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Florence Nightingale's famous Notes on Nursing, published in 1859, state that "the greater part of nursing consists in cleanliness". In my edition, the foreword points out that much of Miss Nightingale's writing, excellent though it is, is now out of date. In particular, the need for cleanliness is well understood. That foreword was written in 1946. Now it is 2007, and we learn that nurses in the hospitals run by the Maidstone and Tunbridge Wells NHS Trust told patients suffering from diarrhoea to "go in their beds". Between 2004 and 2006, 90 patients treated in those hospitals died from Clostridium difficile, and the disease was a factor in the death of a further 241. Were it not for bad nursing, bad medical attention and bad administration, none of these patients need have died. Indeed, they would not have contracted C. difficile at all unless they had gone into hospital. So, after 150 years' advance of education, technology, prosperity and science, we have lost what Florence Nightingale taught. It was the distressing subject of diarrhoea, indeed, that provoked Miss Nightingale to one of her most trenchant footnotes. She gave the example of how, if a bedpan with a lid were changed only once a day ("As well might you have a sewer under the room"), by a maid rather than a nurse, the problem might go undetected. he bedpan must be changed frequently, inspected, and all of it, including its lid, properly cleaned. I notice that the Healthcare Commission's report on Maidstone says that stool charts, i.e. recorded inspections of the diarrhoea, were made in fewer than 15 per cent of cases. Florence Nightingale adds: "If a nurse declines to do these kinds of things for her patient, 'because it is not her business', I should say that nursing is not her calling." It is a "waste of power", she says, for nurses to do things such as scouring floors, but if it needs doing, they must do it: "the true nurse-calling" puts "the good of their sick first, and second only the consideration what is their 'place'?". The testimony of the families from the Maidstone area is that their relations who died were often humiliated, left in filth, and ignored. The weakest — the old — were treated the worst. It was a failure of systems, yes, but also of individual professionals and of common humanity. Every year, as a journalist, I go to party conferences and hear politicians of all parties make speeches about how wonderful the National Health Service is. Gordon Brown got all weepy this year about how it saved one of his eyes. Last year, David Cameron said that where Tony Blair had spoken of three words — "Education, education, education" — he would emphasise three letters — "N-H-S". The point our leaders are constantly making is not medical, but moral. It is that the NHS embodies organised altruism. It proves that we, as a nation, care for one another. It makes us "the envy of the world", and it makes us good. One naturally wants to agree. We all like to think that matters of life and death are well looked after. And most of us will have direct experience of NHS nurses and doctors who have treated us with great kindness, care and skill. Nevertheless, the basic proposition is not true. The National Health Service is not, morally, or in any other way, the best system of healthcare in the world. Indeed, it is morally defective at its very root, because it does not — cannot — put the sick first. Until this is recognised, it cannot be reformed. The NHS is, with our state school system, the last major survival in this country of the idea of the 1940s that government can decide what is best for us and make sure that it is done. Aneurin Bevan, who invented the thing, once said that not a bed-pan (that object again) should fall to the ground without the minister knowing about it. A colleague of mine, who investigated alternative healthcare systems when the extreme dirtiness of many British hospitals first became an issue, went to France to compare. In hospital after hospital, he found floors so clean that you could have eaten your lunch off them. Did the Health Minister order them to clean them, he asked an administrator. He was met with a look of incredulity. "Of course not. We run ourselves. Patients have a choice of hospital. If they do not choose us, we get no money. No hospital can survive if it is not clean." Two weeks ago in Bournemouth, Gordon Brown was on to the subject of C. difficile, babbling about ordering "deep clean" and more than doubling the number of hospital matrons to 5,000. "Bring back matron" has become a party conference cry, like "Bring back the rope" used to be. But matron will be only a name so long as Mr Brown (or whoever is Prime Minister) ultimately decides who should have what where. We all know that a Minister for Industry could not possibly decide how many computers we produce or how many investment banks we should have. We all know that a Minister for Food could not wisely decree what vegetables should be sold in which shops. But we cling to the idea that a single organisation employing 1.4 million people, with the GDP of an entire Scandinavian country, run by politicians, can meet our health needs. Suppose Sainsbury's cold meat counter was found to have helped kill more than 300 people, would the company survive? Yet the NHS sails on, dealing death. According to a report four years ago by Professor Karol Sikora, we could save 10,000 deaths a year from cancer, just by hitting the European average; but we don't, and nobody takes the blame. The boyfriend of the chief executive of the death-dealing Maidstone trust tells the press: "No way is she going to talk to you. Why should she?" The trust has arranged her severance pay of £250,000. We all complain about the "target culture" that made administrators in Maidstone ignore actual human suffering before their eyes. But if you have a top-down system of healthcare, targets are the inevitable response to whatever is the latest disaster. In this case, one of the targets was to cut waiting times in Accident and Emergency to four hours (four hours! You wouldn't put up with that to buy a cinema ticket, yet we have been brainwashed into thinking that it's not too bad for your child with a broken arm). In this world without choice, each claim of need jostles against another: either faster A&E, or cleaner bed-pans, but not both. This is all, morally, wrong. It turns the patient from being the entity for which the service exists into a nuisance. Each new patient is just an added cost and each dead patient is an administrative convenience. Under systems of social insurance, such as exist in Germany, Belgium or France, many problems remain, but this most basic one disappears. Money goes with each patient, who can choose who treats him. Therefore every doctor, hospital and nurse wants patients. Our system also turns the nurse and doctor away from their duty, and therefore attacks their moral sense. It tells them to ignore "the habit of observation", which, said Florence Nightingale, was the key skill of nursing, in favour of through-put or targets or — for human nature reasserts its worse side when badly led — sneaking off home exhausted and disillusioned. The NHS is run from top to bottom, and therefore, from top to bottom, it is bad. |