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How could this happen?

Sometimes during your medical career something happens which is so dreadful that it goes against everything you believe being a doctor stands for.

This is what it feels like to read Robert Francis’s report into events at Mid Staffordshire NHS Trust. When you read about individuals not being given basic care, left lying for hours in their own excrement, not being given sufficient pain relief or even food and water, you cannot believe that you are hearing about patients who were ill and being treated in an NHS hospital.

Patients rightly believe that when they go to hospital they are going to a place of safety where they will be cared for and treated with respect. It is shameful that this is not what happened to so many patients who went to Stafford Hospital.

So how could it happen? Despite endless regulations, reams of guidance, several external regulating bodies, how could such poor quality of care go unnoticed for so long?

As Robert Francis said today, such wholesale systemic failure cannot be blamed on one policy or a group of individuals. There is an urgent need to reshape the culture in the health service to prevent similar tragedies happening in the future.

You cannot practise medicine in a zero-risk environment. Every procedure carries some degree of risk and patients should be informed of this and participate in decisions. However, we can stamp out poor and dangerous care, there is no place for it in our NHS.

We owe it to the victims to do more. The answer doesn’t simply lie in supporting individuals to raise concerns about poor practice. We must develop a culture where health professionals not only think speaking out is the right thing to do but where they are congratulated for doing so.

I want the BMA to play a key role in leading the debate about how to reshape NHS culture. We have already made a start. Our recent conference about raising concerns, held in partnership with Patients First, looked at the barriers that prevent doctors and other health professionals speaking out and how these could be overcome. We have since updated our guidance to doctors on raising concerns.

But this is just the beginning. In the months ahead, your views are essential to help us lead the debate on cultural change within the NHS so we want to hear from you. Why did Mid-Staffs happen and how can we prevent it from happening again?  

Mark Porter is BMA council chair

Please leave a comment below or email me at info.nhsculture@bma.org.uk

Posted in:  NHS system reform Mid Staffordshire inquiry

Tags:  west midlands NHS reform

Mid Staffordshire Inquiry

The final report of the public inquiry into the events at the Mid Staffordshire NHS Trust between 2005 and 2009 has been published.

Read our coverage of the report and find guidance on the key issues raised.

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