The Heart of the Matter

“Dismissive attitude of staff, a disregard for process and procedure and an apparent indifference of NHS staff to deplorable standards of care”” concluded England’s Health Ombudsman Ann Abraham in her Office’s February report into ten cases involving older people. The stories made me angry and frightened – after all we will all be there one day, asking to be treated not just competently but kindly as well when the infirmities of old age take us into hospital. These are ten stories of unnecessary pain, indignity and distress.

Does complaint data change anything?

What is happening here to turn those working to provide care for the elderly in whatever setting into what would appear to be callous, uncaring figures who do not listen or notice what is happening on their watch? The National Voices submission on Complaints and Litigation to the Health Committee just before Christmas made the point that sometimes staff were happy to fend off complaints because they needed to protect internal relationships and not upset the institutional apple cart. The NV evidence made much of the need for decent complaints data especially at the front line – the escalated complaint as many past reports from the Ombudsman attest, is well-written up and publicised. This information is key to higher standards of care in theory at least. But the evidence is piling up that nothing much is improving either in the way complaints are handled or in the use that managers within the NHS make of them.

What is stopping improvement?

Can we identify the reason for these low standards of care, indifferent performance in managing the subsequent complaint and the unchanged attitudes picked up by the Ombudsman who is still awaiting “convincing evidence of a widespread shift in attitudes towards older people across the NHS”? What is stopping these changes for the better being accepted and implemented by people eager to escape accusations of brutality and neglect?

No connection with reality – the NHS management system condemned

The best explanation I have seen about why the lessons are not being learnt and why staff attitudes figure so highly in complaint cause data comes in a report from the Lean Enterprise Academy ‘The NHS Bermuda Triangle (and how to escape it)“. This is the most interesting if depressing piece of analysis of management performance in the NHS I have seen recently. What it does that differentiates it from other research in a very crowded field is the bluntness of its conclusion that the way things are done now in the NHS cannot work because the current NHS management model has no connection with reality. This is the root cause why all the good stuff which the authors believed their methodology delivered, disappeared into the NHS Bermuda Triangle to be forgotten and never seen again.

They concluded that the top down management system delivers new demands and new initiatives without any reference to the capability of the system to resource or act on them. Futhermore, management keeps its gaze upwards to spot the next set of new initiatives winging their way from on high and turns its back on the realities of the front line as managers prepare to set up another project to study the way they were to meet the next set of targets and create the measures/ KPIs (key performance indicators) to go with it.

And the answer is 515

The consultants asked those managers the simple question -“how many projects are you doing?” and pressed for an answer that went beyond the instant but unquantified response ‘Too many!’  In one establishment they counted 515 projects with each manager doing about 50 each. At an hour a project per week, this would appear to leave no time for the day job at all. This was totally new data for the managers concerned. What was also new information was that the so-called patient pathways were organised with no thought for the patient experience – 85% of the patients’ time was spent waiting.

Also the researchers documented for the first time the way that setting 11 strategic objectives could roll down the organisation gathering moss to such good effect that the commitment created 350 KPIs – indicators which might be “key” to the managers, but which measured nothing of value to the front line and whose existence merely served to feed the beast of a set of management priorities which were wholly unconnected to the needs of that front line and – we do not appear to have mentioned them for a while – the patients.

The promise of action – another new project

So when I read in Ann Abraham’s report that an appropriately chastened Trust has promised a raft of actions such as a review of all nursing documentation, introduction of a five day pain management course , a new ‘holistic assessment’ tool for the palliative care team, that is at least 3 new projects right there to be added to some hapless manager’s current 50. Will something happen? Let us not hold our breath.

GPs – the new project managers

We worry because we are now in a situation where an administration dedicated to localism and patient-centred change has issued from the top a directive for change and is looking for implementation of changes and budget cuts with little reference to patients. The interesting variation this time around is that the ranks of the management and the PCTs that harboured them, on whom Government might have relied in the past to take on the project are being culled. Whether those managers looked up or to their front line, does not matter since they will not be there at all.

The new managers of the system will be those front line operatives formerly known as GPs. Now it is their turn to  have 50 projects each and their practices will be run by their reception teams whose ability to deliver service quality and innovation has in the past been um…patchy.

It seems that as the wheel of change rotates once more, the only thing that we can be sure of in the NHS is the regularity with which it turns its back on chances to deliver a health care system that does indeed bring an experience as patients that spares us the pain, indignity and distress that the Ombudsman found was all too often the lot of patients if they were old, frail and had multiple problems.  They ought to get the best care, not the worst.

The Moore Adamson Craig Partnership supports user and public participation,  trains lay representatives and develops responsive  health, care and education organisations.  We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing.  Feel free to contact us to discuss the opportunities.

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