This weekend, the excellent health editor of the Sunday Times, Shaun Lintern, revealed how NHS England has been suppressing damaging reports from national clinical audits it funds.
‘The lesson from every major patient safety scandal is that failing to confront uncomfortable truths only allows unsafe care to persist,’ the paper quoted Jeremy Hunt as saying, adding that the NHS ‘should be championing independent scrutiny and transparency – not creating the impression that reputational management is taking precedence over patient safety.’
Unable to control what the NHS does, managers naturally concentrate on controlling how it’s perceived
It’s more than an impression. National audits are being muffled and constrained, their authors forbidden from making recommendations to the hospitals in which they find problems. They are barred from contacting the media, or even from repeating recommendations when they discover that previous similar suggestions have been ignored.
Demands that the NHS adopt the airline industry’s approach to safety aren’t wrong, but have become incantations masquerading as ideas: like saying the NHS should be more efficient, without explaining how that should be achieved. Few people offer specific ideas, fewer offer good ones, and fewer still accept from the start that even the best ideas come with costs and unintended consequences.
Our new Prime Minister has a track record. Burnham was Health Secretary when calls mounted for a full public inquiry into Mid Staffs, and he resisted them. Fortunately, we now have Yvette Cooper, a PPE graduate from Balliol, with her own strong track record of stopping small-boat arrivals as Home Secretary. I do not mean to single her out unfairly. Every one of her predecessors has called for more NHS efficiency, and under every one the NHS has grown more bloated. And since Jeremy Hunt’s invocation of an aviation-style no-blame safety culture, every Health Secretary seems to have repeated this call except James Murray, who simply didn’t have time.
The problem is that the NHS is, and will always remain, a fundamentally dishonest organisation. There are many honest people working in it and there are even some honest people in management. But for structural reasons the institution itself is not, and cannot be, honest.
The reasons for this are simple. The government has total responsibility for the NHS while possessing little real control. Public-sector restrictions blunt the ordinary managerial powers of hiring, firing and differential reward that give private companies at least a chance of efficiency. Unable to control what the NHS does, managers naturally concentrate on controlling how it’s perceived.
The position is obvious, but no government can admit, even to itself, that it is the case. Pretence comes from the top. All the way down managers are hired on the basis that they will deliver what they lack the tools to deliver. To get on in NHS management one has to reject the evidence of one’s eyes and ears. One has to lie.
One of the few really excellent managers I have met was entirely open about this. Perplexed, I asked him why he’d got into management. ‘I saw who else was interested,’ he replied, ‘and I wasn’t going to let the evil lazy bastard ruin my department.’ And that, I think, is what motivates the best people – not the fantasy they can save the NHS, but the knowledge that someone stupider, lazier and less decent is always ready to make it worse.
As a junior doctor, I took part in research testing the accuracy of hospital mortality reviews. I visited a number of hospitals and re-examined random samples of their investigations into patient deaths. Sitting alone in one of those hospitals one weekend, I read the notes of a bricklayer in his early forties, with a young family, who came in with an infection just before a Bank Holiday weekend. His vital signs and blood tests on arrival showed he was dangerously ill and should have prompted immediate discussion with intensive care. Antibiotics and aggressive intravenous fluids, along with close monitoring and repeat tests an hour or two later, would have been defensible.
Instead, there was no further entry until the evening of Bank Holiday Monday, when he went into cardiac arrest and the resuscitation team failed to restart his heart. I went backwards and forwards through the notes trying to work out whether pages were missing. They weren’t. I sought advice from senior colleagues and was told to contact the hospital’s medical director. Eventually the hospital replied that it had reviewed the case and put in place procedures to make sure it never happened again.
I often think back to that man and regret my mistake. Telling the medical director was reasonable, but while I had the patient details to hand I should also have phoned the coroner and the police. Nothing in the hospital’s response gave me reason to think the man’s family were told that poor care caused his death. Nor do I think there were any real improvements.
The same hospital continues to be notoriously bad. Why would it ever not be, when it serves a deprived area which few people seek out as a place to live and work? National pay scales leave managers little freedom to attract staff to the least popular places, so anyone seeking a management job there must boast they will fix a problem without having the tools to do so. They must lie. The exceptional few will lie only to others, and then privately do their best. Most will just lie to themselves.
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