Fears over ‘toxic’ team of surgical consultants
‘Aggressive behaviour’ safety warning
A “DESTRUCTIVE, toxic culture” has developed in a team of consultants who operate on patients across Scotland and which amounts to a “recipe for serious patient safety issues”, according to a leaked report.
Unless the clinicians accept they need to change and work better together, the investigation says their unit – which looked after 3000 patients last year – cannot continue to operate.
“Forceful and at times aggressive behaviour” is described in the independent report, which was ordered by NHS Lothian after concerns were raised about the Vascular Unit at Edinburgh Royal Infirmary.
This department, with almost 50 beds, relies on a group of seven surgeons, six radiologists and seven anaesthetists.
It runs a national service treating patients with life-threatening bulges in their main artery as well as dealing with other diseases in veins and arteries for the NHS Lothian population.
The report, carried out by two leading vascular surgeons in England, describes a breakdown in relationships where management is seen to favour one surgeon and “a gang culture” is perceived among the other consultants.
The clinicians are said to actively look for errors in each other’s work with some taking notes and recording events so they can refer to the material when criticising colleagues and use it to defend themselves.
“These processes are taking considerable time and effort and must be consuming time that could be move profitably applied to patient care,” says the report.
Referring to probes into hospital scandals in England that led to a number of deaths, the report later adds: “The care delivered by this unit appears to be more based on surgeons, individual careers and their dysfunctional relationships rather than on safe patient-centred delivery.”
The authors, Mr Tim Lees, clinical director of Freeman Hospital in Newcastle, and Mr David Berridge, a medical director for Leeds Teaching Hospitals NHS Trust, looked into the care of a number of patients treated in the department, including a 43-year-old man who died four days after his operation.
They found the surgery did not go as planned, that it was perhaps “inappropriate” for a surgical trainee to undertake the procedure initially and that later other staff felt the surgeon in charge needed help, but he apparently disagreed.
While noting there is no clear evidence such issues directly contributed to the death, the report says: “Interpersonal differences between surgeons on the vascular unit may have affected the willingness of surgeons to request or to offer assistance during a complicated case.”
The department’s facilities were praised and the results of “thoracic abdominal aortic aneurysm surgery” – the national artery service that performed 47 procedures last year – are considered “excellent” by the authors.
But there is concern the unit is not offering the full range of treatment options in the same reasoned, evidencebased way patients get in other hospitals – particularly a potentially safer alternative to open surgery where a coil is inserted through the arteries to protect the artery walls.
Questions were also raised about the way junior doctors are being trained in the unit, with allegations of bullying and concern about the experiences they are getting.
The authors found evidence staff members were being encouraged to take sides, with at least once instance in which a veiled threat was made.
Dr David Farquharson, medical director for NHS Lothian, said: “We know this report does not make comfortable
reading, but as soon as concerns were brought to our attention we commissioned this external review of the vascular service to ensure patient safety and good quality, person-centred care remains our top priority. We will not tolerate bullying or harassment in the workplace and this approach is embedded in the values of NHS Lothian. We have also developed systems to improve the way we deal with poor individual performance at work and introduced a clearer system for escalating concerns about performance.
“The immediate actions, identified in the report, have been implemented and an expert steering group has been created to progress other recommendations as a matter of urgency.”
Professor Ian Ritchie, president of the Royal College of Surgeons of Edinburgh, said: “I absolutely believe that clinicians of all sorts and of all disciplines have to respect each other and have to work together in order to achieve good outcomes for patients. In doing that it is important to recognise that there is a lot of effort and commitment by all people involved because teams do not just form they have to be worked at.”
THERE was no careful political language, no diplomatic euphemisms, just strikingly honest language and a devastating conclusion. According to a report leaked to The Herald, a destructive and toxic culture has developed among the clinicians at the vascular unit at Edinburgh Royal Infirmary which amounts to a recipe for serious patient safety issues. Unless significant changes happen in the department, the report concludes, vascular surgery should not continue in the city.
The investigation into the unit was ordered by NHS Lothian after it received reports that the relations between the clinicians had broken down and its conclusions could not be clearer. According to the authors, who are two of the leading vascular surgeons in England, relations have deteriorated to such an extent that the ERI clinicians are actively looking for errors in each other’s work. Management was also seen to favour one surgeon over another and there are questions about the way junior doctors are trained. There was also evidence some staff had been encouraged to take sides.
None of this behaviour should be happening in a well-functioning hospital department, but there are at least some positives. The report says the facilities at the unit, which looked after 3,000 patients last year, are excellent and the results of the national service it runs to treat bulges in the main artery are equally good. This is reassuring and it should be some consolation that, unlike some of the hospital scandals in England, the problems at the unit were uncovered before patient care could be compromised.
However, the report makes it clear that a risk to patient care does exist and action must be taken quickly. NHS Lothian has already moved on some of the issues and is understood to have appointed a new clinical director. The report also highlights the appraisal system and the structure staff can use to raise concerns. We know from previous cases – not least the suspension of two surgeons at Aberdeen Royal Infirmary – how important it is NHS staff feel they can take their worries to management and that they will be acted upon if necessary and NHS Lothian must act to ensure such a system is working work in the vascular unit at ERI.
There are also lessons for staff as well as management in the report. Firstly, staff have to work as a team for a department to function well and this was clearly not the case at ERI’s vascular unit when the investigation was carried out. Tensions will always exist in a group of humans, but with the report reaching such a damning conclusion, the clincians must now work out their differences. It will not be easy – as Professor Ian Ritchie, president of the Royal College of Surgeons of Edinburgh, says, teams have to be worked at – but if NHS Lothian can make the changes it needs to make, then so too must the clinicians.
The clinicians should also take particular note of one part of the report. Referring to the recent hospital scandals in England, such as Mid Staffordshire, the report says the functioning of Edinburgh’s vascular unit appeared to be based more on the staff, their careers and their relationships rather than the safe patient-centred care described in several of the reports into the scandals. It is that patient-centred approach that should be at the heart of every hospital department. The staff and managers at ERI’s vascular unit must now put aside their differences and work towards achieving it.