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Thursday, 21 February 2013
The Modern NHS in Pure Culture
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The Francis Enquiry into the failings of the Mid-Staffordshire NHS Trust will almost certainly repay close reading, and will also be invaluable to future social historians of our country. Indeed, it will tell them all that they need to know: for far from being a betrayal of the ruling principles of the NHS, as claimed by the Health Secretary in the Sunday Telegraph of 6 January, the events in Mid-Staffordshire were their apotheosis. To put it bacteriologically, Mid-Staffordshire was the modern NHS in pure culture, uncontaminated by such organisms as kindness, competence or the most elementary concern for patients. Where these persist — and of course they persist in many places — it is in spite of the administration of the NHS, not because of it. Even under the worst of totalitarian dictatorships, human qualities cannot be everywhere eliminated.

What the Francis Enquiry will almost certainly reveal is a combination of the ravening ambition of bureaucratic mediocrities, institutionally perverted incentives that reward those who do worst, the creation of a nomenklatura class at the head of an apparat staffed by bullied, intimidated, fearful but also unscrupulous apparatchiks, intellectual dishonesty with compulsory lying on a vast scale, the proliferation of procedural objectives and bureaucratic tasks completely unrelated either to reality or to the welfare of patients, all combined with a revolting tendency to Pecksniffian self-congratulation and righteousness and an inability or unwillingness to speak or write in plain English.

The fact that those at the top of the local bureaucratic hierarchy, having decimated the immediately surrounding countryside, moved on to higher or at least even better-paid things (such as private consultancy with the NHS) will not surprise observers of the NHS, because they have long known that no senior manager is ever truly sacked from that vast charitable organisation for the outdoor relief of second-rate bureaucrats. We should abandon the expression "turning up again like a bad penny" for "turning up again like a sacked NHS manager".

The Francis Report will almost certainly say that while it is the worst case that has so far come to light, the Mid-Staffordshire case is far from unique: and indeed, why should it be unique, when the principles upon which its management acted were those that pervaded, and continue to pervade, the NHS? It is a long time since I first asked the question of an NHS manager, "What is the government order you would refuse to obey?" and received no reply, because (I suspect) there is no such order. I remember a manager in the hospital in which I worked before my retirement, with no medical or even nursing qualifications, prowling the wards to look for patients who could be hurried home so that beds would become available for patients who would otherwise break the government's four-hour rule, that is to say the rule that no patient should wait more than four hours after the decision to admit him had been taken. The concern that patients should not have to wait for more than four hours was not for their sake, of course, but merely so that the central government could claim that it was improving services, and so that the hospital could claim to have met its target. In the event the target was met by the simple expedient of redesignating hospital corridors as wards, satisfactory all round - except for the patients, of course.

Not long ago I was asked conduct an inquiry into a spate of fatal events among the patients of an NHS Trust, and to determine whether there was a single factor that explained them. There was not; but when I reported to the Medical Director of the trust that while there was no such factor, it was clear to me that his staff were incompetent, unmotivated and completely unaware of what the purpose of their work was other than the filling in of forms (thousands of them, often with contradictory answers to the same questions in them), he replied with an almost Buddhist calm, ‘But that is the standard expected these days.' He reminded me of a collaborator in an occupied country explaining that there was nothing he could do in the face of overwhelming military force.

Just as the Mid-Staffordshire NHS Trust was not unique in the NHS, so the NHS is not unique in British public administration, but rather one example, and perhaps not even the most important example, of the way in which it now works. It is true that scandals in the NHS cause more commotion when they are uncovered than scandals elsewhere in the public sector, because we are (wrongly, in my view) more worried about our health than anything else. But for the long-term future of the country, education is more important. There is a deal of ruin in a nation, said Adam Smith; but the use of procedural outcomes in practically all the educational institutions of the country, from kindergartens to universities, is one way to produce that deal of ruination.

Who is responsible for this ruination? I think Mrs Thatcher, with her crude sub-Marxist view of the professions as mere exploitative monopolists, set the process going, putting the bacteria in the milk as it were. She thought that the methods and disciplines of the marketplace, imposed by ‘scientific' management, but in the absence of anything resembling a real market, would eliminate chronic inefficiency in the public service. This was naïve, not to say stupid; only too predictably it called into being a managerial class, cunning and unscrupulous, that quickly developed its own vested interests and that was easily able to outwit any little politician who lined up against it. After all, a minister is only for a few months; a bureaucrat is for life.

Moreover, Mr Blair seized his chance very cleverly, transforming his party from that of the working to that of the nomenklatura class. The chief executive of one of the NHS trusts in which I worked stated quite openly that he job was to get the government re-elected. The problem is that defeating this class is like trying to get the sourness out of sour milk.

So we have seen the future, and it is Mid-Staffordshire NHS Trust. The  best we can hope for (though it is a rather forlorn hope) that any reforms suggested by the Francis Report will not make things worse. Unfortunately, for every disaster produced by the adoption of procedural outcomes there are six procedural outcomes waiting to be adopted.  

First published at Standpoint.

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Posted on 02/21/2013 4:51 AM by Theodore Dalrymple
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