The impact of #N30: a day of action

Maximum disruption.  That’s the purpose of going on strike.    You will  have read the global figures on the impact of the Strike Action on November 30th but I felt it was important to write about the local impact.  Let’s begin with some basics

1.In an average District General Hospital (DGH) they will undertake about 2,000 outpatient appointments per day and 180 elective operations.

2. On an average week day, a DGH will admit about 80 patients through A&E.  On the weekend this will drop to 65.

Based on the above, the staffing levels are determined and bed moves are managed.  The Trust will run its operations tightly.  Any  significant increase in A&E attendances & admissions will be felt across the Trust.  Naturally, weekends have lower staffing levels because of the lower number of potential admissions.   On top of this, every Trust has sophisticated admission prediction tools, and they will increase / decrease elective activity in response to these predictions.   But like the weather, these predictions are sometimes wrong.

Turning to elective operations, the theatre list will be determined by the consultant who is recommending the surgery.   Each surgeon has different views on how their patients should be treated, and consultants do not “swop” or operate on another consultant’s patient except in exceptional circumstances.  The list is drawn up by specialty.  Eg a respiratory consultant will operate on all patients with lung conditions, including those with Cancer.

The same applies for outpatient appointments.  The key difference with outpatient appointments is that a patient may present with a persistent breathing issue [for example] and in the course of the appointment the potential diagnosis of cancer may present.

There were two strike exemptions on November 30th: one was emergencies, the other was cancer.  But as you can see above, it is incredibly difficult to pull out and determine who is a cancer patient on any given day without considerable effort.

Some Trusts treated November 30th November as a Bank Holiday.  Whilst it might be a sensible approach, I’m not sure how they pulled that off. Not withstanding the fact that it was [otherwise] a normal working day in terms of predicted admissions, but also the fact that usually, with planned cancellations, six week’s notice needs to be given.   Six weeks is deemed as the appropriate length of time to arrange cover / re-arrange appointments in a way that is not disruptive to the Trust.

Since the legislation states that strikers do not need to notify their employer before the day that they intend to go on strike, many Trusts had no idea of the true extent of the disruption.  They faced two choices:

1. Continue as normal, assess the situation at 8am on the day, and cancel as appropriate

2. Make cancellations at short-notice.  However, the Trust may find itself in a position where many staff arrive for work, only to find that there is no work to do.

The  impact on patients should not forgotten.  The exemptions were around cancer or emergencies.  But what abut the patient who’s been suffering for years with their leg?  Their routine operation scheduled for the 30th November is going to change their life.  And then it’s cancelled.  Or the patient who didn’t know she had cancer, until she attended an  outpatient appointment and through discussions with her doctor the diagnosis is made?

Other Trusts took the brave [but in my view the only] option to continue as normal.   What was not seen on Wednesday was the considerable work that was done behind the scenes by managers in Trusts to ensure that the hospital continued to run on November 30th.  The same managers who are in the unions that were out to strike.  And this work continues, as Trusts attempt to recover from the Day of Action.  As I said, maximum disruption.

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The Drowned & The Saved

Last night, I put down my book (Primo Levi’s The Drowned and the Saved) to watch the Panorama programme about the gross failure of care in a UK residential care home.   I went from reading about  inhuman behaviour to watching it on TV.

Whilst I’m not saying that the care home at the centre of Panorama’s programme last night was like a concentration camp, there are certain common themes: the abuse of power, the cruelty that humans are capable of, and the despair of the victims.

A few years ago my gut told me that there was “something not right” about a clinical service I was working with.  There were small things that I saw, read, heard about that when pieced together made me feel uncomfortable.   There was nothing substantial, no evidence of wrong-doing, just this gut feeling.    Then one day a Senior Manager came to me to tell me that they had the same gut feeling.

We spent some time developing a plan and we enlisted the support of  an Occupational Psychologist.  I spoke to my boss, who in turn supported me when I met with our Chief Executive.  My CEO listened and I was given resources for six months and the go-ahead to implement our plan.

But what had caused this service to deteriorate?   My Occ Psych called it “Institutionalism”:   a group of individuals who had worked with each other over a significant period of years with few (if any) newcomers to the group; a group that worked in isolation – often caused due to geographical reasons (but this is not always the case).  As a result, bad behaviour and poor standards creep into the service.

Certainly there was a power-base.  It wasn’t necessarily the senior members of the management team.  There were alliances within the group and the struggle for power was continuous.  However, the greatest threat was the newcomer – the person who challenged “the way we do things round here”.    At first, the group would try to seek an understanding with the newbie, convert them.    But in essence, there were two choices

a) To go “native” – to join the rest of the group with poor behaviour.  Or at least stand at the side and allow it to happen.  They are probably told that even if they do report it – nobody would believe them.  To be honest, for many this option is taken in order to survive.  For a Healthcare Assistant who has been unemployed for six months it is undoubtedly easier to conform, as the other option might lose them their job.

b) To challenge the behaviour.  However, the group would close ranks and there would be signs of bullying and intimidation towards the newcomer.   After a short period of time the newbie will simply move on to their next job.

So the role of a Whistleblower is incredibly important in these situations.  They need to be taken seriously and protected. It’s also important that there is strong HR leadership – patient in executing their strategy, and compelling  in their vision to ensure that the right people are engaged along the journey.

But it’s not easy.  In my case I still distinctly remember a Saturday afternoon when I was at home working. I burst into tears:  not because anything had happened, but because I feared the potential of something happening;  because I was frustrated – if there had been evidence  of misconduct I could have advised on a swifter and more definitive approach (although paradoxically, there had been evidence it would meant that a patient had already been abused).

Was I successful?  In six months – no.  But we had made some fundamental changes, both in terms of personnel and organisational culture.  A robust development plan was being implemented, and I felt assured that the service was increasing its level of clinical care.  But there was still so much more work to be done.

In the aftermath of yesterday’s programme, there have been suggestions that it’s the CEO of the residential care home who’s at fault;  and that the CEO of the CQC has failed in his duty to ensure such care homes are regulated.

I disagree: it’s all our responsibilities to follow our “gut” when we believe that the standards of care aren’t quite as high as we expect them to be.  Senior managers need to listen, and then have the confidence to take appropriate positive action.  If we don’t, we will forever have to carry the burden of our own guilt.