NHS failures will stay common until we hold management accountable

Thomas Cawston
THIS is a story of appalling and unnecessary suffering of hundreds of people,” said Robert Francis QC yesterday. For those who think that the NHS is more important than the patients it exists to serve, and the taxpayers who pay for it, the publication of Francis’s report into the failings of Mid Staffordshire NHS Foundation Trust is a dark moment.

In an impressive, exhaustive 2,000 page study, the result of 18 months’ work and £13m, Francis exposed poor care, the neglect of patients and the victimisation of staff who raised concerns. Mid Staffordshire may not be the rule, but it is far from the exception in the NHS, a point backed up by a slew of recent scandals. In this respect, this tragedy is the tragedy of history repeating itself.

Francis placed the responsibility for Mid Stafforshire’s failure firmly with its leadership, especially its board. He is right to do so. Care quality and compassion for patients was forgotten. Concerns and complaints were ignored. The organisational culture was perverse, from the leaders right through to the frontline. A system of targets, and the registration system for hospitals at the time, may have been partly to blame. The wider NHS system also failed to pick up on this, and checks and balances didn’t work effectively.

The Francis Report hit the nail on the head in its diagnosis of what went wrong at Mid Staffordshire hospital. And its greatest legacy will be how it might prevent such failures from happening again.

But with the dust still settling on the last reorganisation of the NHS, Francis refrained from demanding yet another overhaul. Instead he called for a “fundamental culture change” in the health service, with a “relentless focus on the patient’s interest”. He offered 290 recommendations on how this could be achieved. These ranged from simplifying national regulation, introducing a “duty of candour” for all doctors and nurses, to teaching staff the importance of compassion.

There is not “one culture” in the NHS that needs to be transformed, however. While an NHS culture failed patients at Mid Staffordshire, an NHS culture at other hospitals in England delivered high quality care. Leading institutions like University Hospitals Birmingham and Salford Royal have clear commitments to patient safety and patient care now. Their staff already have a commitment to candour and compassion.

Unlike Mid Staffordshire, these hospitals have also taken steps to be better employers and introduced active performance management of staff. At Salford, the performance of staff is measured according to achievement and values, ranking employees from “role model” to “unsatisfactory”. The quality of nursing care in each ward is measured, performance is ranked and the responsible staff held to account. There is no secret to high quality care. It is simply down to strong and effective leadership of doctors and nurses.

While the failures at Mid Staffordshire were supposedly the result of cost-cutting in the NHS, other hospitals have been able to improve quality at the same time as saving money. Elite institutions have reformed services to deliver safer and better care, often through reducing medical errors and complications, which in turn improves efficiency. Managers have taken the initiative to develop their own positive cultures, and have not waited for a mandate from on high.

The Francis report shines a penetrating spotlight onto the failures of the NHS. But national efforts to improve quality too often shift responsibility away from those who should take control – the chief executives and boards. As the report rightly recognises, it is individual NHS organisations that should be responsible for their own quality rather than government imposing central control.

Pioneering hospitals have transformed themselves to achieve higher quality, but the rest are in danger of falling further behind. If failing institutions cannot develop cultures of excellence for their staff, there should be a clear system of consequence for the management. One option must be the takeover of whole hospitals by new organisations, whether run by the public or private sector.

It is unlikely the Francis report will be the last word on problems in the NHS. But if these inquiries are to become a lot rarer, the government will need to empower leaders, and not shy away from holding failing hospitals to account.

Thomas Cawston is research director at the independent think tank Reform www.reform.co.uk