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Good people do bad things
  1. John Saunders
  1. Correspondence to Professor John Saunders, Department of Medicine, Nevill Hall Hospital, Abergavenny, Gwent NP7 7EG, UK; saundersjohn{at}doctors.org.uk

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Bad things happened at Mid Staffordshire National Health Service (NHS) Trust (mid Staffs). The key question, having determined what, is to ask why. Why do good people do bad things? Upon this depends the sorts of actions that we might propose, extending and realising those made in the Francis report itself.

In their valuable paper, Newdick and Danbury analyse the issues from the perspectives of individuals, systems and then through the lens of cognitive psychology.1 All three perspectives offer food for thought and all three factors contributed to the failure. But which offers insights into the best possibility of progress? Wisely, that is left for us readers.

We are reminded at the outset of the 2001 inquiry into the deaths of children at the Bristol Royal Infirmary.2 That event is now so distant that many younger doctors are entirely ignorant of it and many older doctors will, like me, remember it as primarily a failure of three men, all disciplined by the General Medical Council (GMC). We can recall, for example, the demonstrations outside the GMC building as those accused of substandard practice arrived—perhaps most notably against the surgeon, James Wisheart, an obviously decent man. But return to the report itself and one realises how flawed is this recollection. Bristol was characterised by ‘poor organisation, failure of communication, lack of leadership, paternalism and a “club culture”’ with ‘a failure to put patients at the centre of care.’2 Its conclusion too was that children were ‘failed by the system that was supposed to make them well.’2 Enough resemblances here. And rather than my flawed recollection of three guilty men, the Bristol report begins: ‘Bristol is not an account of bad people. Nor is it an account of people who did not care, nor of people who wilfully harmed patients. It is an account of people who cared greatly about human suffering, and were dedicated and well motivated …. It is an account of healthcare professionals working in Bristol who were victim of a combination of circumstances which owed as much to general failings in the NHS… than to any individual failing. Despite their manifest good intentions and long hours of dedicated work, there were failures….’2 Rather than individual vilification, the Bristol Report offers understanding.

The 19 pages of its summary remain worth reading: short enough to prescribe for study rather than the impossible recommendation by Newdick and Danbury that the Francis report (1782 pages, plus 815 in the first report) should be compulsory reading for all clinical undergraduates—for which the nine pages of Robert Francis's Press statement represent a more realistic aspiration for study. (Or the NHS director's equally unattainable suggestion that ‘every individual needs to take the time to read the full report.’).3

How depressing it is that the secretary of state has demanded an explanation as to why the professional regulators have ‘struck nobody off’ or the prime minister striking the same populist note: ‘We expect hospitals to take disciplinary action against staff who abuse their patients. We expect professional regulators to strike off doctors and nurses who seriously breach their professional codes.’4 Yes, of course we do: but such existent powers did not prevent events in mid Staffs. Tough on poor care, yes; but more productive might be toughness on its causes. Emphasis upon individual discipline has manifestly failed. The main failings, according to Francis, were those of management and regulators. Newdick and Danbury show that there is no shortage of standards. The issue is enabling and promoting their realisation. The public mood may demand individuals to put in the stocks, but mature reflection acknowledges that there is a more complex debate to be had around the limits of obligation for professionals, the factors that motivate or discourage, the disempowerment that is inevitable in a more highly managed service and the promotion of virtue. These are beyond diktat, guidelines, unread protocols on hospital intranets and managerial exhortation. Intelligent kindness,5 medical humanities and the lessons of psychological experimentation may have more to offer.6

What has shocked most of us, I would guess, is not the numbers of estimated excess deaths in mid Staffs (appalling though that is), but the instances of uncaring and unkind behaviour. We return to the Platonic question in the Meno: can virtue be taught?7 How does an understanding of the Aristotelian (and Kantian in the Tugendlehre) writings on virtue sit with a view of ethics that often goes no further than a definition of four principles? When Francis recommends, without qualification, that ‘staff put patients before themselves’8 or that nursing recruits should be able to ‘put the welfare of others above their own interests’,9 does this suggest paradoxically that supererogation becomes obligatory? How far does responsibility for the welfare of the patient extend beyond the welfare of others to whom I also have responsibility, well after I have exceeded any norm of reasonable working hours? And Kantians will ask, do not I have duties to myself too? In short, what is a reasonable and achievable aspiration? The best is often the enemy of the good. Demanding the unreasonable may achieve no more than demoralisation. What is compassion?10 Is it always needed?11

Newdick and Danbury avoid the platitudinous conclusion that ‘further studies are needed’. Yet, in pointing to the pile of previous NHS reports, they raise the question as to what inquiries achieve, beyond more ineffective regulation. Mid Staffs was primarily a failure of practical ethics, not of protocol or guideline driven care, nor one of professional ignorance or expertise. Continued engagement, discussion and study must surely be required about the nature of professional obligation and its realisation. Much of that will be educational. A helpful start would be the publication of a short annotated ‘reader’ for students (ie, all of us) with relevant extracts from the series of reports to which Newdick and Danbury—and Francis himself—refer.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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