Nursing and the "Speckled Jim Trial"

Nursing and the "Speckled Jim Trial"

Recently two nurses who worked at Mid Staffs were 'struck off' by the NMC for their actions whilst working for the trust. Like many people, they were members of a union - in this case the RCN. A collection of Tweets from Julie Bailey @CuretheNHS, Shaun Lintern @ShaunLintern and Rebecca @MsNaughtyCheese (who is an intensive care nurse working in London) questioned the role of the RCN in "supporting bad care". @MsNaughtyCheese even objected to her RCN fees being used to represent bad nurses.

All this is vaguely reminiscent of the episode of Blackadder Goes Forth where Captain Blackadder goes on trial for shooting a carrier pigeon, which is in fact the beloved pet, Speckled Jim of the mad General Melchitt. Melchitt opens the trial of "the Flanders pigeon murderer", and readily agrees to the defence lawyer being charged with wasting the court's time for turning up.

Representation is an important aspect of any judicial or quasi-judicial process, and this is what the majority of RCN members pay their fees for. As one Tweep pointed out to 'Rebecca', what if she made a mistake? Then she would be the bad nurse and wouldn't need any union representation? Of course she would be breaching the Cure the NHS requirement for 'right first time', that is to say zero harm and zero error rate. 

Cure the NHS and the cherry tree parable

Cure the NHS and the cherry tree parable

Cure the NHS have made several rather confusing and contradictory pronouncements - although they are not alone in this. One example is the mantra that the problem wasn't the mistakes made, but the cover-up. In fact, of all the allegations made by CTNHS, a cover-up is the flimsiest. There is no evidence for a cover-up at all. 

Other commentators have said similar things - Liam Donaldson stating "To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.” This meme is very much on the lines of the cherry tree parable. The legend is that George Washington chopped down his father's cherry tree. When his father asked who chopped down the tree, the young George confessed and was forgiven. This episode probably never happened, but in any case it is unhelpful. Confession and apology doesn't restore the damage inflicted, and the notion that candour would prevent any punishment or restitution is clearly nonsense. The fact that a criminal or tortfeasor is genuinely remorseful is a mitigating factor, but they still have to be held to account. Otherwise the glib and manipulative wrongdoer goes scotfree.

This rather maudlin meme is a theme with Cure the NHS. One of the bases for their vendetta against Andy Burnham is that he didn't meet the group personally, whereas Jeremy Hunt did. Most people would think that actions are rather important than a cup of tea and some metaphorical hand-holding, but not to Cure the NHS.

Julie Bailey has Tweeted 

we all make errors but no one should ever be harmed in the NHS and We need zero harm & right 1st time

Deb Hazeldine Tweeted
Otherwise loved ones have died in vain, and failings repeated, thats heartbreaking for families

This has the rather puzzling implication that loved ones have not died in vain if those failings are not repeated, as if macabre experiments have suddenly become acceptable in healthcare. Together these pronouncements make for pseudo-sentimental incoherent nonsense. Everyone makes errors, but these errors shouldn't cause any harm? Right 1st time must entail a zero error rate. The zero harm target has been showed to be inimical to honesty and transparency in the construction industry.

Julie Bailey is no patient safety expert, and it's understandable that her statements make no sense. She is simply a relative of a patient. Why then is she being paid to talk to NHS staff? And what is she saying to them? 

Moral panic and Puritanism in the NHS?

Moral panic and Puritanism in the NHS?

There are times when it seems that there is something different about the aftermath of Mid Staffs. Other scandals have emphasized the variability of quality of care in the NHS and the failings of individual units, but there has been a heavy whiff of moral panic over the last year - politicians proclaiming a problem of "lack of compassion" in the NHS, campaigners shouting "murderer" at the then Secretary of State for Health, Andy Burnham, and a move to criminalise "wilful neglect".

Now Shaun Lintern, junior healthcare journalist for a nursing magazine, is questioning the RCN funding the appeal of two nurses who had been working at Mid Staffs who were struck off  by the NMC, in its capacity as a union. This seems a very Puritanical and vindictive line of argument, probably explained by Shaun's close link to the Cure the NHS campaign. All unions are there to represent their members, and presumably the appeal had some merit. The RCN is no more "supporting poor care" than criminal defence lawyers are supporting crime. By the logic of @MsNaughtycheese she would not want to be represented if she ever made a mistake, as that would be "supporting poor care".  No union has to "fight for people patently unsuitable for the job" - representation does not entail arguing for the absurd.

Puritans fail to accept human frailty, and they just have to hope they get the mercy they refuse others if they ever make a mistake. It is part of the essence of moral panic to focus on a small group, the "other", who are then "dealt with" to root out the problem. This witch hunt is not a helpful strategy to transform the NHS culture, and leaves a decidedly nasty taste in the mouth.

The 'Cheers Hunt'/Cure the NHS campaign have said they do not want simple human error to be punished, but they don't seem to respect the labour rights of nurses - and without union representation nurses will be punished for simple human error. Julie Bailey's book 'From Ward to Whitehall' is a quite awful torrent of abuse, and her attitude towards the nursing profession is questionable. Also, without unions nurses are vulnerable to being punished by their employers for whistleblowing. So the RCN and other unions need to continue to represent their members, and resist the attempts of campaigners associated with 'Cheers Hunt' to bully them into passivity. 

Safe Care continued

Safe Care continued

I believe that safe care is a continuum. If this is the case, then it follows that debating safe care without reference to resources is pointless. It seems logical that the greater the resources, the "safer" care can be. If the patient is not paying for his or her healthcare directly, then there are issues about resource allocation. I will use the example of thrombolysis (clot-busting) for myocardial infarction (heart attack) to make two points about safe care.

1) Safe care is predicated on a medico-legal standard of reasonable precautions which is based on imperfect knowledge and often risk aversion. 

When thrombolysis was first used, it was considered correct to obtain a chest X-Ray prior to administration to rule out an uncommon alternative diagnosis aortic dissection, which would be worsened by thrombolysis. Probably any physician omitting this step would have been successfully sued if this complication had arisen. The current guidance is to omit chest X-Ray, because a) it doesn't actually rule out aortic dissection and b) the benefits of swift thrombolysis outweigh the risks of harm

2) Safe care depends on who the bill-payer is.

A study some years ago showed that when a patient was having a myocardial infarction, if they were Medicare patients they wanted the latest thrombolytic drug which reduced the chances of suffering a stroke. If they were paying for their own treatment, they were far more likely to opt for the older treatment which was much cheaper, but had a small chance of causing a stroke. 

Safe care - what is it?

Safe care - what is it?

There are lots of people talking about safe care, as though there is a sharp dichotomy or that safe care was easy to define. Of course there are all sorts of ways of measuring various outcomes, and comparing the performance of different hospitals on these outcomes, and we can arbitrarily define the lowest performers as providing "unsafe care", but then that tacitly acknowledges that the standards expected change with time - what is an acceptable level of mortality from heart surgery in one era is very high in another. So clearly what is acceptable is relative to the circumstances. 

It is also clear that there will be some natural variation. Some surgeons are more skilled than others for example - but that does not mean that the lesser skilled surgeon is not a good surgeon. The more skilled surgeon who takes on more complex cases may end up with a higher mortality rate than the lesser skilled surgeon. If the patient cannot get his operation because surgeons are worried about their mortality figures, that puts the risk from the hospital to the patient. 

One way of assessing care is the rate of "never events". The concept of never events is related to reimbursement of hospitals in the US Medicare system. The idea was that hospitals shouldn't have a perverse disincentive against preventing certain adverse events that are eminently preventable by getting paid to treat them. A hospital that gets paid for the care of a pressure sore has not lost out due to their negligence, and in fact has gained. The designation of "never event" does not automatically mean that these events should never happen. It is possible to design a system that when implemented properly eliminates the possibility of surgical instrument retention, for example. The system can prevent human error by an individual missing such an error. 

Some of the other "never events" are not in this same category, for example "Intraoperative or immediately post-operative death in an ASA Class I patient". Certainly this should be incredibly rare, but there will be rare circumstances where an unexpected reaction results in death in a fit, healthy individual. Similarly "Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility". Again, this should be very rare, but factors outside the control of the healthcare providers could result in this "never event occurring" (NB: these are US examples). 

Safety of care is a continuum, and there should be constant efforts to improve the safety of healthcare. Complacency is never an option, but constant flagellation doesn't seem too great either.

Subtypes of the genre

Subtypes of the genre

You may have heard the portmanteau term “pracademic” to describe someone who is both an academic and an active practitioner in the field. There’s never enough portmanteau words, so here’s some more to describe various species of the academic world:

Actademic: an academic and an activist*

Brackademic - academic who indulges excessively in cake

Clickademic – a colleague who is on the internet all day, whether genuinely working or looking at cat videos on You Tube

Crackademic – psychopharmacologist e.g David Nutt

Eckademic - expert on Scottish independence and the SNP

Flakkademic – colleague who courts controversy and publicity, often a pain in the neck e.g. Richard Dawkins

Fracademic - controversial petrogeologist

Hackademic - expert on cybersecurity or horse riding academic

Knackademic - colleague guaranteed to send any project down the toilet, also any senior academic hankering for retirement

Lackademic - poor academic in either sense of the term, lacking either money or talent (or both)

Macademic - either computer scientist or academic fond of fast food (or both)

Mockademic – a colleague who has no real academic credibility

Ochademic - any Scottish academic (may also be known as a Jockademic)

Plaquademic – either a colleague with walls plastered with certificates and awards, or one with terrible dental hygiene & halitosis
Prickademic - the genuine practitioner/academic's poor relation - instead of being a practitioner, well...you can guess the rest.

Pukkademic - bona fide academic
Rockerdemic - a colleague who is an avid fan of metal and practises air guitar in his office. Politely provide with headphones if necessary.
Quacademic - a colleague who is a compulsive member of quangos, or an academic physician with rather unorthodox views. Or a colleague who looks like a duck. 

Sackademic – the Vice Chancellor (need I say more?)

Sickademic – colleague who is either genuinely poorly or a major lead-swinger
Shtickademic - depending on context, a colleague who is a genuine hoot or a complete bozo.

Slackademic – exceptionally lazy colleague (also term for someone who never wears a suit or skirt, no matter what the occasion)

Smackademic – child psychologist who studies the effect of corporal punishment e.g. Dr Spock
Snackademic - colleague who eats lunch (and possibly breakfast and dinner) in their office in an attempt to get more work done. Instantly recognizable by used plates on pile of papers.
Stackademic - colleague who resorts to time-honoured filing system of large piles of papers all over his office. Also colleague with stacks of funding and/or publication, immune to the powers of the Sackademic (above) and often pursued by the Suckademic (below).

Suckademic – colleague who is sycophantic, usually to the sackademic (see above) in an effort to keep their job

Tackademic - either an expert on adhesives, or a colleague who compulsively puts up notices around the place (aka Tin-tackademic)

Taffademic – a Welsh academic

Trackademic – sports scientist (also US – one obsessed with gaining tenure)

Whackademic - criminologist specializing in study of Mafia hits

Yakkademic - colleague inordinately fond of their own voice

Yukkademic - colleague with office full of houseplants, or with objectionable personal habits or taste in clothes*

*(Thanks to Martin O’Neill and Ayala Prager for their suggestions and encouragement)

Examples of Risk Externalisation in Medical Practice

Examples of Risk Externalisation in Medical Practice

The existence of "defensive medicine" is disputed by many lawyers. Many doctors perceive that the threat of being sued makes them so risk averse as to practise bad medicine. Lawyers argue that the legal system tackles only medical negligence, and so good medicine is the only means to prevent law suits. Regardless of whether or not the legal system should have this effect, most doctors are convinced that the threat of legal action affects medical practice in a negative way in some circumstances. 

Defensive medicine can be divided into positive and negative effects. Positive defensive medicine means doing more - more tests or treatments. Negative defensive medicine means doing less treatments - for example, a surgeon not performing an operation on a high-risk patient. In the NHS, the hospital is sued rather than the doctor so a successful law suit has no financial consequences typically for the clinician. However, there are other issues such as media attention, reputational damage, disciplinary or GMC proceedings. 

Positive defensive medicine can be part of a process of "risk externalisation" - the doctor by ordering more tests or treatments reduces his risks, but may increase the patient's risks. I came across an interesting and stark example of this.

A patient who has been diagnosed clinically with confidence as having typical migraine has a 1 in 4,000 chance of having an otherwise "silent" brain tumour. Thus a clinician might order a CT scan of the brain for all his migraine patients because if he missed one brain tumour it would end his medical career (his perception). 

Given the known risks from the radiation associated with CT scanning, is it the correct approach? That is the big question