Mark Newbold

A CEO’s view on Francis report implications

Unsurprisingly, the publication of the Francis report has led to much reflection among managers, clinical leaders, and health commentators. My (pre-publication) concerns are here, but we won’t get answers for a while, until the government has taken a view on the 290 recommendations contained within the report.

But what about doctors? What are some of the implications for the profession?

Doctors do not emerge from Francis unscathed. Whilst the main deficiencies were in ward-based nursing care, mortality rates were persistently high and doctors failed to raise concerns effectively. Much has been made of the ‘climate of fear’, but I struggle to believe this alone explains why concerns were not raised early, loudly and persistently. After all, there is safety in numbers and many hospital chief executives have lost their jobs over the years as a result of a Consultant Staff Committee vote of ‘no confidence’ – why not at Mid Staffs?

I have argued for a re-wording of the GMC’s Duties of a Doctor to make much more explicit the duty to raise concerns about wider care issues involving patients other than their own, for instance elsewhere on a ward or in a hospital. The second duty ‘Protect and promote the health of patients and the public’ is perhaps too general in this respect?

There are implications for services too, that I have alluded to in my Weekly Diary and which need considering in detail. Essentially, the quality and safety concerns relate to our acute general services, and predominantly medicine. And if we are honest, these have been less glamorous areas of practice, and less invested in, than many of our specialties. Specialists have progressively pulled out of the general on-call rota, knowing that the way to build a career and a reputation is to focus on their work as an ‘-ologist’.

But most of the work of an acute hospital is in ED, acute and ‘general’ medicine, and care of the elderly. I believe if we are to make a step improvement in quality standards, we need to invest a greater proportion of our resource in these areas. More doctors, and maybe more nurses on wards with high acuity?

Such a move will have knock-on effects. I cannot see how to increase resource here without decreasing investment elsewhere. Add in the move to 24/7 acute services, and we have a huge need for new investment. That can only mean spreading the available resource less thinly and reducing the range of services on a particular hospital site?

It can be argued that, anyway, concentrating specialist services on fewer sites leads to better outcomes, with acute stroke or PPCI or cancer services often quoted as examples. But perhaps it needs to go further, with improvement of acute general services as the main driver?

As I see it, I will have to orientate my hospitals more strongly around acute services if I am to rise to the Francis challenge and really improve care quality standards with more staff, more capacity, and more time to care. If this leads to relinquishing some ‘high end’ services then many doctors will be concerned, because building a specialist service portfolio is deeply ingrained in medical culture. It is how progress is judged, and it is often the way by which hospitals are judged when selecting jobs.

If Francis provokes the development of a new world, maybe it will be a world where ED, acute  and general medicine, and elderly care medicine, are higher up the unofficial hierarchy – at the top even? Any thoughts?

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15 Responses to “A CEO’s view on Francis report implications”

  1. cd says:

    if ED, acute, general and elderly care medicine are serious in their quest to move up the unofficial hierarchy, they need to become as attractive as the current holders of the top positions. that is done by rewarding their staff with a simple and quantifiable measure of appreciation … it is called “money”. idealistic talk does not pay a mortgage.

  2. Mark Newbold says:

    cd – But basic pay is same in all specialties and my sense is that private practice is less of an influencer for the younger docs coming through. And recognition and investment would make working conditions more agreeable?

  3. Flip flop says:

    Ultimately, that is what hospitals are going to provide under general taxation – acute and emergency services. First we’ll move towards regional specialisation, and then we’ll move to ‘paid for’ elective or highly specialised services – backed by a new insurance system.
    Mid Staffs isn’t just about resources though is it? It’s about making our hospitals culturally caring rather than production lines. Not sure that costs money.
    Instead of these banal, three-line whips to attend mandatory training that HR teams spend hours on and benefit no one, what are the boards of hospitals going to do to create the right culture around care? How are they going to be visible and exemplify it? These things have to come from the top, rather than some ‘consultant’ dropped in to sort a problem out.

  4. Mark Newbold says:

    Flip flop – ‘caring’ doesn’t need to cost money I agree, but we have to understand why we haven’t got sufficient of it now? I suspect the unrelenting pressure on our acute areas is a significant factor, and more doctors and nurses to staff more capacity will cost money. My staff absolutely feel they are too few for the demands placed on them, so asking them to ‘care’ more isn’t likely to be effective?

  5. Malcolm Morrison says:

    If ‘resources’ (money or staff) are inadequate, then the resources that ARE available MUST be directed towards emergency care – and elective care (rgardless of tarets) MUST take a back seat.

    But good quality care on wards SHOULD be driven by the consultant and the Ward ‘Sister’ (whatever he or she is now called!) who must INSIST that patients’ basic needs are delivered properly in a timely fashion. If this means bringing back the ‘old fashioned’ consultant ward round with THE WHOLE TEAM – so be it. Do modern ‘Matrons’ not do ‘ward rounds? Do managers never see the wards? It only needs ‘normal vision’ to see when a patient is in a ‘wet’ or ‘dirty’ bed – or in pain. If relatives can see it, why can’t professionals?

  6. cd says:

    mark – private practice maybe less of a factor when making a decision about one’s specialty, but stress levels – due to exposure to the most unpleasant parts of society (A&E), shift patterns that play havoc with any circadian rhythm, full 24/7 shift systems with no extra pay for ooh/weekends/bank holidays (when everyone knows that australian ER docs get at least time-and-a-half for ooh) – in brief: quality of life – certainly plays an increasing role with todays junior doctors. why? because they know that they will not retire at the age of 60 and that their life will not get better after a few tough years as trainees. today’s juniors are not as easy to fool as their predecessors any more. thank god for that.

  7. dh says:

    I have yet to meet an individual nurse (or doctor) who did not ‘care’. But clinical responsibility has been taken away from the front line staff and “more important” targets imposed leading to the current demoralisation. The ward sister should have complete authority as before: if the cleaning is outsourced – fine – but if not adequate she can insist it is redone. If that is outside the contract (over which she had no control), too bad: indeed whoever made the contract should be criticised. Playing games and calling someone a ‘Matron’ without her role is just PR.
    Give the clinical power, and therefore responsibility, back to the front line staff (sisters and consultants) and clinical priorities would rapidly return. Managers should be the facilitators of clinicans, not their controllers.

    Specialisation and centralisation of services has been inexorable, and results seem to support improved results in each particular area. But it comes at the cost of general services: I suspect you cannot have both. Few surgeons could open an abdomen expecting gangrenous bowel and deal with the aneursym (and vice versa).

  8. Malcolm Morrison says:

    To ‘dh’. I agree, except for one thing – we must TAKE back responsibility. Clinicians (of all ranks) on the wards must INSIST on proper standards of care. It is a brave manager who will OVERRIDE a CLINICAL judgement – particularly if asked to “put it in writing”!

  9. Mark Newbold says:

    cd – I agree re quality of life but we need to find a way around this don’t we? The demand is clearly there on a 24/7 basis, and we know outcomes are poorer when cover is less. We need to make the acute specialties more attractive, but not just be paying premium rates – any ideas?

    dh – I agree with your analysis and indeed have written about this elsewhere. Targets have achieved some good things, but they were implemented in a way that has driven a wedge between managers and front line staff. This will prevent much more progress if we do not address it. I favour local prioritisation to central dictat, because that way we can agree to empower front line without risk of ‘failing’ centrally driven targets?

  10. cd says:

    mark, you want to have smthg people cherish: their weekends, their bank holidays and their regular night’s sleep patterns. 24/7 personnel lose their friendships and relationships with people outside medicine who work normal hours – and you want it without paying premium rates. sorry, but this is ridiculous…

  11. Lab rat says:

    Mark, you dismiss the climate of fear too glibly. It takes serious cojones to blow the whistle and render yourself unemployed/unemployable. I’m not aware that a vote of no confidence by consultants would achieve the desired effect of removing a CEO either, is that correct?
    In my own Trust I see the disastrous effect of budget cuts, particularly on nurse staffing. I flag it up with some effect through the appropriate channels but I would not confront the CEO head on or whistle blow. I have a mortgage and school fees to pay!
    I also think that consultants do far more out of hours work than the media give us credit for, and that any further out of hours needs to be properly paid for – no one gives up their weekends/family time out of goodwill.

  12. Mark Newbold says:

    cd – i understand but mortality and outcome studies tell us that non-office hours need full senior cover rather than on call, for acute specialties at least. Proper rewards should be paid but I struggle with the notion of ‘premium’ rate supplements for what is core work rather than additional duty. What matters is the total reward for doctors – do you not think that current remuneration for doctors is sufficient to cover some out of hours input? If not perhaps salary differentials should be introduced to recognise that some specialties are more onerous than others? The profession has always resisted this but maybe it is time to consider??

    Lab rat – not meaning to minimise but doctors surely do not have to act individually if serious care quality issues are present? If the Consultant Staff Committee raises a concern then it will be heard at senior level, and no doctor will be taking a personal risk? As the most powerful profession I struggle with the notion that doctors cannot raise issues collectively and with influence, because they clearly can if there is the will to do so?

    You are right re consultants unpaid commitment it is indeed significant. But should we be relying on this to the degree that we are currently? Should we not formalise and reward appropriately, including with time off at other times of the week?

  13. Malcolm Morrison says:

    Glad to hear that Consultant Staff Committees still exist! I had heard that they had been disbanded in many Trusts; if they have, time for a ‘resurrection’?

    Good emergenct care requires good consultant ‘support’ – which may mean ‘attending’ in the hospital, if only to do a ‘post take’ ward ound on a Saturday or Sunday. BUT such ’emergency cover’ MUST form part of one’s ‘Job Plan’ so would be ‘rewarded’; but, of course, this would mean less time for ‘elective’ (planned) work. But, if there are not enough consultants to provide both for emergency care AND ‘target compliance’ then CLINICALLY emergencies MUST take priority. And it is the duty of managers, Trusts, and politicians to explain this to the public – what they call ‘transparency’!

  14. cd says:

    mark – you need to present your mortality and outcome studies to those who hold the purse strings and convince them that it is worth while to pay the premium that full ooh service rightly carries. whoever thinks that full 24/7 rotas do not deserve the payment of premium rates can jolly well deliver that service him/herself!

  15. Roopa, Paediatrician says:

    Dear Mark,
    In Paediatrics we still have the concept of ”General Paediatrics” which I think is lost in adult practice. However doing excellent ‘General Paediatrics’ does not have the same professional status as being a sub-specialist, nor it is rewarded in the same manner e.g. CEAs which are usually awarded for doing work outside your department and trust! When a consultant is so engaged in regional and national work they have less or no time to fully engage in their own department and ward locally!
    Thus sub-speciality work takes priority and acute and inpatient work (which is the main function of the hospital) is left to the most juniors in the department (FY1s, FY2s, ST1-3s … ) and doing acute work is seenas waste of consultant time or something beneath them!. The same is true about nursing staff. Any good nurse soon becomes ward manager (doing what HR should be doing e. g. Sickness management and HR sit in office doing what I do not know) and away from the shop floor. This culture is so engraved in NHS that profession does not see anything wrong in this. Doing acute work is seen as something beneath them by consultants.
    We need to have experienced clinicians at the front end doing better ‘Gate Keeping’, in EDs and Assessment Units. So we investigate only who need investigations, we admit only those who need admission. We need to train juniors to think about resource implications, we do that very little in hospital practice, (so they do not think about it when they become consultants). Senior clinicians need to communicate with GPs directly, so they do not send everything to EDs or hospitals. To achieve this with the present work force, job plans need to be looked at and profession and trusts need to decide what is the priority? ‘General’ services will only be regarded highly if there is professional and local cultural change. Perhaps ‘salary differentials’ is the answer to elevate status of acute work.

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