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Golden handcuffs

Golden handcuffs

“Golden handcuffs” in corporate land are normally financial incentives to stop employees from leaving.

My friend described to me yesterday a different type of “golden handcuffs” at play in his NHS Foundation Trust. I spent an hour with him, a youngish NHS Consultant in England. He works as a general physician. He also has direct links to the  RCP, of which he is a senior member. As you would expect, he was knowledgeable about what is happening to the National Health Service, which he adores. But he feels that the system in his Trust has gone very badly wrong. Whilst autonomy and independence of NHS Foundation Trusts are both key features of the policy, he feels it likely that similar behaviours are being emulated in other Trusts. He feels there to be a rife ‘target culture’, led by non-clinicians. This, he attributes, occurred when the new management took over in the Trust, rather than when there was any change in central party politics.

He feels essentially that he and colleagues in the NHS are being ‘bought with silence’. He feels, rather perversely, that awards which promote, say, excellence, leadership or innovation are in fact having an unwanted effect. People, he says, with numerous awards, even if they have strong misgivings about the system, are far less likely to raise concerns. Raising concerns makes it more difficult to get an award; and awards impact on your assessment for clinical excellence awards. The Trust he works in is described as having ‘clinical leaders’ who are essentially ‘yes men’ or ‘wing men’, who “protect” higher management. He’s adamant that management have become really focused on one thing: their own reputation management. However, he does want his tale to be heard, as he feels that there are lessons to be learnt about how clinicians interact with management in the English NHS. He feels that the English NHS has become a joke in the way the system is basically rigged towards not identifying good practice, and not sharing any issues with patients.

The background to this is as follows. To be honest, the coverage of the problems in the NHS had washed over me when it veeered towards a complicated statistical debate. I watched the news coverage like many of us did. We all got a bit sidetracked with the thousands of excess or needless deaths allegations. We wondered about its statistical validity. We wondered about the truth of some of more hyperbolic claims in the media. Some people that it was all a ruse to picture the NHS in a permanent state of turmoil and disaster, interspersed with some quality gems about how fantastic the NHS is. He feels that the NHS as a public service could be superb, but has concerns that the public-run NHS has allowed itself ‘to get into this mess’.

When I mentioned his remarks to someone, that  person even said, “Is this guy for real? It’s too good an account. Isn’t it fiction?”

What he described truly shocked me. I’m an avid supporter of the NHS, but what he described was very clearly a system in his Trust which had gone very badly wrong. Even worse, it was extremely unlikely that patients would know about poor quality care because of the resistance of clinical staff and managers to tell the patients. His Foundation Trust is one of the best performing hospital units in England, with one of the best figures for the 4 hour wait. The management is indeed very keen to trumpet loudly this figure. And yet the way the acute medical takes are being run  are utterly shambolic, according to him.

He feels that it’s become impossible to monitor the quality of his team’s clinical decision making. There’s no way of ascertaining whether patients were given the best available management steps, as the service is totally uninterested in discussing cases openly. The management prefer to rely on targets instead, and increasingly they’ve stopped measuring certain targets (such as length of stay). A poor length of stay figure in his Trust will invariably be spun as problems in discharging a patient to the community, rather than the notion that the patient was not properly given the correct management in hospital. A mention of ‘C difficile’ on the death certificate would trigger a root cause analysis, however. Because of staffing issues, he only has a skimpy foundation years team, and one Staff Grade; he has no Registrar. Apart from things blatantly going wrong, generating a complaint, there’s no way of telling whether other Doctors are exercising poor judgment in clinical decision-making.

But he does “blame” various people. He blames his management for refusing to acknowledge any bad news, let alone offering any solutions. He doesn’t blame the majority of nurses whom he perceives as being worn out and demoralised by the conditions they’re working in. But he does blame the senior nurses who are trying to spread the idea that everything’s great, for not risking their bonus. And most of all he blames other Consultants for mostly keeping silent about the poor medical management of the patients. He says he presents his findings at the Grand Round, and senior consultants often come up to him to thank him for being problems. But in the same breath he says nothing of ‘them’ report the same problems. He says of all the people it’s the junior medics who are likely to raise complaints. That’s because they don’t get any experience in medicine of clerking and managing a patient, so it’s in their interests to express their training concerns.  And bear in mind this a “University teaching hospital” too. My Consultant friend was even able to raise an audit of these concerns at the tail end of a meeting with the Deanery and management staff. The management staff had no idea that they were about to be ambushed, and had presented an unblemished account. But the manoeuvre worked, as the Deanery is now receiving detailed feedback from my Consultant friend. And, particularly, the junior doctors didn’t mind raising these concerns as they are mostly looking forward to leaving the Trust, as it’s felt that they’re there on a ‘merry go round’ basis.

He says the culture is insufferable. “You keep your head down. You merely survive.”

He writes e-mails to his senior clinicians, but he never receives replies. People who raise concerns are first ignored, then discredited, then attacked, and starved of any mechanism for career progression. He says the management is ‘totally uninterested’ in his views on  clinical quality control.  He describes a ‘really horrible’ culture of exclusion if you voice any concerns. He says nothing can disrupt the script between the clinical leadership and the management, of how to paint the performance of the Trust in public.

He says the whole Emergency Room is set up wrong, as it has too few beds, and there’s no choice but to shunt patients to any ward within four hours. He explains a team of mainly Emergency Room (ER) doctors see the patient. Towards the end of the four hour window, a Specialist Registrar will do a minimalistic thirty minute clerking, only to be followed by a brief assessment by ER Consultant as a ‘sign off’. When the patient is received by him on a medical ward, often the basic admission investigations like bloods and chest x-ray haven’t even been done. He says he often deletes inappropriate medications off drug charts, and orders outstanding investigations. But he feels exasperated at firefighting.

He feels the complaints procedure in his Trust is virtually non-existent. Whilst patients receive a ‘welcome pack’ from the nursing staff about how to make a complaint, the staff actively do not explain to patients how they can complain about this care. This I think is a complete anethema compared to the solicitors’ regulatory code where solicitors should explain the complaints procedure on their first meeting. He says complaints are never actioned upon anyway. There’s no critical feedback loop from primary care to hospital care, or vice versa.  He finally adds that the Friends and Families Test is not going anywhere in his Trust, as patients aren’t told when they receive bad care at all. If anything this test is being used by management to promote how excellent the Trust is, as management benefits from such positive reporting.

He says he’s had incomprehensible messages appearing to come from management how his discharge letters should use preferred terms such as “urosepsis” to “UTI”, or “NSTEMI” to “acute coronary syndrome”; and nobody can work out why apart from how his FT gets paid. As to what to do next, he freely admits having drawn blanks with his own NHS FT’s management and clinical ‘leaders’. He’s reported it so far to the Medical Protection Society, so I suppose he’s waiting to hear what happens. He feels that the BMA are utterly irrelevant to his concerns. He knows that the mandate for an external review from the Royal College of Physicians can only come from management. And unsurprisingly they haven’t asked for an external review. So he intends to by-pass management, being completely at the end of his tether, by asking the College directly. This reckons is a fatal flaw in the system, but one which is easily remediable.

I asked him why he hadn’t gone to the press. I thought he’d come up with the usual Doctor-patient relationship, but surprisingly he explained he hadn’t deliberately just in case it would give the Trust’s management to ‘cover their tracks’. He did look genuinely upset at this thought. He’s been invited to become an Inspector for the Care Quality Commission. He feels this is the only way now to voice his concerns.

But most of all he blames other Consultants for Mid Staffs. He feels it was up to the Consultants ‘to say something about it‘. Those who did were victimised. Those who didn’t survived. He says he can’t put up with the situation any longer because patient safety is being compromised simply so the management can ‘look good’. He feels quite paradoxically that ‘competition’ has resulted in this mess: competition amongst health professionals not to whistleblow, and competition amongst hospital managers who don’t give a toss for patient quality of care as long their national rankings for key metrics are good.

And he feels that his personal situation is not unrepresentative. This, above all, is the thing that I find the most scary.


  • rogerkline

    Spot on. Can be repeated hundreds of times. A culture of denial. And punishing the messenger. The best trusts know this is a hopeless way to improve performance but the rest just carry on as if Mid Staffs never happened.

    • Barry Davies

      The tragedy of mid staffs wasn’t the grossly overstated problems, i.e. no one drank from vases that weren’t actually there, and the death rate was at most possibly one, see Francis report, but that the failure of the trust system has been completely ignored by the sensation seeking media, and papered over by the government. Stafford could lose its hospital, and will at least lose vital services because of political dogma, and poor management practices that have been introduced by the government, the target culture has no place in the nhs whatsoever. The fabrications about the care at Stafford, and the continual use of the word s Scandal hit, by the Scandal hit BBC have not helped at all, and see to be part of the governments intent to privatise the whole nhs as soon as possible.

      • Mervyn Hyde

        Well done, Mid Staffs had 50,000 people march through the town in support of the hospital, why didn’t the BBC report it, had they been marching against the hospital there would have been wall to wall coverage.

  • foodbankhelper

    Good for him for speaking about this. I don’t think his personal experience is in any way unrepresentative. Terrible medical and nursing staff/patient ratios are impacting on patient care, in my view. How much regular audit of patient outcomes is really going on now? Recently spent six weeks visiting two acute wards (in a PFI hospital – not a foundation trust) every day for most of the day. I could see all the pressures on medical and nursing staff, and on the healthcare assistants who are relied on to provide personal care. No bed left empty for more than an hour or two. Very sick patients marooned for weeks, then suddenly discharged while still seeming to be poorly. No equipment on hand for weighing patients. No sign of infection control nurse in all that time. Did not seem to be any available single bay rooms if patient did require isolation for MRSA care etc. Hospital was bursting at the seams with patients. Hard to find a tissue viability nurse. Pain meds not given out in timely way as senior nursing staff v thin on the ground and desperately overworked. Porters rushed off their feet. Ambulances parked outside A&E a couple of times a week unable to deliver patients as department full. Overstretched diagnostics. As for weekends (and that’s another story) – in my (albeit lay) view hospital not safe then. The staff I managed to talk to wanted things to be better, are terribly sad about what’s going on, and are deeply committed to their patients. That’s why they went to work in the NHS. Are patients being deliberately failed by the way the hospital is being run, while staff are starved of colleagues (particularly senior ones who could help get a grip on the situation), equipment, diagnostics and the other resources they require? If this is the case, why might it be happening? What is this hospital’s budget being spent on? Higher PFI repayments? Getting ready to become a foundation trust?

  • Concerned consultant

    How the NHS bullying culture has led to poor patient care and why a Mid Staffs was inevitable with the current system:

    I write this anonymously for fear of reprisals.
    I read this article and an article in the Guardian online “Why did doctors and the BMA keep quiet about Mid Staffs?” Most hospital consultants reading about Mid Staffs see the same problems in their own trust to differing degrees. It is obvious that the consultants in that hospital had become disenfranchised.
    I feel it is necessary to explain a bit about NHS hospitals, doctors pay, and how the very existence of the NHS in it’s current form has led to the sad situation that healthcare has found itself in today in the UK. There are a number of factors, which have come together which have led us to this point. These are probably only apparent to those working in the hospital system.
    During the Mid Staffs enquiry, one of the hospital consultants was asked “Why didn’t you say anything about the poor practices”. His answer was “ I have a mortgage to pay”.
    Doctors, how they are paid and NHS management:
    Hospital doctors become Consultants in their mid to late 30s after many years of training and before that are paid on the junior doctors’ pay scale. The basic consultant’s NHS salary starts at around £70,000 per year and this increases per year for around 10 years to a maximum of around £90,000 per year without any Clinical Excellence Awards for a full working week of 40 hours. Although paid for 40 hours, I don’t know of any consultants who don’t do significantly more hours than the 40 hours. Whoever thought that a professional senior doctor’s job could be subject to a clocking on and clocking off system as has been attempted with the new consultant contract was very misguided. There is no other way as a consultant within the NHS to achieve higher pay apart from the CEA system. To become a hospital consultant takes around 15 to 20 years, and approximately 10 more years more than a GP. GPs earn far higher salaries than hospital doctors in their late 20s and early 30s. Hospital doctors are “juniors” into our mid 30s at a time when our university friends have been GPs for years and earn twice our salaries and are their own boss. In addition, training hospital doctors do more exams and work longer hours than GPs for many years. Only those with drive and determination get to pass out as a consultant after many years of long hours and study.
    How the CEA system has been hijacked by management and leads to poor care:
    The Clinical Excellence Award system has been around for many years. CEA awards are pay increments for consultants. Consultants can achieve up to a maximum of 9 points via their local trust and each award is worth somewhere in the region of £3000 per year annual salary increment. Consequently, for a hospital consultant to earn what the average GP partner earns he would have to work for 10 years to get to around £90k and then add on 6 CEA awards, almost impossible with the current system unless you do a lot of research or management. Hospitals have approximately 0.2 of a CEA award per consultant in the hospital to award per year (it used to 0.3) so if the awards were spread evenly it would take 5 years per consultant to achieve one pay increment of £3000. Consequently this is why GP is far more attractive than hospital medicine to most junior doctors now.
    CEA awards in the last 10 years:
    Having spoken to other consultants in other trusts it is obvious to many of us who like to look after patients that the increase in “the management culture” within the NHS is directly implicated the drop in standards of patient care.
    Until about the year 2000, CEA awards tended to be spread evenly around the consultants who all did a bit of management and worked with the senior nurses and secretaries to provide a consultant led service. With the increase in middle management since the late 1990s and the increase in bureaucracy, it has led to a situation in which almost the ONLY way to achieve a Clinical Excellence Award is to be heavily involved in management or heavily involved in research/teaching. Consequently for non-academic consultants who focus on patient care above all else there is very little chance of achieving a CEA award on any year’s application. Perversely this acts against good patient care, because, for a doctor to be heavily involved in management means that he/she HAS to be taken away from patient care a lot of the time. The management pressure to go to meeting after meeting has increased massively in the last ten years. Such doctors rely on others to look after their patients. They are often absent from clinics, ward or theatre. This is something, which is overlooked by management since management are happy to have management-focused doctors to come to their meetings. What else do they know? Running the hospital is more important than patient care to them as long they tick the boxes and make their targets. This absenteeism from clinical care of the consultant who is away at management meetings isn’t officially recorded because a patient who is seen by a junior doctor on behalf of a consultant is still logged as a consultant led episode, even if that consultant was not involved. NHS patients don’t know any better and so can’t really complain about seeing a non-consultant doctor.
    With regard to CEA awards, the emphasis on management roles has become paramount in the last 10 years. The same doctors in every trust get all the awards since they become close to management. They sit on all the committees and do far less patient care than those who look after the patients. They are seen as being “Trust Boys” and are paid more. This system attracts bullies, since those that get into a position of power then get paid more than their colleagues, are given the task of making cuts to other consultants pay or limiting their resources for services and this leads to even more kudos with trust management. If they don’t mind not being liked by colleagues they become more successful with management. NHS trusts have now become battlegrounds between the patients and carers on one side and management on the other whose task it is to get more every year with less resource.
    Doctors in management are required to go to endless meetings since that’s all that management know and understand. Many of the management have no experience outside the NHS and very few have any power to make important decisions due to the overly bureaucratic nature of the NHS. Hospital managers increasingly don’t know anything about medical patient care since they aren’t medical. Many have a nursing/clinical background but got out long ago. Also, to be a doctor or a nurse and leave patient care and go into management attracts a certain type of person who obviously doesn’t like dealing with sick patients on a daily basis. Those clinicians who perform a management role that are not comfortable with “moving to the dark side” usually get out after a couple of years and go back to patient care which they enjoy.
    Trust Clinical Excellence Awards committees meet once per year and have appointees from different hospital departments and the executive board. The hospital consultants apply via a laborious online form in which one puts down one’s achievements in terms of developing service, providing a quality service, management roles, research and teaching. The committee then gives marks to each applicant based on what they put on their form. A small percentage of doctors applying achieve a point each year. The medical appointees on the committee tend to be the management-orientated -those who have learnt the system and are chosen by management to be on there. The system has become a game in which groups of doctors who work together and are politically savvy within the trust take it in turns each year to represent that department on the committee. They then give higher marks to their colleagues and as result get paid more. Of course, this would be impossible to prove in any give Trust but is obvious to consultants who work in the hospital system. The whole thing is cloaked in secrecy and the results aren’t published. The executive board also give higher marks to the doctors involved in management and so those consultants who aren’t “on the inside” get very little votes and rarely get any awards. They are often told that it’s about “ knowing how to fill the form in correctly” and there are tricks to that. Essentially those that understand the system and are on the inside get the awards.
    Of course it is those management type of people who get into medical and nursing politics at a high level. If they were patient-focused they wouldn’t have moved away from patient care.
    What happens is that those consultants who want to concentrate on patient care and go the extra mile for patients do very badly within the NHS trust. They might be working very long hours and seeing more patients than other consultants but they don’t get CEA awards no matter how much they are loved by their patients, the quality of care they provide or how hard they work in their clinical work because it’s just seen as “doing your job”. It is very difficult to measure quality of care so they can’t claim to be better at their job than the management focused doctors who see their patients less often but who are respected as having “leadership qualities”. They don’t attend management meetings since they are busy with patients, and are seen as being unengaged with management and the bigger vision of the Trust. They end up in constant battles and arguments about lack of resource while those that get into bed with management, see fewer patients, get paid more and are given all the resource they need to support their service which they run from afar via registrars and staff grades and senior nurses. Being patient-focused leads to a consultant being very unsuccessful in the NHS.
    This leads to a “them and us” atmosphere between the patients and caring doctors/nurses on one side and management on the other. If the doctors complain, they are first ignored and are seen as being a problem and then batted away. Most people just keep their head down. If the patients complain, then the NHS bureaucracy swings into action. Most complaints are about the “service” and not about the team looking after them but the consultant/nurse who is responsible for the patient is always asked to answer the complaint. This is probably the main reason why doctors and nurses at Mid Staffs didn’t report incidents of poor care. Essentially, the incident reporting system is used as a bullying tool in which the busy nurses and doctors at the coalface are summoned by management to explain what went wrong. This investigation process also leads to more work and takes the doctor or nurse away from patient care.
    In the past 10 years or so there has been a gradual shift away the consultants being able to run their practice in the way they see best. This has been to standardise care but actually has just led to more bureaucracy and inability to improve care. There have been a number of reasons for this but the changing of the consultants’ contract to a “clocking on, clocking off” timetable about 10 years ago and the increase in middle management has led to consultants being no more than an employee who just turns up to do a job of work rather than someone who is responsible for the whole of the patient pathway. This has helped to fragment care, already fragmented by the internal market in hospitals in which one department is charging another for every paper clip. Consequently, the average consultant has become the equivalent of a registrar in the old days with no power to improve their service. It becomes counterproductive to see more patients and provide a better service than a colleague. There is no thanks or reward system for good patient care or going the extra mile to look after patients better than anyone else. Perversely it punishes the individual trying to improve the service who end up doing way beyond their contract in terms of patient care and being referred more patients because the care is better which just adds to the vicious circle of having too many patients and too little resource to make things better. They become disgruntled over the years.
    Increasingly, patient focused consultants who actually want to deliver quality care are moving into private practice since not only does it make up the salary gap to GP/hospital management, but one doesn’t have to deal with the unpleasant over-managed, bureaucratic anti-patient culture of the NHS.
    Sadly, I can’t see things improving, since in order to right the system, the government would have to admit that as a public organisation, the NHS would have to be managed less and not more. Essentially, they would have to go back to trusting the doctors and nurses to run the service. The NHS hospital management teams and the senior management orientated doctors and colleges would be the first people consulted. They will always be able to justify having meetings about meetings about meetings.

    Yours faithfully,


    • Mervyn Hyde

      Thank you, I think most that work in the private sector would recognise the failings you describe. This is the real price we pay for private sector involvement, increased bureaucracy and inefficiency, management diktat over practical common sense from the people working at the coal face.

      This has been the driving force in management practice ever since Margaret Thatcher proclaimed that “management had the right to manage.”

      The success of that can be demonstrated by the level of downsizing of companies throughout Britain, I worked for a multi-national company that in the mid eighties employed 46,000 workers and today employ less than 6,000. The other small point in addition to that, these same companies refer to matters such as black holes in pensions, then withdraw from final salary schemes saying they can no longer afford to contribute to them, whilst on record stating how they made record profits.

      The people of this country have been duped by politicians into believing that the private sector knows best, the facts though prove otherwise.

      Over the last forty years public services have been under attack and ridiculed to undermine them; making it easier for public acquiescence to facilitate the takeover by the private sector.

      This has led to increased costs on the NHS (PFI) 70 times the actual cost of provision, privatised services such Harmoni, Arriva, Circle, etc., that have been a disaster. the list is too long to mention but the facts are that wherever the private sector are the under-perform and cost the NHS more than what was previously provided. Need I mention the outsourcing of cleaners in the NHS and its implications.

      Our whole way of life is now dictated by the private sector, that has been the objective of all the political parties for forty years and why they have deliberately interfered with our public services. People need to fully understand the implications of those actions and instead of passively accepting them, make sure that at the next election we vote only for those who that will reverse everything that has happened since Thatcher.

      There is nothing a sovereign government can’t do, the established parties will have us believe that once contracts are signed that they written in tablets of stone, that is totally false. If it means re-nationalisation then so be it. This coalition had no mandate to privatise our NHS and therefore no right. The American trade bill that is currently being thrust through parliament is an abdication of responsibility by this so called government is working directly against the interests of its own people.


      We are being sold down the river by career politicians who have no regard to lives of ordinary people and those people need to wake up.

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