Tribal tensions on the ward are putting patients at risk

Initially headlined as “I saw what needs to be fixed in the NHS. Reheadlined as “Tribal tensions on the ward are putting patients at risk” by Camilla Cavendish (C.C.) in The Times 17th November 2013.

“Managers bullying staff into fiddling cancer figures. Whistleblowers gagged  with pay-offs. A&E doctors coping with patients who should have been  seen by the GP. And that’s just last week’s headlines. With so many of the  staff at loggerheads, it’s not surprising the National Health Service  sometimes seems to forget about the patients. On Tuesday, the government  will give its response to Robert Francis’s inquiry into Mid Staffordshire  NHS Foundation Trust, in whose care hundreds of people died unnecessarily  and others suffered appalling neglect, left in their own urine or desperate  for water.

As part of that response, the decision by health secretary Jeremy Hunt that  staff who are found guilty of “wilful neglect” of patients should go to jail  has provoked fury among unions, which claim that it will create a “climate  of fear”. But it was appalling that so few staff faced any consequences in  the wake of Mid Staffs. It would be indefensible to argue that staff who  perpetrate the kind of abuse we saw at the Winterbourne View private care  home cannot be jailed.

In the past year, Hunt has challenged every part of the system for not doing  enough for patients. He has published information to help patients judge for  themselves and he has created the first hospital failure regime. He wants  people to be held to account and he is right.

It is true that there is a delicate balance to be struck to make the NHS more  open, not more defensive. That is one reason why Hunt has decided not to  criminalise managers who obstruct information. But ultimately we need a  system where those sanctions almost never need to be applied; because the  bad practice was rooted out long before.

What is the culture that needs to be changed? Francis described it as putting  the “business of the system ahead of patients”. I have seen many examples of  this. A few months ago I was with a chief nurse who had arrived in her new  post at a big hospital to find senior nurses ensconced in upstairs offices  wearing suits. When she asked them to put their uniforms on and go back onto  the wards, two of them did not know where their wards were.

On another day I was in an A&E where a healthcare assistant, Rob, talked  about seeing the same group of people arrive in suits every Friday. They  stand with their arms folded, looking grimly at a list of incidents. “They’ve no idea who we are,” he said. “Do you know who they are?” I asked.  Rob looked surprised: “No.” These are staff in the same hospital, supposedly  with the same mission, but never even making eye contact.

Many of the problems in the NHS are management issues, which could be solved  with strong leadership. The best hospital chief executives value their staff  and build teams. They solve problems for doctors and nurses, shield them  from bureaucracy and demand high standards. But elsewhere in the NHS, “management” means administration, not leadership….


But to cut a long story short: when I started looking at things from the  perspective of the people at the bottom, it became clear that we need to fix  the top. As a patient myself, I had been unaware that an army of healthcare  assistants now do the bulk of intimate care, because nurses are so burdened  with paperwork. And I had no idea that, while some wards are staffed by  happy teams, others are in a state of what one nurse in a London hospital  described to me as “warfare”. The levels of resentment that emerged in some  of our focus groups, the way that some healthcare assistants feel ignored or  belittled by nurses, is deeply depressing.

It’s also dangerous. Many patients see more of these junior staff than of  anyone else. Their morale has a big impact on care. And they can prevent or  create potentially fatal infections and pressure sores. In other words, even  the most junior staff are crucial to patient safety.

This was a lesson I learnt from Guy Hirst, a former British Airways pilot. He  suggested to me that the NHS learn from the airline industry. Forty years  ago, US accident investigators found about 70% of air crashes involved human  rather than equipment error. The majority of errors were failures of  leadership, teamwork or communication. As a result, airlines began to teach  all staff that passenger safety was their explicit, shared goal. They also  trained them in “human factors”: to explain that everyone is fallible under  stress and to ensure that staff respect each other and discuss mistakes  openly.

Today, commercial aviation is safe, with only just over one life lost per 10m  flights. Patients do not fare as well. A few years ago, Britain’s chief  medical officer said the odds of dying as a result of being treated in  hospital were 33,000 times higher than those of dying in an air crash. Now  healthcare is, of course, a great deal more complex and unpredictable than  aviation. But these figures do concentrate the mind.

A firm believer in learning from industry is James Titcombe, whose baby son  died from an infection in 2008 after midwives repeatedly refused  antibiotics. James was the whistleblower who courageously exposed systemic  failures in Morecambe Bay. He is also a former project manager in the  nuclear industry. He wants the NHS to train people in human factors, publish  staffing levels and empower staff to speak out.

The results can be dramatic. Hinchingbrooke Hospital in Cambridge has borrowed  a programme from Toyota called Stop the Line. This lets any member of staff  halt a procedure if they think the patient may be at risk. In one recent  case, a patient was about to be stitched up after surgery when two theatre  nurses found a swab was missing and “stopped the line”. An x-ray showed the  swab in the patient’s abdomen. It was removed, saving the patient from harm  and the hospital from heaven knows what kind of negligence claim.

In its first year, this simple scheme has halved the number of serious  incidents, an incredible figure. Yet it was introduced only after a strong  leadership team took over a failing hospital. If Hunt uses his new failure  regime to bring in strong leaders then there is hope that the NHS will  finally become a place where everyone feels able to “stop the line”.

To read the Cavendish review, go to

C.C. has spent many hours studying and writing about the Health Service and she has doubtless see it in London. I wonder what she would have to say about the rural areas, especially Wales? Good Leadership is as rare as good morale, and since all the staff recognise the futility of a system founded on sand they are disengaged. It is the philosophy of a free health service encouraging dependency and paternalism which needs to be challenged, and CC has not yet appreciated this.

This entry was posted in A Personal View, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

1 thought on “Tribal tensions on the ward are putting patients at risk

  1. Pingback: Grieving for the NHS. The softer specialities and locums. Ration for higher earners, and where insurance could cover. | NHS reality. An NHS soapbox. Speakers' corner for the NHS.

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