How the rise of NHS managers silenced doctors

The killing spree of Britain’s worst child murderer began on June 8 2015 at the Countess of Chester Hospital and lasted a year and 16 days.

It is impossible to comprehend the agony that Lucy Letby caused to the families of her many victims. However, it is reasonable to assume that their horror has been compounded, and will be for the rest of their lives, by the knowledge that at least some of her seven murders and six attempted murders might have been stopped.

We now know that after the first flurry of unexplained baby deaths, a senior doctor quickly drew a link to the presence of Letby. We know that he and his colleagues repeatedly raised concerns with hospital management. We know that they begged for the young nurse to be removed from the ward.

That they failed, that for months bosses dismissed their concerns or refused even to listen to them, raises profound questions about how the NHS confronts uncomfortable truths.

Who wields the power?

In particular, who really wields the power in hospitals these days? Who is ultimately responsible for keeping patients safe? And, unless the system changes, is another Letby only a matter of time?

Consultants struggle to pinpoint the moment their power waned. But most agree that it has.

While the image of patrician medics commanding their wards like army officers always owed more to caricature than reality (think Sir Lancelot Spratt in Doctor in the House), there was a time in living memory when consultants could, in the words of NHS whistleblower Peter Duffy, “stamp their foot”.

“I do think consultant power has been eroded,” said.

“He or she used to be very much senior within their own team. They were very much in charge.”

To a large extent, this was thanks to a pyramidal structure within hospital units informally known as “the firm”.

Sleep-deprived junior doctors

A gang of sleep-deprived junior doctors working hundred-hour weeks would provide the bulk of the care, overseen by a handful of experienced registrars.

They, in turn, would be led by a head consultant who would tend to concern themselves with only the most complex cases.

In some ways things are better now. The junior doctors are less exhausted and therefore less dangerous. Meanwhile the proportion of consultants has increased, meaning that the average patient is more likely to see one.

The downside, said Mr Duffy, a consultant urological surgeon, is when something urgently needs to change.

“The old days when a consultant could essentially stamp their foot and say ‘we really need this for patient safety’ are gone.

To get anything done in the NHS these days you have to go through a committee and consultation exercises, submit proposals. You won’t hear back for months.”

Three main classes

In practice, units are now run on a “triumvirate” basis, reflecting the three main classes of employee within them: doctors, nurses and managers.

Consultants are still in charge of patient care, but they hold no management power over nurses and exist at the whim of the executive class for funding and major decisions.

This was demonstrated with chilling force in the Letby case.

By July 2015 she had murdered four babies and attempted to kill two more.

Dr Stephen Breary, head consultant of the neonatal unit had established that Letby had been present for each and informed the director of nursing, but to no effect.

In late October, by which time the fifth murder had taken place, plus two attempts on another baby, Dr Brearey raised his concerns with the unit manager.

However, despite being head consultant, that was all he could do. Again he says nothing was done.

Relations can be difficult

Dr Andrew Hartle, a consultant anaesthetist at Imperial College Healthcare NHS Trust in west London, said that relations between medical and nursing teams can be difficult.

“I don’t know what the pre-existing culture at Chester was, but sometimes teams of doctors and nurses get on really well and others it can be very tribal,” he said. “There can sometimes be an anti-doctor culture.”

The tension is partly caused by the fact that nurses tend to be more aligned with the hospital executives.

“As you work your way up through the nursing hierarchy you get closer to management,” said Mr Duffy. “A senior matron in an NHS hospital would be closer to management than a consultant these days.”

This is because, in general, the more a nurse is promoted the more administration he or she will do and the less patient care.

A doctor’s career is, by contrast, more fluid. Even if they lead a unit, they will still spend at least 50 per cent of their time treating patients, and after a few years they are likely to return to full-time medicine without it being considered a step down.

As such, trusts are these days more likely to be led by someone with a nursing background, and this was the case at the Countess of Chester, than medical.

‘Different background and culture’

Imperial is relatively unusual in almost always having had a chief executive who is a doctor.

“There are far more ex-nursing CEOs than doctors,” said Dr Hartle. “They have a different background and culture.

“Consultants not being in control is not necessarily a bad thing as long as they are listened to about clinical matters. But do they have less influence? Possibly?”

Given all of that, what happens when something goes wrong?

“Senior managers should not be demonised,” said Mr Duffy. “But as people get higher up the system it tends to attract more ambitious and driven individuals.

“You climb the greasy pole by keeping things quiet on your watch. There is an incentive to close things down when there is a threat to your organisation, reputationally. A lot of that is down from on high, NHS England and the Department of Health. No one likes a scandal.

“There is an overwhelming temptation to just bury it, like you saw in the Letby case, which they nearly did. Most managers are decent people but the closer you get to the executive board the more ruthless they get.”

‘Awkward doctors’

He should know.

Mr Duffy’s stellar career was effectively destroyed by his employer, Morecambe Bay NHS Trust, after he blew the whistle on an avoidable death.

He was subsequently demoted, lost more than £30,000 in overtime payment, and referred to the General Medical Council no fewer than seven times on, he contests, spurious charges to punish him for speaking out.

Now 61, he has voluntarily erased himself from the medical register to avoid further stress.

The tactic of setting up kangaroo courts to silence awkward doctors was recognised as far back as 2015 in the Hooper Review, and yet it is commonly acknowledged to still happen.

Only this June, investigators began a review into University Hospitals Birmingham NHS Foundation Trust, one of largest in England, over allegations that executives were targeting doctors with referrals to the GMC.

The practice is certainly alleged to have taken place in the case of Letby.

Dr Susan Gilby, who succeeded Mr Ian Harvey as medical director at Countess of Chester, said in a BBC interview that, during the handover, Mr Harvey warned her that she would need to pursue action with the GMC against the consultants who had raised the alarm about Letby.

Perhaps needless to say, Dr Gilby is now suing the trust for constructive dismissal.

‘Scam and a scandal’

In theory, whistleblowers are supposed to be protected under the Public Interest Disclosure Act.

However, according to one anonymous consultant who was sacked after raising concerns about multiple patient deaths at his trust, “the whistleblowing law is a scam and a scandal”.

“We are commanded to raise concerns because of the duty of candour. But then they set about discrediting you and forcing you to leave to keep you quiet.”

Raising an issue of patient safety is all too often taken as a disciplinary issue.

In the case of The Royal Sussex County Hospital, where police are investigating around 40 deaths over allegations of medical negligence, a recent Care Quality Commission report explicitly warned bosses about “a potential culture of “normalising” safety concerns and conflating these with individual poor behaviours”. Whistleblowers who argue their case at an employment tribunal have a success rate, according to government statistics, as poor as 3 per cent.

However, before things get to that stage, managers have subtler tactics to shut down patient safety concerns.

Mediation the answer

One is to recast the matter as a personal conflict between staff, rather than a clinical problem that needs investigating, with mediation the answer.

This was another tactic seen in the Letby case: doctors who raised concerns were instructed to write to the nurse to formally apologise, or attend mediation with her.

One recommendation of the Francis report into the patient deaths scandal at Mid Staffordshire NHS Foundation Trust, now more than 10 years old, was for each trust to appoint a Freedom to Speak Up Guardian, a nominated person who will escalate concerns from rank-and-file staff.

However, trusts have considerable flexibility as to how the job should be done.

Dr Hartle currently fulfils the role at Imperial. But, he said, “It’s unusual for a doctor to hold this role.”

It is worth noting that, in general across the NHS, Dr Hartle believes patient safety and clinical governance to be in a happier place than in the aftermath of Mid Staffs.

Where does the NHS go?

So, where does the NHS go from here?

Should there be a new regulator that can strike off managers? Another answer could be to boost the number of medically trained people on hospital boards.

A statement from Dr Nigel Scawn, the medical director of the Countess of Chester NHS Foundation Trust, said: “Since Lucy Letby worked at our hospital, we have made significant changes to our services.”

Jane Tomkinson, acting chief executive officer at the Countess of Chester Hospital NHS Foundation Trust, said: “The trust welcomes the announcement of an independent inquiry by the Department of Health and Social Care. In addition, the trust will be supporting the ongoing investigation by Cheshire Police.”

A Countess of Chester Hospital NHS Foundation Trust spokesperson said: “In March 2020, the trust commissioned an independent, in-depth investigation. 

“The investigation is examining the management decisions and actions taken in response to the increase in neonatal mortality between June 2015 and July 2016. 

“The trust continues to support the investigation. The report, nearing completion, will need to undergo due diligence and independent legal processes, and has not yet been shared with the trust. 

“In addition, the detail of the investigation will no doubt need to form part of the independent inquiry and therefore the trust would welcome the opportunity to discuss this with the chair of the independent inquiry once they are appointed to determine next steps regarding the investigation report. 

“It would therefore not be appropriate for the trust to comment further on the investigation at this time.”