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Newdick and Danbury1 rightly point to the depressing fact that not much seems to have changed since the Kennedy report2 following the Bristol scandal. The Bristol inquiry concerned the standards of care applied in the treatment of a relatively small group of patients, namely babies with serious heart problems, devastating and tragic though the consequences of failure were in those cases. The exposures at Stafford showed that many of the issues seen in Bristol persisted and affected many more patients. Doctors in Stafford showed themselves as reluctant to engage in clinical governance as their Bristol colleagues had been. Arguably ‘club culture’ existed in the managerial sector as well as the medical profession.
Newdick and Danbury's argument that the deficiencies exposed in Stafford were not unique to that trust has been strengthened since by the Secretary of State's expressed concern that standards at some other hospitals are ‘mediocre’,3 and the strong echoes of Stafford discovered at a number of other hospitals by among others, the Keogh Review.4
A number of professional staff at Stafford must not only have realised what was happening to patients, but have dissociated themselves from any personal responsibility. Why did the duties imposed on healthcare professionals have so little impact? The authors rightly point to a belief that there was no point in doing so because nothing will be done. Nurses filed many incident reports involving staff shortages, but received little or no feedback,5 were discouraged from repeating this concern.6 Such a phenomenon is by no means limited to staff at Stafford or the health service. Two recent surveys have suggested that the majority of informants in financial services experience only inaction.7 ,8
Other reasons suggested in the Public Inquiry report include the fear of victimisation by colleagues, of the type suffered by a brave A&E nurse who reported pressure to fabricate patient discharge times,9 and the fear of adverse consequences for career or remuneration reported to be felt even by senior doctors and disseminated to junior doctors by their seniors.10 It was to combat inhibiting factors of this sort that the report recommended that those who raised concerns should always be given feedback, as well as making obstruction of honest disclosure to patients and harassment of whistleblowers criminal offences.11
The authors argue that lack of clarity in policies about what constitutes an incident that should be reported may contribute to failures to do so, but, given the clarity of professional codes is this a convenient excuse to avoiding an uncomfortable step? It will never be easy to make a report which may result in criticism or adverse consequences for the reporter or the reporter's colleagues. When an incident causing serious harm or worse has occurred, the fear of an adverse reaction by the affected patient, his/her family and friends, colleagues, the employer, a regulator or the media is perfectly rational. The fear of consequences was often given as the reason for inaction in the evidence offered to the Public Inquiry.
An explanation for the failure of clinicians to react appropriately on behalf of their patients is, the authors argue, to be found in a distinction between ‘complicated’ and ‘complex’ problem solving. As the authors recognise, this interesting analysis is a simplification; clinicians and managers will use some aspects of each technique. However, the explanation makes an essential point about the design of systems of safe and effective healthcare. In an imperfect world, it is not possible to provide perfect care to all comers all the time. An emergency department may be overwhelmed by patients because of disasters, supply issues, finance or staff shortage. A doctor (or a nurse) faced with such issues is likely to make decisions using a triage approach by prioritising patients with the greatest clinical need and the best chance of survival. A manager may look for the most defensible decision consistent with the perceived priorities of his/her superiors. Surely both should look jointly for the best solution for patients given the available resources. In order that patients and the public are properly involved in such decisions, the decision-making process needs to be open and transparent. If a service cannot be offered safely and in accordance with fundamental requirements, then it should not be offered at all.
The authors go on to argue that managers are more likely to use intuition (‘System 1’) in ‘complex’ problem solving, whereas clinicians will tend towards ‘rational’ (‘System 2’) thought processes. The latter may be at a disadvantage when trying to challenge managers and become more diffident. The authors do not explain why it is not equally likely that managers become diffident in the face of expertly presented evidence-based and rational arguments in favour of a patient-centred solution. In many hospital settings, this is presumably what occurs; therefore, it remains unclear why in organisations such as that in Stafford the opposite occurred.
Newdick and Danbury attribute disengagement between clinicians and managers to the use of these different thought processes. The explanations offered by senior clinicians to the Public Inquiry for not pursuing concerns included vulnerability to professional retaliation, worries about merit awards and other material forms of recognition and absence of a personal sense of responsibility. Self-interest could arguably be a common thread attaching these explanations: the self-interest in protecting self, status, career, remuneration and a mutually supportive collegiality. Self-interest may explain the actions of a management class possibly driven by the perceived likely personal and career consequences of failure to meet targets.
If self-interest is a driver of a culture which does not make patients the first priority, an opposing self-interest has to be inserted. Incentives such as celebration of the raising of concerns, rewards for delivery of safe and effective care and respect for participation in innovation and a drive for excellence. Deterrents can also be effective, for example, the introduction of serious consequences for deficiencies leading to serious harm. A balanced and proportionate approach like this, implemented by visionary and exemplary leadership, should be capable of re-filling the professional vacuum that Newdick and Danbury have described so eloquently.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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