[This is the unedited version of an article published by Pulse]

The question on the lips of every GP this week must be: is there anything for which NHS England won’t try to blame someone else? To no one’s surprise, NHS England’s response to their botching of the 2018 annual flu vaccination programme was to attempt to blame the whole thing on GPs. Never mind that they only confirmed the two-vaccine programme in February, months after most surgeries had already ordered their flu for the following season, and having previously announced it the Friday before Christmas, then withdrawn the guidance, then reissued it; never mind that they gave surgeries a deadline of just over a month to get the orders in; never mind that their claim in the announcement that “suppliers have confirmed that there will be enough[…]vaccine to meet demand” was wildly inaccurate: it isn’t their fault.

The full timeline of the announcement is worth recapping. NHSE e-mailed to announce the new two-vaccine programme on 22nd December, with most local area teams getting the message out in the afternoon on the final working day before Christmas, telling surgeries to go ahead and order. By the end of January, however, they had put the whole programme on hold again, and told GPs not to place any more orders for flu vaccine, nor to convert any provisional orders to confirmed orders. Then the final final announcement came on 5th February. The initial steps NHSE took did not fill anyone with confidence.

As a result of this fiasco, flu vaccine uptake has fallen in all key groups, and that risks causing large numbers of avoidable flu deaths. Of course NHS England are therefore keen to suggest the problem is GP surgeries and practice managers mysteriously and abruptly forgetting how to order flu vaccines, rather than taking responsibility for the campaign they’ve run.

But then, very little seems to be NHS England’s fault. Back in 2013, Their deputy chief executive blamed the troubled birth of the 111 service on GPs, who had chosen through “local commissioners” to put the service in place, rather than on her organisation. Their head of Patient Safety blamed GPs in 2015 for not reporting patient safety events. When NHSE’s arrangements with Capita led to hundreds of thousands of clinical documents going missing, they blamed GPs for “not […] complying with guidance”, and doubled-down on that by suggesting GPs “risked patient safety and confidentiality” by forwarding misdirected mail to Capita. When similar problems in Capita’s handling of GP pensions came to light, NHSE blamed this on “the failure of some GPs to follow the correct process for submitting information”, not on Capita.

Mind you, GPs are in good company. NHS England blamed Stephen Fry for deteriorating cancer waiting targets – then, when they saw the Sun headline, found £10m down the back of the sofa for prostate cancer testing. They blamed “possible legal action” for their decision not to fund pre-exposure HIV prophylaxis. Their acute care director blamed “ridiculous waste” in acute trusts for seemingly all the NHS’ problems, and when the issue of deteriorating A&E performance was raised in the summer by the BMA, NHSE did a bit of pre-emptive blaming of councils, social care, and frontline clinical staff.

That last example is of course not exactly blame – it’s more distraction. Faced with evidence that patients are waiting longer for acute care, NHSE ignore that evidence and instead talk about what they’re doing next (“extensive planning for winter”), because that distracts from their past mismanagement, and dodges taking responsibility for the situation now in favour of “looking forward”. Then there’s the dogwhistle reference to “bedblocking”, which lets NHSE prepare to blame local councils who are conveniently responsible for social care, and the contradictory suggestion that, rather than the problem being a lack of beds in the hospital because of all those selfish old people, it’s NHS staff going off sick with the flu.

They used the same trick of blaming staff last winter. Obedient government stooges like NHSE’s national medical director Bruce Keogh were wheeled out in the midst of the winter crisis to suggest that “thousands of healthcare workers were unwittingly putting patients and their own families at risk” through not having the flu jab. NHSE doubled down on this through the year, with NHS Improvement requiring staff who refuse to “explain themselves”. As Margaret McCartney puts it: “the mandatory vaccination argument feeds a line to the media that the stress on the NHS is caused by staff failings”. It’s not NHS England imposing year-on-year funding cuts, it’s the fault of frontline staff for for not doing as we’re told.

There is decent research out there supporting flu vaccination. None of it recommends threatening staff for refusing a jab, or mouthing off in the tabloids about how awful they are. Indeed, the King’s Fund note that “an aggressive campaign motivated by financial incentives may cause some staff members to dig in their heels”, and low update of flu vaccine among healthcare workers may be “a response to the aggressive pro-vaccine rhetoric” staff experience at work.

Their flu vaccine narrative encapsulates the hostile environment that NHS England have created towards GPs and frontline healthcare staff around the country. They may be responsible for the national programme, and their delivery may be half-baked and hopelessly rushed, but make no mistake: it will be the doctors’ fault when it fails. NHSE’s board aim for “clear accountabilities at national, regional, and system level” – it turns out this means that someone else is always accountable.

It’s not just flu. You could look at their “hostile and confrontational” handling of a complaint against a GP practice, at a NHSE area team medical director saying practices unwilling to “transform” must be “allowed to fail and wither”, at NHSE’s most recent director of primary care suggesting GPs should be happy when small practices closed as it was “a rationalisation of providers”. At the same time he was saying this through his anonymous forum profile, he was quoted in public saying “NHS chiefs have not done enough to save struggling practices from closing”. Similarly, immediately after Pulse broke the story of Madan’s comments, NHSE e-mailed round a circular suggesting he’d been misquoted, and his supporters took to social media with remarkably similar messages dissembling about what he said: “if you read the article he is not saying small practices should close”, or “@arvindmadan did not say small practices should close”. That pattern has recurred – NHS England will say whatever they think people want to hear in public, while doing whatever is most expedient in private.

Of course, it’s individuals who’ve got caught saying these things, but these are their leaders, the people NHSE’s system has put in positions of authority and has entrusted with the NHS. For them to “misspeak” so often and so consistently suggests NHSE is systemically incapable of honesty and of taking responsibility for its failures. Until it does, until it puts in place leaders who are good for more than soundbites, it will continue to destroy clinicians’ trust and morale, and to damage the fabric of the health service.

What’s needed from NHSE now is an end to spin, and concrete action on the areas in which they have failed the NHS. Capita is a prime example here, and although the 526 GPs who signed an open letter to NHSE about the failure of the pensions system are still waiting for a response a month on, there are some positive signs. When GP Survival met NHSE’s interim director of primary care, Nikki Kanani, she agreed to take up the case of a junior doctor who, forced to retire a year ago on ill-health grounds, had been left unable to access her pension because of Capita’s incompetence, and was reliant on medical hardship charities to support her family. Of course, that doesn’t fix the system problems, but it is action rather than talk. Right at the top, too, Simon Stevens looked reassuringly disgusted by some members of the House of Commons Committee of Public Accounts trying to get him to ask for “levers” to force GPs to fix the problems NHSE had created around clinical correspondence. These are small things, yes, but the hope is that they mark an end to NHS England persecuting and blaming frontline staff of all stripes when things go wrong. That will require a sea-change in NHSE’s organisational culture, in how it responds to failure, and in how it interacts with the clinical staff who do the work it oversees.