2010 February » Hospital Dr

Archive for February, 2010

Leadership in the NHS: leaving the comfort zone

By Bob Mathers - 28th February 2010 1:29 pm

As classical scholars know, the god of the doorway is Januarius. At his annual reappearance, most of us begin to look to the year ahead with renewed optimism and ambition.

We are infected by a touching desire to take charge of our co-workers. But no sooner are we back at work than the door of reality slams in our face. Power struggles reignite and the sausage factory mentality reasserts itself.

Even if we’re hard enough to survive, it won’t make us better leaders. As Lily Tomlin said: “The trouble with the rat race is that even if you win, you’re still a rat.” What is it about leadership that is so perennially fascinating, enticing and difficult? If you Google the word, you’ll get at least 1.7 gazillion references.

In the film running through our heads, leadership features as an activity beyond the grasp of mere mortals. It usually stars guys like Gandhi, Churchill or Kennedy. It’s an aspiration, not an occupation. In real life, the likelihood is that we will have worked under many more bad leaders than good ones. A bad leader is a ‘loser’. They will have lost any plot that was going, our loyalty and respect and most opportunities to have achieved anything worthwhile. So how do we tackle it?

Let’s first separate ‘leadership behaviour’ from the idea of leader. We are all capable of behaving like a leader because we work mainly within our comfort zone. This gives us the sure-footedness and confidence to fuel those resolutions each year.

We know the territory and have experience to fall back on. Behaviours might be:

• communicating to create a bond and describe a better future i.e. vision;

• encouraging others to perform beyond their previous best i.e. motivation;

• subtly directing people through difficulties or crises without getting too involved yourself i.e. influence.

Leadership behaviour is related to the jobs we do. But the world changes and pushes us every day. In accepting the consequences we sometimes have to leave our comfort zone and operate from positions of less certainty. Are there clues? Look at any leader we respect, to whom we give ready allegiance, who shows us a good example. They have an integrity which inspires us to follow them.

Study their kind of ordinary, day-to-day, low-key leadership style. Chances are it will involve:

• Trust (do others believe what I tell them?);

• Purpose (is there a point or a value to this?);

• Communicating (can I describe this vision?);

• Responsibility (am I right to get involved and take this on?); and

• Risk-taking (have I spent enough time thinking about this?).

The challenge of leadership is not always about ‘big’ or ‘important’. It’s more about continuity, holding things together. Every doctor is a potential leader - of individuals, teams or services. Fulfilling the role means balancing responsibility for serving the immediate needs of patients with bringing through the next generation of practitioners.

In between is the small matter of working within the organisation - those who set out the protocols, organise the resources, pay the salaries and so on. That’s the real challenge, not the status and position of the comfort-zoned day job.

This is the first article in a three-part series on leadership.

Bob Mathers provides non-clinical training for health professionals. Email him on bobmathers@btinternet.com.

Tags: Leadership
Posted in Features | 2 Comments »

Demystifying the negligence claim process

By Dr Sharmala Moodley, MDU deputy head of claims - 12:53 pm

The MDU’s claim-handling team manage hundreds of claims each year arising from members’ work in independent hospitals or primary care. Common reasons for claims include allegations of failed or delayed diagnosis, medication errors, administrative errors, concerns about seeking consent, communication problems, and other treatment mishaps, such as surgical errors.

The number of claims notified to us by members has remained stable and only around 2% ever get to trial but this is little consolation for a doctor who receives a letter from a claimants’ solicitor. Doctors frequently feel angry and distressed and some knowledge of the way in which the claims process works may help them understand what to expect.

Clinical negligence is a failure to provide the standard of care to be expected of a doctor with similar training, skills and experience. To succeed, the claimant must establish that the doctor owed them a duty of care; that the doctor breached that duty, and that the patient suffered harm as a result.

Claims should be started within three years of the incident - 70% of claims notified to the MDU are in this group - or three years from when the patient becomes aware there are grounds for a claim. However, this time limit only applies to competent adult patients. For children, the three year limitation period only begins when they have reached 18 while there is no time limit for patients with a mental disorder or disability. Members with claims which are notified well over ten years after the incident have been assisted.

There are a number of different stages to the claims process itself and they differ within the UK. In England and Wales a pre-action protocol was introduced in 1999 to encourage the informal resolution of claims. If both sides fail to agree, the patient can still pursue the claim through the courts.

Details of the claimant’s case and damages claimed, known as particulars of the claim, must be sent with the claim form or served within 14 days. These must give details of the claimant’s allegations and a breakdown of the financial loss that is being claimed. The defence team then has 28 days to lodge a full defence. The case runs on a strict timetable imposed by the court, including exchange of witness statements and reports from impartial experts in the appropriate specialties to advise on the standard of care provided and whether, on the balance of probabilities, this affected the outcome.

Throughout the process, the claims team works with the doctor to achieve the best outcome. For example, we may invite them to meet with the barrister and solicitor to examine the claim in detail, test the available evidence and identify other evidence that may be needed. Our policy is to involve members in decisions about their claims and we will not settle any claim for the sake of expediency alone, although of course, it is not in anyone’s interests to try to defend the indefensible.

Two-thirds of claims notified to us by members do not result in a settlement but where a claimant is successful, compensation is paid for the harm they have suffered and the impact this has had on their life. The object is to restore patients to the position they would have been in had the negligence not occurred and may include general damages for pain, suffering and loss of amenity as well as special damages which are designed to meet the cost of care, loss of earnings and special equipment or adaptations in the home.

The cost of the average claim settled by the MDU has increased by about 10% per annum in recent years in terms of the level of compensation awarded and the legal costs have escalated to a greater degree. In fact, in over 40% of medical negligence claims settled by the MDU, claimants’ legal costs now exceed damages. We have repeatedly highlighted the problem of spiralling and disproportionate legal costs but we are optimistic that the recommendations in the Justice Jackson report into civil litigation costs, if implemented in full, will restore balance to the system.

Whether or not a claim is successful, we see at first hand how upsetting it can be for doctors to be accused of clinical negligence. For this reason, it is essential that doctors contact their defence organisation at the first sign of a claim.

Access an explanatory podcast on the issue (MDU members only).

Tags: Negligence claim
Posted in Dr Blogs | No Comments »

Leading Labour adviser on health switches to Tories

BBC Health - 26th February 2010 5:57 pm

A prominent supporter of Tony Blair’s health reforms is to advise the Conservatives, arguing the party is now “committed” to the NHS.

Professor David Kerr, a leading cancer specialist, will become shadow health secretary Andrew Lansley’s principal clinical adviser - a paid role.

He said efforts to increase patient choice under Mr Blair had been affected by a “blizzard” of targets.

But Labour says Tory plans to scrap its patient guarantees will be damaging.

News of Prof Kerr’s appointment comes on the eve of the Tories’ spring conference in Brighton, where leader David Cameron will seek to rally party supporters ahead of the general election - which must be held by June.

The party has made health a central plank of its manifesto in England, promising to protect NHS budgets from future public spending cuts.

The Tories said Prof Kerr’s endorsement showed a growing belief that their policies offered the best future for the health service.

Assisted suicide: families can still face prosecution

The Guardian - 3:00 am

Family members involved in “mercy killings” will still face criminal charges despite the publication today of new guidelines to clarify the rules on assisted suicide.

After one of the most widespread public consultations ever carried out, the director of public prosecutions, Keir Starmer QC, has created six mitigating factors against an individual being prosecuted for assisting the suicide of another.

One of the other key changes is the removal of any reference to the condition of the victim - whether they are terminally ill or near death - as a mitigating factor. Instead, the focus has switched to examine the motivation of a suspect when considering whether to prosecute anyone for assisted suicide.

Starmer made it clear that relatives who actively help a terminally ill individual to die are not covered by the guidelines and individuals could be expected to be charged with murder or manslaughter.

The distinction means people like Kay Gilderdale - who was prosecuted for the attempted murder of her daughter who had ME - could still face criminal charges. A judge last month criticised the Crown Prosecution Service for charging Gilderdale and a jury found her not guilty in less than two hours.

Crucially Starmer has removed one key mitigating factor from his original draft guidelines published last September - the fact that the person assisting is a family member. Starmer said it had been removed after a public response raised concerns that family members could be “manipulative” or even “antagonistic” towards the individual who was sick.

Whistleblow: damned if you do, damned if you don’t

By Mike Broad - 1:12 am

The latest report on Stafford Hospital is the most revealing yet. Why? Because it lifts the lid on the management culture at the trust.

You could be forgiven for switching off at the mention of another report into Mid Staffordshire NHS Foundation Trust - there’s been a few over the past year. But there are still some important lessons the Department of Health has yet to learn.

The independent inquiry paints a truly disturbing picture. In A&E, the emergency assessment unit and a number of the wards there were some serious and repeated failures in care. Vulnerable patients were neglected. Mistakes happened but because of weak governance issues weren’t addressed and the organisation didn’t learn.

The report suggests that the hospital’s management focused on costs and targets at the expense of quality. Demoralised, understaffed teams just kept their heads down and got on with it.

Why didn’t more of them speak up? This is the question the GMC would like answered. This week, Niall Dickson, chief executive of the GMC, said: “The report does raise questions about how doctors and other professionals respond when they see poor quality care. Our guidance, Good Medical Practice, which is the foundation of good care and medical professionalism makes it absolutely clear that all doctors must make the care of their patient their first concern.

“If any doctor has reason to think that patient safety is, or may be, seriously compromised then they must take steps to put the matter right. If doctors have concerns that a member of the team may not be fit to practise they must take appropriate steps without delay. This includes raising concerns locally and, if there are still concerns about the safety of patients they should inform the relevant regulatory body.”

Do doctors really need reminding of this? Probably not. I’d take a guess that doctors in the units involved at Mid Staffs were well aware of their responsibilities but knew that if they put their heads above the parapet there might be a huge personal cost.

As the inquiry has found, the doctors were dealing with a fearsome management culture described as secretive and bullying. Don’t get me wrong, if doctors were complicit in poor care they deserve to be investigated by the GMC as some are now being.

But, who would willingly become a whistleblower in the NHS? We’ve supposedly had protective legislation since 1998 and yet doctors continue to be drummed out of trusts for raising concerns.

Look at Kim Holt and Ramon Niekrash for recent examples. There are plenty of others.

Maybe that’s where the GMC’s attention should be. We should also be concentrating on the senior managers - they set the priorities and the level of resource to deliver them. Why is there no regulator that can bring managers to book individually? For me they’re more responsible than an under trained and over worked nurse.

I also believe that patient groups have a strong case in calling for a full public inquiry. There are some bigger issues here. None of the reports have so far resolved the wider systemic failings that allow an underperforming hospital to be highly rated and awarded foundation status. None of the reviews have included a wider discussion on targets and their ability to distort clinical priorities.

Andy Burnham has said “this was ultimately a local failure”. He needs it to be seen as an isolated case because there’s an election around the corner. While it’s doubtful so many problems will present again within one trust, many other hospitals are going to under intense pressure in the next few years and it doesn’t strike me that we’ve adequately dealt with the root causes of this dysfunction.

Tags: Mid Staffordshire, Whistleblowing
Posted in Dr Blogs | 5 Comments »

“Doctors are obliged to whistleblow over care”

By Mike Broad - 25th February 2010 3:26 pm

The GMC has urged hospital doctors to speak out if they see poor quality care in the wake of an inquiry into Mid Staffordshire NHS Foundation Trust.

An independent inquiry, chaired by Robert Francis QC, said this week that the trust had become driven by targets and cost-cutting.

Last year, a Healthcare Commission investigation revealed that at least 400 more people had died at the hospital between 2005 and 2008 than would have been expected due to poor care.

Niall Dickson, chief executive of the GMC, said: “The report does raise questions about how doctors and other professionals respond when they see poor quality care. If any doctor has reason to think that patient safety is, or may be, seriously compromised then they must take steps to put the matter right. If doctors have concerns that a member of the team may not be fit to practise they must take appropriate steps without delay.”

He added: “Doctors with management responsibility must make sure that there are systems in place through which colleagues can raise concerns about risks to patients.”

The GMC is investigating the conduct and performance of a number of doctors at Stafford Hospital following referral by the medical director.

The inquiry report claims poor care caused “unimaginable distress and suffering” for patients.

The culture of the trust was not conducive to providing good care for patients or providing a supportive working environment for staff, the report finds.

A bullying management style was outlined. “A high priority was placed on the achievement of targets, and in particular the A&E waiting time target. The pressure to meet this generated a fear, whether justified or not, that failure to meet targets could lead to the sack,” the report says.

The consultant body largely dissociated itself from management, the report says, and often adopted a fatalistic approach to management issues and plans. There was also a lack of trust in management leading to reluctance in raising concerns.

Staff morale was low and absence and sickness rates high.

The report also points to a lack of openness by the foundation trust board. It cites an incident where an attempt was made to persuade a consultant to alter an adverse report to the coroner, and questioned how candid the trust was prepared to be about things that went wrong.

Governance was weak at the foundation trust, with sub-standard clinical audit, complaints handling and incident reporting.

Appraisal and professional development were a low priority, and deficient performance was not addressed. The report says this was starkly evidenced by two Royal College of Surgeons’ reviews of the hospital’s surgical division and the dysfunction brought to light by them.

The report says: “The few instances of reports by whistleblowers of which the inquiry was made aware suggest that the trust has not offered the support and respect due to those brave enough to take this step. The handling of these cases is unlikely to encourage others to come forward, and the responses to the investigation of the concerns raised have been ineffective.”

BMA council chairman Hamish Meldrum commented: “It is particularly worrying that a culture of fear exists in some hospitals and one which prevents doctors and other health professionals from speaking out when they have concerns. In many cases doctors’ concerns are not heeded and this can inhibit their ability to take further action. We agree with the inquiry’s findings that there needs to be a much greater degree of engagement with clinicians in the management process.”

Some clinical staff were described as uncaring by patients at the inquiry, and the report heavily criticised the standards of nursing and personal care provided.

The report says: “Failure to ensure a proper level of personal cleanliness and hygiene degrades patients, aggravating the feelings of illness, disability and separation from home and familiar surroundings. A wholly unacceptable standard was tolerated on some of the trust’s wards for a significant number of patients.”

Since the original report last year, inspectors have been carrying out regular checks and say that care is now safe.

The government has resisted calls for a full public inquiry, calling it a “local failure”, despite pressure from patient groups and Conservative leader David Cameron.

Read the full report.

Read a timeline on Stafford Hospital.

Tags: Mid Staffordshire, Whistleblowing
Posted in Hospital Dr News | 11 Comments »

Mid Staffs was driven by targets and cost-cutting

BBC Health - 24th February 2010 1:15 pm

Hospital patients were left “sobbing and humiliated” by uncaring staff, an investigation has found.

The independent inquiry said the Mid Staffordshire NHS Trust had become driven by targets and cost-cutting.

The report - the latest in a long line of critical reviews into the trust - said the poor care caused “unimaginable distress and suffering”.

It outlines instances where patients were “routinely neglected”, and documents cases where patients were left in soiled sheets which relatives were forced to wash.

Patients were left alone, leading to falls - some fatal - which were sometimes not reported.

Half of the patients and relatives who gave evidence also cited problems getting enough food and drink.

The report criticised the “ineffective” management which were too often concerned with hitting targets, particularly in A&E, as well as the “lack of compassion” and “uncaring attitude” which was too often demonstrated by staff.

But staffing levels were also said to be too low because the trust was trying to slash costs by £10m.

Four in ten juniors on understaffed rotas

By Mike Broad - 23rd February 2010 4:01 pm

A shortage of junior doctors is threatening to compromise clinical standards, the BMA has warned.

A survey by the junior doctors’ committee reveals that four in ten juniors are working on understaffed rotas following the introduction of the Working Time Directive.

Frontline services like emergency have been the hardest hit, an analysis of rota vacancies shows, with six out of ten of the doctors working in A&E reporting rota gaps.

JDC chair Dr Shree Datta said: “It is clear that it is an everyday experience for junior doctors to be working on inadequately staffed rotas. Given that inadequate staffing levels have been identified as a major factor in the delivery of substandard care - it is essential for patient safety that this problem is taken seriously.”

The BMA survey, which received over 1,500 responses, also shows that four out of ten vacancies were for specialist trainees with at least five years of experience. The majority of rota gaps reported were for juniors who have completed their foundation training years.

Since the WTD was introduced last August, there has been mounting evidence of junior doctor shortages and reduced opportunities to receive teaching and training.

A survey by Remedy showed a high level of rota non compliance among juniors. Then a large survey among surgical trainees showed that two thirds felt training was being compromised. And there was further evidence of record numbers of junior doctor vacancies as more people were required to fill rotas.

Only 273 of 6,646 clinical rotas were granted a two-year exemption from the 48-hour week by the government, with juniors being allowed to work 52 hours instead.

Dr Datta is calling on the government to address the understaffing of rotas.

She said: “It is hugely alarming to that find so many doctors are working in teams short of experienced doctors. In settings like A&E, which is experiencing the highest levels of understaffing, it is especially critical that experienced specialists are on hand to make the decisions that can mean the difference between life and death.

“Clearly many hospitals are struggling to cope with the introduction of the 48-hour week. Running understaffed rotas cannot be the answer. Hospitals need to look more closely at how they organise their rotas. They need to look at reducing unnecessary bureaucracy and inappropriate work so that healthcare teams can offer patients the high quality care they deserve.”

The government asked Medical Education England to conduct a review of medical training post-WTD and is due to report later this year.

Tags: Rota gaps, WTD
Posted in Hospital Dr News | 5 Comments »

MPs call on NHS to scrap homeopathy funding

Healthcare Republic - 11:51 am

Homeopathy should not be funded by the NHS, say MPs.

The Science and Technology Committee analysed scientific literature on homeopathic treatment and found no evidence of efficacy.

Homeopathic products should no longer be licensed by the MHRA because they are not medicines, the committee advised.

The NHS spends £4 million on homeopathy annually, according to the Society of Homeopaths.

In the report the select committee criticised the government for a ‘mismatch’ between evidence of efficacy and policy.

“It sets an unfortunate precedent for the DoH to consider that the existence of a community which believes that homeopathy works is ‘evidence’ enough to continue spending public money on it,” said chairman of the committee Phil Willis and Liberal Democrat MP.

Explanations for why homeopathy would work are ‘scientifically implausible’ and there is no evidence of how it works beyond the placebo effect, they concluded.

Failing DGH to be run by the private sector

By Mike Broad - 11:36 am

A failing hospital looks set to be managed by a private sector company after the only NHS bidder withdrew from the tendering process.

East of England NHS is offering an operating franchise to run the health service at Hinchingbrooke Hospital, a 369-bed DGH in Cambridgeshire, from April 2011. The services include A&E and maternity.

Five companies have progressed to the next stage of the search for a new operating partner for the hospital. Formal submissions were received from: Care UK (Partnership Health Group Limited); Circle Health; Interhealth Canada (UK) Ltd; Ramsay Health Care UK and Serco Health.

All the companies seeking to run the contract have provided elective surgery to NHS patients in independent sector treatment centres.

Cambridge University Hospitals Trust recently withdrew from the race to run the hospital. A spokesman for the trust said: “The competitive bidding process will involve considerable investment in both time and money.

“Continuing to take part would have an impact on services at Addenbrooke’s and The Rosie. Accordingly, we have decided to withdraw from the process.”

The franchise operator will have to help repay an NHS loan being used to underwrite the hospital’s £40m debt.

Dr Stephen Dunn, director of strategy at NHS East of England, denied this was privatisation and explained that staff and assets would remain within the NHS.

“Over the last two months, we’ve held meetings with the potential partners, and they’ve had tours of the hospital and met with medical staff and local GPs. From their submissions we are getting a really good feel for what they think they can bring to Hinchingbrooke and their visions for how they plan to make the hospital sustainable in the long term,” he said.

“This is exactly the quality of ideas and innovation we were looking for with this franchise process.”

Services on the hospital site provided by other organisations, such as Cambridgeshire Community Services, will be unaffected by this franchise offer.

A spokesman for the BMA said: “The NHS has been forced to compete in an environment where everything is skewed to the interests of private providers. NHS services are funded by the public and should be accountable to patients, not shareholders or private equity. We are very concerned about the impact of this development and the precedent it sets.”

Good Hope hospital, in Sutton Coldfield, was taken over by management consultants Tribal in 2003 but there was little improvement and the hospital was soon merged with the Heart of England NHS Foundation Trust in Birmingham.

Tags: Privatisation
Posted in Hospital Dr News | 1 Comment »