There is much talk about the need for cultural change in the NHS, but what might this mean in practice?
In my Trust we asked Sir Ian Kennedy to examine how harm to patients was allowed to continue despite numerous warning signs and significant investigative activity. He reported in December, and it makes salutary and compelling reading. A key message is that we have some way to go before we can claim to have a culture in which the patient comes first.
Sir Ian’s review describes how concerns raised by senior doctors were heard but not acted upon, and when they were the action taken was to investigate the professional concerned, rather than to protect the patient. The harm continued and, as the process was a disciplinary one, it was confidential so that staff members who had raised concerns were unaware of what, if any, action had been taken.
The investigative focus was on technical aspects, when actually the behavioural and probity aspects were more alarming. Non-Executive Directors were largely unaware, because of the confidentiality around the process, so there was no ‘lay’ scrutiny. And in the absence of good data, recall of patients for individual review was very limited. In short, the benefit of the doubt was given to the professional and to the organisation, and not to the patient.
Sir Ian found that clinician to clinician challenge, in the interests of the patient, was limited, and he also highlighted cultural signs of an unequal relationship between professional and patient, such as the common use of the phrase ‘consented the patient’. He rightly observed that consent is something the patient gives to the clinician, and not something the professional does to the patient.
There is more, but I have made my point. We no longer live in a society where people ‘know their place’. We are not afraid to speak up for ourselves, and question those in authority. And we are no longer grateful for the NHS, because we know it is ours and that we do pay for it, through taxation. Accordingly, we demand an equal relationship with our healthcare professional, and with the organisation that employs them.
After 60 years, our health service still has a professional culture. Hospitals are structured around medical specialties, usually based on a single organ. Specialists are recruited according to technical and academic criteria, with little or no regard paid to team working skills, or empathy, or even safety awareness. Once appointed, doctors may prefer to identify with a specialty body, rather than with their employing organisation. They work ‘at’ the hospital rather than ‘for’ it.
Organisation of service delivery is frequently seen as the domain of general managers, or ‘the Trust’, despite evidence that it influences clinical outcomes. Indeed, when he was Chief Medical Officer some years ago, Professor Liam Donaldson pointed out that the way doctors worked within teams was a professional issue, not a managerial one, because it impacted on outcomes for patients.
Managers too, at all levels, have focused on targets, or budgets, rather than the patient. What was not measured has not always been prioritised, or delivered. In 2014, few patients can easily access their own health records, or test results, or indeed their senior decision-maker for a discussion. We have undoubtedly improved waiting times in recent years, but has the achievement for the majority been allowed to disempower the individual? Certainly, the 5% who are ‘allowed’ to wait longer than 18 weeks for an operation, and who then wait very much longer while others jump the queue, may feel it has.
As a result of the Kennedy review, we are embarking on work designed to address these issues. The planning stages have been eye-opening. The more one explores the implications of truly putting the patient at the centre of decision-making, the more clearly one can see the radical and transformative nature of such an approach.
My suggestion for a new year resolution to top all others would be to make 2014 the year in which we start to orientate our NHS around the patient rather than the provider, whether individual professional or entire organisation.
Few will disagree with the sentiment, but the actions are challenging because they will mean changing working practices that have become established over 60 years. This may present a financial risk, and targets and standards may be missed, with all the regulatory consequences that follow.
But the genie is out of the bottle, so there is no turning back now. We must embark on this path, for the reasons that Francis, and Berwick, and now Kennedy (again) describe so clearly, and because it is the right thing to do.
Dr Mark Newbold is Chief Executive of the Heart of England NHS Foundation Trust, and Honorary Senior Fellow at the HSMC