The BMA in Scotland has warned that the NHS too often takes a ‘top-down’ approach to risk management, with decisions ‘foisted’ on the medical workforce without proper consultation or consideration of the impact.
In evidence to the Scottish Parliament health and sport committee, the BMA says senior management at health boards should improve processes for involving those at the coalface, stressing that there is a ‘near-complete disconnect’ between high-level strategic risk management activities and what is happening on the ground.
The committee is investigating clinical governance in the Scottish NHS, and its questions include whether services are safe, effective and evidence-based, what drives decision-making in the NHS, and whether people are treated with dignity and respect.
In its evidence, the BMA says that failing to involve those actually delivering the service at an early enough stage in decision-making can lead to a draconian interpretation and implementation of new ‘rules’ that have an adverse impact on patient care and staff morale.
It warns: ‘Invariably this results in time spent trying to negotiate a “reinterpretation” of what was meant and protracted efforts to find a workable solution – all of which adds to a sense of frustration and confusion for those caught in the crossfire as well as time wasted.’
The BMA says there is variable engagement with medical advisory committees, and says that staff should be encouraged to make their views known.
‘The culture within the NHS in Scotland does not encourage staff at any level to challenge perceived wisdom or ways of doing things to establish if they continue to be effective or could be done differently. This can result in a lack of fresh ideas or willingness to address approaches which are not working well for fear of being seen as “non-compliant”.’
Conflict of interest
The BMA says that there is a clear conflict of interest in having health boards act as their own safety and quality controllers, especially when things go wrong or the system is under tension.
And it adds: ‘The pressure for “only good news” to be escalated is worryingly prevalent and may mean that areas of concern are not always raised because of a perception they will not be well received by senior management.’
Staff shortages mean that doctors are not able to be consistently confident about the safety and quality of services, and this is one of the reasons staff leave, the BMA says.
‘The ongoing issues around recruitment and retention of medical staff mean that those working in the system are under more pressure than ever as they deal with the difficulties caused by unfilled posts and the commensurate rise in already unsustainable workloads. Inevitably this will have an impact, not only on patients’ safety but also on staff welfare and well-being.’
The BMA says that services do treat people with dignity and respect for the most part, although it is difficult to achieve when capacity is overwhelmed, where patients who should be receiving treatment in a room are being treated behind a screen in a corridor.
The BMA believes that quality of care, effectiveness and efficiency drive decision-making in the NHS, saying that for the most part, quality still trumps efficiency, but warns that ‘the very significant financial stringencies now faced by NHS boards throw that into sharp relief’.
‘There are plenty of examples where we are increasingly forced to make difficult decisions that risk compromising the clinical needs of patients because of the pressure on resources. Implicit rationing is all too common and directly opposes the principle of equity for all patients.’
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