O Marvellous Illusion, O Terrible Surprise
Dr Kim Holt is a brave woman. Just how brave will not be immediately obvious to anyone watching her current media appearances at the launch of the “Patients First” campaign today, a confident and articulate advocate for NHS whistleblowers and the right of staff to speak up when patients are in danger. But for those of us who first met her when she was still in the middle of the campaign of bullying, harassment and character assassination that NHS whistleblowers experience, the clues are there – she has said little in public about just what a nightmare she and her family went through with all the might of an NHS Trust ranged against them, but it does not require a great deal of imagination to work out what it feels like to have your income targeted, your integrity trashed, your colleagues turned against you, and your mental health attacked to the point where you begin to wonder if you really are mad. Anyone with any knowledge of the story of Dr Holt and her colleagues’ valiant attempts to raise concerns about the community paediatric clinic in Haringey where poor Baby P was so badly let down must wonder why such obvious dangers were ignored, such experienced and principled doctors were not only not listened to but actively silenced, and why it has taken four years for Dr Holt to be allowed back to work. It’s a horribly familiar pattern. Some of us are all too conversant with the tactics used by NHS organisations to deal with people like Kim who just will not stop going on about patient safety as if it were important, labouring under the delusion that they “must make the care of the patient your first concern” like the GMC tells them. The insinuations of mental illness, the exclusion and isolation, the arbitrary mucking about with salaries, work patterns and contracts, the pressure to accept money to shut up and go away……………….from outside it looks as mad and abusive as the target experiences it to be, and it requires extraordinary strength of character to withstand such pressure. But there is actually a perfect logic to it. It’s an utter clash of values. The mistake that whistleblowers like Kim make is to assume that the priorities of the organisation – in this case one of the most famous children’s hospitals in the world – are the same as their own, i.e. the care and protection of sick children; they are not. It does not matter what the policies say. The organisational priority is the care and protection of the organisation itself – its “name”.
What’s more, the banking culture has infected NHS management to the extent that dishonesty about actual reality on the ground is considered perfectly acceptable……………….to quote a colleague, “It doesn’t matter what’s really happening as long as it looks all right.” A manager I worked with used to refer to the reception staff as the “front-of-house team” – presumably under the impression that we were a theatre. The Trust magazine is known on the ground as “Pravda”, so full is it of pictures of happy smiling staff having a wonderful time and doing a brilliant job. Of course there has to be some antidote to the constant drone of low-level whingeing that constitutes the daily chat of many workplaces, and it is important that staff are praised and rewarded for the good they do. It’s when it tips over into a “We only want to hear the good news” culture that things begin to drift away from reality…………..
It should be no surprise that the more glitteringly illustrious the reputation of an NHS Trust, the more viciously it will react to anyone who points out that it ain’t necessarily so. Success breeds success………………..and it also breeds extraordinary salaries for those furthest away from the patients. Being part of the senior management of such a famous organisation carries tremendous kudos – hung over from the long-gone days when people loved their local hospital and showered it with gratitude for saving their lives and those of their children in the early days of the NHS. Therefore, any admission of anything less than perfection is not acceptable because it damages the brand. Unfortunately, patients do not always appreciate the need for the hospital to meet its targets, and do all sorts of unco-operative things like missing appointments, being iller than expected and staying in too long, and generally being unwell, chaotic, vulnerable and needy. It would all function so much better if they just weren’t there. Real businesses such as supermarkets are as successful as they are because they tailor their activity very efficiently to the population they serve, gathering huge amounts of data about their customer base, knowing what people buy, how much they spend, how they behave. So to put it simply, different stores stock different things to provide what the local population want to buy. But the NHS approach is usually very much the other way round…………….here’s what we’ve got, take it or leave it, and if you find the system difficult to access, unfriendly, inefficient and unwieldy, tough. When Great Ormond Street took over the management of a clinic in an extremely deprived area, how much time was spent looking at the needs of the local population and working out how best to serve them? Working with “the poor and deprived” sounds very lovely and PC but has its own particular set of challenges which need to be provided for, and what works in leafy suburbia will not necessarily work in areas of great need. But when the paediatricians who were actually trying to work there began to point out that it just wasn’t functioning, what happened?
I have worked in a few places that have got into the sort of NHS death spiral that hits badly-managed units – what a friend refers to as “corporate burnout”. * Sometimes all that has happened is that a few key staff have left, got ill or gone through personal crises simultaneously………………many a GP practice is held together almost entirely by the practice manager and if he or she gets ill the wheels come off very rapidly. The difference in that setting is that the “senior management” – the partners – have a vested interest and an obligation to keep the show on the road because it directly affects their income. So although there may be much muttering and grumbling and some outside help may be required, it is rare for a practice to completely implode unless the problem *is* the partners. It is not actually possible for the “senior management” in a GP practice to become distanced from the patients because the partners have to interact with them on a daily basis and be told what issues are affecting them in no uncertain terms. No sitting in luxurious offices miles away from the punters relying on pretty graphs and PowerPoints to tell you what’s happening. The Stafford inquiry continues to provide daily horrific evidence of what happens when money and targets take priority………………staff simply fiddle the figures, and what’s more are rewarded for doing so. Those who pipe up and say “I can’t put that, it’s not true,” are liable to find out quite rapidly that the end apparently justifies the means.
Even if a unit has become so understaffed and under-resourced that it has effectively ceased to function, appearances must be kept up. I once went to work in a setting where this had actually happened: so many staff had left or gone long-term sick that those remaining could not keep up with the workload and waiting times were getting longer and longer. But what was the response? I was puzzled that there did not seem to be any analysis going on of how we had got into such a mess. Should we not be standing back and taking a look at our working practices to see what needed to change? It was hardly a ringing endorsement of the way things had been. But no – we just recruited more staff and carried on as before. What’s more, we continued to accept referrals knowing full well that we had no clinicians to see the patients. I was even more puzzled – another unit, having got to a similar point, had issued a statement that it could only accept emergency referrals while it sorted itself out. Should we not tell our GP colleagues that we were struggling and ask for their support and co-operation while we got through the bad patch? But no, we couldn’t. It would have been an admission of failure. Senior management would not like it: the press might get hold of it and there would be bad headlines. So the letters carried on arriving, and the patients waited………..and waited………….and waited………….
In order to solve a problem it is first necessary to admit, accept and agree that you have one, and then decide on its nature. If you are in a “We are utterly wonderful and we don’t have problems” culture, however, you are a bit stuck. So what GOSH did when Dr Holt and her colleagues raised the alarm is what Trusts generally do: get the diagnosis wrong. Not: “This senior consultant is pointing out a problem and suggesting solutions – what’s wrong with our service?” but “This senior consultant is pointing out a problem and suggesting solutions – what’s wrong with her?”
The process that follows soon ensures that if the doctor was not mentally ill before they very soon end up that way. It’s called “gaslighting”, after the old movie “Gaslight” where the evil husband attempts to drive his wife mad by altering things around the house and denying having done so. ** The clinician is confronted by the “Emperor’s clothes” experience of struggling every day in a highly stressful work setting where none of those charged with managing it appear to be able to see anything wrong, to the point of flat denials of actual events. Not only are they not believed, but insinuations begin to be made that they are dishonest or deluded. This is extremely similar to the pattern experienced by families living with an alcoholic, and can be conceptualised in the same way – the institutional addiction to wealth, reputation and appearance leads those caught up in it to simply refuse to see what is really happening and swear blind that it isn’t, perhaps even believe it. Did you drink that bottle of whisky? – No, absolutely not, how could you suggest such a thing. This clinic is dangerous – No, it isn’t, we provide an excellent service to all our patients, so you don’t know what you’re talking about Doctor.
And what of those guardians of patient safety, the BMA, the GMC and the medical defence unions? Well, let us just say that they did not cover themselves in glory when Dr Holt tried to speak up for her little patients, and the GMC yet again came down on the wrong side by its disgraceful scapegoating of Dr al-Zayyat, the hapless locum paediatrician who was left holding the parcel when the music stopped. One of Kim’s most telling comments in her interview was that while the medical establishment cold-shouldered her, those outside it including the press understood exactly what she was on about.
When Dr Holt took her Hippocratic oath, I would guess that, like most of us, she meant it – perhaps not realising the pain to which her commitment to the welfare of vulnerable children would bring her, but emerging with authority to challenge the culture that pays lip service to patient safety while putting the needs of those addicted to wealth and power first. she and others like her have a real determination to stop the hounding of health professionals who raise concerns and hold the regulators and health service unions to their stated aims of supporting them. So perhaps every newly -qualified doctor should add another essential piece of equipment to their shopping-list along with the stethoscope, the tendon hammer and the diagnostic set. Perhaps it should have the initials of the GMC, the BMA and their defence union engraved on it. Perhaps it should be big and shiny, and they should wear it round their neck at all times to remind their patients whose side they are on.
It should be a whistle.
http://www.patientsfirst.org.uk
* Thanks to Rev. Tom Gordon for the use of this phrase
** Thanks to Dr Cathy Symonds for introducing me to this expression
