Clinical governance and the role of NHS boards: learning lessons from the case of Ian Paterson
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2138 (Published 02 May 2017) Cite this as: BMJ 2017;357:j2138
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The salient aspect in common of Mid-Staffs and Paterson is the prevailing of institutional interests over patients' safety. Of course some NHS managers, and some sociopaths, may be doctors.
The harms here are from decisions that were taken by senior management to persist in cutting staff posts, or to close down potentially damaging complaints in order to protect their institution.
In both cases, patients were put directly at risk as a result of these decisions.
In the case of MidStaffs, even more senior managers then decided to close down NICE's work on the Francis Inquiry's recommendations on safe clinical staffing ratios.
Such decisions are indicative of the culture of management, not a culture of Medicine. It's inaccurate and unhelpful to caption the article as a look at the venality of the "club" of Medicine, when it is clearly management decisions that require scrutiny.
These tensions in the NHS have never been more relevant, particularly as managers in untenable situations seem prone to ape the dissociative behaviour we see so much of from cognitively dissonant Politicians.
Competing interests: No competing interests
The Paterson case raises many issues that have been discussed and debated before as Simon Peck observes. But before we reach for yet more structural changes, regulatory reforms or other initiatives, it seems to me, as Mayur Lakhani suggests, we should consider very carefully how the recommendations from past inquiries have been implemented and what we have learned.
I read the responses from Nick Mann and Manolis Heliotis with some sadness. Both seem to see my editorial as a personal or collective attack on the medical profession. Mann asserts that it is mostly the fault of "NHS managers", but seems not to realise that in the Paterson case and others like it, many of the "NHS managers" he excoriates are clinicians - doctors, nurses and others. It is unhelpfully simplistic to draw a distinction between senior leaders with and without a clinical background - and surely more productive to ask why they and the organisations they lead have not been able to create a more honest and transparent culture of accountability. On the other hand, Heliotis seems to think that people like me who are not doctors are in no position to question or critique the profession - we have, to use his phrase, "no skin in the game". This is an attitude to professional accountability which was commonplace in the medical profession in the 1980s when I first started working with doctors on medical and clinical audit. Thankfully, it is much rarer now, but his comments and their tenor nicely illustrate the enduring cultural challenge.
Kieran Walshe
.
Competing interests: No competing interests
I question what a public enquiry into the Paterson case itself will achieve. The facts are already in the public domain and the story is familiar. And it will not be long before another similar case comes to light and we have the same debate again. Much more useful in my view would be a general consideration of how healthcare is regulated and some reflection on how such concerns might better be addressed in future.
There is no organisation that I am aware of with a remit to investigate serious allegations of poor practice together with the surrounding failures of governance and systems which allow it to occur - except the management of the hospitals themselves. As we see time and time again the response of hospital management is to try to limit reputational damage and I do not see this ever changing. The GMC’s remit is to ensure that doctors on the register are fit to practise – they do not investigate malpractice. The CQC has a defined and limited remit based on prescribed standards – it does not have an open remit to investigate concerns and it does not investigate doctors at all. Likewise the MHRA concerns itself with drugs and devices. The civil courts are concerned with financial compensation to individuals and the criminal justice system requires it to be demonstrated beyond reasonable doubt that a law has been broken in specific cases. There is no body whose remit is to look at a concern, identify the underlying causes and deal with the problem in a holistic manner.
I have taken a small number of cases to the GMC and found their response to be particularly disappointing – in my experience, their investigation methodology is flawed, their case preparation can be poor and they are inclined to dismiss incidents as being one-off without actually ascertaining whether this is the case. The Professional Standards Authority does not have the power to scrutinise a decision by the GMC not to investigate so the GMC can dismiss complaints and is not accountable in doing so. There appears to be no easy way to ascertain how many complaints have been made to the GMC about an individual. I know of a recent request for such information under the Freedom of Information Act which was declined.
Whilst I cannot immediately suggest a solution – in my view the important question for the future is not what happened in this case but how serious allegations should be handled and by whom. The solution might be as simple as having a complaints investigation process that is independent of the management of the hospital in which the problems occurred and which is able to work proactively and across the boundaries of the different regulators and interests.
Competing interests: I am an insurance medical officer who has raised concerns about doctors in the course of my work. These views however are my are own and written in the capacity of a private individual.
There is much in this editorial to support and the reservations expressed subsequently also have force. Nevertheless, there is an additional dimension which is difficult in the circumstances to raise but important to consider. That is the kind of person we would like to see as a doctor.
We all have different personalities. Each one of us is also a mixture; some parts may be excellent, some less so. Some parts are good in some circumstances but not in others. Although we could write a list of the qualities we would like to see in every doctor, we would never find anyone who had them all.
This is true in any field. To take some famous examples, Churchill was often the despair of his chiefs of staff; he himself described Montgomery as ‘insufferable’ and the Cross of Lorraine (de Gaulle) as the heaviest of the many crosses he had to bear. But all three were indomitable when it was needed.
Our predicament is that many of those we perceive to have the most difficult personalities are also the most creative. Those who tear up the protocols, refuse to attend meetings, miss the fire lecture, demur from filling in their own or someone else’s portfolio (the last two described by Henry Marsh, the neurosurgeon), may be telling us something we really need to know and understand. Every so often, the committee, the protocol and the team becomes the problem, not the solution; to hide behind them forever leads to stagnation.
Sometimes, to advance, we need to take risks, to step out of line. And occasionally (we should acknowledge) taking risks ends in disaster
Competing interests: No competing interests
The "Medicine's Club Culture" strapline for this article is entirely at odds with the quoted findings of the Kennedy report, which highlight persistent managerial failings in responding to whistleblowers' reports since 2003. Does Walshe have difficulty distinguishing the chasm that separates NHS doctors from NHS managers?
One might have expected the logical emphasis should have been on Sir Robert Francis QC's call for regulation and accountability of NHS managers to be brought into line with that of NHS Doctors.
Francis described the pressures on managers at Mid-Staffs not to jeopardise their drive towards Foundation Trust (FT) status, thereby allowing staff cost-cutting to escalate to unsafe levels in the pursuit of financial targets which were critical to achieving their FT status. Francis knows he has been ignored by Govt - as cost-cutting remains the prime directive - when he predicts "another Mid-Staffs is inevitable".
It is very clear that doctors blew the whistle on Paterson early on, but were sidelined and silenced by management. The culture of secrecy, as with Mid-Staffs, is to be found in NHS Management not in NHS Medicine.
There are similarities in the behaviour of Heart of England Foundation Trust (HEFT) with the managerial failings that presaged the Mid-Staffs failures as described in the Francis report, 2013.
Is it possible that, having just achieved their own FT status in 2005, HEFT managers may have been disinclined to draw attention to Paterson's performance at their hospital for fear that their FT status might be rescinded?
The institutional secrecy enjoyed by private hospitals who allowed Paterson to carry out banned operations is also highlighted here: that they have zero accountability for the doctors they (putatively) employ, and a failure to publish their data on patient safety, mortality and complications.
A forensic examination of the Paterson case might help Walshe et al understand that the inaccurate and disparaging "club" assignation may well be attributable to a culture of managerial self-interest, but has no tangible bearing on Paterson's medical colleagues.
It is poignant that Health Education England had to be (successfully) sued in court (Day v HEE, May 2017) in order to allow 54,000 junior doctors the same access to legal protections as other NHS whistleblowers.
Which club does Walshe belong to?
Competing interests: No competing interests
What has happened is an outrage and as member of the medical profession, I felt shocked and angry that a doctor could commit such heinous acts. The distress suffered by patients with long term effects is unimaginable and they must be given all the necessary support. So, I agree with your editorial for a Paterson Inquiry (1) particularly to look at why current systems failed. There should be a look at the documentation and outputs from his appraisals and the recommendations made for revalidation.
I would however caution against any ‘knee-jerk’ changes to regulation. An increase in regulation may not have the desired effect and has unintended consequences. It can lead to doctors to practise defensively, over investigate and avoid complex cases (2) which works against patients’ interest. Finally it may not even detect rogues like Ian Patterson and Harold Shipman.
Let us have period of calm and reflection to learn the lessons and consider how things like this can prevented – for they must be prevented - before rushing automatically to more radical regulation. Yes, changes must occur but as a start, let us make our existing systems work better.
Professor Mayur Lakhani CBE FRCGP
GP and Past Chairman, Royal College of GPs
Highgate Medical Centre
5 Storer Close
Sileby
Loughborough
LE12 7UD
@doctormayur
References
1) Walsh K, Chambers N.BMJ 2017;357:j2138
2) Bourne T, Wynants L, Peters M, et al The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey
BMJ Open 2015;5:e006687. doi: 10.1136/bmjopen-2014-006687
Competing interests: No competing interests
Kieran Walshe correctly analyses the issues in the Paterson case with systematic logic and quoted evidence stating that failure occurred despite the reams of reforms and new processes introduced in the last few years. Yet the author jumps to an illogical, unsubstantiated and evidence lacking conclusion that it's the ..."persistent and enduring professional 'club' culture in medicine, which so often acts to protect doctors rather than patients". Yet his own analysis in the article points to massive system failures in process and organisational management. He presents zero evidence in his article that it's the "club" culture in medicine; currently in politics and journalism this is the definition of fake news, skewing opinion for a cause. This false conclusion doesn't help patients or shape good health policy nor does it serve to address the root cause which is process and management failure. Not conspiratorial protection "clubs" in medicine.
Can Professor Walshe come down from his university ivory tower: Has Professor Walshe got skin in the game? Does he practice or has he ever practiced medicine to any meaningful extent? Has he been through the various professional and organisational processes himself on a yearly basis successfully? Does he hone any clinical and management skills on the said processes on the coal face himself, daily in a hospital or GP practice in a way that affects him professionally? Is it therefore appropriate for armchair generals who do not practice and have no skin in the game to label the profession as a "club" without giving evidence in an article for such an outrageous statement? Are there poorly performing doctors? Yes. I have managed several myself and am investigating several presently. But objectively. Without vilification. With proper processes, firmly but also with the requisite compassion where appropriate. Does Professor Walsh have any idea what this involves on a personal and organisational scale?
The correct perspective that Professor Walshe should have given is that there are millions of procedures carried out yearly by thousands of doctors in the UK, 99% of whom do this very skilfully, compassionately and successfully. We need to see this case for what it is: Failure in the implementation of management processes by several organisations and their management leadership structure to arrest poor practice timeously in one doctor in the 1% bracket. As a Divisional Director of Surgery in one of the largest Trusts in the UK I do not know of the "club" Professor Walshe alludes to.
Competing interests: No competing interests
Re: Clinical governance and the role of NHS boards: learning lessons from the case of Ian Paterson
My challenge to Walshe in the rapid response to his editorial was that his otherwise good analysis of the Paterson case came to an illogical, evidence lacking and derogatory conclusion of a "club culture" in medicine. We should expect more of editorial academic vigour. Particularly when derisory labels to a profession are made in an editorial that is read by an international audience of patients and policy makers. Where in my response does it state that non clinicians should not have the right to question our profession as Walshe wrongly states? What my tenor illustrated is that academics paid by the public purse and are side line commentators to a profession they do not practise and have no accountability in, should be vigorous in their assessment of the facts before branding evidence lacking labels such as "clubs" to professionals that are indeed accountable for their jobs to the public, the organisations they work for and to a highly regulated professional body. Doctors lacking clinical judgement are not infrequently suspended from the profession. To whom is Walshe answerable, over his lapse of serious academic judgement in an internationally read editorial, in passing a non-evidence based label of "club" to the current professional medical body in the U.K? Nobody other than a benign medical readership to whom he shows contempt with this label knowing there is no recourse. The meaning of not having 'skin in the game' could not be a more apt description.
Competing interests: No competing interests