19 February 2011

Forest plots and pitch-rolling

Why did so many people get out into their local woods to protest about the sell-off of our forests? Plainly it took our government by surprise. Even Dr Grumble was impressed by the number of people protesting in his local wood.

But some protests are not a surprise. When Grumble's local hospital was under threat even more people were on the streets. Just as in the case of the woods, these were just ordinary people with very limited resources organising themselves to protest. Whenever this sort of thing happens people power prevails - especially if the hospital is in a marginal constituency. The NHS is so important to the electorate that it has even resulted in the election of a single-issue MP. That should surely sends signals to our government that meddling with the NHS is dangerous.

The trouble with the public getting involved in these issues is that sometimes there can be more heat than light. Passion can impede progress. Sometimes it is the right thing to close smaller hospitals. Certainly the NHS estate needs rationalisation. In theory a centrally-managed government-owned service should do this well. The reality is that successive governments have signally failed to even take on the problem.

Every single hospital (and there have been scores) Dr Grumble has worked in has been in need of some form of rationalisation. London is held up by those in charge as being the place with the biggest problems. The problems have been there for a very considerable time. Sometimes governments have made them worse. Westminster Hospital used to be across the bridge from St Thomas'. Despite opposition, it was closed. But then soaring property prices and a hospital sale enabled a triumphant Mrs Thatcher to create Chelsea and Westminster Hospital only a short walk from Charing Cross Hospital in Hammersmith itself not very far from, yes, Hammersmith Hospital. The reasons why hospitals fail to be closed when closure is necessary are political. Sometimes unnecessary hospitals or polyclinics are built for the same reason. What all this shows is just how important the NHS is to politics in this country.

Politicians may be prepared to send young people to die in unnecessary wars but difficult decisions about the NHS seem beyond them. It is this underlying problem that has led governments to the bizarre conclusion that they can deal with their own failings by privatisation or quasi-privatisation. The idea is that hospitals are made to fail in the market. Planning, which has failed to close hospitals, will be replaced by cut-throat competition. Some hospitals will just wither on the vine. There is a blind faith that the market will get right what politicians have not.

But none of this has been thought through. Do politicians really believe that when a local hospital closes because of market forces the local populace is going to accept that? Do politicians really believe that local GPs are going to be able to persuade their patients that their local hospital is no longer needed? Do they really think really think that the electorate will blame GPs for what happens rather than their local MP?

The woods and the NHS are more similar than some might think. We love our woods much as we love our NHS. Why didn't the public want the woods sold? It was because the woods are part of England. They are a part of England which belongs to us all. We want to be able to use them without incurring exorbitant charges. They should not be sold off. They are inviolable.

What does the public think of the NHS? They love their NHS. It is a part of Britain which belongs to us all. We want to be able to use the NHS without incurring exorbitant charges. It should not be sold off. It is inviolable.


So why don't we see the public outside their local hospital with placards? It is because of the soft focus on what is about to take place combined with lots of obfuscation and the ConDem's secret weapon: pitch-rolling. Since this article is so Anglocentric, it is unlikely that any North American readers have got this far. Lest they have, Dr Grumble needs to explain "pitch-rolling". If you have been to a great English public school, as have both the Prime Minister and Deputy Prime Minister, you will know that on Wednesday afternoons in the summer you play cricket. You may have heard of the playing fields of Eton. That's what we are talking about. (There were playing fields in the state schools but they were sold-off for development.) But if you are wealthy you will still have access to a green field and a cricket pitch. Now a cricket pitch needs rolling. It's a backbreaking job but at Eton they have a flunky or two who go out before matches to roll the pitch. The longer you roll it the better it is. They have been rolling the pitch at Eton for nearly 600 years which is why it looks so good. If you don't roll it the ball will bounce all over the place and the boys will get restive.

When it comes to the NHS there has been an awful lot of pitch-rolling. New Labour were masters at it. It has taken an amazing number of forms. Knocking GPs has been one. Who do you think feeds the misleading headlines? Faux consultations have been another. Anybody who filled in the latest forestry consultation will understand. Motherhood-and-apple-pie questions with only one answer cannot be called consultation. And there have been questionnaires about NHS services. When people are happy it goes unreported. Problems, on the other hand, get highlighted - even tiny problems. At one time Grumble found this very odd. Why should government be knocking the very service it was responsible for? The answer is that it is all part of a very prolonged pitch-rolling exercise. It is designed to create dissatisfaction with the NHS and the conclusion that something must be done - usually fed to the public as "no change is not an option".

This pitch-rolling is very powerful. It is a euphemism. If you say something often enough people may believe it. But they are not always taken in. They weren't taken in over the sale of our woodlands. But then there wasn't any propaganda pitch-rolling. Fortunately the electorate are not as daft as our contemptuous politicians like to think.


Prisoner of Hope said...

Dr G your observations on faux consultation (which were spot on) seem to imply that there is little room for improvement in health care because - by and large - satisfaction levels with the NHS remain high.

Unfortunately the "evidence" of satisfaction can be distorted.

From time to time the DoH trot out that 80% and higher satisfaction levels are good news. This "spin" is based on questionnaires sent to discharged hospital patients some months after discharge. Those that experienced poor care and have readjusted to a "normal" life may not wish to remind themselves of indignities and concerns that, had they had an opportunity to raise at the time, might have contributed to organisational learning for the benefit of others.

Even if "satisfaction" levels are as high as 95% this is still not "good news". Many service industries would pay good money to the understand the anxieties and concerns of the 5% they may have failed - particularly if they wish to compete and be judged on the quality of the service they provide.

Not only do hospitals discourage expressions of concern by patients and their carers - at the time - but they do not fully understand the barriers that exist which can underestimates true levels of dissatisfaction.

After 18 months of prevarication and delay I did manage to get a pilot "Have Your Say" exercise started at a major Northern Teaching hospital - basically a blank sheet of paper - no questions, no tick boxes. The positive comments were around 60% and the negative around 40%.

Included in the comments were statements that indicated that patients and carers were not happy to express concerns because they feared it might affect the care they would then receive.

Now you and i know that this is not necessarily the case and many well meaning clinicians would not allow criticisms to affect how they treated an individual patient. In a way that is beside the point. What matters is that the fear exists and can contribute to satisfaction levels being distorted.

Another barrier to true expression of dissatisfaction is the belief that "it will make no difference as nothing would be done". (I have seen the same comment made when analysing crime and safety surveys when respondents explain why they have not reported crimes).

Only when hospitals truly believe in the principles of "continuing process improvement" and are freed from top down, tick box, target setting will the true extent of dissatisfaction become apparent and - what is more important - respected and responded to for the benefit of both the providers and recipients of care.

Dr Grumble said...

I agree with everything you say, Prisoner of Hope. I know of a lot that is wrong in hospitals and there is plenty of room for improvement.

What I was thinking of was some of the survey results I trawled through about GPs. I came to the conclusion that the public was, in general, very happy with their primary care but you wouldn't have known that from the government interpretations of such studies. Not that primary care is without its problems but I think that much of it is very good and much better than it was.

My students are sometimes given the task of asking the inpatients what could be improved about their care. It often surprises me how content patients are. They struggle to find anything that could be made better. They also ask questions about how well they were kept informed about what was going on and the results are good. Of course they may not want to say what they are really thinking but I rather doubt it. Certainly they would be a selected group. And I am suspicious that those that are unable to complain are looked after worst by overstretched nurses. I don't blame them. It is a natural thing to do if you have more work to do than you have time for - which is definitely the case on some wards Grumble frequents (but not all).

I think it is a shame that doctors are not asked about what they think of the care their patients are receiving. I know it would be very negative. I know this because I know what I think. I know what my son thinks (who works in a teaching hospital a long way from Grumbletown) and I know what my junior staff think. Perhaps that is why they don't ask us. Doctors, unsurprisingly, always want better care for their patients so are always looking for what is wrong and can be put right.

The government seems to think that all that matters is what the punters think. But doctors are aware of the problems that really matter more than the patients. But we worry about different things. How does a patient know that somebody failed to check their potassium or that their Venflon should have been removed promptly when the consultant asked for it to come out and not left until the next ward round? Such sloppiness is endemic.

There never was a golden age but there are many things, mostly nursing related, that were very much better 30 years ago. Managers have come up with various solutions to deal with the enormous costs of nursing. As a result we have HCAs doing jobs previously done by trained staff. To deal with the fact that we have staff who cannot think for themselves, we have boxes to be ticked. But boxes to tick cannot match a really good nurse.
Meanwhile investigation and treatment has become much more complicated forcing the few remaining trained staff to focus on these difficult areas and urgent clinical problems. Temporary staff abound and standards inevitably fall. I could go on.

Nurse Anne has it about right, I'm afraid. She might not agree with this but many years ago a senior matron told me that if basic nursing care was taken away from nursing that would be the end of the profession. At the time I didn't have a clue what she meant.

Something does need to be done about these things. But I don't see Lansley's reforms dealing with any of these day-to-day concerns that all of us in hospital medicine are surely aware of.

Stern professionals, nurses and consultants, ruling their wards with a rod of iron were actually better in some ways than the laissez faire, no-blame, box-ticking culture we all find ourselves in. Some of this has gone much too far but it seems that it is completely unstoppable.

Prisoner of Hope said...

>> "I think it is a shame that doctors are not asked about what they think of the care their patients are receiving......Doctors, unsurprisingly, always want better care for their patients so are always looking for what is wrong and can be put right." <<

In that spirit I have given some thought in the past to how that can best be harnessed and wondered if a web site could provide such a service.

What I had in mind was something like "I Want to Give Great Care" (in response to Bacon's appalling site) and then thought it should be open to patients and carers as well .... to act as a sort of safety valve ... for both sides.

So I registered the domain names safetyvalve4NHS.co.uk (and .org.uk). Then I went off the idea.

I thought a couple of (mainly free text) forms could be used to record what stopped a clinician giving - or a patient receiving - great care. It could be completed at the end of a shift , clinic, admission and allow frustrations to be both voiced and vented. A couple of optional drop down fields could allow identification of PCT area and clinical area if respondents wished to assist in analysis.

I intended creating a database that could identify the major themes that emerge and "publish" on the web site on a fortnightly basis. If the same local problems were identified by PCT area then perhaps the "results" could be emailed to the PCTs along with their responses - if any!

Do you think there would be any interest in this among your colleagues / students / patients?

If you and others think there might be then I could invest a little time this spring and set it up and then let you (and Nurse Anne - of course - and others )know.

Dr Grumble said...

There are, of course, internal official ways of flagging up concerns using incident reports. In the early days we were encouraged to use these as much as possible and then it all rather went cold. I repeatedly filled in forms again and again and again on one tiny issue. Eventually I was politely encouraged to stop. Of course, absolutely nothing had been done about what appeared to me to be a simple problem to solve - though it obviously wasn't.

Unknown to me, copies of all incident reports get sent to the National Patient Safety Agency and they did take action. But sadly, despite this, the original problem remains.

Many doctors think filling in an incident report is a waste of time. Of course, it isn't but I can't honestly think of a single example of a report leading to effective action.

I am sure there are a lot of people who would like to vent their wrath on a site along the lines you suggest. But there would be problems. Confidentiality would clearly be one issue. Sometimes you need specifics. Also Trusts would not like their staff flagging up the problems to outsiders.

Having said that I do think it would have the potential to highlight major themes. On the other hand I think those of us on the ground all know what these are already. Many of the problems, though new, are common to hospitals throughout the land. Some recent changes have made things very difficult. Solving these new issues is nightmarishly difficult because they have stemmed from changes over which we have no control.

Perhaps Nurse Anne has a view. She seems to be pretty forthright so she won't hold back if she thinks you are onto a loser.

Cockroach Catcher said...

"Would it have been any different if CEOs of hospitals must by law be fully registered doctors."
"You mean like the old days of Medical Superintendent?"
"Why registered?"
"So we don't have the silly situation of GOS."

I posted a link.Dr Grumble