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February 7, 2013

The Times Opinion, February 7, 2013
Filed under: Private Eye — Dr. Phil @ 11:55 am

The boss must go, NHS staff must step up


How many people have to die unnecessarily in the NHS before someone takes responsibility? It’s a question I pondered as Robert Francis QC delivered his verdict on the appalling care failings at Staffordshire hospital. Francis was angry at the collusion of anonymity, where clinical staff, managers, the trust board, the PCT, local health scrutiny committees, the SHA, the CQC, Monitor, the Health and Safety Executive, the GMC, the Royal Colleges and the Department of Health all passed the buck instead of preventing hundreds of undignified deaths. So what does Francis recommend for this complete absence of accountability? That no named individuals be held to account. Thirty years ago, Roy Griffiths famously said: ‘If Florence Nightingale were carrying her lamp through the NHS today she would be searching for the people in charge.’ I fear Robert Francis has been given the same lamp.


Francis shows a distressing lack of understanding of the difference between scapegoating and demanding accountability from those responsible. In 2006, when the NHS ran up a half year deficit of £600 million, its chief executive Nigel Crisp resigned. Yet when up to 1200 people die unnecessarily in a single hospital, no senior NHS manager resigns. David Nicholson, the chief executive of the NHS, was in 2005 the head of the West Midlands Strategic Health Authority, the body supposedly responsible for supervising standards at Stafford hospital. He should step down, a view privately shared by many of the NHS staff I’ve spoken to, including hospital chief executives.  But only brave relatives like Julie Bailey from Cure the NHS will join me in public. The culture of fear, blame and bullying in the NHS is as prevalent as ever.


Sir David and his top down command and control team have an undoubted talent for sticking to budget, keeping waiting lists down and hitting politically driven targets. But the Department of Health under Nicholson’s leadership existed to ‘manage’ bad news, protect reputations, suppress dissent and deliver only good news to Downing Street. Nicholson is no Nigel Crisp and would only have gone if Francis had decided he was willfully blind to the deaths at Mid Staffs, rather than just asleep at the wheel. But Francis decided that no politician, policy or senior manager is to blame for Mid Staffs. He has conveniently directed a little bit of blame at every level but not enough to get close to accountability. The judge delivers no justice.


So why did the vast army of NHS inspectors and regulators fail to act on the Mid Staffs scandal? Whatever the answer, it’s unlikely to be ‘because there wasn’t a chief inspector of hospitals.’ If that’s the best Cameron can come up with having had a sneak preview of the Francis report, I fear he may have missed the point. NHS regulators are like dozy fielders on the boundary rope. They only have the faintest notion what’s happening on the front line if someone hits the ball straight at them and other fielders wake them up. Even then, there’s a fair chance they’ll drop the catch.  Regulators can only do their job if they listen and act when patients, staff and relatives are brave enough to speak up.


It’s now 21 years since I broke the story of the Bristol heart scandal in Private Eye thanks to the courageous whistleblower Dr Stephen Bolsin. 12 years on from that public inquiry report, which found up to 35 babies had died unnecessarily, we still haven’t safely reorganized child heart surgery. The omens for the Francis Inquiry are not great. Sir Ian Kennedy made 198 recommendations after Bristol, many of which are near identical to the 290 produced by Francis. Kennedy wanted an absolute focus on quality and safety, a culture of openness, humanity and transparency, a duty of candour, better information for patients, better protection for whistleblowers and better training of staff. Much of the NHS produces great care, some is average and small pockets are scandalously bad. Why? Because bad news is still brutally suppressed for political or corporate gain.


Francis’ recommendations read well, but they’re  three years too late. The lessons from Mid Staffs were needed to inform Andrew Lansley before he launched into his vast, untested reforms in 2010. Reorganizations on this scale are invariably dangerous for patients, as was Labour’s desire to make every hospital a self-governing Foundation Trust, a policy pursued by the coalition. Mid Staffs should never have been forced down that route. It was too small and simply not up to the task, just as child heart surgery in Bristol was not fit for purpose twenty years ago. Both sacrificed lives to balance the books and satisfy political edicts.


Was it ever thus? Kennedy complained that the NHS has been “littered” with previous inquiries that were “consigned to gather dust on shelves”. In 1965, a letter to the Times complained about the shocking treatment of “geriatric patients in mental hospitals” and the casual attitude of the Ministry of Health in dealing with these problems. In 1967, an investigation called Sans Everything concluded that the NHS hierarchy denies problems and dismisses complaints as unfounded, even when supported by strong evidence. There is a tendency to lie low and hope the criticism will fade. And complainants are discredited and victimised. This is as good a summary of the Bristol and Mid Staffs Inquiries as you could find.


Nurse Helene Donnelly tried to blow the whistle at Mid Staffs, was told to watch her back and became frightened to walk to the car park. Chris Turner, a junior doctor, described the A&E department as ‘a complete disaster…. immune to the sound of pain.’ A consultant who raised concerns was suspended. NHS whistleblowers seldom win, and often pay for their bravery with redundancy and illness, but they are far more likely to spot problems early than any number of chief inspectors. We need to encourage, cherish, support and protect them, as well as responding promptly to the concerns of patients and relatives.


I do agree with Francis that it’s up to all of us to improve the NHS. If Nicholson releases his infamous ‘grip’ on the NHS, doctors and nurses must step up to the mark to motivate and inspire those around us. Labour made some big improvements in NHS care, but they didn’t deliver a ‘zero harm’ culture in times of plenty. Making the NHS safe and humane when so many organizations are on the brink of going under is a huge task. In the gap between Bristol and Mid Staffs, we’ve learned that large, distant regulators and centralised, bullying management doesn’t deliver safety. More regulation would be a mistake. Great care comes from motivated, frontline staff with good training and humane working conditions who listen to patients and aren’t afraid to speak up when they spot a problem. Time for a bottom up revolution rather than more top down pressure. We need a bidet, not a shower, to get out of this mess.


Dr Phil Hammond is a hospital doctor, broadcaster and journalist.