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Save lives – improve the NHS, don’t worship it

March 10, 2013

In my Daily Telegraph article last week I listed some of the evidence showing that variation in the quality of General Practice harms NHS patients, with unknown numbers damaged, tens of thousands dying early or suffering avoidable diabetic complications such as strokes and amputations, and the chance of having your cancer diagnosed literally varying from practice to practice.

All these are facts, shown and time again in independent studies – many published by the NHS itself. Indeed in the next few weeks another high-profile report will be released showing that the public all too often gets poor primary care.

This applies just as much to hospital care. NHS hospitals (all under the same financial pressures, and with the same committed staff) vary widely. The best are amongst the safest in the world, for example Salford Royal, whilst others such as Walsall Hospital look to emulate such excellence: moving from well below average to becoming a “performing hospital“ with C. Diff infections down 80%, pressure ulcers down 30% and falls down 20% in just one year.

Variation is the cancer in the NHS both between and within organisations. Transparency of performance starts the conversation for improvement.

Sir John Oldham – GP and National Clinical Lead for Quality, Department of Health

But when I and others stand up for patients, demand that excellence should be an ambition across the NHS, and that every child should get the same high-quality care wherever they are looked after – what is the response from some of the country’s so-called leading experts?

Responding in the Daily Telegraph the President of the RCGP said I was overstating the case and my words were overly dramatic. On Twitter Dr Gerada went further suggesting that such comments could cause “moral panic”.

Another experienced GP responded to the daily Telegraph article demanding that I withdrew it at once, apologise to every GP in the country and threatened to report me to the GMC for bringing the medical profession into disrepute: struck off for saying that we need to do better for our patients! (If anyone knows how to link to specific comment on DT please tell me and I’ll add link here. It is comment-822419957)

By chance all this happened on the same day that an ex-Secretary of State for Health claimed that saying parts of the NHS were average would damage the morale of staff – as if the purpose of the NHS is to provide a pleasant, sun-filled, happy-clappy commune for the good of the employees.

Given that we all now except there is variance across the NHS that cost lives I’d like to address these three responses to those that highlight mediocrity.

Firstly, the president of the RCGP says it might contribute to “moral panic“. The only people I can see in any form of panic is a small number of doctors who would rather this was not talked about. Following her line of reasoning would have meant that the NHS would have chosen not to investigate the excess deaths at Mid-Staffordshire, the babies killed at Morecambe Bay Hospital, and that we would never have published the Francis report for fear of causing alarm. Indeed, think how much less ‘dramatic’ it would’ve been if those pesky people haven’t insisted on showing that in Bristol poor heart surgery was killing babies? Have we learnt nothing in the last 20 years?

What actually causes public alarm and concern is the perception that they have been lied to, facts are being kept hidden, or worse, that the Royal Colleges are simply unaware of how much damage is being done to patients by variation in quality (now known as the David Nicholson alibi).

Fact: public trust goes up when Government and the NHS are open and honest, admit their mistakes and show that we are all working together to improve the NHS, not worship it.

The power of information to transform how citizens and clinicians manage healthcare is fundamental, whether providing real choices based on evidence of outcomes, improving performance by exposing variations, or shining a light on seriously poor practices which must be stopped.

Sir Bruce Keogh, Medical Director of the NHS

Secondly, demands from doctors that for highlighting that parts of the NHS need to improve I, and by extension others such as Sir Bruce Keogh (Medical Director of the NHS), should be struck off.

I can hardly bring myself to waste two minutes to write about such doctors and their attitudes. Read the Francis report, listen to the news about openness and transparency, consider the need to support and listen to whistleblowers, but most importantly read the stories of those who worked – and continue to work – tirelessly to expose the awful care at Morecambe Bay and the damage it did to the lives of so many.

Imagine how those carers and patients feel when they read that doctors are still trying to hide failure across the NHS, and to silence those who would speak out on behalf of patients.

Anyway, feel free to refer me to the GMC (my number is 3332531). In fact why don’t you get a petition of the other 7 angry doctors who seem to fear true transparency. I look forward to the coverage in the papers of your views.

I believe we can do so much better than this, I want every child to get the same excellent NHS care I get for my children, and I will not stop speaking out on this issue.

Finally, “damaging the morale of NHS staff”. Nice sound-bite to be picked up by those who seem to think the NHS is a religion rather than a public-service, but really? Let’s move away from politics so we can apply some logic to this.

If we are not allowed to say “parts of the NHS are mediocre and could improve” in case it upsets staff – then by extension we would refuse to investigate stories about bad hospitals such as Mid-Staffordshire, Morecambe Bay and Worcester in case it damaged the morale of staff. Oh, that’s exactly what the NHS had been doing until brave, determined, indefatigable patients did what the NHS and DH management should have done themselves years before.

By extension, the Francis Report would have to be buried as – whisper it not, least it upset NHS staff – it included the occasional slightly negative comment.

I’m not a politician, just a doctor who has always considered it an honour to serve patients, but it strikes me that we should worry less about upsetting staff and burying reports – and more about the number of patients we are burying.

Having worked for many years in the NHS and in my new job visiting hospitals and GP groups across the country, I’d suggest that it is not saying “we need to aspire to do better for our patients” which demoralises colleagues, but rather it is when politicians sitting in Westminster offices say “the NHS is wonderful”  – when those working for patients know that it is not always so and who want the reality accepted.

As a doctor rather than a politician, I’ve been trained to look at facts and evidence. When leaders are honest and open with their teams it does not damage NHS staff morale.

Eleven years ago, David Dalton told his staff at Salford Royal hospital that performance was not good enough, more patients were dying and being harmed in their care than was acceptable, and performance had to improve. Senior staff were made to reapply for their jobs (David Nicholson?) and excellence – not mediocrity – was the expectation and target for all.

How much did morale suffer?

Not actually very much. Well actually, not at all. It actually went all the way up – such that Salford Royal is frequently rated the very best NHS hospital for staff morale.

At the same time their hospital became one of the safest in Europe, consistently one of the very best in the UK, a hospital that the NHS can be rightly proud of and one that the gives its public and patients justifiable confidence that they are getting great, safe care.

There can only be one message to those who say “don’t tell the truth to staff in case you hurt their feelings” – don’t nanny us! Those who work in the NHS are adults. Professionals committed to delivering great care for patients and old enough to handle the truth.

The majority of NHS staff want to work in open, honest organisations that aspire to greatness, highlight excellence and actively detect and drive out substandard care – rather than making excuses for it.

 

But most importantly, to the public concerned that so soon after the Francis Report some doctors still appear to be as concerned about “moral panic”, the reputation of their profession, or the morale of their staff as they are about their patients’ lives, I say don’t worry – things are changing.

There are many, many more doctors, nurses and great NHS managers who are not prepared to carry on like this, who aspire to make the reality of the NHS universally great, rather than just the idea.

These people are working to change the culture of the NHS and will speak the truth good or bad, but the doctors and nurses are not the most important members of the team who will cure what Sir John (Dr) Oldham describes as “the cancer in the NHS”.

Demanding continuous improvement, highlighting excellence as well as poor experiences, it is the wisdom and voice of the patient (the most important member of the healthcare team) that will transform the NHS.

Already unprecedented numbers of patients and carers have chosen to give feedback on their doctors and the NHS teams that care for them using open, independent services like Patient Opinion and iWantGreatCare – and more do so each and every week. (Both sites were founded by doctors determined that the patient voice should be heard. Declaration of interest I was the doctor who set-up iWGC.)

From April the volume and power of the patient voice will be massively amplified: every NHS inpatient will be able to “rate and review” the care they get using the Friends and Family Test. All ratings and reviews will be fully published allowing the public to see what their peers think about their local NHS.

And it will make a difference. It will be the very first time that the NHS has put in place a system to tell patients about their NHS, rather than vice versa, and having discussed this with the CEOs and Boards of many NHS Trusts it is clear that they realise it will bring the patient voice to the heart of their organisation, and to the head of every board meeting.

The best leaders, doctors and nurses want to know what their patients think and how they can improve – they welcome feedback. More and more of them are already asking all their patients to rate and review them, just as they would a restaurant or hotel, and then publishing it – unedited – on the web.

And what about those who oppose such openness and try to block the voice of the patients? Well, would you stay in a hotel that says “we don’t want our guests to rate us or to share their experience with others in case it hurts the morale of our staff or causes moral panic amongst the public”?

 

[I’d like to thank the many patients and carers who have already used iWGC to provide feedback on the care they get: saying thank you to great doctors and nurses as well as offering suggestions on how things could be improved. Your opinion is wanted, is heard by those who care for you, and is invaluable to the next patient looking for great care.]

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