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Patient Abuse - A Bad Case of Management Blowback?

Posted by Dr No on 16 October 2011

abuse.jpgIs there more patient abuse in the NHS today than there was, say, thirty years ago, or are we just better at exposing it? Dr No does not know for certain. He chose a thirty year comparator because it was about that time ago that he was a medical student, and then a junior doctor, and so frequently exposed to different wards and hospitals. His recollections from that time are more of starched white sheets, and of course the starched but very beguiling nurses who smoothed them out, than of beds doubling up as commodes. He does recall once seeing a cockroach on the polished wooden floor of a ward, but it was a one-off sighting of a very lonely cockroach. Today, it seems, the cockroaches have grown in both size and number, many now standing on two legs as they mishandle and maltreat the patients on their ward. Has it come to pass that the once occasional failing has now become normal practice?

Searching in the BMJ, on the grounds that its news coverage would pick up on reports of patient abuse, Dr No found surprisingly little. Top of the hit list was a 1905 report on abuse, not of, but by patients, of the out-patient (then acting much as A&E does now) department - nothing new under the sun there, then. The second hit was a 2003 report not of doctors abusing patients, but patients abusing doctors. Thus far, the trend seemed to be more of the boot being on the other side’s foot. Third up, however, was a report, from November 2000, of an NHS Trust that had ‘condoned abuse of elderly patients’. The boot was back on the medical foot.

But the next seven hits all came from the late 1800s – that’s right, 1800s, all over a century ago – and again were about patients abusing the system. Overall, reports on patient as victims of abuse were rare. One from 1990 covered abuse by carers, but outside hospital, and so not in or by the NHS. A 2005 report, ‘Blind eye to complaints allowed psychiatrists to abuse patients’, did cover the Haslam and Kerr scandal, but, generally speaking, on the basis of contemporary BMJ reports, there wasn’t a lot of it about. What was about, rather strikingly, was a lot of still familiar themes. Page 883 from a 1894 issue of the Journal takes in: (in)competent GPs, medical fees, the threat posed by madwives, and the hazards of artificial feeding on the [incapacitous] insane, all topics very much alive today.

Be that as it may, if there was patient abuse going on, the BMJ clearly wasn’t, at least via its search facility, saying much about it. So Dr No widened his search, to scandals and other sources. To cut a long story short – Dr No wont trouble you with the details – he did find this 2002 BMJ paper, which reports that the number of NHS scandal inquiries has risen sharply in recent decades, from one in the 1960s, to two in the 1970s, five in the 1980s, and over fifty between 1990 to 2001. At least one other significant inquiry, covering seven hospitals, but not included in the 2002 paper, was published in 1968, while a BMJ editorial from 1999 alluded to several others.

So, by the barometer of pressure of significant inquiries, we certainly have seen an exponential increase in patient abuse by NHS staff. But we still don’t know whether that increase reflects an true increase in underlying abuse, or is instead an apparent increase caused by a greater will to expose and investigate abuse, which has itself remained at relatively constant underlying levels.

That said, Dr No does suspect, based entirely on his own direct personal experience, and notwithstanding the loose nature of his present proxy-dependant research, that the rise in inquiries does reflect at least in significant part a true rise in underlying levels of patient abuse in the NHS. He also notes that this rise appears to have risen most sharply over the last two decades, following the introduction in the mid to late 1980s of general management and market forces to the NHS. Could it be that managers, now playing their market and management games in the once consensual NHS, have wrought the most dreadful changes on what was once, bar occasional failings, generally a decent service? If there is even a grain of truth to that chilling proposition, then it is management blowback on a monumental scale.


I don't think things have changed that much since I qualifed 20 years ago. Geriatrics is a Cinderella speciality, staffed by nurses who often didn't want to be there. It is physically backbreaking for nursing staff as all patients on a ward can be immobile (compared to medical and surgical wards) and incontinent, yet the staffing levels are the same. The extra pay geriatrics nurses received to reflect this was removed about 10 years ago. Similarly for medical staff - it is a branch of medicine so there will be 2 middle grade registrars covering 200 beds while the 2 respiratory SpRs cover 20 beds, ditto consultants and junior doctors. Meanwhile the patients become ever more dependent (no longer allowed to die peacefully in the nursing home, their families insist something must be done, they are admitted to hospital where the families expect staff to stop care in order to communicate with them whenever they turn up to visit or telephone). If anything, things have improved - 10 years ago I would regularly see pressure sore over 6 inches in diameter, now they are a rarity. C difficile is also a rarity in the last 5 years. Staff burnout results in less ability to care

Well there is no doubt that hopsitals have changed out of all recognition during the last 30 years. Today we are in the age when some consultants can no longer even be termed specialists but have somehow developed into 'partialists', as jobbing doctor describes them - while definitions of 'elderly' have also changed (nowadays taken to mean those over 80 years of age whereas not that long ago the threshold was 75 and before that 70 - hell, the WHO even put the figure at 65).

I think there also broad distinctions in terms of category of abuse for example by acts of commission (bullying patients, handling them roughly, etc) or by omission (not feeding properly, failure to meet basic hygiene needs, etc) - whether we are talking about today or yesterday, most abuse will probably fall into the omission category not that this is necessarily less harmful in some cases.

So why are things NOT being done?
I think a good starting point is Philip Zambardo's analysis of abu ghraib (why ordinary people do bad things).

Zambardo suggests a dynamic interplay between dispositional factors (bad apples) environmental factors (shitty conditions like Maidstone and Tunbridge Wells NHS Trust or Mid Staffs) and finally systemic changes (the effect of market ideology when applied to health care).

He concludes if you want to reduce the risk of bad behaviour then you MUST pay attention to the influence of a system - conversely when an unhealthy environment becomes the 'norm' (as it apparently did in the two services cited above) then the usual prohibitions which inhibit unacceptable behaviour will inevitably become weakened, as Stanley Milgram elegantly demonstrated.

I do not think nurses have changed in the last 30 years but the system they work in certainly has.

BTW - just to elaborate on the Zembardo's hypothesis - he says there a 7 social processed that grease the slippery slope of evil -they are;
Mindlessly taking the 1st step.
Dehuminisation of others.
De-individuation of self (anonymity).
Diffusion of personal responsibility.
Blind obedience to authority.
Uncritical conformity to group norms.
Passive tolerance through inaction/indifference.

So to go back to Dr No's original question, "Is there more patient abuse in the NHS today than there was, say, thirty years ago, or are we just better at exposing it?" - I would probably reframe it slightly (because I do not think this is PRIMARILY a problem of bad apples) to something like "have conditions arisen in the NHS that increase the risk substandard care, or abuse is more likely compared to 30 years ago?".

If the answer is yes it follows that we must ask who (within the health care system ) is most responsible for creating them - we do know that whenever whistleblowers have tried to highlight deficiencies they are generally treated very badly by their employer

Dear Dr No,

I think there was a lot of underreporting in the past, from a population brought up with lower expectations and to be more deferential. At the very least we have not solved the problem of sub prime care, and most likely it has worsened. As I get older, I try to hold onto the idealism of youth, but in the face of so many issues in the world it is hard not to be disheartened. I do find solace in the book of Ecclesiasticus, like the BMJ "there is nothing new under the sun"

I also muse on when the rot started, and the Griffiths report is not a bad candidate from 1983. There have been other milestones as candidates. Medicine is not immune to the other changes in society dating back to the 1960's of individualism and consumerism, rather than responsibility, duty and vocation. Compassion, consideration and a feeling of social duty are more rare in many aspects of life.

International Internet searches show up similar scandals in most health care systems. I have had patients report similar tales of neglect from several other countries. Most seem to come from the state sector, with fewer from the private system (neglect is rarely the issue there, but some other issues arise). I do not think that good business and good care are in opposition. I do think that the HSCB fails to address the real challenges of providing quality health care to all in society. In particular training of doctors, nurses and other staff is hardly mentioned, but to me the key to progress.


I have viewed Zembardo’s video that without a&e charge nurses comment I would have been unaware of.

It strikes home. Since donning my (nurses) uniform many moons ago I have changed (if only slightly). Although I care deeply about the suffering of others I think it is true to say I am hardened to their plight. I have become hardened to the suffering of others and can detach myself at will – but is this a necessary self-survival strategy? Could I operate successfully as a nurse if I constantly wore the burden of others pain? That said, I am often moved to great sadness when realising the decline of those I care for. I do weep for them.

Yet I am aware of this hardening of myself and wonder if I taken the first step for self-survival? Do I really care or just think I do? Certain events have made me question myself – but as long as I do this is it proof that I still really care? By Christ (no affirmation of religion here) am I still me – who loves/d all life deeply – or am I an uncaring f**k hardened by all I see daily in an effort to survive the emotional rollercoaster of my workplace?

It would be so easy to conform to group norms (I think) if working in an environment where neglect was the predominant factor of supposed care. I have worked in this environment before and if I had not removed myself from it – would I have become a willing (if initially reluctant) participant? Would I have become evil? It is so much easier to conform than to resist. Would I have become an abuser, solely (I would like to believe) in the area of neglect?

I would like to think I would not – but would agree (with Zembardo) that there is the potential for evil in all of us – I know there is!

The above aside and focusing on your proposition (Dr No) that general management and market forces have had a detrimental impact on the NHS; I would say a definite ‘Yes!’ for that is where the rot began.

Hand over the management of any industry to those who are ignorant of its history or understanding of its operation, its ideals, its focus and you have a recipe for disaster The speciality of medicine and its art and science can never be understood by those who do not exist within it. It is akin to NASA handing over space exploration to chimpanzees.

Anna :o]

A&E CN - thanks as ever for your excellent and informative comments - as Anna notes, we are all indebted to your research, and your willingness to tell us what you have found.

Just a note to say that my opening question was as much a rhetorical opening device as much as anything else. The main point of the post (which is again posed as a question) is in the title, and the last paragraph (being two good places to make a main point!), and is this: have the systematic changes brought about by the post-Griffith's Report introduction of general management (as opposed to the pre-existing consensus management: the latter was seen by Hacksaw's government as muddling through; what the NHS needs is kick-ass supermarket style management etc etc) and the internal market (another Hacksaw monster) created a system/climate in which an increase in patient abuse was an all but inevitable unintended consequence?

It is this possibility that links the recent CQC report and the HSCB: if we introduce yet more market reforms, are we not setting up a system that will deliver yet more inevitable unintended consequences, yet more patient abuse?

I suspect hundreds of years ago Robert Burns had a fair idea what the results of Milgram’s or Zembardo’s experiments might be when he wrote:

"Man's inhumanity to man
Makes countless thousands mourn!"

It seems to me that the results of Zembardo's or Milgram's experiments are not very surprising since the consequences have been observed the world over in a multitude of experiments of life. That being the case, why would anyone want to design such experiments on their fellow human beings in the first place? To feed their own need to control others perhaps?

Nevertheless, the fact that they have been performed and repeated time and time again might give some indication of what we should expect from the people that society should select as leaders. What was it in the personalities, life experiences, genes or whatever, that resulted in the minority of participants refusing to continue with Milgram's and similar experiments. Has this question been resolved? Are these people the real leaders? And if so, is the myriad of leadership courses that are on tap nowadays acknowledging these attributes?

Dear Anna and Dr No,

I agree that the toughening up process, and professional detachment can overspill into callousness and cruelty by omission or commission, if in the wrong environment. I do find it a hard line to walk at times myself.

What should be remembered though is that peer pressure works both ways, and is the way we can rehabilitate those that have gone over the line. Most can change for the better if placed into the right supportive and well managed workplace. While the risk of evil is ever present, so is the ability to reform, hence my interest in remedial training. There are some real ethical dilemmas in supervising doctors seen as failing, but it is a very worthwhile experience for both the doctor and trainer. Not everyone will take the opportunity to reform, but most do.


"why would anyone want to design such experiments on their fellow human beings in the first place" - front what I've read it seems both Milgram's & Zimbardo's research was driven (primarily) by a single question; why, in certain circumstances (Abu Ghraib, Auschwitz), are 'ordinary' people complicit, or even responsible for terrible acts?

Looking back all sorts of rationalisations emerged, such the camps were a problem peculiar to Germany (so could never have happened in the USA) - but Milgram demonstrated that ordinary people will do extra-ordinary things once certain conditions prevailed.

If there is more abuse of old people, and I agree with commentators here that there probably is more abuse compared to 30 years ago, then we have to begin to understand why (because I am sure we agree that we would all like to see less).

What do you think happened after the Maidstone & Tunbridge Wells deaths?
x2 nursing assistants were sacked, while a nurse and another nursing assistant were disciplined.

Now maybe these four were 'bad apples' but does anybody think for one second that such 'solutions' will lessen the possibility of the next scandal affecting old people? - I don't.
In what way is such an approach different to rounding up a few hapless street dealers when you are trying to reduce drug activity in an inner city ghetto?

"Why would anyone want to design such experiments on their fellow human beings in the first place" - front what I've read it seems both Milgram's & Zimbardo's research was driven (primarily) by a single question; why, in certain circumstances (Abu Ghraib, Auschwitz), are 'ordinary' people complicit, or even responsible for terrible acts?

Dr No has a copy of Milgram's Obedience to Authority (bought when he was a medical student - £2.50 hardback!). The Nazis crop up on page one in paragraph one and repeatedly thereafter - and there is little doubt that the main purpose of the experiments was to understand better how and why 'ordinary' people commit awful acts. Milgram also makes the point that the 'dangers of obedience' are not limited to Nazidom. In the epilogue he discusses My Lai and Vietnam, pointing out that these events happened under the control of a democratically elected government. Authority is authority, however it got there.

It seems to Dr No that 'bad apples' are an unfortunate combination of red herring and scapegoat - a rotten stinking alliance at the best of times. It seems much more likely that these atrocities arise out of a variant of group-think, a variant in which acceptable social norms (and conscience) collapse under the weight of the in-built, all too common, and at times necessary (which complicates matters further) human need to conform to the herd, and to authority, even when to do so clearly violates what is good.

The problem, Dr No suggests, is not 'bad apples': it is the bad trees, even bad orchards, that allow them to grow.

I think its pretty shocking that Health Care Assistants are the ones to bear the brunt of hospital cross infection problems. The argument is usually and predictably “they didn’t follow the protocol.”

Interestingly, I had lunch today with a friend who out of the blue brought this into the conversation:

He was rather incandescent about this recent report regarding Mid Staffordshire NHS Trust.

He found it difficult to believe that, after the outcry a couple of years ago and the present on-going inquiry, those now in charge of the place didn’t have the wit to realise that they’d need to damn well get their act together and make sure staffing levels in the A and E Department were safe at all times.

But he questioned another aspect: why were the public, local, and national press not making more of a fuss about the number of avoidable deaths that had taken place in the A and E Dept there. He compared this numerically with other deaths that resulted in huge public outcry eg Baby P, Harold Shipman, soldiers killed in Afghanistan etc. He made the point that these un-necessary deaths occurred (I quote) “in a hospital for heavens sake – where large numbers of people are supposed to be protected by caring staff.” He wanted to know why there was not the same outcry as there was when a baby died from child abuse, elderly patients were killed by a serial murderer who also was a doctor, or soldiers bodies were brought home from the battlefield.

We came to various conclusions but I’m not sure if they were the right ones.

“What are the circumstances that make ordinary people complicit, or even responsible for such terrible acts?”

The key word that may well justify these experiments shrouded in dodgy ethics is “circumstances.” But is society any further on in identifying the bad trees or orchards or even the bad weather that causes bad apples? And if society has identified the circumstances what are they doing about it?

So, the question My Black Cat is asking me is: "Has Milgram’s and Zimbardo’s research benefited society?"

Hmmm, for many years I have had the same discussion/argument with my brother-in-law/ego-driven university lecturer that morality/ethics were on a continuous sink, an ever continuous (and unstoppable?) decline where we think and consider less of others and more of ourselves. For many years he laughed at me, yet now agrees with me and has thrown his socialism out of the window as political beliefs do not equate to reality.

Whether we (care to) admit it or not, society is being gradually dumbed down for that is how governments gain control of the minds of the people, we are malleable yet at the same time, this ease to which we are manipulated has detrimental effects on society as we can be manipulated by all.

We have (for the most part) become a nation of sheep in that we follow the diktats of unions, governments and so on – even though we may not realise that we do. Yet there is the herd mentality where we conform to fit in and are capable of the unspeakable

Why was there not an outcry over avoidable deaths at A&E at Staffs? Baby P was a baby and therefore vulnerable, Harold Shipman was a murderer (and therefore of great interest – how did he get away with it for so long?) and the soldiers, the dear soldiers are still regarded as unfortunate victims/cannon fodder in world politics. A&E does not afford a similar emotion.

Why did the management not have the wit to learn from the lessons of two years ago, because they are remote from it – pure and simple. What happens in A&E, on the shop floor is as distant from management as is the moon. Unless you feel it and taste it, it is meaningless and that is what is wrong with the NHS today, once ‘management’ was removed from the medical profession, so was understanding.

“What are the circumstances that make ordinary people complicit, or even responsible for such acts?”

It is a sad fact that if we are not a ‘bad apple’ the potential is definitely there for us to become one. If the circumstances are right, just right and we cannot extricate ourselves from them (for whatever reason) we will be slowly worn down and conform, we will conform to survive.

Anna :o]

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