The situation involving Jack Adcock and Dr Hadiza Bawa-garba is utterly tragic. It seems that both of them have been completely failed.
Where there is disorder and chaos and clinicians have little or no support/supervision, we cannot be surprised at what happens. As a society we seem to tolerate mediocrity in our health services. A ‘make do and mend’ mentality and an acceptance of inadequacy in the NHS workplace. Some people even seem to glorify, and gain satisfaction from working and managing ‘on the edge’, as something that is valiant and positive. Often staff are praised for coping with the chaos, which encourages acceptance of such environments. One of my research participants talked about the chaos in parts of the NHS. “And it’s this variation, you see all these medics in the most fantastic things, and then down the corridor there is just utter and absolute chaos. Utter and absolute chaos… Chaos on the move, all the time, utter chaos on the move all the time, nobody wants to admit that. How the hell do we ‘keep a lid on all of this’?” I am reminded of an article by Traynor et al (2014). They consider that nurses can be “...scapegoated for system failures” (p.56), which may “…enable organisations to continue to function without addressing complex systemic problems” (p.57). The NHS has to address its ‘complex systemic problems’ for the sake of both patients and staff.
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Claire Hilton has recently published “Improving Psychiatric Care for Older People: Barbara Robb’s Campaign 1965–1975”. It is recommended reading for anyone who wants to see improvements in the quality of NHS services. It tells the story of Barbara Robb and her determined campaign to improve the treatment of elderly and mentally ill patients in the NHS.
Of particular interest to me is the responses of government ministers and NHS officials to criticism and challenge. Looking at historical records helps us to understand somewhat, the present problems in the NHS, because in some ways little seems to have changed. Hilton asks how Robb coped with “…officialdom’s tendency to reject critics and criticism and to maintain the status quo?” (p.57) and the “…hostility and discrediting of her work?” (p.8). The answer is with great perseverance and determination in the face of much resistance to her challenge. Following review of historical documents Hilton refers to a number of responses to criticism and challenge from Robbs campaign. · Denial and dismissal of criticism; turn a blind eye “…forces of denial” (p.vii) “He [Barton] also warned of characteristic responses from those in authority to dismiss criticism, including the ‘No comment’ tactic; denial; hoping the fuss will die down; and discrediting the messenger, whether staff, patient or visitor, as malicious, vindictive or disgruntled or ‘too mad, too senile or too deteriorated to testify’” (p.126) “Howe, following his experiences at Aberfan and unlike the Sans Everything chairmen, was acutely and personally aware that public authorities could turn a blind eye to unsatisfactory and dangerous practices” (p.215) · Blaming, criticism and undermining of the patient “…the hospital authorities were evasive, blamed the complainant and the patient, and provided no convincing evidence that the criticisms were investigated or attempts made to remedy deficits.” (p.45) “The committee implied that patients were at fault, that nurses behaved appropriately and that slapping older people could be legitimate.” (p.178) · Criticism and undermining of critic/complainant “The report accused Daniel of misinterpreting, misunderstanding and distorting her observations, that her judgements were ‘manifestly unsound’ and her ‘sentimental approach’ conflicted with the ‘objective attitudes’ of other staff.” (p.186) · Staff/critics punished/victimised “…rigid hierarchical management in many psychiatric hospitals resisted change and punished staff who criticised disrespectful treatment and care regimes.” (p.46) “Loyalty to colleagues was central to the function of a close-knit psychiatric hospital ‘total’ institution. The primacy of loyalty defended staff against criticism: the critic became the unacceptable deviant. Punishing critics was common—for example, ordering them to do domestic work rather than work with patients, making life intolerable so that they resign, or dismissing them” (p.118) · “…hostility, evasiveness and obstruction from the authorities” (p.88) · Secretiveness and deceit “The Ministry could have dealt with many of their criticisms about standards of care early on, when it received the ‘Diary of a Nobody’ or after Barbara’s meeting with Tooth, but a bureaucratic, defensive and self-justifying culture militated against this. The NHS administrative hierarchy was secretive, hostile to criticism, and sometimes deceitful” (p.251-252) “Hobden, Rolph, Cross and ‘Pertinax’ (1967) all alleged government coverups and lying and that a culture of fear encouraged the silence of hospital nurses.” (p.165) Howe “…noted that the DHSS and WHB sought to conceal damaging information” (p.217) · Self-justifications “…ministerial self-justifying interpretations for doing nothing” (p.82) “…institutional self-justification and defensiveness, if not a conspiracy” (p.165) · Shifting responsibility “Robinson externalised the problem away from the authorities, towards the nurses themselves.” (p.153) “‘Sweeping it under the carpet . . . shift the problem onto somebody else. Back to the quiet life.’” (p.45) “…move the patient to another hospital, with the effect of removing the complainant without dealing with the underlying causes” (p.45) · Accusations of decreasing staff morale and reducing public confidence “NHS managers described her [Guardian journalist Ann Shearer] as irresponsible, denied the allegations and blamed her for worsening staff morale and recruitment, undermining public confidence, and laying the last straw on the breaking backs of staff” (p.207) · Praise staff “Robinson, [Heath Secretary] characteristically, praised the ‘devoted staffs of these hospitals [who] maintain standards as impressively high as they are in so many cases’” (p.79) · Justifications for poor practice “‘Doing one’s best under the circumstances’ is also heard in the NHS today, to justify inadequate clinical services associated with underresourcing.” (p.7) “The committee agreed that some older patients were slapped to get them out of bed in the morning, but there were ‘legitimate reasons for this, provided of course that the slap was not too severe’.” (p.178) “…highlighted the lengths to which staff could go to justify their work patterns and attempt to protect their reputations” (p.223) · Justification through quantification of good or bad practice; minimisation “…brutality took place in a ‘minority’ of hospitals, a tactful, vague and speculative quantification, widely used and loosely interpreted politically as meaning anything between zero and 49 percent” (p.126). “The Ministry’s motivation for its method of managing complaints was partly self-preservation, to avoid ‘disproportionate and damaging publicity’ when, it claimed, most clinical work was carried out to a good standard.” (p.109) “…maintain standards as impressively high as they are in so many cases’” (p.79) · Favourable comparisons “Alfred Broughton MP reassured the House that although mental health services were the NHS’s Cinderella, they had improved enormously and, like the rest of the NHS, were ‘excellent’ compared to those in other countries.” (p.79) · “Statements of NHS superiority” (p.79) “…‘best health service in the world’…created an impression of success and encouraged complacency. Statements of NHS superiority were also unsupported by data” “‘Best’ was a political rather than medical or economic statement and inhibited criticism and preluded a balanced evaluation of services.” (p.79) “Sheltering behind widely held beliefs about the excellence of the NHS, most hospital staff accepted established practices and acclimatised to the standards of care provided” (p.87) “…Robinson defended the NHS, and reiterated his confidence in the system: ‘I am absolutely sure, that the care of our old people in our geriatric and psychiatric hospitals is as good as anything in the world.’” (p.152) “‘I doubt there is another country in the world where the finest nursing service in the world has this kind of ridiculous unnecessary attack made on them by newspapers’.” (p.207) · Lack of/poor investigations/inquiries; not impartial/independent and censorship of reports “Most investigations ended in complete rebuttal of the complainant’s concerns.” (p.111) “The process of investigation, total rejection of the complaint, criticism of the complainant, unhesitating acceptance of the staff report, and removing the patient, resembled complaint handling at Friern and by the Ministry” (p.119) “…RHBs altering the committees’ reports to remove criticisms about themselves.” (p.193) · Arrogance and condescension “…arrogance from those in authority, bordering on bullying, related to designated status within the NHS hierarchy. Men and women who challenged higher tiers of staff in the hospitals, RHBs or the Ministry, were disparaged almost automatically” (p.258) “With condescending responses by those in highest authority” (p.112) · Declaration of powerlessness “When Barbara met Tooth she received a report about powerlessness at the Ministry, giving the impression that various tiers of NHS management could declare powerlessness, pass the buck, shrug off criticism and avoid taking initiative to make changes.” (p.120) It has been interesting assessing these responses. My MP has made several 'declarations of powerlessness' when I raise concerns about the culture in the NHS, victimisation of whistleblowers and the inadequate UK whistleblowing law! Why these behaviours? We have to look at what the politicians and senior officials were concerned about. The Hospital Management Committees feared “…negative publicity” and Robinson was concerned with “…unfavourable publicity” (p.83). “The Ministry’s motivation for its method of managing complaints was partly self-preservation, to avoid ‘disproportionate and damaging publicity’” (p.109). “NHS management gave the impression of an administrative system of concealment, complacency and fear of publicity about inadequacies, which was reinforced by stoic patients and by visitors and staff fearful of complaining and discouraged by the system from doing so.” (p.131). “Fear of the effects of negative publicity was associated with defensiveness, deception and coverups in various NHS settings, from individual hospitals to the Ministry, including Robinson’s announcement of Findings and Recommendations in the Commons. Sans Everything and subsequent inquiries revealed unhelpful patterns of NHS administration, such as seniors denying allegations of malpractice, rejecting criticism from those without formal qualifications and victimising whistle-blowers.” (p.237) In clear contrast, regarding the Ely Report, “Howe would not bow to embedded attitudes determined to avoid negative publicity” (p.218). Have the behaviours fundamentally changed in the NHS since the 1960’s/70’s? I suggest not. Many people still have major problems in raising concerns/complaints with the NHS at both the local and national level. The responses are often defensive and protectionist. There still seems to be a “…cultural malaise” which can defeat “…expressions of concern by patients and their representatives” (p.110). The power of the desire to protect individual and collective self-image/esteem and status must not be under estimated. Richard Crossman wrote in his diary that Barbara was a “‘terrible danger’ to the government, and a ‘bomb’ who had to be defused.” (p.ix). Thank you Barbara (and all her supporters), and thank you to Claire Hilton for sharing Barbara’s very important story. This story is also described in National Health Stories: Scandal, by Sally Sheard https://www.bbc.co.uk/programmes/b0b86qzs Further reading: “Whistle-blowing in the National Health Service since the 1960s”, Claire Hilton http://www.historyandpolicy.org/policy-papers/papers/whistle-blowing-in-the-national-health-service-since-the-1960s “Can we never learn? Abuse, complaints and inquiries in the NHS”, Sally Sheard http://www.historyandpolicy.org/opinion-articles/articles/why-we-never-learn-abuse-complaints-and-inquiries-in-the-nhs August 1 2018 Perhaps even sharper is this cartoon reflecting the involvement of staff in the problems at Mid-Staffordshire. Can people raise concerns in the NHS? Is it too risky? Too many NHS whistleblowers have been seriously intimidated and victimised when they have raised concerns. Do people want to raise concerns? It is certainly easier to hide from reality. The "Hear no, see no, speak no" saying is very relevant for the NHS, and was a phrase used by several of the research participants. mac’s title of “Blow no whistles, see no whistles, hear no whistles”, very sadly, accurately reflects an everyday reality in the NHS.
There are of course other people who should be added to the list of the nurses, doctors and NHS managers, who don't want to see the reality and do not want to whistleblow. It takes a lot of people to ignore a major failure/disaster. There are also the politicians who don't listen to concerns as detailed in the Gosport report. The police and others were also criticised. “Between 1989 and 2000 at Gosport War Memorial Hospital…
The general public also cannot bear to hear any ‘bad news’ about the NHS. This I think was seen to a degree in the recent 70th anniversary celebrations. There is the tendency to idealise the NHS and far too many people seem to want to express their love for the institution, to the extent they would prefer to ignore the failings, and the sufferings of patients and their families/friends. Julie Bailey whose mother died after being ill-treated in Mid-Staffordshire hospital writes that the NHS has become a “…dangerous Sacred Cow, above criticism for many despite its obvious failings” and that the NHS appears to be “...pathologically unable to improve” (From Ward to Whitehall, 2012, p.295). There is within our society a serious reluctance to face up to the problems in the NHS. |