Apathy: In the year 2004, while my father lay dying in intensive care at Northwick Park Hospital, I went to a vending machine I had seen near the hospital refectory. It ate my money and delivered nothing in return. There was a number on it, for people to call for refunds. I stored the number in my mobile phone, but figured I could save other people the inconvenience of my predicament by putting a note on the machine. I asked catering staff, a porter, security staff and a nursing sister in turn if anybody could put an 'out of order' note on the machine. Each refused any responsibility. The nursing sister was standing chatting in the main hospital corridor, but said she was too busy (too busy to stick a note on the vending machine, but obviously not too busy for social chat). It seemed staff only care about the welfare of people in their hospitals when it is on their job description. I went back to intensive care, borrowed a pen, adhesive tape and some paper, and put a sign on the machine myself.

The fact that several people would have lost money to the vending machine is of little significance in the grand scheme of things. I have used this example because I feel it is the sign of a more serious underlying disease; chronic apathy. I have a fair idea where this apathy comes from. During 2003 I was a facilitator for the emergency services collaborative project at a London teaching hospital. The project’s purpose was to ensure patients spent no longer than 4 hours in accident and emergency in accordance with the NHS plan. I worked with one other facilitator under a project manager. When I accepted the job I was under the illusion that we would actually be changing procedures to speed up the hospital’s functioning. Experienced clinical staff were quick to give me a reality check.

Failure to listen to clinical staff: The project had been running for at least two months before I started work, but when I asked people, nobody could tell me about any changes they had noticed. A senior radiographer told me that nothing was going to change and my job was a waste of time. A registrar asked me why the NHS was wasting money on my salary instead of employing another nurse. I asked the junior clinical staff what was slowing them in their jobs and how they thought those things could be changed. They were full of good, legitimate ideas. I forwarded the staff’s ideas to my manager. I am not sure what happened to them after that. Perhaps they were put straight into the bin. A general manager informed me that we were not there to improve working conditions for staff, but to improve patient experience. Perhaps the management was unable to see the relationship between these two factors. Even the A&E consultants’ ideas were belittled behind closed doors. After my first month in post, the only changes I heard my manager boast about were plans to put a line on the floor from A&E to x-ray to stop patients getting lost, and improved lighting. The radiographer’s predictions were coming true.

Little personal empires: Change was hampered by territorial disputes and an unhealthy culture in which it was normal to look for reasons why changes would not work, rather than look for ways to make changes work. Defensiveness had developed because historically managers failed to consider the needs of the organisation as a whole when making changes in their own departments. If medical or surgical services expanded for example, no provision was made to expand therapies or diagnostic services such as x-ray to meet the extra demands they would face. Outpatient clinics were similarly over-booked. A new computer system was due to come in for the A&E administrative staff some time after the project. Their manager was therefore resistant to project-specific changes to the way her staff worked. Similarly the general manager in charge of X-ray would not allow discussion of minor changes to x-ray forms, which could have significantly improved the workings of the project as a whole. To me, these behaviours seemed nothing more than territorial displays by fearful individuals.

Cheating: Many clinical staff were unmotivated to co-operate with the project because it was of little importance relative to patient care. They had not seen any significant changes the whole time the project had been running and no obvious action had been taken on the ideas they had generated. As a result information necessary for audit (such as the times patients left A&E) was often not recorded. At times, inadequate data was recorded for up to 50% of the patients who passed through A&E. My manager’s solution to this was guessing what time patients left A&E according to the time written by the last entry in their notes. In my opinion that meant we were essentially making the results up. Part of my job was calculating the percentage of patients who spent more than 4 hours in A&E. The other facilitator, our manager and I took turns doing this. The statistics always looked worse when I calculated them, and one day my manager told me my calculations were wrong. I had been taking the number of patients who had spent more than 4 hours in A&E as a percentage of the total number we had recorded times for. My manager instructed me to express the patients we knew had spent more than four hours in A&E as a percentage of the total number of patients. My manager’s method assumed all of the patients who we had no recorded times for had passed through A&E in less than 4 hours; a convenient but imaginative interpretation of statistics. At this point I realised my job was not to help repair the health service, but just paper over the cracks.

The crunch came for me in the week hospitals’ star ratings were being measured by A&E patient journey times. The management staff were put on a rota, so that at least two of us were in A&E 24 hours a day to hurry the clinical staff. This was not a sustainable change, but a short term fix to create an illusion of performance. I was part of a scam to fool the government and the public. I was surrounded by nurses who were working harder than me. I was paid more than them, but my job was making absolutely no difference to healthcare quality. The only ethical thing to do was resign. When I did so, the other project facilitator repeatedly asked me if I thought she was a bad person. I got the impression she felt guilty about her job too. It was not long before the Labour party was boasting in Parliament about emergency care improvements. I realised how naive I had been all my life. I no longer have faith in any government statistics.

Cheating was widespread (Revill 2003). NHS management is like athletics. If some Trusts cheat, others have to just to stay in the game. Scams range from general figure fiddling to restricting access to services (Woods 2005), or charging relatives extortionately for car parking (Daily Mail 2006) when they visit patients. The personal and professional lives of clinicians are scrutinised by professional bodies for our protection. Therapists for example are regulated by the Health Professions Council (Evans 2005). I believe we need a regulatory body to police and protect us from NHS managers. Until NHS management is regularly independently scrutinised I believe it will continue to waste money and generate fiction.

References:
Daily Mail (2006) Anger over 'scandalous' hospital parking fees. http://www.dailymail.co.uk/news/article-381346/Anger-scandalous-hospital... 29/3/2006

Evans R. (2005) HPC finance director jailed for £130K fraud. Therapy Weekly 32(24):1

Revill J. (2003) Whistleblower lifts lid on NHS culture of secrecy http://observer.guardian.co.uk/nhs/story/0,,882509,00.html 26/1/2003, Hospitals faking cuts in casualty wait times. http://observer.guardian.co.uk/nhs/story/0,,953395,00.html 11/5/2003,

Woods S. (2005) PCT blasted over missing GP targets. http://www.richmondandtwickenhamtimes.co.uk/display.var.596729.0.0.php

Walking into the hospital where I work this morning I noticed a sign telling anybody with respiratory tract infection symptoms to stay away, to avoid infecting patients. I walked past the sign with a small cough and then blew my nose at the first available discreet opportunity. It seemed like the sign did not apply to me; it only applied to the public. During my first hour at work today I noticed a physiotherapist with a cough and a healthcare assistant with a cold. The only person to bat an eyelid at my coughing for the last two weeks was a Sister. She rewarded me with a dirty look, but said nothing. Despite frequent hand-washing, the likelihood is that I was infected by a colleague and my inconsiderate behaviour will have in turn infected many of my colleagues. The next person to use this keyboard will probably be infected, as will many others afterwards. Why have I come to work then?

Abstract: This blog entry reflects on my experience as an occupational therapist treating a terminally ill patient and my lack of understanding of a doctor's and a palliative care team’s perspective.

What happened:
I once treated a deteriorating patient diagnosed with gall bladder cancer. She did not know her diagnosis or prognosis and asked for rehabilitation to go home. Her relentless efforts to mobilise were not rewarded as she became progressively weaker and she asked me several times what was wrong with her. I asked the doctor responsible for her care to see her to answer her questions but he told me that things must have been explained to her, because the palliative care team had seen her, and he therefore deduced that she must have memory problems. A mini-mental state assessment revealed no memory impairments so I read through her medical records and was unable to find any notes to say that anybody had explained her diagnosis and prognosis to her. When I presented this information to the doctor he told me that just because something had not been documented, that did not mean it had not been done. I then contacted the palliative care team. They told me that the patient’s daughter had asked them to withhold information about diagnosis and prognosis to avoid upsetting her mother.

Abstract: This blog entry reflects on my personal feelings of occupational alienation and how they were stimulated by the use of occupational alienation and occupational injustice as weapons in a foreign country. It provides examples of politically and internationally generated occupational risk factors. Finally it describes my self-treatment using the limited means I have. Luckily for me, those means are far less limited than those available to people in the country that inspired this blog. THIS BLOG INCLUDES PICTURES FROM WAR, INCLUDING DEATH. YOU MAY THEREFORE WISH TO AVOID READING IT. The pictures in the referenced material are much worse and are likely to shock most people, so think carefully before looking at material from the reference list. Thank you.