In Sans Everything, published in 1967, some of the worst failures in the care of the elderly and of elderly people with mental illness were identified at seven hospitals across the country. Physical and verbal abuse of the most appalling nature was alleged; however what was just as shocking was the follow-up government report into the allegations. Regarded as a whitewash, the report characterised those who raised concerns in the most deplorable terms, describing one whistle-blower as ‘a most unreliable witness, whose judgment was manifestly unsound…a rather a solitary person with a somewhat simple mind’ and used further disparaging remarks to invalidate her testimony. Concerns were left unaddressed, and a toxic culture was allowed to grow.
As a medical student working at the Health Foundation over the summer as a policy intern, I helped to research and write some of the Policy Navigator timelines. Setting out the history of health policy and the scandals and policy developments that have brought us to where we are today, the timelines explore past successes and failures in insightful detail.
What has surprised me was that the high level of scrutiny the NHS is under is not something new, the scandals happen again and again. Financial challenges, like the one we are in now, have happened again and again, and however hard it is to address long term problems at a time of constrained resources, it is often only during these times that the effects of long term problems become apparent.
While something that happened in the 1960’s might seem like it has little relevance to the modern NHS, as I have immersed myself in the history of the NHS, these events seem less like they occurred in some disconnected past. The language used by politicians in the 1920’s sound as contemporary as if they were written yesterday, let alone almost a hundred years ago (see for example the Dawson Report which set out a comprehensive policy for the extension of the health service). The failures in care are fundamentally the same failings as that seen at Mid-Staffordshire NHS Foundation Trust.
The challenges we faced then are still with us now and it is often the most basic aspects of care on which we have failed. And while there is no doubt that the improvements made in regulation are important, with better inspection of services playing its role in identifying areas of concern and establishing best practice, the scandals throughout the history of the NHS have continued despite all the improvements made by new regulatory regimes. By the time failure has been identified, for many it is already too late, and so we must directly address what is wrong with the culture that allowed these scandals to occur in the first place.
So as a medical student how do I think we could combat the culture in some hospitals that allows bad care to continue? What have we historically overlooked? There is no single answer, but if culture change is one of the central themes of addressing these problems, then addressing the culture taken up by those entering the NHS must be of critical importance, as it is they who will shape its future.
As the Francis report notes, medical students and trainee doctors are in a unique position. We experience the culture of many different hospitals, giving us a greater capacity to compare and contrast. It recommends that healthcare providers should be required to seek out the feedback of medical trainees. While this could go a long way to addressing elements of poor culture in the NHS, medical students are not going to be able to pick up all the potential failures that might only be seen by more experienced eyes.
Working in policy at the Health Foundation has given me a greater appreciation for quality improvement (QI). I am privileged to be a student at Imperial College London which in many respects is leading the way in QI. The university requires medical students to design a quality improvement programme addressing some area we have identified during placements, which includes engaging health care professionals involved with care in every stage of the project. The culture of health care needs to change to one where QI is seen as an essential part of the job, and better training of health care professionals could support this.
I feel I have learned so much about the NHS, and why its idiosyncrasies are the way they are. The way the NHS works and the culture of those who work in it is defined by history. To understand it and know how to improve that culture, it is vital to explore its history, unflinchingly looking at the NHS’s worst failures, and perhaps only then can we hope to ensure a Mid-Staffordshire never happens again.