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Not good enough: Mid Staffs was no one’s fault, apparently

I do not work in a hospital. I do not work in Stafford. I’m a GP from elsewhere.

This small city and its local hospital are now at the eye of the hurricane, and the ramifications will be as important as Dr Shipman and the Bristol Children’s heart scandal. It will affect all doctors in the UK.

We have now had five reports on what went wrong at Stafford, including the latest, which is a second bite of the cherry for Robert Francis QC. I have not read the report (three volumes and 290 recommendations), and only know what I know from the prism of what others have read, and the edited extracts I have seen.

There are some early lessons here for those of us working in primary care. The first thing to know is that it is a process that is deeply set in the Establishment. It was requested by the coalition Government (because the events occurred under the previous Labour government), and it had a long opportunity to see it before everyone else did and prepare its response. The terms of reference can be set by those ordering a public inquiry, and they can pick who to do it as well. These are caveats, but important ones.

The overriding sense of the report is that it has gone into the evidence and the analysis of that evidence in great and appropriate detail. Where I feel it becomes less robust is in some of the apportioning of blame, and recommendations for change.

I just want to remind myself of what happened: at least 400 people, and possibly up to 1,200, died in a smallish hospital in the middle of England. People’s mums and dads, their nans, grandads, uncles and aunts. People whose deaths were avoidable or postponable. That is horrific.

Many will look for reasons why this happened, and ask why nobody is being brought to task about this. Some 400 or more deaths and nobody’s fault? Not good enough.

Many should take a share in this disaster. They should include nurses and doctors, managers and directors, supervisors and regulators, policy analysts and journalists, and lobbyists and politicians.

Having worked in the NHS since 1975, I have seen changes come and go, and my judgement is based on nearly 40 years of experience of being at the sharp end of medicine.

The origin of this process lies with Margaret Thatcher and her ministers. It was she who decided to commodify health and try to give it a value - so that it could be changed, using a market.

The development of the internal market in health is the start of the process which ultimately ended with the death of someone’s mum, unnecessarily, in Stafford General Hospital in 2006.

Equally, Mrs Thatcher’s successors continued with the process of marketisation, egged on by lobbyists, think tanks and special advisers. This was a consistent policy down the years, and followed by politician after politician, with civil servants facilitating it,

So, as we have seen the apotheosis of the policy - writ large in Stafford - we must ask ourselves who was responsible for this end result? Who actively promoted these changes down the years, and how many people were asleep at the wheel when all this was going on?

I am not a hospital doctor. I do not work in Stafford. Today, I am ashamed of how the service I joined as a young man has changed so much. And killed so many people.

And, apparently it’s no-one’s fault.

Not good enough.