By Bruce Newsome
By international comparisons , British health and social care is inefficient and dissatisfactory: it is the most expensive health service in the world, but has more avoidable deaths, longer wait times, and unavailable services than almost all peers.
Bear in mind that twelve years have passed since around 1,200 avoidable deaths at Mid-Staffordshire Hospital, which were followed by multiple investigations and recommendations for change, and then more scandals.
Earlier this year, the long-standing Health Secretary admitted that parts of the NHS deliver “unacceptable ” care. Last week, we learnt that four out of ten care homes failed inspections during the first half of 2017 – a record rate. A separate freedom of information request revealed that violence and abuse against mental patients reached record levels in 2016. In the same week, Labour obtained evidence that English maternity wards closed temporarily 382 times in 2016 – another recent record. Naturally, by the end of the week, Jeremy Corbyn decided to refocus his criticisms of the Government on failures of health and social care.
While the Labour Party wants to blame austerity, the Conservative Government is in the habit of blaming culture, but nobody is discussing the overriding cause: accountability.
The false excuse of money
First, take the false excuse of money. The worst scandals occurred when the Labour government was throwing money at health and social services in the 2000s, which literally bankrolled the inefficiencies, internalisation, and self-righteousness that make fair analysis so unfashionable.
Since 2010, it has been easier to blame resources. For instance, the National Childbirth Trust recently reported that mothers in labour are being “treated like cattle” in NHS wards: half are reportedly left alone for hours without care or painkillers. The report’s authors – in consultation with the professional groups – chose to interpret the results as evidence for understaffing, when they could just as well be evidence for unprofessionalism.
Anybody using the NHS can see inefficiency: its posture is almost entirely reactive rather than preventative; the patient is forced into multiple appointments to meet staff who don’t work the same hours (unlike America, where departments are always open to patients with the time for an immediate referral); British staff waste time managing appointments in person (without the capacity for the patient directly to access their own doctors by telephone or internet), or interviewing patients to fill out forms that could have been filled out by the patients, or verbally describing risks that could have been read by the patients in their own time.
That’s before we consider the waiting times, which exacerbate costs, such that cancer patients are not treated immediately, or physiotherapy is not available soon enough after injury to prevent permanent damage. Bear in mind that these are all issues of supply or delivery, independent of increasing demand due to migration and unhealthier lifestyles.
Even emergency care shows avoidable inefficiencies. I’ll give personal observations: my local emergency room has three people on the reception desk, of which the first verbally interrogates, before referring the patient to the third person, who takes the same information for entry into a computer. The second person does nothing. The patient takes a seat, until a fourth person assesses the injury. None of these people actually treat the patient. The patient waits for hours – the Government’s target (since 2000) is less than four hours waiting for urgent care: the flow under my observation was six persons in three hours: that’s 30 minutes per patient, when no injury needed more than cleaning and dressing, and the staff outnumbered the patients. The general atmosphere is unhurried and uncaring – patients are treated as bothers, and ridiculed for their stupidity of injury.
The false excuse of culture
British public servants and politicians have fallen over each other in their eagerness to call for cultural change, without recommending the accountability that would drive cultural change.
In 2013, Julie Mellor, then the Parliamentary Health Service Ombudsman (PHSO), criticised the NHS for a “culture of defensiveness” and “a failure to listen to feedback” (together: a “toxic cocktail”, in her words). Later that year, a clinical professor completed an inquiry into safety within the wider NHS, which recommended a legal duty for all healthcare workers to admit their mistakes, a “zero harm” culture, and “minimum staffing levels.” In 2014, Jeremy Hunt promised an “open culture that learns from errors and corrects them”, following the example of the airline industry. In 2015, Parliament’s Public Administration Select Committee (PASC) “ commend[ed] the Secretary of State’s determination to tackle the culture of blame and defensiveness”.
Ironically, criticising the “culture of blame” is a way of avoiding individual accountability. To blame “culture” is convenient for authorities that rationally want to avoid the blame. It’s rational, but that doesn’t make it right. It’s also ineffective. Culture is an attribute of a group, so is no one person’s fault.
Focusing on culture change without accountability achieves nothing beyond a temporary change of awareness, until everybody re-acclimates to lack of accountability.
Unaccountable systems are riskier systems. Most practitioners are probably caring and ethical, but good intentions can be over-ridden by natural, everyday contradictions as simple as distraction. When practitioners are not held to account, they become less mindful and honest.
For instance, reconsider that report that four in ten care homes failed inspections so far this year. A newspaper calculated that rate, after the Care Quality Commission failed to report any rate by year: instead, it reported a rate of two in ten homes in the longer period since October 2014; moreover, it has successfully prosecuted only five care homes in two years.
Who is accountable for health and care failures? Parliament’s Public Administration Select Committee (PASC) has reported that the authorities for investigating healthcare failures in Britain are too numerous and unaccountable. It counted more than 70 organizations involved in health complaints or investigations, of which “[n]o single person or organisation is responsible and accountable for the quality of clinical investigations or for ensuring that lessons learned drive improvement in safety across the NHS.”
The ultimate authority for complaints against health and social care is the misleadingly titled Parliamentary & Health Service Ombudsman (PHSO), which is neither accountable to Parliament, nor responsible for any particular health or care service. No parliamentary committee or politician can overrule it. The PASC can only examine its reports.
As you would expect, the PHSO’s unaccountability encourages the PHSO’s irresponsibility. The PHSO usually refers complainants back to any of those 70-odd other organizations, until the complainants exhaust whatever complaints system exists at the organisational level – or (more commonly) the complainant gives up on a costly, confusing, and unrewarding system.
The PHSO traditionally has investigated only one per cent of complaints – as if 99 per cent of complainants had the time and motivation to complain unnecessarily. In 2013, Mellor suddenly promised a ten-fold rise in the number of PHSO investigations, but 10 per cent is as arbitrary as one per cent. The PHSO actually investigated less than eight per cent in the subsequent fiscal year, or merely 2,199 complaints; the NHS alone received 175,000 complaints that year. The PHSO’s own surveys show that more than 50 per cent of Britons who consider complaining about the NHS do not bother, expecting no useful result, and that staff are reluctant to properly investigate complaints because they expect retaliation from their own hierarchy. The PHSO advises persistent complainants that their only recourse is a judicial review – a civil legal action beyond the resources of anybody but the fabulously rich.
The PHSO routinely fails to acknowledge complaints, claims that complaints are incomplete or improper, misaddresses responses, or reduces or reinterprets complaints. The complainant has no right of appeal against the PHSO. The PHSO dedicates no case officer to a complaint – thus, complainants are forced to deal with a different correspondent with almost every reply.
If the PHSO deigns to investigate at all, it refuses to investigate persons – only the organisations that have failed to satisfy complainants locally. In fact, the subjects of complaints are usually anonymized in reports. Consequently, the worst that the organisation can expect is a ruling that “mistakes were made,” for which it should apologise and perhaps compensate (to the inconsequential tune of a few thousand pounds), but no particular person is ever named as responsible.
A Complaints and Accountability Office
Years have gone by since these flaws were publicized, without reform.
For some reason, the Secretary of State and thence the PASC touted the system in 2014 for investigating airline accidents as their exemplar, but investigation is a purely reactive solution, and accidents are only one extreme form of failure, even if airline risks and health risks were analogous (they are not). In 2015, the PASC, in consultation with Hunt, recommended “a national independent patient safety investigation body,” but specified the PHSO by another name.
Mellor herself resigned in July 2016 after admitting to mishandling correspondence about her deputy, who had resigned in April after evidence emerged of his cover-up of sexual harassment by a fellow executive at a NHS Foundation Trust. Her replacement is (unlike her) a career ombudsman, but his staff could be anybody – the public can demand no transparency about their qualifications or performance.
In 2016, the Government published a Bill to create a Public Service Ombudsman that would absorb the responsibilities of the PHSO. This would replace one quango with another. The authority that should be accountable for a public service should be the deliverer – in this case, the Department of Health, because government departments are accountable to Parliament and thence the electorate; quangos are not.
The department happily informs hundreds of complainants per month that it has no role in complaints. In reply to the PASC in 2015, the Secretary of State ruled out a complaints department on bogus logistical grounds. The department must establish its own Complaints and Accountability Office, which in turn must be accountable to the Secretary of State and thence to Parliament, for a more efficient and effective healthcare system for all Britons.