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A Consultant Physician tells why he is leaving and expresses his concerns for what the NHS has become
A Broken NHS: The Decline of Medicine by Dr A W
Some adult medical services provided by the NHS will match the best provided anywhere. Amongst these are cancer, heart, and stroke services. Over the past two decades most emphasis has been placed on developing and funding such speciality services, not least because they score highly in media profile. But in this period the standard of treatment of the NHS acutely ill older medical patient has failed, substantially, to achieve its potential. That is why, after nearly twenty five years working as an NHS Consultant Physician in the acute general medical setting, I have resigned from full time employment without waiting for retirement. I have also made a decision not to return to a substantive role working in the NHS. Despite a previous longstanding commitment to the ideal of NHS medicine, why did I make these choices? The reasons relate in part the experience at one specific NHS Trust, and partly to general perceptions about the changes forced on the practice of hospital general medicine over time.
I became increasingly aware over the last two decades that changes were being imposed on the way I practised general medicine so that I was no longer able to exercise autonomy – the essential pre-requisite to sound clinical practice – in clinical decision making. Rather it was a requirement to become an accessory, indeed an accomplice, to the delivery of increasingly inadequate, chaotic, and often substandard in-patient medical service over which I had no control as a consultant, as target driven decision making came to supplant the clinical medical imperative. By clinical imperative I mean that the medical needs of the patient must, first and foremost, determine decision making. That way the patient’s best interests are met.
This subordination of clinical standards to management and financial imperatives has over time led to a loss of clinical (medical) ‘ownership’ of patients across the acute setting. Ownership is an important, but currently undervalued medical concept, where the treating physician not only takes full responsibility for and directs the care of his or her patient from the point of entry to exit from hospital, but also is intrinsically committed to ensuring the very best will happen for his or her patient in or out of hours. This was always the case before team based care and consultant led wards were dispensed with by management driven change. These days for example it is not uncommon for an acutely ill person to ‘travel’ through three differing medical wards and ‘teams’ within the critical first three or four day period of admission, with all the upheaval of multiple ward changes and the greatly enhanced clinical risk involved. The discontinuity of care embedded in this process leads to all sorts of avoidable adverse patient events and morbidity. Those adverse events I encountered I would report, when-ever possible to the Trust, either within or outside the statutory mechanism of critical incident reporting. After the best part of a decade of such reporting, in either open discussion or with submission of formal Clinical Critical Incident reports, not once did I receive from the Trust any feed-back or even acknowledgement of an incident report from the Trust. It eventually dawned on me that the Trust was just simply in denial – or disinterested.
I first recognised this problem as long ago as 2004 when I was compelled to close my ward to admissions after management had repeatedly ignored my concerns over deaths from poor hygiene and infection. At that time it was not uncommon to find the ward window sills, curtains, and toilets to be smeared and encrusted with dried faeces, and I was aware that ‘well’ elderly patients would arrive on the ward, only to acquire the Clostridium difficile which was being re-cycled between patients, and then that some of these ‘well’ elderly would become ill, and even die. The response of the Trust management to this ward closure, not sanctioned but done in desperation, was more related to their concern over the impact of the closure on bed availability than for my patient well being, and to warn me that I was at risk of disciplinary action if I did not re-open the ward immediately to admissions. That the ward was cleaned before it was re-opened supports the view that the decision to close was well founded.
This perverse prioritisation was emphasised some years later after the Trust had closed a high dependency unit in one of its hospitals but yet continued to sanction admissions of critically ill medical patients requiring high dependency monitoring to general wards, albeit within a supposed ‘high dependency area’ (but where of course the nursing and technical back-up was not simultaneously ‘up-skilled’). The subsequent deaths of several patients were, I believed, a consequence of insufficient access to the appropriate resources, and again, in frustration at the absence of any Trust recognition of the problem, I reported to the Coroner a death which I believed was a direct consequence of this downgrading of care. The Trusts response (other than to issue a defence at the court) was to admonish and again caution me. That death was found to be from natural causes allowed awkward questions to be brushed under the carpet.
Over time it became obvious that since the NHS had bought into a model of delivery of acute medicine which subordinated the clinical with a financial and management imperative, there was an inevitable and fundamental decline in basic standards of medical practice and thus in-patient welfare. This inversion of priority has been exacerbated by the imposition of the new contract on NHS consultants, the purpose being to control, monitor, and obtain more efficiency from consultant activity through ‘job planning’. But the real effect of this change has been to demolish the previously highly regarded and essential ‘unwritten contract’ between the NHS employer and its doctors. Thus doctors have been discouraged from giving the extra commitment to their patients that can make the difference to clinical outcomes by, for example, staying on after hours to see a patient through a crisis. These doctors now clock on and off, and others come in who know nothing of the clinical nuances of the individual patient, but are relied upon to provide cover. This single change not only embeds but also perpetuates high clinical risk, especially in the general medical setting. The EWTD is usually cited as the root cause of this situation but it is actually a distraction and an insufficient and unjustified excuse for the failure to address the deconstruction of the basic idiom of clinical medicine.
Despite the loss of ownership, consultants continue to allow themselves to be held responsible for the outcome of their patients. This paradox contradicts all informed modern management doctrine. Medical consultants are required to respond to every complaint, as if they have full responsibility for any event. Although they accept this responsibility they no longer have any control over the circumstances which lead up to the problems which develop. The paradox, whereby hospital doctors are required to take responsibility, but are no longer able to exercise control, exacerbates and perpetuates substandard and chaotic care. It leaves these doctors in a perpetual dilemma.
A predictable corollary of all these managerialist changes to the idiom of hospital medicine is that basic clinical method in young UK trained doctors has deteriorated. These doctors may be in ‘training’ and might meet their local Deanery ‘box ticking’ targets, but objectively there is erosion, over time, of basic clinical medical skills, diligence, and rigour. Essentially this new management led system is building in successive generations of serially de-skilled junior doctors in the UK. Unfortunately the deconstruction of clinical method embedded in all these changes is enthusiastically supported by a cohort of doctors who, indifferent to the obvious long term consequences to the discipline of clinical medicine support this new dispensation. It is difficult to explain this, other than that this is done for personal influence and advantage in their work setting.
It is also enlightening, but not surprising, to see the marked disconnect which exists between the PR of the NHS and its Trust managements over their achievements’, and to relate to these the clinical reality in the acute setting and the wards.
In conclusion, I believe that there is a pending crisis in acute general medical care in the NHS. Junior doctor training in this arena especially has deteriorated; clinical standards and diligence have been eroded. Clinical method has been de-constructed by loss of ownership and targets. NHS management continue to respond to each successive disaster with their empty platitudes and their often repeated mantra: “lessons will be learnt”. But there is no will to deal with these core issues. What is true for Mid Staffs is reflected in many, many other hospitals and Trusts. I have never had a problem in the past with making my concerns known, but letters to news papers, approaches to politicians, coroners, etc, went either un-acknowledged or clearly raised too many difficult questions which were better just avoided.
All rights: Dr A W Consultant Physician 17th March 2013
Doctors.net.uk is the website more visited by doctors than any other in the UK. It has this week polled physicians with the question, ‘Have you seen any evidence that your trust/employer is encouraging staff to report incidents of poor care since the incidents at mid-Staffordshire?’.
The results were, from a total of 230 doctors responding, only three GPs agreed there was evidence of encouraging reporting of poor care, while 29 GPs reported no evidence of NHS employers encouraging such reporting since the mid-Staffordshire story broke.
For those involved in secondary care, such as hospitals, the figures are 46 doctors agreed there was encouraging of reporting of poor care, but an overwhelming majority of 152 saw no evidence of NHS employers encouraging poor care reporting since mid-Staffordshire.
How can the NHS develop a different relationship with whistleblowers, unless managers say and do it?
‘Compromise’ agreements, or ‘gagging orders’ are widespread when a doctor leaves a Trust. Managers force doctors to sign these documents by threatening consequences if they don’t. Another mechanism by which the NHS stifles clinicians is the use of the reference. NHS Trusts now often require a reference from your previous line manager, before considering your application for a post. But what happens if you have fallen out with your manager because you highlighted dangerous care?
The NHS is practically a monopoly employer of doctors in the UK, so if you have dared to go against your local manager, then your ability to practice medicine is curtailed.
The General Medical Council says doctors have a duty to report poor care. But what has it done about the few senior physicians who have colluded with NHS management? These are usually Medical Directors and Clinical Directors who are party to these compromise agreements and gagging clauses.
We believe that the General Medical Council should seek to investigate any doctor in a managerial position who has been involved with coercing colleagues into signing these ‘super-injunctions’. Patients have been put at risk as a result of this kind of collusion. The severest penalties should be pursued against these medical directors. We also believe that such an investigation of these compromise agreements should be retrospective, just as the Francis report has been.
One standard technique the NHS uses is to accuse a whistleblower of not raising their concerns early enough, opening up the prospect of investigation and punishment by the GMC.
This strategy is part of a long list documented by Private Eye magazine in July 2011. Private Eye catalogued various means the NHS gags whistleblowers, besides forcing doctors to sign ‘silencing agreements’, included gathering dirt on whistleblowers by concocting misdemeanours, as well as incessant spurious investigations.
Private Eye points out in its special whistleblowing report entitled ‘Shoot the Messenger’ and published 08/07/2011, that the USA has its own National Whistleblower Centre, offering support to whistleblowers, given how stressful it is. Private Eye points out whistleblowing has been found more effective than officious regulation and costs much less.
The scandal of gagging of doctors in the NHS is not just endemic today, it has a long history, and is therefore deeply embedded in its culture. Given the scale of NHS reprehensible care that is now being uncovered, why is no one asking about the real scandal – how come there are so few whistleblowers?
The government would prefer that any uncovering of terrible treatment should be done by official bodies in order to keep control.
One of us (PB) wrote a book on the difficulties of being an NHS whistleblower. Entitled ‘Who Cares? True stories of NHS Reforms’, published in 1997, it documents NHS persecution of clinicians who had the temerity to put patients first.
For example, the book goes behind the story of Dr John Spencer consultant radiologist at Luton and Dunstable Hospital NHS Trust, who, in 1994, had signed an agreement not to speak publicly about the circumstances surrounding his early retirement, which included discovering that the trust’s chief executive tapped his telephone. The chief executive, Mrs Averil Dongworth, eventually resigned after consultants passed a motion of no confidence in her, but is now working as the chief executive for Barking, Havering and Redbridge University Hospitals NHS Trust.
If you ‘hack’ phones in most industries you are targeted for arrest – if you work for the NHS you get promoted to chief executive.
Former NHS Chief Executive defies “gagging clause” and intimidation threats
Patients First condemns the attempt by the NHS to intimidate whistle-blower Gary Walker and prevent him from appearing on the BBC Today programme on February 14th to publicly voice his concerns about the culture of the NHS. Mr Walker was forced out of his post as Chief Executive of United Lincolnshire Hospitals Trust after ‘expressing concerns about the balance between targets and delivering patient care effectively’. He likened what was happening as trying to force his trust into becoming another Mid-Staffs.
With his house on the line Mr Walker was forced to sign a confidentiality agreement with a ‘Supergag’ which in the wake of Francis report and the condemnation of such agreements he intends to breach.
Kim Holt said ‘The text of the letter (attached) that was sent to Mr Walker after the BBC approached the Department of Health for comments on his allegations is no more than a crude attempt to intimidate Mr Walker and prevent him making the public aware of how the culture of the NHS is damaging to the interests of patients.
It is amazing that such a letter could be written to him particularly in the light of the letter from David Nicholson dated 11th January 2012 (copy attached). This letter from David Nicholson makes it absolutely clear that it is not appropriate and totally unacceptable to seek to gag people in the way that Mr Walker has been gagged.
In the wake of the Francis report Jeremy Hunt the Health Secretary has said that he was considering people being jailed if they cover up mistakes. What is Mr Walker to do; allow a cover up in such circumstances?
Finally of course one of the recommendations of the Francis report is a duty of candour and there is real discussion about an obligation to place a legal duty on people to raise concerns.
In the light of all of the above it is absolutely staggering that such a letter could have been written to Mr Walker. It can only show the degree of nervousness that the Department of Health have over Mr Walker exposing the true culture of the NHS which fails to protect whistle-blowers who put patient safety first.
Either ministers knew this letter was being written in which case they should be held to account or they are failing to control their civil servants and lead the NHS properly and effectively. Either way ministers must be held to account for this shocking state of affairs’.
Health Select Committee interview with Robert Francis re the Mid Staffs Public inquiry My Thoughts. By Patients First founder Kim Holt 12th Feb 2013
The first questions of the session focussed on the culture that had allowed the Stafford tragedy to happen; not enough staff seemingly spoke up. Concerns if raised were not looked at and complaints hit brick walls. This was by any standards the opposite of what was hoped for following the Bristol Inquiry.
After sitting through maybe an hour the pattern of questioning became clear; the Health Select Committee were wondering how there could be such appalling failures and no accountability. Robert Francis’ explanation was that he had been given the remit to detail events and question how the regulators had responded. It had not been his role to examine individuals’ role primarily because he argued that they would need a just and fair process, with legal representation and so forth.
Fair enough; after all as a whistleblower I know exactly how it feels to be up against the establishment and one thing that I held on to is the hope that the processes managing my employment dispute were fair and honest.
The professional bodies that could hold individuals to account seem not to have been able to identify any persons so far despite the appalling care. Is this not only a management failure of the highest order but also a failure of the professional bodies, such as the NMC and the GMC? It seems these professional bodies have serious questions to answer about their processes and whether they should become more pro active in looking for underperforming staff.
An area of much debate for the committee then related to the widespread use of health care assistants on many wards. It transpires that there is no agreed system of training them and there is no current registration and so presumably no expectation that they would raise concerns if they observed substandard care. I am sure that many health care assistants do a very good job but without training and standards this must be a massive area of concern and a priority to be addressed.
I am still bemused how nurses allowed their wards to become so understaffed without raising concerns at a senior level within the Trust. Of course I know and understand the realities of challenging poor standards; before you know it the tables are turned on you.
Robert Francis acknowledged that when raising concerns about staffing managers could suggest that the messenger was unable to cope and somehow they were at fault, rather than the level of resource. I think this is a huge reason for staff being bullied; in my view; the expectation that they should continue to work when overstretched for long periods of time can result in burn out and depression.
Where next? Patients First are committed to raising awareness about strategies used against whistleblowers; want to ensure that frontline staff are informed and made aware of safe whistleblowing procedures, and most importantly we want the entrenched bullying culture to be dealt with as it wastes so much time, energy and creates fear. That is the most dangerous aspect of the culture, that we must find ways to address.
The focus of the Francis report is on mainly on Mid-Staffs Trust. He has pulled his punches in drawing conclusions about why this Trust had failed patients so badly, why the care of patients was less important than achieving Foundation Trust status. Although the Prime Minister’s statement to Parliament put a lot of emphasis on ‘system failure’ and included a number or actions to address these wider system failures
However, in his concluding statement in the press conference he calls for every person in the NHS to reflect on these findings and recommendations. He recommends that all organisations be required to report on their response to the recommendations and that the Health Select Committee monitors how organisations and the health care system respond.
Dr Kim Holt will today be at Holyrood today speaking to the cabinet secretary regarding problems with whistleblowing in Scotland.
Anyone Scottish health professionals who has suffered following whistle blowing can contact firstname.lastname@example.org
The following is Patients First’s response to the CQC consultation document ‘The next phase: Our consultation on our strategy for 2013 to 2016′. The response was sent 3rd December 2012 and is included below in its entirety.
More information on this process can be found on the CQC website here.
Patients First welcomes the opportunity to comment on the CQC Consultation document on its ‘strategy for 2013 – 2016.
Our overall comment is that we are disappointed with this document. It is not a strategic plan; it is a statement of strategic priorities underpinned by general statements of intent.
A strategic plan sets out how the strategic goals and priorities will be achieved, it sets out implementation programmes which are specific, outcome focussed, measurable and timed. This document does none of those things.
Given the context of a national regulator which has been subject to major criticism, which has failed to identify serious harm in institutions it has inspected, and which has been subject to expressions of lack of confidence from significant sectors it regulates, CQC faces a major task in establishing credibility and confidence. It is difficult to see how this plan will do that.
One of the many things that surprised me when I first qualified as a doctor was discovering how much time you spend at work signing your name. The pen is as much of a necessity as the stethoscope and the tendon hammer and all the other bits of kit you have to buy to practise your profession – perhaps even more so. Sign this script. Sign this form. Sign this passport application, stock order, sick line, referral letter, set of accounts, controlled-drug book, death certificate…………………..this tiny ceremony happens over and over again during each working day, enabling and authorising and validating and endorsing the activities of our professional lives. A doctor’s signature has power. So does the ritual of signing, which is why we see TV images of Prime Ministers and Presidents signing treaties and agreements with minions handing them each a special fountain pen. We understand that something important is happening, an alliance is being made or a war ended.
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Abuse of care home residents will continue without radical reform, warns Peter Beresford.
The first thing that needs to be said about what’s come to be called the Winterbourne View scandal, is that it was systemic and that the pressures that gave rise to it are likely to be on the increase rather than on the wane. The first Panorama programme which broke the story in May 2011, showed the most squalid and routine abuse of people with learning difficulties. One of the authors of the serious case review report on Winterbourne View talked of the failure of all involved in the scandal, psychiatrists, management, support staff and police.
The second Panorama programme, aired on 29 October 2012, showed that this was not an isolated incident, reporting an even more disturbing back story of people routinely being shunted between locked hospitals, unsafe and at risk of further abuse. The government has said that it will be announcing policy reform shortly. This will need to be radical and far-reaching.
It is now nearly half a century since progressive commentators made a convincing case that people with learning difficulties should not be kept in hospitals and that these and ‘treatment’ approaches were ill-suited to meet their rights and needs. Instead of institutions in the NHS, what was needed was community-based support that responded to the individual, addressed their unique needs and built relationships between them and skilled practitioners. These would be the basis for empowering service users and dealing with the so-called ‘challenging behaviour’ that has long been recognised as a by-product of isolation and institutionalisation.
What seems to be making matters worse has been the shift in this field to the private sector as service providers of choice for successive governments. The authors of the serious case review of Winterbourne View spoke of its owners, Castlebeck’s preoccupation with profit rather than need, even though they in turn denied it. For-profit providers are associated with higher levels of abuse than third sector providers. They are also associated with more traditional and institutional provision, rather than more progressive services, more supportive of the choice, control and independent living that policymakers pay lip service to.
Yet as is so often the case with such systemic failure, it is only those on the front line who seem to be subject to control. Eleven workers have been convicted since Panorama broke the story, with sentences of up to two years imprisonment for the criminal abuse of service users. They all bear a responsibility. But so do many others; the Care Quality Commission for doing nothing at the time, Castlebeck for making a profit out of misfortune; the commissioners for taking the easy way out of their responsibilities for people with learning difficulties and their families, and government after government for only responding to the crisis of care at the point of scandal and front page headlines.
As has long been recognised in the context of child protection tragedies, a process of policy development based on scandal, inquiry and ad hoc action, is a recipe for disaster. Large-scale problems don’t go away just because one case gains a high enough profile to demand a one-off political response. If people with learning difficulties and other disabled people are to be safe in services and live full and equal lives, then services need to be democratised, independent advocacy needs to be resourced and whistleblowers need to be properly protected. The lesson of Winterbourne View is that none of these crucial components is close to being in place. Any government proposals for reform in this area must squarely address all these issues.
Peter Beresford is Professor of Social Policy at Brunel University. He is also Chair of Shaping Our Lives, the national disabled people’s and service users’ organisation and network.
This article first appeared on the Disability Now website – to see the article click here
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Definitions of a whistle-blower
“a person who informs on someone engaged in an illicit activity” Source: Oxford dictionary
“a person who tells someone in authority about something illegal that is happening, especially in a government department or a company” Source: Cambridge Advanced Learner's Dictionary
Or to Blow the whistle:
“bring an illicit activity to an end by informing on (the person responsible)” Source: Oxford dictionary