A letter from London: who are health services serving?

1 January 2014

JO ANN WALTON writes from London about lessons to be learned from yet another NHS bad news story – this time one where ‘bullied’ health staff falsified cancer patient waiting lists to keep funding flowing.

I am writing this from a desk at City University in London. I am here to discover more about nursing and health matters in the United Kingdom and future learning and sharing opportunities.

Something that is becoming all too familiar here is the constant media attention on problems in the National Health Service. It seems that the media tell a new and shocking story nearly every day. I have written before about the Francis Inquiry and related stories continue to appear. Happily, while here I have met many influential leaders making a difference in meaningful ways. So there are good stories to be told …

Yet another shocking NHS story…

Perhaps I ought to apologise about writing about yet another of the bad NHS news stories. This is the story of Colchester Hospital, where the CQC (The Care Quality Commission, Britain’s health watchdog) has reported staff were “pressured and bullied” into falsifying cancer patient waiting time statistics in order to meet government targets.

The CQC reported the Colchester Hospital University Foundation NHS Trust to police, with the media suggesting criminal charges may be pending against some managers involved. It is believed the falsification, involving up to 6,000 patients, may have led to several patient deaths.

The story is shocking and worrying. How does it happen that a health service industry – whose purpose is the treatment of illness and injury – can inflict such harm? How could managers be so out of touch with their industry’s purpose that they force employees into such unethical and dishonest behaviour? What is happening in the lives of the “pressured and bullied” staff that enough of them are ready to comply? And how, after all the publicity surrounding the Mid Staffordshire inquiry, could managers ignore staff warnings of major problems within their own health service?

From news reports, it appears that the situation was brought to senior managers’ attention by both nursing and administrative staff, along with professional groups’ representatives, but the warnings were ignored. It is understood a union group were the whistleblowers who informed the CQC.

It is also alarming that several NHS quality reviewers failed to notice the tampering of dates in patient records (and the resulting false statistical returns) until the whistleblowers’ information was taken seriously. Unsurprisingly, UK unions are now calling for better protective legislation for whistleblowers.

Better whistleblower protection needed here?

The Colchester case also provides food for thought in New Zealand. I have written before about the need for nurses to have the courage to speak out. It is easy for frontline health workers (the majority nurses) to be blamed for problems in health care. But nurses are not responsible for all things that go wrong.

Do we need better systems of whistleblower protection? Or are we already able to tell the truth about systemic problems to the right people at the right time? Do we have a suitable mechanism for identifying and investigating systemic problems? Does the New Zealand health system have adequate safeguards? Britain’s Care Quality Commission and their Chief Inspector of Hospitals are charged with reviewing the quality of health care across the UK. It was during a visit by the CQC that the problems at Colchester finally came to light.

The Colchester Hospital case raises serious issues about the disconnect between financial incentives and the core business of a health service. When entire systems are dependent for their funding on meeting “quality measures” (that may not actually measure quality), we shouldn’t be surprised that perverse incentives kick in. At Colchester Hospital, records were presumably falsified so funding streams would continue. The money kept flowing, as it appeared Colchester was ‘delivering’ the desired outcomes. My hunch is that the money would have stopped if the truth had been told. This would not have helped patients on the waiting list, either. So this aspect of the health funding system was also flawed. How well are our quality measures reflecting health service functioning?

Who are health services serving?

A third aspect to be explored is the cohesion of purpose (or lack of it in Colchester’s case) across the entire health services team. Successful businesses have a common vision and purpose from top to bottom of the business. From the board room to the front of house, everyone knows and agrees what they are there to do. Clearly something went wrong with the vision at Colchester. Is your workplace one where governance, management, and frontline operations (nurses and doctors to porters and cleaners) all know who and what they are there for?

From the times of ancient Greece, we have known that patients require a team effort for them to get well. While sightseeing at the National Science Museum, I found a quote from Hippocrates in medical history exhibition. Actually, it is the first of his Aphorisms, which have informed medical practitioners and scholars for centuries. Here’s what he said:

“Life is short, the craft long to learn, opportunity fleeting, experiment deceptive, and judgement difficult. Not only must the physician be ready to do his duty, but the patient, the attendants, and external circumstances must all conduce to a cure.”

Is our health system conducive to curing patients? What do you think? I would love to hear from you.

Jo Ann Walton is Professor of Nursing at Victoria University of Wellington and an elected member of the Nursing Council.