British hospital's diagnosis should be a red flag

Evoking memories of my involvement with the 2004 Special Commission of Inquiry into patient care at Sydney's Camden and Campbelltown hospitals, the recent release of a report into Stafford Hospital, in the West Midlands region of England, puts the spotlight on patient safety and how easily a hospital can lose its way.

Four-hour targets in Stafford Hospital's emergency department were thought more important than patient care. This loss of focus on patient safety and service quality provides important lessons for clinical managers, hospital executives, boards and regulators here in Australia.

Queens counsel Robert Francis's final report into the hospital, which criticises care, culture, governance and leadership, exposes failures at every level; as its board and management allowed ''a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care''.

The hospital's problems first came to public attention when it was investigated by Britain's Healthcare Commission, following the discovery of apparently high mortality rates in patients admitted as emergencies.

At Stafford Hospital, between 400 to 1200 more deaths than expected occurred in the years 2005-09. Statisticians have developed a variety of tools to adjust for differences in patients and services with standardised hospital mortality ratios (HSMR), comparing actual death rates to the rate that would have been expected statistically.

In Australia, the Australian Institute of Health and Welfare has performed this analysis, but HSMRs identifying hospitals have not been published. A high HSMR is a patient safety red flag and a warning sign warranting investigation. The board and management at Stafford ignored this red flag.

The focus on performance, finances and targets at Stafford discouraged staff from raising their concerns about patient care. They lost confidence in the hospital's willingness to take their concerns seriously. The scene was set for a patient care and patient safety implosion.

Initial concerns were raised by professional bodies about ''dysfunctional management'' of the surgery department and by nurses about the emergency department. On the NHS star rating system, the Mid-Staffordshire NHS Trust dropped from three stars to zero.

Dissatisfied with the hospital and trust response, the first of five inquiries began.

In 2009, Sir Ian Kennedy, the chairman of the then NHS regulator, the Healthcare Commission, said it was the most shocking scandal that he had investigated.

In 2010, Francis's first report found ''appalling standards'' of basic patient care and compassion, and that the board and hospital managers had failed to address serious problems.

Dr Bruce Keogh, the NHS Medical Director, condemned the hospital trust for a complete failure of leadership.

In the recently released report, Francis calls on boards, managers, clinical unit heads and regulators to look for, and respond to, early warning signals for patient safety problems.

He recommended that patient-centred care be a fundamental core duty of all clinicians and managers, that hospitals be required to be ''honest, open and truthful'', with a culture of transparency that encourages care concern issues to be raised by patients, families and staff. He went further, and recommended that deliberate obstruction of this duty of candour and breaches of fundamental patient care standards become criminal offences.

Historically, Australian hospitals have largely left patient safety and clinical quality to their clinicians to monitor. It has been only in the past 15 years or so that this important responsibility has become accepted as one that boards, managers and clinicians share as part of clinical governance of a hospital. We have a good hospital system overall in Australia, but we can, and must, continually make it safer for patients.

Much work has been done, including the establishment of bodies such as the Australian Council on Healthcare Standards, the Clinical Excellence Commission in NSW and the Australian Commission on Safety and Quality in Health Care. There are plenty of reports and the My Hospitals website provides data on processes, wait times and cost per case. However, we still struggle to publicly report on the safety and quality of patient care.

Hospital clinicians and managers need to ask themselves how often they look for the early warning signs of a patient safety problem. Is a robust system of clinical governance in place? Do care staff feel comfortable in raising concerns about patient safety and patient care? Where is the data on the patient safety and clinical quality on their hospital's website?

Stafford Hospital is a tragedy that should not have happened and Francis's report is a warning beacon to Australia from the other side of the globe.

Dr Tim Smyth is a former deputy director-general at NSW Health and is a special counsel with the law firm HolmanWebb.