Don’t give up the day job

No sooner had I talked up the electoral candidacy of the recently qualified Italian hygienist Nicole Minetti, than it all went horribly wrong for the young lady. I wish to apologise unreservedly to her, and can only conclude that either my unsolicited attention, or that of Silvio Berlusconi, was the kiss of death for her (please phone in your votes on this one – the phone lines will close on 1 April).

For those of you who thought there were rather too many other things of greater import going on in UK dentistry right now, and who therefore missed the story, Nicole had been selected by Silvio Berlusconi’s People of Liberty (PdL) party as their official candidate for the seat of Lombardy in this month’s regional elections. But, following allegations of electoral process irregularities, this is one of two seats where the electoral process has been deemed invalid. I do hope Nicole kept her
ultrasonic scaler plugged in because it looks like she might soon be needing it again after all.

It is never sensible to be too hasty in giving up the day job, although it sometimes makes excellent sense to return to it. Living proof of this is Lord Darzi, he of the ‘High Quality Care for All’ NHS blueprint fame.

Lord Darzi returned to his former role as an eminent and highly respected surgeon last July – sensible fellow – but, in 2008 during his temporary alter-existence as a health minister appointed by the present government, he commissioned three independent reports from three internationally respected, US-based consultancies (JCI, the Rand Corporation and IHI).

Given that they were funded from NHS resources, at taxpayers’ expense, it does seem a little curious that these investigations and reports were not specifically referred to in Lord Darzi’s final report, although a DoH spokesman is quoted as confirming that the reports were ‘extensively discussed’ internally – although ‘never intended for wider circulation’. Nor were they made available to the independent inquiries into various hospital-acquired infections which resulted in thousands of deaths of patients under the care of NHS Trusts in Kent, mid-Staffordshire and Essex.

Indeed, they were squirrelled away safely out of the range of public scrutiny and have somewhat embarrassingly come to light only under a recent Freedom of Information application. But the reports are all pretty damning, and the messages in all three of them are hauntingly familiar and not what the NHS wanted to hear (or make public, it seems).

The story is one of managers cracking the whip to ‘cram in patients’ and move them through the system as quickly as possible in order to meet waiting list and other targets, and making it impossible for staff to do their ‘day job’ of keeping patients safe and properly cared for. 

Medical paternalism
One of the reports boldly headlines something that I have regularly bemoaned in this very column and elsewhere, i.e. the fact that any discussion of standards and quality is rendered meaningless unless it takes place in the context of what the patients want out of it all. Every quality guru in the world (except those advising the NHS, it seems) describes quality in terms of the needs, wants and requirements of the end customer. But the patients themselves are, says one of these reports, almost invisible in the prevailing culture of NHS ‘improvement’.

It is medical paternalism of the worst possible kind, where it is not even a case of ‘doctor knows best’ any more, but one of ‘NHS manager knows best’. Or, perhaps even ‘DoH knows best’ – but does anyone (especially the patients) seriously believe that?

Other revealing insights in the three reports noted the disconnect between those providing the frontline services, and those managing the service at all levels, and the endless, meaningless and wasteful restructuring that demoralises and distracts those delivering the patient care.

A ‘culture of fear and slavish compliance’ was described where the target-driven NHS environment was concerned. But the implication is that collecting data and meeting targets is no longer simply the practical means of performance measurement, but instead has become the day job itself, rather than caring for patients.

The Institute for Healthcare Improvements (IHI) fears that the whole thrust of the NHS consultant and GP contracts is progressively de-professionalising the delivery of patient care, and I must say that I have a lot of sympathy with that view. And is there not a resonance with nGDS and nPDS, where the concept of continuing care, and building long-term relationships with patients, has been replaced by an episodic, widget-stacking unitocracy?

Spending time with patients, talking with patients, building their confidence and helping them to prevent oral disease no longer has a value. And if you don’t value it, you won’t get it. IHI speaks of doctors finding it easier to fall in line within the NHS microsystem than to fight it, so they effectively work to rule, putting targets first and patient care second. The ones that decide that they can’t stomach it, leave it. We all trained to be professionals and dumbing this down to the level of ‘providers and performers’ is no coincidence; it acts as a metaphor for the underlying methodology.

The day job of dental clinicians – whether working in general or specialist practice, or in the hospital or community dental services – has always been the care and treatment of patients. But latterly, one could be forgiven for thinking that patient care is simply what they do in between all the other stuff. If the other stuff is genuinely and honestly contributing to patient care, then there is a place for it. If it is not, then we should be questioning it and asking who or what it is designed to serve, if not the patients. Politicians need metrics to fill reports and to give themselves statistics to quote in order to defend themselves when they are challenged.
And, when the numbers paint a pleasing picture, it doesn’t take a Freedom of Information application to unearth them – they are quoted relentlessly and at every opportunity.

If dental health professionals were left alone to use their professional skills and to treat patients now and again, access would not need to be the first word in the DoH dictionary.

It was just as much a problem for the government of the day 60 years ago, a few years after the first ever NHS dental contract was introduced. But, ironically, the problem then was too  much access, and the government didn’t like that either. The ‘fix’ was to restrict access and put a brake on demand by introducing patients charges for NHS dentistry (it was initially free). And yes, in case you were wondering, the profession got the blame then, too, for doing too much treatment and for making itself too available to NHS patients. It’s a funny old world, isn’t it?

And finally
It is so refreshing when all the rubbish is stripped away and we get a glimpse of how things should be, and (in some cases) used to be. I was therefore heartened by the story of Mrs Gillian Chapman, whose husband Dr John Chapman was one of several healthcare workers who died of mesothelioma after having worked in a hospital in London that had been constructed with the extensive use of asbestos. One surgeon’s family had received £1.15 million in compensation, but Mrs Chapman – a widow now in her 70s – has spurned a potentially similar award. She has no intention of bringing a claim, explaining: ‘I don’t approve of people who go around chasing ambulances.’

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