Healthcare Features
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An NHS trust and a local authority have been sharply criticised following a joint investigation by the Health Service Ombudsman and the Local Government Ombudsman into how a vulnerable man with schizophrenia was left to live in “unacceptable” conditions.
The joint Community Mental Health Team run by St Helens Metropolitan Borough Council and the 5 Boroughs Partnership NHS Trust was responsible for the care of Mr B, who had a long history of involvement with mental health services.
He lived independently in his own home for more than ten years with a support package, which included regular visits from a support worker and a community psychiatric nurse from the CMHT along with practical help from cleaners employed by St Helens.
But Mr B’s health and living conditions deteriorated and he was unable to care for himself. He also developed a serious physical illness.
His cousin, Ms A, contacted 5 Boroughs and the council after becoming concerned about his personal health and hygiene and the condition of his flat. Dissatisfied with their responses, she complained to the Ombudsmen.
According to the cousin’s account, Mr B had come to their aunt’s home in a dirty and unkempt state. He had lost a lot of weight and was feeling unwell.
She visited his flat and found cockroaches and flies as well as food that was more than a year out of date. There was uneaten takeaway food, stains on every surface, and faeces and urine stains on the carpets and furniture. The cousin said it took her several days to clean the flat.
When Mr B returned home, his physical health deteriorated and he was admitted to hospital in an emergency. He was found to be suffering from malnutrition, dehydration and a number of other symptoms.
Mr B was subsequently diagnosed with a type of bone cancer and died later in a nursing home.
The Ombudsmen’s report did not uphold two of Ms A’s complaints, namely that: Mr B’s consultant psychiatrist had failed to respond to his poor physical state and had instead prescribed inappropriate drugs for depression; and that no one had supported Mr B to claim the welfare benefits to which he was entitled.
However, the report concluded that the CMHT had failed Mr B. It said that his care plan was not properly implemented, there had been insufficient contact over a period, there had been poor communication, and there were gaps in records.
The report also said there had been a failure to review Mr B’s care, to assess in depth his mental state, capacity or risk. The council’s cleaners had raised concerns but little action followed, it added.
The Ombudsmen said they could not definitely conclude that there would have been a different outcome for Mr B, in terms of the diagnosis and treatment of his myeloma. But they did find that the failure to implement his care plans and to manage risk appropriately played some part in his rapid deterioration.
The Health Service Ombudsman, Ann Abraham, said: “This is an extremely sad case about a vulnerable person who was not supported in the way he should have been. The Trust and the Council failed to deliver the standard of care Mr B was entitled to and he was left to live in unacceptable conditions.”
Anne Seex, the LGO, said the investigation had resulted in assurances from 5 Boroughs and St Helens that lessons had been learnt and others were now less likely to suffer as Mr B did.
“A key lesson is the importance of observations from workers like cleaners who had the most regular contact with Mr B,” she added.
Seex added that the Ombudsmen’s power to investigate complaints jointly was particularly important when health and local government join together to provide a combined ‘seamless’ service. “Joint services mean joint accountability if things go wrong,” she said.
In recognition of the distress and emotional upset Mr B’s family experienced, the Ombudsmen recommended that the Trust and the Council apologise to Ms A and pay her £2,000 compensation. They called on the public bodies to pay a further £1,500 to cover her legal costs.
The Ombudsmen also asked 5 Boroughs and St Helens to produce an action plan within three months of the final report, setting out what they would do to prevent other vulnerable people being let down in the same way in the future. The Trust and the Council have agreed to all of the Ombudsmen’s recommendations.
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National eligibility criteria and portable assessments should be introduced to ensure greater consistency and fairness in adult social care, the Dilnot Commission on Funding of Care and Support has recommended.
In its Fairer Care Funding report, the Commission also called for the government urgently to develop a new, more objective assessment scale as the basis for the future system.
The report said the current adult social care system was not fit for purpose and needed urgent and lasting reform. Its other key recommendations include that:
- Individuals’ lifetime contributions towards their social care costs – which are currently potentially unlimited – should be capped. After the cap is reached, individuals would be eligible for full state support. The Commission said the cap should be between £25,000 and £50,000, but it considered that £35,000 was the “most appropriate and fair” figure;
- The means-tested threshold, above which people are liable for their full care costs, should be increased from £23,250 to £100,000;
- All those who enter adulthood with a care and support need should be eligible for free state support immediately rather than being subjected to a means test;
- Universal disability benefits for people of all ages should continue as now. The government should consider how better to align benefits with the reformed social care funding system. Attendance Allowance should be re-branded to clarify its purpose;
- People should contribute a standard amount to cover their general living costs, such as food and accommodation, in residential care. A figure in the range of £7,000 to £10,000 a year would be appropriate;
- In the short term, it is reasonable for a minimum eligibility threshold to be set nationally at ‘substantial’ under the current system;
- To encourage people to plan ahead for their later life, the government should invest in an awareness campaign;
- The government should develop a major new information and advice strategy to help when care needs arise. This should be produced in partnership with charities, local government and the financial services sector. The Commission backed the Law Commission’s proposal for a statutory duty placed on local authorities to provide information, advice and assistance services in their areas. “These should be available to all people, irrespective of how their care is funded or provided”;
- Carers should be supported by improved assessments which take place alongside the assessment of the person being cared for and which aim to ensure that the impact on the carer is manageable and sustainable. The Commission supported the Law Commission’s proposals to give carers new legal rights to services and improve carers’ assessments; and
- In reforming the funding of social care, the government should review the scope for improving the integration of adult social care with other services in the wider care and support system. “In particular, we believe it is important that there is improved integration of health and social care in order to deliver better outcomes for individuals and value for money from the state.”
The report urged the government both to implement its reforms and ensure there is sufficient, and sustainable, funding for local authorities. “Local authorities will need to be able to manage existing pressures as well as the new requirements resulting from our reforms,” it warned.
“The Commission recognises the government’s commitment to social care in the latest spending review settlement; however, the impact of the wider local government settlement appears to have meant that the additional resources have not found their way to social care budgets in some areas,” the report said.
It added that the resources made available locally for adult social care each year should be transparent. Any periodic review of local government financing should also have regard to the importance of the sustainability of funding for adult social care.
The Commission, led by economist Andrew Dilnot, said its proposals would cost the state around £1.7bn. The report also calculated that no individual would lose more than 30% of their assets, and predicted that new financial services products would emerge to offer people further protection of their assets.
In a letter to the Chancellor of the Exchequer and the Health Secretary, Dilnot argued that extra state resources would be required in this area if greater private resources were to be unlocked.
“Without the state taking on some of the risk, individuals will be unable to use their assets effectively and the involvement of the financial services sector will remain limited,” he said.
The report outlined how demand for social care is significantly outpacing expenditure, with the gap increasing year on year. Dilnot said the issue of funding for adult social care had been ignored for too long.
“We should be celebrating the fact we are living longer and that younger people with disabilities are leading more independent lives than ever before,” he said. “But instead we talk about the ‘burden of ageing’ and individuals are living in fear, worrying about meeting their care costs.
“The current system is confusing, unfair and unsustainable. People can’t protect themselves against the risk of very high care costs and risk losing all their assets, including their house. This problem will only get worse if left as it is, with the most vulnerable in our society being the ones to suffer.”
Dilnot claimed that under the Commission’s proposed system everybody who gets free support from the state now would continue to do so and everybody else would be better off.
“Putting a limit on the maximum lifetime costs people may face will allow them to plan ahead for how they wish to meet these costs,” he argued. “By protecting a larger amount of people’s assets they need no longer fear losing everything.”
A copy of the full report can be downloaded here.
Philip Hoult
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The Information Commissioner has demanded a culture change in the health service in relation to data protection, warning that it “needs to do more” to keep patients’ personal information secure.
The watchdog said five more health organisations had given undertakings after being found to have breached the Data Protection Act.
The latest incidents include:
- Ipswich Hospital NHS Trust misplacing 29 patient records in February 2011 after a member of staff took them home to update a training log and then lost the records. The information, which included sensitive personal data relating to operations carried out on patients, was subsequently recovered. Ipswich Hospital agreed to implement mandatory data protection training for all relevant staff by 30 June 2011.
- Dunelm Medical Practice in Durham sending discharge letters about two patients’ routine operations to the wrong recipient. A member of staff had failed to spot that they had entered the recipients’ fax number incorrectly. The third party organisation which received the faxes immediately alerted County Durham and Darlington NHS Foundation Trust before destroying both documents. According to the ICO, Dunelm Medical Practice has agreed to send Electronic Discharge Letters by secure email and only fax them in exceptional circumstances. It will also programme the fax machine with the numbers for the regional branches to better protect the information in future.
East Midlands Ambulance Service NHS Trust, Lancashire Teaching Hospitals NHS Foundation Trust and Basildon and Thurrock NHS Trust have also recently signed undertakings.
The Information Commissioner, Christopher Graham, said: “The health service holds some of the most sensitive personal information of any sector in the UK. Millions of records are constantly being accessed and we appreciate that there will be occasions where human error occurs.
“But recent incidents such as the loss of laptops at NHS North Central London - which we are currently investigating - suggest that the security of data remains a systemic problem.
Graham said that while the policies and procedures may already be in place, “the fact is that they are not being followed on the ground”.
He added: “Health workers wouldn’t dream of discussing patient information openly with friends and yet they continue to put information on unencrypted memory sticks or fax it to the wrong number.
“The sector needs to bring about a culture change so that staff give more consideration to how they store and disclose data. Complying with the law needn’t be a day-to-day burden if effective measures are built in and then become second nature.”
The Information Commissioner said the watchdog was working with Connecting for Health to identify how it could support the health service to tackle these issues. The ICO’s guidance for health organisations is available here.
The ICO is yet to levy a monetary penalty on a health organisation. This contrasts with the local government sector, where four councils have been ordered to pay a combined £370,000 over the last year.
See also: is local government a soft touch for data protection fines?
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The existing, fault-based system offers the best opportunity possible for NHS patients to establish the facts of their case and obtain redress, an influential committee of MPs has said.
The health select committee had looked at no-fault compensation schemes but decided that the current regime should be kept, albeit that some changes needed to take place.
“The activities of ‘claims farmers’ drive up the costs of pursuing a legal case and these organisations must be subject to tighter regulation,” the MPs said.
The report – Complaints and Litigation – meanwhile warned that the government’s decision to end legal aid for clinical negligence cases “could erode the settlements for the most seriously injured claimants, and could undermine access to justice for many”.
The MPs also urged the government to bring forward the details of its plans for speedy resolution of smaller claims.
Other key findings from the report were:
- The improving level of satisfaction with the local resolution stage of the complaints process was welcome, but more could still be done to improve the patient's experience. “The government is now in possession of sufficient data to enable a full review of the system, and should do so without delay,” the MPs said. “In this review, it should carefully consider the development of separate systems for investigation and resolution of customer care complaints and more serious complaints about clinical issues."
- The operational and legislative framework within which the Health Service Ombudsman operates requires review. “Patients and the public perceive the Ombudsman as offering a general appeals process to the local stage of the complaints system, whereas the role is in fact much narrower than that,” the MPs said. The review would look to make the framework compatible with this wider purpose.
- Patient advice and liaison services (PALS) are a useful first point of contact for complainants, “but need to be more capable, more visible, and integrated into other systems for resolving complaints”.
- Independent complaints advocacy services (ICAS) support patients with the practicalities of complaining and provide important support, especially to vulnerable complainants. However, there are artificial boundaries that get in the way of this work. “For example, ICAS cannot currently support patients to make complaints to the General Medical Council or other professional regulators, a situation that should be remedied by the government.”
- The NHS needs to do more to promote the awareness of, and access to advocacy.
- Commissioning authorities have the potential to be the engines that drive improvement in the complaints system. When things go wrong in their care, patients expect full disclosure of the facts, "something that is not always the case".
- Supported by culture change, a contractual duty of candour between providers and commissioners, and between commissioners and their populations would support openness and honesty in the NHS. “Model commissioning contracts must reflect this and must also mandate access to comparable data on complaints to commissioners. Where a complaint is found to be valid, and an organisation puts an action plan in place, these action plans must be implemented by the provider and returned to the commissioner and the Local Healthwatch, who can observe progress.”
- It was difficult to establish which organisation monitors the performance of the NHS against complaints standards. The committee said it could see potential for failing organisations to be overlooked.
- Healthwatch England should receive intelligence about NHS providers from Local Healthwatch organisations, and should monitor the performance of all providers of NHS care and treatment against a set of agreed complaints handling standards.
- Although the government’s proposed health reforms do support greater information sharing between bodies, they required further strengthening. The committee said it had ongoing concerns about how primary care would be commissioned, and also how complaints about primary care would be handled in future. The forthcoming "Information Revolution" report needed to at least consider how complaints data could be used by the NHS to help it to learn and improve.
- The government's proposals for ending the secrecy of Foundation Trust Board meetings were welcome.
- Change would only happen in the NHS if there was a change in the culture, as well as in the procedures and practices. “Staff must feel that there is clear guidance on when they will be held to account for errors, and when these will be seen as systemic failings of an organisation,” the MPs said. “They should receive regular feedback on the volume and nature of the complaints about them and their teams, and anonymous patient feedback should be used to support improvement.”
Philip Hoult