I was the health secretary when NHS England was set up. Although there are advantages to depoliticising operational decisions, it has led to massive and counterproductive overcentralisation. The NHS has become the most micromanaged healthcare system in the world. Hospital chief executives are frequently working to more than 100 operational targets, making innovation and longer-term change impossible. GPs have about 80 of them. So as long as scrapping NHS England does not mean replacing bureaucratic overcentralisation with political overcentralisation, Wes Streeting is on the right track.
But I am worried about something else being missed. In the huge blizzard of organisational change, there is a risk of eyes going off the ball when it comes to broader patient safety risks. In December, the charity I set up, Patient Safety Watch, published a report put together by a team of people at Imperial College London led by Prof Ara Darzi. It suggested that if our standards were as high as the top 10% of OECD countries, every year fewer patients would die. Twelve out of 22 patient safety metrics have been going in the wrong direction in the past two years. It is a wake-up call about the tragedy of avoidable death, highlighted magnificently by Merope Mills in her successful campaign for Martha’s rule after the tragic loss of her daughter.
Why is this a concern? Because right now, tens of thousands of civil servants are starting the process of reapplying for their jobs after the axing of NHS England. In 2013, I saw with my own eyes the upheaval this kind of structural change causes. So my plea to Streeting is not to let organisational upheaval distract him from the gritty business of making sure we improve standards of patient care on the frontline. A figure of 13,500 avoidable deaths a year isn’t just a statistic, it is 37 patients lost every single day. Thirty-seven families whose lives are tragically and needlessly ruined. And a massive cost for the NHS because, according to the OECD, about 10% of the cost of modern healthcare systems is putting things right that should not have gone wrong. That is £15bn of savings no one would disagree with right in front of our eyes.
The biggest area of risk is NHS maternity units. The bill for settling litigation claims for maternity issues has risen to nearly £2bn a year. In the decade up to the start of the pandemic, the NHS made real strides in reducing baby deaths and stillbirths, but the latest data suggests that they are going back up. Particularly worrying are the ethnic disparities involved: black women giving birth are nearly three times more likely to die than white women.
A major investigation by the midwife and community activist Donna Ockenden into maternity services at Nottingham University hospitals trust is uncovering some harrowing failures of care. But even more worrying is that those failures appear to be part of a pattern: she found the same issues at Shrewsbury and Telford in her 2020 report. Dr Bill Kirkup found similar things going wrong in his reports on East Kent in 2022 and Morecambe Bay in 2015.
Every one of those reports has identified preventable deaths, staff shortages and deep-rooted cultural failings such as an overemphasis on so-called “normal births” which in practice lead to delays in vitally needed interventions by obstetricians. It is true that overall staff numbers have been going up and the NHS long-term workforce plan has doubled or nearly doubled the number of doctor, nurse and midwife training places. But if we are going to stop babies dying or becoming disabled because of medical error, we cannot wait for the decade it will take them to come onstream.
What then needs to happen? First, it is essential that improving maternity safety is part of the new 10-year plan as it was in the last one. That worked: between 2013 and 2019, extended perinatal mortality fell by 18% – from 6.04 per 1,000 total births to 4.96 – equivalent to about 770 fewer baby deaths a year. We also need a system to make sure that recommendations from public inquiries, the independent Health Services Safety Investigation Body (HSSIB) and coroners are actually implemented. There needs be a central repository of recommendations with public accountability as to who is responsible for implementing which ones by an agreed date.
It is also critical to put in place a turnaround programme for the 10% of trusts where maternity safety is rated inadequate by the Care Quality Commission (CQC). After the Mid Staffs scandal, which saw hundreds of patients die as a result of poor care at Stafford hospital, Bruce Keogh led a national review of 14 NHS trusts with high mortality rates, leading to 11 being placed in special measures with high-level central support. Most of them were turned round fast. Maternity services need a similar intervention based on robust, independent inspections by a reformed CQC we need to see back on its feet.
Finally – and most challengingly – we need a renewed focus on dismantling the blame culture that makes it difficult for clinicians to be open about mistakes and failures, and therefore make sure the system learns the necessary lessons. This problem has been largely cracked in the aviation industry, which has made dramatic progress in improving passenger safety. It has proved much harder in healthcare systems where death is inevitably a more normal occurrence. But no system has thought harder about the ethical issues involved than the NHS – if anyone can solve this, it is surely us.
Tackling these issues cannot wait until after new and better NHS structures are put in place. If England had the same maternity safety levels as Sweden, 1,000 more babies would live every year. Nothing would demonstrate better that the NHS really is turning a corner.
Jeremy Hunt served as secretary of state for health, later secretary of state for health and social care, from 2012 to 2018
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