The crimes of Lucy Letby - a nurse who was convicted of murdering seven children and attempting to murder another six - is a multiple personal tragedy for the families involved. It is impossible to imagine what pain they have gone through.
However, the case also raises profound questions about the way the NHS is run.
Much attention has focused on the actions of NHS managers, with headlines such as:
“Hospital bosses ignored months of doctors' warnings about Lucy Letby” (BBC).
The Daily Telegraph went further:
“Doctors wage war on NHS managers after Letby”.
There is going to be an inquiry. They will be in a position to apportion blame, which I certainly am not.
One thing that I am sure will quickly become evident though, is the complexity of the relationship between managers and those providing care in the NHS.
It is understandable that many are already criticising managers for not doing enough to respond to the concerns that were raised with them. But where does that lead? The logical response would be to require managers to be more active in managing performance of those providing care.
Is that what health professionals really want?
Managing performance in the NHS is an incredibly difficult task. Managers face all kinds of constraints on their actions. Care professionals are (quite reasonably) well represented, the legal and regulatory frameworks are complex, and it is often difficult to pinpoint exactly where the responsibility lies when things have gone wrong. Taking action against those who provide care can be very messy in terms of its impact on team dynamics and keeping the rest of the service going.
The NHS is currently in the process of implementing a new approach to responding to incidents involving patient safety, known as the Patient Safety Incident Framework (PSIRF). One of the key aims of the new approach is to reduce the emphasis on blaming individuals. The Interim Chief Investigator at the Healthcare Safety Investigation Branch (HSIB) says that the new approach “reflects the key principle that guides our national patient safety investigations – a focus on understanding how incidents happen rather than attributing blame or liability.”
There are very good reasons for putting the focus on “understanding” and improving the service. But how compatible is that with the responses that are now being discussed to the Letby case?
How do you strike the right balance between addressing concerns about individuals and focusing investigations on improvement?
Another popular idea being discussed is the regulation of NHS managers. This is supported by the British Medical Association, amongst others. The Sunday Times says that “a disregard for patient safety by managers” has been a thread running through the worst NHS scandals in recent years. The paper says that the Letby inquiry must be “the last to find bosses closed ranks”.
I don’t have any objection to the regulation of NHS managers - although I don’t think that it will be an easy thing to implement.
More than that, I am not sure how much difference it will make. It is one thing for NHS managers to be not very good at some aspects of their (very complicated) jobs. It is quite another to have them struck off or disbarred from their jobs for underperformance.
What managers need is not so much regulation, as better management.
It is worth considering what incentives NHS managers are given by their bosses.
Start at the top. The Prime Minister has five priorities for the government. Three relate to the economy, one to immigration, and one to the NHS. The health one is, of course, about waiting lists:
“NHS waiting lists will fall and people will get the care they need more quickly.”
This objective is about output - see more people, and see them quickly.
The chief executive of the NHS says that it has three key tasks for 2023:
Recover our core services and productivity
To make progress in delivering the key ambitions in the NHS Long Term Plan
To continue transforming the NHS for the future.
Delivering services, delivering targets, delivering transformation.
Where does patient safety fit in to these messages from the top? Is it any surprise that managers prioritise 'keeping things going'?
Now I’m not saying that patient safety isn’t important to those running the NHS - of course it is. But can we imagine managers being given an objective to focus on quality and patient safety and not worry if throughput falls a bit? No, of course not.
I practice, the key role of NHS managers is to treat as many patients as possible while hitting financial targets. And that is what they try to do.
Throughput and money are easy to measure, quality and safety aren't. Managers are instantly pounced upon if they start to slip in these areas - to the point of the Secretary of State for Health calling hospitals on Monday morning to ask about performance over the weekend. Maximising throughput will be their prime focus as long as that is the leadership they are given.
If we want to see change in that, it will need to come from the top.
The Letby presents really difficult questions:
Does there need to be tighter regulation of health professionals?
When should investigations place blame on individuals?
Are the incentives that NHS managers are given the right ones?
There are no easy answers to these questions. The Letby case makes them harder to avoid.
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