Yesterday, it was revealed that in the three years to March 2008 at least 400 more patients died at the Stafford hospital than would have been expected at an average hospital of its size and case mix. The Healthcare Commission's chairman, Sir Ian Kennedy, described it as a story of "appalling standards of care and chaotic systems for looking after patients ... There were inadequacies at almost every stage". The patients died at a time when the hospital was trying to achieve foundation status, which would signify that it was rated as one of the leading NHS hospitals in the UK.
Yesterday's news about massive clinical failures at the Stafford foundation hospital - a supposed flagship institution - did not come as a great surprise to those of us who work in the NHS. Rather, it was a graphic illustration of the growing disconnect we see every day between a target-driven culture and the best interests of our patients.
This is not just some unrepresentative rogue hospital. Rather, it is an extreme manifestation which serves to epitomise the way the NHS and its medical staff have been forced to operate in recent years.
Across the country, there are more than a few hospitals with problems not dissimilar to Stafford's. The Mid-Staffordshire trust that ran the hospital was making an aggressive attempt to tick boxes and achieve foundation status. In theory, once you have got more control, you can spend more money - but in pursuit of that, you chuck the baby out with the bathwater. They achieved foundation status, yet their quality of patient care was very bad. A hospital is able to tick all the boxes, yet still utterly fail its patients.
How did we get into this situation? Well, the Stafford problems can be traced back to the reforms of the Conservative government in the early 80s, and the obsession with market forces as an unlimited good. At that time, the health service was in need of reform; it needed to be brought up to date. But the desire to find better ways to manage the day-to-day running of the hospital morphed into a perception that clinical staff - doctors in particular - needed kicking into gear. There was this assumption that came with it, that doctors - and nurses - could not be relied upon to drive clinical efficiency on their own, through sheer professionalism and pride in their work.
When the NHS was set up, it was an egalitarian system, "free at the point of access, independent of the ability to pay". Recently, there have been much-repeated anecdotes featuring consultants down at the golf course or working in the private sector on NHS time - and while those people probably existed, they were a tiny minority. The vast majority of doctors were out there doing far more than their fair share of work, because they believed in the delivery of a good service in the best interest of their patients. Unfortunately, no one could measure goodwill or professionalism.
So we went from a system driven by professional pride and duty of care to one that would accommodate market forces. This led to the paramaterisation of everything the bureaucrats could find to score.
From the outset quite a lot of people said, "Look, there's a problem with bringing market forces into the NHS, because the conditions for an open market don't exist." If Tesco does so badly that it's inoperable, Tesco goes bust and closes, and Sainsbury's wins. But you can't close a hospital if it goes bust - or at least, it's extremely difficult.
What's more, there aren't any truly useful measures of health outcomes. People say that they want to know how many of their surgeon's patients die, but as a raw measure that means nothing - it depends on the case mix. However it encourages doctors not to take on the risky cases. It leads to cream-skimming, where we say, "I'm going to take this guy because he's a good bet, and he probably won't die. Whereas this guy probably needs the operation but might die, which would make my stats look bad."
So what the government decided to do instead was make hospitals compete on things that mostly weren't related to clinical outcomes; things that could be easily measured, such as the four-hour wait in A&E. If you talk to clinicians, they'll say this has nothing to do with outcomes and doesn't improve the care that patients receive. You can find ways to fiddle the numbers to tick that box, and you can put resources in to try to meet the targets.
Of course, while you're putting resources into that, and at the same time trying to balance the books, you've got to take resources away from something else. A competitive trust is chiefly going to pay attention to the things that are going to get it points. And the four-hour thing gets you points. It doesn't matter whether that's going to make a difference to your healthcare.
The pressures are worst in the acute side of things, such as A&E, where doctors are made to get their patients in and out as fast as they possibly can. There is a whole line of managers making sure that patients don't stay a minute longer than four hours - otherwise, they're breaching [missing their targets].
Almost every day you get medical registrars, very senior people, saying, "I was in the middle of writing a drugs chart and talking to the patient and someone clicked off the brakes and wheeled the patient out." Because if the patients are in a clinical decision unit, or a holding area, they're no longer in A&E.
And, equally, you'll be in the middle of trying to prioritise your care - trying to deal with the sicker patients rather than the less sick - and someone's disagreeing with you, saying you have got to get patient X or Y out because they're about to breach the targets. There's lots of David Brent-esque jargon like that. Never mind that in that instant the best thing for that patient is to stay with the doctor, or the nurse, or whoever's looking after them, rather than to be wheeled away to somewhere else. What ticks the box is getting them out of A&E.
The result is that all the areas in the hospital that aren't measured have less attention paid to them. Literally anything that isn't a foundation target becomes a Cinderella service.
I think the urge to drive efficiency in the infrastructure of the NHS - something that certainly did need to be addressed - has been confused with the assumption that doctors weren't pulling their weight.
Scoring systems and competition can usefully drive efficiency when it comes to things like heating, buildings, catering and IT - but this has become entangled with the delivery of healthcare by clinicians. Non-clinicians have been incentivised to drive clinical processes that they understand only partially, if at all. Clinical process is so much more complicated than a business that buys and sells stock items. Yet we're trying to apply the same rule book.
What we've seen over the last 20 years is a systematic deprofessionalisation of doctors and nurses within the service. Those not involved in management are regarded simply as service delivery providers. We have seen the proliferation of management consultants within the NHS. But again, it is not clear that they have a true appreciation of the complexities of healthcare delivery. We are not selling clothes off a rack in a shop; it's not like that.
Of course, one of the things you do to improve your financial appearance is try to deliver the same service with fewer staff. And so, in the case of Stafford, we hear of there being no staff around. That's because, in a lot of these places, when they're trying to get foundation status, they're forbidden from hiring new staff. You can't put that cost on the books in the year you're trying to achieve foundation status.
The changes that were started in the 80s - which were then vociferously opposed by the then Labour opposition - were extended and amplified by Tony Blair and then Gordon Brown. Again, it's not all black and white - there were many useful reforms that allowed people to at least attempt to get their arms around how a hospital works as a complex system. However, the pendulum has swung too far in that direction. By reducing healthcare to a few measurable statistics, to create a target-driven culture, we have all but destroyed the essence of what was the NHS.
