Learning the lessons of Mid Staffs

Mid Staffs became synonymous with NHS failings: a lack of personal responsibility and a failure to care for patients. Writing exclusively for the GMC blogsite, campaigner Julie Bailey talks about her ongoing concerns and her hopes for responsive – and responsible – regulation.

It’s nearly seven years since I began the campaign to cure the NHS following the death of my mother. For eight weeks, I watched a ward of vulnerable patients suffering at Mid Staffs Foundation Trust hospital, with doctors, nurses and managers walked by suffering patients: few helped them.

Losing like I did has had a profound effect and I made a commitment to expose what was happening and to stop it happening to others.

Little did I know that, seven years on, I would still be battling to have the patient voice heard and to stop suffering of our most vulnerable.

I was just expecting to say what I had seen and the suffering would stop immediately but unbeknown to me, I was about to have my eyes opened on how deep the failings extended within the NHS.

Cure the NHS is made up of a small group of patients or relatives who share the same aim of a safer NHS. We battled for two years campaigning for a public inquiry under the Inquiries Act 2005, to try to expose that something had gone badly wrong not only at Mid Staffs but the wider NHS.

Our fears were confirmed during the Mid Staffs Public Inquiry (MSPI), where we heard about failings from every organisation that should have been there to protect, the public. The group sat through every day’s evidence and what we heard was that the NHS had forgotten the patient and more importantly had forgotten that the NHS was about keeping patients safe.

Since the Francis Report all organisations involved, including the General Medical Council, have published their responses.

It is refreshing to hear that their response to the MSPI will include listening to medical students, English language proficiency and joint working with other regulators.

The NHS is wonderful at listening to itself and those within it and yet thinking it hears the public’s voice. So, I was pleased when the GMC invited me along to talk to their staff and then even more pleased to hear that my talk was so well-attended.

The GMC receives around 9,000 referrals a year and only 200 are considered by a full tribunal hearing, the others being closed at an earlier stage. A recent audit of the GMC’s work by the Professional Standards Authority (PSA) examined 100 cases and found that, although overall the GMC’s Fitness to Practise procedures protected the public, mistakes in a staggering 22% of cases.

Of the 44 doctors referred to the GMC over the Mid Staffs, only one has been struck off, and that was for fraud. That decision was like a kick in the stomach to the group and sent repercussions wide. What organisation can fail so badly and yet even the clinical leaders were not held to account? To be honest, though, no-one was. Everywhere I go now clinicians approach me and are as unhappy as us with the GMC’s decision.

The lack of accountability I believe has sent a dangerous signal to the wider NHS but there is little we can now do about it. Many have said we should appeal the decision but I haven’t the strength to fight the system anymore. We have to live with what has happened and trust that changes will now be made.

It became clear after the MSPI that the system would be blamed and no individuals within that system would be held to account. What’s important now is that any future failings are addressed to promote quality care: lessons need to be learnt and the GMC must help to protect the public as it should.

The GMC, like all the other regulators in the NHS, has a long way to go to prove to the public that they are there to protect them and to uphold standards within the medical profession. But they can only work with the tools they have got and some of those are out of date. It was disappointing to hear that the regulatory and urgent changes that were needed to update the GMC processes to protect patients weren’t included in the Queens Speech.

Although this is a blow to the GMC, there are signs they are moving in the right direction, including setting up a whistleblowing helpline and a pilot scheme involving patients in the complaints process. They have produced Good Medical Practice, a guide for patients on what we should expect from our doctors.

The public want a responsive regulator, one that is outward facing and proactive which the GMC says it wants to be. We all have to hope that the regulatory changes that are needed are implemented by this Government before Parliament is dissolved in 2015. It will be a clear signal of their commitment to patient safety too.

The public want evidence, evidence that change has taken place and that when doctors fail they will be held to account. Cure the NHS will be watching closely as to how well the GMC along with the other regulators, help to protect us which they hadn’t in the past but those regulatory changes are critical too.