Getting clinicians to speak up is the real key to fighting poor care
To the list of life’s certainties, Benjamin Franklin might have added the change from strong to light-touch public sector regulation and back again.
Complaints about bureaucracy diverting clinical staff and others from delivering care lead to promises that the burden of regulation will be reduced. Then along comes a scandal and cries of “something must be done” and the need for “annual inspections” once more becomes imperative.
It is the NHS equivalent of the claim that more bobbies on the beat is the best way to fight crime – an argument which trumps all evidence to the contrary and largely acts as a way to reassure the public.
In December 2009, Care Quality Commission chief executive Cynthia Bower assured HSJ that public and political outcry over care failings would not lead the regulator to increase the intensity of regulation.
Nineteen months later she tells HSJ that Winterbourne View and other scandals have demonstrated the need to “cross the threshold” to assess care.
Ms Bower claims this change of tack is a result of the disappointing findings of the CQC’s reviews into dignity and nutrition, but she also admits the public “want inspectors on wards… talking to frontline staff, observing care”.
The public, she adds “don’t want to hear about light-touch regulation”.
The CQC chief executive must, legally, remain silent on the public inquiry into the care failings at Mid Staffordshire Foundation Trust. So whether the CQC is jumping before being pushed by the inquiry’s recommendations will have to be surmised.
On the ground, inspections have merit, but they have never been a panacea. It is to be hoped the seminar section of the Mid Staffs inquiry scheduled for November and designed to tease out the lessons from witnesses might determine how inspections can be made more effective without placing such a burden on those being inspected that the result is counterproductive. It may also like to consider from where the extra £15m to fund the CQC’s proposed new inspection regime might come – and whether that sum may be better spent.
A far more powerful contribution than increasing the frequency of inspections can be made by those working in the system raising concerns about poor care.
Ms Bower stresses that commissioners and “providers and their boards” must “play their part”.
However, she stresses the role of professional regulators in underpinning the competence of “the person sitting in front of” the patient.
This theme is picked up in another perceptive intervention by Stephen Dorrell’s Commons health committee. In this week’s report on professional regulation he calls on the medical and nursing regulators to remind doctors and nurses that “failure to act” on concerns over the quality of care is “a serious breach of professional obligation”.
While the report focuses on regulators, Mr Dorrell in his usual subtle way is stressing the need for individual clinicians to take responsibility for the overall care system in which they work.
That responsibility is shirked for reasons ranging from apathy to ignorance to fear. Were the professional regulators – together with employers and professional institutions – able to overcome these barriers, it would be a huge advance.
Ms Bower makes one final point – merger with Monitor would remove the CQC’s advantage of not having to “think about money”. She is right about resisting a merger, but it still leaves the question hanging of how staff – particularly clinicians – can make a judgement between sensible efficiencies and dangerous cost cutting.
It is important that this often difficult calculation can be made – as it allows staff to raise concerns before care deteriorates seriously. Given the NHS is likely to need to find ever greater efficiencies for the rest of the decade, it is the crucial question affecting the quality of care.
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Readers' comments (11)
Anonymous | 28-Jul-2011 11:52 am
Great article Alistair! It highlights the precise reason why GP Commissioning is doomed to fail. When the oceans of bureaucrats and administrators (Daily Mail speak, sorry) are no more just who is going to feed the unremitting DoH beast? It won't be the GPs'. When the next scandal hits (as it surely will) who will be there to answer the questions and undertake the inevitable witch hunts (or investigations). Agin it won't be the GPs'. The denigration of NHS Managers and admin staff doing valuable work, albeit not in the jaundiced, one dimensional world of the tabloids is a national scandal and one which will come home to roost. To ask GP's to commission services at the same time as tying their arms behind their backs because they have to make unrealistic financial savings will not work. The quality/cost conundrum will further exascerbate the likelihood of systemic failure. Grass roots clinicians must speak out when they are concerned about quality being undermined to the point of being dangerous. But the question is will they? I have my doubts when jobs are in short supply but redundancy and job cuts are plentiful. The survival of the fittest comes in to play. Moreover in the current challenging climate I would imagine that more inspectors would be as welcome as an STD!
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Anonymous | 28-Jul-2011 1:59 pm
A great response to a great editorial! I personally have risked voicing a few minor critisms of cuts and changes in our clinical support service but have judged anything more contentious to be potentially career threatening. The NHS is not the only place that has to balance it's books - so do I and the dole queue or downbanding in the latest reshuffle won't do a lot for my mortgage repayments. A major safety issue is one thing, but an undesirable level of quality will not see me taking risks I cannot afford. Call me selfish but I need that monthly pay check
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Anonymous | 28-Jul-2011 6:16 pm
Individuals in hospitals and other care settings do indeed need to take responsibility and blow the whistle loud and shrill when they see problems emerging.
The CQC should set up a proper confidential whistle-blowers hotline for this BUT they should also get stuck into on the ground inspections.
The argument that inspections somehow equate to bobbies on the beat is wrong-headed. Any group of processionals caring for others need to know they could be checked upon at any time.
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Anonymous | 30-Jul-2011 10:33 am
Where would £15million come from to pay for better care quality inspections? Is your readership aware that Foundation Trusts spend 60% less on audit fees than other Trusts. Is that because FT audits are done to a lesser standard or because non-FTs have been paying too much?
Do your readers know how much the NHS has been spending on management consultants who happen to be directors of NHS Trusts or their close associates/relatives?
Then what about the good old NHS Confederation, an organisation that has twice failed to file its audited accounts on time in the last three years. maybe some savings could be made there.
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Patrick Newman | 1-Aug-2011 2:12 pm
It is the duty of all citizens to blow the cover on malpractice whether it is in the public or private sector. In the vast majority of cases it can be done with minimal risk but it does require rigour. I write from personal experience - dont ask!
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Anonymous | 1-Aug-2011 5:13 pm
Alastair,
An excellent beginning to the discussion and I would like to expand upon it.
1. CQC misses the point on clincial quality. It can influence the outcome - not by putting more inspectors out in the wards but by promulgating regulations that create an accountability model within the trust and among the clincial (and administrative) staff. Requiring trusts to have a "system of quality" and responsible executives held accountable (notably the medical director and service chief) is a far more effective way to proceed. Then as Demming says, you inspect what you expect.
2. Giving the medical director post real authority (instead of head of the local club of doctors) and accountability (the two go hand in hand) for development and delivery of the quality system - and training them to be good clinical executives is critical to the success. There are some within the NHS that understand this need, but nobody near the top has taken a position on it that I have seen.
3. Giving clinical staff access to performance and quailty data has demonstrated that they will begin to self-correct when exposed to their own data. When will trusts do this in a form that is easy to consume (and believable) by the clincial staff?
The regulators such as Monitor and now CQC are presented with a problem, it reminds me of the story of the workman who only has a hammer...everything looks like a nail. It would be refreshing for this discussion to develop more fully and influence "the regulators" to evaluate a less costly and more effective means of insuring quality and safety for our patients without always wanting more people and money.
There are good models where quality systems (continuous quality improvement, Demming, etc.) can be adapted (and have been successfully adapted in the past) to healthcare with stunning results. If combined with a more thougthful regulatory framework, where accountability with consequences is enabled, the NHS will emerge as a world class health delivery organization. Otherwise, you'll get more of the same no matter how much you spend...
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anne cassidy | 2-Aug-2011 12:27 pm
It was Abraham Maslow with the hammer quote, to give him is due, he was one of the fathers of humanistic psychology.
But anyway, in my opinion, the CQC should only consist of qualified clinicians who understand specific specialities and the worst and the best of practice. The need to have worked on the frontline in their speciality and be uptodate on best practice.
Without staff on the frontline expressing their concerns without fear of being 'victimised' then nothing will ever change. Whistleblowing should be seen as a 'virtue' and not as 'troublemaking' for management.
In an ideal world!
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Anonymous | 2-Aug-2011 7:31 pm
Anne,
In an ideal world...but even in one as imperfect as ours, the need to create incentives and penalties combined with holding leaders accountable within a system of quality is critical. As in all formal quality systems, all members of staff must feel safe in highlighting issues and/or improvement opportunities. In "bad" systems, whistleblowing is often used to beat down those for whom the system was intended to help. You must always watch out for the "law of unintended consequences"...but that's no reason not to do it!
By the way, having a regulator that is staffed by people qualifed to regulate seems obvious...but unfortunately it needed to be said. And not just about CQC.
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Richard Pound | 3-Aug-2011 8:14 am
I couldn't agree more with your points Alastair, and I believe that everyone would agree that in a 'perfect world' everyone would speak up when they see things they don't like or feel are detrimental to patient care. The question is therefore, how do we get people to speak up to break this culture of silence or culture of avoidance where we all collectively ignore issues?
The answer is not a single silver bullet of more inspections, regulators or better data - it's a combination of factors that will influence people to change - factors that motivate and enable people to speak up. People need to be constantly personally motivated to speak up, they need to have the personal skills to speak up (not as easy as it sounds): People need the social support at all levels, so they feel able and encouraged to speak up; People need to know that the consequences of speaking up or 'whistle blowing' , is not going to lead to isolation or sidelining or worse - in fact we need to publically celebrate when people do speak up. Finally we need to create an environment that makes it easy for people to speak and remind them of the importance of this.
Combining these '6 sources of influence' into a single influence strategy for change is the only way to get people to speak up. Very very few people come into work to harm patients and provide poor care, but we are blind and outnumbered by the various sources of influence that determine our behaviour - and stop us speaking up when we see things going wrong. If our sole weaponary to get people to speak up and improve care is 'regulation', we are failing to understand the complexities of human behaviour.
We did some 'Silence KIlls' research with hundreds of NHS staff last year, and have shown that if we do use these 6 sources, you are 10 times more likely to get people to speak up.
If anyone would like a copy of this research, please email me at richard@gra.uk.com
Thanks Alastair for re-starting this debate, that is the key to improving patient care.
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Anonymous | 3-Aug-2011 8:40 am
'The strange thing about the dog is that it did not bark, my dear Watson'. Is it not the case that most of the problems in the NHS are because it is overflowing at every level with dogs that do not bark ?
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Anonymous | 3-Aug-2011 11:45 am
It might be a good idea to change the word 'whistleblower' to something more positive, as whistle blowing I think is now considered to have negative connotations. Having been a whistle blower in the past, I know from experience, I was viewed as 'dangerous' even amongst my own colleagues who knew abuse was going on. Some of them were the perpetrators of the abuse so I didn't expect them to throw a thank you party for me, but even those who hadn't particpated, the good guys, viewed me as some kind of 'loose canon' and distanced themselves from me. I would do the same again even though it was tough and I ended up being sent home by a manager a year or so later because of the 'strain' it placed me under. Somehow you are viewed as a 'traitor' for sticking up for the patients against your colleagues. Ultimately after a long investigation I was offered a post 'elsewhere' to remove me from the bad feeling of others, or was it? When whistleblowers are treated in this appalling way I can fully understand why they do not want to put themselves into the firing line, but if as above, all this could change, and it is already too long coming, then at last we shall be free to the do the 'right thing'. It is a sad lesson to learn that some managers really don't want to know about what goes on behind closed doors and a real eye opener for me at the time because I was naive enough to think that they would want to know. The dogs aren't barking because they are too frightened of a beating. They have probably seen other whistleblowers hung out to dry, ex-communicated and left a wreck wondering what on earth it was they did that was wrong, when they themselves would have liked to have reported the same problems also. If reporting abuse then leaves you wide open to become a victim of abuse by the people you reported the abuse to then what hope is there for people to volunteer themselves for that?. Every concern raised, wherever possible, should be resolved at the lowest level possible, but when this does not happen, then there is nothing left but to blow the whislte, and as it stands at the moment, take your lumps! What a farce.
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