Malevolent Neglect

Much has been written about the substandard care and appalling conditions that led to the premature deaths of as many as 1,200 people at Stafford Hospital in England. As the story unfolds, it appears that the government's insistence that this was an isolated circumstance, not indicative of the National Health Service (NHS) as a whole, is a pitiful excuse bordering on criminality.

The British Health Department recently commissioned a series of independent inquiries into the quality and safety of care in the NHS. Completed and presented to the department in the summer of 2009, the reports were withheld from the public until a London-based think-tank forced their release. The bombshell reports put the lie to the government's claim that the deadly scandals of Mid-Staffordshire and numerous other hospitals were aberrations in an otherwise splendid system.

Obsession with targets and not care, flawed systems of self assessment, a culture of blame and fear and most of all patients at the bottom of the pile of priorities. Together these reports paint a damning picture. Their findings should've been released at the time. You can't just bury bad news.

This statement from Katherine Murphy, Director of the Patients Association of Great Britain, illustrates the keen frustration of reformers and watchdogs when confronting the mighty bureaucratic behemoth that is the NHS and Department of Health. Murphy continues:

Arguments that hospital failures were one offs now look very empty. These reports clearly state that nobody knew enough about the quality of care being given across the NHS to make those claims.

The regulatory framework for monitoring patient care and outcomes relies upon hospital "self-assessments" to determine whether care was up to standard. Not surprisingly, this self-grading regime resulted in a maypole dance designed to show compliance with the standards rather than measure the actual implementation of the standards. Obviously, any claim of effectiveness would be fictional, since you cannot measure what you haven't done. Staff felt compelled to judge their performance (and the performance of those they supervised) by the scores achieved on periodic NHS inspections rather than actual outcomes experienced by the patient. 

When pressed for explanation, a Department of Health spokesman huffed that "England is one of the world leaders in the international drive to improve the safety of health care."

Such self-serving statements offer scant consolation for the estimated 43,000 families who have lost a loved one in the NHS due to avoidable circumstances. Since coming to power in 1997, the Labour Party has nearly tripled the funding for the NHS, yet they still fumble haplessly in attempts to reform the multi-layered bureaucracy -- a bureaucracy seemingly determined to reduce NHS expenditures through a policy of malevolent patient neglect. Perhaps the Department of Health could begin by acknowledging that being a "world leader" in rescuing your citizens from their own government-run health system is not particularly laudable.

A report from the Department of Health's own Nutrition Action Plan Delivery Board (NAPDB) tells us that 239 patients have died in NHS hospitals in 2007 (the most recent year available) from malnutrition. The report goes on to say, however, that these statistics are somewhat misleading in that they reflect only 0.05% of the total deaths where malnutrition was involved, meaning that the extrapolated number would approach 50,000. 

The NHS claims that the conservative Tory Party in Parliament are misreading these "complex statistics" and that the majority of the deaths in question involve malnourishment stemming from other diseases, such as cancer, rather than malnourishment alone. The counterargument from the NAPDB report says,

We know that malnutrition predisposes to disease, it delays recovery from illness and it increases mortality. It follows that the effect of malnutrition on mortality rates is substantially greater than the number reported to have died because of malnutrition.

While the actual number of deaths involved is of great importance, the lesson to be learned in the United States is found not in the numbers, but rather in the argument itself. In Great Britain, the existence of a single-payer "socialized medicine" system places the responsibility for the health care of citizens in the political arena, exposing the decision-making process to the whims and aims of politicians. Any group of citizens can assert standing to argue for fewer resources for one group and more for their own -- and with politicians being the linchpin of such an arrangement, we can rest assured that decisions may likely be clouded by electoral or purely parochial concerns.

Of course, not all politicians are craven and corrupt. Yet a number of them are, and that fact is reason enough to give them a wide berth. In America, our insurance companies and hospital groups have a market incentive to provide the best possible care for their customers. As with any capitalist venture, a poorly performing hospital or insurance company will soon find its revenue in a raisin-like condition, leading to both reforms and a subsequent boost in performance, or to Chapter 11 and new ownership. The ObamaCare legislation upsets this balance, weighing heavily on the side of regulatory bureaucracy.

Given that politicians unerringly seek to insert themselves between an issue and a camera whenever possible, perhaps the greatest benefit of a market-based system is in limiting their function to one of persuasion and advocacy instead of empowering them to goose-step over the concerns of the populace they serve. To be sure, government plays a leading role, but until ObamaCare, the pols haven't been allowed to stage a one-man show.

Bureaucracies tend to place process above all else, leading to a checklist mentality where "the process" is sovereign. Loyalty to "the process" becomes a precondition to advancement in the bureaucratic realm. This has proven axiomatic across cultures and eras. It is to our enduring shame that each generation seems destined to relearn this harsh lesson through the needless deaths of the most vulnerable and innocent among us.

The author writes from Omaha, NE and may be reached at