An NHS that treats people as individuals
Jeremy Hunt's speech to Reform.
Thank you, Andrew [Haldenby, Director, Reform].
A central tenet of the medical profession is to ‘first, do no harm’.
Last week, Robert Francis published his report on the culture of the NHS in the wake of the disaster of Mid Staffs. Collectively, the NHS failed that basic principle.
The stories of appalling care from that hospital continue to shock, years after they took place.
People routinely left without pain relief, without food or water and left to lie for hours, even days, in their own urine and excrement.
A betrayal of patients. And a betrayal of the vast majority of people who work for the NHS.
People driven by the innate compassion and humanity that led them to devote their working life to looking after others at their most vulnerable.
So today I want to look at some of the lessons we must learn from perhaps the most shocking betrayal of NHS values in its history.
Jo Tomlinson, Nurse of the Year
Let me tell you about a remarkable woman.
Last year’s Nursing Standard ‘Nurse of the Year Award’ went to Johanne Tomlinson. Jo is an extraordinary staff nurse who happens to work in a prison. She noticed how many prisoners with mental health issues - the ones who were particularly aggressive and confrontational - were ex-servicemen.
In response, off her own back and on top of all of her other duties, she studied all she could about Post Traumatic Stress Disorder and worked with the mental health charity Combat Stress to set up a 10-point care model and an anxiety care group in the prison.
Single-handedly she has transformed the lives of many prisoners in a way that will profoundly improve their chances of a successful reintegration into society.
Her colleagues describe Jo as ‘dedicated’, ‘passionate’, ‘engaging’ and ‘remarkable.’
And the prison where Jo works? Her Majesty’s Prison Stafford. Literally a 5 minute drive from Stafford Hospital.
How can we have such radically different levels of care in the same system? In the same town? Even in the same hospital? For even in Stafford Hospital, at the time things went wrong, there were good wards, good doctors and good nurses.
Definition of success
The great irony is that despite last week’s report you could make the case that the NHS has never been better.
Once, a cataract operation would mean a week with your head immobilised by sandbags. Today, it’s over in 20 minutes and you’re home the same day.
Once, hip replacements were so rare, patients were asked to return the hip after they died. Today, 1,000 are done every week.
Once, people would regularly wait for well over 18 months for an operation. Today, it’s down, on average, to 8 weeks.
Each a dazzling tale of a system overcoming the odds, forging forwards and beating back the enemy at the gate.
But to focus on these achievements alone would be wrong. Because in our hearts we know that despite the progress, we’ve also lost something.
We know that success is about more than the number of hips replaced or targets met. Hospitals are not factories. People are not just ‘conditions’ or ‘episodes’.
Not everything that matters can be measured
So the first lesson from Francis is to recognise that not everything that matters can be measured. The old management adage that ‘what counts is what’s counted’ could not be more wrong.
You can’t measure whether a busy nurse stops to give a thirsty patient a glass of water or not.
You can’t measure whether an elderly dementia patient is respected or patronised.
You can’t measure the difference between a nurse in a bad mood and a nurse whose smile lights up a whole ward.
There is an understandable desire for any organisation to focus on what can be measured, often because managers and politicians think that’s how they’ll be judged.
And there is a role - yes - for targets. We were waiting too long to access services - and the 18 week elective and four hour A & E targets helped to change that culture.
But when ambulances circle hospitals unnecessarily, when patients are admitted to hospital when they could have gone home, or when wards get cleaned only before an inspection - that’s when you know that the ambition to meet an objective has become twisted into a target that must be met no matter what the cost.
As George Orwell said it in 1984: ‘if you kept the small rules, you could break the big ones.’
The institution must not trump the individual
The next lesson from Francis is that we must never allow the needs of an institution to become more important than the needs of an individual - of the very people it was set up to serve.
It was a catastrophic mistake to build a structure - a structure we still have now - where corporate goals are not aligned with the fundamental purpose of the NHS - to provide medical treatment with humanity, dignity and respect.
Which is why we need a fundamental overhaul of the hospital inspections regime. And under the new Chief Inspector of Hospitals working for the CQC we will introduce some key safeguards to stop institutional ambitions ever trumping the human needs of patients.
Crucially - this is not another layer of bureaucracy, more paper work and less time for patients. Rather, a Chief Inspector will draw the multitudinous inspection regimes together and focus them on what is really important.
It will put quality of care first, on a par - or even more important than - financial stability.
The definition of success for a hospital under the new inspections will include listening to patients and putting their needs first.
The way you look after people needs to matter as much as the number of hips replaced or the number of targets met. So we will ask the new inspectors to make judgements about the quality of a hospital’s care that will be intrinsic to its overall published success.
That will mean inspectors spending time talking to patients and their loved ones.
It will mean looking at patient safety records for evidence of a zero-tolerance approach to avoidable harm like MRSA or bed sores.
It will mean checking whether complaints procedures are about learning what can be done better or just fobbing people off with process - something Ann Clywd and Tricia Hart’s work will help us understand.
And, crucially, examining whether staff or patients would recommend the care they received to their own friends or family and if not why not.
If a hospital fails to deliver the level of care that we would expect, it will be put into a failure regime.
At the moment, failure to meet CQC standards simply does not have enough consequences for the management of a hospital. Losing control of your finances matters - of course - but losing control of your care matters even more - and boards need to know that their jobs are on the line if they don’t sort out those problems.
Most important of all, we need an inspection regime where the public know as much as the professionals.
Right now, because there is no overall judgement about the performance of a hospital, the public are kept in the dark about problems - even when the system knows they exist.
The pressure for change is reduced, bad practice festers and, as we saw from Mid Staffs, tragic consequences ensue. We must harness the power of patient and public knowledge to drive up standards.
Avoiding the biggest trap of all
But as we make these changes, we must avoid a huge elephant trap: to think care and compassion can be commanded from on high either by regulators or politicians. Endless boxes to tick, cumbersome bureaucracy and burdensome regulations are a big part of the problem - they cannot be the solution.
Let’s look at some of the madness we have at the moment.
- the major London hospital that in just over a year had 43 different external reviews by 24 different organisations
- the Chief Executive of one of our best teaching hospitals who worked out it would take her 38 hours a week to attend all the external meetings she is asked to go to, most of which have nothing to do with patient care
- the Foundation Trusts that report having 60 different regulatory, licensing, commissioning and public scrutiny authorities to report to and comply with
- a nurse who recently reported having to fill in a 22 page form and then 10 additional forms just to admit one person to a trauma ward
- nursing staff spending overall a fifth of their time on paperwork, much of it duplicated – more than a million nursing hours a week not spent with patients
- or a GP who says he spends an hour a day chasing others in the system for information which should be readily available - blood tests, x ray results and patient letters
As we tackle this big change, we must remember that treating people as individuals, with respect and compassion, is not alien to the NHS.
It is why it was set up.
The great vision of which we are all so proud, that no matter who you are - rich or poor, city or countryside, young or old - no one is written off, everyone is looked after with humanity and everyone is treated with dignity and respect.
Values set out so clearly in the NHS Constitution.
It is because they believe in those values that people give their lives to the NHS.
So this is about freeing the outstanding doctors and nurses who deliver care week-in and week-out.
And stopping the dead hand of micro-management from crushing the goodness out of them.
I have asked Mike Farrar of the NHS Confederation, who is here today, to work with all the national bodies to look at how joint inspections and shared information - focused on the things that matter most to clinical success and patient care - can improve clinical outcomes and free up more time to care.
The objective of this work is to see if it’s possible to reduce bureaucratic burdens by one-third.
He will report his early findings in March to inform our initial response to the Francis Inquiry.
And in order to make sure we learn the right lessons from Francis and not the wrong ones, I intend to follow a clear principle. If a bureaucratic burden must be added, it must be outweighed by others being taken away.
This will challenge our system to embrace technology, end the duplication of paperwork and free up time for those on the frontline in a way that has often been talked about but never properly delivered.
Conclusion
Healthcare is as much about the interaction between human beings as it is about the success of a particular treatment.
It is the kind word, the hand held, the compassion that accompanies the competence.
It isn’t necessarily about new policies. Or milestones and objectives and timelines, important as those things can be.
But good healthcare is in the moment. The minute by minute interaction between a person in need and a person there to help.
If, in that moment, a doctor or a nurse treats a patient as they themselves would wish to be treated, then all is well. But if not, the callous can become the commonplace and things can unravel very quickly indeed.
Let me finish with words from TS Eliot we should not forget, when he said, “It is impossible to design a system so perfect that no one needs to be good.”
Thank you.