PEOPLE go into hospital to die. This might not have been their
intention, but, as they approach the end of their lives, their
medical needs often dictate that a hospital is the only place where
they can receive the care that their failing bodies require. As a
consequence, hospital staff are dealing with death every day. Many
deaths are natural, gentle, and predictable; others are unexpected
and traumatic. This is the context in which Sir Bruce Keogh's
review of 14 hospital trusts with higher than expected mortality
rates should be viewed. Hospital staff work in an environment where
death is often still seen as a failure, and in a wider culture that
today lacks a unifying religious or philosophical understanding of
mortality. They must cope with it in their own ways, and,
inevitably, a proportion of them cope badly. This is one of the
fundamental reasons why the other review reporting this week,
Baroness Neuberger's investigation of the Liverpool Care Pathway
(see article),
called for fundamental changes of approach in end-of-life care. A
sound programme to ensure that people in their last days are given
the correct level of treatment has, in some cases, been applied in
a disorganised and uncompassionate way.
Much of the blame for the poor treatment in the 14 trusts named
on Tuesday must rest with the individuals who, when a professional
and caring response was called for, failed to provide one. The
Department of Health is right, however, to target the management of
these trusts. The culture of a hospital - what standards are
accepted, how the staff are treated, how funding is used - is up to
them. This is, of course, another set of individuals, and the
Health Secretary has promised that the guilty ones will be
replaced, as is right.
There is a danger, though, that a fundamental weakness in the
NHS is being ignored. Its present organisation into a series of
competing trusts resulted from applying a market model to the
Health Service. Under market thinking, a monopoly is a bad thing,
leading to inefficiency and complacency, and evidence of these was
easy to find in the old NHS monolith. But a working market model
relies on a balanced relationship between supplier and customer,
and here there is confusion over who the customer is. To a degree,
it is the patient, who experiences the hospital's care, or lack of
it, first hand. But patients' knowledge is limited. They know how
long they have to wait for treatment, and this became, for a while,
the chief measure of a hospital's performance. But they do not know
about outcomes: comparing surgical success-rates between trusts,
for example. For this, the Department of Health remains the
customer, and the Government is thus to blame for failing in its
scrutiny of its chosen suppliers. In the end, the market is just a
business model: a successful supplier will provide the required
level of service for the lowest price. The Health Service deserves
more than this. Another reorganisation is out of the question, but
a recognition that there are principles and practices that override
commercial concerns would be a good place to start.