The police and the National Health Service’s (NHS) own Security Management Service (SMS) claim there’s no specific threat of direct terrorist action against hospitals, their staff, their patients and their facilities. This short-term response to recent terrorist operations in both London and Glasgow is agreed, but what about the long term implications for the NHS and its societal role?
We should not forget the ‘near miss’ earlier this year in which a Midlands-based terror cell planned to kidnap a serving British soldier from hospital and hold him hostage prior to a public execution on the Internet.
At a Healthcare Security Management Conference held last November, a Government security department dismissed suggestions of an internal threat from within the NHS. That dismissal was challenged by several hard-bitten intelligence and security veterans of the Cold War and Northern Ireland tours, experienced enough to identify a correlation between the current terrorist threat to national security and the Communist threats we once faced.
Although the purpose and delivery of the threats differ markedly, both were clandestine and required high levels of security – with belief in a political ideology and/or faith figuring highly in the motivation of activists. To this extent, we should not be surprised at the incidents we have witnessed of late.
The birth of terrorism
While commentators regularly suggest that terrorism spawns from the disadvantaged, it actually evolved in the late 1880s from middle through to upper class students, intellectuals and professionals lawyers, priests, doctors and teachers among them disenchanted with the inactivity of the Czarist regimes in Russia. They wanted to improve the lot of the lower classes, and resorted to direct action.
Generally, this culture has not changed, with the foot soldiers being the disadvantaged. An interesting facet of urban guerrilla groups is the leading role played by women.
Sometimes, terrorism can have consequences far in excess of the perpetrators’ expectations. It was an act of terrorism that triggered the First World War, resulting in the disposal of three European monarchies in 1918 and the subsequent rise of Communism.
Several Middle Eastern terrorist organisations have (or once had) doctors at the helm who see terrorism as nothing more than a discriminate military operation in a legitimate war. Dr George Habash, for example, formed the extremist Popular Front for the Liberation of Palestine (PFLP), and was instrumental in planning several aircraft hijacks in the 1970s and 1980s, quite apart from military attacks on Israel. Dr Ayman al-Zawahiri deputy to Osama bin Laden trained as a paediatrician, pharmacist and psychologist.
While doctors have long held a special place in Western society, in other cultures, engineers, doctors and teachers are far more prestigious, with priests not far behind. The provision of quality healthcare in wealthy Middle Eastern countries and Cuba is something that some Western countries are still trying to achieve. We are entitled to hold extremist views and permitted, within reason, to share this through passive militancy, such as films, art, writing and broadcasting. However, as soon as this is converted into direct action, extremist militancy becomes unacceptable.
When the prestigious professions are levered into politics by those who respect their own profession and trust their wisdom, they can encounter endless debates, hidden personal agendas and corruption which, in turn, frustrates their drive for social progress. Some may be radicalised and turn to direct action when they feel the time is right.
Militant thought turns to action
This evolution from benign militancy within the political framework to direct action is the classic metamorphosis from law-abiding citizen to terrorist or guerrilla. When an Iraqi al-Qaeda spokesman recently said to Canon Andrew White who organises the only Anglican parish in Baghdad – that: “Those who cure you will kill you”, this is truly worrying because it implies that al-Qaeda is prepared to undermine the tradition of medicine as healer in the pursuit of its ambitions.
Direct action against a hospital is traditionally seen as causing almost irreparable damage to any cause. However, if the recent allegations and suggestions from the US that hospitals have been ‘surveyed’ by a terrorist organisation are to be believed, this places healthcare institutions in a position where they do not want (or like) to be as a target. Add to this indirect terrorist threats for instance, armed terrorists arriving as casualties, the disruption when terrorist casualties need to be guarded and the consequences of investigations when suspects are confronted.
The public is already suspicious about the loyalty of certain groups and individuals making good use of our hospitality. In much the same way as Communist country and home grown spies posed a major threat to the West by ‘burying themselves deep’ into society, it is inconceivable given global events and the large number of medical staff recruited from countries posing a risk to Great Britain that the suspects collected in the UK and Australia are an isolated group.
What better sanctuary than in the biggest ‘safe house’ in the country, where: “Trust me. I’m a doctor” is still prevalent? Where, until recently, work permits were not required for medical staff and in which rigorous vetting is difficult or, maybe, ignored because the applicant is a medical professional?
Add to this the ease of reaching the ‘safe house’ using the now discredited online Medical Training Application Service in which junior doctors were appointed for posts without interview. It’s also inconceivable that some colleagues did not know the suspects were active militants. Rooting out the disease of any radicalism and terrorism can only be tackled from within.
Role in national security
The failed bombings in London and Glasgow serve as a sharp reminder to the NHS of its role in national security. While NHS Trusts were busy preparing to deal with the unlikely event of hospitals being bombed, the creeping cancer of terrorism from within was missed.
The NHS employs an ethical Code of not directly recruiting staff from countries that cannot afford to lose healthcare workers. However, if individuals from countries covered by the Code seek employment in the NHS, and meet the professional and linguistic criteria under the Highly Skilled Migrant Programme, they compete alongside other applicants.
Only since April 2006 three years after the Iraq War began, and terrorist threat levels in the UK rose have overseas doctors had to possess a work permit. Prior to that date (astonishingly some would say, given the historical threat), overseas doctors didn’t need a work permit to participate in UK-based post-graduate training.
Under General Medical Council rules, doctors must have a visa to work in the UK, a valid passport, a job offer and a requirement to pass clinical and linguistic tests (in addition to a reference from their previous employers). There’s no requirement for applicants to be subjected to a counter-terrorism check. Indeed, at the time of writing, and in spite of recent incidents and allegations that doctors are involved, NHS Employers (NHSE) an organisation which advises NHS bodies on developing procedures to prevent unsuitable people from obtaining employment still sees no reason to change that status quo.
How much this has to do with the NHS diversity programme is not clear. Nevertheless, should it be the case that an applicant’s CV takes precedence over checks into extremism in a climate when the internal security of the nation is at high or severe risk?
Criminal Records Bureau (CRB) checks are mandatory for all new NHS staff likely to be in regular contact with patients. However, this vetting only applies to UK criminal records. NHSE encourages employers that it’s good practice to carry out a CRB-type check for applicants who claim never to have lived in the UK, and for those who’ve spent time overseas. However, it is not mandatory.
In any event, the current vetting regime remains with NHS organisations to satisfy themselves that those employed are suitable to work in the service. Compare these lightweight checks to those demanded of UK-resident citizens involved in security.
The culture of diversity
Now the difficult bit what to do without affecting the culture of diversity so endemic in the NHS, itself a huge organisation that has, yet again, found that it’s not immune from the ills of society, and has been thrust into the front line because of its inability to recognise that placing doctors on pedestals fuels embarrassment.
Although it has done so unwittingly, the NHS has provided a safe haven for suspected terrorists, and indirectly affected the direction of national security. On that basis, should the NHS be vetting its own staff?
It is to be hoped that the NHS Employers’ view of carrying on as normal is short-term, because if NHS managers and HR professionals are unwilling and/or unable to carry out decent checks on health sector employees from overseas, this leaves an uncontrolled open door to the UK for extremists and places our national security at greater risk.
It is important that the NHS acknowledges this threat to national security probably exists from within, and then takes appropriate measures to reduce it by way of rigorous vetting and security investigations into allegations of militancy and extremism.
Critical to this response is to upgrade the remit and efficiency of the NHS security function from the top down to be involved in defending the country and the NHS against extremism by thinking outside of the box.
As a benchmark, the NHS should look to security regimes within the Ministry of Defence – supporting the Armed Forces, but also the defence industas ‘good practice’.