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Hear No Evil: How the One Way Street School of Management runs through the NHS like a sewer

July 1, 2013

‘A rotten culture took hold…Again and again, a desire not to face up to the reality of poor care saw institutional secrecy put ahead of patient safety. This was a shocking betrayal of the public and the overwhelming majority of NHS staff’. Writing in the Daily Telegraph, these were the words of Dr Dan Poulter, Parliamentary Under Secretary of State for Health and practising doctor, in the wake of the the Morecambe Bay/Care Quality Commission cover up scandal, just the latest in a shameful litany of PR catastrophes to rock the NHS.
Decrying ‘NHS culture’ has lately become almost de rigeur for anyone with pretensions to being a health commentator. It started with the Francis Report. Describing the moment the findings were made public, Roger Taylor in his book God Bless the NHS says that ‘when all the evidence had been sifted; when the lawyers had carefully judged the behaviour of the politicians, the bureaucrats, the doctors and the nurses…it turned out that none of them were to blame…all along, lurking in the background like the butler, it was the “culture” that had committed the crime’. Why? Because ‘it was the culture that “too often did not consider properly the impact on patients of actions being taken”’.
We are right to be shocked by this – in fact, we are right to be very shocked indeed and very angry. We, the public, pay for the NHS from our taxes, and the news that our welfare has been subordinated to the protection of inadequate individuals, back-watching bureaucracies and self-serving politicians confirms all our worst fears about unaccountable government and shadowy elites. Much the same point was made a Nursing Times editorial this week, along with an inexplicably catty hint that the ‘rotten culture’ extends right to the top. ‘Last week, the media did their usual’ the magazine sniffed ‘and turned to their health story go-to man Gary Walker, the [whistleblowing] former former chief executive of United Lincolnshire Hospitals. His view is that…those in the NHS are under pressure to conceal when things go wrong because ministers won’t want to hear about it’.
When he talks about ‘those in the NHS’, Mr Walker, a former top manager himself, presumably means ‘other top managers’. But replace the word ‘ministers’ with the word ‘managers’ and you have a situation with which more lowly staff are also all-too familiar: the classic management technique of unofficially cutting off all bottom-up channels of communication on the grounds that they could potentially carry bad news. Because once managers know about it, the onus of doing something about it shifts to them.
A striking example of this ‘one-way-street’ school of management as applied to lower levels of the NHS was provided in a response to the internet version of the Nursing Times editorial. An anonymous poster transcribed the contents of an email allegedly sent by a Divisional Manager to ‘All Ward Sisters’ at a trust in the south-west of England. It noted that some wards were refusing to accept transfers from ED at certain times because staff were either on break or doing the drugs round. It concluded by stating that ‘In future the site team will…overrule the ward staff decision/statement if they decide the move is required in order to maintain the safety of the patients in ED’. ‘The safety of the patients on the wards’ observed the poster ‘is not mentioned’.
Whether it’s for genuine or not, this email definitely has the ring of truth about it. Anyone who has worked on the wards in a large hospital in the last few years cannot fail to be aware of the permanent low-level warfare over admissions. ED, under pressure to meet waiting-time targets, needs to transfer patients to wards as soon as beds become available. The wards meanwhile, struggling to cope with the patients they already have, prefer to schedule admissions for times when they can give them the attention they deserve. The result is a series of manoeuvres (“the side room needs fogging”; “the patient can’t go to Discharge Lounge because he can’t sit in a chair”) applauded by one side as ‘standing up to management’ and dismissed by the other as obstructive ruses designed to court popularity with colleagues at the expense of sick patients.
Targets did not create this situation – industrial relations are as old as human history – but by raising the stakes, they have exacerbated it. And while the culture they produce at ward level is not exactly ‘rotten’, it is decidedly unhelpful. Firstly because nurses feel that their legitimate concerns about patient safety are wilfully interpreted as just laziness; and secondly because constant skirmishing fosters an inward-looking, ‘us and them’ mentality where kudos and admiration accrue not to the nurses who are the most skilled patient advocates or the best clinicians but to those who are most vociferous in ‘fighting the ward’s corner’. Concealment of poor standards is by no means the inevitable outcome of this environment; but where staff feel that the only people who understand them are their peers, toleration of sloppy care by those same peers perhaps becomes more likely.
In the context of the recent furore over nurse education, it’s surprising to learn that a very pertinent piece of recent research seems to have slipped under the radar. Attempting to ‘identify  predictors of successful transition from undergraduate student to registered nurse and…whether any particular pre-registration paid employment choice impacted on transition’, Craig Phillips et al (2013) concluded that although any pre-registration workplace exposure was beneficial, ‘post- registration institutional work factors appeared to be stronger predictors of successful transition than pre-registration employment factors. Assistance in dealing with complex patients, orientation to a new environment, and respect from colleagues were the best predictors for successful transition’.
There is a problem here however: where the moral lodestar has gone awry, respect is earned for the wrong things. Management intransigence forces a situation where respect from peers is gained, quite understandably, through adopting a certain reactive stance at ward level. Inexperienced and impressionable nurses in particular could be seduced by the folk-hero glamour of ‘standing up for the staff’; apply enough pressure, and in some extreme cases, you could end up with a situation where this comes at the expense of always “consider[ing] properly the impact on patients of actions being taken”.
The answer is not the abolition of targets; targets are not going to go away. But it seems clear that the ‘one way street school of management’ runs through the NHS from top to bottom like a sewer. If hospital managers are as shocked as the rest of us by the alleged goings-on at the Care Quality Commission, maybe they should take a closer look at themselves.

Phillips, Craig et al (2013) Predictors of Successful Transition to Registered Nurse. Journal of Advanced Nursing; 69 (6): 1314-1322.

Taylor, Roger (2013) God Bless the NHS: The Truth Behind the Current Crisis. London; Faber and Faber.

For Nursing Times editorial and responses, see http://www.nursingtimes.net/opinion/editors-comment/patients-are-at-risk-until-nhs-culture-changes/5060198.article?blocktitle=Editor%27s-comment&contentID=7874

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