What hope do we have of being looked after in hospital if targets are more important than care?
The Observer, Sunday 22 March 2009
To my knowledge, the only writer who has ever dared give a psychopath the implausible career of an NHS manager is Christopher Brookmyre, the fast and funny Scottish novelist. In his 1996 Quite Ugly One Morning, the villain, Stephen Lime, moves from the City to run an Edinburgh hospital. He hates the idea of doctors overruling executives. “They just couldn’t see, could they?” he rages. “The people who had medical experience were precisely the wrong candidates for NHS senior management, as they brought too much sentimental baggage.” Doctors “haemorrhaged funds to give some old grannies a few more years of drooling and incompetence”, and space in buildings which might be sold for a fortune if only the “coffin-dodging” patients disappeared.
To get a share of the profits from handing the land to a corrupt developer, Lime bribes a surgeon to start poisoning the elderly. Brookmyre makes his manager’s lust for money a plausible motive, but what could he do with the managers of the Stafford Hospital? They were not driven by greed or a psychopathic fury. Their motive was so banal no novelist could entertain it: they wanted foundation status for a north Midlands hospital. To win that pathetic prize, 400 patients, maybe up to 1,200, died, amid silence from the professionals who were meant to protect them.
Just as hardly anyone in the City spoke out as the banking system careered towards catastrophe, so those who ought to have shouted from the rooftops about patients begging for help from excrement-stained beds bit their tongues. Their dereliction of duty is all the stranger because, while Labour did not regulate the City, it sent an army of quangocrats to monitor the NHS and helped staff raise urgent concerns by providing statutory protection for whistleblowers.
For all that apparent encouragement, whistles were not blown by doctors or nurses in Stafford. Instead of independent professionals with the confidence to defend the public interest, the Healthcare Commission described sullen staff, bullied by managers and neglectful of patients. Doctors told its investigators that they had been “proletarianised”: turned from professionals with their own codes and standards into employees who must obey.
The management implemented a “dictate and impose” approach when it decided to allow untrained or partially trained nurses and secretaries to rush patients through A&E so that the hospital could meet its targets and attain the sanctified foundation status. It “steam-rollered” staff and made it clear that it “did not welcome critical comments”.
The enemies of the public sector, who railed against consultants in the James Robertson Justice mould, who thought the NHS was run for their benefit, can see the results of the triumph of target-setting and box-ticking over professional autonomy. We now have a service where doctors are so frightened of the sack they go along with callous neglect. One senior figure explained: “Doctors know that if they cross the NHS they put their career on the line. In London, consultants with private practices are maybe more forthright, but on the whole doctors with only the NHS as an employer have a poor record of defending patients.”
Mortgages make cowards of us all and a cautious consultant who wanted to warn of mass deaths may well wonder who to blow the whistle to. Labour abolished the community health councils, which once acted as effective voices for patients and their relatives. The supposedly independent non-executive directors on trust boards can be guarantors of the public interest, but across the NHS they also know that if they shout too loudly about the colossal costs of a Treasury PFI scheme or the failure of the latest unworkable IT project from the Department of Health, they will not advance in the quangocracy.
In Stafford, directors fell into a second trap and were captured by the management. The Healthcare Commission noted that the board gave “considerable attention to marketing and public relations” and never asked for reports on death rates in the wretched hospital its members were meant to be monitoring.
Suppose whistleblowers were to turn to the press. They would find a cowed Fourth Estate, which is being battered by the recession, and a judiciary which does not believe in freedom of publication. Last week, Mr Justice Blake banned our sister paper, the Guardian, from publishing leaked documents from Barclays which showed how the bank was avoiding the taxes the little people have to pay.
To me, it seems obvious that the public has a right to know how the rich increase the tax burden on the rest of us. It is not at all clear to the judiciary, however, and there is no guarantee that the judges would not also silence a paper which wanted to publish internal documents from a fatally dysfunctional hospital.
The final discouragement to a potential whistleblower came with the news last week that Cynthia Bower, former chief executive of the West Midlands Strategic Health Authority, which was meant to check standards at Stafford hospital, is likely to be the head of the new health regulator, the Care Quality Commission. A public service has to be just, and while I am sure Ms Bower is an admirable bureaucrat, in many respects her promotion makes a mockery of national justice.
To put it another way, whistleblowing codes and regulatory quangos are no more use than the targets for rushing patients through A&E, if there is not a self-confident culture to uphold just standards. If that culture could not develop in the boom years, when money was being poured into the NHS, how will it grow in the worst recession of our lifetimes? With jobs vanishing, Brookmyre’s “sentimental baggage” will be jettisoned as all but the bravest keep their heads down and watch what they say.
• Nick Cohen’s essays Waiting for the Etonians are out now from 4th Estate