It is tempting to join the chorus demanding that NHS 24 must now ensure no family ever has to experience the same misery as that endured by the relatives of Shomi Miah and Steven Wiseman. But that would be to indulge a delusion, because NHS 24 is institutionally immune to the mindset that could make it efficient.
It is a catastrophic example of the producer culture that renders Scottish public services incompetent and arrogant. Until the mentality that sustains it is expunged, abysmal standards are inevitable.
The tenacity of that mentality was exposed last week with NHS 24’s refusal to accept damning criticism from Sheriff James Tierney or to apologise to the families of the two young people who died as a result of its blunders. It takes a titanium heart to rule out a grovelling apology to these grieving families. What made the refusal all the more galling was Tierney’s finding that it was “tragically clear” NHS 24 was to blame.
Unreserved regret is apparently not an option in this case. Instead we have seen a defence of the skewed internal logic that dictates NHS 24 exists primarily to serve the interests of health service employees rather than patients.
Consider the origins of this service. It was invented simply to reduce the burden on doctors. Since January 2005, general practitioners in Scotland have been relieved of the obligation to provide care out of hours. Calls to their surgeries are automatically forwarded to NHS 24 call centres. The taxpayer is required to finance a 25% salary increase while simultaneously paying for a system that replaces doctors with nurses.
Given Scotland’s reverence for the medical profession, such indulgence might be understood in isolation. But it is not a solitary example of the producer interest taking precedence over the public interest. In May, the auditor-general revealed that he could find “little evidence” that the McCrone deal on teachers’ pay has delivered value for money.
McCrone awarded a 23% salary increase and cut teachers’ working week to 35 hours. As with NHS 24, auxiliary “support staff” were hired to reduce the workload on salaried professionals. The consequences include failure to reduce class sizes, limits on extracurricular activity and universities complaining they have to re-educate students from Scottish schools. It is hard to imagine a more complete waste of money. Unless, of course, you adhere to the perverse principle that public services are there primarily for the good of their staff.
Given the scale of Scotland’s public sector, it might almost be plausible to argue that such generosity serves the greatest good of the greatest number. The executive does so daily. But that ignores the responsibility vacuum we have in Scotland. It was plain in the indefensible claim by Dr George Crooks, NHS 24’s clinical director, that, despite the avoidable deaths of two blameless patients, “there has not been significant underperformance on behalf of any single member of staff within the service. So no individual has been directly disciplined because of either of these cases”.
It takes breathtaking insensitivity to regard errors that allow people to die as inadequate justification for sackings. I would gleefully start with Crooks and work down. But Scotland is used to this. Social workers were exempted from disciplinary action after 11-week-old Caleb Ness was killed by his brain-damaged father. A report found that Caleb should not have been left in the care
of his parents and identified fault “at almost every level in every agency” involved. But nobody was guilty.
When services are run to secure the contentment of their producers, nobody ever is. Whether applied to medicine, social work
or public administration, self-regulating communal provision is the antithesis of professional responsibility. The individual’s duty of care becomes lost. Unless they are exposed to market discipline, these organisations promote buck passing and internal politics and ignore high standards. Their currency is the grey uniformity of the lowest common denominator.
Part of the problem is that Scots are historically inured to receiving third-rate services from state agencies. Here the apparatus of rationing and regulation that was so important in wartime metamorphosed seamlessly into peacetime. The worst single result among numerous failures of bureaucratic planning was housing policy.
The Cullingworth report of 1967 found that two decades of government-sponsored house building had left one in three Scots living in substandard housing. But the vast bureaucracy by that time employed to chuck up soulless high-rise blocks, shoddy maisonettes and grimly identical houses cared not a jot.
Families still formed crowds around council offices to see who had been allocated the latest new homes. Each was careful to fawn to the official who compiled the list. Failure to abase oneself meant relegation to the bottom. Millions became supplicants at the feet of officialdom.
We never truly got rid of that corrosive ideology. In seven years, devolved government has expanded it back into every crevice of national life. This primacy of the producer interest under home rule has seen good money squandered.
For all the moral lacunae we can identify amid its death throes, Tony Blair’s government rode to power on a brave pledge. It promised to apply to public services the consumer-oriented ethic Conservatives had brought to industry. Schools would serve their pupils and hospitals their patients. Local government would drop the ideological lunacy of Labour’s wilderness years and respond to the needs of council taxpayers. Some of it has really happened.
There is further to go, but that will happen whoever wins the next general election. David Cameron has embraced new Labour policies on the public services as enthusiastically as Blair and Brown embraced Thatcherite economics. It would be electoral suicide for Cameron to do otherwise, because in England producers have begun to learn they are consumers too. Teachers have children. Doctors get ill. Consumer interest is the closest to pure public interest government can get.
Of course, it is not perfect. Public servants exposed to market forces that oblige them to prioritise the needs of the people they serve still make mistakes. But at least they do not delude themselves that fatal error should be excused simply to safeguard the interests of the system that creates it. We despise the squalid inefficiency that saw factories in the Soviet Union produce millions of left boots. But that example of producer dominance is morally indistinguishable from the version that allows patients to die so that doctors need not interrupt their dinner.
