Intended for healthcare professionals


In brief

BMJ 2003; 326 doi: (Published 29 May 2003) Cite this as: BMJ 2003;326:1162

Truths, untruths and health service regulation post Bristol

The Skidmore case is interesting as he was dismissed by his trust
amid allegations of misconduct relating to a single episode. He had been
accused of untruthfully stating to a patient, her family, the hospital
authorities, and the local community health council that the instrument
that had punctured an artery during an operation had been faulty and
returned to the manufacturer.[1,2] The arterial puncture had, according to
the anaesthetist's contemporaneous notes, then led to blood loss and the
need for a short period of cardiopulmonary resuscitation. Mr Skidmore had
claimed in his explanation of events that blood loss was normal and that
resuscitation had not been required. Having been sacked he was then
referred by the trust to the GMC but the complaints were dismissed at the
preliminary proceedings committee stage.[3] Mr Skidmore won his case
because the trust dismissed him using personal rather than professional
misconduct procedures.[2]

Are standards of truth and being held to account different for
managers? Many managers have been less than truthful when making claims
about waiting lists but have been paid off rather than held to account by
a trust.[4] Nor, in general, have they been sacked for deception as was
claimed by Nigel Crisp in a recent appearance before the Public
Administration Committee.[5]

Truths and untruths arise elsewhere in relation to management issues.
For example, is the following truthful or untruthful in relation to an
explanation for a trust's pay award?

"One other factor affected Director remuneration in 98/99 and that
was the regrading of two Board level posts following an independent
external review. This review compared salaries with similar sized Trusts
across the NHS, having regard to size and complexity of organisation and
the specific duties and responsibilities of individual Directors. The
decision to re-grade these posts was taken by the Remuneration Committee
with the involvement of our external auditors XXX who continually audit
the work of the Remuneration Committee to ensure probity."

At face value it seems a full, open, and believable explanation.
However, it would be improper for the external auditor to be involved in
remuneration committee decision making. It is also the trust's own
internal auditor that ensures the probity of remuneration committee work
not the external auditor. The external auditor in 1998/99 was only obliged
to see that pay information and a government pay guidance compliance
statement were present in an annual report not check on their truth and
accuracy. That checking of detail was the role of internal audit in
helping to ensure internal financial control within the trust. Were these
deliberate untruths or were they misleading claims made through lack of
knowledge about internal control arrangements and internal financial
control that would be of some considerable concern in an experienced chief
executive responsible and accountable for such matters?

Doctors, managers, and the Department of Health should promote the
culture of openness in the NHS to ensure that mistakes are acknowledged,
explained and learned from so that they are not repeated. The NHS needs to
be perceived by the public as an open and honest organisation and a place
where the truth is told and its staff are trustworthy. It is important
that there are suitable independent systems in place such as , for
example, the GMC for doctors and the NMC for nurse and midwives that will
hold people to account for personal or professional misconduct and will
also ensure that procedures are used fairly and appropriately. It is time
that senior health service managers caught up with the needs of the public
and a modern health service and had a truly independent body in line with
the recommendations made by Professor Sir Ian Kennedy following the
Bristol Inquiry.[6]

[1] In brief. Surgeon wins support of House of Lords. BMJ

[2] Professional or personal misconduct. Skidmore v Dartford and
Gravesham NHS Trust. Times Law Report, Friday 23 May 2003.

[3] Dyer C. Surgeon wins court of appeal battle four years after
dismissal. BMJ 2002;324:192.

[4] National Audit Office. Inappropriate adjustments to NHS waiting
lists. London: The Stationery Offfice, 2001.

[5] Public Administration - Minutes of Evidence. Thursday 30 January
2003. Minutes 920 and 921.
ix/3013001.htm (accessed 27.3.03)

[6] Learning from Bristol. The Department of Health's Response to
Report of Public Inquiry into children's heart surgery at the Bristol
Royal Infirmary 1984 - 1995.

The views expressed are those of the author and not the employing
organisation whose management follows the spirit and details of government
pay guidance letters.

Competing interests:  
None declared

Competing interests: No competing interests

14 June 2003
Nigel Dudley
Consultant in Elderly Medicine
St James's University Hospital, LEEDS LS9 7TF