Unsurprisingly, the publication of the Francis report has led to much reflection among managers, clinical leaders, and health commentators. My (pre-publication) concerns are here, but we won’t get answers for a while, until the government has taken a view on the 290 recommendations contained within the report.
But what about doctors? What are some of the implications for the profession?
Doctors do not emerge from Francis unscathed. Whilst the main deficiencies were in ward-based nursing care, mortality rates were persistently high and doctors failed to raise concerns effectively. Much has been made of the ‘climate of fear’, but I struggle to believe this alone explains why concerns were not raised early, loudly and persistently. After all, there is safety in numbers and many hospital chief executives have lost their jobs over the years as a result of a Consultant Staff Committee vote of ‘no confidence’ – why not at Mid Staffs?
I have argued for a re-wording of the GMC’s Duties of a Doctor to make much more explicit the duty to raise concerns about wider care issues involving patients other than their own, for instance elsewhere on a ward or in a hospital. The second duty ‘Protect and promote the health of patients and the public’ is perhaps too general in this respect?
There are implications for services too, that I have alluded to in my Weekly Diary and which need considering in detail. Essentially, the quality and safety concerns relate to our acute general services, and predominantly medicine. And if we are honest, these have been less glamorous areas of practice, and less invested in, than many of our specialties. Specialists have progressively pulled out of the general on-call rota, knowing that the way to build a career and a reputation is to focus on their work as an ‘-ologist’.
But most of the work of an acute hospital is in ED, acute and ‘general’ medicine, and care of the elderly. If we are to make a step improvement in quality standards, we need to invest a greater proportion of our resource in these areas. More doctors, and maybe more nurses on wards with high acuity?
Such a move will have knock-on effects. I cannot see how to increase resource here without decreasing investment elsewhere. Add in the move to 24/7 acute services, and we have a huge need for new investment. That can only mean spreading the available resource less thinly and reducing the range of services on a particular hospital site?
It can be argued that, anyway, concentrating specialist services on fewer sites leads to better outcomes, with acute stroke or PPCI or cancer services often quoted as examples. But perhaps it needs to go further, with improvement of acute general services as the main driver?
As I see it, I will have to orientate my hospitals more strongly around acute services if I am to rise to the Francis challenge and really improve care quality standards with more staff, more capacity, and more time to care. If this leads to relinquishing some ‘high end’ services then many doctors will be concerned, because building a specialist service portfolio is deeply ingrained in medical culture. It is how progress is judged, and it is often the way by which hospitals are judged when selecting jobs.
If Francis provokes the development of a new world, maybe it will be a world where ED, acute and general medicine, and elderly care medicine, are higher up the unofficial hierarchy – at the top even? Any thoughts?
This blog was written for Hospital Dr and originally posted here on 18 February 2013
Dr Roopa Mulik
Roopa, Paediatrician says:
April 12, 2013 at 1:33 pm
Dear Mark,
In Paediatrics we still have the concept of ”General Paediatrics” which I think is lost in adult practice. However doing excellent ‘General Paediatrics’ does not have the same professional status as being a sub-specialist, nor it is rewarded in the same manner e.g. CEAs which are usually awarded for doing work outside your department and trust! When a consultant is so engaged in regional and national work they have less or no time to fully engage in their own department and ward locally!
Thus sub-speciality work takes priority and acute and inpatient work (which is the main function of the hospital) is left to the most juniors in the department (FY1s, FY2s, ST1-3s … ) and doing acute work is seen as a waste of consultant time or something beneath them!. The same is true about nursing staff. Any good nurse soon becomes ward manager (doing what HR should be doing e. g. Sickness management and HR sit in office doing what I do not know) and away from the shop floor. This culture is so engraved in NHS that profession does not see anything wrong in this. Doing acute work is seen as something beneath them by consultants.
We need to have experienced clinicians at the front end doing better ‘Gate Keeping’, in EDs and Assessment Units. So we investigate only who need investigations, we admit only those who need admission. We need to train juniors to think about resource implications, we do that very little in hospital practice, (so they do not think about it when they become consultants). Senior clinicians need to communicate with GPs directly, so they do not send everything to EDs or hospitals. To achieve this with the present work force, job plans need to be looked at and profession and trusts need to decide what is the priority? ‘General’ services will only be regarded highly if there is professional and local cultural change. Perhaps ‘salary differentials’ is the answer to elevate status of acute work.
MarkN
Thanks for commenting Roopa, I completely agree about general work. Our challenge is to make this really important work as rewarding as possible for professionals!
Jonathon Tomlinson
Holistic (generalist/whole patient) care has moral implications. Referred to as the collusion of anonymity by psychoanalyst Michael Balint in the late 1950s, there is a tendency for specialists to stick to their organ of interest leaving responsibility for the patient to ‘someone else’, ultimately ‘nobody’. In nursing literature, Menzies Lyth (again late 1950s) showed that in order to protect nurses from the emotional burden of ‘holistic’ care, tasks were separated so that nurses weren’t burdened with the responsibility of caring for the whole person. In studies of doctors and nurses who murdered Jews in the Holocaust, the job was made easier by breaking down the task of killing into parts so that the killers didn’t get to know their victims.
The lessons from Ballat and Campling (Intelligent Kindness) are that care of the whole person and continuity of care are vital if we are to be compassionate and kind.
Sadly, the move towards industrial models (the Toyota model) and super-specialisation is enthusiastically promoted by the major think tanks, the most powerful medical professionals and politicians.
There is a pragmatic argument as well. An aging population and improved survival from cancer and other chronic diseases means that problems of multimorbidity and polypharmacy are significantly increasing.
Generalists are needed more than ever before.
Andrew Vincent
Jonathon Tomlinson’s comments are really interesting. The approach of whole patient is the underpinning premise of case management for people with complex health and social care needs in the community to prevent or reduce admissions. The theory is also that 1 person with a 10,000ft view can deal with the whole patient much better than any single individual in their own organ area, much the same as here.
However, case management has not always been successful because a ‘whole person 10,000ft view’ requires you to exercise it that way i.e. it’s an attitude or approach. Case managers still regularly just address the symptoms they find i.e. the more reactive, epidosic, task-focused approach.
If I were to be provocative, I would say that an individual’s GP is this in the community but that the patient doesn’t have that equivalent in the hospital (where the GP really couldn’t be close enough).
I see this as an issue of ‘ownership’. Someone needs to take a leadership role for each patient if whole-patient-centred is the desired approach. Whether that’s a generalist or simply a designated, knowledgeable person to act as orchestrator of a pathway with many components, driven by goals for the patient rather than components of care, is probably worthy of much debate. A whole new model perhaps…
I guess what Jonathon is highlighting is by breaking components into somewhat dehumanised steps, we not only run the risk of the person not being considered but also that when the care fails, it isn’t actually any individual’s responsibility.
Hesham
We need to beware the unintended consequences of this approach
The much-touted economies of scale are very rarely realised. As the recent HSJ article below demonstrated, it is the smaller, nimbler DGHs which are often the most efficient. Huge trusts, such as Pennine Acute become unwieldy monoliths in which patients and clinicians can become submerged in bureaucracy.
Secondly the increasing sub-specialism can lead to isolation of services. The majoriy of patients in hospital have multiple morbidities and would need benefit from several specialities. This becomes more difficult with the segregation of expertise and leads to more tortuous patient journeys.
For example, a child who was admitted today following a seizure arrived in one hospital with an assessment unit, was transferred to a second with an inpatient ward, transferred to a third for a neuro-surgical review and needs neurology input from a fourth.
http://www.hsj.co.uk/news/policy/district-general-hospitals-top-efficiency-league/5052429.article
Lou Scott
Hi Mark
Your twitter discussion seemed to focus on geriatrics, but please remember that it’s not just elderly people who need generalist physicians.
As a young person with multiple morbidity, the various medical and surgical superspecialists I encounter have little understanding of the relationship between their specialty and my multiple diseases and don’t appear to know very much about general medicine/basic drug interactions – they are like glorified technicians/mechanics with a limited skillset and an extremely narrow outlook on medicine and patient care. As a sometimes vulnerable patient, I find this system worrying.
Why not learn from the lessons of the US and introduce a hospitalist system or at least start employing general internists who are not scared of complexity or multiple morbidity. Why isn’t generalism valued in medicine? Internal medicine is still a specialism in other Western nations.
Also isn’t there something wrong with a medical profession that is more concerned with status, lifestyle and acquiring wealth than with getting down to the basics of caring for sick patients? Maybe someone should look at the type of people who are recruited into medicine these days.
Michael Brennan
General Medicine/ed/acute/elderly are what u like to describe as the bread and butter of a hospital, they take up the majority
Roger Stedman
Hi Mark, I completely agree, but the problem isn’t just investment – you are asking for an acute reversal in a cultural trend in medicine that has been going full pelt in a ‘flight from the front line’ for the last 15 years. I’ve always said you only need four types of doctor to run a hospital – ED, Elderly (Acute) Care and Intensive Care – The problem is they are just not out there, we are throwing money at the problem but failing to recruit because the training system is not producing them. Young doctors are not choosing those specialties because being an -ologist is more remunerative and has a better lifestyle and more ‘status’.
Andrew Vincent
Incidentally, following our Insights Quiz (1,475 participants presented with 20 MCQ questions on emerging healthcare system), we have to conclude that those people also don’t understand the issues or the system – mean score was 4.8 out of 20 (ouch!).
Consequently, we have designed a version of the quiz for teams and services to run for themselves, allowing them to assess their insight for themselves and face the reality of whether they understand or not.
It’s free-of charge – our contribution to getting wider awareness of a massive problem – everyone’s fighting over a problem that is fundamentally different from what they think it is. Difficult to develop sensible dialogue and solutions under those conditions!
Nadeem Moghal
And I would add general paediatrics. In all these areas of the disappearing generalist the other not so hidden issue is that on the whole it is the junior doctor who delivers the medicine – a trainee generalist on the way to an ology. We have to train the future generations but not every service and every hospital has to, or can. The Americans appear to have reinvented the generalist through the hospitalist. Readjusting the archaic 1946 incentive scheme would also help.
Andrew Vincent
Hi Mark
You raise, very wisely, the moral, ethical and plain old practical dilemma facing senior managers (especially senior medical ones) – we have a fixed financial resource in healthcare (Government has zero ability to borrow or raise more taxes) and so any beefing up requires a reduction somewhere, which is inevitably resisted. This IS the case for disruptive innovation – find a better way of doing something in one area so you can free up resource for another area.
In terms of the duty of medical professionals to raise concerns, if I provided one piece of behavioural advice it would be the creation of safety for those raising.
Inevitably, that would also leave you open to many ‘shouts’ about concerns where staff simply don’t like changes you are proposing, itself more likely in light of the above financial dilemma you have identified.
The answer to this is the creation of MUCH greater awareness that ‘WE’ (collective clinical-managerial teams) survive, thrive or demise by the results we COLLECTIVELY achieve. Inherent in that is that no safety concern should be ignored by anyone BUT that no concern should be raised without a genuine belief in that concern.
I am sure you are guessing this is my case for ‘distributed leadership’ underpinned by my belief that we will only get sensible behaviour when intelligent people surface ALL of the issues facing them, reach consensus on what they mean to them and consensus on what they should do. That means financial decisions are also clinical decisions and vice versa and the whole team, clinical and managerial, has to collectively accept responsibility for the combined outcome in each domain, rather than our current madness of simply blaming each other for the destruction they create in each others domains!
Andrew