Savi Hensman

Sacrifice or change? The NHS and health after Mid Staffs

By Savi Hensman
March 23, 2013

“Heads must roll” declared newspaper headlines, after a report on appalling mistreatment of patients at Mid Staffordshire NHS Foundation Trust, resulting in many unnecessary deaths. In particular there have been numerous calls to sack Sir David Nicholson, one time head of the strategic health authority to which this hospital reported, who then rose to the top of the NHS.

It is not surprising that relatives and friends of those who died or suffered badly should want to see the guilty punished. They are right to insist that frontline staff should not be scapegoated while those at the top get off lightly.

Also those tempted to neglect patient welfare may think again if they know they are likely to face penalties. Failure to put service users’ needs first should certainly not be rewarded. And laws protecting people from harassment and violence should be enforced, whether the victim is a senior stockbroker or penniless pensioner.

Yet press and public reaction is more problematic. As with other scandals in health, social care or child protection, even people not directly affected are often keen to see culprits blamed and symbolically or actually executed.

This goes beyond the wish to see rules which govern community life applied fairly to everyone. Since time immemorial, humans have conducted sacrifices when things seemed out of kilter, reuniting societies and restoring a sense of harmony.

Nowadays, too, finding a target for communal wrath and seeing heads roll can offer a sense of closure – until the next time.

Mid Staffordshire: a system that went wrong

Much healthcare in the UK is of course excellent. When there are serious failings in NHS and private hospitals, these are sometimes regarded as the fault of uncaring or incompetent nurses, doctors or healthcare assistants. However, while individuals can be at fault, badly-designed systems can have a highly damaging effect.

In recent years, researchers, health professionals and managers have learnt how to reduce surgical errors by learning from fields such as aviation. Practical measures such as checklists are more useful than simply punishing staff each time preventable problems arise. Overall, health systems can promote or hinder good practice.

Time and again, when failings are identified in research by public bodies or national voluntary organisations, there are promises of improvements, reflected in policy documents. For example the 2001 National Service Framework for Older People and accompanying documents set out many helpful principles and practice guidelines for healthcare.

Yet according to Robert Francis QC, who headed two inquiries into Mid Staffordshire, “There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they offered no help to get to the bathroom.”

While top managers focused on meeting targets and achieving foundation trust status, “Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care. Patients were discharged without proper regard for their welfare.”

Though he made devastating criticisms of some individuals and organisations, he focused mainly on stopping such suffering from happening again. Anger and blame can be part of a grieving process but in other situations they may be a distraction.

That change of heart and conduct is better than ritualised sacrifice is a key theme of Lent. So is the importance of recognising our own part in what is wrong in the world, rather than simply blaming others. In the words of Psalm 51, what God desires is “truth deep within me” and “wisdom in the depths of my heart”; “you desire no sacrifice, else I would give it” but “a broken and contrite heart, O God, you will not despise”.

Those who are not Jewish or Christian may not use such phrases. However many may identify with the urge for real or symbolic sacrifice that offers catharsis and the value of a more costly process of growth and change, individually and collectively.

The Mid Staffs findings are uncomfortable reading for those of us who work in health and social care or in checking how the system is functioning, especially since there are echoes of past scandals. For instance, a 2007 report on failings at Maidstone and Tunbridge Wells NHS Trust highlighted some of the same issues.

Clearly, lessons have not been adequately learned, and there is a grave danger that the vulnerable will be subjected to unnecessary suffering and death again and again. While some of the valuable advice from inquiries has benefited service users, many of the underlying problems persist.

Putting targets and finance above service users’ lived experience

In recent decades, the alienation that many frontline workers in industry felt has often been regarded as an ideal at professional and managerial level and for public sector staff, especially at a senior level.

While public sector organisations can usefully learn from aspects of well-run private sector organisations and vice versa (e.g. around using user experience to improve services), attempts to be ‘businesslike’ in the wrong way have increased the risk to patients.

A ‘purchaser-provider split’ has been introduced in health and other services, partly to open the door to greater privatisation but also because being focused on targets and profitability is seen as desirable. This is partly because of the notion that frontline staff are inherently untrustworthy unless incentivised by rewards and punishments administered from on high, often by people on high salaries with minimal contact with those affected by their decisions.

In Mid Staffordshire, top managers were desperate to meet the demands of those at the top of the NHS, sometimes prompted by politicians’ decisions to introduce new measures that would supposedly result in improvements. They failed to heed the concerns of frontline staff, patients and carers.

Regrettably, in the midst of an even greater round of restructuring and policy change imposed by ministers despite opposition from doctors, nurses and the public, there are risks that similar problems to those in Mid Staffs could go unheeded. In fact, if private contractors are running services, there may be even greater difficulty in bringing such matters to light and taking action.

Who matters?

Another common theme in many scandals is that the groups most affected – older and disabled people or children in care (or other kinds of need) – already tend to be undervalued by society.

It is still regarded as socially acceptable to starve services of the resources to meet basic needs, resulting in sometimes horrific neglect, while a minority of people take such prejudice further and actively abuse them. People with learning disabilities, for instance, may experience active mistreatment as at Winterbourne View private hospital, or miss out on vital prevention and healthcare.

Government budgets which slash funding to local authorities with responsibility for adult social care and support for children in need, and squeeze the NHS, so that millionaires and profitable big businesses can enjoy tax cuts, send out a damaging message. Likewise the ripping up of the social security net, accompanied by politicians’ rhetoric that fuels the perception of disabled people as ‘scroungers’, creates a dangerous climate in which discrimination can seem reasonable.

Yet even the previous government, which invested in improving the NHS, sometimes sent out unhelpful messages about disabled people of working age, and also pensioners using public services. Sometimes underlying this was perhaps the notion that those not immediately ‘productive’ – in the sense of helping rich people to get richer, whatever other contribution they might have made or continued to make to society – were unworthy of too much ‘investment’.

For instance, it was rightly pointed out that better prevention and community support could help avoid unnecessary hospital admissions among older people and help some to return home more quickly, benefiting them and avoiding waste of resources. Yet this at times became distorted into the notion that such patients had minimal need of expensive hospital care, despite being at the highest risk of serious disease.

Terms such as ‘bed-blockers’ were commonly used, stigmatising elderly patients. And it was often taken for granted that their experiences in hospital would be negative.

Such attitudes, and exaggerated assumptions about being safely able to treat large numbers of very sick people in community settings, can still been found among top managers in the NHS. For instance Sir David Nicholson said in 2013 that “our modern hospitals have a highly technological way of operating. They are fast-moving and are organised around getting a diagnosis, referring the patient to the right place and getting treatment. They are very bad places for old, frail people. We need to find alternatives.”

But Professor David Oliver, president-elect of the British Geriatrics Society and former national clinical director for older people, questioned the “pervasive belief that the acute hospital is not ‘the right place’ for older people. Much hope is being invested in more care outside hospital and a greater focus on prevention and the proactive care of people with long-term conditions. But, however well we do this, older patients with complex needs will continue to present to hospital and to be our largest inpatient group. So, instead of constantly presenting older patients as a threat to the system, we need to design hospitals around the needs of the (older) patients who actually use them”.

He urged that “Doctors should challenge poor, undignified or unsafe care or ageist attitudes for older patients at every turn and be good role models through their own behaviour.” Almost everyone can play a part in challenging prejudiced attitudes in others and themselves.

Groups such as older and disabled people should no longer talked about as though they are simply a drain on resources, without referring to their contribution to communities, or as if their lot were necessarily so miserable that a little extra suffering would not make much difference. This may involve challenging injustice at all levels.

Learning from the past and preventing unnecessary suffering in future

When individuals fail in their responsibilities with serious consequences, in some instances they may feel honour-bound to resign. And sometimes disciplinary action, dismissal or prosecution may be appropriate. However if system failures have played an important part in a tragedy, these should be tackled, and injustice avoided.

Being attentive to the diverse experiences of those who tend to be marginalised, as well as carers, advocates and frontline workers, recognising differences and rejecting quick-fix ‘solutions’ that are unlikely to work can be uncomfortable and requires patience. It may also mean questioning the status quo, and values that are wrongly given priority over basic needs and rights.

Adequate funding to meet health needs is important, including having enough nurses and doctors in both hospital and community settings. Healthcare assistants and other care staff also have an important part to play, but do not usually have the same level of training, which may be very important if, for instance, a patient’s condition is deteriorating. Other professionals, from physiotherapists to pain control specialists, can also do much to improve quality of life.

To a top decision-maker with private health insurance, slashing the budget for public services that meet basic needs in order to cut taxes for rich individuals or already profitable big businesses may seem relatively painless. This is not the case for a patient lying in his own excrement, or hallucinating and terrified.

However, though spending enough to meet care needs is important, how resources are used also matters.

Public services in decades have faced frequent policy changes and restructuring, often seemingly led by ministerial whims or dubious theories, diverting attention from vital concerns. In all sectors, being ‘profitable’ may be seen as more important than being safe, even if this is more costly in the long term.

Amidst constant insecurity, staff who wish to survive and thrive learn to focus on doing their masters’ bidding, and contractors (including many voluntary organisations) play along. They may even brainwash themselves into believing that the latest directive really must be in users’ interests. These are also features of many scandals, including Mid Staffs.

Some new policies do more good than harm, but this cannot always be assumed. Again, the wider public can help to make sure that awkward questions are asked, and staff who put justice above self-interest supported, not dismissed as naive or troublesome.

Seeing heads roll may feel satisfying, but preventing needless suffering in future is better.

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(c) Savitri Hensman is a regular commentator on politics, ethics, religion and health / welfare. She is an Ekklesia associate.

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