Your correspondent, Dr Maybelle Wallis (NHS’s culture of denial allowed Lucy Letby to keep killing babies, 21 AugustLetters, 21 August), reflecting on the Lucy Letby case, correctly pinpointed Margaret Thatcher’s introduction of “general management” as a pivotal moment in the culture of the NHS. The idea was that senior managers from the private sector should be brought in to run local hospital provision, which would be increasingly based on local trusts competing in the “internal market”. My local health authority was headed by someone with no NHS experience who had previously run a biscuit factory.
The great pity is that, despite no mention of them in the 2001 election manifesto, New Labour’s introduction of foundation trusts from the following year sought to further institutionalise the fragmentation of the NHS into competing local units, following this “business” model. While some of the most detrimental elements of the initial proposals were fought off, the end result has still been an increasingly inward-looking, defensive management culture with an instinct towards concealment if reputational damage is a possibility.
We may criticise NHS managers, but crucially they operate within a wider culture established by our politicians. If both the main parties encourage, at the heart of the NHS, a culture of competition rather than collaboration, then the end result is quite predictable.
I hope there will be a full statutory inquiry into the Letby case, and that among its terms of reference will be establishing the implications of these changing NHS management structures for its prevailing culture and the effective and safe provision of care.
Former Labour MP and chair of the Commons health committee (1997-2005)
Amid the understandable searching for answers to the havoc wreaked by Lucy Letby, we find calls to further strengthen and improve independent structures that are unafraid to hold practitioners and managers to account in the wake of malpractice. Important as these are, they seem to ignore the elephant in the room: lack of resources. It appears that Letby was working in a critical area with minimal supervision.
In a fully staffed NHS, she would have been observed by experienced and trusted staff involved in, and accountable for, good practice 24 hours a day, seven days a week. Anyone with recent experience of the NHS will understand that this is a distant dream.
While the standard of NHS service has deteriorated over the last 30 years, hospital management has mushroomed. Managers in trust hospitals are unregulated and unaccountable. In conjunction with boosting NHS funding, there needs be huge reform to hospital care management. Clinical autonomy has to be restored. Without such reform, we will continue to waste valuable resources, suffer further haemorrhaging of trained clinical staff and witness ever-increasing morbidity and mortality. And, yes, there will be further Lucy Letby cases.
Dr Helen Zeitlin (retired consultant)
There has been well-deserved criticism of the senior management and former executives of the Countess of Chester hospital trust, including calls from doctors’ organisations for professional accountability similar to that in medical and nursing professions.
This seems to have overlooked the fact that the medical director in post at the time of Lucy Letby’s crimes was a consultant surgeon, and that both the director of nursing and the chief executive had been nurses. The hierarchy managing Letby were also nurses. I worked in the NHS for more than 30 years, and the vast majority of the executives I saw maintained the highest professional standards, particularly regarding patient care. Please let’s not allow this abhorrent episode to turn into another witch-hunt of all NHS managers.