Dr Phil Hammond, broadcaster and GP turned hospital doctor

How are you with failure? As a GP, you get used to it. Drugs don’t always work, even when NICE says they should, and patients don’t always do what they say they’re going to do. Large trials that treat everyone the same don’t always have the answers for the individual in front of us, so we add a bit of guess work and personal preference to the science, and hope it works. But sometimes it doesn’t. Failure is part of life and medicine.

We all fail sometimes, but if we start failing all the time (because we’re stressed, or depressed, or reaching for the vodka to get us through the day), can we be confident that someone will step in to protect our patients? In my experience, the NHS—and the people who work in it—are not always reliable when it comes to spotting and acting on failure.
Don Berwick, the NHS’ newly appointed safety tsar, recently told NHS staff: ‘Do not distance yourself from the staff at Mid Staffordshire; you would have committed similar errors in an unsafe environment.’1 Some staff at Mid Staffs tried to speak up but were shut up, leading the Nursing Times to launch an excellent ‘Speak Out Safely’ campaign ‘... to help bring about an NHS that is not only honest and transparent, but which also actively encourages staff to raise the alarm and protects them when they do so.’2 But as the pressure mounts to make the NHS look good in time for the next election, it’s hard to see how this will become a reality.
The NHS has done remarkably well in the last 2 years, given the slow-down in funding, but the wheels are starting to loosen. The dramatic rise in 12-hour trolley waits in A&E is one recurring failure, but the winter has been tough, most of the patients are frail and elderly, and there is nowhere else for them to go. Discharge may be delayed because of a lack of social care beds, and so elective operations are cancelled.

The health reforms are forcing GPs to confront failure on a larger scale. As commissioners, we’re now directly responsible for spending vast sums of public money. We need to track outcomes, admit failure, and decommission (a polite word for ‘close’) services that aren’t delivering good quality care or, more contentiously, can’t do it for the right price.
So what should the NHS do if a provider fails? It’s not simple. There are now three different failure regimens for the different types of providers of NHS services. NHS trusts follow a Trust Special Administration (TSA) process for unsustainable providers, which has been in place since 2009 and is triggered by the Secretary of State. Monitor?3 oversees a new Trust Special Administration process for Foundation Trusts (FTs). Once FTs get into difficulties, they can now no longer revert to NHS trust status.

Monitor can also take proactive action to prevent failure of FTs, if it spots warning signs in time. In order to protect patients’ interests, services that need to stay in the area will continue to be provided, even when a provider enters the failure regimen. And clinical commissioning groups (CCGs) will help decide which services are continued; these will be termed ‘Commissioner Requested Services’.

In order to finance the continuation of these services during the failure regimen process, a levy will be charged to all providers to generate a ‘risk pool’. So even if providers have made savings themselves, these may be taken back to bail out neighbours. As for private providers going under, a Health Special Administration (HSA) process is planned for April 2014. Failure and closure are controversial, emotive, and unavoidable in the current financial climate. And they happen in the full glare of the press. GP commissioners will have to toughen up quickly.


  1. NHS England conference. Creating conditions for safety. London: 16 April 2013.
  2. Nursing Times website. Speak out safely.
    www.nursingtimes.net/opinion/speak-out-safely/ (accessed 9 May 2013).
  3. Monitor website. www.monitor-nhsft.gov.ukG