For anyone bereft since Breaking Bad came to an end, this is a second installment in The Persecution of Heretics Murder Mystery series. Episode one can be seen here.
The harassment of healthcare staff has been a backburner in British news recently. There have been a series of pieces in the Daily Mail, usually to the forefront of everything in healthcare, and the BMJ. A House of Commons committee was convened to explore the issue and produced a report – here.
But what does harassment in healthcare look like?
Slightly over a year ago, some of us here in North Wales saw gob-smacking (Irish for jaw-dropping) harassment at close quarters – bullying of a kind that none of us had never imagined seeing in our careers. After the event, disguising the identities of those involved, and adding some references, I wrote up a piece for a distinguished academic journal figuring that this was something that needed to be put on the map. The journal wouldn’t engage.
Here’s what was sent to them.
Just as a job contract protects an employee, so also a mechanism for the Protection of Vulnerable Adults (POVA) sounds like good thing. Interventions to achieve just this within healthcare began to take a statutory albeit vague shape in the late 1990s with the Protection of Children Act (1999), the Standards of Care Act in 2000 and the Safeguarding Vulnerable Adults Act in 2006.
But just as Zero Hours Contracts now sound more like a modern form of slavery than a good thing, so POVA reveals itself to have the potential to become an instrument of employment terror rather than something to protect the vulnerable.
Anyone working in healthcare comes across adults who by virtue of physical or mental infirmities and social situation are vulnerable – a woman who might be mentally handicapped being possibly beaten and locked away in an annex, for instance. A POVA team comprised of up to 10 professionals from varied backgrounds may be assembled to make the call as to what to do. This is not a recipe for agreement and effective intervention. And when something is done and the woman pleads to be let back to her “home”, what then?
This is what POVA was. Here is what it could morph into.
In an average sized mental health unit, there could be a significant incident a day where someone claims to have been abused or bullied by a member of staff. There are no criteria to distinguish between real or imagined abuses. There are no criteria to distinguish between properly vulnerable patients and psychopaths, or even management plants.
Alerted to a possible abuse of a patient that might involve a member of staff, managers of a service have a duty to act quickly – long before a team is assembled.
What do you do as a manager of the service in which a complaint arises? You have to ignore almost all complaints or life would be unmanageable. And you know your friends are not capable of abuse. But you have an option to claim you have to do something in the case of any incident that offers you an opportunity to achieve a strategic goal.
You could remove from duty the person who has been the object of the vulnerable person’s complaint, or a charge nurse for the ward that day, or the matron in general charge of the ward or the manager in charge of the unit in which the ward is, or any of the tiers of managers responsible for running the service of which this is one unit, all as part of a “securing the scene of the crime” operation.
In practice you pick the person who has been most awkward. The person who may be frustrating your plans because they have voiced concerns about patient safety after drastic reductions in staff-patient ratios or procedures that are increasing risk by putting continuity of data ahead of continuity of care.
As a manager you pretty well have to march someone out of their job on the spot with no questions to answer. You invoke POVA and Hey Presto their Union will do nothing except advise the person to do nothing while any investigation runs its course. POVA is complex. No one understands any more about it than the 99% of the readers of this article who will never have heard the term before.
You replace the removed person with one of your people – on a temporary basis of course. It’s likely you are operating in an organization that has a large number of people in acting positions, filled on the basis of expressions of interest rather than open advertisement. These will all move as told but may not be able to revert to their original positions as readily should the unlikely time ever come when this is required.
It’s all too easy for abuse like this to happen within a mental health setting and this may be why it seems to have developed there. But there is no reason for such a convenient management tool to remain there. If vulnerability has no operational definition then all patients are vulnerable.
An increasing proportion of the population has some condition like ADHD or autistic spectrum disorder or is on some medication that puts them at risk in some way and they too can be regarded as vulnerable if need be.
They may be “traumatized” by an interview with a journalist or by the subsequent representation of their story. As a senior manager you don’t have to send the journalist on gardening leave – you can send their immediate superior who is responsible for them.
If this sounds as unbelievable as Zero Hours Contracts once sounded, it is time to start adjusting.
This disguised account was based on real life events in the Hergest Unit where Anne Ward and Shyam Kishto, the managers in charge of Aneurin and Cynan wards were summarily dismissed on the First of July last year within minutes of each other. Supposedly two unrelated POVA events had happened on the wards that they were responsible for, and they could not be let darken the door of the Unit until these were investigated.
For anyone who has seen the old movie J’Accuse – it was just like the moment where Dreyfus was stripped of his medals, his epaulettes and the top of his hat was punched through.
Everyone knew for months this was coming. Anne and Shyam had been outspoken on issues of patient safety. It was only a matter of how management were going to do it. No one guessed POVA.
In response to what happened thirty five nursing staff blew whistles in support of Dreyfus One and Dreyfus Two. The Health Board didn’t listen. Their medical and nursing colleagues took the issue to Welsh Government and contacted David Sissling, then the CEO of NHS Wales (now left), who intervened and had them reinstated some months later.
It turned out that there were no incidents and there was no investigation. Ward and Kishto lodged a Grievance complaint which they won in full. All the papers from this are available.
The only outcome from the Grievance appears to have been that the manager with the greatest visibility in the process – and perhaps the most dispensable – was asked to apologize. He did so. The suspicion is that managers these days have training in how to respond to statements like “Your behavior is ******* appalling” with pat words like “thank- you for this constructive feedback”. Apologies are meaningless.
For the last year Ward and Kishto have had to work at close quarters with management staff that have done this to them. This might be endurable if management behavior had changed – but there is no sign of this – just the opposite in fact.
The Hergest Unit is one of three District General Hospital mental health inpatient units managed by the Mental Health CPG (Clinical Programme Group) within Betsi Cadwaladr University Health Board (BCUHB). The mental health CPG is run by Drs Giles Harborne, Marie Savage, Alberto Salmoiraghi, and senior nursing staff including Simon Pyke and Adrian Jones. This management team are answerable to the board of Betsi.
The Grievance taken out by Ward and Kishto found comprehensively against management within the CPG. But the Betsi Board have done nothing. CPG management continue to do ever more egregious things; getting me referred to the GMC is the latest.
For those of you who like your murder mysteries red in tooth and claw, the Ward-Kishto incident gives a feel for how “thuggish” local management can get. There might not seem to be any reason to look beyond local management and a revenge motivation to explain the abuses that have been happening since, particularly, as it would seem, local management can do pretty well anything without sanction from above. But:
So what is going on? Watch this space.
“If they stop telling lies about me, I will stop telling the truth about them”. David Lange
“Cricket is the English idea of fair play – eleven against one”. Beachcomber
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This is a very scary story – And I would like to act to help.
Thank you for alerting others – And thank you for expressing openly in a situation where there are clearly powerful forces ranged around that can hurt you.
I look for personal integrity in this and the ability of humans to act for the good of all and not just in their own self-interest. We all have to live with our own consciences and the impact of what we do.
If there is anything that I can do then please can someone let me know.
Some of this sounds like the start of a classic downsizing-and-privatizing campaign. I’ll use the Chicago public schools as an example, and see if it fits:
You start with significant cutbacks that get a little harsher every year, till everyone agrees there’s a Crisis in our Schools, and the middle class are scurrying for private options. Then you sound a big alarm about said Crisis, making sure to demonize Bad Teachers for the mess. It’s all about the Children, of course; well-heeled nonprofits spring up called Children This and Children That, to demand “Reform.”
Their first target is the evil teachers union, which exists only to protect Bad Teachers. Our schools need Accountability, they say, and being business leaders, we know that means Metrics. Stuff we can count. The kids are soon drowning in standardized tests, which make real learning even harder but generate lots of numbers that confirm their schools are “under-performing.”
Next comes a grand program for the “transformation” of the most Under-performing Schools. This turns out to mean firing the entire staff, who can then re-apply for their jobs, letting you weed out the Bad Teachers. Who turn out to be the squeaky wheels, the whistle-blowers, and some of the teachers most loved & respected by students. The Crisis gets worse; now most of the working-class parents are running for the exits if they can.
You contract out a few dozen schools to for-profit operators, give them extra funding (taken from the regular schools), let them hire their own (non-union) teachers and boot out the inconvenient kids. You hold them up as the solution to the growing Crisis. Soon a lot of the regular schools are below capacity and can be “consolidated” (closed) while you give out another batch of those private contracts …
difference in health care, I guess, is that the drug and device companies aspire to run the show even in the public health systems (until they can get them priva-tized, anyway). They know which Bad Nurses and Bad Doctors they’d like to be rid of too! Probably the same group management is after. Bless every Bad, Bad one of you, and I hope you’ll call on the growing number of Problem Patients to back you up.
I am deeply sorry Dr Healy that you have been the subject of Scapegoating and a report has been sent to the GMC against you — we had the same here in Ireland some years ago against Dr Michael Corry – another psychiatrist speaking out about the wrongs to the patient of Irish psychiatry and dangerous drugs – he too was reported to the Irish Medical Council. It amazes me that in so many great works of Science – there is no mention of the Science of TRUTH in their works.
Is this because of Corporate/Pharma submission and Corporate/Pharma control?
Did Einstein have Corporate Puppeteers dangling his strings?
Why are many Scientists and Doctors today not free thinkers and free do’ers?
With so much education – Scientists and Doctors today are not “allowed” to be free thinkers – free professionals to put the patient’s safety first – Why?
The reality is that Governments have become weed mongers…weeding out the doctors who puts Patient Safety first…weeding out the Advocates of the patient..
William Osler’s best known saying is “Listen to the Patient, he/she is telling you the diagnosis” – but how many doctors are “allowed” to listen to the Patient?
Free will is compromised. Pharma’s will is powerful.
Thank you for this update. It is truly frightening how the governance of a large publicly accountable organisation can go so wildly wrong.
I spent 20 years working for that trust and the various names it’s been known by before. Glad I left it last year after reading all this. I worked under Simon Pyke and Adrian jones. Worked in same hospitals as Giles for 15 of those years.
Some of those involved in management are more suited to roles in the muppet show than running a trust.
Not surprising it’s gone to pot. Good luck clearing your name.
Thank you, Dr. Healy for this timely post.
I needed something more substantial than my own– pretty well articulated, forensic summary- to inform the nursing union representative who will be at my side when my employment status is addressed.
It never ceases to confound me how corrupt the noble profession of **caring for vulnerable human beings ** has become.
At the start of my nursing career, I was valued and promoted for displaying exemplary regard for the well being and humanity of my patients and their families and I was equally motivated by the appreciation from my patients to apply myself to continual study and professional development.
Now– when I should be mentoring new graduates and providing leadership for the model of care that is advertised as *cutting edge* by the for-profit, corporate owned hospital where I am employed, I have a target painted on my back by *management* , who is rewarded for cutting the budget by hiring inexperienced nurses!
I think we should spare no effort in executing our duty to protect the public, the masses, the vulnerable among us, AKA : the *market* for the wealthiest business on the planet.
Gosh, it must be tough being surrounded by so many people in the wrong. It must be draining fighting the good fight single handedly as you do. Incidentally you haven’t said whether the GMC did anything. Have you ever considered referring people to the GMC yourself? If you have, what happened?
Will answer questions when its clear who you are and where you’re coming from – the comment seems snide and bears no relation to the post
I came upon your blog after following up on the Hay festival. I meant no offence by my comments. I thought your remarks on the GMC would benefit from clarification, and hence asked my questions. No need to reply
For me, it has been tough negotiating the transition from my professional role in a mental health care setting to a service provider for a profit seeking business– that maintains the same title and the same slogans that once had relevance to caring for patients– but now are little more than sleazy marketing tools.
My transition period has had bench marks, spanning about 20 years, that my peer group/colleagues and I only see clearly now, on reflection. We aren’t embarrassed to admit that the dramatic increases in salary kept us from delving too deeply into the mind set of a different sort of management team. Our good work, smiling faces and thoughtful caring were being rewarded. Our standard of living reflected the value of the work we were doing. Right? Makes sense.
I cannot tell you the exact year when most all of my outside of work discussions w/ co-workers centered on some new policy or protocol that seemed counter intuitive to the best approach for treating patients. But I clearly remember 2005 as the beginning of the end of academic debates amongst the members of the multidisciplinary treatment team. No more literature searches and journal article presentations shared at weekly staff luncheons. No in-service education initiated by senior nurses who were setting an example of on-going professional development. Actually, the resource room, once overcrowded with books, journals, and filing cabinets stuffed with current info related to all relevant topics in mental health diagnosis and treatment– was transformed into a tastefully furnished conference room. In this setting, it was clear that we had undergone some almost overnight revision of our roles. Authority replaced collaboration. This was a new top – down model for dissemination of treatment plans.*Collaboration* itself vanished, but the word remained. We read it on our framed mission statement. We shared it with out ‘clients’ via the patient info handbooks. Someone in management moving amongst us, like a magician, using smoke and mirrors, slight of hand. No one we actually knew– anymore, as the faces changed with shorter intervals between the introduction luncheons and the farewell parties.
The dynamic described in this post by Dr. Healy began in concert with the questioning and the push back from — the most knowledgeable , most experienced nurses.
Here’s the thing, Sam– the *tough part* .There really is such a thing as a ‘medical model’, and it is based on a process of ongoing observation, assessment and evaluation of response to care, that includes the subjective statements of the patient. If you had practiced this model for, say– 10 years, and suddenly it was replaced with prompts on a computer screen(choose one, or fill in the blank) and check lists that even unlicensed staff could complete, would you think something might be wrong? If your role changed from respected professional to pill pushing minion — would you suspect anything? Maybe not. Maybe you would appreciate less demand on your cerebral energies– and check your personal email and facebook or book vacations with all your *new* free time- at work.
BUT, since the medical model for assessment and treatment is grounded in the science that is required learning for health care professionals, sooner or later there will be events or issues that you cannot help but attribute to the new policies and protocols that replaced solid nursing/medical practice. If you do, you are likely to believe that your realization will be appreciated as “ensuring patient safety and well being”. If you keep your mouth shut when your important contribution is ignored, nothing much will happen, BUT if you go up the chain of command with your ‘safety breach’ issue, or solicit your colleagues into taking up the cause with you, that it when — you will enter the twilight zone— the zone where suddenly nothing makes sense, especially the call you get for a meeting with your supervisor. In that meeting you are likely to be told that a complaint has been received about you– either from a patient a co-worker– or family member of a patient. The complaint will be read to you as though it were fact and your perspective isn’t anymore important than your voice in treatment team has been for quite awhile. You could get anything from a verbal warning to suspension pending investigation.
Is it tough to be surrounded by so many people who are wrong? No. It is tough to be in what still looks like a mental health care facility, but is otherwise– other worldly and full of not so good surprises.
Business is business, and business must grow—
regardless of who’s gonna suffer—, you know.?
Ultimately, I think it is the service users — formerly known as *patients*who are likely to suffer the most.
I guarantee that Dr. Healy is not fighting the good fight single handedly.
Without prejudice. Dr Healy your comments have been duly noted and admiration for the senior managers running the two wards is noble. Despite this bad publicity perhaps it might be worth mentioning how one of the units associated with the two units in question who work hand in hand was recently awarded with the AIMS accreditation. Furthermore they received an award for the implementation of safewards, a intervention that has moved from the ark ages into the new age. A patient centred psychotherapy which has seen less restrictive physical intervention. The heart of Hergest is the nursing care given to patients which clearly is not noted here but more the ramblings of past issues and POVA’s. Whilst we remain to dwell on past issues we have no hope of moving upwards and onwards.
I don’t know who “Anonymous” is, but according to the NHS website it’s the Taliesin ward at Hergest that’s been acclaimed as an early adopter of “Safewards.” It’s a lovely-sounding program that aims to reduce the use of restraint and seclusion, by using Soft Language, positive expectations, etc.
All good ideas and worthy goals. My question is, has Taliesin simply adopted a fine new set of buzzwords, or has it actually reduced the use of seclusion?
One aspect of the Safewards system I did find rather pathetic. To help patients feel like they know the ward staff, they are urged to post little sheets on the bulletin board giving “safe” personal details about themselves. Dr. Jones is the mother of two lovely boys; she loves hiking with her dog Pepper and studying local history – that sort of thing.
As a former patient I can tell you that a person in crisis, admitted to a locked or “intensive” ward, needs above all to feel that someone who knows her is on the team. Someone who has seen her in happier, more functional times, knows what she has lived through and accomplished, and can communicate this to the staff who may see only an incoherent or “disruptive” patient. In other words, her own doctor or therapist.
I hope Safewards will incorporate this idea and put an end to the current fashion of having a “hospitalist” or “ward specialist” take charge of the patient instead. The idea has its downsides even for physically ill patients. For someone in a psych ward it’s frightening and demoralizing – and a cute little bio of the new doctor will not help. Nor will Soft Language, if it’s used simply to dress up the same old harsh reality.
Yes, I have seen the change to, what was called, the “functional” model in mental health wards in which the continuity of care is broken on entering the ward and the psychiatrist responsible for patients in the community is replaced by a specialist on the ward – This was explained to me as being more efficient and allowing better allocation of resources as and when needed on the ward – Yet it was clear that when the change happened there was less psychiatrist time devoted to patients (presumably the whole idea really) at a time when they most needed someone who knew them (which would also be more efficient and effective). The most effective route was to have some specialist on ward psychiatrist and, where it existed, to maintain contact with the psychiatrist from the community who knows the person concerned.
You say: “…The heart of Hergest is the nursing care given to patients which clearly is not noted here …”
To that I would add, that the heart of nursing care requires a nurse with a mind free of worry about being removed from duty on the whim of management– of bearing the shame and the loss of wages for an incident that may not even be thoroughly explained to him/her.
There is no clear way upwards and onwards until this twisted management tool, this sledge hammer is no longer a threat to anyone whose *heart* is in caring for patients.
Yes, a happy team of people about to give their service for the best motives is absolutely the best way – particularly in mental health. As someone who has seen both business practice and the NHS mental health services it is clear that to treat the staff as if they are some kind of selfish and very limited human beings means that so much less of their ability to care and give is released – It is truly astonishing how a real understanding of how to motivate staff to give of their best has been lost along the way – It seems that true giving care can’t really be measured and therefore is not valued by many of todays modern management practices.
I think that when we illuminate the objectives of management on inpatient psychiatric units, zero in on their motivation for deciding to discount “safe care for the patient” as the objective for ALL practices on these units, we might *astonish* the regulatory and licensing boards who have given free reign to management – or not?
I am astonished at the element of collusion by the well educated and highly esteemed professionals in whom the public has placed trust and authority over the care of vulnerable human beings. Those people we expect to be the most concerned with scientific evidence and the voices of the people they employ, AND the people they serve, are making concerted efforts to deny the truth, deny the harm caused by the treatment paradigm that coincidentally has made most of these individuals quite a bit wealthier than they imagined possible in the field of health care 30 years ago. Collusion on this scale, has to be viewed in terms of what has been denied; of what has no significance– and measured against the purpose and premise of the roles of the collaborators.
Giving care can be measured in the happiness of those receiving and giving the care. The happiness derived from robbing care givers and patients of the dignity of their lives is measured in dollars — and unfortunately, too many care givers are happy with the job security that goes hand in hand with remaining silent and ignorant.
The disconnect between what one claims to be doing and the evidence of the harm one’s actions is causing may be the leading cause of *psychosis* — formerly known as *cognitive dissonance*.
The same is still happening on every level , try spending some years on the bank and you will see modern day slavery close up , and lets not forget Ive had no paid holidays in all that time