Mid-Staffs: the inquiry has missed the mark

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The terrible failures at Stafford Hospital were not about resources. They were about deep-rooted cultural problems that top-down recommendations will do little to change

The report on the Mid-Staffs NHS Foundation Trust makes appalling reading for any of us, let alone those who were intimately involved. Worryingly, there is some evidence to suggest that this is not an isolated case.

There are news reports that five other hospital trusts are to be investigated over their mortality rates following the publication of the Mid-Staffs report.  It is said that an immediate probe is to be launched into Colchester Hospital University NHS Foundation Trust, Tameside Hospital NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust and East Lancashire Hospitals NHS Trust.

Furthermore, a firm of solicitors is reported to be representing relatives and patients with regard to legal action at ten NHS Trusts. If this is the case then I suggest we cannot just dismiss Mid-Staffs as an aberration but we must look for more systemic causes and solutions.

In spite of the length of the inquiry – and the effort put into to it by the inquiry team in coming up with its 290 recommendations – I am not convinced that it really hits the nail on the head, or offers workable solutions.  At first glance, it seems to me that the inquiry report is correct when it talks about the need for fundamental change and shifts in attitudes and culture in the NHS.

However, it is not clear there is any evidence that the cultural changes needed will be achieved by: legislation, criminal charges, regulation, inspection, greater ministerial supervision and other controlling methods. Changing cultures is much more subtle than that.

First, let us deal with the resource issues head on. I find it difficult to believe that patients being forced to drink water from flower vases and lying in soiled sheets for many hours is a consequence of financial pressures.  In much of the past decade the NHS has had record growth in resources.  Furthermore, between 1997 and 2006 the Royal College of Nursing’s own figures show that the numbers of qualified nurses in the NHS grew by 25% in England and by around the same in the rest of the UK.

 Can we really believe that this sort of behaviour can be put down to ‘lack of resources’ or ‘pressure of work’? I know from personal experience that there are many many dedicated and hard-working professional nurses.  But am I the only person to have noted in some hospitals  four or five nurses sitting at the central station in a ward chatting or texting?  It looks more likely to me that a lot of the problems of Mid-Staffs can be put down to a lack of proper professional leadership in the nursing profession, not shortage of resources.

Second, there is an issue about the role of effective financial management and control in an NHS Trust. The inquiry report comments that it was the board which took the decision to pursue a cost-cutting drive to achieve foundation trust status, and it was the board which refused to listen to the complaints of patients and – at times – staff. Now whether the board went too far in a drive to cut costs I do not know but what I do know is that there is a balance that must be struck between the delivery of services and effective financial planning and control.

The reality is that NHS Trusts have finite resources and have to deliver services within that resource constraint. This problem will not go away no matter how many inquiry reports are produced. The danger now is that NHS Trusts will go too far in the other direction and take decisions resulting in huge financial overspends. This is particularly a concern at present in a period of financial austerity where NHS Trusts are having to identify large scale savings. Research I have recently completed on financial governance in NHS Trusts suggests that there are significant weaknesses in NHS financial governance which will be exacerbated by the pressure of austerity.

Third, I would also focus on the relationships between managers and health care professionals in the NHS. In my 35 years’ experience of the NHS it seems to me that this relationship is at best, somewhat distant and at worst antagonistic and lacking in trust. Health care professionals often see NHS managers (or administrators as they prefer to call them) as ‘the enemy’ involved in collaborating with government to deny them the resources they need to treat patients as they think fit.

On the other hand, NHS managers often see health care professionals as unwilling to accept the realities of finite resources, defensive about their own professional status and practices and unprepared to engage, fully, in the decision-making process as to how resources should best be used. (Anyone who doubts this situation exists should have a look at TV programmes such as Casualty or Holby City to see how NHS managers are portrayed.)

This week I heard a debate on the radio about the NHS which involved a number of health care professionals and a politician (no, there was no NHS manager invited). As usual, the cry came up for a greater involvement by healthcare professionals in decision-making in the NHS. Similar arguments were heard at the time the Health and Social Care Act 2012 was going through Parliament and indeed subsequent changes were made to take this on board.

I actually think most NHS managers would welcome such increased involvement and engagement by health care professionals provided those health care professionals accepted the realities of finite resources and were also prepared to be fully accountable for those decisions that they were involved in and would not stand on the sidelines carping.

Let me give an example to illustrate this point – the issue of budgetary management in the NHS. In my experience, health care professionals often argue for them to hold budgets and have more influence on the way resources are used.

However, when we explore this further what this often means is that while they want to get their hands on the money, they do not usually want to deal with the administrative workload associated with managing budgets; deal with, for example, problems such as high levels of staff sickness or maternity cover which impact on budgets; deal with the pressures of declining budgets caused by financial austerity; or be accountable for the services they provide based on the resources available.

If any of the above take place the usual response is to pass the problem to managers or administrators to deal with.

 I think it is essential  that cultural change takes place in the NHS if we are to avoid repeats of the Mid-Staffs scandal. However, I am not convinced that the inquiry’s recommendations are the way forward. Much has been much written about how organisational cultures can be changed and the first thing to say is that it is difficult.  Maybe iwe should heed the words of John Kotter, perhaps the leading global expert on cultural change in organisations. He makes a number of key points.

First he asks, what is the nature of the problem?  Virtually no one clearly defines what they mean by ‘culture,’ and when they do they usually get it wrong. 

Then he asks, how does culture change?  It changes through a powerful person at the top, or a large enough group in the organization, deciding the old ways are not working, figuring out a change of vision, acting differently, and enlisting others to do the same.

If the new actions produce better results, then this is communicated and celebrated. And if they are not killed off by the old culture fighting its rearguard action, new norms will form and new shared values will grow.

And finally he asks, what does not work in changing a culture? The answer is, some group deciding what the new culture should be; drafting a list of new values which are passed to the PR or HR departments, with an order to tell people what the new culture is. They cascade the message down the hierarchy, and little or nothing changes.

In Kotter’s words: that’s the whole story. Which path to cultural change will the NHS take?


About Malcolm Prowle

Malcolm Prowle is professor of business performance at Nottingham Business School and a visiting research professor at the Open University Business School. Malcolm is an expert on the economics, finance and management of public services. He has advised ministers, senior civil servants and public service managers on a wide range of public policy and implementation issues

18 comments on Mid-Staffs: the inquiry has missed the mark

  1. Michael Stirland says:

    Well said Malcolm.

    All too easy to blame the administration and for their heads to role when the reality is basic professional standards being neglected. However, an organisation which doesn’t actually listen and care about basic care and even is being told not to do so by their own professional body (eg let the parents or relatives come in and do this) doesn’t give a lot of hope for those staff who do care.

    Stafford hospital is not unique – such poor standards can be experienced in many places.

    Malcolm is right though some staff are excellent and go above the call of duty to ensure good care but if the top of the professional tree isn’t giving the leadership, the culture is bound to follow that path.

  2. Tony Elliston says:

    I believe the problem is that nursing has stopped being a vocation and has become a career. It is not about a lack of resources but a lack of care. We need to stop hiding behind the myth of the NHS as a national treasure and see it for what it has become. There are still good people who want to do the right thing, but they are increasingly becoming outnumbered by the indifferent and the jobsworths.

  3. Warren Park says:

    There is mystique in the NHS and healthcare generally. The public have nurses aligned with angels and doctors as super heroes who are unduly revered to the point of being unchallengeable. This allows these professions in particular to engage in emotional blackmail, laziness, misconduct and incompetence with relative impunity.

    Of course the members of the Trust Board and all those in senior clinical and managerial positions at Stafford are responsible. They should be held to account. Surely there is a case for prosecution for corporate manslaughter under the 2007 act and surely too where injury and death have been caused by neglect a case for personal prosecutions under the Health and Safety at Work Act which does embrace injury to the public as well as workers.

    Culture is at the centre of this. We can come at the problems that arose from all angles but you end up back in two places – the culture in the board room and senior management and the culture in delivering patient treatment and care in wards and clinics. I don’t accept that accountants are responsible for this and it is a common ploy to blame administration and middle management in the NHS to deflect blame.

    But let me be controversial here. If I found my wife or my children or elderly relative in the condition that patients have been found there would be a serious incident. I would call the police, I would refuse to leave and I would confront directly the staff involved. The confrontation may become violent. I do not understand how such a situation did not blow up on many occasions and bring down the people running the hospital.

  4. Richard Kerley says:

    Excellent, thoughtful piece; though I disagree with/take a different view on some aspects. e.g. Is it really the case that 290 recomendations are a sign of considered judegment? Does the [inevitable] next enquiry list 300 recommendations?

    That said, far more helpful than some of the instant comment of yesterday.

  5. Stewart Critchlow says:

    About a year ago a friend of mine who was at that time a medical practitioner at Stafford Hospital told me that they had been been forced to cancel a full morning’s clinic in order to provide their departmental manager with some performance statistics. As a result several patients had their treatment cancelled at short notice in order that the manager could prove that they had met their targets.

    My friend recently to took early retirement because targets were obviously more important than patient care. Where there are targets and “jobs worths” employed to enforce them, then everything will revolve around the achievement of those targets at the expense of all other considerations.

    Stafford Hospital has been singled out as a scapegoat and pilloried over the last few years, but it is becoming obvious that the spotlight needs to move on to other hospitals and that the NHS nationally has some questions to answer. So do the politicians who instigated the target culture in the first place.

  6. Not surpringly perhaps, I find myself in broad agreement with all of the comments.

    Just one point though on something Richard said. I certainly don’t want it to be thought that I think 290 reccomendations is a good thing. Like he suggests, we are in danger of having a macho culture with regard to inquries with each one trying to supersede the previous one with yet more reccomendations.

  7. Andrew Burns says:

    Good stuff, really thought provoking.

    Agree completely that culture change is required but not on how to do it.

    Trying to ‘inspect and regulate’ poor quality out will never be as successful or sustainable as designing good quality into the system.

    And to do that is all about a ‘tone from the top’ that puts patients at the heart of the system and aligns clinical, management and financial responsibility……and that is much easier said than done!

  8. Mike Keene says:

    A very good article but I’m afraid the bottom line is that patients are not failed by ‘cultures’ or ‘systems’ but by people and the people actually have to be made accountable, starting at the top, ie the people who frame the cultures and systems.

    The Navy get it right; if a ship founders, the first person to be called to account is the Captain, not some lower middle-order players. …and yes, very occasionally they shoot an Admiral “for the encouragement of the others”!

  9. Mike

    While I like your Naval analogy, the question in the NHS is who is the captain and who gets sacked for service failures? Is it the Secretary of State who never resigns or gets sacked for service failures? Is it the CEO (it often is) whose authority gets hemmed in by: the Department of Health, regulators, the health professions and uncle tom cobbly and all? Or is it the consultants whose power and influence about hospital matters is still very strong?

    One problem seems to be the fuzziness about responsibility and the lack of clear accountability. There is the old adage about if everyone is to blame then none is to blame.

  10. Warren Park says:

    People are complex. That was a discussion tonight on ‘This week’ about the fact that sympathy can be found for Chris Huhne and his complex family circumstances. He has done something wrong, but that does not make him completely wrong or all his other actions to date in life malpractice.

    But culture is important. Leadership from the top helps to define how people are expected to behave. How leaders behave at each level of the organisation is a reference point for staff and influences their behaviour. In the end individuals are responsible for each action, inaction and failure, but an ethical culture is far more likely to raise the standards of their behaviour than an unethical one.

  11. Manjeet Gill says:

    Well said. Leadership is something we do not understand well in this country in terms of ability to change cultures and accountability. The fact you quote Kotter reinforces that the USA gets it better as a senior leader who also had executive experience from that country once said to me. Focus on structures and rules does not work yet how can we collectively work to change this? As then SOLACE lead on leadership I would welcome networking with likeminded colleagues.

  12. Yve buckland says:

    I agree that there needs to be a change in culture. This is in NHS leadership right from the top. A fish rots from its head. Julie Bailey and colleagues are right about seeking ultimate accountability. And if the NHS is ever to change and really start putting patients at its heart, they need to start listening to what these people are saying.

  13. Richard Shilling says:

    A good article – thank you, and one that accords in some ways with my experience. I worked for 10 years in NHS finance, and my wife works as an associate specialist in the NHS so I get to see both sides. So yes, you’re quite right, financial pressure does not directly lead to the appalling care we’ve seen here but bureaucratic target-setting does lead to demotivation and perverse incentives that slowly erode morale and motivation, and encourage caring for KPIs not patients. Combine that with macho management cultures (of which I was part) blindly enforcing centrally-set targets and there is bound to be an impact on patient care.

    That’s not to excuse those involved in Mid-Staffs, but I do believe this is an institutional problem across the NHS. My wife’s clinics overrun because they are overbooked, as this is the only way to ensure all patients are met within deadline. In the private sector, a company would either have to fund more clinics or see customers leave. In the NHS both patients and staff have to put up with inadequate resources, and as patients can hardly be described as deferential nowadays this means the clinicians receive a fair bit of abuse too. We know that one of the highest stress factors in any job is lack of control and we know the impact of continued stress on performance. Patients are bound to suffer and staff to care less.

    For my own part I have tried to negotiate budget reductions in radiography brought about because purchasers want to reduce the activity they contract for, with both myself and the manager knowing that activity was actually increasing and that the change in purchasing simply meant more patients accessing the service through A&E. I still feel a sense of shame as I remember her coming close to tears as I tried to negotiate staff cuts.

    The blind rush for foundation status, like the blind rush for trust status before it is profoundly damaging. It starts as a rush for extra funding and finishes with punishment for those who have not yet achieved it. The threat of a takeover by another hospital exacerbates this, as senior management fear for their own jobs and prioritise financial stringency over patient care.

    Add to this poor food and cleaning standards as cuts and outsourcing bite, poor facilities for staff, consequent high turnover and increased use of agency/locums and you couldn’t design a more dysfunctional system. Personally I think it says much for the dedication of almost all NHS staff, clinical and not, that the NHS is still rather good.

    The only real solution to this is impossible to imagine any current political party supporting. Fund hospitals sufficiently to cope with activity, staff appropriately so that the hospital can work efficiently (and I mean ancillary and management here too) and trust healthcare providers to get on with their jobs without fake markets, forced outsourcing and yet more restructures. Trust and empowering people to get on with their profession works. Soviet-style central control doesn’t.

  14. george foster says:

    Malcolm makes a numbert of valid points, as usual. What surprises me most about the Francis report is that NO ONE is blamed.. a major weakness… when the report blames the system….all then have an immediate defence..it’s not crap management but the system.. so that’s ok then..change the system..again and again and again…..

  15. Alan Harrison says:

    Patients are not represented in the NHS structure. There is no local democratic control or accountability.

    Public Health comes under the democratic control of Local Government from April 2013. Why can’t the rest of the Health Service follow?

    Margaret Thatcher would probably have survived the Poll Tax if it had been administered by HMRC.

  16. Downonthefarm says:

    I find it significant that most of the people who suffered here were elderly. Other recent scandals have afflicted the vulnerable, that is children or the elderly. The problem is wider than the NHS. It reflects the values in our society where the vulnerable and inconvenient are marginalised. The hospital to its detriment imported these values so the flaws are systemic. By all means blame the Board as they ‘set the tone’ and this will make an example but the rot is deeper. I also don’t think big general hospitals are good places for the elderly as their care needs are often complex. We may have to accept expensive and intensive care for our elderly and someone must pay for that.

  17. I know this is anecdotal and personal but I have to agree with “down on the farm” that big hospitals are not good for the elderly. A relative of mine was hospitalised for a year prior to death. She was transferred after three weeks in a DGH to a small “cottage” hospital, The standard of nursing care was immense in the cottage hospital and gave her a good quality of life before she died. The standard of care at the DGH left much to be desired.

    What is the solution? After 35 years involvement with the NHS, I haven’t got a clue. Not sure anybody else has either even though they pretend they have. I suspect there are huge historical and societal forces at play here beyond our comprehension.

  18. Kate Jackson says:

    I have heard from a former nurse that in the hospital where she worked, it was more important to record that care had been given than to actually provide the care. For example, if it was written in the patient’s record that the bed had been changed every day, if there were a claim against the hospital for poor care, the records would be produced thus “demonstrating” the bed had been changed – even if the bed had been changed only once a week, or less.

    It seems perverse to me that recording that you have met your targets is more important than actually meeting your targets.


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