First, do no harm. Primum non nocere

21 03 2009

Regular readers will know of my hesitancy in becoming significantly involved in medical management. Some of this is due, on my part, to a lack of education and understanding of the complexities of the role. Partly however this is also due to deeply held, negative views regarding the overall aims of management compared to those of a clinician. I struggle with the different mindsets required to fulfill the two roles as I find the goals are not complementary but may often be totally divergent.hippocrates2

Now, as any good Greek scholar will know, “Primum non nocere” (first do no harm) is NOT part of the Hippocratic Oath. Primarily of course, the phrase is in Latin and Hippocrates was Greek! Secondly, even rough translation of his original treatise does not reveal a section that could even be mistaken for this now clichéd phrase. There are various interesting thoughts as to the genesis of the myth but the most common is that  in Epidermics, Book 1, section XI, Hippocrates wrote,

“Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm.”

The concept is however true that a physician, by whichever oath or code they practice, regards the health and care of their patients as of paramount importance. The scope for debate within that statement is huge but in the sternest of interactions between clinicians and management the power of that phrase and its interpretation underpins the behaviour of clinicians.

The news yesterday of yet another hospital; Birmingham Children’s, being severely criticised for its lack of care for its patients leaves every clinician with a feeling of shame. No matter the management edict, the targets or the funding issues, clinicians will struggle, often against the odds, and yes, even against the management, to provide the best care they possibly can. My sadness is further increased that this is yet again happening in the face of a current Healthcare Commission Report of apparently excellent (measured) standards and the award of Foundation Trust Status for delivery of these standards.

What does all this mean? It shows the gross inaccuracy of  heuristics applied to patient care, it shows that management are repeatedly willing to sacrifice patient care on the twin pagan altars of targets and foundation status and all this depresses me. These situations are clearly a failure of management and whilst the reasons for this failure may be complex, unknown or even unknownable they are contrary to our basic premise; “first do no harm”.

Do I want to take on a management role and prevent this happening? Is it possible to prevent this in the face of management pursuing goals at such expense?

A world of difference.

17 03 2009

Two stories are currently dominating the news reports; Mid Staffordshire NHS Trust and Royal Bank of Scotland. Two stories of management pursuing goals deemed laudable, each receiving recognition within its own field of “success” only to have revealed the ultimate costs of those achievements.

Sir Fred Goodwin and the Board of the Royal Bank of Scotland are not the cause of the current financial “downturn”. There is no doubt that behaviour such as theirs contributed significantly to the failure of the Group and the subsequent, some would say required, major Government support of the Bank. Mr Goodwin received a knighthood, “for services to banking” and is currently involved in some discussion, shall we say, regarding the value of his pension/pay-off/ severance/reward from the company. Currently, the financial reward for his “services to banking” is to be paid probably tax free to a value that has as many digits as my mobile phone number. He has simply “retired”.

The management group of Mid Staffordshire NHS Trust strove through their actions in the three years leading up to 2008 to fulfill the Government standards regarding financial probity and clinical targets. The Trust was given the accolade of Foundation Status in recognition of its efforts in achieving those quality standards.  The “Annual Healthcare check” from the Healthcare Commision for 2007-8 can be found here. A snapshot of their performance is below.


Impressive eh?

Today, it is being widely reported that the Health Commision has found that the management pursuit and achievement of their stated goals was at the expense of clinical care. During this same three year period it is reported that there has been significant failures of management and clinical governance lead to unnecessary suffering and a significant number of deaths. How exactly this fits with the report issued last year is open to conjecture.

I’m sure we’re all pleased to hear that the senior managers of this Foundation Trust have “retired” too.

There’s so much I feel about this whole situation and its wider context that just breaks my heart.  Perhaps leaving it unsaid speaks louder than any words.


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