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Plausible Deniability

December 11, 2014

By Basket Press

To pick up on the themes of my Nick Clegg post, a comment made about it and in light of the Health Service Journal‘s latest ‘campaign‘, I thought it might be useful to examine how or why someone in his position might not know what is happening in the health services.

I shall reiterate that I do not find it at all credible that senior politicians do not know. For example, Alan Milburn, a former Secretary of State for Health, has a partner who is a consultant psychiatrist and one of his closest political friends was married to a senior health commissioner: did no-one talk to anyone else? But for the sake of argument I shall take it that they don’t…

Anyway, we need to look at how information (and bear in mind my post about NHS counting) passes up and down the system and the factors which influence this. Whistleblowing will be covered in another post, as will other relevant aspects of management culture.

Everyone at the sharp end of health care, clinicians, admin, support services, knows the existence of and pressures caused by poor staffing, inadequate training, arbitrary targets, inconsistent and bullying management, cuts to services, whatever, but somewhere along the line this knowledge disappears, so Milburn, Clegg and others don’t know about it, or so they say.

Former trust chief executives or senior managers have occupied important positions in NHS England, the Department of Health or National Institute for Mental Health in England: do they not know what was going on? Could they not tell someone? And if they didn’t know, then why not?

Us nurses have our Nursing and Midwifery Council guidance to tell us what to do. OK, so over many years of experiencing staffing levels so low that they threaten patient and staff safety, staff health, clinical outcomes and the like I, as with many others, reported these to my management. Did anything change? Of course not! Was it even listened to or documented? Maybe not…

In one service, where I was part of the management team, the clinicians, such as me (especially me, as I was the noisiest) were forbidden by the general manager from raising any resourcing and staffing concerns, of which we had many. Even when we did raise these concerns they weren’t minuted, and any attempts to have the minutes changed to be accurate were resisted. Why? Because the next two layers of management had said so, which included someone at board level… Those two layers of management also oversaw another unit about which huge concerns were raised by staff (some of whom were threatened with violence) and families, which were never investigated. Ultimately there was a fatal incident there, which they couldn’t ignore, but was likely preventable if they had acted sooner.

What can one do when members of the trust board do not want to listen to concerns and clearly do not want those concerns raising, let alone officially documenting? These are the official channels through which we are required to complain, those to whom we are required to report any concerns. The role of the unions and their inaction is another matter again.

The managers in question there were later the subject of a confidential inquiry carried out by an external, and very well respected, member of The Great and Good. Those of us interviewed for it were very critical of many things and several of us cited the above. The report went to the trust board, and there it stayed: it has never been released and no trace of it exists.

The climate of fear in this organisation was very old. As just one example, when I was a student there over twenty years earlier, four of us complained about standards of care on a ward (racism, verbal abuse of patients, inadequate assessments and documentation, and worse that we couldn’t fully back up). The Director of Nursing Services heard about it, did not ask about the substance of the complaints, just who made them and then on finding out one name tried to intimidate one of my group into retracting. The Director of Nursing’s protegés remained in positions of authority for many, many years, defining and shaping the culture.

In another job, the chief executive of that trust lived by the phrase “Don’t bring me problems, bring me solutions!”. So no-one ever told them about any problems, which included things as basic as a shortage of sheets and pillow cases on wards, inadequate catering budgets, as well as chronically low staffing levels on many units. I was never clear that the staffing problems on my ward were ever communicated beyond the level above me, who knew all about it. I was threatened with disciplinary action for suggesting that I spoke to someone higher up the pole. The solutions for many of those problems would have involved high level discussion with commissioners… Y’know, funding and that class of thing…But to do so would have, in their eyes at least, involved some senior and junior managers admitting that they could not manage within their existing budgets, i.e. failing, which they would never do even if it was the truth.

And there you have part of the problem: management culture becomes such that admitting to any form of difficulty is not allowed, either because there is a fear of perceived failure or because the language of official discourse does not acknowledge certain terms, not conforming to the prevailing culture leads to threats, dissent is to be squashed by whatever means, relevant information is not passed on to those in higher authority, and so those at the top can honestly say they don’t know…

Plausible deniability is maintained…Information rarely goes to the top, and if it does it “disappears” so it cannot be traced nor retrieved…

You weren’t there man, you weren’t there!

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