The Scottish Review 7 February 2013
NHS scandal: Part II
Blowing the lid off Scotland's secretive health service
The story so far
Rab Wilson, a mental health nurse, conducts a one-man campaign for the release of 'critical incident' and 'adverse event' reports by his employers, Ayrshire and Arran Health Board. Over a three-year period, 132 of these incidents and events resulted in death. The board refuses to release the reports. Mr Wilson appeals to the Scottish information commissioner, who finds against the health board and issues one of the most damning judgements ever delivered against a public body in Scotland. The senior management survive the scandal.
Until fairly recently, the adverse event policy of NHS Ayrshire and Arran included an unambiguous commitment to a transparent reporting process:
An anonymised copy of the report will be provided to all members of staff involved in the incident.
There were sound reasons for this policy, this 'duty of candour' as we should now call it. It meant that nothing was hidden. It meant that everyone could learn from the incident. But when Rab Wilson was involved in one such incident, he did not receive a copy of the report and, when he asked for a copy, the board refused to give him one. The board was thus in clear breach of its own policy. It then attempted to bully Mr Wilson by accusing him of being 'vexatious' and compounded its folly by hindering the investigation of the Scottish information commissioner, denying the existence of 56 important documents which later turned up 'apparently by accident'.
We can now reveal that, in January 2011, when it knew that a full-scale investigation by the Scottish information commissioner was inescapable, the board changed its adverse event policy. An anonymised copy of the report would no longer be provided to all members of staff involved in incidents – not that it had been anyway.
The revised clause read:
A full copy of the report will not be issued to any individual, either patients, relatives or staff members, without the explicit authorisation of either the Executive Medical Director [Robert Masterton] or the Executive Nurse Director [Fiona McQueen].
An explanation for this change was attempted in the new policy: 'Staff are not automatically entitled to a copy of the full report, as the report relates directly to the care of a patient and the associated confidentiality issues'. The sentence does not even make sense. It went on to state that 'staff are only entitled to request access to patient information that is necessary for the care of a patient'. Rab Wilson referred the document to the Plain English Campaign, which concluded unsurprisingly that the new policy was difficult to follow and added: 'There is a real chance that important information, vital to future patient care, could be denied to case workers or that such information is simply not requested by people for fear of being frowned upon'. Exactly.
It is difficult to believe that the non-executive directors of NHS Ayrshire and Arran – the ministerial appointees – would not have known of this change of policy. So why did they go along with it? As Mr Wilson puts it, the new policy 'was not only less transparent than the previous one, but was actually designed to prevent staff from seeing copies of these reports'.
The timing of the change looks very bad. In January 2011 Mr Wilson was on the warpath, having extended the scope of his request to cover many other reports apart from the one involving himself, and the information commissioner was sniffing around his case. The board chose that moment to introduce a policy which removed an important entitlement from its frontline staff, left power in the hands of two individuals, and significantly reduced its public accountability. It was inexcusable.
Yet no one in senior management was disciplined at any stage and the non-executive directors went on collecting their fees. Most of these non-execs have subsequently retired, but one remains. He has been paid almost £50,000 for attending meetings of NHS Ayrshire and Arran in the last six years. Before he goes at the end of next month, he should issue a statement either backing what the board did or publicly dissociating himself from it.
Meanwhile, Rab Wilson has repeatedly asked the chairman of the board, Dr Martin Cheyne, for clarification of its policy in clear language. Mr Wilson put two questions:
Can you inform me what the current wording is in our policy on how adverse event reports are accessed by those directly involved in such events? and
Do Masterton and McQueen still have total and exclusive control over the dissemination of reports?
These are simple, straightforward questions to which any public body ought to be able to provide simple, straightforward answers. To republish Dr Cheyne's reply without his permission would be a breach of his copyright, so you will have to accept my word that his response is as clear as mud. Neither of the questions is answered. The Executive Medical Director and the Executive Nurse Director are not even mentioned. I have read the letter half a dozen times and still have no idea what it means.
Last week, in his latest attempt to get at the truth, Mr Wilson wrote to Dr Cheyne (a former ICI executive with an honorary doctorate from Glasgow Caledonian University) and told him frankly that his reply made very little sense. He referred Dr Cheyne to an editorial in the Scottish Review on the abuse of language by public bodies and asked him yet again to clarify the board's policy. There has been no response.
Ayrshire and Arran Health Board rewards its senior management handsomely. Dr Masterton, the Executive Medical Director, who may or may not still be calling the shots on the dissemination of reports potentially embarrassing to the reputation of his board, is the highest-paid worker in the Scottish NHS. He receives a salary of almost a quarter of a million pounds a year.
For that money, we are entitled to a public statement from Dr Masterton explaining why an issue of patient confidentiality which had not arisen in all the years that the old policy was in force suddenly arose around the time that the information commissioner began to investigate Rab Wilson's complaint.
Something has to be done politically. It is a fundamental weakness of the system that Scotland's area health boards decide for themselves how critical incidents and so-called 'adverse events' are investigated and what lessons should be learned from them.
When the events are as adverse as the removal of a healthy organ or the avoidable death of a baby during labour – just two of the many 'events' which have afflicted the NHS in Scotland in recent years – there is a compelling case for a standard national policy applicable to all health boards. The cabinet secretary for health, Alex Neil, should introduce such a policy without delay in order to reassure the public that unnecessary deaths in hospitals are being properly investigated and reported.
A 'duty of candour' may be introduced as a statutory function of the NHS in England after yesterday's devastating report on failings at Stafford Hospital. A duty of candour – with criminal prosecution for failing to observe it – should be introduced north of the border too. Mr Neil has to look no further than his native Ayrshire for proof of its urgent need.