Countess of Chester Hospital pedestrian enterance. Countess of Chester Hospital pedestrian enterance. Source: Denise Turner - Wikicommons / cropped from original / shared under license CC BY-SA 2.0

NHS worker Elly Badcock looks at the background to the heartbreaking case of infant murder and argues that underfunding, staff shortages, and the whole ethos of privatisation has severely damaged the NHS

The harrowing case of Lucy Letby’s murder of seven babies and attempted murder of six more has dominated the news since her conviction last week – understandably, given the deeply horrific nature of the crimes. Now that the details of the court case have been made public, another part of the story is coming to light: the actions of senior NHS management who were allegedly made aware of serious concerns around Letby and chose not to act on them, but instead to isolate and criticise the medics who raised them.

The experience of Dr. Stephen Breary and Dr. Ravi Jayaram is devastating. Having first raised concerns in 2015, they were told it was unlikely that Letby had any link with the babies’ deaths. They waited months for further official responses from the hospital trust, commissioning their own independent review by a neonatologist in the interim. In a particularly egregious instruction from hospital bosses, both doctors were told to write formal letters of apology to Letby for the concerns they had raised. 

This series of events is heartbreakingly unsurprising to many who have worked in the NHS. In 2015, the same year as concerns about Letby were first raised, QC Robert Francis published a report into NHS staff’s experience of whistleblowing. Respondents in his research stated  ‘The reality of a whistleblower is … fear, bullying, ostracisation, marginalisation and psychological and physical harm.’ Another respondent shared the horrendous circumstances they directly attributed to whistleblowing: ‘I have often been so depressed by this experience that I have often considered suicide. I live in fear that the hospital will carry out its threat to sue me and take my home from me if I don’t pay their costs quickly.’

There is a deeply entrenched culture in NHS executive management of prioritising reputation over safety. Whistleblower Helen Donnelly, who gave evidence about deadly failings of care in Stafford Hospital from 2005 – 2009, said ‘There was not a culture that encouraged and enabled staff to speak up and if they did as I did, we were bullied and threatened.’ She reported being locked in a cupboard, threatened that her nursing notes would be edited to make it look like she had made prescribing errors, and she was left scared to walk to her car after her shifts in case she was attacked. 

It is no secret that the NHS is in dire straits. Campaigning organisations such as Keep our NHS Public, NHS Staff Voices and NHS Workers Say No have been raising concerns for years around chronic underfunding and understaffing levels, in turn driven by a government determined to run the NHS into the ground. Every healthcare professional will have experienced the impossibility of providing top-notch care on an understaffed ward, affecting them on a very deep level. One nurse commented ‘I have an overwhelming feeling of sadness that I cannot provide these vulnerable human beings with the care they need and deserve.

Undoubtedly, underfunding plays a huge role in creating toxic working environments. When not being able to feed or bathe your patients properly becomes the norm, people and organisations become resilient to failings of care which should never be acceptable. However, underfunding in itself is not enough to create such an abhorrent organisational culture, where senior management can directly ignore evidence as appears to be the case over Letby.

Understanding the role of privatisation in creating this culture is absolutely key. Under Thatcher and then Major, the first hospital trusts were established in 1990. Prior to this, hospitals and community services had been managed by regional or specialist health authorities. With the advent of hospital trusts, each trust was given the ‘freedom’ to directly generate money from patient care. In addition to the money awarded to each trust by central government, trusts can extort patients and families via parking charges, selling hospital land to developers, and treating private patients. The key issue here is that each trust is effectively run as a stand-alone business, in direct competition with other trusts; either geographically for neighbouring trusts, or by area of practice for trusts that wish to establish themselves as specialists in one area of medicine.  

Whilst hospital trusts are being run as competing businesses rather than a fully nationalised public service, there will always be a drive from senior management to avoid ‘scandal’ regardless of the impact on patients. As seems to be the case with Lucy Letby, hospital executives will go to unspeakable and baffling extents to protect themselves from ‘reputational damage’, regardless of the very real damage to patients. A neonatal unit with a child serial killer on the books is about the worst form of reputational damage a trust could have. But rather than take immediate steps to safeguard patient safety, which would have likely raised very public alarms, the trust did not act on multiple concerns for the lives of vulnerable infant patients. 

Unlike the many doctors and healthcare staff threatened with referral to a professional regulator when they whistleblow, NHS managers and commissioners have no regulatory body to oversee their conduct and behaviour. Prior experience in the NHS is only ‘desirable’ to become a practice manager and NHS commissioners have no formal entry requirements. As is so often the case, when NHS managers oversee poor and potentially deadly care, they are quietly moved to another trust and allowed to carry on working with no reflection or oversight of their professional conduct. 

In the wake of how Countess of Chester NHS Foundation Trust failed to deal with concerns around Letby, healthcare staff are rightly calling for a regulatory body to oversee NHS managers. This is an absolutely necessary step; but it fails to challenge the root of the issue. As long as the NHS is run as a series of competing private businesses, senior management will always be driven by business needs rather than patient care. 

Frontline NHS staff must continue to stand up to the enemy within; continue to blow the whistle, on serial murderers such as Letby but also on the shocking behaviour of those who enabled her. But only when the NHS is fully in public ownership can it be run in the interests of patient safety. Otherwise it will continue to create the breeding grounds for horrendous acts like these to take place.

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