From “doctor knows best” to “market knows best”

We are consistently told by this government that the public sector is wasteful and inefficient and that the private sector offers much better value for money for the ‘Great British Taxpayer’. The evidence for this is scant to say the least. In the rush to marketise statutory provision, the need to assert the superiority of the private sector has overtaken the evidence that supports the assertion. However, such is the robustness of the ‘market knows best’ argument that this lack of evidence has ceased to be any sort of barrier to the rolling out of the policy. Even when direct evidence that the private sector is failing is available, it doesn’t appear to be embraced by the media in the same way that public failings are. There is one rule for public and another for private, and clearly private is seen as good whilst public is bad!

Writing in the Guardian this week, Colin Leys offered a damning review of a Care Quality Commission (CQC) report conducted into the private hospital BMI Mount Alvernia in Guildford. The original report was published in late Spring, and I have to confess I had missed its initial publication. The report catalogues a very real failure of a private provider. A private provider that was contracted to offer publicly funded NHS services.  The failings in Mount Alvernia hospital included instances that put patients at “significant risk”, which on occasion were “life-threatening”. The hospital subsequently failed a follow-up inspection in May 2013, which found it failed to meet three minimum safety standards. Leys also points out that BMI (the owners of Mount Alvernia and one of the 4th largest for-profit healthcare providers in the UK) generates 20% of their annual revenue from treating NHS patients. This is clearly not a story of small local provider in Guildford. Specifically Mount Alvernia was required to take action in terms of ‘safety and suitability of premises’, ‘safety, availability and suitability of equipment’, and in terms of ‘supporting workers’. Leys paraphrases the CQC report, stating

“There were not enough nurses, staff were not properly trained, records were not being kept, samples were incorrectly labelled, out-of-date blood was used in a transfusion, resuscitation equipment was broken, no checks were made that all instruments had been removed at the end of operations. One surgeon reportedly refused to wash his hands between patients, saying he had “low infection rates”.”

Consider Mount Alvernia in the context of Mid-Staffs. There is little similarity in how these events were reported. The Daily Mail printed one story about Mount Alvernia, as did the Daily Telegraph. Mount Alvernia’s status as an outlier is implicitly accepted, in that there are no calls for a sector wide national review of private providers. Both Mid-Staffs and Morecambe Bay were also outliers, but there has been no such acceptance of this status for the public providers.

The Mid-Staffs scandal spawned two public inquiries and led to the Keogh Review of 14 hospitals adjudged to have excess Hospital Standardised Mortality Ratios (HSMR), that is to say, higher than would be expected rates of deaths within the wards. Much of the discussion (after the second Francis inquiry) has been about the role of management culture in skewing professional practice. About how the pursuit of foundation trust status could create a climate where those areas of professional practice not relevant to that application were neglected and ignored. As such, rather than bad professionals, we might talk about bad management in the context of Mid Staffs. Similarly, when considering the Keogh Review, and the focus on HSMRs, the allegation was that those hospitals under review had elevated HSMRs. The impetus for the inquiry rested at the level of systemic practices, rather than professions ‘gone bad’. The point is that the identification for inclusion in Keogh was not necessarily based on failed CQC reports, but on statistical anomalies. There is also the need to consider the controversy around the veracity or even utility of HSMRs as a metric. In 2010 the British Medical Journal described them as a “bad idea that just won’t go away”. Mount Alvernia, conversely, was found to be problematic based on a CQC inspection, with concerns raised about everyday practices.

There is something far more immediate (and troubling) about these failings than an elevated death rate, which can be caused by any number of anomalies (hence the controversy about their use). The Mount Alvernia problems might suggest more endemic failures in staffing across the hospital, with insufficient training and such like. It is a supreme irony that such is the high standard the NHS has set itself, when it fails to live up to these standards, this failure is used to undermine the principles that created that standard in the first place. That these same standards are not as rigorously applied to the private sector seems apparent, but then this government has never been one to let the evidence get in the way of the ideology.