The trial of a British neonatal nurse, Lucy Letby, who is accused of killing seven newborn babies and attempting to kill ten more, a trial which is currently ongoing, has as a side issue revealed some aspects of the internal workings of National Health Service management that are worth examining and discussing. Whilst for reasons of sub judice I cannot discuss too much about the case against Letby itself, press reports about evidence given by doctors about the conduct of NHS management do cause me to wonder about the quality of NHS management and managers.
It appears that medical staff who were concerned about the fact that babies were getting into distress or dying from unexplained causes when nurse Letby was on duty, took their worries to their local senior management at the Countess of Chester Hospital. However the senior management refused to entertain suggestions from front line medical staff that the highly unusual deaths of two out of three babies in one case of triplets might have been the result of medical malpractice. Senior management refused to take the alleged killer nurse off duty until an internal investigation into the deaths was completed.
The Daily Mail said:
A senior hospital executive ignored three warnings by a consultant paediatrician that Lucy Letby might be responsible for a number of deaths in the neonatal unit, a jury heard today.
Karen Rees, a duty executive in urgent care in June 2016, insisted there was no evidence against the nurse, and refused to take her off duty until the sudden and unexplained death of a triplet was properly investigated.
Stephen Brearey, a paediatric lead at the hospital, told the jury at Manchester Crown Court that he called Ms Rees because he could find no natural cause for the death of Baby O.
Whilst I completely agree that suspicions sometimes do not equal guilt when there are aspects of a case, such as the death of completely healthy babies on a path for discharge, that might indicate the presence of a problematic member of staff, then there might be a case for temporarily suspending an employee about whom there are suspicions of work problems or malpractice. This path of action would of course be hard on innocent medical staff who were suspected without good reason, but it could be the better and more cautious path.
The Mail added:
Letby, 33, originally from Hereford, is on trial accused of murdering seven babies and attempting to kill a further 10 premature babies on the neonatal unit. She denies all the charges.
Dr Brearey told the court that even before the twins’ deaths, he and some of his colleagues had raised concerns with management about the association between Letby’s presence and deaths they had seen on the unit.
‘I phoned Karen Rees, the duty executive in urgent care, who was familiar with the concerns already.
‘I explained what had happened and said I didn’t want Nurse Letby to come back to work the following day or until this was investigated properly. Karen said no to that, and (that) there was no evidence.
‘The crux of the conversation was that I then put to her ”Was she happy to take responsibility for this decision in view of the fact that myself and consultant colleagues would not be happy with Nurse Letby going to work the following day?”
‘She responded ”Yes, she would be happy”. I said ”Would you be happy if something happened to any of the babies the following day?” She said ”Yes”.
If this decision by the manager had come out of the blue and without any background then maybe this would have been the correct decision. But the manager was already aware that there were allegations about a particular nurse stating that the nurse was present when babies died or who were suddenly sick without good explanation for such sickness or death.
Action was taken about a week later and it appears that the nurse was then suspended. The appeals to management, according to the Mail reporting the words of witnesses, were made not by medical colleagues who had an animus against the defendant, but by those who had initially refused to believe that there was a potential alleged problem with this particular member of staff.
As I said I can’t comment too much on the facts of the allegations at the centre of the case in question for legal reasons but this case does raise questions about the calibre of NHS management. Management in this case seemed to be extremely concerned with following correct procedure, such as policies about properly investigating allegations of bad practise and not casting aspersions on a member of staff without proof.
Whilst it is all well and good that innocent staff are protected from false or malicious allegations, it is not an organisational mindset that is able to act quickly when there is a need for management to act swiftly. I am of course speculating here but I get the impression that the management member who was confident in her assertions that she was happy for the nurse in question to remain on the ward, might have been so confident because she may have suspected that her own management would back her up. They’d back her decision up because she’d followed proper procedure and because she’d been following proper procedure everything might have seemed OK from her perspective. Management in an bureaucracy can get sclerotic with agreed procedures and policies that more junior management needs to abide by lest they get in trouble with those above them in more senior positions. This is not an organisational model that is able to cope with situations where there is a need for management to make immediate decisions and especially not life or death decisions.
Anyone who has ever had anything to do with dealing with NHS bureaucracy will understand just how sclerotic it can be. Trying to get them to act on something or provide information is like trying to get blood out of a stone. Like any large organisation there is a tendency to always ‘go by the book’ but what if going by the book itself causes problems?
We should ask some very awkward questions about how the NHS is managed. We should ask is it being managed for the benefit of the managers and the staff, or is it being managed for the benefit of the patients? We should also ask whether there has grown a culture of ‘tick box management’ in the NHS that encourages a chronologically long rather than short decision making path and also whether this type of management and its treacle like speed in making vital decisions is creating bad outcomes for patients?
” … is it [NHS] being managed for the benefit of the managers and the staff…”
Given the never-ending litany of cover-ups, shocking failures that result in managers “gfailing upwards” etc. I would have thought the answer was clear.
But I suppose I might be wrong.
As I’ve argued elsewhere, whatever your general view of the NHS as an idea there is clearly something wrong with it and that “wrongness” is why it’s consumption of the national purse has increased from ~24% to >40% over its life, whilst beds have dropped 75% (hence the annual winter crisis that the NHS cannot or will not actually plan for), Whilst the numbers of medics, health assistants and managers has mushroomed exponentially.
My question is simply this: how come an organisation that gets an ever greater share of our resources, is ever ballooning in organisational size (but not patient capacity in terms of beds) is so often unable to provide even a safe service?
It should be obvious to all that throwing money at it has not, does not and will not solve the problems. (Yes, I acknowledge the problems of staffing, but why did the NHS start with roughly 7 beds per nurse but needs about 1 nurse per bed for example and the situation regarding the doctor:patient ratio is even more extreme in terms of its changes over time.)
Some really good points there, thank you. You are right when you say that there are number of different views of the NHS some unthinkingly supportive and some very critical but no matter where we come from or what political river we are floating along, one thing that can be agreed is that there is as you say ‘something wrong’ with the NHS. Some people believe that the NHS can be improved with more money but you could chuck the entire GDP of the UK at the NHS and it might not be that much better than it is at present.
As you say it’s odd that the amount spent on the NHS has gone up but in some areas it can have worse patient outcomes than can be found in healthcare systems that are at the other extremes of state and private, such as the USA. The fact that they cannot plan for easily expected situaitons such as a greater workload in winter where there are more respiratory diseases and other winter related conditions tells us volumes about how badly the NHS is managed.
I believe that there should be comprehensive healthcare for a nation’s citizens as it is a part of the social contract between government and citizen but the NHS doesn’t particularly well serve the citizen and in some cases serves those who come from overseas specifically to ponce off of it much better than those Britons who’ve paid into it for years. Whilst the NHS contains some excellent and dedicated individual staff members, the NHS model itself is not fit for purpose. It’s overly costly, it’s not giving good value for money, it’s politicised to such an extent that governments cannot get the NHS to effectively police who uses it and therefore it’s become a world health service open to anyone who can get their feet on British soil. The politicisation has seen the NHS grow a parasitical caste of management staff whose entire existence is to promote bollocks like diversity equity and inclusion or to suck at the government funded teat of ‘climate change’. The outcomes are bad and there is little or no choice for the customer. It’s a 1930’s solution to a set of 21st century healthcare problems. Having the NHS the main provider for modern healthcare is like trying to do online banking with an original Enigma machine, it ain’t going to work.
There must be a better way to provide comprehensive healthcare to Britons without the now obvious problems of the NHS but without the obvious problems caused by a complete free market or a private system where health insurance is unaffordable for too many. Other nations both in Europe and elsewhere seem to be better at providing healthcare for their citizens so why can’t Britain?