“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.
