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Sometimes during your medical career something happens which is so dreadful that it goes against everything you believe being a doctor stands for.
This is what it feels like to read Robert Francis’s report into events at Mid Staffordshire NHS Trust. When you read about individuals not being given basic care, left lying for hours in their own excrement, not being given sufficient pain relief or even food and water, you cannot believe that you are hearing about patients who were ill and being treated in an NHS hospital.
Patients rightly believe that when they go to hospital they are going to a place of safety where they will be cared for and treated with respect. It is shameful that this is not what happened to so many patients who went to Stafford Hospital.
So how could it happen? Despite endless regulations, reams of guidance, several external regulating bodies, how could such poor quality of care go unnoticed for so long?
As Robert Francis said today, such wholesale systemic failure cannot be blamed on one policy or a group of individuals. There is an urgent need to reshape the culture in the health service to prevent similar tragedies happening in the future.
You cannot practise medicine in a zero-risk environment. Every procedure carries some degree of risk and patients should be informed of this and participate in decisions. However, we can stamp out poor and dangerous care, there is no place for it in our NHS.
We owe it to the victims to do more. The answer doesn’t simply lie in supporting individuals to raise concerns about poor practice. We must develop a culture where health professionals not only think speaking out is the right thing to do but where they are congratulated for doing so.
I want the BMA to play a key role in leading the debate about how to reshape NHS culture. We have already made a start. Our recent conference about raising concerns, held in partnership with Patients First, looked at the barriers that prevent doctors and other health professionals speaking out and how these could be overcome. We have since updated our guidance to doctors on raising concerns.
But this is just the beginning. In the months ahead, your views are essential to help us lead the debate on cultural change within the NHS so we want to hear from you. Why did Mid-Staffs happen and how can we prevent it from happening again?
Mark Porter is BMA council chair
Please leave a comment below or email me at [email protected]
Poor daily care has been the norm in many departments and hospitals for over 10 y ears, resulting from the Project 2000 , which abolished the SENs and transferred care to untrained auxiliaries. The few remaining SRNs have little time for wound dressings or patient care.
Finding beds is a constant battle. Managers rarely if ever visit the wards, and consultants are now just another member of the team (until something goes wrong) with little influence. We are often afraid to speak out and few would dare publicize shortfalls through the press for fear of retribution.
We need to restructure nursing (bring back SENs) and involve doctors again in nurse training.
There also should to be some mechanism whereby doctors can bypass the hospital management to inform a watchbody about unacceptable care without the risk of retribution. (Inspections rarely see the true daily situation)
Managers and Chief executives need to visit wards unannounced (I never saw nor could even recognize the last 3 chief executives at my hospital).
The constant reorganization of the management structure whenever a new chief executive arrives (which was every 2 years in my hospital) is a waste of time, money and effort, as is the costly reorganization of the health system whenever there is a change of government ,which diverts attention from the real problems.
Finally, hospital doctors must somehow be allowed to rekindle the spirit of a vocation instead of just a job: We should be watching standards, not clocks.
I was dismissed from the NHS 30 years ago for whistleblowing ( telling a family that the six month planned delay in their baby's pacemaker was a budgetary issue ). I had no support from the GMC, BMA or my Indemnity Insurance, and it was made clear to me that a Consultant was now a functionary of Management in the "new NHS". If you give a traffic warden power he will immobilise your car. The subsequent audit in the NHS was about money, not about standards of care, and the effects of bureaucratic power have been a major decline in the standards of care at all levels, for which Doctors have abrogated responsibility. I am old enough to remember an NHS where Doctors were in charge and the service was better.
Actually, Robert Francis is completely wrong (although he wouldn't be able to say it) â€” such wholesale systemic failure can be blamed squarely on one group of individuals â€” successive Secretaries of State for Health!
Since Ken Carke brought in Unit General Management (UGMs) in NHS hospitals when he was SoS for health in 1984-5, he and subsequent politicians with the Health Portfolio ( think Virginia Bottomley, Brian Mawhinney, William Waldegrave, Stephen Dorrell, Alan Milburn, Patricia Hewitt, John Reid, Andrew Lansley, et al ) have intentionally, aggressively and systematically undermined the Hospital Consultant position â€” They have brought us to heel and achieved control as was their collective long term agenda and strategy. An effective authoritative powerful Hospital Medical Staff Committee with good relationships with the local GPs would have prevented the horrors of Mid Staffs. There has been systematic dis-empowerment of Hospital Consultants with closure of Consultants messes, staff rooms, coffee rooms, dining areas, and emasculation of the old style Medical Staff Committee. All cohesion within the consultant bodies has been forfeit and may never be retrieved. The esprit de corps has almost entirely evaporated along with the enjoyment and sense of worth. Several years ago most Hospital Consultants realised that they were being completely marginalised. Health Secretaries allowed and encouraged Hospital management to mirror the private sector with Boards, Chief executives, NEDDies and all sorts of 'people who don't see patients' able to dictate to 'people who do see patients' exactly what we must and must not do. We have 'learned helplessness' â€” we are so used to being ignored and dominated by the administocracy (the managerial hierarchy all the way up to the Secretary of State for Health) that we are certain we can no longer influence our own hospital environment. And it's no good politicians saying that "we all have the luxury of hindsight" â€” because we had foresight â€” but we were ignored. Mid Staffs is a tragedy â€” but sadly I believe it is not an isolated phenomenon.
I resigned my post as an NHS consultant of nearly 20 years standing due to my disillusionment with the NHS having been a life long adovcat of care free at the point of delivery.
The NHS trust I used to work in was regarded as a successful high performing organisation and yet it had the same malaise that affected Mid Staffs albeit to a lesser degree. Below I list the background problems that led to my resignation.
I personally witnessed the manipulation of inidents away from the principles of finding truth and knowledge ( for patients and staff) towards making the organisation and its systems apper to be faultless.
Verbal complaints regarding these issues were ignored and written complaints met with unwitnessed admonishment and unsatisfactory written replies. Protecting the reputation of the organisation (executive team) appeared to be the main priority.
The main focus was the achievement of targets with evidence that this focus was damaging to safety or quality being largely ignored.
Staff dissatisfaction and poor patient care whilst acknowledged was regarded as an insurmountable problem.
When trainees rightly raised concerns they were labelled as " failing individuals mounting a personal vendetta".
Bullying individuals following their own agenda of self aggrandisement were not only openly tolerated but regarded as successful as long as they achieved thier targets.
Having tried and failed to rectify the above problems and with an increasing concern that my protestations would result in action against myself I took the decision to leave.
Sadly I suspect this situation is repeated many times in the NHS.
Thank you for your expression of urgency, as BMA Chair of Council, on the need now highlighted for culture change.
It is though not just within the NHS that change in culture is needed. Rather it is in society as a whole, in the chains of command from luckier electors down to unlucky patients, from senior politicians down to the newest of cleaners.
Your emphasis is exactly right, on partnership. Consideration is due with urgency, of the necessary conditions for sustained freedom of responsible expression, in speech and action. Self-discipline is our need, the perfect punitive a vain hope, the best of guides the conscience, informed by feedback that is trustworthy at least as to intent. We have no more need of a charter for the frivolous than for the rule of fear and greed.
If we wish the fruits of democracy, the balanced good of all, we must - with Aristotle - rule out as ant-democratic any vote or process destructive of essential equality, the security of an equal income-share for all except perhaps those properly judged as lazy or criminal.
Need it be observed here, again, that fear for the livelihood of self and family is a 'very powerful' force in the aversion of gaze, the silencing of tongue, and worse? For 'everyone' to be 'allowed to play their part', for 'rule' in our society to be 'of, for, by the people', for dialogue and decision-making to be 'representative' of the interests of the people, our need is inescapably of equal stable partnership.
Observation as specific as the above has been directed towards senior politicians and medical professionals, repeatedly, over at least the last forty years, 'answered' in denial of 'corruption by self-interest', or by excuse in 'the art of the possible'. We are again at risk - thinking to 'stamp out' symptoms, leaving untreated the disease underlying - of making things only worse.
25 years ago, trying to work in Community Medicine, I warned of a quarter of a century in eclipse for that specialty (now back to 'Public Health'), from failure to address conflict of interest. I hope that I was not too optimistic, and that the whole profession will bring 'social medicine' back to life.
We need to make 'whistle-blowers' and 'Hospital Inspectors' redundant, education affording understanding and agreement amongst all of capacity, that 'the public interest' is a virtual interest, 'definable' only in the collective pursuit of a free people, each of us enabled to follow conscience, each of us allowed rational trust in all others, liberated to find fulfilment in competing to be our best.
Trapped in a poisoned system, competition for pay has gripped medicine scarcely less than other professions, fuelling political competition in promise of tax-cuts (for 'hardworking tax-payers', and the others). As a result, we are seeing front-line medicine - and medical contribution to leadership - priced out of the market.
Atomisation of care is now so advanced in at least one sphere of evolved expertise, that of 'Family Planning', as to threaten the retreat of holistic ambition to a few centres of excellence, perhaps accessible by urban wealth, but lost for a generation by most.
More broadly, the question now as for decades remains, in the face of literally 'crying need', in our busy clinics, on our busy wards, WHY do we not share our national 'income', AND our work, with the millions allowed 'no work'?
I am proud to say that I followed the guidelines and dynamic advice given by the BMA throughout my career in the NHS and supplemented this with letters,book chapters and "informal, off the record " briefing [of non-patient ] data to the press and BBC.
I suceeded in attainig the desired results in most instances. The rest were dealt with through establishing harmonious relationships with senior Trust board members and encouraged them use ther good offices,
Very sad to see NHS in this state after working for NHS for 31 years. Nobody else apart from Politicians can be blamed for this sorry state of affairs as they don't listen to grass root staff of NHS who work hard to keep NHS on track. Please bring back old system , and make Consultant responsible for their staff and ward management. Also Matron should be replaced to run the ward as in past one Matron was enough to keep staff working hard and efficiently. I am still quite optimistic that this can be achieved if there is no undue Political and Managerial pressures.
Mid Staffs sounds like most hospitals I've worked in.
It is crystal clear, and was before the report, that doctors working for managers will not produce medical excellence. I learnt long ago not to call out mistakes or laziness as it would be labelled as "arrogant" or "rude" by the namby-pamby no-blame-culture NHS system.
Doctors try to produce a high standard of care despite managers and targets, not because of them.
Simply, the managers should work for the consultants, as they do in most health systems, including our own general practice system.
Most of us were painfully aware of the failings in the system long before this report. I protested, was gagged and got out. Parenthetically I am now very happy in an environment where clinicians are involved in decision making.
Mark, either you were brain dead or away on too many BMA junkets during the slow train wreck that the NHS has experienced. To express outrage and concern at this point is too little, too late, and smacks of political posturing.. The BMA were not there for me when I was hounded out for speaking uncomfortable truths and nor were the BMA there for our patients and the profession when all of this was occurring. Who is to blame? Well, in many respects is was the medical profession. I vividly remember being sneered at for talking about professionalism and far too many doctors took the easy way out in the darkest days of the NHS. Sadly, I doubt that the medical profession will ever recover in the UK but strong leadership is required now, not platitudes.
It is so sad to read these comments, yet, sadly, I can only concur. Ward rounds have been full of evidence of patient neglect, dry mouths, wet beds, nutritional concerns. These were occurring repeatedly. Ward rounds interrupted to move patients.
When I worked in an acute Trust, a medical manager repeated my ward round, with out consultation, deciding sick patients could be sent home on the flimsiest of reasons, despite them still being sick.
Working in an Community aspirant FT, the same issues pertain. Staff are frightened to speak out, services re being cut to meet the FT financial criteria. Mistakes are under reported because a blame culture has arisen
The Board are disconnected hand have limited experience and the organisations reputation is going down hill.
Disagreement results in being side lined, disenfranchised and shouted at in public meetings.
I would put my name to this but at this stage I am not ready to face the storm that would follow
Professor Jarman reports that in 2007, after two decades of Americanisation, the DoH sought US help on NHS regulation, only to suppress the advice received.
The Institute for Healthcare Improvement reported a culture "more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement".
From the International branch of the US Joint Commission (for organisational accreditation and certification): "a 'shame and blame' culture of fear appears to pervade the NHS and at least certain elements of the Department of Healthâ€¦ (a culture) affirmed by Healthcare Commission leaders who see public humiliation and CEO fear of job loss as the system's major quality improvement drivers".
To the Mid Staffordshire Public Inquiry, Professor Jarman reports, the department's permanent secretary and its counsel described the US reports as "caricatures", in reliance perhaps on the JCI's finding of "an emerging aspirational tone across the Department of Health ('world class commissioning', 'clinical excellence pathways')".
If we learn nothing else from the above, it is that fine words are no guarantee of improvement, at least not under current proivisions for democracy, and not necessarily perhaps even through promotion and maintenance of the "honour and interests of the medical profession", with promotion of "high quality healthcare" as an afterthought.
Professor Jarman has kindly responded to the BMJ's commission, his selection of references made with authority and with no competing interests.
Unfortunately for the implied thesis of blame beginning with Roy Griffiths in 1983, scandals were not before unknown. In 1981, then with seven years of post-graduate hospital medicine experience, and after intensive reading of official reports as an entrant to Community Medicine, I listed four main problems in Healthcare Delivery:
Unhealthy industrial relations. Starvation of preventive and community care. Detrimental deployment of medical manpower. Suppression of NHS patients' interests.
The salient causes boiled down to injustice, misallocation, near-criminal folly, and institutionalised corruption-from- purpose. My solutions, deliberately moderate in pace, with appeal to professional conscience, boiled down to liberation in equal partnership, freedom from material conflicts of interest.
Not just in medicine, concern for justice has become narrow, focussed on keeping-up with those getting-ahead, understandably defensive of personal, family and professional interest and influence. From this vain pursuit - in not just healthcare, but also the press, police, business, banking, even politics - the poisonous fruits have lately been made very apparent.
By scandal now driven to consider "what is best for patients", perhaps to make the answers "our primary consideration", are we not obliged to address the corruption-from-purpose that is institutionalised by income-inequality and insecurity?
We have overlooked the greatest of scandals, exclusion from belonging, of savage impact on the innocent and the willing, on the direction of 'our' society, on international relations, and at least possibly even on prospects for 'our' future on Earth.
I think we can all look back and recount stories of poor management at all levels and poor care.
Why has this occurred?
Certainly driven by the target driven mentality and the need to address false fianancial assumptions. but also the need of our political masters to show they have done something with their time in office. otherwise why are they there!
What effect has this had?
It has led to a climate of bullying of all staff, managers, chief executives, and regional staff, which is now prevalent all across the country.It has always been clear that this comes from the very top down.
Unfortunately this behaviour has been seen to occur whichever party has been in power.
How can this be addressed ?
It will need all those who hold power to want to change their philosophy about what sort of care they want delivered.
When they ask for changes to be delivered ,they need to be realistic over what time frame the changes are expected to occur and when they are to be reviewed. (not 1-2 years but 5-7 years)
Chief executives and senior staff should be expected to see through changes and to be responsible for the consequences.
Staff shouldnt be moved up and out to region when failing at lower level.
Gagging clauses should be removed.
Clinical governance systems need to be reviewed .lead by senior clinicians from both primary and secondary care with members alternating the chair CEOs of the hospital and local CCGs should always be in attendance but non voting. There needs to be non- clinical reps from boards of hospitals and CCG present who have voting rights.
(by clinicians I mean medical and nursing and anclllary support staff).
All staff should be allowed to write in a concern regarding clinical organisational care.
The committee should have the power to require the exec team to make changes.
Inspecting bodies should look closely at the work of the clinical governance team and the executive team should be called to account for not addressing issues raised
The neglect that patients suffered at mid Staffs is not exceptional. Patients, particularly elderly vulnerable ones, are being neglected in many NHS hospitals. What is exceptional is the sheer scale of the problem in mid Staffs.
Many staff in mid Staffs have questions to answer, but in my view the main issue is the culture of senior administrative staff that stems from the upper echelons of the DOH.
Prior to the mid Staffs scandal senior managers had it drummed into them by the DOH that their overwhelming priority was to balance the books. It did not matter how good the standard of clinic care was at their hospital(s), if they went over budget they had failed. If balancing the books meant that some aspects of patient care were neglected, so be it but, and this is the difficult bit, that neglect could not be so blatant as to attract adverse coverage in the media. This explains the bullying of medical staff at mid Staffs who might otherwise have spoken out about the problem.
I am not sure that even now the DOH has got the point that the welfare of patients is paramount and should trump the holy grail of balancing the books.
Dr Tim Cantor asks, has the DOH "got the point"?
Liberation of conscience has to be understood, asked for, and mutually 'afforded', not commanded or merely prayed for.
The "welfare of patients" is a worthy banner, but so too is "national solvency", neither a flag to be waved simplistically.
The necessary liberation has to be of the individual, of EVERY individual, ENABLED to act and speak 'in conscience', SECURE in the knowledge that - unless irredeemably vexatious - no part of livelihood is at issue, neither for self nor - unless to be judged lazy or criminal - for any advised or complained of.
For such liberation, of ALL, at the front-line for care and campaigning 'in conscience', AND at the top for 'in conscience' budgeting (for on-going credit-worthiness rather than constant balance), there is no rational alternative to Equal Partnership.
Material conflict of interest cannot be the basis of 'rational trust', other than that 'between thieves', desperate at the bottom, corrupted in the middle, perhaps 'absolutely corrupted' at the select top.
Society-wide agreed income-equality, however 'odd and problematic' at first sight, has logically to be at the heart of our 'prescription' for democracy, equal partnership the only tenable contractual basis for a healthy society.
Unhealthy undemocratic options there are aplenty, our duty here to identify them. Wide understanding of their certain threats has to be ensured, contrasted with the promise of our own ethical prescription for genuine democracy.
It is hard 'to come forward' as a victim of abuse, over the years made complicit, but we owe this to our vocation, to the transmission of our caring culture, for the sake of our patients otherwise alone with their troubles.
The culture of the NHS was from the start hobbled by its context, issues of freedom and competition more than highlighted by the retention of private practice for private reward. Over the decades, conflict of interest within and without has so damaged both the NHS and the wider economy as almost to force the confrontation now ending in so much destruction.
As patients and relatives we feel it, the blinkering and rationing of care, the dying of hope, the fear for the future. Too late 'at the point of need', protest is now crushed by an avalanche of 'reform', clean-sheet commissioning is overwhelmed in radical departure from organic growth, managers only clinging to the wreckage.
Not of least significance amongst imminent disappearances and slow car-crashes, is the provision of 'best care' for the roughly one third of women (NHS staff included) who have until recently, through open-access Community Clinics, benefited from the century-evolved skills of 'Family Planning'.
Termed now Sexual & Reproductive Healthcare, from the supposed demands of 'specialty recognition', and the supposed savings in 'specialty de-recognition' (to be at once redundant AND the fount of training for 'afterthought providers' in General Practice and Genitourinary Medicine), the way forward has been rendered a puzzle, as much for 'under-fire' current practitioners and 'options-open' current trainees, as for 'out-of-depth' commissioners and those 'at the top' now asked 'to stop bullying'.
Ironically, some in Community Health look for 'support - as traditional' - to Public Health, another specialty that over-patiently has awaited repeat of the lessons of history, over decades hardened by the coming and going of NHS scandals, wisely restrained given lack of understanding shared with the 'pragmatic' body of Medicine, failing its prime role of advocacy for democratic government, for pursuit of 'the public interest' in equal partnership.
I fear that we are too busy, with patients and red-tape and our neglected families, too busy even to examine 'the body' of society, the limited bulkheads of our holed Titanic.
Doctors have a duty not only to their patients but also to their managers and insurers. Most patients do not know this so when mistakes are made they tend to blame the doctors. My ongoing problems with healthcare for over 30 years, led me to believe that certain doctors were wholly to blame. Recently a Consultant told me that he has to take precautions on behalf of the hospital so that I don't sue them. There should be more openness and honesty in the NHS. If and when there are problems, let us know. Don't become a part of the problem as this only serves to promote unnecessary pain and suffering.