Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern

Welcome to this week’s Risk Register. Let me know about safety and workforce issues. You can contact me in confidence here.

Shaun Lintern, patient safety correspondent

GMC takes important first step

The standard you walk past is the standard you accept, goes a well known line. When senior NHS staff look the other way on issues of safety it prevents accountability and learning, as well as perpetuating and in many ways directly contributing to poor care for future patients. The scandals at Mid Staffordshire and Morecambe Bay both had their genesis in senior staff who looked the other way when they could have prevented things spiralling into disaster.

The General Medical Council this month made a first step towards sending a clear message to senior doctors that turning a blind eye to problems is unacceptable. The medical watchdog’s independent tribunal service struck off the former medical director at Royal Cornwall Hospitals Trust, Robert Pitcher, for failing to take action over concerns about the performance of surgeon Rob Jones.

This is the first time the medical regulator has struck off a doctor for management failings instead of mistakes linked to clinical care – a fact many patients may find inexplicable.

The GMC decided not to put the case against senior medical directors at Mid Staffordshire to a tribunal. Regardless of the advice that there was no prospect of success, the GMC appeared to ignore that there was a public interest in the tribunal ruling on the cases.

But in striking off against Dr Pitcher, the GMC is now making clear that if you’re a doctor in a senior position, your duties under the medical code of practice around management of others and protecting the public are not diluted by being several steps removed from an incident.

Dr Pitcher failed to take appropriate steps to protect patients from risk of harm and ignored the conclusions of four expert reviewers who warned there were “significant concerns that require resolution” – identifying 46 serious failings in Mr Jones’s practice.

However, this ruling could further act as a disincentive for doctors not to step up into senior management roles. Equally, the treatment of whistleblowers and the lack of a culture of openness about mistakes in the NHS is far from encouraging.

Nevertheless, senior doctors have a duty to patients not under their direct care, and having that underlined by the GMC is no bad thing and long overdue.

Something wicked this way comes

Leaked documents seen by HSJ reveal for the first time what Health Education England expects the new band four nursing associates to be able to do. And for those familiar with the evidence around nurse staffing and patient safety they could make frightening reading.

The internal documents say nurse associates will be expected to work independently of qualified nurses and will be expected to calculate drug doses safely, as well as administer medication, including controlled drugs, without direct supervision of nurses.

Critics of the nurse associate role, which is supposed to be aimed at creating a career framework for band two and three healthcare assistants, say it will be used and viewed as nursing on the cheap – a substitute for registered nurses.

The role is being developed in the absence of evidence and in the face of mounting research that shows a link between substituting nurses for non-nurses and an increase in mortality and harm.

There is a case to be made for an enhanced band four healthcare assistant role, but allowing them to calculate and administer controlled drugs risks undermining nurses and could be a tempting option for trusts faced with pressure to reduce their paybill and a paucity of qualified staff.

There is a worrying lack of discussion around safeguarding nurse numbers in the NHS and ensuring nurse associates are not used inappropriately.

What we say matters

HEE deserves praise for its efforts to encourage nurses to return to practice, even though this is not its job (it is responsible only for future supply of the workforce). It has invested more than £5m into the project, which has attracted more than 1,500 nurses back.

But the national education and training body has also fallen into the trap of belittling nurses in some of its advertising. For example, in one tweet it said “nurses are beacons of care, hope and compassion”, while a radio advert described the “hands on caring” of nurses, etc, etc.

What is lacking in the campaign is a celebration of nurses as highly skilled and technically competent professionals, with extensive medical knowledge and the ability to critically interpret research and advocate evidence based treatment. Nurses no longer just wipe the brow of the surgeon and fold the bed sheets. As medicine and technology have advanced so has nursing – making it a profession requiring a degree.

Too often the NHS, national bodies and the media can stereotype nurses as angels who have some sort of natural gift to hold patients hands and whisper nice words to them. This implies someone else is actually responsible for the advanced clinical care many patients need.

The reality is that clinical care is a multidisciplinary team effort, with all staff involved, but nurses are often the critical factor in good patient outcomes. Yet they are too easily stereotyped as hand maidens. Perhaps HEE’s ads are a defensive reaction to criticism of nursing post-Francis? If so it’s the wrong answer – the profession needs to celebrate and recognise in itself the high level of skill required to be a successful nurse.

Contrast the approach of HEE to this recent video posted by the Johns Hopkins nursing school in the US. It includes a nod to care and compassion but also references nurses testifying to Congress and interpretation of data and research. Its website says: “The magnitude of the profession is much more than what meets the eye.” It has launched the hashtag on social media #wegotthis to show nurses as they are and will undoubtedly make any nurse feel pride in their skills and professional ability. Let’s see more of this in the UK.