Freedom: a matter of life & death

Stephen Dorrell, chairman of the Health Select Committee, wants to stop the NHS enforcing "gagging clauses" on former employees. He's more correct than he knows. The issue here is not just one of freedom, but of life and death.

I say this because of something Joseph Hallinan says in Why We Make Mistakes. He points out that whilst the accident rate for aiplanes has fallen sharply since the 1930s, the rate of medical misdiagnosis has declined more slowly (pdf), so that - in the US - well over 30,000 people a year die as a result. A big reason for this difference, says Mr Hallinan, is that:

ORs are typically hierarchical places, with the surgeon on top; cockpits are not...When it comes to pointing out potential errors, everyone [in a flight crew] is considered equal (p194).

Hierarchy inhibits feedback: nurses don't challenge doctors; junior doctors don't challenge senior ones, nobody challenges managers, and so on.

But feedback is essential for improvement.If a musician couldn't hear what he was playing, or a golfer couldn't see where his shots went, do you think either would get better? This point is emphasized by Matthew Syed in Bounce. Feedback, he says, is "the rocket fuel that propels the acquisition of knowledge". Good feedback "is the reason why mankind has progressed." Geoff Colvin agrees:

We've examined at length the importance of frequent, rapid, accurate feedback for improving performance. Most organizations are terrible at providing honest feedback...Tet nothing stands in the way of frequent, candid feedback except habit and corporate culture. (Talent is Over-rated, p131-2)

It's in this context that "gagging orders" are - literally - fatal. They limit feedback. Sure, the feedback might be noisy - an outgoing employee might have questionable motives, but a noisy signal is (probably) better than none. Whistleblowers are essential to progress.

Of course, nobody thinks that removing gagging orders is sufficient. Matthew Green says: "To implement any kind of change in the NHS means challenging a whole mass of entrenched hierarchies". And Paul advocates weekly meetings between management and staff. They are right. Improvements come from feedback, which requires openness and a sufficiently egalitarian atmosphere that encourages junior staff to speak honestly.

Why, then, could anyone possibly oppose this? Simple. Feedback challenges the self-image of the powerful; it tells doctors that they are not godlike experts, and managers that they are not running immaculate organizations. Alex Massie decries the narcissism of the left. But that is merely irritating. The narcissism of the powerful can be fatal.  

Comments

[Luis Enrique]

this tale of rejecting dissent in healthcare reminded me of the famous Semmelweis story, which I only discovered recently (I suspect by following one of your top blogging links) - I was just googling to try and find where I read about it, when I discover the story itself is a myth. Or at least, so these guys claim

http://www.bestthinking.com/articles/science/biology_and_nature/bacteriology/expert-skeptics-suckered-again-incredibly-the-famous-semmelweis-story-is-another-supermyth

[SimonF]

Isn't this the point of exams and the much maligned league tables?

[aragon]

All fans of House (series 2 episode 8) will be familiar with the Mortality and Morbidirt Review (MMR).

Or you can look at the more detailed literature.

http://www.health.vic.gov.au/clinicalengagement/downloads/pasp/literature_review_mortality_and_morbidity_reviews.pdf

"The strongest barrier to MMRs appears to remain the focus on individual
clinician rather than a more general, systems approach to errors.
7" p18

First Timothy was a problem in Stafford.

The obsession with money. While clinical staff may have to be aware of the relative costs of proceedures and treatments, their priority should be patient care not reducing costs, and understaffing is clear management failure.

And this culture is set from the top, with the prospect of Foundation status and financial controls obsessing the management at all levels.

The obsession with money, papwerwork and targets, all came from the very top, although the primacy of patent care is assumed by the public.

A system wide review of the NHS and the obsession with finance including PFI etc.
Clinical staffs priority has to be patient care.

Management need to provide the resources for the clinical staff (the purpose of the NHS). Financial and administrative controls are management not the clinical staffs problem.

A change of culture within the NHS away from the primacy of finance.

[Metatone]

There's an extra issue which is too often ignored - insurance claims.
We desperately need something like the New Zealand model - no fault compensation for medical accidents - as right now there's a lot of pressure on doctors not to admit mistakes and a lot of pressure on managers to squelch whistleblowers because of the insurance implications.

[Metatone]

Worth noting in passing that implicit in what I'm reporting about the insurance situation is that the insurance companies are sometimes unethical in their everyday practices. This shouldn't surprise, but it wouldn't hurt to take action on that angle too.

[Jem Wallis]

"When it comes to pointing out potential errors, everyone [in a flight crew] is considered equal"

This didn't just evolve in the cockpit of aircraft - it has had to be inculcated into all aircrew as a consequence of a number of tragic accidents.

One notable example being the case of the Tenerife tragedy in 1977 where two jumbo jets collided in fog largely as a consequence of mis-communication and an unwillingness of junior crew to challenge the senior pilot: I believe the fatal instruction from the senior KLM pilot was something along the lines of "Fuck it, we're going".

After the tragedy, crew had to be trained to challenge hierarchy and their own instincts.

In a similar vein, after the Kings Cross fire, staff on London Underground also had to be trained to be much more assertive in ordering commuters to obey instructions.

Tragedies in the operating theatre or elsewhere in the medical system have to lead to similar practices being adopted in the health service.

[Tony Woolf]

Airlines and aircraft manufacturers have a huge overhead of safety costs compared to other systems because air accidents tend to kill hundreds and receive huge publicity. I don't think the public minds that air fares are higher to pay for this, so the safety culture of air travel should be applied to other areas where a lot of people get killed or hurt. The obvious ones are medicine and road transport. This would mean less focus on individual wrongdoing (though not excluding it altogether of course) and more on systems.

[RobG]

As a medical student, I'll be very pleased to see any change which encourages openness and undermines dangerous hierarchies in medical settings. That said, I think the organisational and intellectual culture within healthcare is already light years ahead of many other areas of the economy (as it should be). For one thing, the need to justify every step of medical care with the most rigorous evidence available, is always on doctors' minds. There are constantly discussions and debates among clinicians about whether this or that decision is justified by the research evidence. This is an area where reliance on experience and hunches (i.e. things coloured by cognitive biases) is strongly frowned upon, unless there is no relevant research to guide decisions. Coupled to the fact that the primary considerations in your work are 'what is best for the patient', along with 'what is best for the wider public who fund and rely on this service', and the experience of working within the NHS is substantially more humane and enlightened than most other organisations. Hopefully the removal of gagging clauses will further strengthen this.

[Cassandra]

There is a slight problem in assuming that mistakes and accidents are the main problem in health care settings which could be prevented by allowing dissent currently prevented by the hierarchical nature of the organisation.

The problem I suggest is much bigger. The problem is that corrupt practices are now bedded at the highest levels of professionals including doctors and nurses who float upwards into management. Doctors already are paid grossly in excess of other professionals on top of which they are paid in secret additional amounts of money in the shape of clinical excellence awards. Trust management decides who get what level of clinical excellence award. Of course this is all legal one might call it legal corruption, as only those things that suit the upper echelons of management shall be rewarded. Senior doctors do what they are told for money and despite the misleading name are quite happy to keep it secret.

The GMC is complicit contrary to Nial Dickson's claims regarding revalidation. Revalidation is a paper excercise in which the Medical Director of the Trust in most cases shall tell the GMC whether he or she is satisfied that doctor should be given a licence to practice medicine or not. The senior echelons of management have now by GMC been given a stranglehold over the minions. Would they really come out and point out the follies and flaws of the Medical Director now more akin to the Beloved Leader.

Up until now the stories related to the PFI scandals and other procurement scandals in the NHS have been that the managers were too dumb to prevent the fleecing of the public. This might be a charitable view. If the serious fraud office was so minded they might want to investigate the contracts that smell of corruption and in house behind the door deals. After all why is it that multimiliion pound deals awarded to SERCO, Virgin are not being looked at. There is a stench in the air.

Then what about all of the senior DH, PCT and SHA officials who after working in highly paid positions then move on to even more lucrative positions in the private sector. Unlikely for their talents but very likely for their contacts and influence inside government departments. If this is not true then perhaps the DH would like to publish the performance management of David Nicholson of North Staffordshire fame, Cynthia Bowers of CQC disaster fame, Liam Donaldson of the MTAS fiasco and tamiflu fame.

Yet it is not only the senior managers in the NHS for the same are seen in the banks, the food industry, the oil industry, the energy industry, the insurance industry one could go on with this endless list.

Open up the archives for all and sundry to see and many skeletons shall fall out from the many closets.

The cost of all this; blood. A lot of blood and too many blood stained hands.

[jon abrams]

"The accident rate for aiplanes has fallen sharply since the 1930s, the rate of medical misdiagnosis has not"

This may be more to do with the fact that the captain and crew in flight will be potentially subjected to a direct punishment i.e. death as a consequence of a 'misdiagnosis'.

I wonder if in other situations 'on the ground' hierarchy, status etc reemerge?

[Jeremy Scott Wings]

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[Cardiac MRI coil]

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[Robbo]

"But feedback is essential for improvement."

Hmmm. An alternative to improvement of large, disfunctional organisations, is their replacement by better ones. This is what capitalism is about, anyone can try their hand, if they can obtain the resources, and productive assets gravitate into the possession of those best able to use them. It is also the reason why government sweetheart contracts and the frank exclusion of capitalism from education and healthcare has had such dire results.

[zetaclear.cc]

This post hits home. It is SO challenging to eat healthy everyday. I only have one child and am working less hours than before I got pregnant, and I have to be extremely organized to get the healthy plate of food on the table at most meals (I try to eat healthy as much as possible and make sure that my family has homemade, fresh food too). I lead a healthy household and also try to use eco-friendly products. We are just finishing our garden and are growing tomatoes, chives, green peppers, cilantro, parsley, and others that really save time and money. To us, it's worth it. We feel good sand have energy and have peace of mind knowing that we are trying to eat fresh foods whenever possible.