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 tinyurl.com/mcf7js9
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.