In March, 10,000 NHS staff signed a letter to UK prime minister Boris Johnson demanding better protection against COVID-19. Nurses and doctors wanted to treat patients without fear of infecting them and to minimise their own risk of falling ill. But they lacked the proper protective equipment.
The problem they described was rooted in changes made long before the arrival of the coronavirus. The NHS’s reduced capacity for dealing with the pandemic – including a lack of PPE – has been the result of years of allowing financial considerations to dictate the quality of care. Back in 2017, the government rejected advice that the NHS should stockpile protective equipment in case of a potential influenza pandemic. The reason? An economic assessment found it would be too expensive.
Such failings are representative of the long-running trend, beginning in the 1980s, of letting the logic of the market dictate how health and social care systems are run, both in Britain and abroad. It has left many systems without the capacity to withstand a crisis of the scale we’re currently seeing.
In turn, the pandemic has seen whistleblowers in health and social care disclosing systemic failures to protect staff and patients. The marketisation of health and social care, we suggest, has increased the need for these whistleblowers to protect the common good – and we need to support them better.
The results of market logic
The US’s private healthcare system epitomises the failure of letting the market govern care services. The country spends 17% of its GDP – or US$3.6 trillion (£2.8 billion) – on health, more than any other nation. Despite this, almost 30 million Americans (9% of the entire US population) remain uninsured because their employer does not offer health benefits or they cannot afford their own insurance. These are mostly working-age adults in families with low incomes.
The inaccessibility of health services to those who need them has contributed to the US having the highest number of COVID-19 fatalities in the world (together with one of the highest death rates per 1 million population). Yet, even while the pandemic spreads, some of its poorest hospitals and other healthcare institutions have had to put much-needed staff on leave. Having to compete in a ruthless market environment, they cannot afford to pay them.
The pandemic has also exposed failings in care homes. Prompted by the rising costs of elderly care and users’ expectations for personalised services, both the UK and Sweden introduced a market-based system of care in the 1980s. The idea was that encouraging competition among multiple providers would deliver more cost-effective and responsive services and empower consumers by letting them choose among them.
Large for-profit businesses with no prior experience of delivering such services were encouraged into the market. In the intervening years, research has clearly shown the deficiencies of these changes. Both sociological and economic analyses debunk claims that the market delivers high-quality care services efficiently.
In order to reduce costs, both British and Swedish organisations have come to rely on short-term staff with rudimentary training. During Sweden’s COVID-19 outbreak, a lack of continuity and skills stemming from using short-term staff has contributed significantly to the high death toll in care homes, exacerbated by the relaxed approach to social restrictions that was adopted by the government.
Sweden’s care homes account for half of the country’s COVID-19 deaths.
In the UK, care homes account for half of all excess deaths. Higher rates of infection among residents have been linked to these institutions relying on temporary workers and not offering sick pay to staff (incentivising them to work even if ill).
The need for whistleblowers
Health professionals’ disclosures have become a societal safety valve. Over 100 UK carers have called a whistleblowing helpline to report safety concerns during the pandemic.
Whistleblowers’ disclosures are invaluable for showing us the necessity of reform, and also the specifics of what must be done. The Mid Staffordshire NHS Trust scandal – which saw up to 1,200 patients die as a result of substandard care – was made known by a whistleblower. So too the infamous failings in paediatric heart surgery at Bristol Royal Infirmary in the 1990s.
However, whistleblowing is typically a last resort, requiring significant moral courage. The sector can be hostile to doctors and nurses who disclose wrongdoing. Because of this, we need stronger systems for making disclosures and effective protection for whistleblowers forced to go outside their organisation to speak up. Offering whistleblower protection that covers all employees at an organisation is also key.
But first and foremost, we should bring health and social institutions back to their rightful purpose. This work should start by putting to rest, once and for all, discredited market-driven ideologies and prioritising providing good quality care.
Marianna Fotaki has received funding from the ESRC Transformative Grant Scheme, the British Academy/Leverhulme Trust and the Association of Certified Chartered Accounts for some her work on whistleblowing.
Kate Kenny has received funding from the ESRC Transformative Grant Scheme, the British Academy/Leverhulme Trust and the Association of Certified Chartered Accounts for some her work on whistleblowing.