Lifeboat NHS

A film about freedom to speak up in NHS Scotland based on an edit of the evidence session of the Health and Sport Committee, Scottish Parliament, held on 13th June 2017.

This is just an edit. A subjective view. Nothing more and nothing less.

At the end of the corridor

 

Director General for NHS Scotland

I have found it impossible to communicate directly with the Director General for NHS Scotland.

The Director General for NHS Scotland does not reply to e-mails sent to him unless you follow this advice from his office:

Paul Gray 02

Please note: The above includes only the first paragraph of the
Deputy Director's letter of the 15 October 2015.

It is essential to note that the Director General had repeated opportunities to make it clear to me that this was the process of communication to be followed. Unfortunately this never happened.

My advice to the Scottish Public is to carefully follow the advice as given by the Deputy Director, Colin Brown. Otherwise you may risk being considered “unwell”, as I have been,  for contacting the Director General through his, openly available Scottish Government, e-mail address.

Paul Gray, PAG1962, Year of Listening, NHS Scotland

Mr Paul Gray, the Director General for NHS Scotland: 
Year of Listening, 2016: "I've taken time to listen"

Over the last 8 months I felt it would not be constructive to attempt to communicate with the Office of the Director General of NHS Scotland.  However, following the EU Referendum the Director General wrote a letter to all NHS Scotland staff in which he stated “I greatly value the contribution of every member of staff in NHS Scotland”. Given that this had not been my experience, I wrote to dghsc@gov.scot expressing this reality which has led me to consider early retirement and asking: “I would be interested in your thoughts and if you have any words of support for me.”

I received the following reply (reproduced here exactly as it was sent):

paul-gray-director-general-chief-executive-1-july-2016

Below: an audio recording of a contribution I made to a 
BBC Radio Scotland discussion on retirement:

My communications in the past to the Director General related to my endeavour to put patients first, specifically in the areas of an ethical approach to the diagnosis of dementia and relating to my petition for a Sunshine Act. The lack of support I received in return is strikingly at odds with the following statement made by the Director General on the Scottish Health Council film below:

“We worry about transfer of power, transfer of responsibility. As far as I am concerned, the more power that patients have, the better. The more power that individuals have, the better. Because they are best placed to decide on what works for them.

To be frank, there is very clear evidence that if people feel powerless their wellbeing is greatly reduced.

If people feel that they have a degree of power, a degree of autonomy that actually helps their wellbeing. So to suggest that it involves something that relates to a loss of power on the part of the service provider, in order for the service user to gain, I think is quite wrong.

I think the service user, the patient, the carer, can have as much power as they are able to exercise without causing any loss or harm to the service provider whatsoever. Indeed I think it is greatly to the benefit of service providers to have powerful voices, powerful patients, and powerful service users, who are able to help us understand what works for them.”

Our Voice: support from senior leaders. 
Published by the Scottish Health Council

Perhaps the following explains why this admirable rhetoric does not seem to play out in practice:

Whistleblowing in NHS Scotland from omphalos on Vimeo.

In Dumfries and Galloway Health: Opinions & ideas, the Director General for NHS Scotland had published in July 2015: “Leadership in a rewarding, complex and demanding world”. The article is worth reading in full but here is one quote:

paul-gray-nhs-scotland-scottish-government-1

This was the response of the Deputy Director as shared with the Director General when I shared my experience of the NHS initiative “Everyone matters”:

deputy-director-to-director-of-nhs-scotland-hes-another-of-our-regular-correspondents

This report in the National describes the Director General’s approach to whistleblowing, an approach that would seem to address only selected recommendations of Sir Robert Francis:

No if yer a whistleblower it's no

all-nhs-workers-should-have-the-confidence-to-speak-up-without-fear-pag1962-paul-gray-chief-executiveThe above interview was published in the Herald on the 26th September 2016.

nhs-staff-too-scared-to-speak-out-paul-gray-chief-executive-pag1962

first-steps-towards-a-more-open-nhs-scotland-paul-gray-herald-chief-executive

In the month before the Director General shared his views with the Herald he had sent the following communication. I acknowledge that I have been persistent but would maintain that this was because of the lack of any substantive responses from his Department. This sort of behind the scenes approach by those in a genuine position of power highlights the very culture that Mr Gray needs to address.  I share the conclusions of the Editor of the Herald that “public statements of intent are not enough”.

from-the-director-general-nhs-scotland-15-aug-2016

“appropriate” and “correct” concerns in NHS Scotland

After sending an update of my petition for a Sunshine Act to the Chief Executive Officer of NHS Forth Valley I received this reply. Whilst I was employed by NHS Forth Valley I raised concerns that HDL 62, the Scottish Government Circular sent to all Chief Executives in NHS Scotland, was not being followed.

Jane-Grant,-NHS-Forth-Valle

Two aspects of this letter from the Chief Executive Officer for NHS Forth Valley are worth further consideration:

(1) Transparency:

When I was an employee of NHS Forth Valley I was formally written to by Dr Rhona Morrison, Associate Medical Director. In this letter from the Associate Medical Director, which was both unsigned and undated, I was described as “unprofessional” and “offensive” for raising concerns that NHS Forth Valley was not following extant Scottish Government guidance on transparency regarding declarations of interest.

This letter confirmed that I would be “invited” to  an “informal” meeting by the Associate Medical Director’s immediate peers.

My experience of this “informal” meeting was that my character, reputation and probity were robustly questioned by the Medical Director, Dr Peter Murdoch, and the General Manager, Mrs Kathy O’Neill. This meeting was not minuted. This meeting left me distressed.

A number of weeks after this meeting I resigned from NHS Forth Valley. On my resignation I had this  feedback from those who I had cared for and worked with

(2) Freedom to Speak Up:

The Chief Executive Officer reinforces in her letter the “importance of a culture of openness and candour”. However, Jane Grant, the Chief Executive Officer for NHS Forth Valley then goes on to give qualifications: that any concerns raised should be “appropriate” and “correct”.

Whistleblowing in NHS Scotland from omphalos on Vimeo.

To conclude: it appears to me that there are still significant barriers to raising concerns in NHS Scotland. If you click on the image below you can read the full review by Sir Robert Francis. I have selected one particular recommendation which I think will require a different mindset to that suggested in the letter from Jane Grant, Chief Executive Officer for NHS Forth Valley:

Freedom05002

Update: November 2016:
On the 22 March 2016 the following petition was lodged by 
Pete Gregson with the Scottish Parliament: PE01605: Whistleblowing 
in the NHS - a safer way to report mismanagement and bullying.

On the 24th November 2016 the Public Petitions Committee considered 
all the submissions requested as part of evidence gathering. 
This included a letter from the Chief Executive Officer for 
NHS Forth Valley. This letter was commented on in particular 
by Angus MacDonald, MSP:

pe1605-nhs-scotland-whistlblowing-jane-grant-nhs-forth-valley

Treatment of staff who revealed serious concerns about patient safety and care

This article was published in the Herald Scotland today:234

I made this film today before I had read this report:

Freedom to speak up (punctuated by philosophy) from omphalos on Vimeo.

The GMC and doctors’ suicides

In October 2014, Dr Margaret McCartney, in her “No Holds Barred” BMJ column, asked: “Does the GMC deserve its current powers?

Mgt Gmc

The full open-access text of Dr McCartney’s BMJ article can be accessed here

On the Friday before Christmas 2014, the GMC (the General Medical Council) published this internal Review: “Doctors who commit suicide while under GMC fitness to practise investigation”CropperCapture[1]

The PULSE reported this inquiry by highlighting the fact that the GMC plan to introduce “emotional resilience” training for all doctors:

PULSE GMC

This PULSE article on the GMC and doctors’ suicides has so far gathered 331 responses. This would appear to me to be unprecendented in recent PULSE history.

Meantime in the British Medical Journal, two letters have recently been published. The first by Dr Ben Bradley: “Who watches the GMC?

Ben Bradley, GMC

And the second letter by Christoph Lees: “The GMC and doctors’ suicides“:

Christoph Lees

I have put together these communications because if the GMC wishes to regulate against “any other behaviour that may undermine public confidence in doctors”  it needs to consider the potential consequences of such an approach. One risk is that such action may hamper “duty of candour” and thus patient safety. It may also risk further “disconnect between doctors and managers” (the GMC internal inquiry established that 54% of those who committed suicide had been referred by their employers).

Whilst it is essential that doctors have a strong regulator, the inevitable tensions and risks of the regulatory process need to be considered. I am writing this post to add my voice to those who urge that regulatory approaches taken by the GMC are more openly discussed.

“When managers rule”

The title from this blog-post is not mine. “When managers rule” was the title Professor Brian Jarman gave to his British Medical Journal Editorial published two years ago this Christmas.

When-managers-rule2

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:

ari1

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.

In a previous post I noted how often NHS staff mentioned the word “disconnect” in the report into Aberdeen Royal Infirmary:

ari4

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”:

This word, “disconnect”, was also used by Sir Robert Francis in his report on the Inquiry into the terrible failings at Mid-Staffordshire NHS:

Francis-prescription

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.”

Not just wrong it was truly dreadful from omphalos on Vimeo.

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.”

Untitled-1

In a wish only to assist the “Real World Group”, in the following posts I humbly offer my feedback to NHS Forth Valley Board:

 Ethics, a doctor and his hairt-beat 

Seeking Transparency

 A little tearful (and McCall Smith)

 “Believe me, that is not the way to get things done”

 Social Media policies (NHS Scotland) 

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.

22

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.”

shoot-the-messenger

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:

disregard

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.

neil-12-oct-14

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.

CropperCapture[1]

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.

“Toxic culture” from omphalos on Vimeo.

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:

44

Conclusion:
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

Ethics, a doctor and his hairt-beat

I had several envelopes like this delivered through my letter-box.

Immediately recognisable, even before opening, I felt my heart (‘hairt’ in Scottish) beat much faster.

I shall try and explain why.

hairt-beat

This is another pattern that I wish to present.

Alexander McCall Smith, as an admirer of my films, wrote to me about our shared interest in patterns. He recommended this book “A pattern language” which has inspired some of my recent posts:

026

The envelopes from NHS Forth Valley to my home address were always from Senior Managers and nearly always officially reminded me of “Good Medical Practice” as issued by the General Medical Council.

Here is an example from a letter from the Medical Director of NHS Forth Valley, Dr Peter Murdoch, to me dated 21st May 2014. It was part of a wider letter .  The letter made references to my “behaviour”. The letter summoned me to an “informal” meeting with the Medical Director and General Manager for NHS Forth Valley:

21-may-2014

When I was off sick, due to work stress, the Locum Consultant who covered for me, had the following experience:

annoyed & demanding

The Locum Consultant concluded that this demonstrated:

disregard

This was the Locum Consultant’s experience of the Medical Director, Dr Peter Murdoch. There was no action taken here.

three

I have many interests: interests which remind me how little I know. One of my interests is in ethics.

In my 13 years with NHS Forth Valley my ethical interests were in three broad areas.

In my time with NHS Forth Valley there was no forum to discuss ethics.

The FIRST was:Timely-can-we-do-better

It is fully accurate to say that not one of my consultant medical colleagues in NHS Forth Valley shared my advocacy for a timely approach to the diagnosis of dementia. Today it is the basis to the diagnosis of dementia across Europe

The SECOND was:
transparency1

I share the view of most ethicists and many in academia that education and research should be free of marketing. Free of any distortion created by financial incentives. I have petitioned for a Sunshine Act (or clause) for Scotland. I believe that a central, open-access register would be straightforward and not at all costly to set up.

The THIRD was:
consent

My view is that we need to consider more fully the importance of consent. Any intervention, be it a test, or a “tool”, or a treatment can have potential benefits and potential harms. These need to be shared as best as we can.

The Former Cabinet Minister for Health and Wellbeing, October 2014:

Neil-12-Oct-14

This week, the General Medical Council published:

CropperCapture[1]

This report confirmed that 54% of those doctors who committed suicide had been referred by their employers.

One response to this GMC investigation remarked:

“There is a parallel with whistleblowing here. The stress of the situation caused mental health difficulties and the person concerned is therefore dismissed as being unwell. Which comes first?”

My experience in raising ethical considerations, and thus trying to put patients first, was very difficult indeed.

I do hope other healthcare professionals, if they raise genuine concerns, will not face what I have faced for raising ethical considerations.

I see a pattern here. So did a senior NHS doctor who wrote to me recently:

“No wonder NHS doctors live in fear when threatened with the GMC for raising ethical concerns in the workplace.”

Why I resigned from NHS Forth Valley

I resigned from work on the 6th June 2014. Some folk have been wondering why. Below I offer briefly the background to my decision to resign and why it was a matter of more than just principle.

I have worked for NHS Forth Valley as a Consultant in older adults in Clackmannanshire for nearly 13 years. I leave with an unblemished record.

It has been hugely rewarding for me and indeed a privilege to share in the lives of the wonderful elders of Clackmannanshire often in a time of need. The team of which I was part worked with dedication, compassion and professionalism even though at times we had to make difficult decisions due to the demands placed on our service. The support from colleagues in primary care, social work and third sector was greatly valued and our joint-working a source of satisfaction long before integration of services was ever considered.

As a consultant I faced the steep-learning curve of the non-clinical aspects of today’s medicine and the shifting sands of political mandates and targets.

What follows is a brief account. It is to help explain and perhaps allow wider reflection, including my own. It seems to me that finding the words to express complex matters in writing helps me to “see” better. I am aware that this will be one account, open to challenge as none of us (thank goodness) will have the same view on life.

The factors involved in my resignation were complex. Life is complex after all. The beginnings of all this go back many years when I was faced with a difficult situation. I was concerned that our most elderly were more at risk of mis-diagnosis of dementia. This was at a time of incentivised targets for the early diagnosis of dementia (HEAT target 4 in Scotland) and increasingly I found that elderly patients were being diagnosed with “early Alzheimer’s disease” but in fact did not fulfil internationally accepted clinical definitions of dementia. My concern was that in the late stages of life individuals who would never develop dementia were being told they had it. What was in truth an increased risk of developing dementia was being expressed to patients, families and carers as a definitive diagnosis. My dilemma in speaking out about this was that very few others seemed to share my concerns. This seemed to me to be the case across a range of professions and jurisdictions.

My approach was first to discuss this with colleagues, which only confirmed that my view was that of the minority. I then raised the matter through the appropriate channels of line-management. Initially I was supported in raising my concerns. However this did not last: the most likely reason for support being withdrawn was that I was diverging from the majority.

From that time on my professional life got tough. I wrote an account of my concerns called “Peter’s Lost Marbles” the transcript of which I turned into a short film. This transcript and film were praised by the then Chief Executive of the Mental Welfare Commission and by the then Lead Policy Officer for Alzheimer Scotland. Both these National leads suggested that the transcript should be published in a journal and that the film version be used to encourage wider understandings of the complexities involved in the early diagnosis of dementia.

NHS Forth Valley decided that an “External Review” would be held. I was unaware that it had been documented ahead of this  External Review, by the Medical Director, Dr Iain Wallace that“ the main concern is with PG [Peter Gordon]”.

Increasingly isolated, and no longer included in strategic meetings to improve “joint working” it was difficult to know how to proceed. Through stress I was signed off by my GP and was off for 6 months. Interestingly having been off once before in 2004 (my only severe depression caused by discontinuation of Seroxat) I found that I was re-defined by certain Consultant Old age Psychiatrist colleagues as a case of “recurrent illness”.  I have found it very difficult to escape this stigma and my experience has been that my profession is just as likely as any other to see “illness” before the person.

I have always taken a pluralistic approach to science and have been a lecturer in Medical Humanities. I am interested in ethics, professionalism, philosophy and their crucial contribution to the evidence-based medicine that I aspire to follow. It was my interest in professionalism and my concern that medical education was inextricably linked to marketing that led me to advocate greater transparency in financial conflicts of interest. I have pursued this with some determination. I have petitioned the Scottish Government for ‘A Sunshine Act’ and have argued that we should at least have transparency of financial interests equivalent to that which we expect of our parlimentarians.

My experience has been that it is not easy to pursue transparency in the health service. If anybody is interested much of this can be followed here.

The final straw for me with NHS Forth Valley was that I no longer felt that my concerns about staffing levels in the team of which I was part were being taken seriously.

Update: March 2017:

NHSG003: Dr Peter J Gordon written submission on NHS Governance in Scotland:

I want to very briefly summarise my experience relating to two of the requirements of the NHS Reform (Scotland) Act 2004, which requires all boards to demonstrate
that staff are:

(1) involved in decisions;

(2) treated fairly and consistently, with dignity and respect, in an environment where diversity is valued;

I have worked as an NHS doctor in Scotland for 25 years. In 2014 I resigned from NHS Forth Valley after working for 13 years as a Consultant because of my
experience that the Board were not complying with the above. I now work for NHS Lothian. I plan to retire early because of my experience when working in NHS Forth Valley.

On my resignation I received this feedback from patients, carers, colleagues and staff in many sectors. I have actively spoken up for patients when I have come across harm (unintentional or otherwise). I spoke up regarding two main areas:

(a) the Timely diagnosis of dementia

(b) Transparency of competing financial interests in NHS healthcare staff

Timely diagnosis has now been adopted right across Europe.
This approach had no support whatsoever in NHS Forth Valley. In terms of the 2004 Act I was not “treated fairly and consistently, with dignity and respect, in an environment where diversity is valued” for advocating a timely approach to the diagnosis of dementia.

Parliament: PE1493: A Sunshine Act for Scotland.
This was taken forward by me as an individual as a petition to the Scottish

The petition was closed last year after a Public Consultation found the Scottish Public supported my petition. In terms of the 2004 Act I was not “treated fairly and consistently, with dignity and respect, in an environment where diversity is valued” by NHS Forth Valley or other NHS Boards for advocating such transparency.

At the time before and after resigning from NHS Forth Valley I was not “involved in decisions” as required in the 2004 Act. There were communications about me with other NHS Boards such as Healthcare Improvement Scotland and NHS Tayside. I now believe I was “blacklisted” and that my references were influenced negatively by input from senior staff in NHS Forth Valley.

I have long since realised that there is no possibility of individual redress for me regarding my past treatment as an NHS Scotland employee. It is my hope that the committee will be able to encourage a genuine change in culture so that other employees working in NHS Scotland feel empowered to put patients first. It is essential that this is the case even when that employee finds him/herself in the minority amongst his/her colleagues or indeed challenging government policy.