Time to stand up and be counted

Robert Francis’s report on Mid Staffs calls for a change of culture in the NHS. But whose culture is it that needs to change?

Nursing is a tough and poorly paid job. People who choose to become nurses don’t expect to find themselves ignoring patients’ needs. But when you are rushed off your feet you can’t spend time by the bedside to chat to patients. In some hospitals it appears you don’t even have time to change soiled sheets. And you can’t be kind to a sick patient while you are ticking boxes on your iPad.

Nursing can seem a long way from the image that I absorbed from Sue Barton, Student Nurse when I was young. When my elderly mother was admitted to hospital she had a named nurse we were told to speak to about our mother’s condition. Only she never seemed to be on duty when we visited and no-one else was prepared to fill the gap. Cheerful caterers put my mum’s food on her table, and then cleared it away uneaten. She couldn’t see it, and she was too weak to lift a fork. No-one was unkind, but equally no-one seemed to see what was happening, or not happening. Yet there was no glaring deficiency that would put up red flag to the Trust Board. The Department of Health’s statistics would look fine.

The public says bring back matrons. But the root of the problem isn’t the culture of nursing. It’s too few nurses, too few beds. Beds and nurses cost money. So diabetic patients are on ENT wards, ENT patients on gynaecology wards, any patient on a trolley. At Mid Staffs we have seen the consequences of managing nursing for cost rather than for care.

Doctors seem to have come better out of the Francis report. Though we know that all is not well. A patient asked a GP colleague “Why aren’t doctors like Doctor Findlay any more?” He answered “Because patients aren’t like Doctor Findlay’s patients any more.” Social changes have spelt the end of cradle to grave continuity of care. But, like nurses, doctors still look after their patients with kindness if they have the sensitivity and the time. These days more hospital doctors introduce themselves to their patients and take the trouble to listen. Evidenced-based medicine and case discussions – and legible patient records – make it easier for practice-based GPs to follow up a colleague’s patient. GP locums have become expert in the art of creating a therapeutic relationship in 10 minutes.

So whose culture is it that needs to change?

When Tony Blair introduced his reforms of the NHS, I chaired a meeting of local GPs and consultants. A consultant stood up. He and his colleagues, being employees, were increasingly constrained by their employers.”You GPs”, he said, ”still have the freedom to plead for your patients. You lose it at your peril. You lose it at your patients’ peril. You must speak out.”

Around the same time, I was sitting in the Boardroom of a local Trust at a meeting with the chief executives when the door was pushed open and a man sidled round it. Grunting and grinning and grinding his teeth, he made a dash for the boardroom table, grabbed a handful of sugar-lumps and made his exit. There is something to be said for having a Trust boardroom on the same corridor as a ward for long-stay mentally infirm patients. Too many hospital managers are isolated from patients.

Whose culture needs to change? The government pays lip-service to services for patients, but managers are judged on cost, so the only figures they see have £ signs in front of them. And whistle-blowing doctors are the messengers bearing bad news. So they were shot. Gagging clauses are now to be banned. But will they find another way to silence those who speak out? It seems that today the NHS is only a no-blame culture if you are at the very top, and kicking the cat goes all the way down the line to the nurses.

And while we’re at it, what about the culture of patronising politicians? It isn’t motivating to hear an MP saying our performance is mediocre.

What the NHS needs is managing from the bottom up. Why not ask all front-line staff for one thing they could change for the better? It doesn’t have to be big: little things mean a lot – and may generate savings too.

Until that culture change happens, it’s time for doctors to stand up and shout when patients are suffering. If we don’t, who will?

But who’s going to listen to a locum? Well, there is strength in numbers. Get together with colleagues. Speak to as many different organisations as you can. Be persistent. And use the media if you have the confidence and the contacts. We are a privileged profession and it is our duty. To the NHS, to patients, to ourselves.

Judith Harvey

This article first appeared in the NASGP Newsletter April/May 2013

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