The report of the independent inquiry into the surgical malpractice of Ian Paterson is welcome. I carried out a similar review for the Heart of England NHS Foundation Trust seven years ago when it became clear that something was wrong and patients were being harmed. My review was limited to Paterson’s NHS practice. The independent inquiry’s report examines his practice in the private sector as well, and, just as importantly, the communication (or lack thereof) between the NHS and that sector. The jigsaw is now complete: the picture in all its horror is now revealed.
But, while it is of great importance to reveal that picture, it is perhaps even more important not to lose sight of the fact that there is a much bigger picture. The NHS is a marvellous institution, performing myriad acts of care and kindness every day and more than a few minor miracles. But we must not blind ourselves to the fact that things regularly go badly wrong. The truth is that there are frequent eruptions of failure. We can all remember them. They are like signposts to the dark side of the NHS—Bristol, Morecambe Bay, Mid-Staffs, and so on, and so on.
The danger is that we treat each of these eruptions in isolation—as a one-off. They command headlines for a day or two and provoke promises of “never again” from all and sundry. Then the news cycle moves on. The patients harmed are left with their harm. Current and future patients are left with their anxiety. Healthcare professionals are left with the taint of blame, whether warranted or not. The NHS is left with another scar.
These disasters are not one-offs. They indicate that there are systemic weaknesses in the NHS (and even more so in the private sector). These weaknesses have been known about for decades. They are routinely recited in the latest “report” or “review.” Ways of remedying them have also been known and repeatedly recited. But still horrible things happen.
The time has surely come to make an effort to do something about this bigger picture. We need to be bold. It must be a major undertaking. It must involve those who have the necessary knowledge and experience and can be fearless. It must put at the forefront the concerns of patients and those who care for and about them. If 2020 is to mark a fresh beginning, what better place to begin than getting the NHS right? Limping from disaster to disaster, slagging off managers and doctors and nurses en route, is no way to respond to the systemic weaknesses that bedevil the NHS.
What are these weaknesses which cause things to go wrong?
First on the list is leadership or lack of it. Time and again, Reports comment scathingly on the poor quality of the leadership in a hospital or trust. Not everyone can or should be a leader. The ability to lead an organisation is not something you just pick up as you do your job. It calls for particular personal qualities which need to be tested and skills which should be taught. It is a career long activity. Training leaders is a major investment in the Armed Forces. It is not in the NHS, despite desultory recent efforts.
Secondly, there is the problem of weak management. Bullying, over-bearing behaviour, non-compliance with agreed practice are some of the many examples of challenges that managers must face. If they are not carefully selected and trained they will wilt before these challenges. Patients and other healthcare professionals will suffer.
A third weakness that is a precursor to failure is the toxic culture which sometimes overtakes an institution. The various tribes of doctors and nurses fight their wars, among themselves, or against some perceived threat (from revalidation to changes in the rules about parking!). Professional organisations are torn between keeping members happy and establishing norms of proper conduct. Failings come when they forget that they exist for patients, rather than the other way round.
Fourthly, there is the regulatory framework. Apart from being fragmented, the vigilance of the principal regulator of the NHS, the Care Quality Commission, is not always at its most alert. And if the principal regulatory model is to visit institutions, things will be missed if you don’t know what you are looking for. The problem is made worse if you don’t look beyond the boundaries of organisations. I tried, when Chair of the Healthcare Commission, to develop a model of regulation based on data—that standards should be agreed as to what could properly be expected of a hospital or trust (including its interactions with other organisations), that data which would measure compliance with those standards should be identified, that these data should be made available to the regulator, that it should be analysed to allow assessment of performance, that the results should be published, and that failing hospitals and trusts should be helped to improve (avoiding the too-easy “blame and shame” route). The Healthcare Commission was abolished just as its method revealed the failings at Mid-Staffs, to be replaced by a less intrusive and therefore less effective regulator.
A fifth weakness relates to data. The only way in which an institution can know whether it is doing well or heading for disaster is to have access to all the relevant data describing its performance in meeting the relevant standards. It is a regular feature of failings in the NHS that such data is not effectively collected, does not reflect the fact that patients experience care along a pathway, and is not widely shared—this is especially true as between primary and secondary care and scandalously true as between health and schools or social care. Moreover, when concerns are raised, data is argued over rather than acted on. Furthermore, in interactions between the NHS and the private sector, the sharing of data is often rudimentary at best. This was a particular feature in the case of Paterson, enabling him to continue to operate in private hospitals for years after concerns were being raised in the NHS.
A sixth weakness is a particular feature of the private sector, but has implications also for the NHS. It is the potential conflation of a therapeutic relationship with a commercial relationship. In Paterson’s case, better-off patients were re-routed to the private sector. This was known. It should also have been realised within the NHS that it exposed patients to the risk of exploitation, thereby warranting significant vigilance.
A seventh weakness is that, at times of stress in an institution, the first people who are overlooked are patients. They are made to wait, they go from place to place, having to tell the same story again and again to different people, their concerns and rights are brushed aside (they are “consented” rather than being asked to consent), they are not kept informed. If you want a clue as to whether a hospital is failing, just look at how they respond to patients.
These, then, are the weaknesses which constitute fault lines in the NHS. Failings grow out of them. So, why are they not remedied, since they are so-well known? The answer is frustratingly simple. The NHS is a political enterprise. So it’s the politics that matter. It’s no good blathering about “taking the politics out of health.” If you want the taxpayer to fund it, then it’s political. So, there has to be the political will to do something. And then you have to get the politics and policies right.
But in the current politics of healthcare, rather than address the weaknesses that we all know about, we are treated to rhetoric about more hospitals and more doctors and nurses. It takes more than a decade to grow a doctor and around five years to grow a nurse. So short of buying them off the shelf, things aren’t going to change soon. And as for hospitals, we need to restore those which currently are dilapidated, but in an era of integrated care and care in the community, lots more hospitals sounds simply misguided. But it means that talking about the real problems that stalk the NHS and produce periodic disasters can be left for another time.
Ian Kennedy is Emeritus Professor of Health Law and Policy at University College London. He set up and chaired the Healthcare Commission (2002-09) and is the author of The Kennedy Review into the surgical practice of Mr Paterson published by Heart of England NHS Foundation Trust (2013).
Competing interests: None declared