NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says

BMJ 2013; 346 doi: (Published 06 February 2013) Cite this as: BMJ 2013;346:f847

Re: NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says

In the aftermath of the Francis report, much discussion has focused on the "culture" within the NHS. The assumption underlying this commentary is that individual doctors and nurses failed in their duty to patients, and that this reflected a uncaring culture verging on a deliberate and sustained indifference to patient's needs.

What is not said however, or at least not loudly or often enough, is that the managerial architecture of the NHS is fundamentally incompatible with optimising patient outcomes.

As a junior doctor, I regularly sit down with friends who for some reason (better pay, career prospects, and working conditions?) decided to pursue alternative careers. One, for instance works for Deloitte, the accountancy firm. A comparison of the structure of the organisations is enlightening.

FY1 doctors work in a small team, supervised by and reporting to seniors (SHOs and SpRs) who do a similar job to mine, and who at one time did my job and thus understand it. Above them is a consultant with overall responsibility for the team. This model parallels the structure at the accountancy firm. It works well, those with more experience have more responsibility, and benefit from understanding the practicalities of the roles they supervise. Beyond the level of consultant however, the comparison begins to fall apart. Whilst premier law or accountancy firms would never accept having people at the very top with no experience as a lawyer or accountant, for some reason the NHS is populated with senior managers who are completely disconnected from the service they run. The reason for this is obvious. They have often never worked as a doctor or nurse. They know nothing of the job at the level at which patient care is delivered. It is surprising therefore that we consider these people a good choice to run a hospital. We have no more right to express surprise when things go wrong than would be justified if Lord Darzi was asked to run BMW.

The relationship between managers and clinical staff in the NHS, rather than paralleling that of our strongest companies, is more akin to that between the Soviet Red Army and political commissars in the 1940s. One branch of the organisation gets on with the job, tactically ignoring proclamations from the ivory tower in the name of getting things done. Rarely does communication flow the opposite way, from the front lines backwards. No channels exist for this to occur, and those at the front, rightly or wrongly, believe that any attempt to do so would be forlorn. By 1946 there were 600 men in Russia for every 1000 women. It is not a management structure we should to emulate.

The consequences for patient care are dramatic. As a house officer I have had to justify to the nursing manager (first time I met her incidentally) why we weren't going to discharge each patient that day. I thought saying "this gentleman's sodium is 119, it was 134" was a good justification for keeping him in. It wasn't. I had to go on to explain that "having a new sodium of 119 is bad". Other conversations have gone along the lines of "please don't move this woman from AED majors, I don't care if she's about to breech, her systolic is suddenly 82 and we don't know why". She was moved anyway. I was later told that senior nurses in AED have lost their jobs due to the number of breeches. I doubt they were laid off by any of the consultants.

The reality is that the NHS has the wrong people in the wrong positions. Only when this is changed can we expect the "culture" to follow. It will only change if the people at the very top know how to take a blood culture, rather than just issuing proclamations reminding us of the importance of avoiding contamination. I know the importance of avoiding contamination. It would be much easier to do so however, if we had the right equipment. Why we expect people in supplies and purchasing who have never taken a blood culture to know what equipment is necessary is beyond me. This is the problem. It is the same problem that leads to understaffing amongst nurses on the ward, or to equipment issues in theatre.

The Francis report should stimulate us to question as an institution how the events at North Staffordshire occurred. As an entity, the NHS needs to think about what management is necessary and desirable. Until this addressed, we will never be able to ensure we don't suffer a repeat of the terrible events in the North Midlands.

Competing interests: No competing interests

10 February 2013
Thomas Hayes
House Officer