News emerged last week regarding practices at Colchester
General Hospital in Essex (see http://www.bbc.co.uk/news/uk-england-essex-24819973)[1]
with Essex Police investigating whether a criminal investigation was
appropriate. To summarise the situation, waiting time data was being falsified
and staff who expressed any concern over changes made to that data were being
bullied to keep quiet. More importantly, cancer suffers who should have waited
no longer than thirty-one days for treatment were, in extreme instances,
waiting more than three times as long.
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| Colchester General Hospital. Photo: Daily Mail |
Coming on top of the scandal involving unusually high mortality
rates at Stafford Hospital, which were subject of a cover up and a public enquiry
that was criticised for not being wide ranging enough, and with other hospital
trusts being found wanting after being placed under public scrutiny, one might
gain the impression that the National Health Service (NHS) is crumbling around
our ears. The NHS, created in 1945
following recommendations made by the Beveridge Report of 1942 (it amazes me
that, even in time of war the government had the desire to commission such a
report), is one of the greatest legacies that any UK government, of whatever
political hue, has left us.
Fifty two years after the foundation of the NHS, and on the
eve of the 1997 election, Tony Blair told voters they had 24 hours to save the
NHS. Typically, government decided saving the NHS could be best addressed by
introducing guidelines, frameworks and procedures, regardless of whether or not
these reduced waiting lists or improved patient care. Jonathan Fielden,
chairman of the British Medical Association's (BMA) consultants committee, said
at the time; "The biggest problem is that the government has not engaged
with doctors. They have imposed these targets from the centre which have
interfered with clinical judgement."
Fielden could have been speaking about any field of
government activity; governments are obsessed with targets, with guidelines and
procedures but not with how these impact the public, the consumer of the
services (be they consumers of central or local government services) nor indeed
the very people tasked with delivering these services. This last group of people are expected to
maintain or improve services while coping with increased and onerous reporting,
often with fewer resources.
In 2000, after eight
year old Victoria Climbie died at the hands of her guardians in Haringey, the
local authority were heavily criticised and as a result introduced new
guidelines and procedures to avoid a repeat. In 2007, in another widely
published case, Haringey Council were again taken to task over similar failings
which led to the death of toddler Peter Connelly. And just last month Haringey
Council were again in the news when they failed to adequately protect another
child, known only as Child T, who suffered fifty or more bruises to the body
after being hit repeatedly with a belt and a stick before finally being taken
into care.
It would be easy to blame the individuals involved; to blame
the overworked Social Worker spending more time on admin than dealing with the
children they are supposed to protect; too easy to blame nurses and doctors in
hospitals where meeting targets is given greater importance than treating
patients. The goal of meeting targets and reporting on whether targets are
being met is an evil that impedes anyone doing anything productive. Cohn’s Law succinctly sums up this problem as
it states “The more time you spend in reporting on what you are doing, the less
time you have to do anything. Stability is achieved when you spend all your
time reporting on the nothing you are doing.”
Today, as we have seen with the Victoria Climbie and Peter
Connelly cases, any institution that has to face up to its failings does so by
introducing new procedures but usually fails to address the actual issue. Thus
Social Workers, or nurses, or doctors, or anyone actually engaged with helping,
protecting or treating the public is not tasked with performing their principle
task in a more efficient or effective manner, but rather with reporting more
rigorously on how they are performing. Thus the Social Worker or the nurse or
the doctor is presented with numerous additional tasks, none of which benefit
the people that they are serving, but which can assure government and regulators that past failings
are being addressed by enabling timely reporting of future deficiencies.
A key problem that I see in the services delivered by the NHS,
by central government and by local government is that a culture has developed
which seeks to ascribe to these non-profit making, beneficent organisations the
same methodology as is prevalent in
multi-national, shareowner controlled, profit making corporations. Should the
NHS have the same ethos, targets, and reporting structure as British Petroleum?
No. Should Haringey Council operate, report and structure itself in the same
was as Marks & Spencer? No. Private enterprise is not immune to similar problems,
where projects are particularly prone to the syndrome described in Cohn’s Law,
but in these companies we are less likely to be concerned with matters of life
and death, but rather with profit and loss.
So, what is the answer? Indeed, is there an answer? In part
the fact that in all areas there is greater reporting, greater visibility, is
good as it means that failings are not swept under the carpet. It would be
naive in the extreme to believe that the failings that we have seen in
Stafford, in Haringey and in Colchester are unique or that they are a new
phenomenon. In the past, however there would likely have been less evidence,
less accountability. The key, whether failings are found and kept in house, or
found and made public, is that the failings are addressed.
Patients’ lives are saved by nurses and doctors exercising
their clinical skills; vulnerable children are saved from abuse by Social
Workers with the experience, and equally importantly the time, to investigate
their circumstances and implement solutions. Whatever the means by which
failings are addressed, greater reporting and more stringent procedures are not
enough on their own; no patient’s life was saved purely because of better
procedures, no vulnerable child was saved from abuse because of more accurate
reporting.
I have little doubt that at Colchester General the false
reporting that occurred was, in the topsy-turvy world we now live in, driven by
the fact that adherence to procedures has become more important than doing the
right thing and reporting on what is being done is now more important than
actually doing anything. In organisations it now seems the norm that not
following procedures but achieving a successful outcome is a greater sin than
following procedures (which may be flawed or inappropriate to the
circumstances) and failing to reach a satisfactory result and that reporting on
whether targets have been met is more important than actually reaching those
targets. This is not to say that procedures and targets are unimportant, but
rather that they are tools useful in achieving the primary goal of the organisation;
following procedures and producing data on targets are not ends in themselves,
merely means to achieving an organisation's principle goals.
Doubtless the recommendations as to how the failings at Colchester General should be
addressed will include a thorough review and tightening of procedures and
improved performance monitoring; improving patient care may be purely
coincidental.
[1]
The report in full can be found at http://www.cqc.org.uk/sites/default/files/media/documents/ins1-916119012_rdee4_colchester_general_hospital_20130827_f2.pdf
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