Britannia Radio

November 30, 2009

A diminishing ethic of care

Daily Mail, 30 November 2009

The crisis over standards of NHS care appears to be worsening almost by the day.

Figures published in the latest Hospital Guide from the part-NHS, part-private Dr Foster organisation show that 12 hospital trusts including those with ‘foundation’ status are ’significantly underperforming’ — including nine which had been rated good or even excellent by the NHS watchdog, the Care Quality Commission.

A further 27 are said by Dr Foster to have had unusually high mortality rates, generally considered a warning sign of care or treatment inadequacies.

True, comparative statistics like these are a minefield, and using death rates as a marker of performance can be misleading. But only a few days ago, horrific conditions were revealed at Basildon NHS Trust — which Dr Foster states has the worst mortality rates in the country.

Care Quality Commission inspectors found blood-spattered walls and filthy conditions with brown running water, mouldy bathrooms and soiled furniture and commodes.

It is hardly surprising that more and more people are beginning to fear that, far from curing their diseases, a stay in an NHS hospital might actually kill them.

And the common factor in most of these cases is the shocking level of basic hygiene. The children’s hospital Alder Hey was issued with a warning notice for breaching basic infection standards.

Three ambulance services were also issued with the same notice after failing properly to decontaminate equipment or to provide clean services for high-risk patients.

A few months ago, it was revealed that up to 1,200 avoidable deaths had occurred over three years at Mid-Staffordshire NHS Trust, in part at least through appalling standards of hygiene.

Yet cleanliness is the elementary precondition of health care. What has gone so badly wrong that this is being systematically disregarded?

Of course, many health service staff are punctilious about cleanliness and their work achieves the highest professional standards.

But in general, this problem has resulted from a pervasive health service culture in which the ethic of caring has been replaced at all levels by putting self-advancement first — with the minding of backs coming a close second.

Once upon a time, nurses provided the quality assurance on cleanliness. Matron ran her hospital with military discipline and enforced the highest levels of hygiene through the ward sisters.

Nurses understood that keeping patients, wards and corridors spotless was an essential part of their vocational calling. In her seminal Notes On Nursing, published in 1860, Florence Nightingale wrote that ‘the greater part of nursing consists in preserving cleanliness’.

It meant the nurse needed to have the most elevated of motives to put the care and dignity of her patients first. Accordingly, lowly functions such as washing patients, administering bedpans or scrubbing the wards were invested with high moral significance.

Now, however, nursing tells itself this is ‘demeaning to women’. So it expects nurses to have degrees and other paper qualifications — which has encouraged many to believe they are too grand to get their hands dirty in order that their patients and hospitals are clean.

But this problem goes way beyond nursing. Ever-burgeoning ‘targets’ act as perverse incentives to NHS regulators to tick boxes without actually using the evidence of their own eyes.

The mania for regulation has resulted in serial empire building, in which not only have frontline staff found their professional independence undermined by distant paper-pushers, but many themselves have jumped on the bureaucratic gravy train by becoming NHS managers.

And the more regulation there is, the worse things have got.

Foundation hospitals, after all, have their very own regulator called Monitor. This is said to be scrutinising the eight foundation trusts which have failed to reach basic standards. But what has Monitor been doing all this time while patients at these hospitals have been dying needlessly?

Then there’s the Care Quality Commission itself. Eight NHS trusts among Dr Foster’s 12 worst performers were recently judged by the Commission to be ‘good’ or even ‘excellent’ in its Annual Health Check ratings.

Even now its head, the Labour place-woman Baroness Young, says no further action is necessary against the 12 trusts and that some of Dr Foster’s data is ‘alarmist’.

Yet she also acknowledges that some information published by her Commission is up to 18 months out of date. And although her inspectors uncovered appalling neglect at Basildon, the Commission previously rated that Trust as ‘good’ for its quality of service and ‘excellent’ for its financial management.

Now Lady Young says the current inspection regime is ’simplistic’. For that, read ‘ludicrously self-serving’. Incredibly, it turns out the ratings given to hospitals rely on their own assessment of their performance.

So at Basildon, managers gave themselves — grotesquely — 13 out of 14 possible marks for cleanliness and performance, while the Alder Hey Trust declared itself the ‘best in the country’.

To cap it all, the chief executives of the eight trusts with the highest death rates awarded themselves bumper pay rises to suit their scandalous self-regard.

And the Care Quality Commission missed what was actually going on because they, too, relied upon these patently unreliable judgments.

As a regulator, the Commission is worse than useless. How many other NHS trusts have been giving themselves near-perfect marks and huge pay rises while leaving patients to die in filthy sheets as the Commission nods its approval?

When the Mid-Staffordshire scandal was uncovered, ministers gave an assurance that this was a one-off. Now we know this was simply untrue.

Even now it is hard to find anyone who has actually carried the can for any of this. All these managers and regulators and quangocrats who presided over, ignored or even misrepresented appalling standards of care should have been sacked.

Hundreds if not thousands of patients have died needlessly because of their manifold incompetence and neglect. Yet with the exception of one or two executives who were forced to step down, it would appear that they are all still on the NHS payroll.

Even in Mid-Staffordshire, the chief executive resigned without being subject to disciplinary procedures and received a huge pay-off and £1million pension.

From the ministers who have sloughed off accountability onto the quango empire they have spawned, to the regulators and watchdogs and managers and the whole self-serving bonanza of bloated bureaucracy, how many will actually be held accountable for any of this at all?

This is not, however, a problem that can be remedied by adopting different criteria for grading hospitals or issuing even more targets. There is a yet deeper lesson here.

Unprecedented shedloads of money have been funnelled into the NHS. Yet far from standards having improved, they have collapsed at the most basic level of all — elementary hygiene.

It’s hard not to conclude that much of this money has gone to managers and quangos run by Labour cronies in an obscene merry-go-round of profiteering and self-regard, with knighthoods, peerages and gold-plated pensions and pay-offs being gaily handed out while patients are dying needlessly on their watch.

This surely tells us two things above all: that Labour politics has become fundamentally corrupt and amoral; and that, tragically, the altruism at the heart of the NHS has become a diminishing asset.

Only by taking power over healthcare away from the politicians who have forfeited our trust and putting it, instead, into the hands of patients will the abuse of power by the NHS over the weak and helpless finally be brought to an end.