Scrubbing Up: Has the NHS got its priorities wrong?
The recent critical report into avoidable deaths at Stafford Hospital has given rise to an outpouring of frustration and anger from doctors, nurses and managers who tried to raise concerns about standards in their hospitals.
Is this a natural response to such a devastating incident - or is there a more deep-rooted problem at the heart of the NHS?
Loyalty to the NHS is not simply demonstrated by following instructions or performing a particular set of tasks. It is demonstrated by the deeper loyalty to patients and, often, patient groups.
This is the very value that makes the health service so loved, of course, and it actually gives the system an invisible stability because it is a bond shared by staff across the professions.
In my role, I spend a fair amount of time visiting hospitals around the country, and you can soon pick up the culture of the organisation. In some trusts, it is clear that the chief executives and their management team value the input of all the clinical staff - and vice versa. They work as a team and hence their organisations thrive even in an austere financial climate.
However, there is a pernicious style of management that pervades some hospitals and leads to a fractured doctor-manager relationship.
My sense is we are going backwards and collegiate working seems to have deteriorated in the past few years. I do not have hard evidence to show that, but, as a college, we hear much more about what Robert Francis QC described in his report, which is the prioritisation of business management systems over the delivery of good care.
It is not just the system in itself, nor the targets. It is important to keep the waiting lists down, both in accident and emergency departments, and for the non-urgent work.
We should applaud the fact that the waiting list for some cardiac operations has fallen in recent years from 18 months to four weeks. No-one would return to the days of patients lying on trolleys for 24 hours in a casualty department.
But many of the tensions between staff arise when targets around the lists are enforced against a doctor or nurse's better clinical judgement.
Hospitals have to find a way of allowing the expression of clinical judgment, based on what is best for the patient, to be the guiding principle.
At the coalface
These are the experiences of what you might call a "coercive environment" recounted to me in the past few weeks, since the Francis Report was published.
- A senior NHS chief executive told me of the immense pressures put on them by regional managers through the performance data. He said: "There is no appetite to really understand and face up to the cracks that are emerging in the service." He is struggling to staff the wards - but overall the NHS has a surplus, with money going back to Treasury. As he said: "This cannot be right. How might the public react if they really knew this?"
- Dr Kim Holt, a senior community paediatrician, talked recently to me at the King's Fund charity. She warned her managers staff shortages and poor record-keeping at St Ann's Hospital in north London would lead to problems. Six months later, Baby P was seen there but signs of the physical abuse were not spotted. She had tried to tell the Care Quality Commission about her concerns but was told that it was a strategic health authority responsibility. Her trust offered her a large sum if she went quietly, but she refused to sign a gagging order.
- A consultant surgeon tried to protect the training of his junior doctors - one of the keys to raising standards of care. He had no say over the number of patients that he should have on the lists and in clinics, which didn't leave him with enough time to train the staff. When he complained, he was told that training was not a priority for the trust, and that he was the problem as "obviously he did not like being managed".
- A senior specialist told me: "The NHS is an overworked machine. My teaching hospital is asking us to make 5% efficiency savings, with the threat that the cuts will be made for us if we don't identify them ourselves, with no discussion with managers as to what this means for clinical priorities. It's as if we're making plastic widgets in a factory, not dealing with pain and illness."
- A former theatre nurse who is now a surgical patient herself at a hospital in the South East is too scared to report what she saw on the ward very recently. Her email to me said: "I was horrified when a patient came on the ward after having colorectal surgery. I only saw the staff twice come and look at her and one time she wanted to be sick and rang her bell. Eventually a healthcare assistant came in and stood at the end of her bed, threw a sick bowl at her and told her to throw up in that."
The NHS now sees many more patients with diseases that come in older age, and with less money available, so Jeremy Hunt, his ministers and the professions now have to find a way of fixing the "overworked machine" in order to provide good, high-quality care.
The Royal College of Surgeons is here to help, but we want to see tangible changes coming out of the Francis inquiry, and I'll highlight just two of our main recommendations.
Firstly, patients' concerns and their experiences must be acted on, not ignored. We are pleased the government has announced that it will establish a review to look at how trusts currently act on complaints when concerns and issues are raised. Separately, we believe that the government should also look at improving the representation of patient safety and dignity issues at trust board levels. Patients must be put back at the centre of care.
Secondly, we want far clearer standards for organisations and professionals to comply with, to improve patient care. As a college, we set standards for the whole of surgery, but we would like to have a greater role in the way in which they are embedded and overseen in the NHS. The government needs to involve us in this work so that the public will know that the standards of their care are supported by the best clinical evidence.
In my profession, there exist strong affiliations that attach to the individual surgical specialty that has helped to train and support you throughout your career, creating a lifelong allegiance to a code of conduct towards patients and towards members of the team, and it exerts a very great influence upon a doctor. I don't think that this is always well understood by ministers or senior officials, but they ignore it at their peril.
An open culture, devoid of gagging clauses and secrecy, and one that enables all the staff to work productively together will forge much stronger care. This commitment to the patient and to an ethical code of conduct, so sadly lacking in the case of Mid-Staffs, needs to be respected and nurtured.
In my view, it is the key to rejuvenating the NHS.