At the time that the Editorial was published my family, many of whom have had a career in healthcare, found themselves discussing it. The Editorial also attracted a significant number of written responses to the BMJ.
Two years on from the publication of Professor Jarman’s Editorial, my thoughts have returned to it given the recent short-life review of quality and safety in Aberdeen Royal Infirmary:
I generally find that narrative is the best way of approaching, and perhaps best appreciating, complex matters such as this.
Here I shall set out a narrative of my two years as an NHS consultant since Professor Jarman’s Editorial. I hope that my experience can add, in some small way, to the wider appreciation of “culture” and the potential consequences for NHS healthcare.
Entry 9.24 of the report seems to capture the disconnect, with words used like “disengagement” and “detached”. It also raises the experience of frontline staff where concerns were “not being satisfactorily addressed” or “being met with silence”:
NHS Forth Valley, at their Board Meeting of April 2014, discussed (under item 8) a “FRANCIS ACTION PLAN”. This plan was led by the Medical Director: “Discussion took place around the detail of the Francis learning. Dr Murdoch advised that this would be an ongoing process which will require regular updating and scrutiny.”
NHS Forth Valley agreed to follow the recommendations of the Real World Group that “Boards should identify the impact of how they work as a board, on their degree of engagement, morale and wellbeing.”
In a wish only to assist the “Real World Group”, in the following posts I humbly offer my feedback to NHS Forth Valley Board:
In response to Professor Jarman’s Editorial, Narinder Kapur said in January 2013: “sadly, in parts of the NHS patient care is sometimes seen as secondary to managerial imperatives. If a clinician is performing to high standards in terms of clinical excellence and professional conduct, yet gets on the wrong side of a manager or a medical director, whether it be for whistleblowing or other reasons, he/she may well suffer serious consequences as a result”
Narinder Kapur considered that “Managers and medical directors need to be held more accountable for their actions. Any disciplinary process brought by managers or medical directors must respect the three key principles of independence, expertise and plurality”
NHS UK provides helpful advice on workplace bullying, which it suggests can involve “excluding and ignoring people and their contribution and unacceptable criticisms”. My workplace narrative, described in the above posts, carries such experiences. This ultimately led me to offer my resignation from NHS Forth Valley after 13 years continuous employment.
Around the time that the Medical Director led NHS Forth Valley’s review into “Francis”, I was “invited” by formal letter to attend an “informal” meeting by him. This meeting left me very distressed. At this “informal” meeting the Medical Director and General Manager for NHS Forth Valley used words to describe my “behaviour” such as “threatening”and “intimidating”. I was reminded at the meeting that I was “obliged contractually to reflect on this”.
Dr Philip Pearson, Consultant Respiratory Physician, Plymouth Hospitals, felt that “perhaps the most disturbing comment” of Professor Jarman’s Editorial was “NHS managers reliance on ‘shame and blame’ and fear of job loss as quality improvement driver.”
I do not regard myself as a “whistleblower”. I raised concerns about patient care by following my employer’s system of line-management. Nevertheless, my experience would seem to have many similarities to those described by whistleblowers, such as bullying, mischaracterisation, stigma and isolation. It was this, and not mental illness, that led my doctor to recommend that I take sick-leave. I was off for 6 months. Whilst I was off, the Consultant Locum covering for me, also had concern about patient safety and wrote to senior managers in NHS Forth Valley. In communication over these clinical concerns the Locum Consultant concluded that the Medical Director demonstrated:
In my experience, NHS Forth Valley management ask their staff to “reflect” on their behaviour. My concern is that managers may not find the same need in themselves.
In my 13 years as a consultant in NHS Forth Valley our service for the older people of Clackmannanshire had not a single visit from any Medical Director.
In the year following my 6 month “sickness” absence, the Service Manager in charge of our service visited once.
I welcome that the Scottish Government supports duty of candour as confirmed by the former Cabinet Secretary for Health & Wellbeing. The recent findings of the inquiry in NHS Grampian reveal many of the barriers to achieving this. It is clear that this is not limited to one Scottish NHS Board: David Prior, the chairman of the Care Quality Commission for NHS England recently disclosed that one in four staff have reported bullying, harassment or abuse from colleagues and managers. Mr Prior was also concerned that the NHS is failing to listen to those who challenge poor care and champion the rights of patients. He says those who try to speak out are too often “ostracised” by their colleagues and managers.
The recent review into suicides by doctors who were undergoing fitness to practice investigations revealed that 54% had been referred by their employers. This has left me reflecting on my own experience with NHS Forth Valley in trying to put patients first. My experience was that senior managers repeatedly reminded me of the GMC and “Good Medical Practice”. I was urged to “reflect”.
In a recent BBC interview, Shona Robison, the current Cabinet Minister for Health, Wellbeing and Sport was asked if she thought the “toxic culture” reported in NHS Grampian could be happening elsewhere in Scotland? The Health Minister seemed almost to sigh, and then momentarily paused, before reminding us of the role of Healthcare Improvement Scotland.
The external inquiry by Healthcare Improvement Scotland into NHS Grampian identified a range of concerns and issues which included “the relationship between some senior medical staff and the NHS Grampian senior leadership”. In consideration of this inquiry the current Medical Director for NHS Forth Valley stated:
In trying to put patients first my recent experience as an NHS Consultant has been very difficult.
Recently at a family gathering I was asked, given the distress that trying to put patients first has caused, “was it worth it?”
This was a difficult question to hear and contemplate. I do know that I am not perfect. I also know that we have now had two external enquiries, one in England and one in Scotland. Two major NHS inquiries in a matter of years. Both inquiries concluded that there seems to be something generally wrong in NHS culture. Both inquiries highlighted a growing “disconnect” between managers and frontline staff.
My fear is that both the “culture” and the “disconnect” are not being effectively addressed. Professionalism and candour risk being further devalued as a result.
So “was it worth it?” Despite the experiences I have outlined, I wish to document some personal successes:
- I advocated a timely approach to the diagnosis of dementia, when virtually nobody else would. It is now considered the best approach across Europe.
- I have promoted transparency across NHS Scotland (and will continue to do so)
- I continue to advocate that we routinely consider ethics in every healthcare encounter