated the foundation as “fair” or “good” throughout the period when clinical standards fell dramatically.
One could blame the foundation regime, under which trusts are allowed to undergo less inspection and monitoring, but it is arguable that the regulators are being asked to judge services against the wrong priorities, with financial performance remaining their pre-eminent concern. As Pollock says this focus on business and performance targets has led to trusts “squeezing out more for less and driving out basic humanity and compassion”.