It’ll never catch on. The “duty of candour”, that is. If you hadn’t heard, that was the main element in last weekend’s leak of reforms to be suggested by the official report into the horrifying events at the Mid-Staffordshire NHS Trust. This was the hospital where between 2005 and 2009 as many as 1,200 patients met their deaths directly as a result of neglect by staff. Some had been reduced to drinking water from bowls of flowers left by relatives, so unconcerned were the nurses by their patients’ plight.
Yet the whole process of attempting to regulate bad practice in the NHS out of existence seems doomed to repeat the failures of the past. After all, the regulator of hospitals, the Healthcare Commission, had passed Mid-Staffs as fine, even after it had received notification of the abnormal death rates: it just assumed that the figures must be wrong.
More importantly, good care can never be a matter of ticking a box, regardless if one of those boxes includes such a basic question of integrity: “Have you at all times fulfilled your duty of candour?”. Would you expect anyone to answer such a question honestly, if he or she had lied to a patient? To be fair, the proposed new statutory “duty of candour” seems most geared to ensuring that, when things do go wrong, the medical staff involved admit this at the outset, thus avoiding the long legal battles which ill-treated families currently have to fight in order to establish the truth about what happened to their relatives.
Yet one pervasive problem is that, at least among older patients in this country, expectations of quality of care are extraordinarily low: if that were not the case, the disgusting abuse at Mid-Staffordshire – far and away the worst example of a number of institutional failures within the NHS – would not have taken so long to come to public attention. This might be a function of the quasi-religious faith that so many have in the National Health Service, which means that, as with rotten priests in the Catholic Church, those suffering ill-treatment or even abuse feel it would be heretical to complain or ask awkward questions.
There is also the fact that treatment in the NHS seems to be free. Of course, it is not: the public pays for it through taxes – indeed, over the past 20 years that sum has tripled from £40bn to £120bn. Yet because it is free at the point of use, it is easy to see how the patients can be made to feel grateful for whatever they get, as if all the treatment were an act of charity by the staff. Above all, there is no real choice of provider. Imagine if all the hotels in the country were compulsorily owned by the same company, and it was impossible to take one’s custom elsewhere to a rival firm: how good would you expect things to be? Anyone who spent time in Russian hotels under the Soviet system would know the answer.
Yet there are signs that this might slowly be changing, even though the Coalition felt forced by pressure exerted by the British Medical Association and the public sector trade unions to water down its legislative commitment to encourage more competition between hospitals. Three months ago, I visited Hinchinbrooke Hospital in Cambridgeshire, the first NHS district general hospital to be run by a private group. That group is Circle, Europe’s largest medical partnership, which consists of almost 2,000 doctors, and has ambitions to run many others of the 30 NHS hospitals which are said to be failing.
Last month, the National Audit Office criticised Circle for running up a further £4m in debts at Hinchinbrooke, more than twice the £1.9m deficit it had projected when it successfully tendered for the contract back in 2011. Yet the objections from the unions at that time were much more primordial: the introduction of private management would cause patients to be slaughtered. Thus Unison declared: “This is a disgrace, putting patients at serious risk. Privatisation, which brings in the profit motive, will damage our NHS.” Meanwhile, the Labour Health shadow Secretary of State, Andy Burnham, said: “This is not what patients, public or NHS staff want.”
Yet when I went to see what was going on, it was clear that great improvements had been made. The Accident and Emergency department, which had been “served a notice” under the previous management, had become, according to the official figures, the top performing such unit among all hospitals in the region, based on the speed with which patients were being seen. As a result, more people needing A&E were choosing to go to Hinchinbrooke, and fewer to the two main neighbouring hospitals: that is competition working for the benefit of the health service – or at least it would improve overall, if the funds follow the patients’ choices. The risk is that commissioning bodies within the NHS instead direct flows to the least-well performing, in order to disguise the level of failure.
The most heartening aspect of my visit to Hinchinbrooke was not just talking to a patient who said “I’ve been asking for things and getting what I want; the staff here are prepared to do that little bit extra”. After all, patients could say the same thing about nursing care within a number of the best state-run hospitals. No, what was most encouraging was the high morale among long-term staff who said that they felt completely liberated by the way in which the private management had let them act on their own initiatives and trusted them to do so: the dead hand of NHS bureaucracy – so brilliantly satirised in Getting On, the BBC geriatric ward sitcom – had been swept away. In return, yes, the medical staff had needed to become more productive: in other words, giving more to the patients.
It is astounding that we should have taken so long to get to this point. In Germany, for example, about a third of general hospitals treating patients paid for by the state are privately run; and it does seem that this is partly a result of a more demanding public. Dr Massoud Fouladi, the medical director of Circle, told me that his experience from working as an ophthalmic surgeon both in Kent and northern France not that much more than 50 miles away, was that “in this country, older patients are completely undemanding compared with those in France. The difference between Ashworth where I practise and Lille is very obvious. Here, patients will endure waits which would cause people to have a fit in France.”
So it’s clear what’s needed in the wake of Staffordshire: not so much yet another new system of state regulation, but the realisation by the British public that it should get up off its knees and stop prostrating itself before the false god of the NHS.