FLASHPOINTS #9: Dysfunctional healthcare, toxic cultures, and how to talk to doctors
An interview with Martin Bromiley OBE
Every day, people place their lives in the hands of doctors, nurses, midwives. In the vast majority of cases, that trust is repaid in the care, skill and expertise with which healthcare professionals carry out their work. But sometimes, those professionals make mistakes, and those mistakes can harm or kill patients. Worse, some of them engage in routine practices that are dangerous or positively harmful to the people in their care. In the last couple of weeks alone, two examples of the latter have to come to light. At the Edenfield Centre, a mental health hospital near Manchester, an undercover BBC reporter has revealed how patients were being routinely demeaned and abused by staff. A newly published NHS review has concluded that at two hospitals in Kent, systemic malpractice by midwives led to up to 45 babies dying unnecessarily.
Coincidentally, both of these examples made the news after I decided to interview Martin Bromiley about healthcare malpractice (we reference the Edenfield case, which made headlines on the day we were talking). This conversation was actually prompted by an individual’s story - specifically, a piece written by the Guardian journalist Merope Mills about the death of her daughter, Martha. Mills’s piece tells the story of how a bad but survivable accident became a fatal one, after Martha’s case was mishandled by NHS doctors. I know many of you will have read the article already. If you haven’t, I suggest you do. It’s a harrowing, enraging read, and an astonishing piece of writing, which raises urgent questions about the culture of the NHS (questions relevant to healthcare systems around the world). It also asks us to confront a deeply uncomfortable question: how much trust should we place in doctors?
After reading it, I knew exactly the person with whom I wanted to discuss the issues it raises. I first met Martin Bromiley eight years ago when I wrote a profile of him for the New Statesman. Without wishing to give you too much homework, I really recommend reading it because his story is amazing. But I’ll give you the very short version.
Martin is an airline pilot. In 2005, his wife Elaine entered hospital for a routine nasal procedure, but the operation was botched by doctors. She suffered catastrophic brain damage and died. As he emerged from grief, Martin resolved to change the way that the NHS thinks about medical error, which is what he has focused on since, alongside his career in aviation.
Martin is immersed in the science of decision-making, safety and error. He was part of the airline industry when it successfully reduced accidents by instituting a worldwide program of procedural and cultural change. One of the big problems in aviation was overly hierarchical relationships between pilots and junior pilots and crew, with more junior staff feeling unable to question or challenge more senior staff. That cultural dysfunction was leading directly to disasters and deaths. The industry took steps to change that culture and it largely succeeded.
In healthcare, the same dysfunctions exist, and they result in harms to patients. But healthcare is way behind aviation and other ‘safety-critical’ industries when it comes to addressing them. Martin has made an extraordinary impact on the NHS over his years of campaigning but, as is evident from the Mills story and the cases I mention above, there is still a long way to go.
In this conversation I ask Martin about the systemic dysfunctions highlighted by the Mills article (dysfunctions which, by the way, are from unique to healthcare, even if there are few industries in which the human stakes are as high). He identifies a cultural problem he calls the “normalisation of deviance”. I also ask him for advice on a question with which I think many of us are grappling. We respect and rely on doctors, but we also know that sometimes they get things wrong. Given that, how should we interact with them during critical conversations about our own health, or the health of those we love?
Martin, we last talked properly a few years ago. What progress has the NHS made since then on the issues you campaign on?
In the mid-2000s I remember a conversation with a surgeon who had written a paper on patient safety. He told me that one of his peer reviewers introduced himself by saying he was ‘a junior doctor with no special interest in patient safety’. At that time, that was a perfectly logical thing to write. Patient safety was just assumed. Obviously patients are safe. We've moved on a lot since then. Doctors, nurses and policymakers will talk about the science of safety. There is now a Healthcare Safety Investigation Branch, and a curriculum for patient safety which will apply to every single one of the 1.4 million people in the NHS. But the problem is still with us. In Merope Mills’s article she mentions that 150 patients die of avoidable harm every week. That is the kind of average figure we're talking about in the NHS. That's just for England: across the United Kingdom it will be more. Those are just the reported cases - it may be far worse. In the case of Martha, for instance, I'm not sure her death would have been picked up had it not been for her mother’s advocacy.
It would have had to cross a clear line, and the problem is there often isn't one. People die all the time in healthcare. So there’s a sense that, you know, ‘These things happen’. Professor Sir Bruce Keogh has spoken eloquently about the ‘acceptability of harm’. When I first got involved in the NHS, hospital-acquired infections like MRSA and C. difficile were in the news. The rates were quite staggering. Many people in the NHS took the attitude, ‘Well, obviously people are going to die of infection in hospital, it's a dangerous place.’ Since that time, it has been tackled, and some hospitals go months and months without deaths from these infections. But at the time, it was just a shrug.
A lot of things get missed because of that shrug. Well, it happens. I’d like to think that a coroner would pick up on the issues involved in a case like that of Martha’s. But coroners are usually not specialists. In a case I've been dealing with recently in which someone died through medical error, the coroner went for advice to the hospital where it happened. They went to the unit where it happened and asked the specialists! And of course they told him, well, this happens. In the end there was no inquest. So it's not just the healthcare system that is often oblivious to the fact that a death could have been preventable, it’s the coronial system as well. People are very willing to accept that it is just one of those things; it's bad luck, people did their best, it just didn't work out. As I was told in Elaine’s case.
The Mills story highlights a culture of deference and arrogance in the NHS. Was that familiar to you?
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