The Keogh report into 14 hospital trusts with unusually high death rates focuses, naturally enough, on local standards of care and treatment. But what was the responsibility of successive governments in these unnecessary deaths? I say “successive” because no recent government has an unimpeachable record in its management of the NHS.
Politicians have never been able to leave the National Health Service alone. They have an urge to keep on reorganising it, overturning what went before. That itself is a part of the explanation of what has gone wrong. In 1991 the Thatcher government brought in the so-called internal market and put GPs in the driving seat only for Tony Blair to come into power in 1997 determined to scrap these reforms and replace competition with collaboration. But three years later, Labour reversed course. It brought back competition and markets; it drew up a vast array of performance targets and national guidelines in an attempt to create uniform standards of care. Primary care trusts were created to purchase healthcare on behalf of GPs.
Enough already! So before the 2010 elections, the Conservatives sensibly promised to avoid “massive structural reorganisation”. And then the new Secretary of State, Andrew Lansley, launched probably the most substantial reorganisation the NHS has ever known.
The cost of these interventions by Secretaries of State, who lacked knowledge of public health or experience in running large organisations, has been heavy. Not only were they expensive, but also they had the effect of switching the attention of senior medical staff away from their patients to organisational matters, and unsettling everybody else down to the most junior nurse. While well-managed hospitals could take these zigzag changes in their stride, the weaker ones, those on the Keogh list, found they were one more heavy burden.
More important still, a lot of the problems uncovered at the 14 hospitals have to do with staffing levels. And for “staffing levels” read financial resources, the responsibility of government. Earlier this month, Sir David Nicholson, chief executive of NHS England, said the health service faced a £30bn black hole in its finances by the end of the decade because of rising demand. And while it would not be the whole answer, it would help if the NHS was able to streamline by centralising services such as accident and emergency care, cardiac surgery and maternity units. But no, politicians of all parties conspire to thwart plans to save resources.
Even three Cabinet ministers – Foreign Secretary William Hague, who opposes the downgrading of maternity and children’s services in his constituency; Justice Secretary Chris Grayling and Work and Pensions Secretary Iain Duncan Smith, who lead protests about threats to local A&E units – are prepared to frustrate necessary reform. In at least 15 areas of England the NHS is attempting major reconfiguration but always in the teeth of opposition from MPs of all the main parties. Lord Darzi, the heart surgeon who spent two years as a health minister under Labour redesigning NHS services, calls this “the politics of saving lives versus the politics of saving votes”.
Moreover, if saving votes were more important to politicians than saving lives, you would think that they could partly redeem themselves by designing effective regulation that would give a clear signal of problems at individual hospitals. Indeed they did try. The Healthcare Commission was set up in 2004 to promote and drive improvement in the quality of healthcare and public health in England and Wales. It aimed to achieve this by becoming an authoritative and trusted source of information and by ensuring that this information was used to drive improvement. In 2008 the Care Quality Commission replaced it.
However, to see how badly these eminent bodies discharged their duties, take the example of one of the hospitals on the Keogh list, Basildon and Thurrock, where the “mortality ratio” from 2005 until last year was 20 per cent above the NHS average, with up to 1,600 more deaths than there would have been if it had the average level of deaths among its patients. From 2005 until 2009 Basildon and Thurrock was given a “good” rating by first the Healthcare Commission and then by its successor, the Care Quality Commission.
I have left until last the most shocking example of political incompetence – or, rather, negligence. It comes from the testimony of Sir Brian Jarman, now 80 years old, who was Professor of Primary Health Care from 1983-98 at Imperial College School of Medicine and President from 2003-4 of the British Medical Association. He devised the “The Hospital Standardised Mortality Ratio”, the methodology used in the Keogh report.
Earlier this month Sir Brian went on to the main TV news channels to accuse the Department of Health of having been “a denial machine”. His data on high death rates was ignored for a decade. “We felt we were banging against a locked door. They were denying our data even though there was no real reason. At the time there was pressure from Downing Street and pressure from ministers… Ministers have an electoral interest in getting out good news…Effectively they had to deliver good news for the minister. The minister then indicated that the pressure came from No 10.”
Andy Burnham, who was Secretary of State at the time and who still takes responsibility for health questions in the House of Commons, rejects Sir Brian’s charges. But I fear Sir Brian’s comment accords with all we know about the behaviour of government ministers. They believe to confess failures in a public service would be as foolish as a car maker admitting, say, that there was a steering fault in one of its models. It doesn’t do sales any good!
As a result of the manifest shortcoming of politicians – and here, as you will see, I engage in wishful thinking – I should like to see a parallel exercise to Sir Bruce Keogh’s: “A review into the performance of recent Secretaries of State for Health”.