As part of the government’s response to the Francis Report in misconduct in the NHS, they have introduced a “duty of candour” for clinical staff. It is designed as an antidote to the bullying culture that led to the abuses at the Mid-Staffs NHS Trust.
A recent study by Durham University found that nearly half of all NHS staff have witnessed bullying at work. Another survey found that a quarter of doctors and a third of nurses say they have been bullied into doing things they know are bad for patient care. Bullying is endemic in the NHS. It creates a toxic atmosphere in which patients die.
The duty of candour may help healthworkers stand up to the bullies and blow the whistle on poor standards of care. It may stop management covering up poor practice. But “candour” alone won’t stop the systemic causes of bullying in the NHS.
Recently, Workers’ Liberty’s Lewisham Hospital Worker bulletin was told of an alleged incident in a neighbouring hospital where a patient died on a trolley wait because there were no beds in the intensive care unit. The doctors and nurses who cared for that patient will no doubt be candid in reporting the incident. Their managers will be candid in the way they conduct their investigation. But if it is found that this was an unnecessary death, who will take responsibility?
This isn’t the nurses’ or doctors’ fault. These people have no say over how many beds the hospital keeps open. Hospital management cannot be held responsible either. They can only run a service with the money they receive from the commissioners. The commissioners in turn are working within the budget restraints imposed by the government. Neither managers nor commissioners can magic cash out of the sky.
Ultimately it is the government funding cuts which are responsible for this patient’s death. But will the government take responsibility? No chance! In fact, as part of the Health and Social Care Act, the Secretary of State for Health is no longer legally responsible for providing a comprehensive health service. The statutory duty that makes the government responsible for the NHS no longer exists. They set the budget but they aren’t responsible for the service!
With the the Hospital Closure Clause (118) being pushed through Parliament under the cover of the Care Bill, this tendency is set to get worse. Section 118 gives a faceless bureaucrat — the Trust Special Administrator — dictatorial powers to shut down hospitals with no accountability to the public.
The NHS has a bullying culture because politicians have introduced a mechanism so that those with the most power have the least responsibility. Nursing staff have very little power but are held responsible for everything that happens on our wards. As everyone above ward level squirms their way out of taking any responsibility, frontline staff hunker down worried for our next pay packet. The threat of disciplinary and losing our PIN hangs over us with every clinical decision. Those with power crank up the pressure with further cutbacks and “initiatives”. The decisions are made at the top and the rest of us have to deal with it.
Jeremy Hunt implies that bullying happens because of nasty managers and spineless workers. In fact, it happens because the system is set up so that those in power are not responsible for the consequences of their own decisions. They pass responsibility down the chain of command, whilst concentrating ever more power in their hands.
Nye Bevan, the NHS’s founder, said that if a bedpan drops in a hospital corridor he wanted to hear the reverberations in Westminster. Jeremy Hunt and his New Labour predecessors are not hearing the falling bedpans. The performance data that management demand and which is passed up the hierarchy to the politicians is a unreliable reflection of the reality on the wards. The real scandal at Mid-Staffordshire was that everyone from the hospital management up thought it was one of the best NHS Trusts in the country! It took a mobilisation of the local community before anyone with any power realised that patients were dying of thirst, in their own shit, in their hospital beds.
The people at the top inhabit an alternative reality, a world of spreadsheets and number-crunching. A hospital can produce perfect data at the same time that it is filling up its mortuary.
It is worth considering what is going on here. Driving improvement, ensuring a consistency of service and planning future investment are necessary parts of running a health service. To do these things well requires accurate methods of data collection. Health economist Allyson Pollock argues that the pre-1980 NHS had much more efficient and useful data-collection methods than we have nowadays in spite of all our IT systems. Traditionally NHS data was used to determine where the NHS should expand or contract its services, which treatments were working and how to spread best practices. It was public and transparent.
Much of the data-collection that now takes place is for a different purpose. While Thatcher was loath to privatise the NHS, for fear of public outrage, she was keen to bring capitalist management technique into the NHS. Thatcher replaced much of the old NHS management with “general managers” including appointing the former boss of Sainsburys’ supermarket as the Deputy Chief Executive. These managers implemented Taylorist strategies for management control of the labour process, taking a forensic look at what doctors and nurses were doing and designing ways to standardise practice through clinical audit and data-harvesting. While these strategies may drive efficiencies in supermarkets and car factories, the labour process in the NHS involves complex clinical decisions. A tension emerges between management’s appetite for control and the clinicians attempt to provide patient-centred care and apply their considered professional judgement.
By the 1990s this managerial culture was bolstered by the attempt to marketise the NHS. At the heart of neoliberal ideology is the belief that capitalist markets are superior to state planning as a means to run public services.
They claim that the NHS is too big and too complex to be managed by mere mortals. Only the “hidden hand of the market” can effectively and efficiently “manage” such a large organisation. With this dogma being pushed by an aggressive lobby of American private health firms, the Tories then New Labour and then the Tories again tried to replace the old NHS bureaucracy with this miracle-making, all-powerful market.
The market is supposed to do what management could not do — drive up efficiency and cut bureaucratic waste. In fact, it has increased both inefficiency and bureaucracy. A market is simply the buying and selling of commodities. But what are the commodities that the NHS produce? How to you attach a price tag to diabetes management, or childbirth, or forced detention and treatment under the Mental Health Act? The attempt to impose a market means that all the complex tasks that take place in the NHS have to be quantified. This in turn gave an extra impetus to management to design tools to measure what is happening in clinical areas. It created an insatiable demand for data even if this meant doctors and nurses spending hours at their computer screens filling in management’s tickboxes. In this way, management transform clinical work into into figures which can then be linked to funding.
There are five main problems with the approach to data harvesting.
1) The data may or may not reflect reality. Excellent performance only means that the ward staff are ticking the boxes on a form or computer screen. It does not mean that the tasks have actually been done. For example, Solidarity was told of a older adults wards where management have brought in a long checklist of personal hygiene tasks that nurses are supposed to tick off throughout the morning shift: change pad, clean teeth, wash face, shave, cut nails, wash hair etc. Management believe these forms will allow them to micromanage the nursing staff from behind their computer screens. Nurses tell us that they often perform tasks but forget to check off all the boxes on the form. Or if they are extremely busy one shift, they may tick a few extra boxes just so management don’t start complaining about poor performance. So much time wasted by management and staff for what will always be meaningless data.
2) Some performance measure are completely inappropriate for the clinical setting. For instance, some palliative care nurses have targets for the number of patients they speak to about smoking cessation. There are probably lots of things that a dying smoker wants to discuss with their palliative care nurse but giving up cigarettes isn’t one of them. Unsurprisingly hardly anyone takes up the offer of joining the smoking cessation programme but that does not matter. As long as the conversation has been had, the nurse can tick the box!
3) Sometimes the way a performance target is measured creates weird behaviour on the part of nursing staff. Recently, Solidarity heard of a clinical audit designed to monitor how psychiatric nurses were tending to the physical health of their patients. This is quite unobjectionable. The physical health of psychiatric patients is often neglected. However, a large portion of the audit was concerned with whether the patient’s details were written correctly on the front of their chart. Before audit day, nurses are locked away in the office vigilantly crosschecking their spelling while patients in psychological distress fend for themselves on the ward. One nurse calculated that it was possible to score very highly on the audit, and get top marks from management, without doing any physical health checks at all!
4) The demand for paperwork shifts clinicians’ attention. A recent RCN survey found that due to low staffing levels, 86% of nurses complained that there was not enough time on their shift to do all the tasks they needed to do. Of these 66% said that the main task left undone was “talking/comforting patients”. Talking and comforting patients, like other “soft skills”, is not easily quantifiable and not easy to plug into a spreadsheet. It is not prioritised by management and so it falls off the to-do list of overstretched nurses. At Mid-Staffordshire, staff were so focussed on ticking management’s boxes that (in the words of one junior doctor) they became “immune to the sound of pain”.
5) The worst consequences of this data-obsessed culture are the targets that have perverse results on patient care. The famous example is the four-hour waiting target in A&E. This led to some patients being left outside in ambulances during busy times because the clock only starts when the patient enters the building. Another famous example is the targets for putting patients on the Liverpool Care Pathway, which incentivised clinicians who were willing to diagnose an early death!
Successive governments and their big business advisers thought that all this data could be mashed together to create their dream of a healthcare market. With all this data, the accountants started to work out how to attach price tags onto the different complex tasks we perform. From the 1990s onwards, thousands of accountants have been employed whose job it is to attach price tags to different hospital treatments and send each other invoices, bills of payment and credit notes. The accountants and their hangers-on now consume 15% of the NHS budget and they are rapidly expanding.
The “duty to provide” comprehensive healthcare was the foundation stone of the NHS. It was a phrase that was included in every Health Bill from 1948 until it was ditched by Andrew Lansley in 2010.
It meant that the government had to put aside a certain amount of money that would cover the costs of healthcare for all. They would monitor demand from the previous year to work out the budgets for the next year and organise the long term investment strategy. Historically that money has always fallen short of what was needed but it was near. This is no longer the case. The demand for healthcare is outstripping supply. People are dying on trolley waits. The market is wreaking chaos across the system as human suffering is miscalculated into pounds and pence.
The market rationalises healthcare into a number of easy-to-commodify step-by-step processes. But its deaf to human suffering. It is creating a toxic environment where healthworkers are bullied into servicing the performance targets whether or not this benefits the patients. We are turned into drones, micromanaged into situations that harm patients and then blamed for not exercising our own clinical judgement.
All hierarchical organisations are susceptible to bullying. People in power enjoy a certain freedom to manipulate, cajole and abuse those with less power. Capitalism creates a world where some individuals own whole factories, hospitals or vast tracts of land as their personal property, while others only own the clothes on their back. Capitalism is a system in which bullies thrive. The only real antidote to the culture of bullying is workers organising in unions and taking back the power from the bullies.
The power of the bully can only be broken by a democratic movement from below. Such a movement would lead to better care in the NHS and open up possibilities for a more equal and democratic future.