Richard Vize on the commission on dignity in care for older people

Richard VizeThe consultation document published today by the Commission on Dignity in Care for Older People has powerful messages about the role of hospital doctors and the training of doctors and medical students.

The commission, a joint enterprise by the NHS Confederation, Age UK and Local Government Association, was established in the wake of investigations by Parliamentary and Health Service Ombudsman Ann Abraham into shocking failures in the care of older people. (I should declare an interest – I wrote the commission’s report.) It moves on from the increasingly frequent exposure of such failures by identifying the underlying causes for poor care of older people in hospitals and care homes and recommending reforms. It calls for “fundamental changes to culture, leadership, management, staff development, clinical practice and service delivery.”

Central to the commission’s analysis is that if senior managers impose a command and control culture that demoralises staff and robs them of the authority to make decisions, poor care will follow. To get care right for older people and everyone else, clinical staff throughout the trust have to be able to use their professional judgment to “do the right thing” for patients.

It endorses the call made last year by the King’s Fund for leadership development to extend “from the board to the ward”, so that all clinical staff have the ability and confidence to challenge poor practice.

This recommendation is an explicit rejection of the idea of an heroic trust chief executive leading the way, with the clinicians following in their wake. It makes clear that, in many trusts, power needs to be redistributed throughout the organisation to allow medics and other clinicians to take the decisions essential to providing high quality care.

But delivering this huge cultural shift requires doctors to take more responsibility for everything that happens in the hospital. In particular, the commission calls for the medical director and other senior clinical staff to take more responsibility for the quality of care, and for there to be more collaboration between them and the rest of the top management in setting the trust’s culture. The commission heard that consultants are as likely to say they work “at” a trust as for it, sometimes indicating an unwillingness to share responsibility for everything that happens there.

The commission also has tough words about the quality of medical training and practice. Evidence to the committee revealed that many doctors have an inadequate understanding of dying and death and are often uncomfortable with discussing them with patients and families. Despite the fact that, according to the Alzheimer’s Society, around a quarter of hospital inpatients have dementia, there is a shocking lack of appreciation of what it is like to be one of these patients. Doctors and other clinical staff lack basic training in how to talk with them to minimise distress and help them understand. Evidence to the commission quoted in the Daily Mail revealed one doctor who said he took a “veterinary” approach to patients with dementia.

The commission heard how care by multidisciplinary teams had led to doctors being unwilling to challenge evidence of poor nursing care. Shared responsibility must not become shared abdication of responsibility, the commission warned.

Today’s medical training puts far greater emphasis on the patient’s perspective than 30 years ago, but the commission wants further reform. It calls for medical students to be selected for their compassionate values as well as their academic prowess, and an understanding of dignified care to be central to the ethos instilled in medical students from their very first day.

The commission will be writing to every trust asking for views on this consultation document, and much more work will follow to try to make the recommendations a reality. But the report makes clear that reform will not be brought about by the NHS Commissioning Board or the Care Quality Commission; each trust and individual staff will have to decide if they are going to act.

Richard Vize is a journalist and communications consultant. He was the editor of the HSJ 2007-2010. He edited the Guardian supplement for the NHS Confederation conference.