Tiredness and Overwork can be Lethal

MD’s first ever Eye Column (Eye 785 17/1/92) featuredjunior doctor Chris Johnstone ‘who won the right to sue Bloomsbury health authority for subjecting him to a particularly onerous obstetrics job.  Johnstone had taken his decision after falling asleep at the wheel: he used a portable EEG to measure his cerebral activity during a 48 hour shift and found that he was registering sleep waves while sewing women up after labour. Despite his high court victory, the job remained the same and the doctor who followed him spent time in intensive care after a paracetamol overdose.’

Like many junior doctors at the time, MD made catastrophic errors while overworked and sleep deprived, and drove his car off the road after an 81 hour shift. Several colleagues committed suicide during or after such long shifts, and it became clear that poor judgement, exhaustion and mood disturbance caused by sleep deprivation and work related stress was contributing to the deaths of doctors and their patients. 30 years ago, junior doctors were paid just a third of the standard rate for overtime, so it was much cheaper to make one work 120 hours a week than to hire three to work 40.

But the problem wasn’t just political resistance to funding and staffing the NHS safely. Many senior doctors embraced the macho culture of workaholism, and often the alcoholism and drug addiction that went with trying to keep your eyes open for 81 hours. Some would boast of being on call 24 hours a day, 7 days a week when they were juniors, in a secretive culture where cock-ups were buried. In the 1992 election, MD stood against Health Secretary William Waldegrave with the strapline ‘If junior doctors were prisoners of war, then under the Geneva Convention the sleep deprivation they suffer would be considered torture’.

There is now clear evidence for the danger of sleep deprivation for everyone. The less you sleep, the quicker you die from any combination of depression, anxiety, dementia, stroke, heart disease, obesity, cancer, diabetes, suicide and accidents, especially falling asleep at the wheel. Doctor specific research found that they are far more prone to diagnostic, treatment and surgical errors when they are sleep deprived and fatigued, particularly when having to make complex decisions under pressure. They are also more prone to needlestick and scalpel injuries, and crashing on the drive home. This helped convince the government to legally cap the hours doctors can work. They are not supposed to do more than a maximum 72 hours in any 7 days, with a maximum shift of 13 hours with rest breaks every 4 hours. They can still be on call for 24 hours, or 48 at weekends if it is somehow deemed to be ‘safe.’

The problem is that doctor numbers have not increased to compensate for the reduced hours and increased demand of very sick patients with multiple illnesses and the myriad high tech treatments that could help or harm them. And there are no legally mandated safe staffing levels to protect junior doctors (and nurses) from abuse. So they work very intensively and often longer than they are supposed to because their rotas are often not fully staffed and they are covering several jobs. The fatigue from this level of overwork is likely to be very dangerous, particularly when combined with alternating shift patterns that disrupt regular sleep routines and diminish recovery. Even worse, they are hung out to dry if they make an honest and inevitable error in such dangerous circumstances.

When Dr Hadiza Bawa-Garba returned to Leicester Royal Infirmary in 2011 from 13 months maternity leave she may already have been sleep deprived. She certainly needed induction training. Yet she was put straight on call for paediatric emergencies with no induction and an absent consultant and registrar. She had to cover 6 hospital wards across 4 floors, responsible for dozens of critically ill children during a 13 hour shift with no time for breaks. The IT system crashed.  An emergency prevented her from attending the vital morning handover. Amid largely great care she made serious errors in one case (Eye ). The Crown Court deemed this to be gross negligence manslaughter. The GMC then compounded this injustice by striking her off. Over £300,000 was donated to her appeal to overturn the GMC decision. The Appeal Court  verdict is awaited from the lord chief justice, Ian Burnett; master of the rolls, Terence Etherton; and the lady justice of appeal Anne Rafferty. Doctors are stuck between a rock and a hard place, legally and professionally obliged to admit errors but punished by the court and GMC if they do. And neither take into account the proven dangers of overwork, lack of rest and sleep deprivation. To destroy the career of a brilliant paediatrician with a previously unblemished career for honest mistakes in such an unsafe setting is simply unforgivable.

Oh GOSH

In this new era of candour and transparency in the NHS, how hard is it for the media to expose poor practice? Very, if you’re taking on a national treasure. On April 18, 2018 tucked away at 10.40 pm, ITV Exposure screened ‘Great Ormond Street: the Child First and Always?’, a documentary collaboration with the Bureau for Investigative Journalism.  It revealed that consultants in GOSH’s Department of Gastroenterology had been misdiagnosing and overtreating young patients with Eosinophilic Gastrointestinal Disease (EGID). Children had been prescribed powerful immunosuppressant drugs and/or put on highly restrictive diets too quickly and left on them for too long. This was well known within ‘gastro circles’ for years and was documented in a Royal College of Paediatrics and Child Health (RCPCH) review in 2015. So why did it take nearly three years to surface?

When hospitals realise they have a problem, they can invite a Royal College in for ‘independent expert opinion’ safe in the knowledge that the Trust senior management ‘owns’ the report and can ether refuse to disclose it or heavily redact it. Reputation management still trumps transparency in the NHS. When the RCPCH returned to GOSH in 2017 to check for improvements, it found it hadn’t even shared its 2015 report with key members of staff, never  mind parents or the public. However,  journalists working on the story managed to get a copy and when they started challenging GOSH, it spent £130,000 of public money on an aggressive defence from Schillings to try to muzzle the exposure. This resulted in interminable delays to the documentary and when it finally aired it contained compelling evidence from consultant whistle-blowers, patients and parents of the harm done but no interview from GOSH, no mention of the legal threats, no-one called to account by name and no mention of what the commissioners and regulators knew and when.

GOSH rightly shared the urgent concerns letter and critical report from the RCPCH with the Care Quality Commission (CQC), which had recently inspected GOSH yet staff had not apparently raised these concerns with inspectors, which makes a mockery of the inspection process. The CQC was fully aware that, according to independent experts, the gastro service‘was not being delivered to the standard we expected’ which ‘results in children undergoing invasive procedures and treatments which could unnecessarily compromise their physical or psychological well-being.’ In addition, staff were fearful of the consequences of putting a name to their concerns. When the CQC report appeared, it mentioned that the RCPCH review had taken place and that the GOSH had acted on it, but made no mention of the serious concerns. Unbelievably, it rated medical services (which includes gastroenterology) as ‘outstanding’ and praised the trust for its ‘open and transparent culture’.

The CQC’s inept report raised reputational eyebrows at NHS England which commissions specialist services from GOSH and had seen the RCPCH report. Dr Andy Mitchell, medical director for London at NHS England, wrote: “I believe there is a significant reputational issue here, not only for GOSH but for the CQC,” he said. “Seems to me this could attract a lot of attention, much more than the Leicester/epilepsy saga.” (a reference to the overdiagnosis and overtreatment of children with epilepsy– Eyes passim). GOSH also commissioned two reports into long-standing concerns about safeguarding across the Trust, an aspect of care which the CQC had somehow praised. One review found a tick-box culture in which safeguarding had been delegated to a committee by the hospital board and there was little evidence of learning from mistakes. “There was universal agreement that the level of record keeping, body maps and safeguarding medicals is far below the standard required. This has serious medico-legal implications. Some children with bruises and fractures were sent home in breach of procedures, and “a number of children presented with ritual burns and the response varied”. A child with a non-accidental injury after an alleged assault was “not examined adequately” and referred back to the local service.  A further review confirmed these findings.

GOSH, like many other trusts, is sinking under the weight of demand but it should have sorted out the problems in its gastro department long ago. Instead, it closed the department to most new referrals, a damage limitation exercise that has caused chaos in surrounding hospitals, and it fiercely defends its reputation.  If hardened hacks struggle to hold it to account, what chance anxious parents? Meanwhile in 2018, the CQC finally noted GOSH’s‘defensive approach when challenged on performance and safety’, and rated the leadership as ‘Requires Improvement’. So does the CQC.

Happy Birthday NHS?

 The NHS was 70 on July 5, with just five years to wait before all the introspection, celebration and politicisation is repeated for what remains of it at 75. The UK will forever be remembered as the first country to introduce universal healthcare and the last to fund it adequately. The NHS is constantly playing funding catch-up with Europe but nothing can reverse the damage done by decades of parsimony. If we had committed the same percentage of our GDP as Germany to health since 2000, we would have put £260 billion more into the NHS. Germany too sometimes struggles with demand, but not in crumbling estates using outdated equipment and technology, with queues extending down the corridors, patchy access to GPs and millions on the waiting list for hospital treatment. This isn’t about how we pay for healthcare, simply that we don’t pay enough.

Jeremy Hunt hopes that an NHS App will revolutionise the service and end the ‘8am phone scramble for GP appointments’ but it won’t end the desperate shortage of GPs, and the tech-savvy patients will simply jump the queue. In its 70 years, the average annual funding increase over that time has been 3.7%, to absorb the costs of inflation, new treatments and the demands of patients living longer with diseases that previously killed them. After eight years at 1% funding growth, the strictest politically-enforced rationing program in its history, the Office for Budget Responsibility concluded the NHS would need 4.3% growth a year to stay on the road. The Government has pledged 3.4% for the NHS England budget only over the next 5 years, omitting increases for health education, training, public health and organisations such as NICE. This works out at 3% of the overall budget, which isn’t enough to halt the decline of universal care. Theresa May and chancellor Phillip Hammond insisted the money be ‘wisely spent’ and the Pavlovian poodles at NHS England promptly announced 17 ineffective treatments it would scrap to save money. It’s important to embed evidence in the NHS, but blanket bans are rarely sensible and tonsillectomy and varicose vein operations will greatly benefit some patients. Any money saved is dwarfed by the money wasted on continuous political ‘redisorgnisation’ and the fees for lawyers, accountants and management consultants that goes with it, never mind the pharmaceutical industry rip offs. The NHS needs evidence-based reform above all.

Labour is keen to claim all credit for the NHS but its origins go back to the Public Health Act of 1848, which realised the importance of clean air, clean water, nutritious food and humane living and working conditions to health. This realisation was not entirely altruistic, and in part triggered by a shortage of workers and soldiers. On discovering 30% of working class recruits were malnourished and unfit for military service in the Boer War,  a school health service, school meals and school milk were established in 1906.  After the first world war, Lloyd George promised ‘Health for the Heroes’, set up a ministry for health and introduced health insurance but for workers only. Churchill’s war-time coalition agreed the need for a National Health Service, and universal care was an essential cornerstone of William Beveridge’s visionary welfare reforms in 1942. True, the NHS would not have happened ‘overnight’ without the passion and commitment of Labour health and housing minister Nye Bevan, who had to overcome repeated objections from both the BMA and Conservative MPs.  Prior to the launch, Labour Prime Minister Clement Attlee gave a placatory speech thanking all parties for their role in establishing the NHS. This incensed Bevan, who was determined to brand the NHS as a Labour creation. He had also witnessed the harm to his family and community caused by prolonged Tory austerity. So instead of celebrating the eve of the NHS on July 4, 1948, he delivered his infamous ‘Conservatives are lower than vermin’ speech in Manchester, which attracted even more excrement through his letterbox and allowed Churchill to declare he was mentally unwell and should check himself into one of his new NHS asylums.

Some Conservatives joined ‘Vermin Clubs’, including a young Margaret Thatcher, who thirty years later tried to strangle Bevan’s baby and switch to a private insurance system. Her ministers dissuaded her, but instead she started off the internal market that has slowly suffocated the service over 40 years. Thatcher believed that the NHS is for poor people and emergencies, and anyone who can afford to go private should do so.Yet despite the underfunding and over-meddling, the NHS fares well on international comparisons for cost-effectiveness and fairness but lags behind on outcomes. This is largely because the UK has poor public health and alarming inequalities that determine disease incidence and premature death far more than NHS funding levels. The NHS is mainly a National Illness Service, designed to repair and rehabilitate but not to prevent. We dive deeper and deeper into the river of illness, treating the untreatable, without wandering upstream to stop people falling in. Unless more funding goes to into preventing illness, the NHS will not improve. The government is merely turning the funding taps on a little more without putting the plug in. Happy Birthday.

The Gosport Scandal – another cover-up, another failure of consultant-led care 

At Gosport hospital from 1989-2000, Dr Jane Barton was deviating so widely from the accepted clinical guidelines for prescribing opiate drugs via syringe drivers, that it could be spotted from space. The situation may not have been helped by the use of easily confused syringe drivers, one of which discharged its contents over an hour, the other over 24 hours. Many countries replaced such drivers long before the NHS, which still operates on the CATNAP principle (Cheapest Available Technology Narrowly Avoiding Prosecution). The Gosport inquiry found that hundreds of patients admitted for respite care and rehabilitation, who should never have come anywhere near a diamorphine driver, died shortly after this ‘treatment’ was commenced (often combined with the sedative midazolam). Some of the nurses charged with starting the drivers tried to speak up and were silenced, others accepted that was just how things were done in Gosport. As at Bristol, the institutional blindness to poor practice was known by many people over many years at many levels of the NHS, from the consultants who supervised Dr Barton and reviewed her drug charts, to the managers who failed to act on the concerns of the whistle-blowers and eventually the coroner, police and a full-house of incompetent regulators.

The NHS had plenty other dirty secrets at that time, largely attributable to the stress of trying to provide universal care with insufficient resources. When MD qualified in 1987, junior surgeons would do major operations for the first time unsupervised, with their consultant not even in the hospital. Patients would have no idea about the competence and experience of their surgeon. Doctors of all grades and specialties would work ridiculous hours and make catastrophic errors under pressure, but notes would be lost or altered and they were rarely exposed. Patients were often not told their diagnosis for fear it might upset them, and were usually designated ‘not for resuscitation’ (NFR) by the medical team without any prior discussion with patients or relatives. Staff who questioned such resuscitation policies, such as nursing student Kenneth MacDonald at two Aintree hospitals in 1992 (Eyes passim), found themselves removed or suspended from working on the wards in question.

In such a ‘hard to challenge’ culture, it’s easy to see how Dr Barton’s prescribing prevailed, and nurses could mistakenly believe that patients who weren’t terminally ill but died shortly after commencement of a diamorphine infusion must have been close to death anyway. As the late Dr William Pickering asked ‘Who picks up doctors mistakes?’ (Eyes passim) MD has long agreed with Pickering that the NHS needs a truly independent medical inspectorate – free from loyalty to any NHS institution, professional or political brotherhood – that is properly resourced and  staffed by experienced doctors and nurses who are mandated to swiftly investigate all serious staff, patient and relative concerns, as well as any ‘red flag’ mortality data and unexpected deaths. By having full and swift access to all medical records, inspectors could spot the rudimentary diagnostic and treatment errors that constitute the great bulk of NHS harm, and publish their reports contemporaneously and in full so they can be acted on and learned from,  rather than wait for an inquiry to report 30 years after concerns were raised. This would require significant funding, to be repaid by better outcomes. The Government’s current solution is a lame Healthcare Safety Investigation Branch which only investigates ‘up to’ 30 incidents a year and will keep some of its evidence secret in a ‘safe space’, which hardly inspires confidence.

Opioid drugs such as morphine and diamorphine have revolutionised end of life care, relieving pain and distress, and, when used appropriately, often prolonging a good quality of life rather than shortening it. Individuals can have very variable responses to such drugs, with some requiring much higher doses than others for control of symptoms. Patients need to be carefully monitored and have their spiritual, social and emotional needs tended too as well to give them relief from what Dame Cicely Saunders, founder of the hospice movement, called ‘total pain.’ Towards the end of life,  doses of opioids often need to be increased to relieve pain, but if this shortens life, it is not illegal if the prime motive was to relive suffering (the so-called double effect). A very over-worked Dr Barton was prescribing this palliative care treatment for patients who weren’t terminally ill, often without any discussion or consent from patients or relatives. She may have been doing it ‘just in case’ they developed pain or distress when she wasn’t there, but there were many more appropriate and less risky drugs that should have been used.  It was left to the nurses to decide on the precise dose. ‘Just in case’ became the institutional norm, unthinkingly accepted and often fatal. The fear is that the Gosport scandal may discourage the proper use of opioids in palliative care and any meaningful debate on assisted dying. As with all of medicine, consent, explanation and understanding are key.