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Hush money and the 'cannot culture': an inside account of the NHS

Do nurses take pride in their jobs? How many doctors take bribes to keep their mouths shut? A retired professor of medicine speaks out on the NHS in this extract from upcoming book 'Public Service on the Brink'.

21 September 2011

The following is from 'Public Service on the Brink', an upcoming book describing the denigration and undermining of public services and the public service ethos in the UK. This edited extract is taken from a chapter on the NHS by a retired professor of medicine. ('Public Service on the Brink', March 2012, ed. Jenny Manson, Imprint Academic.)

Status, not pride…

What seems to be a basic misunderstanding of the public sector ethos is the idea that people are best motivated by status rather than the work itself. Today we have 'clinical specialists' and 'extended scope practitioners' where we had ‘nurses’ and ‘physiotherapists’. The tacit implication is that just being a nurse is not good enough. It also implies that to be at the top you need to do more than what you are trained for - to 'extend' your scope.

Motivating people to achieve their potential is no bad thing but one of Parkinson's laws looms large here. People rise to the level at which they are no longer competent. Here there is almost a deliberate pressure to make that occur because the real reason for 'extending scope' is not hard to find - it is cheaper to have a nurse or physiotherapist extending their scope and doing something a doctor would have done than employing a doctor. The cynicism is transparent.

The flip side of asking people to do more than they are good at is the pervasive sense that nobody can be trusted to do the job. Here the false culture of protocols and procedures raises it ugly head. Time and again we hear someone with a straight face saying that a disaster will not be repeated because 'procedures have been put in place'. What they do not seem to have an inkling of is that if procedures need to be put in place it must be because the people involved do not know why they are doing what they are doing.

People who know do not need procedures. Putting procedures in place is the problem, not the solution. Procedures are intended to deal with unknown eventualities but can never do so - in fact they make it less likely that such unforeseen eventualities will be dealt with intelligently. 

Nursing seems to have suffered particularly badly from the procedure obsession. The reasons may go back a long way. Up until the 1960s most nurses were young women wanting something to do while looking for a partner, supervised by a small number of older women, many of whom may have remained single because of war. Their combined dedication and vulnerability were exploited with low pay and a lack of respect for their skills.

Arguably the profession then lost faith in its own judgement. It was co-opted by the bureaucracy. Procedures took over. This may seem an unfair analysis. However, I was interested to hear a personal account of health care experiences on the radio in July 2010 in which the speaker singled out nurses as having lost touch with what they are there for. Only very recently has there been some sign that this might be reversed. Restoring self-respect to the nursing profession such that they can see their job not as following procedures but as solving people’s problems is a key priority for English healthcare. 

What is needed in the co-operative environment of the public sector is an enjoyment of being one of many, solving problems as they come along. Politicians do not seem to grasp that the really useful people in the public sector are those for whom, unlike politicians it seems, the greatest incentive is being able to do the job they want to do. 

The 'Cannot' Culture

Protocols do sometimes have a place in a complex activity, at least in training and double-checking. The real problem arises when they dictate what cannot be done, without saying how else a problem can be solved.

A patient calling an ambulance cannot be taken to the hospital they came out of a few days before if it is a hundred yards further away from their home than another hospital. Patients cannot have their treatment in casualty if to do so would mean they are still there at the four hour deadline. In my case, I was not allowed to take a member of my family fifty yards in my car from one part of a hospital to another, resulting in a six hour delay in emergency treatment for the relief of agonising pain. I know what it is like to be on the receiving end. Repeatedly my patients have said they have gone away empty handed from pharmacy with my prescription, because a pharmacist has found a reason for saying something cannot be prescribed. It does not seem to occur to people that the patient might come to harm from the imposition of a cannot regulation.

One might be tempted to put this down to a general weakness of human nature. However, it seems that at present this is a peculiarly English problem. A colleague on an extended visit from Spain commented shortly after arriving that she had never previously encountered the sort of obstructiveness she found everywhere around her in London. In Spain people make mistakes but if told they apologise and try to resolve them. In England problems are seen as just the way things are; finding a solution is not the agenda. The only agenda is sticking to procedure. 

The cannot culture seems to run deep in the philosophy of NICE. We are more or less at the bottom of the league in Europe for recommended use of new drugs for rheumatoid arthritis. NICE guidelines even require the prescription of more expensive drugs when a cheaper drug is available, apparently just because once a NO is in place it cannot be shifted. Saying NO is more important than making sense. There was a time when such behaviour was considered a quaint quirk of colonial outposts. Now it seems to be on our doorstep.

Toadies and Hush-Money

However easy it may be to blame management for all our problems we also need to ask to what extent front line staff collude in the process. One of the recent fall-out stories of the Baby P disaster was the revelation that doctors are paid large sums to keep their mouths shut when tempted to make public statements about poor service provision. Even I was slightly surprised that colleagues were being offered over £100,000 to maintain silence, but only because I thought such overt bribery would be illegal, not because of the existence of bribery. 

The entire salary system for doctors now draws on a hush-money principle. Dating back to the early NHS hospital consultants have been eligible for 'merit awards' putatively intended to reward hard work. How the system worked at first, and what motivated it, I am not sure. Putting in extra hours and significant innovation did get recognised, although no doubt there was an old boy network. Whatever the original situation, the scheme now fulfils a very different function.

Whereas, initially, awards were judged by peers, climbing up the ladder is now largely a matter of pleasing local management. This may not be overtly apparent but the way things are structured that is how it works. We are paid to sing the praises of the new system and its managers. Awards cannot be given just for looking after patients. You can only qualify on the basis of work done 'in addition'. Nobody sees patients other than on a contracted basis so the 'additional work' is sitting on committees, mostly chaired by managers, or others with an agenda of ‘good practice’ that traces back to political expediency. (Meetings are often scheduled for times when one is contracted to see patients so generally awards are given for doing less doctoring.) Thus the reason for sitting on committees is to get a pay rise through toadying. People who join committees to say something useful are marginalised because they cause trouble. 

Is this unwarranted paranoia? It might have been, but curiously, once raised, the notion is self-fulfilling. This is how junior colleagues believe the system works so they keep their mouths shut at all times. Hence my colleague’s comment that I could be critical but they could not.

More sinister is the rise of a group of doctors who turn toadying into a full time job. Rather than toeing the line they aggressively promote support for management antics. They are the new apparatchik, eager to take every opportunity to show their ability to slash through the undergrowth of human hopes and fears and show how uncompromisingly they can champion the cause of progress (otherwise known as cost-cutting). Machismo becomes a more important quality than medical skill. I remember a consultant appointments committee at which the appointing hospital's medical director's main concern about a candidate was not his competence or commitment to patient care. It was whether he was too nice a person to fight his corner in casualty in the dog-eat-dog world of who can get their patient admitted instead of someone else's.

Jonathan Edwards is a Professor Emeritus in the Department of Medicine, UCL. 

To contact Imprint Academic about 'Public Service on the Brink', please email Anthony Freeman on [email protected] 

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