The secret life of the NHS

Despite the fact that the Labour party promised greater openness when in opposition, now that it is in government it seems as anxious as its Conservative predecessor to ensure that bad news about the health service is suppressed. In this article and the next, Judy Jones looks at ways in which the government controls what we hear about the NHS and at how it took the health department 10 months to reply to the BMJ 's critique of its policy on the private finance initiative.

When the last Conservative government was in power the BMJ published articles about the suppression of free speech and information and the politicisation of the NHS and health care.¹,² These cited numerous examples, ranging from “gagging” clauses in contracts and suppression of independent reports to people being told, in essence, to keep quiet about service cuts or other matters that were potentially embarrassing to politicians.

The Labour party's promises of free speech, openness, impartiality, and more democracy and accountability in and around the NHS and elsewhere helped secure the party a landslide victory in the last general election. In the interests of free speech and pursuance of political impartiality, the BMJ has repeated these earlier exercises. We have collected some fresh examples of attempts to prevent disclosure of “public interest” information and of political chicanery since the change of government in May 1997. Against the backcloth of recent rebellion in Labour's ranks over the government's freedom of information bill, we feel it timely to report, once again, on what the government of the day would rather you didn't know.

Summary points

• The Labour party's promises of openness and more democracy and accountability in the NHS helped secure the party a landslide victory in the last general election, but the BMJ has collected examples of attempts to prevent disclosure of “public interest” information and of political chicanery since then

• Despite Labour's promise of a new “open and fair” system of appointments to health bodies, NHS trusts have been packed with Labour activists since the election

• NHS staff have been pressured by management and government representatives not to give interviews or make press statements critical of NHS services

• Labour has shown no enthusiasm for reducing the secrecy surrounding the licensing of drugs by the Medicines Control Agency

• Despite explicit legal protection being granted for whistleblowers in 1998, NHS staff still have difficulty in raising concerns about the professional standards of colleagues

Purges and “placemen”

(1) NHS trusts have been packed with Labour activists since the party was elected to power promising a new “open and fair” system of appointments to health bodies. Dame Rennie Fritchie, the independent Public Appointments Commissioner, reported that 288 non-executive directors and chairs were declared Labour party supporters in 1998, compared with 49 Conservatives and 28 Liberal Democrats.³ Evident political bias in appointments meant that more experienced and skilled candidates were often overlooked, her report said. It concluded that local council nominations for NHS chair and non-executive posts should end, and that the appointments system merited “fundamental review.”⁴

Shooting the messenger

“One particularly damaging development in the Conservative years has been the emergence of a culture of fear in the NHS. . . . We believe that all staff should be able to speak their minds” (Renewing the NHS: Labour's agenda for a healthier Britain, Labour party health policy document, 1995).

(2) In November 1999 Eric Morton, outgoing chairman of the Healthcare Financial Management Association, and his successor Barry Elliott were summoned to receive a private “dressing down” by Sir Alan Langlands, then NHS chief executive. The association had taken the liberty of publishing a survey warning of a looming £200m deficit, and senior association members had told journalists at a dinner that the deficit could rise to £1bn when historical underlying shortfalls were taken into account. Addressing the HFMA annual conference, Sir Alan later pointedly remarked: “We are not paid to bleat about resources. We are not paid to undermine the service entrusted to us.”

Afterwards, Mr Elliott said in a statement: “Media interest surrounding our survey has caused the legitimacy of our association to do this to be questioned. We clearly need to continue to represent the needs of our members, but need to work more closely with the Department of Health to ensure we do not inadvertently compromise public confidence in the NHS.”⁵ In April 2000 the National Audit Office reported that NHS trusts and health authorities had running deficits close to £200m.⁶

(3) Lord Robert Winston, the renowned fertility specialist, launched an outspoken attack on the state of the health service under Labour earlier this year.⁷ In a magazine interview the Labour peer said that a “conspiracy of silence” had kept Tony Blair in ignorance about the depth of its financial and structural problems and that the government's promise to end the internal market had been “deceitful.” But a reported throwaway remark naming the hospital where Cherie Blair would be having her baby threatened to overshadow the thrust of his onslaught.

On the day his interview made headlines across the media, Lord Winston had a “conversation” with Alastair Campbell, the prime minister's spokesman. Within hours, the peer issued a statement via the Press Association saying that Labour's policy on health was broadly right. “I am not privy to the content of that talk, but it sounded mind-bending,” his New Statesman interviewer, Mary Riddell, later observed. “Winston emerged from his home on Friday, looking beaten and dejected after his No 10 debriefing. . . . At issue now was new Labour's suppression of the dire state of the health service.”⁸,⁹ Two days after the interview was published, Blair appeared on the television programme Breakfast With Frost and promised that, by 2006, UK health spending would be raised to the European Union average,¹⁰ a pledge that became the centrepiece of the chancellor's March Budget.

(4) When an NHS trust in Northern Ireland reneged on promised funding for a new 10 bed drug rehabilitation unit, a consultant psychiatrist expressed his concerns to a newspaper. As a result, he was called to account by his trust's chief executive, who told him his actions were “ill judged, ill advised, and detrimental to the trust.” The consultant construed the dressing down as a warning and asked the BMA for advice. Since the BMA's intervention the consultant has experienced no further difficulty with his chief executive.

(5) This was one of six such cases handled in the past year by Calvin Spence, the BMA's deputy Northern Ireland secretary, involving consultants who were “challenged” by their trusts for giving interviews or making press statements about local NHS services. One consultant was censured by his trust for publicly supporting a campaign to reverse a decision to close a hospital. His censure followed representations to the trust from the then minister for health in Northern Ireland, John McFall. “The consultant concerned felt extremely threatened throughout this process and remains very wary of making any statements at all in respect of this hospital,” Spence told the BMJ. “Undoubtedly, these two cases are the worst I have come across in my 10 years with the BMA in Northern Ireland.”

(6) In a Bournemouth bar, during last autumn's Labour party conference, Victoria MacDonald, health correspondent for Channel 4 News, was confronted by Joe McCrea, at that time special adviser to the then health secretary. He unleashed a stream of abuse at her, including the words: “You fucking bitch, you stitched me up.” At one point during the tirade, McCrea picked up a mobile phone and hurled it through the air, narrowly missing delegates before it smashed against a wall. After being dowsed by the contents of another journalist's wine glass, McCrea took his leave.

MacDonald explained the reason for the attack to the BMJ: “He thought I was off message, because of a film I had made about the waiting list initiative.” In the film, which was made as a result of a number of off the record briefings, MacDonald suggested that the then health secretary, Frank Dobson, was keen to ditch the initiative, because it was distorting priorities. “McCrea did not like the word ditch,” she said. “He thought it was damaging to the government, though he did say that ministers had come round to the idea that waiting times were more important than waiting list numbers.” His attack was reported in the Guardian and the Express though the reasons the two papers gave for it differed.¹¹,¹²

On message, on line

(7) Joe McCrea has been drawing on his experience at the Department of Health in his new job as the project director of a new electronic “Knowledge Network.” According to Cabinet Office documents written by McCrea, its aim is to arm all ministers with a regularly updated “common script” to rebut attacks on government policy and “top line themes and messages” from a single computer database.¹³ Presumably, the database will be administered by a new Ministry of Truth.

Drugs secrecy

“Patients need information in order to be involved in and informed of decisions made about their health. The public have been starved of information that they can use to make informed decisions.” (Renewing the NHS: Labour's agenda for a healthier Britain, 1995).

(8) Much to the dismay of campaigners for open government, the Freedom of Information Bill, currently before parliament, proposes no repeal or amendment of Section 118 of the Medicines Act. This section heavily restricts disclosure of information obtained by the Medicines Control Agency, Britain's drugs licensing authority, in pursuit of its statutory obligations in order to protect commercial confidentiality of pharmaceutical companies. Critics such as Maurice Frankel, director of the Campaign for Freedom of Information, have for years argued that Section 118 amounts to a “blanket ban” on the disclosure of information about how drugs are licensed in Britain, in contrast with the relatively transparent regime operated by the US Food and Drugs Administration. However, Britain's new Food Standards Agency has recently been granted legal exemption from the provisions of Section 118 in respect of disclosure of information about veterinary medicinal products.

(9) Michael Buckley, the parliamentary ombudsman, has criticised the withholding of information by the Medicines Control Agency about meetings of the Committee on Safety of Medicines, in particular declarations of interest made by committee members. The agency cited seven exemptions to the Code of Practice on Access to Government Information in attempting to justify its refusal to give information about such declarations to the independent pharmaceuticals research organisation Social Audit. The ombudsman found that much of the information withheld could be released without infringing the confidentiality laws laid down in Section 118 of the Medicines Act. The ombudsman's investigation revealed that declarations of interest had been made by members in relation to certain antidepressant drugs under discussion at five meetings of the Committee on Safety of Medicines in 1998.

Overall, it took 16 months and an exchange of 150 letters between the parties involved for the Medicines Control Agency to decide how much of the Committee on Safety of Medicines' minutes of meetings could be released. “That aspect of their handling of the review merits strong criticism,” the ombudsman noted. As a result of the ombudsman's investigation, which itself took seven months, the agency agreed to disclose the names of members of the Committee on Safety of Medicines who had declared interests.¹⁴

In a letter to the permanent secretary at the Department of Health on the matter, Charles Medawar, director of Social Audit, observed: “In my experience, in this case and many others, secrecy makes medicine dangerous; it inhibits essential feedback and constructive criticism, and the opportunity to learn from mistakes.”

(10) In the same session of parliament, the ombudsman upheld a separate complaint about undue secrecy by the Medicines Control Agency—this time in relation to the drug Myodil, an oil based dye used in a technique known as myelography. In 1987 the manufacturer of Myodil withdrew it from the UK market despite a decision by the Commission for the Review of Medicines—now part of the Medicines Control Agency—to grant a product licence for a further five years. Arachnoiditis is an occasional but potentially serious side effect of the drug, causing inflammation of the spine, chronic pain, and sometimes paralysis. Several people who developed the condition after undergoing myelography brought a civil action against the drug company in 1991.

A member of the public complained to the ombudsman in 1998 after the Medicines Control Agency refused to disclose information about the safety, quality, and efficacy of Myodil that had been considered in reaching the decision about the product licence in 1987. The permanent secretary at the Department of Health backed the agency's stance. After the ombudsman's intervention, the agency agreed to disclose a “substantial amount of information” about Myodil. The ombudsman described this as a “suitable outcome to a wholly justified complaint.”¹⁵ Myodil was first granted a product licence in Britain in 1972.

Whistleblowers

(11) Public Concern at Work is an independent charity that promotes accountability and good practice at work. Since the start of 1998, it has been asked to assist with 677 “public interest” cases of malpractice reported in confidence by whistleblowers. Principally, these have arisen within the public services: some 143 from the social care sector and 99 from health care. Ben Urdang, the charity's legal case worker, told the BMJ that the concerns of nurses and doctors about the professional standards of colleagues make up the bulk of the healthcare caseload: “Very often, the people who come to us have already tried and failed to resolve the matter in other ways.” However, as a result of the explicit legal protection for whistleblowers enshrined in the Public Interest Disclosure Act of 1998, the stigma attached to such individuals is disappearing: “We are beginning to see a culture shift, but there's still some way to go.”

Only 24% of NHS trusts in London mention in staff job descriptions a requirement to report poor performance in colleagues. A third of trusts have no policy on whistleblowing.¹⁶

Figure.

UPPA

Lord Winston: looked “dejected after his No 10 debriefing”