When T.S Eliot spoke of the folly of trying to ‘Devise systems so perfect, that nobody will need to be good’, he effectively described a distinction between the left – who instinctively turn to systems to get things done, and the right – who tend to believe in focusing on individuals, people, and their values. In a world where the centre-ground has become over-crowded with political parties all frantically claiming it, and a rainbow array of party hues (Blue Labour, Red Tories), this is a distinction that still makes some sense.
In fewer areas is this distinction seen more clearly than how we think of our public services. Whether we think of them as the people who work in them on the front line, or the systems they work in.
This is why the NHS debate that has arisen in the wake of the Mid Staffs scandal is so important – and why the question over the future of David Nicholson is about much more than just one man. It is about how we see the NHS; as systems, driven by managers – or an organisation that is as it is because of the people who work in it.
However ‘New’ Labour wanted to describe itself, the legacy of its reforms of the NHS are now sadly characterised by imposing system after system, and target after target. And it was sadly predictable that this emphasis on devising the perfect system, including targets and a complex universe of different bodies and different tick-boxes, would do what history has shown societies based on someone’s idea of perfect system tend to do: erode the autonomy and identity of those who work and live in that system.
Back in 2008, the man to whom we are now looking to turn around our NHS, Obama’s former healthcare adviser Don Berwick, wrote a report on the state of the NHS. This was presented to the Labour government. Its damning findings were promptly buried. (We can only speculate on how many of the 2,800 excess deaths that occurred between the presentation of the report to ministers, and the general election in 2010 could have been saved if Berwick’s 2008 recommendations had been urgently acted upon.)
Amongst the description of culture of compliance and fear in our NHS, and amongst the description of the inadequacy of our NHS quality assessment systems (yes, all sadly familiar stuff) there is a quote from a doctor which sums up the legacy of this systems-based approach. This doctor’s quote was one amongst many which said:
‘The GP and consultant contracts are de-professionalising, and have had the peculiar effect of simultaneously demoralising and enriching doctors. Basically, we’ve lost the ‘volitional work’ of the doctors, and far too many of us are now just working to rule.’
It shows how little the Labour government of the time understood what makes doctors tick. The Consultant Contract, which paid doctors for the work they actually did, demonstrated how the then government completely under-estimated the professional drive of most doctors to work to make patients better. The result, like so many initiatives of that time, was to spend more money, whilst simultaneously driving a hatchet to the NHS’s most precious asset – the professionalism – or vocation – of its workforce.
Instead of celebrating the motivation of their NHS workforce, the then government machine seemed scared of the professionals themselves and determined to squash their influence.
One disastrous example was to take the task of quality assessment away from respected medics, who knew their stuff, and give it to a sequence of quangos of tick-boxers. As one doctor said to me: ‘as long as the operating theatre looked clean, it would tick the box, and the person asking the questions had no understanding of what they were looking for.’ That explains why, under New Labour, hospitals happily waltzed through all the tick boxes and romped towards Foundation Trust status, while the reality was horrifically different. If our ‘Ofsted style’ reforms are to make any real difference, who does the inspection is far more important than the structure in which they do it. The expertise contained in the Royal Colleges should be central to all of it.
Interestingly, as the concept of ‘vocation’ has been pushed out of political understanding and management of the people who work in the NHS, so the word itself has shifted its meaning over the last decade or so. “Vocational” ( Latin voco-vocare, to call) originally means a motivation for doing something – ‘a calling’ – that internal drive to accomplish a task for its own sake and benefits, beyond logical benefits of remuneration. (You can have a vocation to do anything; but it is usually associated with services like being a vicar, doctor, nurse, vet, military). However, it has now come to mean a specific set of manual, practical skills and crafts – plumbing, electrician, construction. The migration of this term to a set of practical abilities seems ill-fitting and patronising to those essential and massively under-valued skills. But, equally, in removing the word from its original context, it begins to remove the concept from its original context as well – and the idea that our doctors and nurses may be motivated primarily by their ‘vocation’ slips away as the word wanders from its original meaning.
But if we are to have any hope of achieving the culture change that is now universally called for within our NHS, it should be obvious that we can no longer rely on systems. We need people to be good. Our NHS cannot meet the terrifyingly expanding demands upon it without the vocation and professionalism of the work-force that has enabled the NHS to withstand so many structural changes over the years (no less than nine in the last government’s time in office). Take away the professionalism of our doctors and nurses, and the NHS is just an empty shell.
That is why all our policies should be driven towards nurturing and nourishing professionalism in our NHS. Nursing qualification reforms are a good start. Putting clinicians at the heart of commissioning is a good start. But we need to go much further. The European Working Time directive, for example, which limits doctors’ working week to 48 hours is daily eroding professionalism and risks breeding a generation of ‘clock-on, clock-off’ doctors.
Much needs to be done, and there is not much time. The landscape has been blown apart by the revelations at Mid Staffs; but it will settle and harden, and the opportunity for change that this earthquake of appalling revelations offers will be lost.
If we say that David Nicholson, the Chief Executive of the NHS, widely distrusted and resented by a hospital-floor workforce who see him as synonymous with a culture of gagging, bullying and the stifling of professionalism, is indispensable, it indicates that we see the NHS as simply a system.
But the NHS is not David Nicholson. It is not a system. It is the people who look after and care for patients on a daily basis, empowered by good managers. If we believe that the NHS is people and values, and not a ‘system so perfect that nobody needs to be good’, it cannot be led by a man who has become the embodiment of an era of de-professionalisation of our NHS, and whose very determination to stay on illustrates his complete lack of any sense of personal responsibility.
We must be brave and seize this opportunity to create the new culture of the NHS, fight back against the erosion of vocation, and trust in the dedication and ability of our professionals. Therefore, David Nicholson must go.
Charlotte Leslie is the Conservative MP for Bristol North West. She tweets @CLeslieMP.
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