In the wake of the Lucy Letby case and the unspeakable and unmendable loss and harm her actions have caused, the system and the press will call for more legislation. Politicians and those in positions of authority will want to be seen to be acting decisively. The calls for new laws and more accountability and perhaps even a new healthcare management regulator will become almost irresistible to all but the most informed. But more legislation will not achieve anything other than increase the bureaucracy that is already strangling public services and waste yet more taxpayer money on pointless expensive jobs for professional panjandrums and box tickers.
There is a wealth of legislation already in place now, and it did not work. This is the same legislation that was introduced on top of previous legislation which we were all told was not working. This was in turn introduced to deal with previous issues that we were all told should not be allowed to happen again. The Nolan Principles, the Duty of Candour, and the Fit and Proper Person test for NHS directors. Every time new legislation is introduced, we are told that this is the legislation that is needed. We are assured that this time it will be different. But legislation exists and thrives in the absence of trust and character. Demonstrating compliance with arbitrary standards merely rewards those who play the game. We should not forget that in almost every health and care scandal that has surfaced, the official regulator had recently given their blessing to the offending institution. When new rules and measures and compliance regimes are introduced they become surrogates, false reassurances that often create more problems than they solve. The Nolan Sisters have done more for humanity than the Nolan Principles of Public Life.
The NHS offers a wonderful real-time example of a public service that has mastered the art of keeping its regulator the Care Quality Commission happy, while at the same time slowly descending into unsafe chaos as it hides those things from the regulator that it did not want to reveal. In the nine years since the introduction of the Fit and Proper Person test for NHS directors, not one meaningful outcome has emerged from it and the CQC, the official regulator of health and care services in the UK, is still largely unclear about what it is and how they should police it. The constant development and implementation of cack-handed legislation offers an illusion of progress which in many cases hides the fact that the NHS is now less transparent and open than at any other time in its history.
As for the calls for a new body to oversee NHS and health and care managers, there are existing bodies of which I myself have been a member for some years. The Chartered Management Institute has a code of ethics for all its members, but that doesn't stop some of them from behaving immorally and at times illegally. Then there is the CIPD, the body pertaining to represent the HR profession. Yet the human resources departments of the NHS and wider public services house some of the most dysfunctional and divisive people and practices in the entire system. The central and amoral role that HR managers and directors have played in most of the healthcare and public service tragedies of the last two decades cannot be underestimated. The kennel of HR houses the attack dogs that are unleashed on those who dare to challenge the preferred organisational narrative and blow the whistle on unsafe practices and people. I dream of a world without HR departments and directors.
I do sympathise deeply with many of the clinical staff, doctors, nurses, surgeons, and therapists who are now calling for healthcare managers to be held to account by similar membership bodies to the ones that they as practicing healthcare professionals are obliged to be members of, but these calls will not bring about the real and significant culture change that is so obviously needed. They also fail to acknowledge that in many cases the membership bodies that represent health professionals have often been a hindrance to patient safety by circling the wagons and protecting their members at the expense of the truth. The Nursing and Midwifery Council's now infamous role in protecting nurses involved in the Morecambe Bay NHS scandal is a case study into how a membership body that was designed to uphold standards actually defended unsafe practices to protect its members and its reputation. The need to demonstrate compliance with a set of professional standards quickly and inevitably descends into a tickbox exercise. I'm a Fellow of the Chartered Management Institute, but it doesn't guarantee that I'm a decent humane person with a backbone and some personal integrity. These are the qualities that membership of a professional body cannot measure and they are precisely the ones that got me gaslighted and hounded out the NHS.
The real issue is that NHS and public service chief executives, directors, and senior managers, work in cultures that reward those who welcome and publicise good news without question while denigrating those who bring unwelcome if factual news and information to their attention. The brutal uncomfortable truth about management in the NHS and our wider public services, I deliberately don't use the term leadership because I believe it's largely absent, is that it is lacking in both competence and character. Many of the people who have risen up the ranks of the NHS have never known anything else and most would be unemployable in any other commercial or private sector setting. A large number of senior NHS executives are products of the NHS Graduate Trainee Scheme which takes aspiring ambitious students and turns them into dangerously compliant corporate automatons who can fly a spreadsheet like Biggles and reel off a PR statement like a ninja, but who have absolutely no idea about the world outside the NHS. They have thrived and succeeded by replicating the behaviour of those they have witnessed rising through the ranks before them and pleasing their political and regulatory masters.
Nobody rises in the NHS by questioning the narrative. Positive conflict and challenge are not welcomed or encouraged. When I worked in the NHS I undertook a survey on behalf of the Trust I worked for, the results were not what my director had anticipated and so the bar chart indicators were adjusted and I was told never to repeat the survey again unless I was prepared to only ask the questions we could be guaranteed favorable answers to. I challenged the decision and life was made uncomfortable. When a young girl called Helena Farrell took her own life in January 2013 after being failed by the Trust's Child and Adolescent Mental Health Services, directors and managers withheld relevant information from the inquest into her death to preserve their reputation. They were sitting on a report that showed services were unfit for purpose months before Helena's suicide. The management of reputation always took precedence over acknowledging or admitting patient safety issues.
It is said that people either see the light or feel the heat and the crisis in leadership and management that has been unfolding for many years and which is now undeniably enveloping our NHS and many of our public services is largely a crisis of character. Regulation will not provide the answer. The "can we fix it, yes we can", simplistic Bob the Builder style popular approach to dealing with the NHS needs to change to a more nuanced and thoughtful one. We cannot hope to have a world-leading health and care system without a wider debate about what we want from it, and how we, its service users, funders and shareholders, want to hold it to account. Improvement begins with understanding and Sunlight is the best disinfectant. A useful first step in creating safer more accountable services with less wasteful oversight will be to develop the NHS as an entirely transparent and open healthcare service. This would go a long way to changing the narrative from defensiveness, blame, and denial to acknowledgment, understanding, and ultimately change.
No Wealth But Life - What's Gone Wrong with Healthcare in Britain and How We Can Save the NHS is available in Kindle and paperback from Amazon https://bit.ly/3pqdlaQ