The blame game
My heart sank when I saw the front page headline in The Times a few weeks ago, which read ‘Blundering doctors get protection from blame’. On closer inspection, however, it turns out that not all of the medics in question will need to have been ‘blundering’ in order to escape criticism and disciplinary action. It is quite sufficient for them to have made a minor human error like a lapse in concentration (perhaps when overworked and exhausted).
The article had been prompted by Jeremy Hunt’s contribution to the Patient Safety Global Action Summit 2016, held in London over two days in early March, with some genuinely high profile attendees. Speaking at the summit, Jeremy Hunt set out several new initiatives including the setting up of an independent Healthcare Safety Investigation Branch, and as part of this (as from April 2018) expert medical examiners, who will independently review and confirm the cause of all deaths arising from healthcare incidents. The plan is to introduce legislation that will give local hospital investigators the powers to offer ‘immunity’ to those who hold up their hand and admit errors that might otherwise have gone unattributed and/or undiscovered. If you are getting a sense of deja-vu, this could be because something along the same lines was originally recommended by The Shipman Inquiry, and subsequently by Robert Francis QC in his watershed report following the tragic events of mid Staffs.
Jeremy Hunt explained: ‘A huge amount of progress has been made in improving our safety culture following the tragic events at mid-Staffs but to deliver a safer NHS for patients, seven days a week, we need to unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people.
‘It is a scandal that every week there are potentially 150 avoidable deaths in our hospitals and it is up to us all to make the need for whistleblowing and secrecy a thing of the past as we reform the NHS and its values and move from blaming to learning.’
What is not to like about unshackling ourselves from a quick-fix blame culture? Unveil your shackle-cutter Jeremy. But let us pause for a moment to consider that bit about a safer NHS seven days a week. Like all well-manicured political soundbites it sounds great (as always) but merits a little closer inspection. It is well recognised, for starters, that human factors and system factors conspire to make healthcare riskier when delivered by less skilled and less experienced teams and especially those who are strangers, working in unfamiliar environments with unfamiliar systems and processes.
It turns out that NHS Trusts appear to have breached the pay cap on agency nurses in excess of 60,000 times in little more than a year, so desperate have they been to the plug the gaps of what are fast becoming chronic, continuing shortages of skilled staff. These shortages are particularly acute in the evenings, overnight and weekends and public holidays, but they are in danger of becoming a designed-in feature of the NHS system, which would sit at odds with all the other aspirations, however desirable they are.
The Royal College of Nursing is turning up the heat, pointing to ‘an over-reliance on short-term staffing’ and this has of course also been a recurring theme underpinning the dispute between the government and the junior doctors. It is reported that some individual trusts are having to drive a horse and cart through the agency and locum pay caps on what is almost a routine basis – hundreds of times a week. These caps were introduced after the government was roundly criticised last autumn after revelations that more than £3 billion of precious NHS resources had been spent on agency staff in the 2014/2015 year alone.
One of the welcome themes of the Patient Safety Global Action Summit is a public recognition that when things go wrong in healthcare, there is too little focus on system-wide and process-related issues, and perhaps too great a readiness to embark upon witch hunts in order to point the finger of blame at erring healthcare professionals. OMG – please tell me I am not imagining this.
On reading a little further I discovered that the immunity is not quite as open-ended and unqualified as it seems at first blush. Apparently the GMC and other regulators could investigate any information that reached them directly and independently, even if relating to precisely the same events for which ‘immunity’ had been granted in an internal NHS investigation.
But looking upstream can provide both root cause and mitigation for the imperfect acts and omissions of humans. A decision to invest huge amounts of NHS money to recruit unknown staff to work nightshifts in hospitals where they are strangers to both their working colleagues and to the patients they are treating, is not one that anyone in his (or her) right mind would wish to take. The consequence of that decision might be felt not only by an unfortunate patient or two, but also by the healthcare professional(s) who try their best in an imperfect environment and yet are all too often left to pick up the pieces and the blame – after they have been hung out to dry by a system that has learned how to deflect blame and managers who run for cover.
But upstream from those managers are other decisions taken by people even further from the coalface – high level decisions about public spending, NHS funding, training, staffing, targets and priorities and a whole load of other issues. Amongst them, questions like why it is that so many NHS training places consultant positions remain unfilled. Dentistry is plagued by this resourcing drought every bit as much as medicine, but the impact cascades through the system like a stack of dominoes.
Zero hours contracts
Another ‘upstream’ problem that has a lot to answer for is the commissioning of NHS dentistry at obscenely inadequate UDA values. Those responsible will no doubt see these bargain basement contracts as a triumphant demonstration of their strategic prowess and negotiating skills, but it doesn’t feel much like a triumph when a young dentist attempts multi-visit band two courses of treatment for barely £10 in their pocket for the whole course of treatment.
The NHS may take the view that there are huge benefits in finding providers that are willing to offer services at UDA rates, which after the deduction of practice overheads, pay nothing whatsoever for the time of the performers. Think of all the additional UDAs that can be commissioned with the money saved, for example. May I suggest that you don’t spend too much time thinking because you inevitably end up thinking about the quality of care that can be provided at a consistent loss – patient after patient, day after day, week on week and month on month. The commissioners in question are knowingly buying counterfeit services.
Talking about counterfeit services, there is an interesting parallel with all the recent noise from MHRA, Trading Standards and even the GDC, underlining the concerns voiced by the BDIA about dentists seeking cut-price dental products that are not what they purport to be. The argument goes that dentists must surely know that when they pay a fraction of the usual cost, they are not buying the genuine article.
I would argue that the same applies to the commissioners of dental services. They too must surely know that when they are paying a fraction of the true, reasonable cost they cannot in all conscience expect the same standard of care. But they do of course. And so does the GDC, and the law firms who bring negligence claims.
In both of these instances it is likely to be the dentist who gets the blame when things go wrong. And this allows the politicians the luxury of being able to promise members of the public a high quality service where just about everything is available, most things are possible and patients are consistently safe. So when Jeremy Hunt says that we are making ‘a huge amount of progress’ in delivering ‘a safer NHS for patients’, and are on the move ‘from blaming to learning’ I do hope he doesn’t mean that the NHS is learning how to drive down UDA values, having already learned who to blame when it all goes pear shaped. I admire and welcome his commitment to ‘unshackle ourselves from a quick-fix blame culture’ but the blame and compensation culture has become so deeply entrenched that I wonder if he fully appreciates the scale of his task?