The Ockenden Maternity Review, published today, finds the NHS is not to be trusted – not for maternity care, possibly not at all. Set up in 2022 in response to concerns over the safety and competence of maternity care at Nottingham University Hospitals NHS Trust (NUH), the report finds failures of leadership, governance, and culture:
Poor practice is not investigated; learning is not integrated; and mothers and babies are failed by an organisation they should be able to rely upon.
Perfection is not to be found and should not be expected. My son’s arrival into the world was delayed by a junior doctor’s dishonest laziness. Spotting problems, she prevaricated, arranging unnecessary tests that delayed decision-making until her shift finished. Her replacement acted immediately, saving the lives of mother and baby, but at considerable cost to both.
Donna Ockenden confirms what many other reports have said before: maternity care in Britain is awful. Not all of it, but far too much, and consistently. And the poor standards survive report after report. They are undiminished by managers and politicians vowing to learn lessons. Solely at NUH, says the BBC, Ockenden identified 155 babies who died and another 105 seriously injured, who might have lived and flourished with better care.
NHS maternity care is not peculiarly bad: what’s bad is the NHS
Does maternity attract the worst people? Hardly likely. The alternative is that failings in maternity care aren’t more common than failings elsewhere, just easier to spot. Babies don’t normally die: when they do, we notice. What we don’t notice are old people dying at higher rates, because their deaths are unsurprising. We barely notice our outcomes for avoidable premature deaths are terrible compared to other countries. We don’t see it because we don’t want to.
NHS maternity care is not peculiarly bad, as our cancer outcomes show: what’s bad is the NHS. The system I spend my life working in, and many of whose qualities I treasure, delivers woeful results and keeps doing so regardless of how much money it gets.
I have quoted the American businessman Charlie Munger before in these pages: ‘Show me the incentive and I’ll show you the outcome.’ The NHS has no sane incentives, and it is a testament to the character of most of its staff that the outcomes are not worse still. There is laziness and incompetence and dishonesty galore, as there is everywhere in life, but there is probably more general desire to help as a team than in most workplaces. A great many NHS staff try hard and mean well.
That isn’t enough. A system cannot be left to good intentions, any more than it can be regulated into excellence. You must have good management, which the NHS lacks. We have administrators but they have no power. They cannot hire and fire, promote and demote, they cannot threaten and reward. They operate in a system that pretends to control what it cannot, and roles built on dishonesty attract people for whom it is the air they breathe.
Persistently poor NHS maternity care will not be cured by new regulations or a new regulator. Calls to change the culture will be ineffective unless there are tools for doing so. Some changes would be simple to make. NHS staff like me currently have jobs for life. We earn the same regardless of our effort or quality. There are exceptions for ‘excellence awards’ and bonus managerial pay, but these reward those who successfully hide from delivering the clinical care that matters. They operate as perverse incentives, motivating staff to create pointless bureaucracy and rewarding those who hide from front-line work.
Make all jobs provisional on meeting the demands of managers who themselves are properly incentivised. Give them the power to pick staff and to sack them, give them the ability to alter rewards to reflect performance. There will be cheating and gamesmanship, personal animosity and unfairness, greed and injustice. But all systems have horrors; Ockenden shows the ones we tolerate now are too great. Make NHS staff work harder and work better and the evils you create are likely to be vastly outweighed by benefits. We should train more doctors and nurses than we need, staff like me should compete, and no jobs should be for life.
At a meeting of a right-wing thinktank earlier this month, I heard speakers talk of improving the NHS. New measures should be introduced to encourage us to be slimmer, healthier, fitter. The NHS could be reorganised. Abolishing NHS England might help. In Dominic Cummings’s terms these are the ideas of NPCs, the non-player characters in computer games who mindlessly repeat the same response.
These ideas aren’t right-wing but more importantly, they’ve already failed. Consistently. As the NHS swells, growing ever more expensive and delivering ever worse outcomes, one cannot, whether one is right or left, propose more of the same. Ockenden closes by calling for ‘accountability, learning, transparency and kindness at every level’. Pretty words are empty without mechanisms to bring them about.
The junior who mismanaged my wife’s first labour will now be a consultant, earning the same as all the others. Perhaps she has improved, but I have no grounds for confidence: most systems offer more slack to seniors than juniors, and few NHS staff grow more industrious as they acquire the rank to avoid clinical work. Large institutions need effective management, not just good intentions. Too many of us die too early because the NHS is failing, and some of those who die are babies.
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