Who should watch the watchers?

Like many others, I believe in the ultimate goodness of the majority of people, especially those involved with the care and protection of others. So of course I, like many others, hoped that the tranche of scandals emerging from a closer scrutiny of the NHS would now be over.  But we were wrong. This most recent disclosure of the failings of the Care Quality Commission (CQC) is perhaps the most shocking lapse of morality of all.

Although full details and allocation of blame are yet to emerge, it would appear that the regulatory body designed to protect the wellbeing of patients and maintain standards in UK care facilities have failed spectacularly in their duty. Not only have they failed to monitor standards in an efficient and robust manner, the former Chief Executive, Cynthia Bower, plus her deputy Jull Finney and the media manager Anna Jefferson stand accused of actively covering up damning information regarding their investigation of the high death rate of babies at the University Hospitals of Morecambe Bay NHS Trust.

There have been concerns over the CQC for some time and there is no suggestion that the new Chief executive was in any way involved but this latest scandal puts several major issues (again) under the spot light.

Firstly – just what has happened to the moral compass within pockets of our state funded health system? The Francis report, investigating the Mid Staffs scandal where up to 1000 patients may have died as a direct result of poor care was supposed to be the beginning of the end of these tragic stories. This latest shocker regards the maternity unit at the Morecombe Hospital Trust where a high baby death rate prompted investigation. Babies were possibly dying as a direct result of poor practice. It is now suggested that senior CQC officials covered up information which could have saved other tiny babies. And yet, it would appear, these people put their own jobs and personal interest above the care of the very people they were supposed to protect. At the risk of being over-dramatic, if they were guilty – how do they sleep at night? Is this because they were working in a poisoned environment, immersed a blame culture, with perverse team ethics or no collective emotional responsibility? This is heavy stuff.

Secondly – this demonstrates in blazing clarity the enormous task that faces the CQC. An impossible task in fact. How can a team of experts (I use the term loosely) monitor and investigate over 40,000 health and care facilities throughout the UK? Professor Julian Le Grand, from the London School of Economics stated today that the way the organisation was set up it was ‘daft’ by creating a generalist organisation and merging health and social care for this monumental remit.

Thirdly – the regulatory and monitoring landscape following last year’s health and social care act is very confusing. In a poster created by NHS Employers the section entitled ‘Monitoring the NHS’ describes the 3 key areas as follows:

Care Quality Commission: ‘..is the independent regulator of all health and social care services in England. Its job is to make sure that the care provided meets national standards of quality and safety’

Monitor:  ‘..promotes the provision of healthcare services which are effective, efficient and economic and maintains or improves the quality of services’
Healthwatch England:  ‘..is the independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatches, it ensures that the voices of patients and those who use services reach the ears of decision makers’

This poster also describes NICE, Health Education England, Department of Health, NHS England, Clinical Commissioning Groups, NHS Trust Development Authority, and Health and Wellbeing Boards. All with some level of responsibility for standards. Confused? Who wouldn’t be?

How should we be monitoring our health and social care services? And who should watch these watchers? What needs to be done?

Clarify where the buck starts and stops: Well defined areas of organisational and personal responsibility, measurable standards and a simplified regulatory framework are needed

Give relevant experts the appropriate powers. In my opinion, one of the reasons that the cardiac and stroke networks were so successful in improving standards was that specialist units were awarded accreditation by appropriately qualified clinical specialists. It has emerged that lay people, fireman and other generalists within the CQC were tasked with inspecting hospitals – no wonder significant flaws were missed.

Neutralise conflicts of interest. It has been suggested that the newly formed Clinical Commissioning Groups should bear the burden of regulatory monitoring responsibility. No they shouldn’t – they have enough to do and there is already a risk of blurred lines between poacher and gamekeeper.

Separate health monitoring from social care monitoring. We don’t have joined up care yet so it doesn’t make sense to have joined up monitoring. If the CQC remains, specialist teams must be created.

And, most important of all….

Recognise that monitoring alone isn’t enough to create high quality care. Measuring only does that – it measures. Investment of time, energy and money are still required to build strong leadership within the NHS and support a culture of honesty, transparency, decency and clinical excellence.

I believe (and hope) that there is sufficient intellect, expertise, commitment and skills already within the NHS to make this happen. They just need gathering up and pointing in the same direction.

How can you measure care?

It has just been revealed by the Health Services Journal that Sir Mike Richards has been appointed as the new Chief Inspector of Hospitals. The purpose of this unenviable role has been described by David Cameron to ensure that “a hospital is clean, safe and caring, rather than just an exercise in bureaucratic box-ticking”.

The ‘clean and safe’ bit is relatively simple to monitor. There are a multitude of matrices available to set and measure performance standards, clinical outcomes and achievement of targets. But it is the care bit that’s tricky.

The new Chief Inspector, whose team will become part of the Care Quality Commission (CQC) has said that he ‘will champion the interests of patients’. This laudable aim fails to provide a definition of how to measure those interests so I looked to the CQC for clarification. Their website states their aims related to hospitals and GPs as:

‘We check all hospitals in England to ensure they are meeting national standards, and we share our findings with the public…..We inspect GP practices and other primary medical services in England to check that they are meeting the national standards of quality and safety’

It is absolutely right that national standards of quality and safety are met and monitored on a regular basis. But we still don’t have a benchmark for care.

Emotional intelligence is becoming an accepted principle for describing individuals, departments and organisations. One model to assess emotional intelligence is based on the three I’s – Intention, Interpretation and Impact. If you imagine a ward or GP surgery environment it is logical to project the three I’s to measure care and I would like to see this explored on a more formal basis for the NHS.

In the meantime, of course patient feedback and the ‘friends and family’ test are a valuable tool, albeit a subjective one. But then – care is subjective isn’t it?

Always happy to hear good news healthcare stories I am pleased to have two to report this week. One of my daughter’s colleagues is facing the agony of a very premature baby, born at 26 weeks, fighting for survival in a hospital in Portsmouth. The baby’s father has said that the one thing he doesn’t have to worry about is the care. A nurse is by the baby’s incubator at all times and the precision and intensity of each procedure (such as taking blood samples form underdeveloped veins) is enhanced by the palpable desire of each doctor, nurse and therapist for the baby to survive and thrive. The baby’s parents are in no doubt of the genuine commitment and care of the team who hold this precious life in their hands as medicine and care are combining to give this little mite the best possible chance.

Another example of care is much more low-key. Regular readers of this blog may recall my account of a gentleman (Tom) who was receiving poor care in a ward after breaking his hip. (‘Good care is about personal responsibility’ 21 April). Suffering bed sores, missing meals because he couldn’t reach his food, and becoming more frail by the day, the poor care received was having a direct impact on his will to live. I am pleased to report that Tom’s wife arranged for him to be moved to another hospital where the ward delivered the sort of care every patient should suspect. The medical treatment was the same, but the emotional and physical care was clearly far superior in this second hospital. Little things like making sure his cup of tea was just how he liked it, alongside scrupulous cleanliness and appropriate treatment for his bed sores. Tom is now home – working hard on his exercises and looking forward to walking his beloved dogs again before too long. What a difference moving from an environment with a poor emotional intelligence to one which embodied positive physical and emotional support.

I shall leave the last word to Tom’s wife – who used her own personal benchmarking system:

‘You could feel the care the minute we walked in the door’

 

Public and private can make excellent bedfellows, especially in treating cancer

I was recently asked to write about the future for my latest blog in Health Insurance Magazine and I included a plea for increased cooperation between the public and private sectors. As I wrote ‘There are still some Neanderthals out there who subscribe to the public good, private bad mantra’

I experienced a fantastic example of private and public partnership a few weeks ago when I attended the launch of a molecular screening laboratory in London’s University College (UCL) Cancer Institute. The technical detail of this collaboration between Sarah Cannon, the cancer arm of Hospital Corporation of America (HCA) International and UCL Advanced Diagnostic, part of the UCL Cancer Institute is described in more detail in their press release:

http://sarahcannonresearch.com/about/newsroom/new-genetic-sequencing-lab-creates-tipping-point-for

This is the coming together of an NHS Hospital (UCL) and an American Healthcare company (HCA) to research and treat a range of cancers. The mission of this venture is to enable patients to ‘live with cancer’ through a patient centred approach. No this isn’t the ‘patient centred’ sound bite often quoted by politicians and health officials – this is personalised medicine - the patient focussed analysis which identifies the genetic drivers for specific cancers. In a nutshell, the genetic abnormality which triggers the cancer is identified through molecular profiling undertaken in this joint venture laboratory. The techniques used can now sequence multiple genes in the fraction of the time previously required. Traditional biopsy assessment can be supported with genetic pathway analysis leading to individual treatment regimes saving time, money and lives.

Multiple clinical trials will establish the appropriate treatment pathways and this cancer screening unit gains its income from a variety of sources including charities, research organisations, government funding and drug company sponsorship.

Patients, often with little hope of cure or even a short term future, will be given the lifeline of this molecular screening to find the best possible chance of addressing their genetic abnormality to offer an improvement in longevity and quality of life.

This laboratory is targeting 11 (rising to 35 by July) genetic abnormalities using samples collected from a traditional biopsy. Patients will be admitted to clinical trials from a variety of sources (NHS, research establishments and the private sector) and the initiative is, in my opinion, a significant good news story.

Several major points struck me as I attended this press launch.

Firstly, the genuine passion and commitment of the key clinicians and executives. If you have to face cancer, I can think of no better individuals to join your armoury for your personal battle. Backing professional conviction with hard facts and a heavy dose of realism, the clinical team from UCL and HCA and senior executives from Sarah Cannon seemed to find the right words to inspire and convince. Professor Chris Boshoff saying ‘the future is now available in this laboratory’ managed to avoid sensationalism in his tone and Dr Howard Burris, president of clinical operations at Sarah Cannon referred to this speeding up of tailored diagnosis as a ‘game changer as we speed up the development of novel therapies’. Exciting stuff.

The second key point was the space, manpower and technology available in the pristine laboratory premises. These impressive facilities simply could not have been provided by the public sector alone.

Thirdly, with disappointment I noted that one journalist (but only one I’m pleased to report) was intent on finding the downside of this development. She started her questioning with the comment ‘I’m sorry to be cynical but…’  Of course she wasn’t sorry at all as she harped on about the NHS not being able to fund this initiative and suggested that NHS patients would not be referred to the facility. Regular followers of healthcare news will know the high-circulation tabloid well – it constantly sensationalises health reports and often focusses on the bad, rather than good news stories. The speakers responded to her with courtesy and patience. The point which she chose to miss was that eligible NHS patients presenting with one of the cancers under investigation at the unit will be enlisted in clinical trials as appropriate. Their cancer tissue, collected from traditional sampling techniques can be sent to this laboratory for testing and their tumour signature identified within 7 days. The cost of this is marginal compared to the amount of money saved though inappropriate treatment and the human cost of repeat biopsies and wrong pathways. Add to this the income generated from funded research and additional sponsorship and this is a laudable public private venture.

Dr Burris struck a chord with me when he said that the biggest cost in drug development is time. This is also the most precious currency of any cancer patient. The ground-breaking molecular screening speeds up the voyage of discovery for cancer diagnosis and tailored therapy and can buy precious days, weeks and years for cancer sufferers.

As one patient who, after ten years of toxic therapies, has benefitted from newly targeted drug treatment for his rare cancer said ‘I feel like a normal human again’. However mealy mouthed or cynical you may be about public private partnerships in health – this is a powerful testimony in favour.

 

 

NHS managers could learn a thing or two from Sir Alex Ferguson

As Manchester United fans across the globe prepare themselves for the ‘end of an era’ and mourn the retirement of Sir Alex Ferguson, it is worth reflecting on why he has been one of the greatest football managers of all time.

Regular followers of this blog will be familiar with my penchant for combining two of my great passions – football and health - so of course this landmark is just too significant to go without comment.

Non-believers may wonder why a football related subject should dominate headlines worldwide but Ferguson has his hands on the rudder of a 1 to 2 billion dollar enterprise, equally beloved by the stock market and football fans alike. Why has he been so influential and why have so many column inches been dedicated to this recent news? Because Ferguson is not only a great manager, he’s also a great leader and it’s quite rare to have both in one package.

Much has been reported about the lack of leadership and management in the NHS, both from a macro and micro perspective. Progress, service improvement and high quality care CAN be achieved in our hospitals and primary care facilities, if the teams have some decent leadership. And I’m not just talking about the boardroom, I’m talking about the doctor’s surgery, the bedside, and even the operating theatre – each department needs strong management. So NHS managers and leaders, please read the list below and take note.

Why was Sir Alex Ferguson so successful in managing a diverse group of individuals, each with their own agenda, but with, in theory, a common goal?

Discipline: I’m not suggesting that the hairdryer technique (where Ferguson blasts anyone who displeases him with a nose to nose tirade) but teams do need to play by the rules. Boundaries should be clear, rules well defined and bad behaviour should be noted and censured.

Reward good performance, address bad performance. The two golden words that could go a long way to fixing the NHS – performance management. Many have seen examples of incredible commitment and dedicated care alongside laziness, complacency and cruelty. For every individual failure there was a manager who either missed or ignored bad behaviour and practice. Performance management requires integrity and courage.

Instil pride in the brand and the team. Ferguson made it clear that when a player behaved badly on or off the pitch, he was damaging the Manchester United brand. The NHS has a fantastic brand and yet so many managers ignore this fact. I have seen brand loyalty (to almost a pathetic degree) in workers within the private sector which benefits customers, staff and the organisation in equal measure. Staff should wear their uniform with pride and be encouraged to honour their own teams.

Manage egos and personalities bigger than the brand. Cantona, Keane, Ronaldo – Ferguson had a knack for channelling genius and is probably responsible for saving the career of many an upstart. His controversial sale of David Beckham still smarts, but maybe he was probably right in recognising that the Beckham circus could have unbalanced the team dynamics. One of the biggest challenges facing NHS leaders is how to manage clinical teams. The clinical card is often produced to win a work stream argument. These days, I have found that the big egos aren’t just the consultants (historically the most difficult to manage, especially orthopods and heart surgeons) but therapists, GPs and nurses sometimes inappropriately use their clinical qualifications as a type of diplomatic immunity. Their clinical concerns must be heard and carefully balanced with the harsh reality of health economics.

Earn your stripes. Ferguson worked his way up and was a player himself. The best NHS managers either have a clinical qualification or at least worked within a clinical environment. Jeremy Hunt, the Health secretary, is suggesting that prospective nurses spend more time on the ward before embarking on their training but I think it would be more effective to insist that every manager spends some time either observing or assisting patient care so they really understand the stress and pressure that clinical teams face.

Lead by example and encourage a healthy work ethic. Even at the age of 71, Ferguson is first at the training ground for early morning sessions. Too many NHS managers stay in their ivory towers and should spend more time in committee than at the coalface.

Celebrate success! Ferguson’s ‘dad dance’ at every goal leaves something to be desired, but no-one could doubt his pleasure. There is so much good in the NHS and it should be celebrated.

For senior leaders only – manage the press. Ferguson was criticised for blacklisting several organisations and reporters during his career. But he is a canny Scot and he knew that he needed to control the message. I was at a launch of a new joint NHS/private venture on cancer research the other day. It is potentially a fabulous collaboration, and I shall be writing about it soon. But there was one reporter there, from a newspaper that famously overdramatises health stories and so often gets the facts wrong. She kept chipping away at the potential negative elements of the venture, and even her questions demonstrated that she didn’t quite get it – but these bad news stories dominate the UK press and undermine improvement efforts. Yes, it’s important that the public know about catastrophic events such as the unnecessary deaths at Mid Staffs and flaws in government reforms but the NHS PR machine needs to work harder in sharing the good news too.

I wish you every happiness and good health in your retirement and many many thanks for the hours of pleasure you have given millions Manchester United fans for over a quarter of a century.

Just one thing – could you consider postponing your retirement and replacing Sir David Nicholson as Chief Executive of NHS England? It’s about time the NHS had a premier league manager.

The ‘bed blockers’ who can make or break the NHS - practical pathway mapping urgently needed.

Andy Burnham, Shadow Secretary for Health has now outlined his ‘ideas’ for additional healthcare reform if Labour should win power at the next election. He was quick to state that these are just ideas at this stage but confirmed that he is identifying a ‘clear direction of travel’ for his policies.

The main thrust of his ‘direction of travel’ was to merge social care with the NHS. It would be hard to disagree with Burnham’s assessment that ‘Councils and the NHS don’t work well together’ and most involved with care would endorse a ‘fully integrated system’. His concept of one owner for the responsibility physical, mental and social wellbeing is worthy. But is it workable? What does fully integrated care mean? And how can we make this a reality?

Burnham is absolutely right that a major challenge facing NHS hospitals are the elderly patients who need ongoing care but have no current need for the acute care for which most hospitals are designed. This vulnerable section of the community make up between a quarter to a third of hospital occupancy at any one time which explains why they are sometimes referred to as ‘bed blockers’.

In the same way that that increasing the number of lanes in a motorway can only ease traffic congestion if the slip roads lead somewhere, so NHS improvements can only work if there is a suitable onward referral route for patients ready for discharge. Many patients stuck in acute hospital wards no longer need hospital care but need to continue their convalescence with ongoing care in the community. This care can take place either in their own homes with additional support or in a community care facility.

 

When I was working on stroke improvement initiatives in North West London, we made fantastic progress on providing specialist targeted care for stroke patients. The London Stroke Model defined that stroke patients should be admitted to hyper-acute stroke units within stringent time limits from the initial call for an ambulance. After up to three days of intensive treatment and therapy these patients would be transferred to stroke unit where the specialised care would continue. This system works extremely well, with every stroke unit in North West London reaching the required standards for accreditation and additional funding within a few months. Stroke patients received world class diagnosis, assessment and urgent treatment, vastly improving their chances of not only survival, but retention of a good quality of life.

 

An additional bonus was that each hospital that reached and maintained the required admission times would earn significant uplift in their tariff. Every stroke patient not admitted directly to the specialist unit would count against the hospital. As part of the accreditation process, I joined inspection teams in hospitals to ensure that these stroke units met their targets for accepting stroke patients. The most challenging aspect of applying this stroke model was freeing up beds in these units to enable new patients for admission. Time and again, a patient who no longer required specialist care but needed community support would languish in their hospital bed because there simply was nowhere else to go. In one stroke unit, we had a patient, a homeless man, who was well rehabilitated and no longer needed intensive therapy, but had been in the unit for 66 days (the average length of stay in a stroke unit is around 20 days) because he simply had no home to go to. (We actually threw a leaving party for him when he finally had somewhere to stay). This bed blocking creates a damming effect (and damning for that matter) on the entire system, back to the moment when an unfortunate patient first has a stroke.

Burnham’s ideas of an integrated system are coming from a good place but his direction of travel is fundamentally flawed. Burnham’s ideas are:

·        NHS leads on the physical, mental, and social wellbeing of patients

·        Councils should hold the budget and define the health and wellbeing strategy to make a better link between health and social care

·        NHS should lead on provision, council lead on strategy and commissioning

Opposition is a luxury in politics. You can make bold statements without actually providing an explanation of how highfalutin’ claims can be made real. Burnham’s plans sound like a rehashed, but even less workable solution than the current Health and Social Care Bill, currently being led by The Health Secretary, Jeremy Hunt.

Yes we need more integration between health and social care.  But let’s not make life even more complicated than it is already. Councils are NOT the right bodies to set strategy for healthcare but they should lead social care, and maybe public health. Integration is needed at the interface between the two. To try to reform all at once is terrifying and unworkable.

What we need is multidisciplinary pathway mapping – from cradle to grave, from diagnosis to cure, from acute to chronic care. Individual responsibilities to be defined for each area of care and ownership identified for coordination and cooperation.

Mr Hunt and Mr Burnham – if you would like a lesson in clinical and social pathway mapping, I would be more than happy to oblige.

Good care is about personal responsibility

What is the best way to take the temperature of the NHS? Ask the patient’s relatives. This is why the Cure the NHS organisation has such a powerful voice – or at least it should have,

I try to avoid hysteria and over reporting of bad news stories about the NHS in this blog but every so often I have to share a ‘tale from the front line’

A friend’s husband, a fit and active 70 year old (I’ll call him Tom), recently fell and broke his hip while walking his dog. Two weeks later, he is a frail, broken elderly in-patient with bed sores and a post-operative infection. The care he has received in the hospital in Hampshire has been poor – very poor. Tom’s wife, we’ll call her Liz, is a retired nurse, so she knows something about care and standards. Liz was horrified to note that Tom had bed sores, nasty places on his back and ankle, and challenged one of the nurses about how this could happen. Surely he was being turned regularly – the essential protocol to avoid the breaking down of thin skin due to pressure, lack of movement and poor circulation. ‘Ah’ said the nurse in charge, ‘that would be the agency nurses’. A cheap shot and a poor example of ownership, leadership and responsibility.

Liz also noticed that untouched food was left out of reach from Tom and now makes sure she is there at meal times so she can make sure he eats.To add insult to injury, Liz noticed that the floor beneath Tom’s bed was filthy, with unidentified stains and dust. It was clear that this was of no concern to the nurses when Liz pointed out that this dirt could be an infection risk, so she asked if she could borrow a mop and bucket and clean the floor herself. She was advised that there were no cleaning materials kept on the ward (apart from antiseptic solutions and wipes), as the contract cleaners were in charge of that. Liz enquired whether the contract cleaners could be called to undertake this task and was advised that they only appeared on the ward on pre-arranged times.

Have we learnt nothing from the Mid Staffs scandal? How come if you drop a bottle of tomato ketchup in a supermarket a cleaner appears within minutes? How often have we all heard ‘could a cleaner please go to platform 1’ at our stations but not so in a hospital?

A visit to the NHS choices website gives this particular hospital some reasonable ratings. 8.9/10 for cleanliness, 7.74/10 for overall care and 4.5/5 for patient feedback. Perhaps Tom has been unlucky – maybe an unfortunate set of circumstances has led to this isolated, but nonetheless, unacceptable lapse in service? But this is a very personal crisis and Liz fears that Tom, a normally robust and positive personaility, has given up and may not survive this episode.

Professor Don Berwick, the man tasked in improving patient safety in the NHS, says that redesign of service delivery is needed to make ‘zero harm a reality’. He lists seven imminently sensible criteria to be assessed and improved:

•  Identifying aims for improvement in quality
•  Building capacity through training and education
• Oversight, accountability and influence
• Patient and public involvement
• Measurement, tracking, transparency and learning
• Impact for legal penalties and criminal liability on patient safety
•  Leadership

I absolutely agree with all of the above and will be fascinated to see the outcomes of this initiative. But in the meantime, let’s try to keep this real. Behind the jargon and theory, there are two key players – the care givers and the care receivers. If you ask any patient or their relatives what they want out of the care givers I would guess that their number one request would be simple. Ownership and responsibility. Don't blame agency nurse, contract cleaners, the doctors, targets, budget cuts, reform, phase of the moon or anything else. Ultimately – whoever you are, if you are caring for a patient, it is your responsibility to be the best and do the best you possibly can.

Or am I being naïve?

Damned if you do and damned if you don’t.

I have a great deal of sympathy for Sir Bruce Keogh, Medical Director of the NHS and anyone else tasked with the challenge of interpreting patient safety figures. Like it or not, (and most of us don’t) – medicine is not an exact science. The nearest we can get to certainty is clinical governance - assessing outcomes and constantly monitoring effectiveness of treatments, surgical interventions, procedures and the departments providing these services. Clinical governance relies on statistics and as with any such analysis, validity and relevance needs to be verified and there is still room for error with interpretation.

The accepted wisdom that centres of excellence are the best way forward for specialist services and that there can only be a limited number of these special units in the UK means that some very tough decisions have to be made. None more tough than selecting centres of excellence for children’s heart surgery.

When it comes to NHS units, the natural human reaction is the absolute opposite of the NIMBY (Not In My Back Yard) response for unwanted local development or activity. In fact – we are all most likely to be YIMBYs (Yes In My Back Yard) for most NHS services on offer.

But patients, clinicians and parents must get real. Funds are limited, special skills are limited and high tech equipment is too expensive to be used only periodically. Specialist centres are the practical and cost effective way to ensure that the very best of outcomes are achieved. Of course, it is so much more convenient to take your child for life-saving surgery to a local centre, but if the quality of that local centre is in doubt, however lovely and committed the staff may be, then parents must take heed.

It is in this context that Sir Bruce suspended surgery at the paediatric heart unit in Leeds last week. Initial indications from figures recently acquired suggested that the mortality rate at the unit was unacceptably high. There was an immediate reaction from clinicians and families refuting this claim but Sir Bruce took, in my opinion, the only sensible decision that was open to him – to temporarily suspend surgery. The spectre of Mid Staffs Trust where statistics as early as 2007 that highlighted concerns were ignored (or even worse, covered up) and 1200 unnecessary deaths later, action was finally taken, continues to define the way forward for decision makers in the NHS. We simply cannot allow another Mid Staffs horror to happen. In the same way that a car manufacturer would be widely criticised for failing to recall vehicles with potentially dodgy brakes, so must NHS managers police care facilities, review statistics and act accordingly.

A spokesman from the hospital Trust said: "As we have stressed, the data and other information raise questions. They do not provide answers. These are for the Trust's review to determine. It must be right to put the safety of children first. It was therefore a highly responsible step to suspend the service. We hope that Leeds will shortly be in a position to restart children's heart surgery secure in the knowledge that everything is OK."‪

Sir Bruce has quickly reversed his decision on the Leeds unit and paediatric heart surgery will resume shortly as the figures have been proved to be erroneous and no doubt the staff, patients and parents will all be relieved and delighted.

This reversal of decision also took courage. We must trust that the majority of those involved in decisions regarding patient safety really do have the best interests of those patients at heart. If we don’t believe that premise, and that politics and personal grudges are creating bias and misinformation, then the NHS faces an ever bigger challenge than we all feared.