A "DESTRUCTIVE, toxic culture" has developed in a team of consultants who operate on patients across Scotland and risks becoming 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 into the Vascular Unit at Edinburgh Royal Infirmary after concerns were raised.

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 which could be move profitably applied to patient care," says the report.

Referring to probes into hospital scandals in England which led to a number of deaths, the report later adds: "Currently 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 as described in the Francis Reports, the Keogh Report and more recently the Morecambe Bay Report."

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, look into the way a number of patients were treated in the department including a 43-year-old man who died four days after his operation. They find 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 facilities in the department are praised and the results of "thoracic abdominal aortic aneurysm surgery" - the national artery service which 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, evidence-based 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.

Grave questions are 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 says the department's ability to train doctors should be reviewed, adding: "we do not believe that it is currently capable of delivering the agreed curriculum, and the current toxic environment is not one that trainees should have to witness or endure."

They found evidence members of staff were being encouraged to take sides, quoting one employee saying they were told who they should support if they "knew what was good" for them. The tensions also appeared to be spilling into people's personal lives with some of those interviewed giving "a profound impression of melancholy and unhappiness."

The report, dated April 2015, says: "Very significant, rapid changes need to take place as described in our report as we believe the current situation amounts to a recipe for serious patient safety issues. We fail to see how vascular surgery can continue in Edinburgh if these issues are not addressed."

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 that patient safety and good quality, person-centred care remains our top priority.

"Carrying out this review is evidence of our commitment to openness and improvement. We have been very clear. 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."

Mr 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."