Wes Streeting, you must have a better plan for ailing hospitals than public humiliation | Rachel Clarke
SSeriously, Wes Streeting? After fourteen miserable years of Tory austerity, stealth privatisation, draconian outsourcing, the exodus of Brexit staff and the horror and trauma of Covid from which staff have – as you know – only remotely recovered, it must big NHS plan… being ‘naming and shaming’. ? Complete with inflammatory language designed to scapegoat staff, like the bad managers you’ve labeled the NHS’s ‘guilty secret’? Do you really think this is constructive?
At a time when Ofsted – which contributed to the suicide of headteacher Ruth Perry – has finally retreated from its absurdly blunt instrument of one-word school inspection ratings, it beggars belief that the new Health Secretary thinks hospital rankings are the NHS will help. Streeting emphasizes that the new public rankings are a necessary way to root out poor performance. He wants hospitals to be judged on quantifiable factors such as emergency room wait times, cancer care and the size of their budget deficits. Trusts will be publicly ranked from best to worst, with the CEOs of the worst offenders fired. Meanwhile, the best-performing trusts will be rewarded with extra money to buy new equipment or repair facilities, further leveling the playing field.
There is a colossal cognitive dissonance underlying this plan. Streeting himself is the first to recognize the impact of structural inequality on health, recognizing that disadvantaged groups in British society are at greater risk of poor health and premature death. Yet its return to hospital rankings assumes that underperformance is all the fault of those deplorable ‘bad managers’ and is somehow disconnected from the socio-economic realities of the population they serve. He should know that hospital performance is closely linked to the availability (or not) of social care in a region, the prevalence of poverty, staff availability, local unemployment levels and numerous other factors beyond senior hospital managers’ control. Pretending otherwise is dishonest.
Worse still, rankings are a very blunt and very public form of ritual humiliation – exactly the kind of punitive exercise that has demonstrably negative effects in healthcare. In fact, a “no blame cultureIn medicine, it has been shown to improve safety by promoting openness, discussion and learning from mistakes – yet Streeting wants self-blame embedded at the heart of his reforms. Punishing and shaming struggling hospitals risks demoralizing staff and causing patients to lose confidence in their local trust, while pitting trust against trust in a way that fuels suspicion and division. Trusts will be pressured to try to game the system, putting effort and energy into the only performance standards that ‘count’, while neglecting other important, but newly marginalised, aspects of care.
In short, hospital rankings are a simplistic and retrograde gimmick. This zombie policy should have disappeared for good in 2005 when the rankings were scrapped, four years after they were first unveiled by Alan Milburn, then Tony Blair’s health secretary and now Streeting’s top adviser at the Department of Health. Perhaps Milburn thinks he didn’t go far enough last time, although this jaded NHS doctor is mistaken about Einstein’s definition of insanity as ‘doing the same thing over and over and expecting different results’.
My prescription for improving NHS performance is diametrically opposed to Streeting’s, in that it rests on the principle that virtually no one arrives at work to do a bad job. In fact – and especially in healthcare – most people are motivated by a strong and simple desire to do well. They care. This is the root of the discretionary effort that was known to keep the NHS afloat, but has failed to do so anything but exhausted since the height of the Covid pandemic. When staff go above and beyond what is contractually obligated, by staying late, doing small acts of kindness, taking the time and effort to show patients that they matter, the caliber of healthcare rises. It’s a small example of a wider truth in the NHS: not everything that matters in medicine can be counted, and not everything that can be counted matters.
If Streeting continues to measure performance on spreadsheets and rankings, he will necessarily leave out what is unquantifiable: the compassion, tenderness, humanity, and idiosyncrasies that make medicine a uniquely human endeavor. For example, what I do when I talk to a dying patient about their greatest fears, or explore what makes them feel like life is still worth living – or prescribe a gin and tonic in an iced glass because it gives them reminds them of life they love and not death that hits them. Measuring performance in numerical data sets means erasing all the parts of healthcare that can’t be counted – and we devalue and dismiss them at our peril.