Re: How the message from mortality figures was missed at Mid Staffs
The current debate over analysis of death statistics in the Mid Staffs tragedy is a further example of the failure to grasp the essential problem. It is instructive to contrast the academic debate over the significance of the statistics with the impotent fury of the patients' relatives. On the one hand we have obscure argument about encoding and interpretation of numbers, on the other uncomprehending bewilderment at the obvious cruelty and neglect in what was supposed to be a caring environment.
I am no statistician, but even I know that an association is far from being evidence of causation. In this case I have seen no attempt to correlate the variations in death rates with degrees of neglect and callousness between health authorities. Indeed it is hard to imagine how that might be done, or why. The fact that this appalling routine mistreatment of inpatients in an NHS needed years of examination of abstract data on death rates before it became a matter of public discussion tells us almost all we need to know about the culture of psychopathic insouciance among some managers and politicians in British hospitals.
I qualified in medicine in 1972. Like all people at my time of life I am tempted to view my youth as a golden age lost beyond recall. I try to resist this tendency, but I cannot remember patients being left in filthy urine soaked sheets by demoralised and overburdened nurses. Patients who could not feed themselves were usually given a nurse whose job it was to ensure that they were fed, and those who appeared to be dehydrating were monitored with fluid balance charts.
One of my duties in the years before retirement was as medical attendant of a nursing home for the demented elderly. There was little that I or the nurses could do for the residents but nurse them properly. I remember patients discharged from acute wards at the local hospital with terrible decubitus ulcers which, with proper nursing care healed. Indeed I remember one bed bound patient who was admitted from the home to an acute unit with entire skin who returned some weeks later with terrible sores on buttocks and thighs and sadly died before being able to recover. On several occasions I tried to dissuade patients’ relatives from insisting on acute admission for their parents. I knew that there was little medically to offer to the unfortunate patients, and that the nursing offered in the home would be kinder and more effective than that in the hospital. The staff of the hospital wards I frequented as a junior doctor would have been mortified if one of their patients had developed bed sores in their care. It would have been a disciplinary matter in most cases.
How have we reached this dreadful state of affairs? The answers are not simple, but I fear they are not to be found in the output of spreadsheets and statistical calculations. At least part of the answer must lie in the culture of corporate management which has been applied to the NHS.
Faced with an apparently unmanageable professional medical and nursing workforce there has been a concerted attempt to disempower and disenfranchise them in order to concentrate authority in the hands of the management. Lacking the traditional authority which the professions owned, the managers have sought to cloak themselves in borrowed garments from industrial and academic management. Programmes of management reform have been taken from, for example, Japanese motor factories. Neglecting the obvious points that few if any workers in the NHS grew up in the culture of respect and subservience common in Japan, and that screwing metal and plastic together is rather different from caring for ill people. I fear many millions of pounds have been spent on this and other fatuous exercises which have been as effective as applying the principles of mining engineering to the production of grand opera.
Power has been concentrated in the hands of a management elite who consider themselves apart from the rest of the hospital staff. They issue decrees to the professional staff according to the arcane principles of their creed and are careless of any consequence other than that on the financial and statistical figures on which they are judged. There has been a lot of po-faced agonising from responsible managers, but there seems to be little recognition of the true problem. There has been a collapse of trust between managers and managed. Professional staff who retain the decency and sensitivity to wish to care for their patients become demoralised or are victimised for raising their concerns. A Gresham’s Law of nursing quality applies. Managers spend their time poring over spreadsheets and preparing reports and presentations, when all they need to do is to stand up from their desks and walk into the wards of the institutions for which they are responsible. If they spot a patient who is starving or lying in filthy bedding or a filthy toilet then they should insist that the matter be remedied instantly. We used to have such managers, they were called matrons.
The disaster in Mid Staffs has been brought to light because the statistical data became undeniable. I, and countless other doctors and nurses, not to mention patients and their relatives know that it is far from unique. The caring heart of the NHS has been ripped out and substituted with an untried and experimental artificial organ. Even if none of the (disputed) excess deaths in Mid Staffs could be attributed to negligence of simple decent care of the patients this would not diminish the iniquity of the neglect. We have been robbed of our simple professional moral compass and are being guided by those who have no satisfactory substitute.
We can say of the current Chief Executive of the NHS as the revolting students of the Sorbonne said in 1968 of De Gaulle, and perhaps in this case more appropriately, “Le chie en lit c’est lui.”