Criminalising clinicians is not the answer to care failure or neglect

It has been widely reported in the last few days that doctors, nurses and managers will face jail if they neglect patients (see for example http://www.theguardian.com/society/2013/nov/16/doctors-face-jail-if-patients-mistreated). Press coverage has suggested that this links back to both the Francis Report into Mid-Staffordshire and the Berwick Report into patient safety (the former is correct, the latter, not really, as I’ll come back to). The idea is that, by putting in place criminal sanctions, a deterrent will be put in place to prevent the wilful neglect of patients. I think this is the wrong way to go about this.

The NHS does have a problem in terms of care provision. Part of this is sheer scale – when you have that many organizations all of which are providing NHS care, there will be some clinicians somewhere not doing a job. They may even be engaging in wilful neglect. But sadly, there will be poor care somewhere. The question is, how can minimise poor care as much as possible?

The government plan to make neglect a criminal offence depends upon such an offence being a deterrent. But just about the most robust finding we have in psychology is that, if you want people to do things better, you should appeal to their intrinsic motivation rather than by putting in place extrinsic rewards or sanctions. In more everyday language, if you want people to do a good job, you should appeal to people’s pride in doing a good job rather than trying to pay them to do it, or by threatening them if they don’t. This finding applies double when you are dealing with highly-qualified professionals. We want our clinicians to do a good job, so we need to have systems in place that appeal to their pride in caring, not trying to pay them to do it better, or threatening should their care standards fall. Of course we need systems in place to hold clinicians to account for the care they provide – but threatening them with jail really isn’t the answer.

A key question for me is why does bad care happen? How is it that people who became carers with probably the best of intentions end up neglecting patients? The answers are not straightforward. It can be the result of having to work in dreadful circumstances, brought on by a lack of resources and dreadful leadership. It can be the result of gradually falling standards due to the tolerance of poor care from others. We need a great deal more research to really understand what happens when care fails. But threatening people with jail should they fail to provide good care on the grounds that it will act as a deterrent ignores how and why bad care was being provided in the first place. It assumes that carers are making rational decisions to neglect patients, when the real situation is always more complex and difficult than this.

A second key question is whether the principle of prison-based deterrence ought to apply to our policymakers. If we are going to prosecute carers, then why aren’t we prosecuting government ministers for neglect in policymaking, leading to an NHS reorganization that was not based on research, which wasted billions of pounds, fragmenting care, and demoralising staff? If the government are so sure that deterrents work, why aren’t they making themselves subject to them too? Or is it, perhaps, that by sending a few lowly-paid nurses to jail (as has happened at Mid-Staffordshire, under existing health and safety laws) we can pretend we have dealt with care provision problems and move on, rather than looking harder and thinking this through more carefully?

Francis did recommend that neglect of basic standards be a criminal offence. Berwick was much more circumspect – I read his findings in suggesting that, only in extreme cases should criminal proceedings be used, as expressing the bare minimum agreement with Francis rather than supporting the earlier report. Berwick talks instead about the collective responsibility of care teams, and about supporting carers – the language of punishment isn’t really a part of his report. I think he was right in this. By appealing to the reasons why people became carers in the first place, by supporting them in their jobs, and making sure they have the resources they need to do their job, then we have the best chance of minimising neglect and reducing care failure. Sending people to jail won’t help.

Targets, performance management and the NHS – what happened at Colchester?

Last week, we received a report from the Care Quality Commission that showed that cancer care records at Colchester hospital had been tampered with. Inspectors went into the hospital in August and September, and found 22 of the 60 records that they looked had been compromised in some way. It seems that senior managers were alerted last year (2012) to what was going on, and carried out an internal review, but this did not stop the practice. By way of context, Colchester was one of the 14 hospital trusts with high mortality rates that was included in the Keogh review, and although 11 of those trusts were subsequently put into special measures, Colchester was not. It is worrying that, even under increased scrutiny, the tampering with care records was not picked up earlier. It also seems that Unison and the RCN were trying to raise alarms, but that managers dismissed their concerns. The CQC only seems to have picked up the problems when – in the words of BBC correspondent Nick Triggle, they were told ‘exactly where to look’ (www.bbc.co.uk/news/health-24833412). The trust is now in special measures.

What does all of this tell us?

One view is that this is just what happens when you impose targets on staff in a particular way. Where staff have no ownership of targets, and will be blamed for not achieving them, then they have good reasons to try and ‘game’ them. I don’t know who the originator of the pithy phrase ‘hitting the target but missing the point’ is, but that seems to go on a lot in performance management systems. Targets make us narrow our focus, and the danger with that is, if we forget why we are chasing the target in the first place, we can end up behaving rather perversely. I can manipulate the figures to make it look like I have met the target (as seems to have been the case at Colchester) or I can hit the target and stop – saving my effort for the next time period or going to other activities instead. Or I can stop engaging with activities that don’t have targets attached to them, even if those other activities are worthwhile too. In other words, narrowing focus can be extremely useful, but it can also lead to problems where we forget all the other things that presently aren’t being measured, but are important in our job as well, or where we decide, for whatever reason, to simply lie in the statistical return for the target.

So, if targets cause problems, should be abandon them? There was an interesting discussion around this on twitter, where several people suggested that target-based systems are inherently flawed, and so we would be better off without them. I was interested to see several clinicians, however, suggest that targets are both important and can be useful. They made two main arguments.

First, that we need targets because without them we wouldn’t have seen the improvements that the NHS has achieved in recent years. Think of waiting lists – imposing maximum waiting time targets has meant that managers and clinicians have found ways of driving down waits, and surely that has to be a good thing. Provided that the reductions in waiting time are genuine, and that we haven’t ended up distorting clinical priorities, that seems a good argument. Effectively, we are saying that by finding a target that is in an area that is important, and focussing on it, then they can be a means of driving improvements. This can come through diverting resources into areas we need to improve, or by reviewing care pathways to find bottlenecks or efficiencies. Wherever it does come though, a target can be a means of focusing attention and driving improvements.

A second argument in favour of targets is that they can act as a means for clinicians to be able to challenge managers to provide additional resources. The logic is that, if a trust looks like it is going to fail to meet a target, then clinicians can go to managers to get more resources to try and improve performance against the problem target. If the point I raised above was about focus, this was is about diversion – about diverting resources and attention from one area to another – another area that looks like it has a target that won’t be met. Again, provided the diversion of resources is justified, this seems to me to be a good thing. But of course, if the target being chased is not as important as the area losing the resources, then this isn’t really optimal.

What I’m struck by is that you don’t need centrally-set targets to focus, and you don’t need them to allocate resources sensibly either. Surely it’s the job of our managers and clinical leaders to work out what the staff working with them need to be doing? Targets can help us focus on what is important, but do we really need them to be centrally-imposed us to treat them seriously? I would hope that clinicians are more than capable of working out what they need to do each year to make things better, set targets for themselves to that end, and be held to account for them. I’m not clear why the government needs to be involved. Equally, if the health needs of an areas are such that resources need diverting, then surely we can expect clinicians and managers to work through that debate and come to sensible conclusions. This won’t be easy, as decision about what to prioritise are also as much about politics as they are about evidence, but the alternative, where government sets the targets for us, isn’t the right way forward either as this ignores the importance of local context. What health services in Durham (where I work) need to prioritise is very different from health services in York (where I live).

What I’m arguing for here is for targets to be decided in a bottom-up fashion, by clinicians and managers working out what needs doing, and then being held to account for doing it. And those targets need to be understood as goals rather than fixed measures that we can simplistically tick off once achieved. Patient care isn’t like that. If we get our clinicians and managers to agree goals together, and hold them sensibly to account for their achievement, then we have a way forward in improving services that people will have bought into, and which will be about improvement rather than punishing people for things that they believe they have no stake in.

 

The closing of the walk-in centres

Warren Buffet once said that the difference between a conversation and commitment is a cheque. There’s certainly something in this. If you believe in something you should pay for it, right? So, if one in four walk-in centres are closing, that would suggest that this is because the NHS doesn’t value them sufficiently to keep them open. The NHS isn’t willing to pay for them, ergo, then don’t have value.

But this logic only works if all funding decisions are made rationally. There are at least two reasons why this isn’t the case with the walk-in centres. First, because it seems that many people are waiting longer than want to (or sometimes should be waiting), to get a GP appointment. I don’t have a problem getting a GP appointment in a reasonable time, but understand this isn’t always the case for others, especially those in big cities. If the walk-in centres are providing extra needed capacity, then it would suggest that closing them isn’t right – especially if, as Monitor report, the people using them will end up in A&E instead. That isn’t going to help anyone, and is going to cost a lot of money. We have been told that the walk-in centres are ‘popular’ in press coverage this morning, but I haven’t seen good research examining whether their case-load is made up of non-urgent cases, or whether they are providing a valuable additional service. It seems we don’t really know enough about walk-in centres actually do, and that is half the problem.

A second problem with the idea that, if walk-in centres were useful, then the NHS would pay for them, is that is assumes a market-based rationality. It assumes that patient need and patient choice is driving the system, and I’d be amazed if that were the case. We have been told that the walk-in centres are ‘popular’ as I mentioned above – in which case they should be getting the funding they need, and it seems this isn’t the case. And even if the walk-in centres were popular, that still doesn’t mean they are actually serving a clear health need – we ought to be asking deeper questions as to why people who go in them aren’t visiting their GPs – whether they can’t be bothered to book an appointment, or can’t get one. Whether they actually need to see a doctor, or their needs could be better met through seeing someone else (or perhaps even, no-one at all). Healthcare isn’t a consumer good, as individual patients are usually not in the position to know if the person seeing them knows what they are talking about or not.

So closing the walk-in centres may or may not be a good thing in terms of providing better care. It may be that CCGs don’t want to pay for them because their members aren’t working in walk-in centres. It may be that commissioners don’t have the research to show whether walk-in centres are valuable or not. It may be that we’d all make greater use of walk-in centres if they were more convenient to get to than their own GPs – especially for us commuters.

What the closures do show, however, is the deep irrationality of the purchaser-provider split. If the NHS needs the extra service and capacity that the walk-in centres offer, it should be making the funding available. This shouldn’t be about the localised purchasing decisions of CCG, which seem to be largely unaccountable and unjustifiable here, as these decisions don’t appear to be being based on any particular evidence.