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Care must trump cash

By Mark Borthwick, MSc, MRPharmS

The final report of QC Robert Francis’s inquiry into the circumstances surrounding poor care at the Mid Staffordshire NHS Foundation Trust was published last month (see UPDATE, p35). The document contains extraordinary narratives of neglect, harm and mistreatment of people who were in the care of the NHS.

Pharmacy is not mentioned in the 290 recommendations, and barely mentioned in the body of the report, except to say that there was insufficient clinical pharmacy input, inadequate training time and no antimicrobial pharmacist — and that a pharmacist from the strategic health authority took a report that the trust was weak on medicines management very seriously.

So, does a handful of mentions mean that there is not much in the report for pharmacy to worry about? No, not at all.

The inquiry identifies common themes that underscore poor organisational culture: a lack of openness to criticism, defensiveness and secrecy, working in silos, acceptance of poor standards, misplaced assumptions about the judgements and actions of others and an overriding failure to put patients first in everything that is done.

To my mind, “keeping your head down and getting on with it” is always the wrong response to workplace difficulties and typifies the above themes. Nor does it mean that the right response for staff is to down tools and walk away when things get tricky. NHS staff are now challenged, empowered even, to tackle such difficulties, to consider the adequacy of responses from those in positions of authority and to reject them if necessary.

Mr Francis is clear that it is care and clinical governance, not financial governance, that are paramount. He recommends a “re-emphasis” on the fundamental values and standards of care, a vehement rejection of poor practices, an expectation of honesty and candour, strong leadership (with strong support for leaders) and true accountability for the level of care provided.

Yet, is it possible to maintain appropriate and compassionate healthcare while balancing the books? Of course it is. There will, however, be a point beyond which a reduction in resources just cannot physically be met with a new way of working or a technological advance that improves efficiency. Beyond that point, a cut in funding is a cut in quality — or safety. Expanding professional roles to improve quality — for instance, the recommended widespread adoption of regular multidisciplinary ward rounds (that include pharmacists) — will also involve a rethink of the workforce or further investment.

Trust boards have a troubled road ahead; doing the right thing by patients will undoubtedly bring trusts into financial difficulty at some point. Supported by a culture of openness and transparency, the NHS workforce, governments and the public will need to get behind leaders who do take a stand — even if this might mean missing a financial target.

We can only hope that accountability for care truly trumps accountability for cash, or we will continue to grow leaders who are vocal about the quality agenda while being slaves to a financial one.

Mark Borthwick is consultant pharmacist for critical care at Oxford University Hospitals NHS Trust and chairman of the United Kingdom Clinical Pharmacy Association

Citation: Clinical Pharmacist DOI: 10.1211/CP.2013.11117759

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