Death by Bureaucracy: As we learn the NHS is bankrupt, read this excoriating attack on its managers by a senior consultant

A few weeks ago, I had lunch with four old friends. We have all worked in the NHS for more than 25 years. All of us are consultant surgeons and all trained together at the same London teaching hospital.

We learnt the art of surgery from masters of their craft and all undertook post-graduate research degrees in the same field. We left full of enthusiasm having been appointed as consultants to major hospitals.

Each of us has led large clinical teams performing major cancer surgery as well as elective and emergency general surgery. We are all, sadly, about 50 years old.

We meet a couple of times each year and as always, it was wonderful to see each other. As the wine flowed and the steaks arrived, the gossip got better. But before long the discussion took a distinctly melancholy turn.

There are currently 15 hospitals in 'special measures' because of very serious concerns that patients are receiving such poor care that they are dying unnecessarily
There are currently 15 hospitals in 'special measures' because of very serious concerns that patients are receiving such poor care that they are dying unnecessarily

We started talking about the NHS, our plans for the future and, specifically, retirement. Every one of us confessed that we were considering leaving the NHS early.

My friends are disillusioned, not with being doctors, or the practice of surgery, not with our colleagues or patients, but with an overwhelming sense that we have lost all power over our day-to-day professional lives.

They talked of feeling lost in a sea of bureaucracy over which they have little influence. Our ability to direct and control our own clinical teams has diminished. Those of us with managerial roles find we shoulder an enormous burden of responsibility — but little authority.

My friends are all frustrated to the point of throwing in the towel.

These people were the brightest in their year. They passed gruelling exams and spent years training to perform hugely complex tasks combining intellectual and technical skills.

Between us we have accrued more than 150 years of combined clinical experience. We ought all to be moving on to senior leadership roles. Indeed in any other professional services organisation, such as law or accountancy, that would be our ambition.

But my friends, like so many front-line staff, both doctors and nurses, are in despair.

Yesterday, the Royal College of Nursing called on politicians to say how they plan to pay for an NHS that faces a £30 billion funding black hole by the end of the decade. One in three hospitals is now in the red.

To address this deficit, some nurses are calling for patients to be charged a £10 fee to see their GP. This would raise £1.2 billion a year. But I have a more radical solution: put doctors and nurses back in charge of our health service.

There are volumes of empirical and academic evidence that without the leadership of these two groups of front-line staff, hospitals fail.

At best they become inefficient; at worse they become enormously dangerous.

The best performing hospitals in the world have cultures where clinicians move between operating theatre and ward and the boardroom, drawing on their expertise to inform management decisions.

In the U.S., for example, a third of doctors at Kaiser Permanente, a high-performing healthcare organisation, spend a significant part of their careers taking responsibility for the management of the hospitals in which they practise.

Many trainees want to work longer hours - but young doctors are being told to go home at the end of their shift, rather than stay in order to see to an emergency operation
Many trainees want to work longer hours - but young doctors are being told to go home at the end of their shift, rather than stay in order to see to an emergency operation

Mid Staffs, on the other hand, is an example of a hospital where there was a systematic failure of leadership with terrible consequences for its patients.

There are currently 15 hospitals in this country under 'special measures' because of very serious concerns that patients are receiving such poor care that many are dying unnecessarily as a result.

And it's worth remembering that this deterioration in the quality of care provided by many hospitals has happened despite all the targets imposed upon hospitals which were supposed to improve performance, as well as a significant rise not only in the number of doctors employed by the NHS but also of managers.

Today, according to official statistics, there are 274,000 managers supporting doctors and nurses. They outnumber consultants nearly seven to one.

The causes of poor quality care are complex, but there is no doubt that a lack of clinical leadership literally costs lives.

The disillusion that I and my friends feel is widespread, if not endemic, in the UK.

Our disenchantment is shared by numerous other consultants as well as general practitioners, nurses and other healthcare professionals. Only a couple of weeks ago, a poll suggested that more than 60 per cent of GPs were also considering retiring early from the NHS.

This epidemic of disenchantment certainly wasn't always the case. Doctors have historically enjoyed very high levels of professional satisfaction.

I recall numerous consultants and GPs 20 years ago who were extraordinarily reluctant to leave the jobs they loved. Many worked on long after the official retirement age.

The Royal College of Surgeons calculated surgeons were appointed on more than 30,000 hours of experience 20 years ago - now it is 7,500
The Royal College of Surgeons calculated surgeons were appointed on more than 30,000 hours of experience 20 years ago - now it is 7,500

How has this sorry situation been allowed to arise — and what is to be done?

Let us first be clear that it is not the fault of front-line staff.

Virtually all doctors I talk to enjoy being doctors and the fundamentals of the job haven't changed. Many don't even see their role as a job but rather a vocation. They find deep satisfaction talking to and treating patients.

I don't know a single surgeon who doesn't feel a thrill or pride and satisfaction in the operating theatre. All feel a great sense of fulfilment when patients thank them for what they have done.

It remains an honour to be a doctor. Things have changed, though. There has been too much interference from bureaucrats who know little of the pressures of the operating theatre or a long night on call on the wards. One particular culprit is the European Working Time Directive, which has had a terrible impact on surgical training.

The imposition on NHS staff of this health and safety legislation from Brussels now prevents junior doctors from being on call for more than 12 hours at a time, even if they're not actually working, and limits them to 48 hours a week.

The consequence is that most now work shifts with an inevitable erosion of professional responsibility.

In order to accommodate these shifts there has been an enormous increase in their number — there are now 24 junior surgeons where I work compared to eight when I was training.

This has left today's trainees with eroded levels of experience and diminished opportunities to acquire clinical and surgical skills. Inexperienced, they require more and more senior support.

Many of today's senior consultants worked very long hours as junior doctors because they wanted to gain the experience that being an expert professional requires, especially in fields which required specialised practical skills like surgery.

The Royal College of Surgeons has mounted a campaign to allow junior doctors to work more than

48 hours — not least because many of these trainees actually want to be allowed to spend more time on wards and in the operating theatre to gain the experience they know they need. To date this campaign has not achieved any changes.<

The consequence of this in many hospitals is that more is demanded of consultants who have less support from their junior colleagues.

Senior consultants are now expected to perform straightforward bureaucratic tasks that they used to perform themselves as trainees. This is frustrating and inefficient.

For instance, what organisation would require their most senior and expensive employees (except that these days senior managers get paid even more) to fill in enormously long tick-box forms for patient admissions? Or to fill in similarly tortuous long electronic discharge forms?

As the paperwork required of doctors has increased, secretarial support has been cut.

Meanwhile, today's surgical trainees are 'protected' by a system created not by them but by professional educationalists who have encouraged a clock-watching culture.

The NHS consultant contract is now underpinned by 'job-planning' and units of 'programmed activity'.

Many senior doctors believe this approach is incompatible with the ethos in which we were trained 20 years ago: that the professional responsibility of being a doctor comes above all else.

Their hearts sink when they see the next generation is being schooled in this culture: young doctors being told that they must go home at the end of their shift rather than stay in order to, say, attend the operating theatre when a patient they admitted with appendicitis requires an emergency operation.

Consultants feel frustrated by these issues. But the greatest frustration is how little power they have to do anything to manage and improve their day-to-day practices or to change the system. Every single clinician will see numerous ways that the quality of care they offer their patients could be improved.

All of us are witness to not only poor clinical practice, but also to waste and massive inefficiency every day.

When they try to suggest practical, sensible improve-ments, they frequently find themselves bogged down in bureaucracy.

Meaningful change in many NHS organisations requires almost super-human energy. Surgeons in particular tend to be 'can-do' people.

They are trained to analyse a problem and then fix it.

To be constantly thwarted is particularly frustrating. Many give up trying.

The fundamental problem is that clinicians no longer run hospitals in the UK.

This is in marked distinction to the rest of the world, where they do.

There are only a tiny number of NHS hospitals run by doctors and as far as I am aware no private hospitals.

NHS hospital boards of directors will usually have just one doctor (appointed by the chief executive) and just one nurse (appointed by the chief executive).

Even at the level of clinical teams, consultants no longer run what they do day-to-day but are given instruction by professional managers.

In surgery, for example, this means most consultants are no longer trusted to manage their own waiting lists.

Instead, patients are added to lists by administrators who decide who takes priority, often according to national targets.

I was speaking to a professor of surgery only last week who tells me that he often arrives in the operating theatre unsure who will be on his list that day.

Yes, most hospitals will have 'clinical directors', but they have little authority and doctors have little respect for those they see as having 'gone to the dark side'.

The fatal mistake that hospital managers and many policy makers have made is in trying to remedy the problem through fiddling with existing systems of management or through structural reform.

It is not the fault of the front-line staff - it remains an honour to be a doctor. Things have changed though. There has been too much interference from bureaucrats

It's not clear how much is spent on management consultants each year — to be fair the coalition government has tried to cut the bill — but estimates over the last few years have ranged from £80 million to more than £450 million each year! These are astonishing figures.

Ultimately, these structural solutions completely miss the point. And this is that the fundamental problem facing many NHS organisations is cultural.

The culture that my friends and I trained in and of which we were so proud has been lost in a generation.

To revitalise the service we must give power back to clinicians and the staff within the NHS who actually see and treat patients every day.

Of course this will mean that managers will lose power, which they are mostly very reluctant to do.

I do not wish to be melodramatic, but if the ability to make sound, informed decisions is not handed back to doctors — and nurses — throughout the NHS, it is doomed to fail.

There was enormous opposition when the private healthcare provider Circle — of which I am a partner — was given the opportunity to run Hinchingbrooke hospital, an NHS district general hospital in Cambridgeshire that was faced with closure. Doctors and nurses were put in charge and two years later there have been numerous improvements in the quality of the care provided. The hospital was recently given an award for best quality of care in the whole of England.

The first step in solving the problem is to recognise that, despite a lot of talk, the NHS is failing to capitalise on its most important resource, its staff.

And that it must not only encourage the best NHS leaders and hospitals to innovate and change, but also embrace newcomers who bring new ideas and methods of liberating them of their frustrations.

My friends should have many more years ahead of them in the NHS.

Their early retirement will be a loss to the health service.

All of us — as patients and taxpayers — will pay the price.

We must free doctors to do what they all trained to do, which is, of course, to treat their patients to the very highest standard and with the greatest care and compassion.


Source: Daily Mail



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