1. Reddit, WhatDoTheyKnow and the use of under-qualified medical staff in the NHS

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    Posted in Transparency, WhatDoTheyKnow

    WhatDoTheyKnow and Reddit: bring them together, and amazing things can happen — as we’ve discovered from one of our users.

    We’ve been talking to Yasmin Marsh, who, as part of a small collective of NHS doctors and staff named PA Project Watch group, is investigating concerns around the use of under-qualified medical staff in NHS hospitals and GP surgeries. With a combination of facts received through Freedom of Information requests, and on the ground experience from members of the r/DoctorsUK subreddit, they’ve created a change in policy in at least one NHS Trust.

    What is a PA?

    We asked Yasmin to explain the basics of PA Project Watch’s campaign to us, and anyone else who might not know the finer details of how the NHS functions. So first of all, what does the PA in the group’s name refer to?

    “It’s ‘Physician Associate‘, a role previously known as a ‘Physician Assistant’,” she explained. 

    “A PA is a member of the healthcare team who works under the supervision of a senior doctor to help care for patients. You can train to become a PA with a 24 month MSc or PgDip. 

    “The role was originally designed so that PAs would always work under the supervision of senior doctors and assist the medical team in caring for patients.”

    The trouble with PAs

    OK, so what’s the issue with PAs? 

    “Because no official rules have been set around what they can or can’t do”, says Yasmin, “they’ve been used inappropriately by NHS hospitals and GP surgeries to replace doctors.”

    In these stretched times, it’s perhaps inevitable that shortages are being addressed by any means possible? Yasmin agrees:

    “You can see the temptation for NHS managers and GP surgeries — if there are doctor shortages, fill the gaps with PAs instead. They’re also cheaper than doctors!”

    Yasmin told us that the General Medical Council are planning to introduce regulation later this year, but meanwhile, there are potential dangers around this situation. 

    “I’ve seen first-hand the problems of using PAs,” she said. “It comes back to the old saying ‘you don’t know what you don’t know’. As they’ve only done a 24 month course, they miss covering lots of important topics, and the topics they do cover are only covered in superficial depth, skimming over lots of important medical topics briefly. There’s a reason medical school is five to six years!

    “So, for example, when looking at a patient’s blood tests, I’ve seen a PA miss a common critical abnormality because they simply lacked knowledge — they’d never been taught about that particular blood test abnormality or what it means. If you speak to doctors, these types of errors are happening through the use of PAs up and down the country.”

    So how critical is it?

    “There have been several deaths of patients due to mistakes made by PAs, which have been reported by the BBC1, the Manchester Evening News2, and in two stories from the Telegraph3.”

    WhatDoTheyKnow and Reddit

    So that certainly explains the groups’ concerns, and their desire to do something about it — now, how did WhatDoTheyKnow and Freedom of Information come into the picture? 

    Yasmin hadn’t been fully familiar with the concept before: “I had heard of FOI requests, but I never knew they could be submitted by anybody. I thought you had to be a journalist or an investigator to submit them. However, I found WhatDoTheyKnow through Google when looking for another topic about my local council, and then discovered that anyone could send them.”

    And what about the link with Reddit? Yasmin’s shared FOI responses as the group has received them, allowing for vital scrutiny of the information provided, from those working in the settings in question, who are able to compare the responses with their own experiences.

    “Reddit has been central to this campaign. I’d really emphasise the role of the /r/DoctorsUK community. Without them, this would not have been possible.”

    A strong example comes from the FOI request sent to Torbay Hospital.

    “We received a message from a Reddit user who said this hospital was using PAs inappropriately to replace doctors, often in the paediatric department, but also covering other gaps in the hospital rota like the surgery and medicine departments.

    “After this message, I sent an FOI request to the hospital, asking them how many times doctors had been replaced by PAs. They replied: 

    None, physician associates are not permitted to cover doctor’s shifts.

    “We then posted this on the r/DoctorsUK community asking if this was true, and for any evidence that PAs were replacing doctors. We received testimony from paediatric nursing staff and a rota, showing that PAs regularly replaced doctors in the paediatric department. This demonstrated that the hospital’s response was false. 

    “We then challenged the hospital’s response by requesting an internal review, which led to them admitting that PAs did cover rota gaps in paediatrics and other departments.

    “Did they deliberately try to cover up the situation? Or was this an administrative mistake? We’ll never know. Without Reddit, we would have just accepted the original response and never pushed for the internal review.”

    Real-life results

    And as for whether the request has had any impact? Yasmin confirms that the Trust says they’ve now stopped substituting PAs for doctors.

    PA Project Watch continue in their work. “We’re now asking other hospitals to see if they have been substituting doctors for PAs, and uncovered further evidence: for example, Royal Berkshire sent us a spreadsheet of shifts where PAs had covered for doctors. This story was featured in the Daily Mail, although unfortunately without a credit.”

    And perhaps as a further effect of this campaigning, doctors are now taking legal action against the General Medical Council, because while the GMC is planning to regulate PAs as Yasmin points out, “they could still technically do anything a doctor could do. 

    “This is the central argument of the Anaesthetists United legal case — they want the GMC to create a clear set of limits on the tasks PAs can perform, to avoid them being used inappropriately.”

    But Yasmin’s clear where the problem lies and it’s not with the PAs themselves. “They’ve been let down by their leadership at the Faculty of Physician Associates, taken advantage of by the NHS, and thrust into roles for which they are unqualified and underprepared. 

    “Unfortunately, the NHS culture makes it really difficult to speak up about these issues. We’re trying to shine a light on what’s happening, and FOI gives us the power to do this — but we’re finding many Trusts are now refusing to answer requests about PAs, and we’re having to involve the ICO more and more.”

    Thanks so much to Yasmin for sharing this important campaign. It’s great to see the journey from FOI novice to FOI expert! 

    It’s clear that the group now has enough knowledge to request an internal review to challenge an erroneous response, and to appeal to the ICO when an authority hasn’t met their responsibilities under the FOI Act — and we’re glad that WhatDoTheyKnow has been part of that learning process, not to mention the results that have come from it.

    Video summary:

    1 BBC: Misdiagnosis: Bereaved mum calls for physician associate role clarity

    2 Manchester Evening News: Gran died after ‘physician’s associate’ left treatment in place for 16 HOURS longer than allowed

    3 The Telegraph: Man died from rare heart problem after being discharged from hospital
    Family of film make-up artist call for inquest after treatment by physician associate

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    Image: implusq

  2. NHS Sustainability and Transformation Partnerships on WhatDoTheyKnow

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    We’ve just listed Sustainability and Transformation Partnerships on our UK Freedom of Information service WhatDoTheyKnow.com. These new bodies bring together NHS organisations and local councils with the aim of better co-ordinating health and care services in England (see NHS England’s webpage introducing them).

    In most parts of the country Sustainability and Transformation Partnerships are unimaginatively named. In a few places though the bodies have been more adventurous: we have the bold and strident sounding Success Regime Essex, as well as Together We’re Better in Staffordshire, Transforming Health and Social Care in Kent and Medway, Joined Up Care Derbyshire and one called BOB.

    Some of these bodies appear to be just coming into being, with almost nothing about them online at all and others are more established with staff, websites, boards and published meeting minutes. When researching these organisations we found a handful offered Freedom of Information contact addresses, and commendably Kent and Medway’s even has a log of responses it has already made to FOI requests.

    Most Sustainability and Transformation Partnerships will be subject to Freedom of Information (FOI) law as all their members are public bodies. Some may not be subject to FOI though, for example Surrey Heartlands Sustainability and Transformation Partnership appears to have private company Virgin Care as a member, exempting it from the relevant definition; we list the body on WhatDoTheyKnow anyway as part of our activism seeking to expand the scope of the law.

    What information will a Sustainability and Transformation Partnership hold?

    A few partnerships publish their key governance documents (constitutions, terms of reference, memoranda of understanding), and minutes and papers from their boards; these can give an insight into the organisation’s activities and reading them may suggest information which could be made public via a Freedom of Information request. If the basics of board minutes, and governance documents aren’t published you can use WhatDoTheyKnow to get them online and easily for everyone to access.

    FOI responses from Kent and Medway show large sums of money being paid to “consultants/external advisory firms” to develop a Sustainability and Transformation Plan and hint at bodies elsewhere doing similar. Freedom of Information requests could be made to partnerships elsewhere to ask for information on their budgets and spending.

    The future

    It is anticipated that Sustainability and Transformation Partnerships may “evolve” into “Accountable Care Organisations” ACOs, responsible for all public healthcare in a region; this would make them immensely important public bodies.

    We’ll keep an eye on the organisational changes and try to keep our service up-to-date.
    Maintaining the database of public bodies is a key part of running WhatDoTheyKnow; we have to react to reorganisations in the public sector, and bodies forming, merging, changing their names or ceasing to exist.

    NHS Sustainability and Transformation Partnerships on WhatDoTheyKnow

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    Image: LydiaShiningBrightly (CC-by/2.0)

  3. Changes to public authorities today

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    Posted in WhatDoTheyKnow (only)

    National Health Service changes in England

    Today (1st April 2013) marks a significant change in the way that the NHS in England is structured.  Strategic Health Authorities (SHA) & Primary Care Trusts (PCT) are abolished, and their responsibilities are being taken on by newly created Clinical Commissioning Groups (CCG), the National Commissioning Board, Public Health England and local authorities.

    The split is roughly along these lines:

    • Clinical Commissioning Groups commission elective hospital care, urgent and emergency care, community healthcare and mental healthcare & learning disability services for the local areas they cover
    • The National Commissioning Board covers primary care contracting (GP Contracting, Dental, Pharmacy), specialised services, offender healthcare, secure mental health care and some armed forces healthcare
    • “Top-tier” and unitary Local Authorities take on responsibilities for these aspects of public health: sexual health services, drug and alcohol treatment, health checks, school nursing programmes, giving up smoking programmes and services to prevent childhood obesity
    • Public Health England is a national body which will work closely with local authorities’ public health teams, carrying out a range of activities to protect and improve the nation’s health, eg to co-ordinating work to combat infectious diseases such as flu or infections acquired in hospitals such as MRSA, or to carry out national publicity campaigns to prevent ill health

    This means quite a bit of change to the public authority listings on WhatDoTheyKnow:

    1) PCTs and SHAs are now marked as “defunct” to prevent new requests from being made (see below for more details).

    2) We’ve now listed all the new CCGs, but we’re missing email addresses for around 15% of them.  It’s clear that many CCGs are not quite ready to welcome FOI requests.  Even though they went live today, there are a fair number of websites still under construction (I’ve seen lots of “lorem ipsum” text today), with no contact details.  We aim to get these all up-to-date in the next few weeks as they get up to speed.

    3) The National Commissioning Board and Public Health England have been added to the site

    4) We’ll be adding local Health and Wellbeing Boards, Healthwatch organisations & Local Education & Training Boards soon.

    Police Service changes in Scotland

    Under the banner of reducing duplication and cost-saving (BBC article), police services in Scotland are being completely re-organised with 2 new central bodies replacing all the regional police forces and boards:

    Fire Service changes in Scotland

    Similar changes are taking place with Scotland’s fire services:

    Other joiners & leavers…

    The following is a round-up of other changes taking place today…

    Say hello to:

    And goodbye to:

    And although they’re officially changing, it’s pretty much business as usual for:

    Defunct public authorities

    We flag old public bodies that no longer exist as “defunct” to prevent new requests from being made.  In most circumstances FOI officers transfer across in-flight requests to the relevant replacement authority.  If you need to follow-up a request to a defunct public body (e.g. if there’s no further contact from an authority), the website will let you, however the “old” authority is no longer under any obligation to reply.  You may need to re-send your request to a new public authority which will restart the 20-day clock…

    Please help us!

    Given the scale of change, if you find any incorrect information for these public authority listings, please let us know!  Also please get in touch if you find an email address for any of those we’re still on the hunt for…