The bed manager had no answer. But even a senior doctor’s explicit concerns that the child might die without surgery were not enough to persuade him to relent. Enough was enough.
‘I see,’ said the consultant, curtly. ‘Well. Let me make this crystal clear for you. This child is going to theatre. Now, if you wish to call the chief executive of this hospital, wake him up at home and get him here in his pyjamas to tell me to my face that I am not allowed to save my patient’s life, then – and only then – will I not operate on this child. Otherwise, please get out of my way.’
With that, Sam and his consultant physically wheeled Ayesha themselves down to theatre, where they surgically explored her abdomen. At the scalpel’s first touch, thick yellow liquid burst under pressure from the abdominal cavity. All four quadrants of her belly were swimming with pus from a horrendously inflamed appendix, the worst the consultant had ever seen. ‘It smelled,’ Sam told me, ‘of rotten fish. The anaesthetist had to leave briefly in order to retch.’ Later, the consultant told Sam that, had they not operated when they did, the child almost certainly would have died.
As I listened, aghast, to Sam’s tale, the what-ifs made me hold my head in my hands. What if Sam had not been sufficiently resolute and conscientious to call his boss at 2 a.m.? What if the consultant had been less senior, less confident, more easily cowed by a dogmatic bed manager? What if a little girl had indeed languished in her A&E bed until sepsis overwhelmed her and she died? Perhaps most fundamentally – given that Ayesha had survived only by the skin of her teeth, because two surgeons had stood up to an asinine system in which a man in a suit, not a doctor, dictated whether life-or-death surgeries may occur – what if elsewhere, in other parts of the country, children were slipping through the net? Might other Ayeshas, in short, have already died because hospitals without a single available paediatric bed would rather allow ambulances to keep bringing sick children to their swamped A&Es than be fined for diverting them elsewhere? How would we even know this?
No one could pretend that this is good healthcare. It is not; it is utter madness. Hearing the tale made me want to cry. To a doctor, let alone a mother, the notion that anonymous suits could be stalking hospitals at night, flexing their muscles in this manner with clinicians, was frankly terrifying. It is doctors, not bureaucrats, who know what their patients need, particularly when those patients are in extremis. And if financial pressures are distorting care in this manner – right now, under the radar, in our NHS hospitals – then something has gone horribly wrong with the health service we long to believe is the very best of Britain.
The tragedy for doctors, nurses and managers alike – not to mention the patients we strive so hard to look after – is that we operate within a system that makes fools of us all. When nearly every hospital Trust in the country is running up multi-million-pound debts, as they are, because their income is vastly outstripped by the needs of their patients, Trusts do not stand a chance. Of course, a Trust will fight tooth and nail to avoid the fines that accompany diverts when it is already, financially, on its knees, already facing punitive measures set from on high to address its alleged fiscal irresponsibility. The system – above all the government’s £22 billion of ‘efficiency savings’ that no one in the NHS thinks we can possibly achieve – is set up to pressure Trusts to shave costs wherever possible, let alone incur avoidable ones.
Yet even this misses the most important point – the inescapable, on-the-ground reality – that on this particular night there were no beds. Not in Sam’s hospital, not in any of the local hospitals. There was literally nowhere for Ayesha to go. Even if ambulances had been diverted from Sam’s hospital, how many miles would they have had to drive to find a hospital that could actually admit children safely? What might the potential risks of those long journeys have been for unwell, unstable children? Ultimately, we all know that words – no matter how fine – in the end come up against reality. In the case of the NHS, reality is the actual care that patients receive and that frontline staff both deliver and bear witness to. Reality, on occasion, is nights like Sam’s, when a child nearly dies because there is no capacity in the system to give her the care she needs. And if, as a doctor, my duty of candour – of being honest and open with my patients about mistakes or failings of care – means anything at all, then it behoves me and all of us who work within the NHS to speak out, uncowed, about this reality. How else can we stand up and look our patients in the eye?
‘If you admit you are a doctor in distress, then this will all go away.’
‘This’ was the threat of formal disciplinary action against me, made by a manager in one of my previous hospitals. Candour, I had discovered to my peril, costs. I had had the temerity to break an internal Trust rule I was not aware existed and now I was reaping the consequences. It is difficult to convey how frightening it is, in a profession as rigidly hierarchical as medicine – and as notoriously hostile to perceived troublemakers – to be threatened with disciplinary proceedings. On discovering via email that I might be formally disciplined, I burst into tears on the spot. In medicine, a disciplinary incident dogs you for the rest of your career, its recording a requirement on every subsequent annual appraisal and every future job application. For a junior as junior as I was then, with most of my career still stretching ahead of me, that was a distressing prospect. Which, of course, is precisely why, for a Trust, even a whisper of a threat to take formal action against you is such a powerful means of achieving silence and conformity.
‘What am I going to do?’ I cried to my husband plaintively, temporarily immersed in fear and panic. The answer was provided for me. I received an email summoning me to report to the senior manager to explain my subversive act in person. The prospect of being hauled over the coals by someone fully cognisant of his power to damage my future in medicine was not one that I relished. That night I slept little and fitfully.
Often, doctors who face discipline do so because their desire to protect their patients has forced them into the role of reluctant whistleblower. They know the risks of speaking out, yet the duty they feel to put their patients’ interests first compels them to be candid. Having failed to persuade their hospital management to take seriously their safety concerns, in the end they resort to going above them – perhaps to the doctors’ regulator, the General Medical Council, or to the institution that safeguards NHS standards for patients, the Care Quality Commission. Then, if not beforehand, the full force of their employer descends on them like the wrath of God. Money – supplied courtesy of the taxpayer – is no object as a stellar Trust legal team is lined up against the whistleblower. The NHS is littered with former doctors who, after attempting to raise concerns, have lost their jobs, homes, marriages and health after bitter legal battles with their Trusts. Whistleblowers are meant to have legal protections that enable them to raise concerns about the organisation in which they work in good faith. But, in truth, whistleblowing often destroys doctors, nurses and anyone else who tries to speak out. In standing up for their patients, clinicians can end up sacrificing themselves.
Nowhere was a culture of denial and cover-up more pervasive than in Mid Staffs. When individuals attempted to flag concerns through ‘incident forms’, online reports about issues threatening patient safety, these never appeared to be acted upon. When concerns were reported at Trust board level, these too were invariably ignored. Complaints from patients and their families were swept under the carpet. Sir Robert Francis, in analysing why so few staff members spoke out in Mid Staffs, describes professionals trying their best to raise issues but who, when that failed to have any effect, became disillusioned and in the end gave up. Fear of reprisals also deterred them. Dr Pradip Singh, a consultant at Mid Staffs who tried, if belatedly, to raised concerns about patient safety, was asked why he had not gone further. He explained, in essence, that, though he was brave, he was not brave enough:
Q. How do you answer the criticisms that I suppose might be made that if you’d cared more you would have
gone outside the hospital and raised, as one might put it, merry hell?
A. I would have then ended up becoming either a stroke or a heart attack, and being on the road.
Q. You mean out of a job?
A. Yes. Clear and simple. And I am brave – I mean, what I did takes a lot of guts to do. But I’m not Nelson Mandela … You’re always watching your back. At the end of the day, I’m a human being. I might make a mistake and that could be the end of my career, because it will be used against me. Because the kind of job we’re in, things will occasionally go wrong. It doesn’t matter how good you are, and then that will become the excuse for destroying your career.9
Francis identified frontline clinicians’ fear of speaking out as one of the most important factors that permitted the cruelties of Mid Staffs to flourish unchecked for so long. So detrimental did he regard this culture of fear to the overall aim of ensuring patient safety that he went on to investigate more broadly the experiences of NHS staff who attempted to raise concerns. His ‘Freedom to Speak Up’ review found that the barriers deterring individuals from speaking out about their concerns were ongoing and relentless:
The NHS is blessed with staff who want to do the best for their patients. They want to be able to raise their concerns free of fear that they may be badly treated when they do so and confident that effective action will be taken … Unfortunately I heard shocking accounts from distressed NHS staff who did not have this experience when they spoke up.61
My own transgression was by comparison minimal. I was not even a whistleblower. In expressing my concerns to the press about an unfunded seven-day NHS policy several years before the junior doctor dispute began, I had merely committed the sin – albeit a cardinal one, as I would go on discover – of naming the Trust at which I then worked. This, with hindsight, was exceptionally naïve. Unbeknown to me, a draconian Trust media policy required all employees to liaise with the press office before making any reference to the Trust in the media. That my comment referred to a national government policy, neither criticising nor attacking my Trust in any way, was no defence; I was nonetheless in breach of a formal Trust policy.
I sat before the manager with a churning stomach, yet what I hoped was an implacable exterior. I was told again that if I admitted I was a doctor in distress, ‘this’ would all go away. This is a well-documented tactic used by NHS employers against staff who speak out, an attempt to tar them with the stigma of mental instability, neatly delegitimising their concerns from that moment onwards. It needed confronting head on.
‘I can’t do that,’ I stated, ‘because it isn’t true. If you look through my online portfolio, which I’m sure you have done, you will see that my feedback from my colleagues and from patients is superlative. I am not a doctor in distress. I am someone who saw it as her professional duty to speak out against a government policy I believe will be to the detriment of my patients, because it is unfunded.’
It is fair to say this was not well received. Contrition and admission of mental frailty were expected, not unrepentant idealism. An hour later, the meeting concluded with a curt statement that, no, this was not the end of the matter and, yes, I may yet face formal disciplinary proceedings. Eventually, after nearly two months of worry, I was informed that the matter had been closed. The Trust CEO actually took me aside for a quiet coffee during which he apologised for the whole incident. Alongside my feelings of immense relief, I was left with the uncomfortable conclusion that, if this was how an NHS doctor was treated when they had not actually blown the whistle at all, how much more oppressive must the treatment be of someone brave enough to speak out about local Trust practices they believe are putting patients at risk. It is a wonder anyone puts themselves in the firing line in a culture so authoritarian and closed.
Some months after this unpleasant experience, I was chatting with a fellow parent on the sidelines of our sons’ Saturday morning football match. He was a barrister, specialising in medical negligence, and he took a keen interest as I described my head-to-head with my Trust.
‘Something you might not be aware of, Rachel, is that I actually work in Sir Robert Francis’s chambers. I suspect he may well be keen to hear your story.’
I’d had no idea. But the thought of assisting Francis, however trivially, in his efforts to make the NHS safer for patients was an honour. Several weeks later, I received an invitation to attend an evidence-gathering session as part of the ‘Freedom to Speak Up’ review. Francis had previously described junior doctors as the ‘eyes and ears’ of the NHS whose testimony and fearlessness in speaking out had been integral to exposing the horrors of Mid Staffs. He was keen to hear in person from juniors from across the country with experience of whistleblowing. We convened at an informal meeting chaired by Francis himself in a hall in central London. My story was inconsequential compared with what others had endured. Young doctor after doctor described harrowing treatment at the hands of their Trusts, simply for endeavouring to raise genuine concerns about their patients’ safety being jeopardised. Some had been bullied, smeared and denigrated. Frequently, according to the juniors’ testimony, the mental-health card was played by Trusts who attempted to paint the whistleblowers as unreliable or incompetent due to emotional instability.
I remember looking around the room feeling pride and anger in equal measure. Junior doctors reside near the bottom of the NHS food chain. They have nothing like a consultant’s clout. That these juniors were standing up for their patients, sometimes enduring ferocious workplace bullying as a result, was something I found deeply humbling. That Sir Robert Francis had proactively sought out their testimony gave me hope in a more transparent and open future for NHS clinicians and patients alike.
Ironically, the Trust that took issue with my accidental insubordination behaved impeccably towards one junior doctor whistleblower. Conditions in the hospital’s Surgical Emergency Unit (SEU), where I had once experienced such understaffing, did not improve after I left. So overstretched had the juniors become that one of them took matters into his own hands. Barely a year into his career as a doctor, he wrote a letter to the most senior member of the Trust, its chief executive officer, detailing the dangers to patients of the unit’s understaffing. Every SEU house officer had signed it, a collective cri de coeur from the most junior doctors manning the front line. Their concerns had been roundly dismissed by their consultants and immediate managers and so, en masse, they had decided to go straight to the top. And – to his enormous credit – the CEO not only listened, he insisted that the understaffing must be dealt with. Thus, thanks to one gusty house officer, a whole department was changed for the better. It was a model of exactly how a Trust could do it right.
Nor did it not stop there. For a few years, several other doctors and I had run an annual teaching session for final-year students who were about to embark on their lives as new doctors. In it, we invited current house officers to share with the students their real-life stories of how things had gone wrong when they began to practise medicine. The aims were simple but important. To show that mistakes happen to everyone, that they are nothing to feel ashamed of, that every mistake is an opportunity to learn and to make the wards safer for patients, that doctors are as fallible as anyone – and that this is OK, this is human. Sometimes, the stories were harrowing. One or two doctors cried in describing what had happened. The Trust, keen to embrace a culture of transparency and candour, invited us to extend the sessions to an audience of junior doctors as well. It felt progressive – a small step towards a less adversarial future in which learning from mistakes, not apportioning blame, took priority for our patients’ sakes.
Candour is no longer an optional extra for doctors, and rightly so. For too long, patients and their relatives have been kept in the dark about individual and systemic failings that have led to loved ones’ harm. As a direct result of the brutality of Mid Staffs, in 2015 the General Medical Council and Nursing and Midwifery Council introduced a new professional duty of candour upon all individual
doctors and nurses working in the UK. A clear attempt to circumvent the cover-ups of old, it required us to be honest with patients and apologise when mistakes were made, something that can only be for the good of our patients.
There remains, however, a tension between the new duty of candour and enduring conditions that discourage speaking out. Bullying and a blame culture are still rife within the NHS, but there is also something more insidious driving individual doctors and nurses away from frank disclosure, namely, the example we are set by our ultimate bosses, the politicians to whom we are in some ways accountable. The government purports to champion candour within the NHS. In the foreword to the government’s formal response to the ‘Freedom to Speak Up’ report, Jeremy Hunt declared:
I want to pay tribute to those members of staff, patients and their loved ones who stood up for a culture of truthfulness and compassion, and who would not give in to those who put what they thought were the interests of the system before what was right. The only way to honour their courage is to stand with them by continuing to build a culture that listens, learns and speaks the truth.62
These are fine words. They inspire hope and optimism. But are they sincere? The report itself went on:
In an organisation as large and as complex as the NHS – operating under pressure, under intense scrutiny and in which life or death decisions are made every day – no matter how strong the professional instinct to do the right thing, no matter how powerful the impulse to care, there are inevitably times when it might feel easier to conceal mistakes, to deny that things have gone wrong and to slide into postures of institutional defensiveness.62
Your Life In My Hands--a Junior Doctor's Story Page 20