Of the great climacterical year, that is, sixty three

Now I know what the problem is! I am now in my grand climacteric year. I am in the "mysterious period of life when the the numbers of seven and nine multiplied into each other" (see quote). According to Sir Thomas Browne, this is a vulgar error. Hopefully I will escape this dangerous year.

I now have to wait to see what happens when I'm 81.

Not yet a twitaholic

Doctors' unhappiness

As I tweeted, 'Junior doctors are not happy'. David Hunter usefully sets the dispute over the junior doctor contract and the likely strike action in the wider political context (see BMJ editorial). When doctors were happy, they:-

sacrificed early evenings, studied hard, saw patients, and provided “good” care. In return for these sacrifices doctors got reasonable remuneration; reasonable work-life balance later; autonomy; job security; deference; and respect. 

The drive for greater accountability over recent years has not always been well implemented (eg. see previous post). Care did need to change to be more patient-centred rather than doctor-centred (eg. see previous post). But practice has become too fragmented and dysfunctional. As Hunter concludes:-

resolving the concerns [of unhappy doctors] remains as big a challenge now as [15 years ago], regardless of the immediate outcome of the present dispute.

A sunny ferry trip

Now waiting to sail from Hook of Holland because of fog disruption yesterday to flight to Norwich (see EDP article). At least The Scotsman reports a problem (see article). Could be why I was redirected via Edinburgh tomorrow. I couldn't spend another night on a make-up bed in Schiphol in M terminal, but it's actually very warm and sunny on the ferry! Sailing now.

The case for the Physician Associate

The NHS is promoting the development of the new profession of Physican Associate (PA) (see NHS careers webpage). The role has been seen as "doctors on the cheap", but in fact, although Physician Associates are trained in the medical model, they are not doctors. The competition is more with other allied health professionals.

There are advantages in having allied health professionals trained in the patient-centred medical model. A PA is always responsible to a doctor. The Royal College of Physicians has set up a Faculty of Physician Associates (see webpage).

After training, it is important that Trusts support newly qualified PAs in a professional academy, as my own Trust has done for nurses and plans to extend to other disciplines (see webpage).

Corbyn takes on the media

Pleased to see the anger of Jeremy Corbyn against the media. His sartorial elegance is not relevant. The new kind of politics is not a fashion parade.

Has using mortality as a quality indicator for hospitals died?

BMJ editorial confirms that academic opinion is finally coming round to accepting that Hospital Standardised Mortality Ratios (HSMRs) are not a useful signal of whether something is going wrong in hospital care (see previous post). A linked article did not find a significant association between HSMR and avoidable deaths. Even measuring avoidable deaths is open to interpretation and not an exact science. As a rapid response says, "Monitoring hospital quality by means of HSMR and other mortality indicators has failed to benefit any one except Dr Foster" (see previous post).

People who cause a stir

I've just had a week in Arncliffe, Yorkshire Dales, where John Robinson, my Director of Studies at Trinity (see previous post), is buried. His 1963 Honest to God book, written when he was Bishop of Woolwich, recognised the need for a "secular theology". 

Out of hospital care can learn from mental health services

Great Yarmouth and Waveney CCG (Health East), in whose area I work, have a public consultation (read the consultation document) on introducing out of hospital teams and closing GP community hospitals. This follows a pilot in the Lowestoft area which reduced emergency admissions compared to the previous year (see evidence), whereas nationally figures increased.

The case for change document includes an appendix on the clinical evidence base from national initiatives. Health policy has encouraged a greater range and volume of care to be delivered outside hospital for some time now. Implementation of this policy has been tentative and the SeeSaw simulation by the Kings Fund looked at the reasons why. Primarily this is about commissioning and HealthEast do seem set on making integrated out of hospital care a reality.

The implementation of home based treatment was different for mental health services. It proceeded before that for physical health care. The evidence for Crisis Resolution and Home Treatment (CRHT)  in psychiatry came from several major controlled research studies (see Tyrer & Creed, 1995, for a summary of this evidence). CRHT teams were then implemented as part of a national service framework that modernised services.

There does not seem to be the same controlled research evidence for physical health care. National policy is also more piecemeal with each area being expected to 'reinvent the wheel'. Data from the Lowestoft pilot project is anecdotal. It may be valuable nonetheless but it is limited. The mental health studies did not really show much improvement for clinical symptoms for home care over hospital care, although there was some evidence of greater satisfaction, perhaps particularly for relatives. Bed reduction was possible, although there is evidence over recent years that this has gone too far (Tyrer, 2011).

It is important to be clear about what can be achieved with out of hospital care, particularly for clinical symptoms. It's just that I would have felt more confident about it succeeding, if there had been the controlled research studies to back it up. Nonetheless, I don't think there's any turning back (except, as I said, perhaps on mental health service beds) and its nice to see this initiative leading the field in the area where I work.

The people didn't bother if the Tories won

Only Norwich South (where I live) and Cambridge (where I used to live) are Labour in a sea of blue in the east of England (although North Norfolk stayed with Norman Lamb and Clacton with Douglas Carswell). Even Great Yarmouth is a natural Tory seat with affluent Norfolk farms and villages offsetting areas of depression and unemployment in the town. London did buck the trend with Labour gaining seven seats and increasing their number of MPs. Since the Wilson years and apart from the Blair years, it's familiar to have hopes raised for Labour and dashed on the night.

Speaking up in the NHS

Robert Francis' report on NHS whistleblowing, Freedom to speak up, seems a little bland to me. Maybe this is because, although he heard evidence from individual cases, he hasn't described any specific details of any of them in the report. As he says, "cases are not always clear-cut", but I'm not sure if this justifies his decision to describe generalities only, including ruined lives in some extreme cases. Still, a Guardian article highlighted four cases.

Nor does Francis really attempt to explain the context for the problem. As another Guardian article says, the issue is at least partly managerialism in society in general, not just the NHS. But I think there have been, historically at least, specific elements in the NHS. The financial cost of delays to disciplinary proceedings hardly impinges in some NHS trusts, so that cases take too long to resolve. And, there was a particular phase of command and control leadership in the NHS, associated with the previous chief executive (see eg. previous post), that encouraged a bullying culture (eg. see another previous post). Problems with healthcare regulation related to the annual health check (e.g. see previous post)  and the Healthcare Commission (see another previous post) led to the Care Quality Commission (CQC) being formed, which had to be revamped after going through a rough phase (eg. see another previous post). CQC is still improving its methods and I'm not sure how valid its ratings always are. Nonetheless, special measures do seem to have been helpful for NHS providers that have been through the process (see Independent article, although I'm not sure how much should be made of the mortality statistics), and there may well be benefits from using them more widely.

The exhortation for a healthcare professional to speak up about concerns about the conduct, performance or health of others is important, but this can be misused. Clinical practice is not always objective and there may well be uncertainty about the best course of action for medical interventions. Francis did hear evidence that some people raise concerns for dubious motives. The increasing regulation of doctors over recent years, following the case of Harold Shipman, may have contributed to a climate of fear and culture of defensive practice (eg. see my BMJ letter). This is promoted by managerial over-reaction. Medical errors are not always manifestations of incompetence, carelessness or recklessness (see previous post). Naming, blaming and shaming may not always be the most appropriate response. The form of statements of intent can easily be persuasive, whereas the content doesn't really relate to quality. For all the merits of revalidation, for example, it is easily diverted into a bureaucratic exercise.

As I have mentioned before (see previous post), I am someone who has been suspended twice in my career. I have also been further investigated without being suspended (eg. see another previous post).  My first suspension was related to ideological conflict about critical psychiatry (see THES article). My second was a professional conflict with management, with me raising concerns that relationships between management and consultants needed to be improved. Instead it was me that was accused of bullying, and found guilty, in my view wrongly.

How to align social care with the NHS?

Chris Ham has another BMJ editorial. Setting the context of the debate about the NHS for the next election, he makes reference to the Barker report. A single, ring-fenced budget for health and social care, with a single commissioner is what is needed. However, it's not clear how to implement this as the report's recommendation 5 acknowledges:-

Our recommendation that there should be a single local commissioner for the new single budget does raise the question of who this should be. We have not had time to explore that in any detail, although, as we said in our interim report, a sterile debate should be avoided over whether health should take over the commissioning of social care or whether local authorities should commission the NHS. We do note however, that a number of others, including the House of Commons Health Select Committee, have said that over time the new health and wellbeing boards could evolve into a single commissioner for health and social care locally. That idea has its attractions. We recommend that work be undertaken to explore whether the health and wellbeing boards could evolve into the single commissioner for our new settlement.

AQP primary care psychological therapies finished?

Exclusive from the Health Service Journal is headlined "CCG interest in 'any qualified provider' scheme dwindles". As the article says, the AQP policy needed to be driven centrally. With no further mandatory requirements this isn't going to happen. And, the difficulty of managing contracts with potentially several providers hasn't been seen to be worth it. That's why I closed down Anglia Mental Health Community Interest Company (eg. see previous post), because it didn't seem likely it could get off the ground.

England depend on Alastair Cook

Is it a coincidence that England seem to do better when Alastair Cook at least scores a few runs? What they need to learn to do is win even if he gets out early.

Ed Balls should be held to account for Haringey's loss

According to the Daily Mail, Ed Balls shows no contrition for removing Sharon Shoesmith in the Baby P case. He doesn't seem to understand that the role of the politician is to avoid whipping up public scapegoating about child protection (see previous post). Read Ray Jones' The story of baby P for a balanced perspective on the case.

As Jones asks, why would anyone want to create such hostility and hatred against childcare professionals? Human beings do have the capacity for savage cruelty against defenceless children. I don't think Ed Balls is unintelligent and should be able to appreciate this.

Labour can't go into the next election with him as shadow chancellor because he clearly finds it too difficult to admit his mistakes about the economy (overspending leading up to the financial crisis) as well as Baby P.

Forward view for mental health services

Chris Ham analyses the impact of the new NHS England chief executive, Simon Stevens, in a BMJ editorial. Mental health would seem to be an obvious area for the development of population based budgets, where NHS Trusts, local authorities and CCGs take on responsibility together. NHS Trusts need to take on more of a role in leading improvements and commissioning alone will be insufficient. CCGs need to take responsibility for increasing referrals when there are current financial restraints.

Gove's discrimination against Muslims

By branding religious conservatism 'extremism' in Birmingham, ministers are making clear different rules apply to Muslims. Read Seumas Milne

The Rolf Harris dirty songbook

Now Rolf Harris has reminded us of Jake the Peg, let's not forget our amusement at the version of his Two Little Boys on "I'm Sorry I'll Read That Again" (see lyrics).

He looks weird, sounds weird and is weird

Why does me saying this about Farage not have as much effect as The Mail saying it about Miliband?

Science and the pharmaceutical industry

Fears about reduction of pharmaceutical R&D funding drive Lord Sainsbury, Chancellor of the University of Cambridge, to argue for blocking Pfizer's potential takeover of AstraZeneca (see Guardian article). He doesn't mention in the article that AstraZeneca had selected Cambridge Biomedical Campus as its new UK-based global research and development centre and corporate headquarters (see press release), which I guess may not happen, at least in the same way, if the takeover goes ahead.

What gets lost in this conflict of interest is whether R&D really leads to therapeutic advances (see Light & Lexchin, 2012). For example, most (80%) of the increase in drug expenditure in British Columbia between 1996 and 2003 was explained by the use of new, patented drug products that did not offer substantial improvements on less expensive alternatives available before 1990 (Morgan et al, 2005). 

Most new drugs are not superior on clinical measures and increase healthcare cost pressures. Medicine has always exploited the placebo effect. Pharmaceutical marketing is not always scientific (Applbaum, 2006). We may need less medicine not more (eg. see previous post).

What can I listen to on car radio?

Just had to listen to Gold via iPad app to make sure it was still there (but without presenters) as could only get Smooth on car radio today - see why. Why change my habit?

Reduce drugs we give people in NHS

The Guardian gives over its front page to an interview with the retiring NHS chief executive, who in my opinion should have resigned in 2009 (see previous post). He argues for an extra change fund to switch hospital to community based care. There is clearly scope for this to happen, but it does need a properly based philosophy of care to underpin it. Actually, what we need as a society is less medicine not more (see another previous post). This means doing what he says we should not do, which is reduce the drugs we give to people.

And there's nothing wrong with serious A&E cases being centralised in major emergency centres, but that's a relatively minor issue compared to providing effective alternatives to admission to hospital. And one of the biggest mistakes would be to dismantle the primary care system we have in this country, which is envied by others, even if it has lost its way a bit with countless NHS managerial reforms. And of course we do still need acute hospitals.

Update on previous post

Even the NHS is supported by the drug companies

Why is Janssen supporting the 2014 Mental Health Network Annual Conference? The Mental Health Network was established by the NHS Confederation, the membership body for all organisations that commission and provide NHS services, to "provide a distinct voice for mental health and learning disability service providers". It is supposed to speak on behalf of the whole NHS, so I'd have thought it didn't need pharmaceutical company money to do that.

The cost of the Guardian

I've been moaning about the Guardian costing £1.60. Today I was charged £1.20 when scanned in the shop even though the paper still has £1.60 on the front!

Blog resistance

Hey, now I know why I blog! See Howard Caygill's Digital Resistance. Blogging "... plays a significant role in delegitimising domination by making it available for scrutiny and comment from a variety of perspectives, potentially contesting the tendency towards monopolization of information, wealth, power and ultimately violence essential to legal rational or even total domination".

The "spectre" of Savile

CockRoache has been found not guilty. Reinforces the case for a public inquiry (see previous post).

Kev, stop tweeting!

Whatever the hurt pride, I can't see that Kevin Pietersen tweeting "I'm shocked and saddened by reports in the media today concerning my future with England ... " has helped his case. Even with Michael Vaughan's support (see Telegraph article), his difference with Andy Flower is something that needs to be sorted out in private, not in the media (which includes Twitter) following the Mail's report. I'm sure Pietersen doesn't mean to bring the England team into disrepute but there's nothing to be gained by 'fanning the flames' in public.

As I said in a previous post, resolving difficulties with Pietersen has not been easy. After all, it was Alastair Cook that facilitated Pietersen's reintegration after the last fiasco. As I pointed out in my tweet, Shane Warne took full advantage of this before the Ashes, encouraging the sledging on the field. As England fall further down the rankings from their peak in 2011 (see previous post), it's important that Pietersen is not made a scapegoat. But the England team is more important than his ego. He shouldn't need to state his desire to help regain the Ashes for England. It should go without saying.

Lack of political leadership on child protection

Ed Balls continues to say he knows better than the Court of Appeal in the case of Sharon Shoesmith (see BBC report). I'm not sure if the bad taste in my mouth about this is worse than his about her payout. Thank goodness Tim Loughton got sacked as Children's minister before his outburst on the Today programme this morning about the same payout (again, see BBC report).

Loughton seems to be just point scoring against Balls, saying that Balls made a botched job of sacking Shoesmith. However, it's fairly clear that the Court was saying more than that Balls merely made a procedural mistake (see previous post).

What we need is for politicians to give a clear lead about the way forward for child protection. At least the chief inspector for Ofsted has said that good child care directors shouldn't be made scapegoats (see Times article). Michael Gove has been reported to be "furious" about the agreement with Haringay council, but this may just be about the confidentiality agreement.

We do need an open discussion about this issue, and the resignation or sacking of Ed Balls should be pursued by Ed Miliband (see another previous post). This would also allow Labour to rebuild its economic credibility and clear out the past poisonous role Balls had in Gordon Brown's inner circle.

Letter to Private Eye

Better value for health care

In July this year, NHS England issued a call to action to debate the issues about the future of the NHS. Monitor's paper about closing the NHS funding gap is in part a response to this debate.

Monitor correctly highlights that staff will have to work "differently and smarter". However, in general its response seems to me to be much of the same eg. reducing waste and a belief that community care is cheaper than hospital care.

There is some emphasis on self-management of long term conditions, but not enough in general about the potential financial savings of more patient-centred care. There is no mention of reducing over diagnosis and over treatment (see previous post). Monitor is going to have to get a bit more imaginative if it is going to sustain flat funding for the NHS.

Lord's will be pleased

Which was the more "ruthless" option? At least England carrying on to a 556 lead (see scorecard), rather than enforcing the follow-on, has guaranteed a fourth if not fifth day for Lord's finances. Still, nice to see another hundred from Joe Root (see previous post).

Maiden test century for Joe Root on home ground

It was worth making the long journey from Norwich to Headingley yesterday. Interesting museum at the ground showing history of Yorkshire County Cricket Club. See video made for 150th anniversary.

British freestyle wrestling's villain dies

Mick McManus has died aged 93 (see Telegraph obituary). What has happened to Kendo Nagasaki, Jackie Pallo, Les Kellett, Adrian Street, Johnny Kwango etc and Kent Walton? I used to watch them on the telly with the old English working class, the Queen and Harold Wilson.

Disciplining Margaret Thatcher

Times article about the authorised biography of Margaret Thatcher by Charles Moore picks up (as does the Guardian) on the memo written by the then head of her policy unit, Sir John Hoskyns, which accused her of bullying her weaker colleagues. Sir John went on, "To survive you have an absolute duty to change the way you operate." The Falklands war followed and the rest is history. I don't think most people knew at the time that the sending of the task force would end in war but winning in the Falklands changed people's attitude to the prime minister.

AN Wilson (see Mail article) argues that Thatcher was not in the true sense a bully because she "reserved her fire for those who - if they had any spunk - were in a position to fight back". I'm not so sure. Her unwanted and unreasonable conduct itself determines whether it is regarded as bullying. I'm not advocating the bullying application of bullying policy (see previous post). She may well have believed that she alone rescued Britain from its post-1945 years of semi-socialist decline, but not everyone benefits from capitalism (see previous post). To analyse any situation from the perspective of the objective and reasonable person is never straightforward as personal experience and judgments will inevitably taint perception. However, she failed to create an environment in which people have the right to be treated with consideration, dignity and respect.

What was unique in severity and duration in case of Mid Staffs?

The government initial response to the Francis report has been published. I still worry that Mid Staffs has been unfairly singled out (see previous post). I'm also not convinced that the new Chief Inspector of Hospitals can provide a "single version of the truth", if there is such a thing, in his or her so-called balanced assessment of hospitals. These matters are always open to interpretation. How this will be helped by inspectors "looking the [Trust] board in the eye" I'm not sure.

Nor am I clear what embedding "a zero tolerance of avoidable harm" in the DNA of the NHS means (see previous post). Harm may appear avoidable in retrospect but not necessarily so before it happens.

It's also good to reduce "paperwork, box ticking and duplicatory regulation and information burdens" but why by at least a third and how will we know whether that target has been met (aren't we supposed to be moving away from targets)?

Can zero harm be a reality in NHS?

Press release from the NHS Commissioning Board confirms that "Professor Donald Berwick is being brought to the NHS to chair a National Advisory Group on the Safety of Patients in England" (see terms of reference and members). David Cameron has asked Berwick "to make zero harm a reality in our NHS". At least he's appreciated that the Francis report needs to be put in the context of patient safety research (see previous post).

Berwick talks well (eg. see video on BBC website). He recognises that most healthcare staff intend well and I too want the NHS to be the safest in the world. But it's misleading to expect no errors in healthcare (see another previous post) and Berwick might need to refine at least his language. Being a doctor is not the same as being an airline pilot.

Berwick must be glad to have left the vitriol of US healthcare politics behind him (see Who is Don Berwick?) It's difficult to relate to some of the emotive language used there (see previous post). But UK healthcare politics too can be based on misunderstandings (see previous post). Hopefully, Berwick and his group can help take the Francis report forward in a sensible way.

Too late to call for David Nicholson to resign

The Mail is keeping up its campaign to get David Nicholson, NHS Chief Executive, to resign (eg. see article) . If he was going to resign he should have done so in 2009 (see previous post). The previous government had already started to change the top-down approach (see previous post). This has got lost in the current government's wasteful reorganisation (eg. see previous post) but David Nicholson has been a steadying influence in the upheaval. That's why David Cameron can't let him go at present.

What Nicholson should be asked to state is where he stands on his claim on Mid-Staffs that “While this was an awful case, it was highly unusual that such poor quality care and patient complaints could go undetected in the NHS for so long and we will make sure this will never happen again.” This was wrong and he should be made to say so. Perhaps the government response to Francis report will say this.

Creating a patient-centred culture in medicine

She may not like me saying if she thinks I am not taking her seriously, but Part One of Julie Bailey's book From ward to Whitehall should be required reading for training health professionals. Part Two is about the politics that followed her mother's death up to the publication of the Healthcare Commission's report (see previous post). I'm not convinced that Robert Francis' recent report has yet answered how to "stop the suffering" in the NHS (see previous post), which has been the motivation for her campaign.

Francis makes no attempt, as far as I can see, to set his findings in the context of the literature about patient safety. A crucial document in this is To err is human, which recognised the common nature of iatrogenic damage. Patient safety has been framed as an explicit public concern since.

The problem is that protocols designed to reduce errors have actually made patient safety worse (see previous post). These factors meant that what was happening on the wards in Mid-Staffs was not appreciated. The Cure the NHS campaign was started because Julie Bailey had a poor response to her complaint. It was so bad (not that I'm blaming the matron who responded and the Director of Nursing that reinforced the response, because they were caught up in this manageralism) that, as far as I know, she has not yet had a proper answer. There clearly has been a culture of investigation at Mid-Staffs since but it sounds as though it has been destructive. According to the BMJ of 42 doctors referred to the GMC only four will face a hearing.

Francis, again as far as I can see, did not pick up on the evidence he was given about the Healthcare Commission "going out with a bang" in the report on Mid-Staffs (see previous post). This doesn't mean that I don't take the evidence from Cure the NHS seriously. It's just that the managerialism introduced by the Healthcare Commission did nothing to support health professionals in exercising their responsibilities in providing care (see previous post). Medicine still needs to become more patient-centred as Francis says. Hopefully the government's response to his report might help to take this forward.

Scapegoating Mid-Staffs

I may have missed something because it's four volumes, but I'm not totally happy about Robert Francis's Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. He wrote in his press statement:

There was a lack of care, compassion, humanity and leadership. The most basic standards of care were not observed, and fundamental rights to dignity were not respected. Elderly and vulnerable patients were left unwashed, unfed and without fluids. They were deprived of dignity and respect. Some patients had to relieve themselves in their beds when they offered no help to get to the bathroom. Some were left in excrement stained sheets and beds. They had to endure filthy conditions in their wards. There were incidents of callous treatment by ward staff. Patients who could not eat or drink without help did not receive it. Medicines were prescribed but not given. The accident and emergency department as well as some wards had insufficient staff to deliver safe and effective care. Patients were discharged without proper regard for their welfare.

Although as far as I know he did not state this, he has done nothing to prevent press claims that the report has exposed "catastrophic standards of care at the trust, leading to at least 1,200 needless deaths" (see Telegraph story). The Trust had a high Hospitalised Standardised Mortality Ratio (HSMR) at the time (there were hospitals with higher rates - see previous post and my post at the time of the publication of the Healthcare Commission report), but in fact Francis makes clear that:

... it is not possible to conclude, without more information than the HSMR alone, that a high outlier is attributable to poor care. Nor is it possible to say that any specific number or proportion of deaths was from an avoidable cause. Nothing to the contrary has been suggested.

To reiterate:

Whether a subdivided or overall SMR is reviewed, it is always important to keep in mind that a high rate of “unexpected” deaths cannot be translated into a number of “avoidable” deaths, any more than a low rate of such deaths means that all is well.

So, the media shouldn't be making such claims about avoidable deaths. And, although the apparent improvement in HSMR rates at mid-Staffs may have been due to "manipulative coding" in Brian Jarman's words, this just reinforces the relative nature of the measure of HSMR and the need for caution in interpreting the data.

My main concern is that despite Francis' attempt to avoid scapegoating of individuals by emphasising institutional failure, he has scapegoated the hospital himself. As he says:

It will no doubt be said that episodes similar to those described ...  could be found during the period looked at in many trusts.

My problem is that he calls this a "complacent attitude". I don't think I'm being complacent by pointing this out. One of my first ever posts on this blog was taking Ian Kennedy to task for bragging that the Healthcare Commission had improved care in the NHS when I knew this was not the case. By saying this attitude is complacent, Francis has avoided dealing with the issue.

As an example, an article in the BMJ this week highlights that problems in the provision of appropriate nutrition and hydration have been reported in the medical literature for nearly 4 decades. As I indicated in a previous post, the BMJ authors note that the Health Ombudsman found a "lack of access to fresh drinking water and inadequate help with eating in half of cases during her investigations into care of older people".

Basic care needs to be taken seriously not only within hospitals but also in care homes and the community. Health care is not an easy job. Mid-Staffs is not the only place where there needs to be improvement in this respect.

Improving university education

Reading Ian Parker's resignation statement from MMU has made me think about the effects of the target culture on universities. MMU has a change agenda based on a corporate strategy that sets 14 key performance indicators. In the current competitive market with other universities, there must be  a question about whether these are achievable. For example, by the law of averages, half of the universities will score above average on student satisfaction and half will score below.

I'm sure Ian has been defending academic values. The Council for the Defence of British Universities (CDBU) has been set up because misguided policies are undermining universities. Target cultures arise from not being able to easily measure a broad social good like "health" or "education". This blog has commented several times on the problems this created in the NHS (eg. see Why do staff report high levels of bullying in the NHS? Note that Ian says he has been bullied and this should be taken seriously.). The boxes were being ticked by NHS Trust Boards in their reports to the Strategic Health Authority but in fact a poor culture of care had become endemic. In a culture that could punish people for failure to meet targets, managers and staff in general are likely to behave dysfunctionally.

It's perfectly reasonable for Ian to defend his students but this has cost his job. Hopefully university education can be improved beyond increasing the number of 3 and 4 star staff submitted to the REF (Research Excellence Framework). As CDBU says, universities should be "places where students can develop their capacities to the full, where research and scholarship are pursued at the highest level, and where intellectual activity can be freely conducted without regard to its immediate economic benefit".

Need for reappraisal of notion of errors in healthcare

Very good article by Sonja Jerak-Zuiderent argues that patient safety needs to be conceptualised in terms of 'living with uncertainty' rather than errors in healthcare. Errors do not necessarily detract from safety and to ensure safety it is important to allow for the possibility that errors will occur. Practitioners live with uncertainty and a margin of error will always occur in their practice. This is not being complacent about iatrogenic damage and harm which is a major concern.

It is problematic to assume that safety will follow from protocols designed to reduce errors. In fact, safe practice requires an openness to change and the need for new responses. Creatively understanding what safety means in a specific instance can even require disregarding established protocols or guidelines. Assuming that safety will follow from protocols loses the benefit of living and acting in the real world. Mistakes need to be valued as a core element of life itself. Living with uncertainty does not mean that anything goes or that one is complacent about errors and is a safer mode of clinical practice.