Clinical integrity and patient safety in medicine.
Discussion
I posted this in another section where no-one seems interested. I'm posting it here as I think there may be a few medics lurking and I would genuinely like to hear opinions.
"Everybody refers to the National health Service. What's national about it, the central franchise holder, (DH/HMG) and that's about it.
The way Trust's are franchised seems to me to be quite like McDonalds, although McDonalds consistency/quality is undoubtably more uniform.
The reality is some Trusts are well managed and provide superb services. Others are not and do not.
Of recent interest is Robert Francis's observations about transparency/honesty in regard to patient safety and how the health sector's equivalence would translate to flying with aircraft falling out of the sky.
In his Inquiry he asked, in relation to the non-disclosure of Mid-Staffs clinical hell: "Where were the Doctors?' I've afraid at one level the answer to this is very simple, they were keeping their heads down so as to ensure their livelihoods. There's plenty enough evidence of what happens to whistleblowers.
That said, I have wondered if there's not another aspect to this culture of Omerta. Namely that many doctors, whilst paying lip service to the benefits of transparency, privately detest whistleblowers and see them as sneaks."
"Everybody refers to the National health Service. What's national about it, the central franchise holder, (DH/HMG) and that's about it.
The way Trust's are franchised seems to me to be quite like McDonalds, although McDonalds consistency/quality is undoubtably more uniform.
The reality is some Trusts are well managed and provide superb services. Others are not and do not.
Of recent interest is Robert Francis's observations about transparency/honesty in regard to patient safety and how the health sector's equivalence would translate to flying with aircraft falling out of the sky.
In his Inquiry he asked, in relation to the non-disclosure of Mid-Staffs clinical hell: "Where were the Doctors?' I've afraid at one level the answer to this is very simple, they were keeping their heads down so as to ensure their livelihoods. There's plenty enough evidence of what happens to whistleblowers.
That said, I have wondered if there's not another aspect to this culture of Omerta. Namely that many doctors, whilst paying lip service to the benefits of transparency, privately detest whistleblowers and see them as sneaks."
Edited by IanA2 on Wednesday 28th May 17:53
Regarding the overall running of the NHS and the governance that involves, I try to keep out of it for the most part. Until I’ve finished my CCT and looking for consultant posts, I have more immediate short term aims and issues.
I do, however, try to help give my opinion on changes that will affect me and my colleagues at our level ie: new clerking paperwork, proformas or the introduction of 'bundles' ie: sepsis bundles. I'll attend meetings on morbidity and mortality discussions to see where we went wrong at a departmental level on a case by case basis and that act to highlight where care could be improved. I’m regularly encouraged (and nurses are very good at this as well) to fill in incident reports relating to any issues seen on the ward – drug errors, communication errors, disputes, clinical mistakes etc. The departments then review these and deal with them appropriately. We often get feedback over any of the more serious reports. This helps with transparency. Our consultants are becoming better at creating an environment whereby we can have information fed-back regarding problems encountered. We are also encouraged to bring our concerns to our consultants should we have them. I can’t think of anyone who would not want to raise a genuine concern that might affect patient safety to their seniors.
What I wonder, is, whether these consultants are then having difficulty taking it further up beyond the departmental level – I think that the departmental governance teams then report to the associate medical directors and ultimately the medical director is responsible for making the decisions on if a true patient safety issue is present and how to deal with it. Ultimately they then report to the chief exec. And yes – some trusts are clearly better run than others.
I have always felt that there is a clearly signposted way for me to raise any concerns regarding to clinical care, either on a case by case basis or at a departmental/trust level. As such, I would be happy to raise concerns and know that they would be carefully dealt with, without any professional repercussions.
I personally hate the expression ‘whistle-blower’ as it brings up connotations of someone in dark glasses providing confidential material to the press etc. I think that the NHS is becoming more open about issues and trying to resolve them and wouldn’t feel like I was a ‘whistle-blower’ if I had to report issues in my ward/department or hospital.
I do, however, try to help give my opinion on changes that will affect me and my colleagues at our level ie: new clerking paperwork, proformas or the introduction of 'bundles' ie: sepsis bundles. I'll attend meetings on morbidity and mortality discussions to see where we went wrong at a departmental level on a case by case basis and that act to highlight where care could be improved. I’m regularly encouraged (and nurses are very good at this as well) to fill in incident reports relating to any issues seen on the ward – drug errors, communication errors, disputes, clinical mistakes etc. The departments then review these and deal with them appropriately. We often get feedback over any of the more serious reports. This helps with transparency. Our consultants are becoming better at creating an environment whereby we can have information fed-back regarding problems encountered. We are also encouraged to bring our concerns to our consultants should we have them. I can’t think of anyone who would not want to raise a genuine concern that might affect patient safety to their seniors.
What I wonder, is, whether these consultants are then having difficulty taking it further up beyond the departmental level – I think that the departmental governance teams then report to the associate medical directors and ultimately the medical director is responsible for making the decisions on if a true patient safety issue is present and how to deal with it. Ultimately they then report to the chief exec. And yes – some trusts are clearly better run than others.
I have always felt that there is a clearly signposted way for me to raise any concerns regarding to clinical care, either on a case by case basis or at a departmental/trust level. As such, I would be happy to raise concerns and know that they would be carefully dealt with, without any professional repercussions.
I personally hate the expression ‘whistle-blower’ as it brings up connotations of someone in dark glasses providing confidential material to the press etc. I think that the NHS is becoming more open about issues and trying to resolve them and wouldn’t feel like I was a ‘whistle-blower’ if I had to report issues in my ward/department or hospital.
I'm not terribly keen on the word whistleblower either, but it's the word in common use.
Here is a document from Patients First which describes the life cycle of the whistleblower. Well worth a read.
[i] Stage one
Fail to acknowledge the concern in a timely manner leaving the whistleblower concerned that the matter of concern is being ignored or even continues
Fail to accept that the concern is genuine and/or serious on the grounds such as that “no one else has complained” or “we disagree with your view” in fact staff do not need to be right in raising their concern, they just need to raise it in good faith.
Explain that nothing can be done because “there are no additional resources or staff” and appeal to the member of staff to “be patient” because ”everyone is doing their best” We know that many of nursing concerns relate to staffing ( RCN survey).
Explain that the concern has been addressed when it self-evidently hasn’t been. This can be done by use of an “ independent investigation”, which is often neither independent nor a proper investigation taking account of all perspectives. The whistleblower is often lucky to be informed of the investigation or given a copy of the full report if one is produced. Eg Sibert report, Phillips report and so forth.
Point out that the concern raised can be seen as criticism of colleagues and should it not turn out to be true then this could result in a “difficult situation” or indeed in disciplinary action for a malicious or vexatious complaint
Invite the whistleblower to withdraw their concern, reminding them directly or indirectly that this “doesn’t look good” on any future reference. Even if that isn’t done, the whistleblower will generally have been completely taken by surprise by the management response and may well withdraw the concern, or go off sick, possibly never to return.
If that doesn’t work suggest that the whistleblower withdraws the concern and agrees that the manager will look at it “less formally” and then proceed to “encourage” staff to raise incident concerns informally with the manager before submitting them, whether or not this accords with the Trust procedure.
As far as possible, ensure that the concern raised doesn’t go anywhere near the trust “risk register”.
Continue to give no feedback on whether anything has been done arising from the concern raised so the member of staff has no idea whether it is being ignored.
Stage two
10. Marginalise the whistleblower by missing them off the invites to meeting that would normally be attending, or miss then off emails they would normally be included in, or invites to training events/CPD they would normally attend
11. Undermine or overload the whistleblower by withdrawing essential resources or simply not providing them. These might include administrative support, equipment, failure to provide sick cover for colleagues that might normally be provided, increasing the caseload, changing their shift patterns or their work base or working area. There are many subtle ways that staff can be undermined and treated differentially to heir colleagues, which increases the level of stress on individuals and makes many feel like resigning.
12. Excessively scrutinise the whistleblower’s work by calling in records, increasing inspections, more one-to-ones, or bringing forward appraisals.
13. Advise work colleagues that it wouldn’t be a good idea to give support, be a witness or over-fraternise with the whistleblower. Suggest that they are not well, have “problems at home” or imply that the whistleblower has been critical of colleagues even if they haven’t. This can be done more or less subtlety. This is some cases has been done openly. If an employer is trying to drive out a whistleblower then this sort of behaviour might even be encouraged.
14. Find a complaint to use against the whistleblower and if one doesn’t exist, encourage someone to make one. This can be a colleague saying “X is a difficult person to work with”, or “i have some concerns about your work”. Every member of staff makes mistakes. Instead of being learning events these become opportunities for harassment. A fishing trip in anyone’s work is likely to find something wrong, missed or unclear. There are a number of examples where whistleblowers have been referred to the GMC/ NMC and have suffered prolonged investigations before being declared as no case to answer but the damage has been done.
15. Raise concerns about the impact on the health of the whistleblower arising from the act of whistleblowing up to and including “you seem very stressed” “are you sure you should be at work” or even “I think you may be a bit suicidal”. Then suggest or insist on a period of sick leave.
16. Suspend the whistleblower on the grounds that there needs to be an investigation into their work, or behaviour. If the whistleblower wasn’t stressed before, they certainly will be now. Ignore Tribunal decisions suggesting suspension may often not be appropriate (UKEAT/0338/10/DA Crawford and Another v Suffolk Mental Health Partnership NHS Trust. At Para 79).
17. Emphasise to the whistleblower that the suspension is a neutral act but also that they must not contact any work colleagues or discuss what has happened – even if their best friends are workmates. This is an aggressive act.
18. Take plenty of time to conduct the investigation, the longer the better. Many staff off work more than six weeks never return to work. (Carol Black. Working for a healthier tomorrow – a comprehensive review of work and health. (2008)) Being suspended is a lonely, demoralising existence.
19. Consider a restructure of the team, department or the work itself after which the whistleblower may be redundant, demoted, transferred to a different team or department. We have evidence of staff being got rid of as redundancy when in fact it was unfair dismissal.
20. Spread the word round the department or team that the whistleblower is unlikely to come back, including moving their desk or changing their rol, even clearing their desk.
21. If at all possible make sure an investigator is appointed who understands that a decision that there is “a case to answer” on all or some of the allegations should be found. If NCAS are involved make sure a convincing set of management witnesses are lined up.
Stage three
22. Meet the whistleblower and outline the steps underway to either make them redundant or restructure them. At this meeting suggest that there might be an alternative way forward which, in the light of “differences with colleagues” or
“what is best for their career” or their “health” might involve
retirement on favourable terms due to ill health or restructure
redundancy on favourable terms (which might not otherwise be available)
leaving with a good reference before any disciplinary process gets underway (or even during it)
23. If the whistleblower is on sick leave remind them that payment will not be for an unlimited period. Keep chasing them.
24. Refer the whistleblower to the professional regulator (e.g. NMC, GMC, HCPC) or warn them that this is under consideration
What won’t happen once matters have reached this stage?
25. Extremely unlikely that anyone will say “sorry we made a mistake”.
26. Extremely unlikely that anyone will say “thank you for highlighting this problem, we’re going to deal with it”
27. Extremely unlikely that if a disciplinary hearing is held that the outcome will be to clear the whistleblower of all charges
28. Extremely unlikely that any counter allegation of bullying, abuse of process, or breach of duty of care by the employer will be upheld or even properly investigated. Discourage witnesses.
How will it end?
29. The whistleblower will start to realise that whatever now happens their career in this particular employer has a serious cloud over it and they may better off leaving
30. The pressures from family and friends may convince them to find a “way out”
31. The worry of being dismissed or being unemployable will become more important
32. Their lawyer or trade union official (or both) may suggest that some sort of “compromise agreement” might be the way out of this situation, partly for their health and partly because either the “legal advice” is they their chances of winning in court are not good, or because what the Trust are offering is as much as they would win in court without the upset and stress – and they will get a reasonable reference without which a future career is impossible.
33. Most whistleblowers find it impossible to keep going and are eventually relieved if still angry that they have left the employer, even if their career may be in ruins.
Patients First’s files continue many variations on these themes. Many NHS employers have been adept at turning public interest concerns into employment disputes. Similar variants on these themes are well known (Hammond, P, Bousfield, A. 21 Ways To Skin An NHS Whistleblower (2011)). The impact was well summarised in Fig 1.
Implications
This “lifecycle” is essential to understanding why the existence of whistleblowing policies and the abolition of “gagging clauses” hardly scratch the surface of the problem. By the time the whistleblower leaves, their primary concern is their health, their family, their future job, some financial cushion, and to see the back of their employer. For many, the original whistleblowing concerns pale into insignificance, especially as they will be told they can still raise them but in practice most will not because the price will be that they will struggle to work again in their profession. As research a decade ago put it:
The greatest fear is that of reprisals from the employer, associates of the bully, and powerful professionals, who may close ranks and compromise the career of the whistle blower
Field T, Becker K, Mackenzie GM, and Crossan L. Bullying in medicine. BMJ. 2002; 324: 786. [/i]
@Ruskie
I don't think there is an National health service, so it cannot, nationally, be broken. I do believe that there are commissioned health providers that are not up to the job, and there are some that perform very well. It sounds as though your organisation is not doing too well.
@HughS47
Whither you have realised it or not, you've rather put your finger on it. What exactly does happen once a SUI has been reported? Is it properly investigated? Are the findings fed back to the team for learning, or is it not investigated (or investigated inappropriately) at all and just stuck in a drawer somewhere.
I know a Consultant who was advised by a very senior figure, indeed someone who is held in international esteem, that once the form had been submitted it should be forgotten as it was the managers responsibility to investigate/resolve matters: cf the GMC's guidance in Good Medical Practice; says something different, does it not?
That said if you do want you career to blossom, you'll be better leaving it to the managers, for if you do persevere, and you do follow the GMC GMP, you'll be subject of an MHPS investigation sooner than you know, and probably sacked. Don't imagine the BMA or the Defence Bodies will support you.
You say things seem more open. I'm not so sure. There's certainly a lot of political chatter, but no real action, but I'm afraid there a lot of whistleblowers in desperate straights because they did the right thing.
Here is a document from Patients First which describes the life cycle of the whistleblower. Well worth a read.
[i] Stage one
Fail to acknowledge the concern in a timely manner leaving the whistleblower concerned that the matter of concern is being ignored or even continues
Fail to accept that the concern is genuine and/or serious on the grounds such as that “no one else has complained” or “we disagree with your view” in fact staff do not need to be right in raising their concern, they just need to raise it in good faith.
Explain that nothing can be done because “there are no additional resources or staff” and appeal to the member of staff to “be patient” because ”everyone is doing their best” We know that many of nursing concerns relate to staffing ( RCN survey).
Explain that the concern has been addressed when it self-evidently hasn’t been. This can be done by use of an “ independent investigation”, which is often neither independent nor a proper investigation taking account of all perspectives. The whistleblower is often lucky to be informed of the investigation or given a copy of the full report if one is produced. Eg Sibert report, Phillips report and so forth.
Point out that the concern raised can be seen as criticism of colleagues and should it not turn out to be true then this could result in a “difficult situation” or indeed in disciplinary action for a malicious or vexatious complaint
Invite the whistleblower to withdraw their concern, reminding them directly or indirectly that this “doesn’t look good” on any future reference. Even if that isn’t done, the whistleblower will generally have been completely taken by surprise by the management response and may well withdraw the concern, or go off sick, possibly never to return.
If that doesn’t work suggest that the whistleblower withdraws the concern and agrees that the manager will look at it “less formally” and then proceed to “encourage” staff to raise incident concerns informally with the manager before submitting them, whether or not this accords with the Trust procedure.
As far as possible, ensure that the concern raised doesn’t go anywhere near the trust “risk register”.
Continue to give no feedback on whether anything has been done arising from the concern raised so the member of staff has no idea whether it is being ignored.
Stage two
10. Marginalise the whistleblower by missing them off the invites to meeting that would normally be attending, or miss then off emails they would normally be included in, or invites to training events/CPD they would normally attend
11. Undermine or overload the whistleblower by withdrawing essential resources or simply not providing them. These might include administrative support, equipment, failure to provide sick cover for colleagues that might normally be provided, increasing the caseload, changing their shift patterns or their work base or working area. There are many subtle ways that staff can be undermined and treated differentially to heir colleagues, which increases the level of stress on individuals and makes many feel like resigning.
12. Excessively scrutinise the whistleblower’s work by calling in records, increasing inspections, more one-to-ones, or bringing forward appraisals.
13. Advise work colleagues that it wouldn’t be a good idea to give support, be a witness or over-fraternise with the whistleblower. Suggest that they are not well, have “problems at home” or imply that the whistleblower has been critical of colleagues even if they haven’t. This can be done more or less subtlety. This is some cases has been done openly. If an employer is trying to drive out a whistleblower then this sort of behaviour might even be encouraged.
14. Find a complaint to use against the whistleblower and if one doesn’t exist, encourage someone to make one. This can be a colleague saying “X is a difficult person to work with”, or “i have some concerns about your work”. Every member of staff makes mistakes. Instead of being learning events these become opportunities for harassment. A fishing trip in anyone’s work is likely to find something wrong, missed or unclear. There are a number of examples where whistleblowers have been referred to the GMC/ NMC and have suffered prolonged investigations before being declared as no case to answer but the damage has been done.
15. Raise concerns about the impact on the health of the whistleblower arising from the act of whistleblowing up to and including “you seem very stressed” “are you sure you should be at work” or even “I think you may be a bit suicidal”. Then suggest or insist on a period of sick leave.
16. Suspend the whistleblower on the grounds that there needs to be an investigation into their work, or behaviour. If the whistleblower wasn’t stressed before, they certainly will be now. Ignore Tribunal decisions suggesting suspension may often not be appropriate (UKEAT/0338/10/DA Crawford and Another v Suffolk Mental Health Partnership NHS Trust. At Para 79).
17. Emphasise to the whistleblower that the suspension is a neutral act but also that they must not contact any work colleagues or discuss what has happened – even if their best friends are workmates. This is an aggressive act.
18. Take plenty of time to conduct the investigation, the longer the better. Many staff off work more than six weeks never return to work. (Carol Black. Working for a healthier tomorrow – a comprehensive review of work and health. (2008)) Being suspended is a lonely, demoralising existence.
19. Consider a restructure of the team, department or the work itself after which the whistleblower may be redundant, demoted, transferred to a different team or department. We have evidence of staff being got rid of as redundancy when in fact it was unfair dismissal.
20. Spread the word round the department or team that the whistleblower is unlikely to come back, including moving their desk or changing their rol, even clearing their desk.
21. If at all possible make sure an investigator is appointed who understands that a decision that there is “a case to answer” on all or some of the allegations should be found. If NCAS are involved make sure a convincing set of management witnesses are lined up.
Stage three
22. Meet the whistleblower and outline the steps underway to either make them redundant or restructure them. At this meeting suggest that there might be an alternative way forward which, in the light of “differences with colleagues” or
“what is best for their career” or their “health” might involve
retirement on favourable terms due to ill health or restructure
redundancy on favourable terms (which might not otherwise be available)
leaving with a good reference before any disciplinary process gets underway (or even during it)
23. If the whistleblower is on sick leave remind them that payment will not be for an unlimited period. Keep chasing them.
24. Refer the whistleblower to the professional regulator (e.g. NMC, GMC, HCPC) or warn them that this is under consideration
What won’t happen once matters have reached this stage?
25. Extremely unlikely that anyone will say “sorry we made a mistake”.
26. Extremely unlikely that anyone will say “thank you for highlighting this problem, we’re going to deal with it”
27. Extremely unlikely that if a disciplinary hearing is held that the outcome will be to clear the whistleblower of all charges
28. Extremely unlikely that any counter allegation of bullying, abuse of process, or breach of duty of care by the employer will be upheld or even properly investigated. Discourage witnesses.
How will it end?
29. The whistleblower will start to realise that whatever now happens their career in this particular employer has a serious cloud over it and they may better off leaving
30. The pressures from family and friends may convince them to find a “way out”
31. The worry of being dismissed or being unemployable will become more important
32. Their lawyer or trade union official (or both) may suggest that some sort of “compromise agreement” might be the way out of this situation, partly for their health and partly because either the “legal advice” is they their chances of winning in court are not good, or because what the Trust are offering is as much as they would win in court without the upset and stress – and they will get a reasonable reference without which a future career is impossible.
33. Most whistleblowers find it impossible to keep going and are eventually relieved if still angry that they have left the employer, even if their career may be in ruins.
Patients First’s files continue many variations on these themes. Many NHS employers have been adept at turning public interest concerns into employment disputes. Similar variants on these themes are well known (Hammond, P, Bousfield, A. 21 Ways To Skin An NHS Whistleblower (2011)). The impact was well summarised in Fig 1.
Implications
This “lifecycle” is essential to understanding why the existence of whistleblowing policies and the abolition of “gagging clauses” hardly scratch the surface of the problem. By the time the whistleblower leaves, their primary concern is their health, their family, their future job, some financial cushion, and to see the back of their employer. For many, the original whistleblowing concerns pale into insignificance, especially as they will be told they can still raise them but in practice most will not because the price will be that they will struggle to work again in their profession. As research a decade ago put it:
The greatest fear is that of reprisals from the employer, associates of the bully, and powerful professionals, who may close ranks and compromise the career of the whistle blower
Field T, Becker K, Mackenzie GM, and Crossan L. Bullying in medicine. BMJ. 2002; 324: 786. [/i]
@Ruskie
I don't think there is an National health service, so it cannot, nationally, be broken. I do believe that there are commissioned health providers that are not up to the job, and there are some that perform very well. It sounds as though your organisation is not doing too well.
@HughS47
Whither you have realised it or not, you've rather put your finger on it. What exactly does happen once a SUI has been reported? Is it properly investigated? Are the findings fed back to the team for learning, or is it not investigated (or investigated inappropriately) at all and just stuck in a drawer somewhere.
I know a Consultant who was advised by a very senior figure, indeed someone who is held in international esteem, that once the form had been submitted it should be forgotten as it was the managers responsibility to investigate/resolve matters: cf the GMC's guidance in Good Medical Practice; says something different, does it not?
That said if you do want you career to blossom, you'll be better leaving it to the managers, for if you do persevere, and you do follow the GMC GMP, you'll be subject of an MHPS investigation sooner than you know, and probably sacked. Don't imagine the BMA or the Defence Bodies will support you.
You say things seem more open. I'm not so sure. There's certainly a lot of political chatter, but no real action, but I'm afraid there a lot of whistleblowers in desperate straights because they did the right thing.
The National Health Service refers to how healthcare is funded nationally and contracted nationally. Using the example of SUIs - the NHS Standard Contract should be used for commissioning every type of healthcare (excepting primary care) and has key terms and conditions in it which state that (for example) SUIs MUST be immediately reported and fully investigated:
Service Condition 3:
NHS ENGLAND
2014/15
NHS STANDARD CONTRACT
SERVICE CONDITIONS
"3.4
The Provider must continually review and evaluate the Services, must implement Lessons Learned from those reviews and evaluations, from complaints, Patient Safety Incidents, Never Events, and Service User and Staff involvement (including the outcomes of Surveys), and must demonstrate at Review Meetings the extent to which Service improvements have been made as a result"
Failure to comply with the above clause is a breach of contract. Which, ultimately could enforce a termination of the contract and prevent that provider from being able to deliver health care services. Being pragmatic, the reality is that there are no viable alternatives and commissioners simply aren't enforcing contract clauses consistently. As an NHS Commissioner, I find it increasingly depressing that CCGs simply don't have the staff or experience to consistently enforce contract levers and sanctions which could support providers to better focus on the needs of their clinicians.
As an aside, Healthcare Providers have been 'franchised' for many, many years. When we consider Healthcare Providers, we need to not just focus on hospitals but on all other aspects of care including Primary Care (GPs, Dentists, Opticians). Primary Care provision has never really been delivered by anything other than contracted qualified individuals or groups of individuals using a standard national contract. When there is discussion about the big privatisation of the NHS, Primary Care is often forgotten.
Smart GPs have been making profits for years, although I will accept that funding is now drying up with demand increasing it is becoming increasingly difficult as any provider of healthcare services to deliver what is needed within the financial envelope available.
Service Condition 3:
NHS ENGLAND
2014/15
NHS STANDARD CONTRACT
SERVICE CONDITIONS
"3.4
The Provider must continually review and evaluate the Services, must implement Lessons Learned from those reviews and evaluations, from complaints, Patient Safety Incidents, Never Events, and Service User and Staff involvement (including the outcomes of Surveys), and must demonstrate at Review Meetings the extent to which Service improvements have been made as a result"
Failure to comply with the above clause is a breach of contract. Which, ultimately could enforce a termination of the contract and prevent that provider from being able to deliver health care services. Being pragmatic, the reality is that there are no viable alternatives and commissioners simply aren't enforcing contract clauses consistently. As an NHS Commissioner, I find it increasingly depressing that CCGs simply don't have the staff or experience to consistently enforce contract levers and sanctions which could support providers to better focus on the needs of their clinicians.
As an aside, Healthcare Providers have been 'franchised' for many, many years. When we consider Healthcare Providers, we need to not just focus on hospitals but on all other aspects of care including Primary Care (GPs, Dentists, Opticians). Primary Care provision has never really been delivered by anything other than contracted qualified individuals or groups of individuals using a standard national contract. When there is discussion about the big privatisation of the NHS, Primary Care is often forgotten.
Smart GPs have been making profits for years, although I will accept that funding is now drying up with demand increasing it is becoming increasingly difficult as any provider of healthcare services to deliver what is needed within the financial envelope available.
AlfaPapa said:
The National Health Service refers to how healthcare is funded nationally and contracted nationally. Using the example of SUIs - the NHS Standard Contract should be used for commissioning every type of healthcare (excepting primary care) and has key terms and conditions in it which state that (for example) SUIs MUST be immediately reported and fully investigated:
Service Condition 3:
NHS ENGLAND
2014/15
NHS STANDARD CONTRACT
SERVICE CONDITIONS
"3.4
The Provider must continually review and evaluate the Services, must implement Lessons Learned from those reviews and evaluations, from complaints, Patient Safety Incidents, Never Events, and Service User and Staff involvement (including the outcomes of Surveys), and must demonstrate at Review Meetings the extent to which Service improvements have been made as a result"
Failure to comply with the above clause is a breach of contract. Which, ultimately could enforce a termination of the contract and prevent that provider from being able to deliver health care services. Being pragmatic, the reality is that there are no viable alternatives and commissioners simply aren't enforcing contract clauses consistently. As an NHS Commissioner, I find it increasingly depressing that CCGs simply don't have the staff or experience to consistently enforce contract levers and sanctions which could support providers to better focus on the needs of their clinicians.
As an aside, Healthcare Providers have been 'franchised' for many, many years. When we consider Healthcare Providers, we need to not just focus on hospitals but on all other aspects of care including Primary Care (GPs, Dentists, Opticians). Primary Care provision has never really been delivered by anything other than contracted qualified individuals or groups of individuals using a standard national contract. When there is discussion about the big privatisation of the NHS, Primary Care is often forgotten.
Smart GPs have been making profits for years, although I will accept that funding is now drying up with demand increasing it is becoming increasingly difficult as any provider of healthcare services to deliver what is needed within the financial envelope available.
I think those who have any real knowledge of the health sector are aware that it's a franchised operation. The problem is in the main, that Joe Public still thinks it's a National service and has no idea that the only National aspect is the franchise holder.Service Condition 3:
NHS ENGLAND
2014/15
NHS STANDARD CONTRACT
SERVICE CONDITIONS
"3.4
The Provider must continually review and evaluate the Services, must implement Lessons Learned from those reviews and evaluations, from complaints, Patient Safety Incidents, Never Events, and Service User and Staff involvement (including the outcomes of Surveys), and must demonstrate at Review Meetings the extent to which Service improvements have been made as a result"
Failure to comply with the above clause is a breach of contract. Which, ultimately could enforce a termination of the contract and prevent that provider from being able to deliver health care services. Being pragmatic, the reality is that there are no viable alternatives and commissioners simply aren't enforcing contract clauses consistently. As an NHS Commissioner, I find it increasingly depressing that CCGs simply don't have the staff or experience to consistently enforce contract levers and sanctions which could support providers to better focus on the needs of their clinicians.
As an aside, Healthcare Providers have been 'franchised' for many, many years. When we consider Healthcare Providers, we need to not just focus on hospitals but on all other aspects of care including Primary Care (GPs, Dentists, Opticians). Primary Care provision has never really been delivered by anything other than contracted qualified individuals or groups of individuals using a standard national contract. When there is discussion about the big privatisation of the NHS, Primary Care is often forgotten.
Smart GPs have been making profits for years, although I will accept that funding is now drying up with demand increasing it is becoming increasingly difficult as any provider of healthcare services to deliver what is needed within the financial envelope available.
Regards SUI's, of course you're right that there are contractually provisions, but how many commissioners have the skills and knowledge to unravel some of the more creative organisational responses? And how many have realistic re-commissioning options?
I am aware of many creative solutions that Trust use to keep their dirty laundry in shady places, and unfortunately, as the Mid-Staffs Inquiry indicated, there didn't seem too many medics signposting the dirty laundry room. And it's not difficult to see why, just read the life cycle of the whistle blower posted above.
Bottom line is until patient safety reporting and disclosure systems compare to the air travel industry, patients will keep dropping into graves.
What still interests me is whether medics, doctors in particular, many of whom are public school products, really do despise those who break Omerta.
IanA2 said:
Lots of wise and sensible things
Absolutely spot on. In my current job, I've been supporting a number of CCGs around the country to enforce the terms and conditions of the contract. It's not rocket science, but requires a level of knowledge and time which time and time again commissioners just don't have resource for or experience of. Plus the very real issue that there isn't actually any real competition, and removing 'standalone' services (Community Diabetes, Phlebotomy, Pathology etc) merely disrupts the financial stability of the hospital provider and adds an additional layer of complexity (not to mention another contract which is unlikely to be properly managed) into the economy. The system is hugely dependent upon clinicians' professional integrity, and I don't believe that is either right or fair.
It's absolutely true that the general public really don't understand how commissioning within the NHS works (nor do the majority of employees from my recent two week inpatient spell!). A hospital Trust, or Foundation Trust, to most people *is* the NHS.
AlfaPapa said:
Absolutely spot on. In my current job, I've been supporting a number of CCGs around the country to enforce the terms and conditions of the contract. It's not rocket science, but requires a level of knowledge and time which time and time again commissioners just don't have resource for or experience of. Plus the very real issue that there isn't actually any real competition, and removing 'standalone' services (Community Diabetes, Phlebotomy, Pathology etc) merely disrupts the financial stability of the hospital provider and adds an additional layer of complexity (not to mention another contract which is unlikely to be properly managed) into the economy.
The system is hugely dependent upon clinicians' professional integrity, and I don't believe that is either right or fair.
It's absolutely true that the general public really don't understand how commissioning within the NHS works (nor do the majority of employees from my recent two week inpatient spell!). A hospital Trust, or Foundation Trust, to most people *is* the NHS.
How is the General Public to understand how the N.H.S.works.Unless you work in the N.H.S.what is the difference between a Hospital or Foundation trust?We do know that what kind of treatment you will receive can depend on your postcode.The system is hugely dependent upon clinicians' professional integrity, and I don't believe that is either right or fair.
It's absolutely true that the general public really don't understand how commissioning within the NHS works (nor do the majority of employees from my recent two week inpatient spell!). A hospital Trust, or Foundation Trust, to most people *is* the NHS.
Foppo said:
How is the General Public to understand how the N.H.S.works.Unless you work in the N.H.S.what is the difference between a Hospital or Foundation trust?We do know that what kind of treatment you will receive can depend on your postcode.
Well, absolutely - when people who are employed by the NHS don't understand the general public don't stand a chance trying to keep up with the constant shifting sands of policy and politics within the NHS.Foundation Trusts have different controls in place over them, they have to undergo a process to demonstrate that they are financially stable and independent. At which point they are 'let off the reigns', given more financial freedom (i.e. no restrictions on the amount of funding they can receive from non-NHS work - charitable donations, provision of private healthcare and overseas funding including research and development) and reporting requirements are lifted.
As a patient, you should see very little difference. Except that FTs will have (should have) more money to invest in their infrastructure and patient care.
Going off topic...
For years, there hasn't been a postcode lottery for healthcare. With CCGs being much smaller than PCTs (the previous commissioning organisations) the difference between policies - particularly those for individual funding such as IVF - is becoming more apparent. However, you can change that. You can choose which GP practice you are registered to (that is your right), and therefore choose which CCG is your responsible commissioner.
More on patient choice - The hospital you go to for treatment *does not* depend on your postcode or registered GP, you have a choice. That choice is a legal right outlined in the NHS Constitution. As long as that hospital is qualified and has an NHS contract, you can have your treatment there.
E.g. Your GP suggests you may need a hip replacement. This is the point where you can choose where to go. You should have discussion about where you may want to be referred and given options, which will inevitably include your local NHS Trust, and the next nearest, but should also include ANY OTHER HOSPITAL you ask for - INCLUDING private hospitals (BMI, Spire, Nuffied) who have NHS Contracts to provide that procedure.
Far too few people know about this right and therefore even fewer exercise it. Which incenses me.
Link to the NHS Constitution:
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/...
I'll get off my soap box now!
IanA2 said:
What still interests me is whether medics, doctors in particular, many of whom are public school products, really do despise those who break Omerta.
Note - I did have to google the definition of Omerta here....I think despise is a strong word. If the situation required it, I'd like to think that doctors would do the right thing and report a situation that required attention - be it a case related safety issue or an institutional/departmental issue. I think that there is an unspoken camaraderie amoungst doctors, to help each other out and cover for minor issues ie: if a colleague had written up a dose of somthing wrong, it was flagged to me by a nurse, i'd probably just change it and mention it to them in passing. I wouldn't feel the need to whistleblow about their prescribing skills unless it became a regular and more serious issue. I don't feel that i'm part of some secret masonic cult that protect their own no matter what. I also think you'd be surprised at how wrong you are about doctors being public school products. I was the only one from my year at school to go into medicine (most of my yeargroup went into the city/law), and was the only ex-school boarder in my year at medschool.
HughS47 said:
IanA2 said:
What still interests me is whether medics, doctors in particular, many of whom are public school products, really do despise those who break Omerta.
Note - I did have to google the definition of Omerta here....I think despise is a strong word. If the situation required it, I'd like to think that doctors would do the right thing and report a situation that required attention - be it a case related safety issue or an institutional/departmental issue. I think that there is an unspoken camaraderie amoungst doctors, to help each other out and cover for minor issues ie: if a colleague had written up a dose of somthing wrong, it was flagged to me by a nurse, i'd probably just change it and mention it to them in passing. I wouldn't feel the need to whistleblow about their prescribing skills unless it became a regular and more serious issue. I don't feel that i'm part of some secret masonic cult that protect their own no matter what. I also think you'd be surprised at how wrong you are about doctors being public school products. I was the only one from my year at school to go into medicine (most of my yeargroup went into the city/law), and was the only ex-school boarder in my year at medschool.
When I talk about whistle blowing I'm not talking about minor errors as you describe, but matter of life and death, and more often death.
Read Robert Francis' comparison with air travel.
I don't know what your area is, but for example, a piss poor surgeon; you see him killing people, everybody else finds some explanation for his rates and keeps silent. Do you disclose, and to whom.
Or perhaps a psychiatrist who sees suicides due to piss poor care, or you see someone being inappropriately restrained and severely injured. Do you disclose, and if so to whom?
Don't get me wrong, from a personal interest point of view Omerta is the best career path. Just look at what happens to those who break it. The list of casualties is long. But silence puts Joe Public at risk. The general population get a dodgy health service and some die before their time. It's no an easy call.
The problem is that whilst many many more people die every year because of piss poor care, than in aircraft disasters, but they have the decency not to cause a fuss by all dropping out of the sky at the same time and dying together, rather they fade away in all parts of the country, unnoticed other than by their loved ones, and unheard.
So the question is still up for grabs, do doctors despise whistleblowers? If they don't why aren't there more? How many whistleblowers get their cases supported by their union?
Edited by IanA2 on Thursday 5th June 02:49
Edited by IanA2 on Thursday 5th June 02:50
It's an interesting discussion to read so far. To a certain extent my working life is ruled by 'fear'. This is not a literal fear but more subconscious at the back of my mind when dealing with patients. The current climate of blame cultures and the associated payouts has got me running scared. There have been instances of allegations made by patients of misconduct in my field that have been false but those people were suspended and in some cases charges brought based on little evidence. I suppose this includes whistleblowers as if I make a mistake and it leads to a death I could be held liable.
I live by a simple phrase, 'Don't give them an excuse'
'Them' is patients, patients family, other services, management, hospital staff. Don't give them an excuse to take my job. I try to be courteous and professional at all times and under severe provocation in some cases try to maintain my composure.
For context I am a Paramedic.
I live by a simple phrase, 'Don't give them an excuse'
'Them' is patients, patients family, other services, management, hospital staff. Don't give them an excuse to take my job. I try to be courteous and professional at all times and under severe provocation in some cases try to maintain my composure.
For context I am a Paramedic.
My thoughts as a community pharmacist are similar to Ruskie, don't give them a reason to complain.
In my role I often see prescriptions that are incorrect for one reason or another, mostly menial errors that are remedied quickly with a phone call to the prescriber. I personally always take a "non blame" approach to my query regardless of the severity. Other errors are often to poor communication between hospital discharge and the GP, no one healthcare professional at fault but perhaps a multitude of failures?
Whistle blowing is there to protect patients and workers alike but as mentioned already there are heavy penalties for all involved often leading to increased pressure on those left in the aftermath. Therefore the whole culture is inherently wrong and is viewed as "sneaky". Alternatively having a discussion with a poor performer, identifying their errors and seeking remedy is not well received either as it becomes almost personal (I'm smarter than you mentality perhaps rather than one professional helping another).
I often despair at patients discharged from hospital clutching a bag of medication that have almost no idea what they are taking them for, those are the ones that worry me!
None of us turn up to work and think I'm going to have a day off doing things right and I'll intentionally amputate the wrong leg, be safe out there!
In my role I often see prescriptions that are incorrect for one reason or another, mostly menial errors that are remedied quickly with a phone call to the prescriber. I personally always take a "non blame" approach to my query regardless of the severity. Other errors are often to poor communication between hospital discharge and the GP, no one healthcare professional at fault but perhaps a multitude of failures?
Whistle blowing is there to protect patients and workers alike but as mentioned already there are heavy penalties for all involved often leading to increased pressure on those left in the aftermath. Therefore the whole culture is inherently wrong and is viewed as "sneaky". Alternatively having a discussion with a poor performer, identifying their errors and seeking remedy is not well received either as it becomes almost personal (I'm smarter than you mentality perhaps rather than one professional helping another).
I often despair at patients discharged from hospital clutching a bag of medication that have almost no idea what they are taking them for, those are the ones that worry me!
None of us turn up to work and think I'm going to have a day off doing things right and I'll intentionally amputate the wrong leg, be safe out there!
pharmvrs said:
My thoughts as a community pharmacist are similar to Ruskie, don't give them a reason to complain.
In my role I often see prescriptions that are incorrect for one reason or another, mostly menial errors that are remedied quickly with a phone call to the prescriber. I personally always take a "non blame" approach to my query regardless of the severity. Other errors are often to poor communication between hospital discharge and the GP, no one healthcare professional at fault but perhaps a multitude of failures?
Whistle blowing is there to protect patients and workers alike but as mentioned already there are heavy penalties for all involved often leading to increased pressure on those left in the aftermath. Therefore the whole culture is inherently wrong and is viewed as "sneaky". Alternatively having a discussion with a poor performer, identifying their errors and seeking remedy is not well received either as it becomes almost personal (I'm smarter than you mentality perhaps rather than one professional helping another).
I often despair at patients discharged from hospital clutching a bag of medication that have almost no idea what they are taking them for, those are the ones that worry me!
None of us turn up to work and think I'm going to have a day off doing things right and I'll intentionally amputate the wrong leg, be safe out there!
Me - What do you take these tablets for?In my role I often see prescriptions that are incorrect for one reason or another, mostly menial errors that are remedied quickly with a phone call to the prescriber. I personally always take a "non blame" approach to my query regardless of the severity. Other errors are often to poor communication between hospital discharge and the GP, no one healthcare professional at fault but perhaps a multitude of failures?
Whistle blowing is there to protect patients and workers alike but as mentioned already there are heavy penalties for all involved often leading to increased pressure on those left in the aftermath. Therefore the whole culture is inherently wrong and is viewed as "sneaky". Alternatively having a discussion with a poor performer, identifying their errors and seeking remedy is not well received either as it becomes almost personal (I'm smarter than you mentality perhaps rather than one professional helping another).
I often despair at patients discharged from hospital clutching a bag of medication that have almost no idea what they are taking them for, those are the ones that worry me!
None of us turn up to work and think I'm going to have a day off doing things right and I'll intentionally amputate the wrong leg, be safe out there!
Patient- I have no idea, the doctor just tells me to take them!
Because we believe in medical staff to do the right thing.If some patients are not sure about the tablets they take when leaving hospital,it is up to the staff to make sure they know.Especially eldery people living on their own with no family.
Medical staff have their failings who is perfect?The reason people whistle blow is because
they feel there is no communication between their so called superiours.
Medical staff have their failings who is perfect?The reason people whistle blow is because
they feel there is no communication between their so called superiours.
Foppo said:
Because we believe in medical staff to do the right thing.If some patients are not sure about the tablets they take when leaving hospital,it is up to the staff to make sure they know.Especially eldery people living on their own with no family.
Medical staff have their failings who is perfect?The reason people whistle blow is because
they feel there is no communication between their so called superiours.
I would disagree. A lot of people whistleblow as a way of getting closer to management/superiors. I have several incidents a year that could be reported but I don't. I tend to have a word on the quiet and let that person know it's a problem and if it continues/happens again then it will be different.Medical staff have their failings who is perfect?The reason people whistle blow is because
they feel there is no communication between their so called superiours.
Ruskie said:
Foppo said:
Because we believe in medical staff to do the right thing.If some patients are not sure about the tablets they take when leaving hospital,it is up to the staff to make sure they know.Especially eldery people living on their own with no family.
Medical staff have their failings who is perfect?The reason people whistle blow is because
they feel there is no communication between their so called superiours.
I would disagree. A lot of people whistleblow as a way of getting closer to management/superiors. I have several incidents a year that could be reported but I don't. I tend to have a word on the quiet and let that person know it's a problem and if it continues/happens again then it will be different.Medical staff have their failings who is perfect?The reason people whistle blow is because
they feel there is no communication between their so called superiours.
Read up on Ed Judason, Kim Holt, Steven Bolsin, Raj Mattu All Doctors, all whistleblowers. They did not disclose: "...as a way of getting closer to management/superiors." They went through hell because they stood up against managers of behalf of patients. There are many more who have had their health and career trashed.
Posted this on SP&L as it relates to PIDA. Generated less interest than a parking ticket. Maybe more folks here will appreciate the seriousness of the issue.
Patients First http://www.patientsfirst.org.uk/ have today published the thematic review of the cases of seventy NHS whistleblowers that they submitted to Sir Robert Francis's Freedom to Speak Up Review https://freedomtospeakup.org.uk/ PF's legal team was headed by Patrick Green QC of Henderson Chambers.
The three key messages are:
1. There should be zero tolerance of bullying.
Bullying compromises patient safety and harms staff. A survey undertaken earlier this year by Nursing Times, i.ndicated almost half of nurses reported being bullied for having raised concerns.
2. In an attempt to obscure the size of the problem and minimise the issue, NHS Employers define Whistleblowing as only happening when the whistleblower reports externally. PIDA thinks otherwise.
Employers can turn the situation around tomorrow by looking at staff engagement and ensuring they act to end bullying behaviours in their organisations.
3. Systemic failure.
The situation is intolerable for patients and PF are calling for a public inquiry into the treatment of whistleblowers and for some form of restorative justice.
Here is the NT coverage with link to the Thematic Review.
http://www.nursingtimes.net/nursing-practice/speci...
Patients First http://www.patientsfirst.org.uk/ have today published the thematic review of the cases of seventy NHS whistleblowers that they submitted to Sir Robert Francis's Freedom to Speak Up Review https://freedomtospeakup.org.uk/ PF's legal team was headed by Patrick Green QC of Henderson Chambers.
The three key messages are:
1. There should be zero tolerance of bullying.
Bullying compromises patient safety and harms staff. A survey undertaken earlier this year by Nursing Times, i.ndicated almost half of nurses reported being bullied for having raised concerns.
2. In an attempt to obscure the size of the problem and minimise the issue, NHS Employers define Whistleblowing as only happening when the whistleblower reports externally. PIDA thinks otherwise.
Employers can turn the situation around tomorrow by looking at staff engagement and ensuring they act to end bullying behaviours in their organisations.
3. Systemic failure.
The situation is intolerable for patients and PF are calling for a public inquiry into the treatment of whistleblowers and for some form of restorative justice.
Here is the NT coverage with link to the Thematic Review.
http://www.nursingtimes.net/nursing-practice/speci...
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