Opinion: Our NHS – the good, the bad and the ugly

nhs sign lrgIt is a week since Robert Francis’s report on the Mid Staffordshire NHS Foundation Trust exposed massive failures in the NHS, from top to bottom.

The silence from the political left is deafening. Of course there has been the usual horror and condemnation, and calls for heads to roll. But this wasn’t just a case of lax professional standards, which can be sorted out with a bit of culture training, it was complete system failure from cleaner up to Prime Minister.

Furthermore the report produced a dense fog of recommendations, which badly needs a clear sense of vision to set priorities. This goes to the heart of political policy on the NHS. Little more than a year ago we were deluged by experts criticising the Coalition government’s NHS reform bill. Where are those voices now? The failure is conspicuous enough on the Labour side, but the Lib Dems are hardly exempt. On Lib Dem Voice there has been just one posting on the affair, from Norman Lamb, which attracted just five comments.  People preferred to talk about equal marriage.

What makes this worrying is that if the left has nothing of substance to say about reforming the NHS, the field is left open to the half-baked ideas of the right. We have already seen this in education. It is not enough to just cheer the good and condemn the bad. Reform gets ugly.

I have personal experience of the good in the NHS. As a recent heart attack victim, the medical treatment I received was first rate. If the nurses were harassed at times, the sorts of things that happened at Mid Staffs were unthinkable. The much maligned care assistants were a real help in keeping the show on the road. The service may have been a bit rough at the edges , but the basics were excellent – and that is the job we ask the NHS to do. And there are many, many more such positive experiences. But it’s not near enough.

Because the bad is still very much with us. At the same time as I was experiencing good care, a friend’s elderly mother was getting treatment that can only be described as callous, as she was pushed onto the Liverpool Pathway without any proper process of consultation. Mid Staffs is only exceptional because the lack of care was allowed to get so extreme. It’s no use blaming Labour’s regime of strict targets either. Before those targets were introduced the NHS was much worse: doctors and managers just seemed to shrug at appalling waiting times. Would those waiting times have been tackled just by increasing budgets?

And so to the ugly. To implement any kind of change in the NHS means challenging a whole mass of entrenched hierarchies, demarcations and working practices. It hurts; whatever you do a number of highly articulate people will resist. But we can’t root out the bad if it’s not done; and given the tide of demographic change, the service will collapse without reform. It’s no use relying on the warm feelings engendered by Danny Boyle’s Olympic extravaganza, or a throwing in cuddly words like, “collaboration”, “caring culture”, “patient centred” or even the latest favourite “integration”. Somewhere there has to be a big stick. And that’s ugly.

As liberals we should be thinking of ways of empowering individual patients, and especially those that are vulnerable. And the ugly truth about that is that it means challenging the entrenched, top-down instincts of most NHS professionals. Do we have the stomach for that?

* Matthew is a Lib Dem activist who blogs at thinkingliberal.co uk

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23 Comments

  • Old Codger Chris 13th Feb '13 - 11:46am

    Headlines always blame the NHS. But, as we know from private care homes, the chief fault lies with the medical profession. It needs to take a hard look at itself.

    Incidentally how ironic that a banner asking me to support Big Tobacco’s campaign against plain packs appears above this article. Has Lib Dem voice accepted money for this?

  • Keith Browning 13th Feb '13 - 12:26pm

    Gagging orders on staff in place at hospitals, being backed up by verbal reminders. Surely these should be made illegal – a simple and quick fix to raising NHS standards.

  • I think the point about inconsistency is good, I had an experience a few years back where I would say the performance was patchy at best (including being left in extreme pain and unable to move) . However, a year or 2 after that our youngest was in special care and it was totally different (all in the same hospital). Even if I read a thousand dictionaries I wouldn’t be able to find the words to express how superb the care shown towards her (and us) was.

    Old Codger Chris is right, it is the medical profession that needs to have a long hard look at itself. Protection of whistle blowers may help, but we shouldn’t need to be in that position in the first place, we need a culture change. One of the comments from the article linked to by Louise Shaw mentioned that each ward should have a large sign stating “We, the staff of the NHS are here to serve the needs of our patients”, it may sound daft but perhaps something cheap like that may start the process of changing the attitude of those staff who need the reminder.

  • Liberal Eye 13th Feb '13 - 2:40pm

    Matthew is right about the deafening silence from the left. But it’s not just the NHS; it applies to just about every difficult issue and that means every important issue. It leaves the right free to set the agenda about the important things. If liberals are to make any progress at all we need the leadership (which in this context includes LDV!!!) to focus folks’ attention on what matters most. There are liberal answers out there but we won’t find them if we don’t look because we are constantly distracted by bright baubles.

    We need to protect NHS whistleblowers and prevent them being gagged as I said at more length in my comment on the Norman Lamb post. This is something our MPs could and should deliver PDQ.

    However, I disagree with Old Codger Chris that the ‘chief fault lies with the medical profession’ – at least not in a simple way. I would bet a lot of money that there is no simple silver bullet type solution. This is a systemic and cultural failure of an immensely large and complex organisation so it is in changing systems and culture that the solutions must be found and that is preminently a management task.

    As an illustration, when my father had a hip replacement many years ago it was obvious that the nursing on his ward was well below par in ways that were certainly impacting his recovery. I decided to call the surgeon but not to attack him from the off until I had heard his side of the story. I was so glad I did that. He revealed that he had only just joined the staff a few weeks earlier and that when his wife – a nurse until their family started arriving – had called in the weekend before to see her husband’s new place of work she was shocked rigid by the low standards and bad patient care. It also turned out (which I had not know before) that surgeons have no control or responsibility for the nursing care. The surgeon resigned a few weeks later.

    The lesson I draw from this (and my own experience in industry) is that the setting in which people work has a huge impact on their ability to perform. If systems are bad and the culture one of box ticking then underperformance will be the rule and costs will be uncontrollable. Just like the NHS in fact.

  • Matthew Green 13th Feb '13 - 3:14pm

    There really are a lot of cultural issues to fix in the NHS. No doubt changing the law will help this, but it also suggests that something is wrong with the leadership – not excluding the politicians. It’s not just being angry about poor care, it’s promoting an atmosphere where people aren’t afraid to report problems.

    I am thinking something else too: better commissioning. The usual bureaucratic approach is what I would call “fire and forget” after military technology. You find somewhere for your patient to go, negotiate the cost, and then you think the job is done. In fact you should be checking that the service the patient gets is up to scratch. In social work it’s called care management. In the PCT led system there wasn’t much of it about. GP led commissioning may be better – except that I expect it will be too starved of resources. Depressingly the current trend in social services commissioning is towards fire and forget (advocated by Eric Pickles, et al), rather than care management. This coud be a liberal cause – but the up-front costs have to come from somewhere – though it coud pay for itself long-term.

  • Liberal Eye 13th Feb '13 - 5:01pm

    Yes, ‘Fire & Forget’ is absolutely the wrong way to go. The ambition for providers of care should be ‘Right first time’. In a programme last week about some of the events at Stafford I was very struck by the story of one woman who went in for something simple but then, because of low standards of care, got MRSA etc and finished up being in for (from memory) nine months. That is where a lot of the money is going.

  • Old Codger Chris 13th Feb '13 - 5:08pm

    I agree with Chris_sh about the variation in standards. I’ve heard horror stories about maternity care locally but a relative is full of praise for the excellent care throughout a very difficult birth.

    Another relative (different hospital) would agree with Libral Eye, very poor nursing care on the ward although the surgical team were excellent – this was a theme in a campaign by The Independent. What on earth has happened to nursing in some of our hospitals?

    Both hospitals incidentally are modern with excellent facilities, they’ve had shed loads of money spent under New Labour. Credit where it’s due, some hospitals near me struggled with Victorian buildings and / or WW2 nissen huts into the early 21st century.

  • Matthew Green 13th Feb '13 - 5:58pm

    Simon. Sorry about sloppy use of “empowerment”. Where patients or carers are not articulate and middle class, then the system should provide somebody on their side as backup…acting as patients advocate or some such. More appropriate to long term care, and not really workable for A+E – but would surely help catch a lot of what goes wrong. Sending vulnerable patients to a care home for temporary treatment and leaving them there for years should be unthinkable.

  • “There are a lot of cultural issues to fix in the NHS”. Yes, I agree, except “cultural issues” can’t be “fixed”. “Fixing” is using your current mindset to solve a problem: “Cultural issues” are that very mindset.

    Some of the “cultural issues” may not be in the medical profession at all, but in the political profession, and in the public – as voters, carers and as patients. Maybe we want to have something, and not pay enough for it? Maybe we increasingly want to offload our elderly and infirm on the NHS, rather than caring for them ourselves?

    Cultural issues invite us on a journey together, a soul-searching. We may all have to be open minded, and admit our share in it. Not that the medical profession doesn’t have it’s share, but the best way to encourage admission is not finger pointing, but owning up to one’s own faults. Let the soul-searching begin!

    PS For a treatment of how cultural change can happen, and be directed, see Part 2 of Charles Duhigg’s book: The Power of Habit

  • Tony Dawson 13th Feb '13 - 6:24pm

    The reason for the silence of the left on this issue is that they were the ones who succeeded where the Tories had previously failed, in isolating the central NHS management and the government from being made to take responsibility for what was happening in individual Trusts and Health Authorities. They also closed down the Community Health Councils, against a sterling rearguard fight from the House of Lords, so there was no one really looking at what was going on in detail anywhere and all quality and cost was left to ‘the market’. For that was Labour’s credo a la Alan Milburn, Stephen Byers, Tony Blair et al. Oh yes, and Andy Burnham, bells his little cotton eyelashes.

  • David Allen 13th Feb '13 - 7:10pm

    I am not sure how worried we should be about the deafening silence of politicians. I am inclined to feel that it is not deafening enough.

    Francis spent years studying what went wrong and produced a complex, informed series of recommendations. To call those recommendations a “dense fog”, and to yearn instead for a simple “clear sense of vision”, is of course a common, and highly destructive, political response. Matthew Green rightly complains that the Right do it, but then seems to be calling on the Left and the Lib Dems to match the Right with their own over-simplistic, unhelpful answers.

    New Labour had a simple clear vision. Since New Labour no longer believed in socialism, a different panacea had to be found. That panacea was managerialism. New Labour’s meritocrats were going to outperform the Tories through sheer brain power. That mean harnessing the computer to devise complex performance management systems which would drive out inefficiencies, save costs, and allow New Labour to improve services without putting up taxes.

    It was, of course, self-delusion. Not because performance management had no merits – it does have merits – but because far too much reliance and emotional freight was placed upon it, and too many political careers were dependent on it. At Mid Staffs, performance management was king, and actually caring for patients had to come second.

    Let’s see politicians recognise that this is not a political issue.

    Or to put it another way – I often complain that Lib Dems spend too much time trying to ignore the real political importance of Left and Right. But on this occasion, when we are talking about standards of care and professional integrity – Just for once, we have found an issue which genuinely isn’t a Left – Right issue!

  • I was and still am critical of the LibDems and their support of Lansley’s health ‘reforms’ (it is just one of several reasons why I will not be voting LibDem again – I did in 2010). I cannot see how on earth the commercialisation of the NHS, as envisaged by the Tories and LibDems, can conceivable help to avert another horror akin to Stafford; the profit motive that is now being introduced into the health service is guaranteed to make matters a lot worse. I have seen in a long working life how the making of money generates the ‘tick box’ culture, as others have noted, this is the very last thing that the NHS needs.

  • @RichardG. “Maybe we want to have something, and not pay enough for it? Maybe we increasingly want to offload our elderly and infirm on the NHS, rather than caring for them ourselves?” Your two ‘Maybes’ for me aren ‘Maybe’ but are certainties. First. In my opinion it is money, or the lack of it that is the heart of NHS problems (this is not an excuse for the horrors of Stafford, those who indiulged in callous or cruel bebaviour should be brought ot book). The fact is that we all want superb 24-hour health care in modern hospitals, whilst we hate paying tax, we want French-style healthcare while paying next to nothing in income tax. Second. We live in a country that is very different to the Brtiain of couple of generations agp. Not that long ago family members lived close to one another, they bore the responsibilty of the their old folk – there was no-one else to do it. In 2013, rightly or wrongly, family structures have changed, and one result is that many people now believe that the elderly are a ‘problem’, and a problem which is entirely the responsibility of the state.

  • “And the result of this NHS cult is that we are never quite brave enough to face the truth. That the NHS is inefficient, just think IT procurement! That it is bureaucratic, cumbersome and unresponsive. That it doesn’t deliver universal care as what is delivered depends on where you live. That the rationing of care is already a reality but that we dishonestly pretend otherwise. ”

    http://labour-uncut.co.uk/2013/02/14/after-mid-staffs-labour-must-be-brave-and-take-on-the-cult-of-the-nhs/

  • Big Dave ” In 2013, rightly or wrongly, family structures have changed, and one result is that many people now believe that the elderly are a ‘problem’, and a problem which is entirely the responsibility of the state.”

    It isn’t just the elderly for whom many people have this view.

  • Steve Griffiths 14th Feb '13 - 10:17am

    @Matthew Green

    “The silence from the political left is deafening”

    “What makes this worrying is that if the left has nothing of substance to say about reforming the NHS”

    What no political left in the Lib Dems anymore, or is that how you’d like it to be? If you mean Labour, say Labour.

  • Steve Griffiths – “What no political left in the Lib Dems anymore, or is that how you’d like it to be? If you mean Labour, say Labour.”

    I think even those who see themselves on the left of the party would describe themselves as centre-left on a national scale. “Left” (unqualified) means something distinctly different.

  • Matthew Huntbach 14th Feb '13 - 10:58am

    We need to restore pride in giving good service in the NHS. What has become clear is that a regime of fear does not do that. Whether that fear is imposed by the market principle “Cut corners, all that matters is doing it as cheaply as possible in order to keep the contract, otherwise your job’s at risk” or by the Blairite principle “Here’s today’s meaningless target, even if you know it’s stupid and will result in a deterioration of service, do what is necessary to meet it, otherwise your job’s at risk”, it DOES NOT WORK to improve real quality of service. When people are motivated by fear like that, all better thinking goes out of their minds, all initiative goes out of their minds, all that matter is they save their skin by doing what they are told to do by bosses who haven’t a clue about what actually goes on in terms of people interacting with people.

  • Richard Dean 14th Feb '13 - 12:16pm

    The report is available from links on the DoH website and it does look valuable, but also a bit foggy- perhaps because of its length. Some of its 18 recommendations seem to have a bit of a generic feel about them, almost textbook. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113447.pdf

    While targets may be part of the problem, it really does look like management (and perhaps senior medical staff) seem to have had little idea of how to design an organizational structure and organizational processes that deliver quality results – little idea of things that we already know are important from studies of industrial settings. Several of the recommendations seem to be about this.

    I looked for a synopsis of the hospital itself – it size and how it was organized – but couldn’t find one, which is a bit surprising in a report like this. Maybe I missed it. I also didn’t find much in the way of statistics capable of showing the relative magnitude of the problems – statistics which would be vital to managers’ as well as politician’s effectiveness, so I guess their absence may also be a problem that needs addressing (eg.Reccommendations 5 and 6).

  • John Broggio 14th Feb '13 - 12:54pm

    As someone of the left, I have to say the reason that most hear little or nothing about the NHS in general & Mid-Staffs in particular is that (1) it is questionable to assert that (New/One-Nation) Labour is left-wing in any traditional sense of the term and (2) the media are remarkably reluctant to give any coverage to those from the NHS who are opposed to the privatisation culture that is being foisted upon the NHS & the public. Not one interview or discussion on BBC’s flagship news programme Today was held on the H&SC bill on its final day in parliament (when the Lib Dems could have helped vote it down instead of banging the cabinet table in joy as it went through); not one. It doesn’t matter what anyone to the left of the coalition has to say on the matter of the NHS if the media never give them airtime to talk about it.

    For me, Nicholson and Burnham have a lot to answer for and if they had any honour, both would carry the can.

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