Is the box ticking culture of the NHS killing its humanity?

The NHS is, ideologically, a form of Communism . . . but that can lead to a ‘Stalinist’ centralised system

The needless deaths of hundreds of patients at Gosport War Memorial hospital in Portsmouth could hardly be more disturbing. The essential compassionate basis of healthcare appears to have been ignored by a regime that systematically prescribed doses of drugs that at times shortened lives, then covered up the abuse for decades.

In the stark words of this week’s inquiry report — which found that some 456 patients died as a result of the opioids they were given, while another 200 may have suffered a similar fate — there was a ‘disregard for human life’ at the hospital.

Patients, their bereaved families and the very ethical foundations of medicine have all been betrayed by this grim saga.

It is particularly alarming that the destructive culture at Gosport was not only allowed to persist for so long, but that so many senior staff and public figures — including doctors, managers, coroners and the police — shamefully appear to have kept it a secret until the evidence became impossible to refute.

As far back as 1991, two brave night nurses working on a ward run by Jane Barton — the GP at the centre of the scandal — spoke of their profound concerns about the number of patients receiving strong but unnecessary painkillers.

Yet their anxieties were dismissed and they were accused of ‘making waves’.

This, I believe, highlights a key problem at the heart of the NhS. The health Service, where everyone receives treatment without paying at the point of delivery and which celebrates the 70th anniversary of its creation next month, is one of our most cherished institutions.

Yet too often — as we have seen in a host of other scandals, most notably at MidStaffordshire, where NhS care at its most negligent over a period of more than four years resulted in 500 excess deaths at Stafford hospital — it promotes a climate of institutionalised secrecy.

NhS leaders, including politicians, managers and clinicians, frequently appear to be more interested in protecting the system’s image than in addressing the service’s serious failings. In this climate of suppression, critical reports are rubbished, whistleblowers silenced and desperate relatives ignored.

The impulse to conceal runs deeply in this very highly centralised, ultra- politicised, heavily bureaucratic organisation.

As a doctor who has been involved in the development of methods for monitoring death rates in the NhS, I have long been troubled by this ethos which puts reputation before patients’ needs.

After the Mid-Staffs scandal, I referred to the NhS’s ‘denial machine’, and that phrase is just as pertinent about Gosport.

FolloWING every harrowing episode, and every subsequent inquiry, we are solemnly told by ministers that ‘lessons have been learnt’ and that ‘it must never happen again’.

So why do the horror stories keep emerging?

Today we are faced with the question as to whether more Gosport-like scandals are waiting to be exposed in the NhS.

It is impossible to know with any certainty, but there are a number of uncomfortable indicators of poor practices within the NhS that may have caused countless unexplained deaths.

one of these comes from the data that I and my colleagues gather on death rates within the health Service, using methodology originally inspired by the Japanese motor industry, which uses statistical monitoring to make cars as safe as possible through continuous quality improvements.

Since 2003, we have been sending mortality alerts to the chief executive of any hospital trust that shows a death rate for any given condition — such as diabetes or septicaemia — which is more than double the national average over the preceding three months. The chances of any alert being false are less than one in 1,000.

Such alerts are also copied to the health watchdog, the Care Quality Commission.

My data reveals that out of nine developed countries I have studied — including the U.S. — the NhS had the highest hospital death rate when adjusted for age, sex, diagnosis and other factors. on a deeper level, there is also the question of whether the morbid culture that prevailed at Gosport — described as one ‘of shortening lives’ — prevails more widely in the NhS?

Throughout the history of medicine, kindly doctors have always acted to end the suffering of the terminally ill if they are in great pain.

The idea of deliberately extinguishing the lives of patients, simply because they are elderly and frail, is utterly abhorrent and should be anathema to anyone working in healthcare.

But is it possible that, through its box-ticking managerialism and sprawling bureaucratic structure, the NhS actually undermines that spirit of humanity? This is not to attack the dedication and commitment of hard-working NhS staff, but to question the culture of their employer.

A classic example of wrongheaded managerialism was the development of the notorious liverpool Care Pathway, which started out as a well-intentioned method of providing palliative care to the terminally ill.

It ended up, in some cases, as a means of rapidly hastening death by withdrawing food and fluid.

In effect, rule-based application of a ‘care pathway’ had replaced genuine compassion.

There were two particular aspects of the liverpool Care Pathway that disturbed me.

The first was the lack of any consultation with patients or their families.

A study by the Royal College of Physicians of 7,000 deaths on the liverpool Care Pathway found that no less than 44 per cent involved patients who were sentient and mentally aware, yet there was no record of any discussions with them before they were put on the Pathway.

The second was that health trusts actually received payments for patients they placed on the Pathway, giving them a direct financial incentive to embrace this practice. After a public outcry and a campaign led by this paper, we are assured that the Pathway has now been abolished — yet I hear of reports that it continues in other forms.

No, what is needed is a wholesale change in the culture of the NhS, so that transparency is valued above protecting the system.

It is no exaggeration to say that the health Service is, ideologically, a form of Communism in that, theoretically, it is paid for by all according to their ability to pay (taxation), and provides for all according to their needs.

But that can lead to a ‘Stalinist’ centralised healthcare system.

The NhS is creaking badly and we need hard-headed candour about the its failings if real lessons are to be learned. In the immediate term, that means three steps.

First of all, proper safeguards should be provided for NhS whistleblowers so they are not afraid of losing their jobs if they speak out.

At present whistleblowers are either fired, gagged and blacklisted — or ostracised and derided, just as those nurses at Gosport Memorial were.

Reports of front-line malpractice should be welcomed as the potential catalysts for improvement, and there needs to be an independent regulator who will ensure whistleblowers are protected, not punished.

Secondly, there also needs to be a similarly independent, rigorous system for investigating complaints from relatives about the treatment of a loved one.

SUCh a system used to exist through what were known as Independent Review Panels, but they were abolished in 2004. The recent establishment of the healthcare Safety Investigation Branch is an inadequate substitute, as it only plans to look at up to 30 cases a year.

The NhS requires something on a much bigger, more effective scale, a body that has real teeth both to challenge erring professionals and to provide confidence to grieving families.

The third step is for the NhS hierarchy and the Department of health to publicise any association or connection with the secretive organisation Common Purpose, which, as this paper has revealed in the past, is a not-forprofit ‘ charity’ that provides leadership training for public sector managers.

There are claims that more than 80,000 executives have now been through its programme.

Many are thought to hold senior positions in Whitehall, the BBC, local government and major police forces as well as the NhS.

Complaints used to be made, with some justification, about Masonic influence in the public sector, especially the police and local government. Common Purpose seems to me to be a new version of this.

I am as uncomfortable with what appears to be its pervasive influence as I am with the NhS culture of denial.

The NhS should be focusing all its energies on its patients and staff. As Gosport so depressingly proves, the cover-ups must end.