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Adverse incident reporting.
An important topic.
Ι Health Board policy: "Suck it and see" Ι CHC bullying: demo at ORS 9th April Ι SCBU demo 28th March Ι
Ι UNISON come out in support of CHC Ι Chasing targets can kill patients Ι
Ι Final ORS report criticized Ι Second Pembs County Council Resolution Ι
Ι Paediatric College President speaks Ι Concerns of retired Maternity Consultant Ι
and in earlier news:
Ι Probe into baby death makes our point Ι Demonstration at the Senedd 24th October Ι
Ι Pembrokeshire County Council Debate 18th October Ι Public Meeting 20th September Ι
Ι 3 new anaesthetists at Glangwili. Why? Ι Hips and Knees to stay Ι
Ι Withybush Consultants write again: "no confidence" in consultation Ι Doctor shortage in Neath Ι
Ι Ten statements that show the Health Board's intentions for Emergencies - or do they? Ι
Ι Outrage! Withybush response ignored by Health Board Ι
... and more. Browse !
Unlike previous pages I have put latest news at the top. I hope you will find this convenient.
May 2013. NHS Wales Staff Surveys published.
Two staff surveys have appeared, with links on the Health Board's website. It is just this sort of survey that led to such interesting conclusions about organisational culture in the Longley report - that a good organisational culture has a powerful effect on patient outcomes. So how do we shape up? Well, not too well, as you can see if you click here.
Suck it and See. Health Board policy on consequences of its proposals.
The Hwyel Dda Health Board have explicitly stated that they are happy not to examine the consequences of their proposals (so-called 'Equality Impact Assessment') before actually implementing them. They say they will see what happens and work out how to deal with any negative impacts as they go along. Are you happy about this? Read more here.
Meanwhile ... There is much fallout in the national press following the Francis Report into the Mid-Stafford debacle. What are the implications for us? See 'the elephant in the room' (as above).
The UK Government is now recommending that nurses should spend a year dealing with bedpans (thus vindicating those of us who deplored the loss of that experience when nursing degrees were brought in some years ago), and that cover-up of mistakes should Reaction on BBC's " Today" programme of 26th March. become illegal, as well as a raft of other recommendations.
And what about the Welsh Government? Well, so far there hasn't been any explicit acknowledgement that some Welsh Hospitals could be exposed to the same risks as English ones.
Our good friend RAMI is here again.
Click to remind yourself about it. However, they have revisited our good friend RAMI in an attempt to firm up methods of assessing hospital mortality. If you read the news of this and also this The press statement refers to an excellent article by the Welsh Stats team (pdf). I recomment you read this. It will give you an understanding of why you must treat league tables with extreme scepticism. press statement, it is apparent that there is now some appreciation by the WAG that this index is dependent on the efficiency of hospital diagnosis coding, but can be used as a trigger to further investigation. Bethan Powys, BBC Political Editor in Wales, has been rather scathing about RAMI, calling it "Ropey And Muddled Information". This is in marked contrast to what we heard from the [former] Health Minister Lesley Griffiths in July last year, who paid obeisance to RAMI.
Our view is that, first of all, high RAMIs should be investigated without any finger-pointing. Mostly they will reveal faulty coding methods. Occasionally they may turn up a Stafford, or maybe just a small excess mortality. Once the high ones are sorted out, the rest should be too - it is eminently possible that low RAMIs could also be caused by faulty coding methods that conceal a much higher true mortality. In other words, the coding systems should be rigorously overhauled throughout Wales, and made robust and consistent between hospitals. Then maybe we can monitor our performance effectively and transparently.
And what of our own Health Board? Well, to give them due credit, they appear to have looked at their RAMI and done something to improve their coding methods. See their website entry about it that contains a link to a more detailed description. However, after reading their detailed description, you are still asking for more detail. The question must be asked: "Exactly what methods do you now use, and are they consistent with those used throughout Wales? please give us full detail."
So where are we now? Following the CHC's revised referral, the Health Minister has responded.
The CHC reiterated most of their criticisms of the consultation process and its analysis, set conditions that should be met by the Health Board for the proposed closures of Minor Injuries units in South Pembrokeshire, that they should be kept informed of the progress of discussions currently going on with the Llanelli clinicians about its A&E, and last but not least, reiterated that the rural nature of the area has not been properly considered by the Health Board. They ask the Health Board formally to drop their idea of developing a level 2 Neonatal Unit at Glangwili Hospital on the grounds that the large financial outlay required would not be justified by the small number of babies that would use it, that the money would be better spent bolstering the facilities in all three counties, and the difficulties and dangers of having to More about the CHC here. travel large distances have not been adequately assessed by the Health Board.
The Minister has now replied in a letter here, dated 31st May. He has asked the Chief Medical Officer to set up a 'Scrutiny Panel', and the CHC to develop more detail in their objections to the Health Board's plans, with a deadline of 21st June. So in Pembrokeshire, as the Health Board have promised to make no changes to MIU until CHC-approved alternatives have been put in place, the remaining major issue that remains is the proposed closure of Neonatal services.
ask: who will feature on this 'Scrutiny Panel'?. If it is the same old names, we can expect it to be no more than a rubber-stamping exercise. However, if fresh unbiassed views are obtained, perhaps from English clinicians or health experts with experience of rural issues, we could be happier with its composition. We shall watch its selection with interest.
Currently the CHC are working with local clinicians to prepare a further document for the Minister by 21st June.
9th April. Swansea Demo against legal threat to CHC at ORS office.
Click for photos and press items.
The CHC is being bullied.
Opinion Research Services (whose director's car is recognizable as a top of the range BMW with the registration 'ORS 1') is bleating that it has been libelled by the CHC in its referral. A threatening letter has been received from solicitors Morgan La Roche. Read about it here and look at Councillor Jacob Williams' site for comment and to make your own.
You can also read more about our local CHC here.
28th March. SCBU Demonstration outside Withybush.
Click for photos and press items.
15th March. Health workers' union UNISON calls a meeting to support the CHC.
Here is the resulting open letter, together with their press statements deprecating the Health Board plans.
14th March (the day after!). Lesley Griffiths writes back rebutting the referral, shortly before she is replaced as Health Minister by Mark Drakeford. She demands that the CHC go back to talk to the Health Board again.
This letter is also available on the HB website (pdf). She tells the CHC that, for example, they should have proposed alternative solutions but did not; so she has demanded that they go back to talk to the HB.
13th March. AM Paul Davies leads a short debate, criticizes the Health Board, its consultation process and its plans, congratulates the CHC on its referral, and pleads for there to be no implementation while that referral is being considered.
Watch his speech on Senedd TV (Item 10: Short Debate).
28th February. Pembrokeshire County Council passes another resolution opposing Health Board plans.See their first vote with a similar resolution here.
Again, the Council unanimously voted to 'vigorously oppose' the Health Board plans. Look at it here.
25th February. The CHC submit a referral to the Minister.
After numerous meetings with the Health Board in an attempt to get some agreement that failed, the CHC submitted their document just before the deadline closed. This document is now available for public view on the HB website (pdf).
15th January. The mixture as before.
At the now widely reported Hywel Dda Health Board Extraordinary Meeting, Dale Hall of ORS presented his report (see what we think of that). Then all the recommendations were unanimously accepted by the Board.
The Community Health Council as expressed by its Chairman Tony Wales are extremely unhappy with the consultation process and the apparent lack of regard for the public response to it, as reported in the local and national press. To be fair to the Health Board, they have published recent rather acrimonious correspondence on their website, so that is a sign of open-ness.
The Health Board chairman in that correspondence refers to their 'Technical Documents' as providing the evidence for their recommendations. In response to that, take a look at our 'Consequences' document (Appendix 3), where we exposed the weakness of the 'Technical Document' case for centralising emergency surgery. They subsequently dropped that idea (see below). We would like to hear the views of the relevant specialists on the other evidence provided in the 'Technical Documents'.
The recommendations were essentially the items polled in the notorious questionnaire, viz.:
● Closure of the Mynydd Mawr Hospital in Tumble near Llanelli. ● Closure of the Minor Injury Units in Pembroke Dock and Tenby. ● Develop an Orthopaedic Centre at Prince Philip Hospital, Llanelli, but retain primary hip and knee replacements at Withybush and Bronglais Hospitals. ● Retain Emergency Services in all three counties, but downgrade that at Llanelli into a nurse-led service. ● Develop a single Maternity and Special Care Baby Unit at Glangwili Hospital while closing down the SCBU at Withybush, yet promising to retain a Consultant Obstetrician service and Inpatient Paediatrics there. ● They also confirmed policies on Primary Care, Mental Health and Transport issues that were not part of the consultation.
How the Health Board claim to have "changed" their recommendations in response to the consultation, can be found in their documentation summarized as follows:
● Enhanced ward facility at Prince Philip Hospital to accommodate patients after Mynydd Mawr closes. ● Open a summer Minor Injuries Unit for visitors at Tenby during July and August. ● Keep major joint replacements at Withybush (but that was already changed before the consultation), call the new facility at Prince Philip an Orthopaedic Centre (leaving out the 'Excellence'). ● Approve a 'clinically led group to re-design the unscheduled care services' at Prince Philip. ● Approve a 'clinically led group to design pathways for paediatric, neonatal and obstetric' services.
Wow! It's breathtaking, isn't it?
No mention of exactly how they propose to sustain a Consultant Obstetric service at Withybush (see how it would eventually be lost without a SCBU).
And what do you think of these 'clinically led groups'? Aren't these supposed to have already been working for over two years (at least, according to the claims of the Health Board). So what's new about that?
Doesn't it seem like another way of saying 'We will close you down anyway; you doctors can sort out how to cope with it.'?
But it is at least a relief to see that they are no longer advocating so-called 'emergency' or 'trauma' centres that were so poorly substantiated in their original literature (see our pages on ' Centralisation', ' Trauma Centre' and ' Longley Report' for more about those topics).
It's not all bad!
We congratulate the Health Board on seeing through a popular new development - the Milford Haven Medical Centre. And here are a couple of lovely appreciative letters about care received at Withybush Hospital.
15th January Health Board Meeting
One week after the ORS report is available, the Health Board wish to make their definitive final recommendations.
This is no time at all for anybody to consider and respond to the report, is it?
Obviously the Health Board believe that they do not have a duty to hear anybody else's view of it - only their own.
Perhaps this is correct within the letter of the law? But it certainly raises the heckles of anybody who has issues with the report - like us. See our comments on the ORS report below.
This is a meeting accessible to the public, starting at 9.30 a.m. in St David's Park, Carmarthen, at the Board Room, Corporate Offices, Ystyth Building. The Health Board still need reminding of the strength of local feeling, about SCBU in particular.
We encourage you to attend the meeting, and if you would like to arrive beforehand and take part in a demonstration, so much the better, preferably with a banner or placard. Have a look on the SCBU Facebook site to get organised on this, and take a look at the relevant placards and banners (really, SCBU and Maternity/Obstetrics are the main issues at the moment) that are available for you to download here.
8th January ORS Final Feedback Report now available
At last this is now available on the Hywel Dda website on this page. The Health Board have also made available submissions that form the basis of the report on their website, though many of them are heavily redacted and our own proposals are omitted. Some of the submissions are very long, for example a 64-page one from Montgomeryshire Community Health Council. We could only count 194 but the ORS stated they dealt with 274 written submissions (p.16), so it appears the list is incomplete. We find ourselves wondering, what's in the 80 missing submissions?
The ORS document is reported in the local papers of 9th January.
We do not think it accurately reflects the views of the people, for the following reasons:
● There's no mention of the widespread opinion (that we have seen and heard from many sources) that the Health Board's questionnaire was biassed to obtain the results they want. ● There's no critical examination of the structure of the questionnaire by ORS, that so many people have been unhappy about. For example mostly the reader is given two impossible choices, without a third box to indicate another one. So a result that appears to favour one alternative may be no more than people feeling forced to choose the "least worst" alternative. Here is one trenchant comment which illustrates this: "It feels that we are being invited to choose which healthy eye we want removed first in order to make life even better for people in Carmarthenshire." ● Comments written in the questionnaire are not analysed numerically so they carry much less weight to the reader than the analysis of the impossible choices that have to be made. ● Shockingly, ORS were not informed of the true situation about the petitions. A 10500 signature petition to save the Withybush SCBU was completely lost!! This was due to the failure of the Welsh Assembly Petitions Committee to pick up the fact that 14000 signatures submitted to them were from two separate petitions. Apparently the Health Board have now been informed of this. It is reported in the Western Telegraph of 9th January. ● The "household" questionnaire is given more weight than the much bigger "open" one. This is despite the fact that
a) only 697 of 5000 randomly distributed ("household") questionnaires were returned - 14%, and the proportions from the counties approximately matched the proportions of their populations. This is a tiny proportion of the 370000 people in Hywel Dda, about 0.19% or less than 1 in 500 people. b) 4422 people chose to return an "open" questionnaire - over six times as many people, many of whom may already have thrown away a "household" one then changed their mind. As 55% of those came from Pembrokeshire with its population of 119000, that is 2432 i.e. 2% which is over ten times those in Pembrokeshire who sent responses to the 'household' questionnaire, or 1 in 50 people. If one assumes that only one person from a family of (say) three will fill in a questionnaire, that is about 1 in 17 families. How can this be less representative of opinion in Pembrokeshire?
● An unknown number of people declined to complete the 'household' questionnaire but later completed the 'open' one. After all, 4303 people received but did not return it. Are we to believe that none of them later completed an 'open' one - especially as the deadline was well before that for the 'open' one? Even it was only a couple of hundred, that could easily have been enough to produce a different result. There could be several reasons. For example, they may have not wished to be identified (each 'household' questionnaire had a unique number), they may have initially forgotten about it then discovered they had missed the deadline so perforce had to complete the 'open' one, or they may have discarded it then changed their mind, in which case they would have had to use the 'open' one. The ORS have failed us here. They should have included an extra question in their 'open' version: 'have you previously received a questionnaire in the post?'. We will never know the answer but had those people completed the one posted to them, it could have crucially affected the result. Accordingly the result we actually have is invalid. ● Of the 4422 submitted "open" questionnaires, 164 were from organisations, such as the Pembrokeshire County Council. Many of these are elected bodies representing many thousands of the local population. While ORS devotes a section to these organisations (page 162-9), there is no attempt to break down these organisations by region, or to estimate the likely numbers of people that each represents. Thus, the collective opinons of many thousands of people (as reflected by those they elected) have been lost. ● Many of these points and more that criticize the report are made in these letters, to the Western Telegraph, and between a retired consultant and ORS - with a response from ORS. ● You can also see the result of a Freedom of Information enquiry about the household questionnaire, and lots of comments on it and the consultation, on Councillor Jacob Williams' website here.
Chasing targets can kill patients!See later comments on this issue.
Yes, that's official. We can say that without fear of litigation. Eight articles on the Telegraph newspaper's website of Sunday 6th January 2013 testify to it. They deal with the fallout from the Stafford Hospital scandal of 2009 and the forthcoming Francis report. Click here to see the first of them, and access the remainder on the Telegraph website.
The President of the Royal College of Paediatrics publicizes views.
Read the common sense expressed in this article. Yes, there need to be fewer paediatric wards, but no, they should not be closed in remote areas - those more than 30 minutes drive from neighbouring units. More on this topic.
Hywel Dda take note.Will our consultants fly? Click for an explanation of why the Health Board's maternity plan is unworkable.
Retired Consultant adds weight to concerns about Maternity. ... and more on this
Another political storm. Remember the one over the Longley Report? Now there's one over the National Clinical Forum.
The ill-effects of the EU Working Time Directive are highlighted.
Read this statement made in response to an enquiry from the Telegraph newspaper. "A Department of Health spokesman said: "The EU Working Time Directive can have an effect on both continuity of care for patients and medical training for junior doctors. This is why the Coalition Government wants to limit its application in the UK so our NHS has more flexibility to support doctors in training and to provide services seven days a week."
The Telegraph article can be found in the 1st November online edition. It highlights that the EWTD, limiting doctors' working hours to 48, has been a key factor in the closure of at least 21 maternity and casualty departments in England, through inability to find enough doctors to fill the rotas.
We have highlighted that a 65-hour rota can be constructed (at least in surgery) that would fulfil all the EU requirements for rest, vastly improve training and job satisfaction, and require fewer doctors for rotas by a factor of 48/65. It would require derogation by Wales from the directive.
Read more about EWTD
Download our proposals for Hywel Dda here. We incorporated this in our proposals for Hywel Dda that were handed to the Health Board and the local politicians. The statement from the Department of Health quoted above suggests they may be at last getting the message. Can we hope for more progress in the foreseeable future - in Wales as well as England?
October 29th 2012. "Consultation" finishes. O.R.S. report of responses awaited.
Evidence. So what evidence underlies the Health Board's proposals?
Just look at Professor Marcus Longley's summary of that relating to Obstetrics, Emergency Surgery and Trauma.
Study our discussion of the
and see how ultimately the most compelling evidence for improving outcomes is for good managment, leadership and adherence to protocols at grass roots level - not centralisation.
Here is an excellent study from 2020Delivery that is one of those used in Professor Longley's report (pdf). According to Longley in "The best configuration of hospital services for Wales", the evidence does not support improved outcomes from centralisation.
He summarizes the evidence on size versus outcome for Obstetrics and Neonatal care as follows ("Quality and Safety" p.4):
"Maternity and Newborn Care Services. There is no evidence of a consistent relationship between outcomes and size of unit and as such no clear conclusions can be established from published research.",
and on General Trauma and Emergency Care ("Quality and Safety" p.3):
"General Trauma and Emergency Care. There is evidence for some patients (such as patients with ruptured abdominal aortic aneurysms) of outcomes improving as unit size increases, but it is not statistically significant. Services that meet clinical standards and consistently follow recommended pathways make the most difference, whatever the size of the unit. There is increasing evidence that outcomes are better when there are more senior doctors on site 24/7 and this is becoming increasingly difficult to achieve in smaller units.".
© Peter Milewski 2012