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At the heart of general practice since 1960

The customer may always be right, but only if you run a business

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I haven’t got around to reading all twenty-odd thousand words of the Francis Report, but I’m reliably informed by that bloke on Radio Four’s drive-time show that they could all be summed up in three: ‘Put patients first’.

Tell you what, just for a change, let’s not.

I’m filled with the same horror that all of you must be at the harrowing tales that have come out of the woodwork about appalling levels of care at Mid Staffs - just the same way as I was shocked by the Bristol heart scandal, the Alder Hey organ scandal, the Maidstone and Tunbridge Wells C Diff scandal, the Furness maternity scandal and the Bedford hospital mortuary scandal.

As a result of a good deal of vigorous shroud-waving by politicians and media commentators alike, we’ve seen hapless patients put first, front and centre, empowered, included, offered advocates, herded through gateways and occasionally defined as experts. They’ve had their journeys mapped, their experiences enhanced, their care co-ordinated and their narratives explored.

God forbid that they fall for this sanctimonious crap yet again. The net result of all of this? Bugger all of any practical use. A few dozen reports that nobody has read all the way through, a few thousand trees felled and replanted, hundreds of editorial column inches filled with rent-a-quotes and a handful of single-issue political campaigns.

So let’s give up on the concept of an NHS that puts the patient first and above all others. Let’s stop pandering to those who dial 999 when their kid vomits once, or who turn up to A&E with an insect bite. Let’s stop reorganising GPs’ appointment systems to deal with the insecurities of people who, ‘are ill or who believe themselves to be ill’.

We already have a medical provider that puts every patient front and centre, calls them ‘delightful’ and lays on cappuccino in the waiting room. It’s called the private sector.

The NHS simply can’t afford such luxuries. It staggers along, propped up by the altruism of the vast majority of the people who work in it. For years and years, that devotion to duty was rewarded not financially, but in ways that made the staff feel valued. Imagine a hospital where doctors and nurses can park their car a short walk from the main entrance, where the food in the canteen is actually edible, where services exist to make their lives easier rather than harder. Where everybody knows your Christian name but still calls you ‘Dr’ or ‘Sister’ on the premises.

You’re picturing your local private hospital, aren’t you? I’m picturing the NHS centres of excellence where I worked in as a junior in the 1980s.

So stuff the idea that fulfilling patients’ expectations is the be all and end all. Let the pendulum swing back to the professionals’ side for once. Just for fun, let the doctors and nurses run the show.

What did for the patients at Mid Staffs wasn’t a lack of expertise, but a managerial regime designed to take the caring out of curing. When a medical registrar writes that he is forced to spend twice as much time on the paperwork that accompanies every admission than he does examining, investigating and reassuring the patient, then surely it’s obvious that something is wrong. All the interminable risk assessments get in the way of patient care, rather than enhancing it, and they were all generated by a management ethos that aims to cover its corporate backside in the guise of a ‘patient-centred approach’.

How many doctors and nurses passed by on the other side at Mid Staffs and failed to raise concerns about the standard of care? We’ll probably never know. Anybody who wants to know why clinicians were disinclined to point out catastrophic failings on the wards should read through Andrew Bousfield’s Twenty-One Ways to Skin a Whistleblower and wonder what they would do in the same situation.

Until the NHS starts to value its workforce and accept that, now and again, their needs might override those of the patients, nothing’s going to change. Designing systems that include clinicians in day-to-day decision-making - advised, but not dictated to, by patients and their families - will be far more effective in improving patient care than any dictat from on high.

The customer may always be right, but only if you run a business. The NHS is not, never has been and never should be run on a business model. Leave that to the private sector.

Dr Tony Copperfield is a GP in Essex. You can email him at tonycopperfield@hotmail.com and follow him on Twitter @DocCopperfield.

Readers' comments (7)

  • We have it better than most other countries! Not as good as some others. We should not be too proud to look at other systems that are better than ours. Australia is prospering not just because it has mineral resources. It's health system works better. Healthier happier people are more productive. You have to have a work class health system to have a world class economy!

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  • Far too much time is being spent by doctors on pointless audits, clinical governance', publications and mandatory training which are now needed just to tick boxes and keep your job but which fail to prevent these scandals. This time wasted is at the expense of what doctors are trained for which is to look after the best interests of their patients.

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  • The time and effort spent on Revalidation in gathering paperwork and brown nosing ones appraiser and colleague MSF assessors will also be time when one's eyes are off one's patients and their best interests. Revalidation will also prevent doctors from whistle blowing for fear of 'rocking the boat' which could result in negative employer appraisals and MSFs and therefore loss of one's licence to practice,

    The BMA must apply for judicial review to scrap these revalidation requirements which run entirely counter to encouraging whistle blowing to prevent similar future scandals and deaths.

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  • Back in the glory days when you were a junior what kind of hours did GPs work and what kind of pay were they getting?

    You sold your autonomy for a pot of gold and no more out of hours - yet you have the audacity to blame patients for the situation in which these poor, vulnerable people at Mid Staffs found themselves in.

    Get some insight.

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  • Spuds

    James Jones you have missed the point entirely.

    The article is not blaming the patients at Mid Staffs, he is blaming the managers and the paymasters for the culture of consumerism they are allowing to flourish, and the excessive amounts of administration that take up so much time these days. He is bemoaning the lack of respect for professional integrity and suggesting that the workforce is demoralised because of it.

    It's difficult to argue against any of that isn't it?

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  • In answer to James Jones, I think I am of a similar antiquity to the esteemed author. I worked a 1 in 2 rota and received about £500 a month I think. However the important feature was that despite this being a big renowned teaching hospital, there was one administrator who knew me by name and was highly respected. He would often ask me if he needed extra cover and I would oblige as much as I could. I cannot see that type of relationship existing now and the hospital will be poorer for it.
    I don't think anyone was blaming the poor patients here who are clearly the victims. I think he was trying to put forward a thought for a solution where professionals take responsibility rather than imagining that what they do is simply a normal job. In GP land, despite the myriad of changes , the buck does still stop with the GP and hopefully such situations will be less likely to occur - and if they do, there is definitely someone to carry the can.

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  • Vinci Ho

    (1) Helping our patients to understand what they really need in health is our job and hence they cannot be always right. Providing people anything no matter whether they know they need it or not , that is consumerism.
    (2) Bill Moyes former Chair of Monitor, said during the inquiry , ' The culture of the NHS ,particularly the hospital sector , I would say, is NOT to embarrass the minister.'. If that is the case, you really we , GP,, can do anything?
    (3) From top to bottom, particularly the top , we need the spirit of a scholar:
    " A scholar must be resolute with great determination. His or her responsibility is a heavy one and the road is long. Practising and teaching benevolence is his or her prime duty. Isn't that very heavy? This duty must be continued until he or she dies. Isn't it very long?'
    Verse 7 of Analects of Confucius Chapter 8
    I cannot see any of that quality in any of these disgraceful 'leaders' , at least in this disaster .
    Please read Philip Carter and Bruan Jarman article in last weekend BMJ. ' Who knew what , and when , at Mid Staffs?'

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder