ZPB’s, Managing Partner and Director of Insight & Strategy, Alex Kafetz, spent the last two years as an independent adviser to the Paterson Inquiry, including aspects of data sharing, measuring performance and transparency of outcomes.
The final report was published on Tuesday 4 February 2020 and raised a number of recommendations for the service in terms of patient safety, transparency of outcomes and patient communications. Alex, shared his reflections of the inquiry in the Health Service Journal, and addressed why the transparency of information available to patients is vital to prevent a scandal like this occurring again. The original article was published on HSJ.co.uk.
“With painful frequency, stories of abuse by powerful people are also stories of a failure of board culture”
Ronan Farrow, Catch and Kill
I’ve spent the last 18-months advising the Paterson inquiry, leading on issues around data, transparency and information sharing. The full report was published on Tuesday 4 February 2020 with several recommendations in how the system can protect patients from doctors who at best don’t have the competence to complete the procedures they are licensed to do, and at worst set out to cause harm
I read Farrows book – detailing his Pulitzer prize winning investigation into Harvey Weinstein – during the closing months of the inquiry as the team came together to review the evidence given by over 200 patients and scores of professional witnesses and attempt to process a manageable number of recommendations for the Secretary of State for Health to consider. Although at first glance, whilst sexual abuse in Hollywood may seem a world away from patient harm in Solihull, the similarities were striking. In both cases a very powerful and egotistical man, of immense value to his organisation and known for a volatile temper had violated women, and not just one or two but many.
Neither of these incidents happened in isolation, people knew, indeed powerful and senior people knew, but did nothing. This was more-so in the operating rooms in Birmingham (at two sites owned by Spire and one by Heart of England NHS trust) where Paterson practised. What did the anaesthetist observing a procedure that didn’t seem right do? Why did the breast care nurse, change the clinical pathway because they were worried the treatment wasn’t right? Why did the CEO and medical director ask for more data or “HR to deal with this,” when they’d been told patients were being harmed? What did the NEDs do, and indeed what’s the point of them if this was happening on their watch? Farrow, in his book, considers which people “could have known” and which people “must have known.” In healthcare we must do similar.
Perhaps the most striking finding in the inquiry is on page 140 where it concludes that when Paterson was suspended in 2011 the NHS chief executive at the time, could not understand why his predecessors had not stopped Paterson operating much sooner. Paterson could have been stopped but wasn’t, fewer people could have been harmed. He was allowed to practise even longer in the independent sector due to a lack of information sharing. The inquiry also notes how poor the boards involved were in communicating with patients and indeed, in some instances saying sorry.
In my area of focus, I’ve been disappointed to investigate how poor the health system continues to be in giving patients and the public information about the quality and safety of health services. The secret society of the NHS described by Alan Milburn in 2001 remains.
Doctors knew Paterson’s outcomes weren’t right and in some cases he was performing procedures outside his scope of practice – as possibly did the insurers and central bodies, public and private, who had access to the data. No-one bothered to make this available to the women of Birmingham, who have had an awakening over the last few years that not all surgeons are equal, or indeed competent. Similarly, women in Shrewsbury, Morecambe Bay and East Kent must have grave concerns about their local maternity units and have no such information about the competency of their midwives.
We need to know, as the inquiry makes clear, basic information about our surgeons (and our GPs, practice nurses, social workers, mental health professionals etc) and this need to be in formats that the public can understand. One of the accusations against Paterson is that he told patients in the NHS that they would have a very long wait for care to steer them to his private practice. Even waiting times, whilst published by NHS Digital are found buried in spreadsheets 4 or 5 clicks down. I’ve been asking NHSX consistently for the last year whether they have any plans in this space and no-one has given me an answer. Let’s hope the impetus of the inquiry focuses their minds away from just being about technology and diverts some attention to data and transparency.
Returning to the board culture point, hopefully they’ll be a number of ways that governance and accountability will be tightened following the inquiry, but we’d also recommend boards review their communications strategies to make sure patients have all the information they need when being treated by the best surgeon possible but also in support from the governing board when things go wrong.
To find out how your organisation can work with ZPB to improve its communications or use and publication of data, email Alex at firstname.lastname@example.org.