08 February 2013

NHS kills thousands due to neglect - no one held accountable

The United Kingdom's state religion - the Anglican Church NHS

A foreigner visiting or moving to the UK discovers soon after arrival that, unlike any other country, there is a remarkable pride and enthusiasm over its state owned, operated and (pretty much) fully taxpayer funded health service.  The initials NHS are more than just a state institution or a public service, but hold a near sacred status in the UK public zeitgeist about healthcare.  You saw it in the London 2012 Olympics Opening Ceremony, directed by the leftwing Danny Boyle, who decided to celebrate the NHS as something distinctly British to be proud of.

It seems, given that universal health care is pretty much universal in the developed world  (even the US has only had a small minority excluded from health care), a trifle odd.  Setting aside the issues of the United States, there are no fundamental issues of access to health care elsewhere in the developed world, even though it is difficult to find other countries that adopt the NHS model - whereby the users never pay for anything (except nominal prescription, dental and optical services fees for some), where there is little choice of provider (your choice is dependent on where you live and you cannot travel to select a different primary health provider) and funding flows from a centrally planned and directed system to mostly state owned providers.

Since its launch in 1948, the NHS has grown to become the world’s largest publicly funded health service. It is also one of the most efficient, most egalitarian and most comprehensive.

If it does say so itself!

A core mantra is "the NHS remains free at the point of use for anyone who is resident in the UK".  Setting aside the rather loose approach it takes to charging non-residents or

It's proud of its size, which it shouldn't be, as it speaks volumes about what is fundamentally wrong with it:

The NHS employs more than 1.7m people. Of those, just under half are clinically qualified...Only the Chinese People’s Liberation Army, the Wal-Mart supermarket chain and the Indian Railways directly employ more people

So the country with the 22nd largest population in the world (5th largest of developed countries), has the world's largest health provider.  More people work in the NHS than the total populations of 40 countries.  Think for a moment as to what that size of a bureaucracy - the largest in the developed world, of ANY kind - does to attempts to change culture, to be dynamic, to have clear lines of accountability, to attracting management and talent from outside the institution (when there are so many seeking a path within the firm). Think what it does for the bargaining power of the professional associations/trade unions who represent so many staff to a single employer.

Any politician talking of privatisation of health care, or charging for GP visits, or health insurance, is treated like he has entered a mosque and drawn a picture of Mohammed.  It was so important to David Cameron that he had to, what was called, "de-toxify" the Conservative Party, by declaring that his Conservative Party is a party of the NHS.  He cited how much his family had used the NHS, because of his late disabled son Ivan.  He ringfenced NHS spending by keeping to the forecast budget of Gordon Brown's government, which included year on year increases above inflation, by excluding it from spending cuts to reduce the budget deficit.

David Cameron wont even entertain different models for delivering healthcare, although the UK government has embarked on reforms that restructure governance within the NHS, by allowing clinicians to determine purchasing policies and priorities for spending.  Yet the more fundamental questions around having a large single entity responsible for healthcare, about a fully taxpayer funded system, with no financial incentives around individual behaviour, and little competition for delivery (certainly not for consumers), are dismissed. 

Banal media debates see those with a vested interest in the status quo damning talk of involvement of the private sector or insurance models as "Americanisation", not realising that most developed countries have systems with a far more diverse range of health providers, with some part payment, than the UK.  It is akin to saying that the Leveson Inquiry recommendations would mean media regulation would be like North Korea.   However, the Labour Party (the parent of the NHS) and plenty of others on the left use the mongrel like US system as the only counter-factual to what the NHS is, like there are no other examples in the world of different healthcare systems.  The NHS and it supporters regularly claim that it is the "envy of the world", yet one struggles to find developed countries that have replicated this example, or to find the NHS delivers above average outcomes, suggesting that the NHS - as the UK's largest state institution - has been adept at promoting itself.  That means the inertia  of the status quo, and the demand that every increasing amounts of money into this behemoth, will deliver.

So when, having had its funding doubled in real terms under the last government, that it is found out that thousands have died due to neglect, alarm bells are going to go off.

Die while you wait

A 31 month public inquiry into Mid-Staffordshire NHS Trust has found that 1,200 patients died needlessly between 2005 and 2009.  Robert Francis QC's report has had extensive media coverage, in which he said “The most basic standards of care were not observed, and fundamental rights to dignity were not respected".  The numerous cases outlined are appalling.   Misdiagnosis, being without pain relief for days, being left in soiled bedclothes, poor hygiene resulting in patients getting infections that killed them, not being bathed for a month, being diagnosed but not treated for a urine infection which proved fatal, dehydration (with a patient drinking out of a flower vase because water hadn't been provided) and so on.   Many of the cases simply involve maltreatment, lack of pain relief and filthy conditions, but some involve fatality as a result.  One patient's family was told she had dementia, when she was hallucinating because of dehydration. Several had falls which hospital staff said "must have happened beforehand". As the Daily Telegraph reports:

So when John Moore-Robinson was admitted after a cycling accident, he was swiftly diagnosed with bruised ribs and sent away with some painkillers. John died a few hours later from a ruptured spleen, which doctors could have spotted if they’d given the 20-year-old the tests he needed.

 It is a disgrace.   

Now it appears that the death rates at other hospitals are 3,000 over what would be reasonably expected.  Who knows the extent of this scandal.

If it had been a private hospital that had let over a thousand die due to infections, and had a litany of cases of  poor hygiene and misdiagnosis, the Opposition, and indeed the NHS sector (including the BMA and the RCN), would be clamouring for its closure and prosecution of its management and board.

When structural failures and negligence saw the Hatfield rail accident kill 4 people and injure 70, it saw an inquiry into the rail industry that eventually wound up the rail infrastructure company Railtrack, replacing it with Network Rail.  All because Railtrack had inadequate maintenance records and an incomplete asset register, so was incapable of holding its contractors responsible for failing to safely maintain its network.  Network Rail as successor agency was taken to court for manslaughter, along with its contractors, and ultimately they were found guilty of breaching health and safety laws.  Individual executives were called to account.

In this case, the inquiry into the Mid-Staffordshire hospital has whitewashed away the concept of individual responsibility.

Nobody is responsible in the post-modern world of new left public services

Gordon Rayner and Stephen Adams have pointed out in the Daily Telegraph the part of the Inquiry report that lets down the families and friends of the victims the most - the denial that anyone is to blame.  It said:

This is not a case where it was ever going to be possible or permissible to find that an individual or a group of individuals was to blame for this.  “When examining what went wrong in the case of a systems failure as complex as that surrounding the events in Stafford, the temptation of offering up scapegoats is a dangerous one which must be resisted. “To do this would be to create the fiction that the behaviour of one person or a small group of people, would have made all the difference...it was not a single rogue healthcare professional who delivered poor care in Stafford, or a single manager who ignored patient safety.”

So it is systemic.  Yes.  Of course it is.  A culture developed whereby it was acceptable to cut corners, to ignore the needs of patients and to conceal mistakes.  The simplest of tasks around hygiene were ignored, and a culture appeared that made patients fearful of nurses and doctors.  Confronting that is a priority.

Yet it is thoroughly post-modernist and terribly convenient for the NHS for the report to fail, completely, to identify anyone responsible for the failings.

It is possible to do so with a railway accident, where there were people responsible for maintaining the track, inspecting the track, signing off on the work done, planning renewals.  They were taken to court and faced charges, that were ultimately dropped.

Why are doctors, nurses and other hospital staff left to be anonymous cogs in a machine that is bad?  Would anyone want doctors who misdiagnose cancer as a kidney stone, or leave infections untreated, to be treating them?

Yes there was a "culture of fear, bullying and secrecy", but who spread the fear?  Who threatened whom?  The Trust Board which did not listen to staff or patients when the complained, is culpable surely.  A focus on bureaucratically determined targets, on promotions and on reporting requirements undermined any interest in delivery of results.  One comment suggested that it smacks of Soviet bloc production target seeking, without any concern for whether what is produced is any use, or the casualties created along the way.

However, it isn't as if the NHS doesn't have oversight bodies, it's just they failed too. So called "community health councils" failed.  Like an exercise in bureaucratic box ticking, the state sanctioned entities signed off each other, but treated complaints by patients and staff like buzzing mosquitoes.  

Why should anyone be surprised though?

It has shades of the BBC Jimmy Savile scandal, where a top (now deceased) star sexually abused underage girls and young women repeatedly, sometimes on BBC premises (and indeed on NHS premises), where it was said by more than a few that it was "known" as to what he was like.  No one is accountable for that either.  No one is accountable for putting an unqualified TV personality in charge of a facility for vulnerable young people. 

Yet of course, this standard is reversed when it comes to the private sector. Railtrack was a private company, as was its contractors.  There are calls, rightfully, for RBS executives and staff to be accountable for the LIBOR scandal.  Tesco jumped when the relatively benign problem of horse DNA in beef burgers was identified.   Whenever private companies break the law or defraud people, there is a political and media frenzy to demand they be accountable.

However, a different standard has been applied to the state sector, especially the sacred cows of the NHS, and the BBC (consider how the most powerful broadcaster in the land influences news about itself).  

It is a standard that seems to have an underlying fear that if people are named, shamed and held accountable, that the whole edifice of the organisation will collapse, that they will point at others, and a vicious cycle will be entered into that calls into question the entire system.

It is the culture that suggests that people aren't responsible for what they do.  It's what generates calls for taxes on fat or sugar or limits on advertising them, because individuals aren't responsible for their own health. It's a culture that blames a system, not the people within it.  

Yet there are individuals who can have the fingers pointed at them, though they have swept them aside.

Julie Bailey, a campaigner whose mother died at the hospital has "called for the resignation of Peter Carter, the general secretary of the Royal College of Nursing, which had told a whistle-blower at the hospital to “keep her head down” rather than fight for change".

If true, this is contemptible. 

Sir David Nicholson was chief executive of Shropshire and Staffordshire Strategic Health Authority, during the initial period when these allegations took place.  He is now chief executive of the NHS for England.  He is apologetic, but resists calls to resign.  His career speaks volumes though of the incestuous management culture of the organisation.  A graduate of Bristol Polytechnic, in history and politics, he has spent his entire career at the NHS.  He was a member of the Moscow aligned Communist Party until his late 20s.  No private sector experience, no formal management degree, no non-NHS experience, no experience in customer service.  A career bureaucrat with no medical training, who is clearly adept at having a focus on meeting bureaucratically determined targets.

Yet, the Deputy Prime Minister (I know, who?)  has "full confidence" in him.

She lists Dr Helen Moss, the hospital’s director of nursing from 2006 to 2009...

Dr Moss was cleared by her professional regulator. The Nursing and Midwifery Council (NMC) said that Dr Moss had “no case to answer”. The NMC refused to say how it had reached this remarkable conclusion, since all details of the case are “private”.

So a public servant who was in charge of nursing at a hospital that was complicit in the deaths of 1,200 people is not accountable to the people who paid her wages. If the buck doesn’t stop with Dr Moss, who the hell does it stop with? Certainly not Stafford’s former chief executive, Martin Yeates, who cut 150 jobs to save £10 million at a time when there were already serious safety concerns. An external report recommended that there was a case for disciplinary action against Mr Yeates, but the hospital board decided on “pragmatic and commercial grounds” to negotiate terms for an agreed departure. Therefore, unlike many of his former patients, Mr Yeates left Stafford hospital not in a wooden box, but with a £400,000 payoff.

Quite.  The NHS, the organisations surrounding the NHS and the systems meant to protect patients failed, because of one overriding factor - people wanted to protect themselves from accountability.  

It goes on and on, as she points out that Cynthia Bower, who was head of the West Midlands strategic health authority at the time, was appointed chief executive of the Care Quality Commission.  She dismissed the deaths as a "statistical blip".

No.  It's simpler than that.

People didn't do their jobs properly.  They were not and are not competent to be in the health care sector.  

Four doctors and nine nurses facing public disciplinary hearings over their behaviour are still working and performing medical procedures for the NHS. Shame you don't know who they are.

Heads should roll.

Limp political response

The "state religion" approach to the NHS remains, with the Prime Minister talking as if he was dealing with a terrorist hostage situation saying "I think the NHS is a fantastic organisation. I always want to think the best of the NHS".  Just in case the Labour Party was ready to trot out its ironic cliche "you can't trust the Tories with the NHS".

He needn't have said the words "Tories with the", for the victims of Mid-Staffordshire have shown that you cannot trust the NHS.  It is literally a lottery as to whether you get professional staff who do their job properly or not.  It isn't one that you can complain about, because if you do, you face a guilt trip because "it's free" or that it will be addressed through procedures you have little exposure to.

The Labour Party response is subdued, having apologised (given it was the government at the time), but saying that it is not typical of the NHS.  Like the Catholic Church pointing out that it wasn't typical for priests to bugger boys.  Yet Dan Hodges, a former Blairite, has pointed out that many on the left are scrambling in fear that their faith of choice may be under attack, and they themselves risk destroying it.

It is absurd that almost all of Britain's health care sector is in one single employer.  It is also absurd that competition and choice are denied a system that delivers such widely varying outcomes, despite having had unprecedented amounts of taxpayers money literally shoveled into it.  It is absurd that people don't face some financial signal for choosing to use the system, or for their own personal lifestyles, and that the failure to do this becomes an excuse to create new sin taxes and regulations on food and drink.

Yet a lot would be gained from Britain looking at the successful models of its neighbours, like Germany, and Switzerland.  Where everyone has health insurance, which people choose from various providers offering a minimum level of care (with more optional), where the poorest get a top up from the state to buy it, where private companies operate hospitals, primary health care services and A&E units, where patients choose their doctors and hospitals, and where the multitude of providers means no monolithic culture can develop.  It means that doctors and nurses associations can't clam up so easily with an omerta code to say nothing of failures or to dismiss complaints from junior staff.   Without a single monolithic structure and source of funds, it is easier to confront failings, for underperforming entities to be closed down and taken over by other suppliers.  It also means that employment in the sector isn't about being in one tent and always moving up or sideways, but about moving out.

It also means the NHS wouldn't be the laughing stock of the world. Find a single American living in the UK who would not choose to use a US hospital over the NHS.

What is most disgraceful is the silence from the usual rent-a-mob protest groups of the left.  The people only too keen to jump on Starbucks for legally paying the minimum possible tax, don't get upset because thousands are dead in a system they worship.  Never mind, for what they reap from this will not be what they wish, as Dan Hodges points out...

where, today, is the liberal outrage? Thousands of people are dead, yet from the Left there is nothing but tumbleweed. When are the tents of the Occupy movement going to start appearing in Staffordshire? When are we going to see nurses hung in effigy?

Yes, it’s an abhorrent thought – hanging a nurse in effigy. Yet the Left will do that to a banker, and not bat an eye. And the bankers did not leave those to whom they had a duty of care screaming in agony.

This is the real threat to our health service. It isn’t George Osborne’s blunt and rusting axe; despite Ed Miliband’s taunting, David Cameron has no intention of letting the NHS become his Poll Tax. It is our own arrogant, complacent beatification of that service, and those who work within it.

If we are to name and shame the bankers, fine. But let’s name and shame the guilty nurses and doctors of Mid Staffs, and the other Killing Trusts too. If we’re up for serious, radical reform of our failing financial sector, fine. But then let’s be equally strident in our calls for reform of an NHS which is just as guilty of systemic failure.

We are not protecting our NHS by placing it on a pedestal and venerating it. We are killing in it. And our NHS, in turn, is killing us.

It is time for a serious public debate, not about the NHS, as if it is the only option, but about health policy in the UK.  It is time to talk intelligently about what is done in other countries, and to start to recognise that what is wrong with the NHS is its very core.  No country can have a best practice health care provider that is a bureaucracy rivaled only by the army in China and the railways in India.

1 comment:

Anonymous said...

Insane. Utterly insane.

So, I assume that the UK would "put the kibosh" on its having "After-hours medical clinics" (as NZ has). Despite their name, these clinics often open during daylight hours and take a *huge* amount of strain off the rest of the health system.

I find it **BIZARRE** that while the UK is rolling out "charter schools" (which I support) for all and sundry, it STILL can't get its head around the idea that a similar model for health-care could be a good idea.

*Massive*, centralised bureaucracies like the NHS are *very rarely* the most efficient way of providing services.