SOCIETY OF CLINICAL PSYCHIATRISTS

 

Chairman: Dr Dermot J Ward, FRCPI  FRCPsych DPM

4 Jubilee Terrace  Chichester  West Sussex  PO19 7XT. Telephone 01243 778716

[email protected]

Editor: Dr M Elameer  MB ChB DPM  MRCPsych

President  Doctors Support  Group: Dr Peter Tomlin  FFARCS

Radnor House  The Headlands  Downtown  Wiltshire  SP5 3HJ  Telephone 01725 513367

 

 

The Francis Report

Mid- Staffs: decades in the making              

Response for  the Society of Clinical Psychiatrists 

 

“The essential unit of medical practice is the occasion when in the intimacy of the consulting room or sick room a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he  trusts. This is a consultation and all else in the practice of medicine derives from it. And because the community believes that this is the essential unit, it regards most highly those persons most skilled in consultation and personal treatment, and it rewards them accordingly. To the persons who facilitate the consultation, the medical administrators, the community is grateful as it should be, but not more so.”

Sir James Spence. The purpose and practice of medicine. 1960. OUP.pp 273-4. London.

Charles Moore's powerful piece on the Francis Report (Let's face the truth about our uncaring, selfish and cruel NHS, Daily Telegraph, February 9) should be compulsory reading for complacently shocked politicians and their appointed senior managers of the NHS. Anyone who has worked in the NHS over the past 20-30 years in virtually any capacity other than as business managers, has been aware of deteriorating hospital patient care standards.

Like, I hope some of us, he noted the surprisingly low key response in the media generally, and including the major political classes to the shamefulness, horror and cruelty , that between 2005 and 2009 up to 1,200 patients died needlessly at Stafford Hospital. He submits that a similar catastrophe, say, food poisoning from Sainsbury’s or Tesco food counters, an outbreak in an army barracks, or a large comprehensive, with similar death numbers over a similar number of years would result in the management being sacked. There would possibly be criminal charges brought. Instead we have Robert Francis QC arguing that those who were in charge, should remain in charge; that the problem was “the culture” rather than any specific bad leadership.

Surely this was most comforting to such as Sir  David Nicholson, the chief executive of the NHS who had been head of the West Midlands Strategic Health Authority between 2005 and 2006. and was therefore the senior manager responsible for Stafford Hospital. A fortnight later Mr Moore’s column headline  was “Sorry to harp on, but the horrors of Mid Staffs just won’t go away” .  Also, inter alia, he pronounced forensically that Sir David Nicholson “should go”.  That Sir David refuses to go because he declares he must see through the current NHS reorganisation beggars belief, given his track record. The Prime Minister’s clear support and stated belief he is the right person, despite his (Sir David’s) record, to continue in office has been quite bizarre. 

Feeling as I do rather like a plagiarist, I will filch no more (and there is much more) from Mr Moore’s article but will repeat my encouragement to those who haven’t read it to try to do so. I am writing for a mainly medical readership. Incidentally, when I say ‘medical‘ I refer to Registered Medical Practitioners. In recent times ‘medical‘ has been used when nursing is actually the focus. I must confess freely also to detesting ‘medic‘ which to me has always meant a good person, with  perhaps some first aid knowledge, helping to stretcher a combat casualty to hospital.               

Why didn’t doctors do something?

As earlier reports were emerging in January 2010 about the dreadful scandal of loss of patient lives at Stafford Hospital the Deputy Editor, of the BMJ, Dr Tony Delamothe, published a thoughtful piece.

He dilated on the importance of systems failures in administration, management and nursing but it is only of the medical professionals he asks “Why didn’t  doctors do something?”  What follows is aimed partly at answering Dr Delamothe’s quite reasonable question.

On February18, 2010 Rebecca Smith Medical Editor of The Daily Telegraph headlined “Culture of fear puts targets before patients, advisers tell NHS”, and stated that politically/managerial driven policies were put before patients according to previously unseen reports from three independent international health organisations for the Department of Health. The information had been obtained under the Freedom of Information Act. The Telegraph piece is about 10 column inches but is packed with hugely important findings. Such begins  to answer Dr Delamothe’s question.

Deliberate sidelining of doctors (this applies particularly to hospital consultants) began in 1983 with NHS Management Inquiry (Griffiths Report) which introduced line management headed by a [mostly non-medical] chief executive. This displaced the triumvirate of senior consultant and matron assisted by a hospital secretary. The quondam natural leaders of the clinical team and innovators in medical policy were pushed to the periphery. It has to be said clearly that hospital consultants are the single most valuable asset in a health service; the most highly qualified and experienced in patient diagnosis, treatment and care of patients and leaders of clinical teams as well as being the most equipped to devise and implement effective forward  healthcare planning. Any diminution  of their role in hospital management and healthcare damages patient care standards as assuredly as night follows day.

But in the NHS perhaps the most basic tenet of general management systems theory - that those charged with  leadership accountability and responsibility must also be given commensurate authority to enable them discharge their duties effectively - has since 1983 been more honoured in the breach than the observance. Incidentally, Mr Griffiths was a Sainsbury’s supermarket manager. Since 1983, doctors have found themselves practising increasingly in a world in which their accountability and responsibilities in the sharp end of clinical practise was undiminished but with more and more erosion of their essential authority clinically and in policy development .  This was also aggravated by a built-in disturbance of the prior clinician triumvirate balance of consultant, matron and hospital secretary. With NHS managers, such as NHS CEO Sir David Nicholson and downwards the situation was reversed; they had power without serious responsibility as he currently demonstrates.  

The managerial fish and the bicycle

Few doctors seemed aware of the profound implications business line management held for the profession and fewer managers were prepared to acknowledge the contradictions inherent in its introduction to the healthcare clinical workplace. Steele, in 1984 (Steele R. Clinical budgeting and costing - friend or foe. BMJ 1984; 288: 1549-51) a non-medical lecturer at the Department of Social Administration, University of Manchester examined the concept of line management, with general managers providing the impetus to manage an organisation. In this theoretical model the board of directors has overall control of the business, looking at overall strategy, including hiring and firing general managers. The unit manager is then responsible for the day-to-day running of the business and short-term production decisions. Within the unit a supervisor supervises the foreman, who supervises workers at the end of the assembly line where the final product emerges. A hierarchy of control is practised. Once “production” levels - the hospital - are reached however the line management analogue becomes confused. Even if the NHS has the hospital manager who will be responsible for the day-to-day running of the hospital, Steele notes that there are already supervisors and foremen in the service department to ensure the efficient running if departments like catering, laundering, portering etc but these are merely support  activities to the hospitals main activity, the care of patients.

He states “this is where any NHS line management system (and therefore the theory) runs into trouble. Those on the shop floor who commit resources and make decisions are the major determinants in the system and not the minor ones envisaged in a traditional line management structure. Not only do clinicians not fit easily into the mould of line management, but, (averred Steele), their nonconformity is buttressed by arguments about clinical freedom.”

In 1985 Dr David St George (St George D. managers attempt to hijack community medicine , BMJ 1985;291: 1589-90.) illustrates further the poor compatibility of general management commercial ethos with that of medical practice...”in a hostile and competitive  environment, where survival of the organisation is at stake, it is far more efficient for power  to be concentrated in an individual who identifies with the overall goal of the organisation (maximisation of profits) but who can also take personal responsibility for short-term decisions”. Where the traditional medical model champions cooperation at all levels in clinical settings, general management must pursue control and competition in its goal of maximising profits.  

Curiously, in 1985, even as government proclaimed the virtues of business management culture’s putative beneficial impact on the NHS with its deliberate side-lining of doctors’ influence and authority in NHS policy, the Association of Public Policy Analysis and management’s own journal published a monograph positing the medical model as especially suited to grappling with policy decisions (healthcare system were not specially addressed here though undoubtedly would qualify for inclusion)  on complex systems, “since it combines practical knowledge with the findings of numerous analytic systems, and includes procedure for dealing with high uncertainty. {Etzioni, A. (1985) Making policy for complex systems: a medical model for economics. Journal of Policy Analysis and Management, 4, 383-395.}

Authority, Responsibility and Accountability

We do not claim that doctors and their teams develop only perfect policies. No, human frailty coupled with the core task of treatment and care of people who are ill or dying inevitably produces distress and dissatisfaction  for patients and their loved ones and indeed involved professionals. But doctors, following long training, experience and responsibility are those least ill-equipped to lead the treatment and care of the sick.    

This was endorsed (not for the first time) in the 1989 Working for Patients white paper on secondary (hospital) care which created, inter alia, hospital Trusts and began the removal of consultant NHS work contracts from regional health authorities to local Trusts. That government publication  confirmed “...the key role of the consultant in the NHS in terms of their 24 hour responsibility for patient care. It is they who are the leaders of teams, responsible for all aspects of the clinical care of patients under their charge.”

However, as duties and responsibilities for patient were so clearly detailed, simultaneously the commensurate  medical authority required to discharge those responsibilities adequately was undermined at a stroke by removal of a freedom of speech clause 330 from Whitley Terms and Conditions of Service for Hospital Staff whereby:-

“A practitioner shall be free, without prior consent of the employing authority, to publish books, articles, etc., and to deliver any lecture or speak, whether on matters arising out of his or her hospital service or not.” Thus the near monopoly employer of doctors seeking to express concerns about service deficiencies and poor standards of care were thereby inhibited from speaking out and those brave souls who did so too often faced paying a high price, mentally, physically, professionally and financially.

A similar clause was included in the NHS Act 1948 whereby medical professionals had  “complete freedom to publish views on the organisation and administration of the service without obtaining consent to do so.” (NHS Act 1948: The position of consultants and specialists. BMJ:1, 845-847).

Gagging and Secrecy

In 1987 Richard Smith, then editor of the BMJ (v295; 1633-4), had already adumbrated an increasingly ominous climate pervading that near UK monopoly employer of doctors, the NHS, in his milestone article, ”Twenty steps towards a ‘closed society’ on health” and the new phenomenon of gagging doctors and concern for freedom of speech. By 1994 that same journal BMJ was moved to publish a series of four related pieces under a composite title “The rise of Stalinism in the NHS” (v309:1640). These witnessed that senior doctors and nurses “were convinced the NHS was beginning to be an organisation in which people were terrified to speak the truth”.  HM Opposition in the House of Commons objected to Clause 330 removal from new trust working contracts and sought reassurance that a similar clause would be re-inserted into Trust contracts. This was rejected by government as were observations of a similar nature made by the British Medical Association, our doctors’ trade union. (Originally doctors did not want the BMA to be a trade union but government at the time insisted it should as, otherwise, it would not negotiate terms and conditions of employment with the profession). Perhaps because of its formal attachment to the NHS as putative most effective national healthcare delivery system in the developed world, its (BMA’s) activities have tended, sadly, and with doubtless the best of intentions, to be nevertheless more disapproval rather than vigorous response.

It is difficult to recall such a massive gap between original aspiration and reality as that embedded in the NHS and what that healthcare system has delivered to the population as exemplified by Mid Staffordshire under the micro mismanagement of politicians. What is also remarkable is what good clinical care doctors and their teams have achieved despite NHS politician-driven maladministration interference in their day to day work.

Perhaps the above points go some way towards answering Tony Delamothe’s pertinent question. My query is why didn’t the BMA doctors’ trade union, do more, to preserve and pursue freedom of speech for doctors. Was It too intimidated? It seemed, and still does seem, that despite earlier blatant  NHS systemic flaws warnings such as Garland’s Hospital, Carlisle 2001, Maidstone and Tunbridge Wells NHS Trust, there was a blindness to the possibility of a disaster such as that of Stafford Hospital horror which is not the first, but the worst so far.  The failure of the Care Quality Commission’s (CQC) “inspections” must rank as utterly unfit for purpose and an inexcusable failure especially in relation to Stafford Hospital.

Yet, Dr Delamothe’s question haunts us. Not only was the management of national health services corrupted, but the day to day patient care and work security of doctors were undermined by institutional intimidation. Those  doctors who voiced legitimate criticism of flaws within existing patient care systems could be dismissed by business managers as merely self interested or “failed team players” and perhaps sent on “garden leave” with full pay; a shadow cast over them and unable to obtain posts elsewhere as they were branded within the whole NHS system.  Commonly they could find application for posts elsewhere, even if short listed, unsuccessful although there had been no formal charges against them. There was one consultant who was suspended for twelve years before being reinstated when it was finally found she had no case to answer. The Suspended Doctors Group (SDG) was founded by the late Dr Harry Jacobs, a consultant psychiatrist, and Dr Peter Tomlin, a consultant anaesthetist each of whom had been suspended at different times. Both were found to have no case to answer but nevertheless suffered intense emotional upheaval and ostracism from many previous colleagues. The group was formed under the auspices of the Society of Clinical Psychiatrists but suspended doctors from all medical and  surgical specialties have been welcomed. The emotional trauma for suspended doctors was vast as is quite understandable. Suicides amongst suspended doctors ceased (with one exception) following the formation of the SDG and its renamed Doctors Support Group (DSG) which continues its work with Dr Tomlin as president. The advent of so-called whistleblower legislation has, to date, not been as helpful as hoped.

Healing the nations’ healthcare system

There has been much recent talk of “returning power to the doctors”. This, I submit has so far been mostly political window dressing. The following constitute some concrete proposals, rather fewer than the 290 suggested by Mr Francis.

(1)We submit that the NHS business management system as imposed  in 1983 and its subsequent development has not only failed our national healthcare system but actively damaged it by its inherent inappropriateness as outlined above. The immediate evidence, Mid Staffs, is but the large tip of an understandably larger Iceberg of patient neglect. 

(2)A freedom-of-speech clause in consultant contracts, abolished in 1989, should be restored. The present system is redolent of the now thoroughly discredited old Soviet healthcare system, an observation originally made by Mr Michael Portillo. 

(3)The restoration of essential consultant authority commensurate with their duties, responsibility and accountability in recognition of their central importance in medical hospital healthcare delivery to patients.

(4)Restoration generally, at hospital level, of senior consultant, matron and hospital secretary/administrator triumvirate; the senior consultant being elected by peers for a limited period to be decided. The custom and practise of the ward sister or charge nurse accompanying the consultant on  ward rounds should return, where it has ceased, as  routine order of the day. Furthermore, the practise whereby, in some areas, family doctors have been referring patients to a “team” rather than to a named consultant should cease forthwith. It is unsafe and a patient so referred may never see a consultant for proper diagnosis and treatment plan purposes.

(5)Crown Immunity was introduced in the early1990s for all NHS doctors without effective opposition. Prior to that doctors held individual medical defence insurance. This conferred on doctors the security of independent individualised protective legal cover for each doctor so insured. The reason the profession objected was it could mean that the local health authority could be prepared to settle  out of court in a charge of alleged negligence or misconduct against a doctor because it might be less costly than pursuing it through the courts. If such were the case there could be no formal clarification of an innocent doctors reputation. Restoration to the individual medical defence insurance position would further reinforce the necessary doctor confidence and legal security which is so essential to effective patient care.  

(6)The treatment of “whistleblowers” on observed NHS system failure exposure has been both disgraceful for the whistleblower and wastefully expensive for the taxpayer. Recently, consumer affairs journalist of the year  Ian Cowie, (Daily Telegraph,  Whistleblowers should be rewarded, not ruined” Feb 23,2013) published a thoughtful piece (mostly he writes on financial matters) of legislation changes in the US whereby whistleblowers are financially rewarded. That is certainly a path worth exploring in the healthcare context. 

(7)The ‘friends and family test', whereby patients will be asked whether they would recommend NHS services to people they know, is being rolled out and is sadly typical of backward government thinking. While it is important that patient complaints and dissatisfaction are appropriately addressed this Society considers that the changes we urgently recommend by improving patient clinical care would so improve the services that the number and sorts of complaints exposed in the Francis report would be much less likely to occur. There is a parallel here with W Edwards Deming’s Total Quality Management (TQM) which the US toyed with for some years in its post-war motor industry and discarded. Essentially, it involved the goal of production process perfection from the earliest to the final phase, aiming at elimination of end-failings rather than inefficient and expensive post production expensive corrections. Following the US rejection Deming, a mathematician and statistician, then sold it to the Japanese with spectacularly successful results in its motor industry while in Detroit, US motoring industry descended into near total destruction from which only now is it showing some signs of emerging.

(8)Reinstatement of tax relief on health insurance premiums. This, was introduced by Mrs Thatcher’s government. Its abolition  was one of the first acts of the new Labour Government in 1997. The person who takes out such insurance is more a latter day saint than someone to be despised (this has applied particularly to Labour politics). He or she has paid their so-called insurance stamp (though such insurance fund does not exist), and thereby shortens the waiting queue of those less fortunate and contributes overall more to investment in healthcare. 

(9)Restoration of Community Health Councils (CHCs) in England. The key function of the CHCs has been to represent the interests of the public in local grass-roots  health service in their district. Abolished in 2003 by the Blair government they continued in Wales for reasons never properly explained by Mr Blair.

Let me end on a relevant comment on the NHS from a New York physician at a time when the worrying health economics ethical issue for doctors holding health budgets figured in the BMJ.

“New York state law may shed some light [on this] question.

Here we’re required to use our best judgement in making our medical orders. We may do neither less nor more, and we may not weigh costs and benefits. So clinical freedom is meaningless: there’s no freedom and no choice, and rightly so.

Breach of this standard is ipso facto malpractice. Furthermore responsibility for professional acts rests with the treating physician and may not be transferred to employers, government programmes, hospital officials or committees, chiefs of service, commissioners and the like. We have no professional duty to any such party; our obligation is solely to our patients.

Who, if anyone, will pay to have our orders carried out remains an entirely separate question.....if constrained by budgets and policies we fail to tell our patients what we think is best for them they’ll never know and will never be able to act in their own interest.”   Carlen R. BMJ 1989: 298; 49-50.   

It is an irony that a colleague from the US, a country we on this side of the Atlantic tend to regard as financially more hardnosed in health care funding, should clarify this matter so pithily for us.

 

Dr Dermot J Ward, Chairman, Society of Clinical Psychiatrists,  March 2013