When the German philosopher Hannah Arendt offered her famous insight about the "banality of evil", she was thinking about Adolph Eichmann and those many others who worked at the coalface of the Nazis' "Final Solution". Arendt's profundity was immortal not because it connected with the enormity of the Nazis' crimes (which were self-evident) but because she precisely pinpointed the nature of the wickedness at their heart. Nazi crimes were doubly repugnant because they were so routine. Could this same observation not now be applied, without hyperbole, to "Our" NHS (GC, lest we forget) in light of the revelations that have come from Manchester Crown Court after one of the longest murder trials in British legal history?
To read the broadsheets is to realise a metaphorical Rubicon has now been crossed. There has been no outpouring of confected hatred about a "monster", notwithstanding Lucy Letby's culpability as an individual. Even the tabloids have reined in the lurid headlines (Myra Hindley, Rosemary West, Beverley Allitt passim) and reported dispassionately. Indeed, the papers have all noted the very ordinariness of the culprit ("beige" according to one police officer) and the mystery of her motivation. As with Adolph Eichmann in the dock in Tel Aviv in 1961, her egregious crimes seem beyond human comprehension.
Rather, the ire has been directed at those administrators, senior executives and "leaders" at the Countess of Chester Trust who, whether through pride, complacency, indifference or sheer incompetence, allowed Letby's killing spree to continue long after the first alarm was raised by a pair of paediatric consultants. There have been calls for a statutory public enquiry which can compel testimony and the wholly reasonable demand (again) that there be established some professional body which can disbar members of the healthcare bureaucracy in the same way that the GMC can discipline medical practitioners. Some are even talking of charges of corporate manslaughter being brought against the trust. There is a widespread sense that this time, an investigation that does no more than produce "lessons to be learnt" will be completely intolerable.
For we have been here many, many times before: Gosport; Grantham; Bristol; Mid Staffordshire; Harold Shipman; Jimmy Savile and Morecambe Bay. So many needless deaths and murders (or rape on the wards, in the case of Savile); so many "lessons learnt"; so many recommendations. After each outrage, another layer of "process" is applied, another quango is created and there is no discernible improvement. Barely eighteen months ago, the Ockenden Report into malfeasance at the Shrewsbury & Telford NHS Trust revealed a culture of management incompetence, professional in-fighting amongst medical staff, buck-passing on a grand scale and official lies. It seems hard to believe, but the annual rate of needless mortality on the maternity wards in Shropshire far exceeded that of the killing spree of Lucy Letby in a neo natal unit in Cheshire. Scroll forward and Donna Ockenden is now to be found examining another spate of unexplained deaths, this time in the maternity unit of a Nottinghamshire health trust.
What accounts for the banal wickedness which seems to characterise so many parts of the NHS? Behind the bald and terrible facts of the crimes of one individual and the genuinely moving testimony of the grieving parents, there were some revelations about the workings of "Our" NHS which make for sober reading:
- The culture of medical professionalism at the Countess of Chester Trust was clearly toxic. Doctors were at loggerheads with the nursing hierarchy and the only way in which medical malfeasance could be addressed was via labyrinthine HR processes which had to be routed through hospital administrators, with whom everyone seemed to be at loggerheads.
- What sane healthcare organisation would allow clinical judgements to be made by non clinicians? At very nearly every stage of the unfolding crisis, the professional opinion of the two paediatric consultants was either ignored or over-ruled. Indeed at one stage they were ordered to apologise to the culprit, who had launched a "grievance" procedure against them.
- If non clinical hospital executives and "leaders" cannot be held to account in the same way as their clinical colleagues, from where do they derive their authority? There have been an increasing number of calls over the years for non-clinicians in leadership roles to be subject to the same processes of "re-validation" and discipline by a collective professional body (such as the GMC) as can be found for surgeons, clinicians, general practitioners and nurses. There should be no mystery as to why this hasn't happened however: nearly half the civil servants at the Department of Health and Social Care are ex-medical administrators. We can't have the ministry subjected to lawsuits, can we?
- What sane healthcare organisation would allow cultural issues to take precedence over clinical decision making? It appears the Royal College of Nursing was quick to take umbrage at the incidence of two male clinicians questioning the fitness of a female colleague (Letby) to work on the neo-natal unit. What patriarchal tyranny ! The doctors were forced to apologise by a craven hospital executive team which thought HR hassles were of greater importance than medical malfeasance. Now the president of the RCN, one Sheila Sobrany, has had the brass neck to claim that the reason why one of the consultant whistle-blowers (Ravi Jayaram) was not believed is because he is "of colour". How does such a stupid and tone deaf person get to lead something like the RCN?
- Premature babies are among the most delicate and vulnerable of patients. How does a neo-natal intensive care nurse get to be allowed to work three 12 hour shifts a week? How on earth can a professional or indeed any working person be expected to remain clear headed and alert for that length of time, notwithstanding breaks? We have been subjected to all the usual blather about how the NHS (all 1.6 million of them) is understaffed and everyone is close to "burnout". The NHS has been "burnt out" for years, largely the result of quite insane staffing practices that allow "life-style" choices by doctors, nurses and administrators to take precedence over their duty of care to patients. Wasn't it strange how (apart from two consultants) nobody in their little "work - life balance" siloes at the Countess of Chester seemed to notice that there was anything amiss about nurse Letby?
- There are thousands of so called "leaders" in the NHS, but virtually zero leadership. Instead, responsibility is diluted by a plethora of job titles (Head of Nursing, Senior Nursing Director, Head of Nursing Care - all actual titles at the Countess of Chester and all with six figure salaries) and accountability is widely dispersed. Despite the lip service paid to the trauma of the poor bloody families who lost loved ones, everyone in any position of authority in this tale has been quick to disassociate themselves from any responsibility. Further, difficult decisions or the application of professional judgement is frequently outsourced - it's much easier to blame a management consultant if there is a cock-up on your watch. What sane developed country has a staff college for the training of the senior leadership team of its armed services but no equivalent for its health care service which is ten times bigger? Why do whistle-blowing "protocols" in the NHS have to be endlessly strengthened if the leadership was any good?
Finally, it needs to be remembered that these are all tales about individuals. It is simply not good enough anymore to talk about the "systemic" failures of the NHS as if its practitioners have no agency. After all, its victims are all flesh-and-blood human beings.
"Stay Home, Protect the NHS, Save Lives" - never were truer words spoken.
