I congratulate the hon. Member for Bristol North West (Charlotte Leslie) on calling for this debate, which I want to widen and, I hope, put on a more consensual footing.
I have a constituent whose grown-up son tragically died of leukaemia some time ago. He went to the doctor many times and was diagnosed as a young, healthy man with glandular fever. A blood test was made far too late, and he died. After the funeral, the mortified doctor wrote to the parents and apologised frankly for her failure and her error. There was no litigation or talk of system failure; there was simply a frank admission of individual human error and a sincere apology, which was accepted.
In many cases of NHS failure, there is no one individual to blame, so people talk of systems and cultures, which we have talked about constantly today. No one individual can be held entirely to blame for the system, so it always seems that no one person is to blame or is prepared to take the blame—even those who manage and design the system, such as Sir David Nicholson.
When a hospital performs badly, and the one in Mid Staffs is simply the most telling example, some of the reasons lie in external factors: in the targets imposed on it, in the requirements made of it—becoming a foundation trust is one it could have done without—and in directions that impaired it. The NHS reorganisation certainly got in the way, according to Francis. When outcomes are poor, it can be hard to determine exactly how to apportion blame and responsibility. Do we blame those who witnessed what went on and did nothing; those who failed to notice worrying trends; those who did notice them but covered them up; or those who could have intervened from on high but did nothing? In one sense, they are all
responsible—and some are more responsible than others. But we live in a very harsh and judgmental climate, as was said earlier, and we forget that people at every stage have mixed motives—good and bad—for not kicking up a fuss, for covering up, for not intervening. Some are good—usually, they are bad—but in most cases institutional or personal reasons outweigh the concern for patients. There are quite legitimate fears that the hospital or branch will be criticised or seen as underperforming, which will be bad for morale in hospital, or that one’s career will be in jeopardy—a legitimate concern—or that one is getting a colleague into trouble. Institutional or personal goals get separated from the avowed patient-centred mission of the NHS. Frankly, that is all too human an outcome, and it has always happened to some extent. The NHS is full of very good people, but it is not yet staffed by saints. All of us at some time cover up for colleagues.
However, we always try to find in an institution a way of correcting for this, which is why we have professional standards in the medical profession and an NHS constitution. It is why we need true accountability, good complaint-handling, protection for whistleblowers, duty of candour, the learning of lessons and, of course, proper redress. That is why we have had legislation on the NHS constitution and increased democratic scrutiny, introduced by both Governments, which I applaud. I am not entirely certain what has happened to the NHS redress Bill, but I applaud that too.
However, we build other sorts of incentives into the system, and it is as well to record them. They appeal to a different aspect of human nature, a more selfish side, perhaps out of realism, perhaps because of an ideological conviction that that is how people work. We model hospitals on profit-making institutions. We make survival dependent on competition with other profit-making institutions, which have gagging clauses in their contracts for good reasons—their competitors. We try to modify clinician behaviour not always by appealing to clinical judgment, but by appealing to the pocket. Therefore, we should not be surprised if the moral atmosphere, at times, becomes a little cloudy. We, as legislators, are partly responsible for that.
If we turn the NHS into a set of businesses united by a corporate brand, should we be surprised if occasionally, individual branches put their interests ahead of those of their patients, choosing to satisfy those who pay—the Government—rather than the patients they serve?
There are many good things that we can do and would wish to do. We can make the complaints process easier. We can assign accountability better, so that an individual’s job and survival in an organisation depends on serving the patient, not on always doing what the institution necessarily requires. We can ban gagging orders, and I applaud the Secretary of State’s move in that direction. We can improve inspection, not by making it more ferocious—we do not need to do that—but by linking it better to improvement. Above all, we need to start thinking about what we want the NHS to be. If we are unhappy with the culture, exactly what sort do we want to have? Do we want the moral enterprise that Bevan envisaged—a contract on behalf of the hale and hearty, to protect the sick and vulnerable—or a set of businesses that sink or swim depending on how good they are at getting state funding? We can either rediscover the moral purpose of the NHS, or regard it as an
organisation that brings to book from time to time the businesses that work within it, independently of the Secretary of State.
Frankly, I know which I prefer, but I have to record that currently we exist in a strange kind of moral limbo. We are judging an institution that looks very different from the original NHS, according to the high standards and moral mission Bevan set. I have a lot of sympathy with the remarks of Harry Cayton of the Professional Standards Authority, who said in The Times only this week that the NHS must rediscover its “moral purpose”. We exist in a kind of moral fog, a state of limbo, and if we want to know who is accountable for that, it is us.
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