Stephen Bradley: Is medical culture complicit in covering up the reality of NHS care?

The Bawa-Garba case shows how outdated medical culture is in a society that won’t face up to the crisis in healthcare

To most people working in health, the outcome in the Bawa-Garba case seems a baffling miscarriage of justice. One explanation is that the judgment springs from a comforting belief of how acute healthcare should be. In deeming the paediatric registrar’s performance “exceptionally bad,” perhaps the jurors were unable to contemplate the alternative: that at times, the performance of the health system itself is exceptionally bad. Punishing one “blundering doctor” upholds a fiction much more palatable than accepting that in a system in crisis, good outcomes and survival often rely on luck.

All those horrifying details presented in court as examples of poor care feel sickeningly familiar to any clinician with recent experience of acute medicine. Any doctor claiming that they could not have made similar mistakes would surely be breaking our professional duties of candour and insight.

Doctors used to feel reassured that the legal system had no interest in criminalising professionals acting “in good faith.” Yet it is now clear that “workload pressure is no defence.” Guidance issued by the GMC in light of the Bawa-Garba case, advising doctors to make concerns about their working environment known, sounds superficially plausible. Yet short staffing and excess demand is now so widespread that many individuals would be expected to escalate concerns on every working day.

What seems so unreasonable to doctors in the Bawa-Garba case is that the terrible outcome was examined without reference to the ramshackle chaos experienced every day by NHS staff. But how could these jurors understand a system with conditions and pressures that are so totally out of step with any other contemporary industry or workplace. That such inadequacies can occur when life is at stake must appear, quite rightly, shocking to anyone unfamiliar with the reality of clinical practice.

If the public are in the dark about the reality of NHS care has our own culture been complicit in the cover up? Has there been a bravado in medicine that excuses the hardships with an ego friendly belief that we are different from other humans?

To many unfamiliar with healthcare, it would surely seem surprising that there is no real contingency for staff vacancies or absences. Yet we flatter ourselves with the ridiculous expectation that any scale of workload can be mastered by eliminating breaks and mustering the will to work harder, faster, and smarter.

From my time in hospital medicine I remember an atmosphere of fear around committing clinical error, but more immediately of violating the strong social norm by betraying evidence of “not coping” or being “a doctor in difficulty.” The pervasiveness of this culture is for me recalled in telling details. One busy but adequately staffed rotation in my hospital was condescendingly dubbed “cardi-holiday.” Only in medicine have I heard the ridiculous term “man up” used in earnest.

The superior aspirations of doctors come through in many of our formal reflections. We feel obliged to become our harshest critic in depositions that list our failings and pledge to manifest less human weakness in future.

The Bawa-Garba case demonstrates the redundancy of medical bravado in a society that has not faced up to the consequences of cutting corners in healthcare. The lesson is that failures in an under resourced healthcare system may be pinned on any clinician in the vicinity when disaster strikes. However inspiring the daily efforts of NHS staff are, a blitz spirit sentimentality is not shared by the wider public who expect a modern and safe healthcare system.

In order to reduce the chances of inflicting such terrible and potentially avoidable loss of life again we need to remain clear that these catastrophes are almost always due to complex system errors rather than individual fallibility. Our professionalism demands that we abandon our traditional reticence about “being political” and point out that while staffing and funding lag further behind demand, patients should expect standards and also safety to deteriorate.

Stephen Bradley is a GP and clinical research fellow, having completed training in September 2016. Twitter @DryBreadnRadio

Competing interests: I serve on the GMC’s PLAB part 2 management group and I am a tutor at Leeds Medical School.