Abstract
Silence from the medical profession has been deafening since the release of the Francis report 1 and the patient stories emerging from Mid Staffordshire. What happened in this hospital should be a hammer blow to the conscience of our profession. What is most stirring about Mid Staffordshire is the destruction of our faith in values long held to be fundamental to our trusted National Health Service (NHS). Just as the printing press shattered the monopoly of the priests, the information in this report about appalling professional behaviours is altering the relationship between patient and doctor.
DECLARATIONS
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AH
AH is the sole contributor
The medical profession's technical and scientific brilliance has not been matched by its leadership or compassion - and yet, ironically, the profession's authority arises from how much it cares. Sir Henry Tate commissioned Sir Luke Fildes to capture the character and bearing of the physician in 1891 in his now famous ‘The Doctor’, of which one million engravings were sold. 2 It resonated with the public's impression of a doctor. How many would sell today? Where have our voices been on behalf of patients since the report was published? As other hospitals are named, the number of avoidable deaths rises steadily. Why has it taken the release of the Francis report for other information to surface?
Journalistic punditry abounds and everyone has a theory, but there is a sense of suspended disbelief. Do we accept what Francis has concluded? Were these deaths and so many others avoidable? Have any lessons been learnt and how do we demonstrate what has been learned? We know, in graphic detail, beyond any attempt at denial, what happened. We know what should have happened. Why was there such a difference? The Francis report explains that it was a failure of people and relationships. Could this have been avoided? How was it allowed to happen? Why didn't we know? Why didn't we ask? There were early warnings: in 2008, a report by the Joint Commission International 3 stated that a shame/ blame culture of fear appeared to pervade the NHS. This culture, said the commission, ‘stifles’ the organization's ability to deliver quality and safety. In the same year, an Institute of Health Improvement report 4 said that the NHS had developed a widespread culture more of fear and of compliance than of learning and innovation.
What makes our National Health Service special is a very simple principle of British life: that the moment you're injured or fall ill…the moment something happens to someone you love…you know that whoever you are, wherever you're from, whatever's wrong, however much you've got in the bank…there's a place you can go where people will look after you and do their best to make things right again. The shocking truth is that this precious principle of British life was broken.
Prime Minister's statement in response to the public inquiry into the Mid Staffordshire Francis Report, 6th February 2013.
Our lives begin to end the day we become silent about things that matter.
In the end, we will remember not the words of our enemies but the silence of our friends.
Martin Luther King, Jr
The culture described by Francis at Mid Staffordshire was characterized by disempowerment, poor communication, isolated professionals, inadequate leadership and inadequate systems and processes. Staff averted their gaze. There was a disconnect between staff and the Board; a culture of fear and poor human resource practices. The consequences were a subtle withdrawal of enthusiasm and the avoidable deaths of 1200 patients.
We are, in the end, all responsible for our actions, conduct and work. The privilege of professions in this country is their right to self-regulate, and wedded to that right is a responsibility to self-police. That duty of self-policing is better characterized as peer leadership, which is built on moral courage and integrity.
We are occasionally led into disbelieving the evidence of our own eyes. There is nothing as deceptive as an obvious fact. Everyone knows, nobody says. The phenomena are well described: normalization of deviance and wilful blindness. These life-threatening phenomena can only be addressed through leadership. Can leadership, then, be taught? The problem is that what is offered reflects what is expected - little of what is taught on traditional leadership programmes prepares would-be leaders for the reality of leading.
There is no doubt, no matter what the rhetoric, that the current drive to cut costs in the context of increasing demand, will inevitably impact, and at scale, on our duty of care to patients. The horrors at Mid Staffordshire were failures of clinical care but, to quote Heather Wood, author of the Healthcare Commission Report5,6 into Mid Staffordshire, ‘these were the symptoms of a serious underlying illness’. Too many people in leadership, from whom we ought to expect more, have been willing to bend the truth and re-write facts for their own convenience. The roots of this affair go much deeper than those who caused immediate harm to patients. The cultures of target setting and comer cutting that caused such anguish to patients and their families, and which have been replicated elsewhere, were set far higher up in the health service. But who was to blame? Apparently, no one and everyone.
Francis and others are, of course, correct: accountability is not about punishing people. True leadership is having the conviction to be accountable. As Leo Amery said to Chamberlin in 1940:
You have sat too long here for any good you have been doing. Depart, I say, and let us have done with you. In the name of God, go. 7
What you permit, you promote.
Footnotes
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