Friday, February 08, 2013

Hippocratic

I have just been watching the late-night press reviews on the telly. The two hot topics of the day are of course the horsemeat scandal, and the appalling hospital mismanagement that may have killed a lot of people, and caused suffering to many more. Inevitably, the strident tabloids are calling for police investigations (that may already have started) but let's have a little think first. The NHS will be the tougher nut to crack in a legal sense because it will be impossibly difficult to separate negligence and poor management from truly criminal acts or omissions. Much of what happened seems best suited to action by the appropriate professional bodies.

Meat fraud is different. I have some knowledge of the food industry, and of the huge international trade in boneless meat. When most meat was shipped in carcass form, anyone in the trade could see what the animal was. These days the meat is deboned in factories, then either vacuum packed or frozen for shipping. Only the biggest and most sophisticated producers would have in-house testing facilities, so everyone else has to rely on his suppliers' assurances. Margins are very tight in meat trading, and there is a huge temptation to cut corners, for example injecting water into meat post-slaughter and of course substituting species. But whoever does this knows he is doing it, and it seems eminently suited to a police investigation - but - given the worldwide cross-border trade in meat, it is going to be very hard indeed to prove that a Polish (or wherever) abattoir falsified the documents for a night shift six months ago, and slipped a few zlotys to the inpector who is trying to pay his kids through college so that they can come and work in England.

Not simple at all.  

31 comments:

  1. The suggestion that "much of what happened seems best suited to action by the appropriate professional bodies" carries the implications that much of what happened is the responsibility of those who are policed by professional bodies, and that the professional bodies are suited to solving the problems. I fear both statements may turn out to be a tad naive.

    In my mind, a lesson from Stafford is that in setting targets, one needs to be aware of the risk of creating perverse incentives. This lesson is applicable to many of the topics raised in this blog.

    ReplyDelete
  2. Meat is getting pricey, gangs are substituting horses. Millions £££ involved.

    The hospital is different. In my day we would never let that happen, in Scotland police check all records when someone dies, in England this never happens. The Administrators, doctors, nurse and all concerned should be charged with manslaughter at least! It is however unusual, and rarely happens elsewhere.

    ReplyDelete
  3. "Much of what happened seems best suited to action by the appropriate professional bodies": does self-regulation ever work when there are serious issues to address?

    ReplyDelete
  4. The hospital problem seems to stem from some extremely poor management, which goes right to the top of the NHS. Leaving aside any legal remedies, it seems to me that there should be some summary and highly publicised sackings "pour encourager les autres", including the top-most managers downwards (preferably without severance packages, enhanced pension pots, etc - if they don't like it they can try their luck in the courts to get these contractual 'entitlements' back).

    One of the worrying aspects of the NHS is that clinical judgment is repeatedly over-ridden by administrators. We should perhaps return to a position in which the senior management roles are held by clinicians. They may need the support of professional adminstrators, but the critical management decisions should be made by the medics, who are the best-placed people to know what is in the best interests of their patients.

    As for horsemeat, I am sure that Bystander's analysis is essentially correct. Sorting it out is going to be a horrendously complex (possibly even impossible) task.

    ReplyDelete
  5. At a minimum, NHS managers are unlike professional doctors and nurses: There are no licensing, appraisal or revalidation requirements for the lay managers, in fact they seem to get continuously promoted regardless of their performance.

    ReplyDelete
    Replies
    1. But Tony, as you well know, all the professional regulatory checks that existed failed to stop Dr Shipman, and there is no evidence at all that revalidation etc. would do anything at all to stop another well-loved doctor doing the same again. There is a considerable body of evidence that lay managers (rather than doctors and nurses promoted out of their area of expertise) are much better at calling clinicians' bluffs, and have begun to strip away some of the layers of incestuous, and frankly self-serving hospital administration, restoring in the process some of those wasted posts to the "patient interface" that so many clinicians had fled.

      Delete
    2. Spot on, Anonymous. Devolving Staffordshire and the like to professional bodies as BS suggests is not compelling. I have a grudging admiration for the way the medical establishment and the BMA retained their grip on the reins after Shipman and Alder Hey. Other public sector professions such as teaching and social services would have been blown apart.

      Predictably, however,light-touch, largely in-house, regulation has not prevented Staffordshire and would not detect other Shipmans, present or future.

      Delete
    3. One of the next big scandals to erupt is slated to be in the area of generic pharmaceuticals, where it has also been suggested that there have been major failings in the area of quality control and assurance, and it is thought that allegedly qualified persons may have turned a blind eye (possibly as often transpires in such cases in return for appropriate consideration) to the import of prescription drugs that were not everything they were cracked up to be [dreadful pun - I'm sorry]. The privatisation of regulatory functions is not without its own risks. There may even be cross links to the present situation in relation to the control of food safety and standards.

      Delete
    4. Anonymous:

      You are correct. Licensing, appraisal and revalidation will not, and are not, designed to catch mass murderers. However, 'as you well know', 'there is ample evidence' that supports these techniques contributing to basic competencies. It is basic competencies that were severely lacking in Staffs, and now, probably another 18 trusts. And if incestuous, self-serving, light-touch, etc. management systems are to blame, then they have been in place at least twenty years and involve NHS managers, not nurses, physiotherapists, pharmacists, doctors, and other clinicians. For example, back then, the ward sister was in charge of her patch, including the cleaners and the tea-servers who had the temerity to set foot in it. No longer, and dirty wards and cold tea result.

      Delete
    5. Actually, Tony, revalidation was explicitly designed to 'stop another Shipman', and was redesigned following criticism in the Shipman reports (in particular the fifth and sixth reports) of the initial GMC proposals. I thought you said you were a doctor. If so, you should really keep up with your reading on clinical governance. As for NHS management, your characterisation misrepresents reality. Many, if not in fact most, senior management positions are and have been held by clinicians-become-managers, be they doctors or nurses. This isn't about cold tea, I'm afraid, but rather much more fundamental failings of care by so-called professionals who have betrayed their statutory duty of care.

      Delete
    6. Anonymous:

      Thank-you but wrong.

      Appraisal / Revalidation re-design began probably about 1996-7, i.e., before Shipman. It would be fair to say that the whole process essentially went on hold 2000 - 2005 while the Smith Inquiry took place. Appraisal re-design then got going again, and, I suppose, it would also be fair to say that the end of the Smith Inquiry, and its final (5th or 6th?) report, may have been the trigger for that reactivation. However, revalidation in today's form was not 'explicitly designed to stop another Shipman', as you characterize it, nor could it ever achieve that. Ask the Royal College of Physicians (if you don't believe me). Tangentially, if you were to say that the re-designed revalidation process has at least one layer of unnecessary and ineffective bureaucracy, then I would probably agree.
      Secondly, it looks like we agree that the problem is untrained NHS managers who are not held accountable, and promoted without any evidence of accomplishment. It doesn't matter if they were formerly doctors, nurses, or bus drivers. It is managerial standards that were not met, probably because those appointed were lousy at being managers, however good they may be / have been as clinicians. And it is about cold tea and cleaners: good managerial systems are needed to ensure that tea is hot and that the place is clean.
      Lastly, you conflate i) breach of statutory duty, which is a criminal matter under the Health and Safety Acts with ii) the civil torts of negligence (for which duty of care needs to be found, if not already agreed between the parties).

      Delete
    7. No, breach of statutory duty is a civil tort. Criminal offences are criminal offences, under no matter what Act.

      Delete
    8. Re Shipman, read Una Lane's evidence to the Health Scrutiny Committee on behalf of the GMC. Several of the Royal Colleges refer explicitly to one of the purposes of revalidation being "to prevent another Shipman"; that the RCP does not should not perhaps be thought so surprising.

      Delete
    9. If you take away a Ward Sister's authority to observe and discipline a cleaner or the tea boy, and that authority devolves to some manager in another building often miles away, then of course the quality of service goes down, and you can't hold the nurse responsible for something over which she has no authority.

      Delete
    10. Section 33 sets out the criminal offences under the Health and safety at Work Act 1974.

      Delete
  6. I hesitate to detract from the gravity of the issues raised, but just have to congratulate you on your title!
    Kate Caveat

    ReplyDelete
    Replies
    1. Thank you. It's nice of you to notice.

      Delete
  7. Imagine the consequences of licencing (and properly validating) senior public sector managers. The first is that they would refuse to conceal the political consequences where costs were to be cut or another crackpot initiative to be instituted. Costs would go up and government forced to think things through. So not going to happen, regulators are ineffective for a reason.

    Imagine the consequences of a kneejerk 'test everything' regime in the food industry. Costs will go up for the honest and not for the dishonest - who leave the market. Then there is the money spent on lawyers and investigators. Cut costs, No Minister. What we can afford is de-facto UniMeat, get used to it - regulators are ineffective for a reason.

    ReplyDelete
    Replies
    1. The dishonest leaving the market is rather the point, Roger, not a tragic perverse side-effect.

      Delete
  8. Look at the good side. That burger you're enjoying might have run fifth at Ascot!

    ReplyDelete
    Replies
    1. And the shepherd's pie was fourth at Wroclaw, and the lasagne was last at the Transylvania donkey derby.

      Delete
    2. And the cheats and rogues who did this probably said to themselves "They'll never find us here".

      Delete
  9. We should be banning the import of "unidentifiable" meat. Carcasses and sides of beef and the like are OK, but mince and "pink slime" (technical term) should be turned back at the border.

    For some reason these DNA tests only give you answers to questions you actually ask. If you're not testing for dog or rat or zebra then you will not find out if meat contains those animals.

    The French had no compunction about banning our beef during the BSE years. We should show similar fortitude.

    ReplyDelete
    Replies
    1. Nationalist:

      Only partly true. DNA can also tell you what species it is not, even if the true original species has not been tested for.

      Delete
    2. If Adam Abdimieye (sp?) really does challenge Mr.Cameron for the Conservative Party leadership, then will we have to refer to him as a stalking lasagna ?

      Delete
    3. Tony, could you explain that more clearly? We know that food retailers and manufacturers, as well as local authorities, have been testing for horse DNA in produce that purports to be beef. If the product in question turns out to be 100% horse, then we know that it's not beef, and not got any beef in it. But if it turns out to be 60% horse, and the lab hasn't tested for beef, we still don't know if it's got any beef in it, and we can't tell what other species it is not (be that donkey, pig, or even human) or indeed might even be. Or have I got that wrong?

      Delete
    4. Anonymous:

      Thankyou. They routinely sample and test for beef by comparing the sampled allele pattern with a known, genuine cow sample. What has happened is that they initially found one set of DNA alleles being consistent with beef, plus a second set of alleles that was inconsistent with beef ('non-beef'). They then presumably had to obtain genuine allele sets for species that they don't usually test for e.g., horse. That then would have led to the inconsistent allele set being reported not only 'non-beef' but also definitely 'horse'.

      When they say something is '100%' horse, it really means that they found horse alleles and nothing else. The 60% - 40% statements mean that for 100 PCR samples, 60 were consistent with cow and 40 are consistent with horse, and that none others were found among the 100. You are right that if they say 60% horse and not what the other 40% is, then you don't know, although it would probably be obviously not pork or human because those allele sets are widely used and easily recognizable. BTW:- horse DNA is good enough to define a breed mix for working horses, and it might have been that which first suggested Romania; however, a more refined technique would have been needed, hence that particular delay from when the first detection was reported.

      Delete
  10. I wonder how much compensation the muslim prisoners who have been fed pork by mistake will be entitled to? It could be a nice little earner. Some lawyer needs to get a class action up and running.

    ReplyDelete
  11. Ha. Ha. So very unfunny, Mr Frost. You're such an expert that you can't even be bothered to look up the man's proper name. It's Mr Afriyie, by the way.

    ReplyDelete
    Replies
    1. In that case he had better change it if he wants Tory pooh-bah buy-in.

      Delete
  12. @ Nationalist, your focus on Muslim prisoners is questionable. Don't you think Jewish prisoners would be just as horrified to have been fed pork?

    ReplyDelete

Posts are pre-moderated. Please bear with us if this takes a little time, but the number of bores and obsessives was getting out of hand, as were the fake comments advertising rubbish.