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The writer is a neurosurgeon and author of ‘And Finally: Matters of Life and Death’
It is impossible to know what Lucy Letby was thinking when she murdered babies at the Countess of Chester hospital. But such events are sadly not entirely unknown, either in Britain or abroad, and reflect the fact that doctors and nurses have the power of life and death over their patients. Perhaps we should not be surprised if terrible things happen occasionally.
But Letby’s motivation, and even the question of her guilt, are irrelevant to another problem — the relationship of hospital management to clinical staff in a state-funded healthcare system such as the NHS. The doctors at Countess of Chester had reasonable grounds for anxiety about Letby’s role in the death of an unprecedented number of babies, and yet were over-ruled by the hospital management. It seems that more babies died as a result.
I joined the NHS as a “junior house officer” in 1979. Over the 40 years of my career, probably the greatest change I saw was the loss of doctor’s autonomy. There can be no question that in the past mistakes and avoidable harm to patients were routinely hidden from the public by the medical profession. The disempowerment of doctors was accelerated by a series of medical scandals such as the case in Bristol in the 1990s where paediatric cardiac surgeons were carrying out operations with much worse outcomes than at other units. But, as with recent events, responsible authorities such as the Royal College of Surgeons failed to take any effective action after a whistleblower exposed the problem.
Margaret Thatcher claimed that the introduction of business management into the NHS would make it so good that “no one will want to go private”. The Griffiths Report in 1983, which created the new class of hospital managers, and health secretary Kenneth Clarke’s subsequent introduction of the “internal market” were a compromise, forced on Thatcher and her free-market acolytes by the fact that the NHS was politically inviolate, a national “religion” as Nigel Lawson complained. But the problem with the NHS at that time, and indeed since, was as much one of chronic underfunding as of any lack of business management and competition.
It is easy to understand the role of managers in private hospitals, which deal mainly with insurance-funded elective work. This comes with price tags, so business management and planning can be applied. Staff training costs are largely borne by the taxpayer, and emergencies go to the NHS. The private sector does not have to deal with the consequences of old age, deprivation and inequality.
Few observers now would consider the attempts, under both Labour and Tory governments, to introduce market competition and choice into the NHS to have been successful. Given the long-term underfunding of the service (with the exception of the Blair and Brown years), hospital managers are caught in a bad place — between their political masters, who want costs to be contained, and their clinical colleagues whose work is always driving up costs. This can easily lead to conflict rather than trust and co-operation.
I have no doubt that state-funded systems, for all their failings, are the most effective and equitable way of delivering healthcare and must be defended against their critics. But it fills me with despair that the failures of the past, with its culture of secrecy and denial, are now being repeated — by the very people who were supposed to prevent them.
The Chester case is obviously exceptional, and it is clearly the case that there are many excellent NHS managers. But if some of them end up ignoring the advice of frontline clinicians, as happened at Chester, and make decisions that have grave consequences for patients, they must be held to account — just as doctors are subject to the General Medical Council, malpractice litigation and even criminal law.