Bristol heart inquiry: Failing hospitals 'should be expelled from NHS'

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Bristol heart inquiry: top story

The investigation

The patients and their families

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The trust chief

Leading article: The Bristol report must mark the end of doctors' lack of accountability

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The Royal Bristol Infirmary Inquiry

Failing hospitals that do not meet nationally agreed standards of care, safety, leadership and basic facilities should be thrown out of the National Health Service, the Bristol inquiry report recommends.

The 600-page report attacks a culture of "pass the parcel" in health care, with too many agencies shrugging off responsibility for monitoring standards.

Professor Ian Kennedy, the inquiry chairman, said one overriding conclusion of the two-year inquiry was that there were no clear benchmarks for care in NHS hospitals. "Hospitals must meet certain criteria. If they fall below and are not meeting these standards they should not be within the NHS," he said.

The inquiry report calls for hospital trusts to be "licensed" and inspected by an NHS agency, the Commission for Health Improvement. Trusts that passed validation would be allowed to continue offering healthcare services. Eventually, licensing should be extended to individual departments and units in a hospital.

There are 198 recommendations for improvements in the NHS, and the report calls for a change of culture in the way doctors deal with patients, better access to information about the performance of hospitals and consultant teams, tighter leadership and nationally agreed standards for quality and care. Professor Kennedy said a key finding of the events in Bristol in relation to the NHS as a whole was the lack of performance standards.

There was no proper monitoring system to collect and analyse information about how well hospitals performed and "confusion from top to bottom about who was responsible". It was a "pass the parcel" system, he said. "Everybody thought it was up to somebody else. Nobody was responsible."

The report calls for the NHS to set up an overarching Council for the Quality of Healthcare, to co-ordinate different bodies regulating healthcare standards, alongside a Council for the Regulation of Healthcare Professionals to oversee the work of the General Medical Council and other regulatory bodies.

Other key messages for the future were that the NHS needed to put children closer to the centre of its agenda, make safety a key issue, be prepared to learn from mistakes and make changes in practice where necessary, as well as collecting more reliable information.

Professor Kennedy said the NHS should "return to its roots and put patients first – what the NHS was founded for".

A chapter on children's health care in the report had been "written in anger" because children had not been given priority for "far too long", he said. The report recommends appointing a National Director for Children's Healthcare Services to promote improvements in the standard of medicine offered to children. It says children's acute care should normally be in a children's hospital close to a general hospital, but that services for the young should be separated as far as possible.

Professor Kennedy said figures showed that a "staggering" 25,000 people a year died in hospital from avoidable causes – the equivalent of one jumbo jet crash per week. "The NHS must do better. This is not a matter of appointing a safety officer on the third floor. It is a matter of embedding safety in hospital culture, right down to the cleaner who does the floors."

More thought needed to go into improving the design of hospital equipment to improve safety and hospitals needed to learn from mistakes. Equipment manufacturers and doctors needed to work together to make treatment safer. There was an urgent need to collect better information when things went wrong.

"We are parlously poor at collecting data. You can't make things safer and learn lessons unless you have data that can be relied on," Professor Ken-nedy said.

He proposed a national system to report mistakes. A national database of such events would be kept by the new National Patient Safety Agency "to ensure that a high degree of confidence is placed in the system by the public".

The agency would be obliged to tell hospitals when urgent action was required, and publish regular reports on "patterns" of events as well as remedial action. The report proposes a confidential telephone line to make reporting mistakes as easy as possible. NHS staff who reported mistakes by colleagues within 48 hours should be given immunity from disciplinary action, but members of staff who covered up or failed to report a mistake would face action themselves. There should be a stipulation in every healthcare professional's contract that mistakes must be reported.

The report is scathing about the "club culture" revealed in some levels of the NHS by events at Bristol. It says the most important change needed is a change to the "culture" of the NHS, with more respect and honesty towards patients, better leadership, openness and involvement of patients with their own treatment.

Among other recommendations are a series of proposals to ensure patients are more closely involved in their treatment and care. "The notion of partnership between the healthcare professional and patient, whereby [they] meet as equals with different expertise, must be adopted ... in all parts of the NHS," the report says.

Patients should be given information about their treatment in a variety of forms, including leaflets, tapes, videos, CDs and "kitemarked" sites on the internet. If patients want, facilities should be provided for them to tape-record key discussions with doctors.

Professor Kennedy said patients should be given plenty of time to ask questions and come to decisions, be given copies of letters and receive more counselling and support. Patients should always be given information about the performance of a trust, specialty and team of doctors to help to make up their minds whether to agree to treatment.

Every hospital should have a "one-stop shop" to help with patients' concerns and answer questions about the care they could expect. Complaints should be dealt with swiftly by a strong, independent complaints department. "When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology."

The report gives strong support to a new no-fault system for settling medical negligence allegations. It says the present system is a disincentive to open reporting and discussion of mistakes. The Government has already promised to look at a new system of no-fault compensation.

THE INQUIRY

* The Bristol inquiry has taken two and a half years and has been the biggest investigation in the history of the NHS

* The inquiry was set up in 1998 by Frank Dobson, then the Secretary of State for Health

* The inquiry was run by Ian Kennedy, a professor of health law, ethics and policy at the School of Public Policy, University College London

* Professor Kennedy was assisted by three panel members, seven administrative staff and three legal counsel

* The inquiry looked at the cases of more than 2,000 patients between 1984 and 1995

* Evidence was given by hundreds of parents, doctors, nurses and outside experts

* The report, which is 600 pages long, makes 198 recommendations about the NHS and child health services