Gaming the system

Mrs Thatcher believed, and John Major and the Blair-Brown administrations followed her in this, that the NHS would give more value for money if internal competition was created. That belief should finally have been refuted with the revelations about the Liverpool Community Health Trust in the House yesterday.

In introducing the Kirkup Report, Stephen Barclay (as has become the norm, Secretary of State Hunt put up a junior minister to take the flak) said:

The report covers the period from the trust’s formation in November 2010 to December 2014, and it describes an organisation that was, “dysfunctional from the outset”. The consequences of that for patient care were in some cases appalling, and the report details a number of incidents of patient harm including pressure sores, falls leading to fractured hips, and five “never events” in the dental service—an incredibly high number for one organisation.

The failings of the organisation were perhaps most starkly apparent in the services provided at Liverpool Prison, where the trust failed to properly risk-assess patients, including for nutrition and hydration, and it did not effectively manage patients at high risk of suicide. The review also identified serious failings in medicine management at the prison. There are many more examples of poor care and its impact on both patients and staff in the report, but what compounds the shock is the lack of insight into those failings displayed by the organisation at the time. This was the very opposite of a culture of learning, with incidents under-reported or played down, warning signals ignored, and other priorities allowed to take the place of patient safety and care for the vulnerable.

We have seen this sort of moral drift before, most obviously at Mid Staffordshire and Morecambe Bay. As with Mid Staffordshire, the management at Liverpool Community Health NHS Trust put far too much emphasis on achieving foundation trust status. The review states that,​ “the trust undertook an aggressive cost improvement plan, targeting a £30 million reduction over five years. This represented a cut in resources of approximately 22%. We were surprised that such an ambitious financial reduction was not scrutinised more closely—by both commissioners and regulators.”

There is a direct line from the decision to pursue foundation trust status in that reckless manner to the harm experienced by patients. Indeed, an earlier report by solicitors Capsticks reported in March 2016 that the interim chief executive who took over from Bernie Cuthel found in her first week that

“there was an underspending by £3 million on district nursing. These teams were devastated because they weren’t allowed to recruit, some of them down to 50%”.

This is a district nursing service in which Dr Kirkup reports that patients were experiencing severe pressure sores, up to what is clinically called grade 3. That was accompanied by many of the hallmarks of an organisation that has lost sight of its purpose. As Dr Kirkup states,

“the evidence that we heard and saw amply confirmed the existence of a bullying culture within the Trust, focused almost entirely on achieving Foundation Trust status. Inadequate staffing levels, poor staff morale and appalling HR practice went unheeded.

(My emphases)

The Welsh NHS may have changed direction following devolution in 1999, but the basic Thatcherite structure is still in place - and the disgraced chief executive Bernie Cuthel now works for the Betsi Cadwaladr Trust.

This view that money motivates public service prevails elsewhere in the UK, from the privatised probation service to the railways. The sooner the government abandons its ideology and adopts an evidence-based approach to providing essential services, the better.