My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Understanding how Francis might understand the world of the NHS

Filed Under (Accountability, Francis Report, Health Improvement, Health Policy) by Paul on 17-10-2012

A few weeks ago we learnt that the publication of the Francis Report on Mid Staffs will now be put off until January. In the interim there have been some concerns shared within the NHS about how the report might understand its world.

As Paul Hodgkin from Patient Opinion said at the conference I mentioned in Monday’s post, if the answer that the Francis report comes up with is ‘more regulation’, then they are probably asking the wrong question.

Earlier in the autumn Mike Farrar from the Confederation suggested that an increase in regulation was really not what the NHS needed and recently the Kings Fund published some interesting thoughts from their head of policy Anna Dixon about how the necessary improvement in quality in the NHS might happen.

We shall of course have to wait till January for the report and its recommendations, but again as Paul Hodgkin pointed out there have been previous enquires – for example Herbert Laming’s report on child abuse – which give us some glimpse of what might come out of any such report.

The Laming Report contained 108 recommendations and many of them were about tightening the regulatory framework within which statutory child care work takes.

More than anything else this form of recommendation springs from the nature of a Public Inquiry, from the fact that the public service disaster that has taken place, happened some time ago. Understandably the public wanted an Inquiry to find out what has happened – to stop it from happening again.

But given the passage of time the main reason that unsafe and dangerous practices in a particular institution occurred no longer applies. The staff concerned, and leadership of the institution, are no longer in post.

It is often several years later by the time an Inquiry reports. Given the staff and the leadership of the institution have moved on all that is left is the surrounding framework of regulation and, since something must be done, it’s the regulatory framework around the problem that must be changed and is almost always tightened up.

But the problem is that the reality improving quality and safety works the other way round.

As Anna Dixon pointed out quality and safety mainly depends upon the work and morality of front line staff. These are the individuals and teams of individuals who carry out the activities that form the core of care. Most people recognise that front line staff within a culture support safety and quality. But sometimes something happens to create a culture where this goes wrong in a systemic way.

That is why the second most important indicator for safety is the quality of leadership in the institution. Do they have the systems in place to notice that a part of their organisation has gone wrong? How do they review their institution to ensure safety?

I have been thinking about these issues because in a couple of weeks’ time I will be on a panel talking to hospital leadership about quality and regulation. Undoubtedly the last thing these hospitals want is a tightening of their regulatory framework. But for me there is a ‘quid pro quo’ of this.

In thinking about this discussion I have been working out a way to quantify responsibility for safety, and I reckon that over 90% of the responsibility for safety lies within the organisation. Most of that belongs to the professionalism of the staff and the rest with the leadership of the organisation.

Think for a moment what would happen if the percentages were the other way round. What would it feel like if 90% of the responsibility for safety lay outside the organisation? And what if within the organisation most of it lay with the Board? This would leave the front line staff feeling that they had very little responsibility and  that safety was a matter for regulators a long way away from the front line.

Any such feeling would be disastrous for the health – or any – care service because it would create conditions where those who are literally ‘hands on’ in providing care felt that the responsibility for safety was mainly external to their actions.

Yet if the outcomes of inquiries concentrate mainly on what goes on in the regulatory framework, they are actively developing an understanding of responsibility for safety that is moving away from the front line.

If more inspectors inspect safety more often, it stops being a front line job and becomes the inspectors’.

This is not a helpful policy outcome in creating a higher quality health service.


One Response to “Understanding how Francis might understand the world of the NHS”

  1. “Most people recognise that front line staff within a culture support safety and quality. But sometimes something happens to create a culture where this goes wrong in a systemic way.”
    True. Here is a good example. In 2010 a RCPCH panel carried out a Review of the paediatric service at Manor Hospital Walsall. The Review was commissioned by request of Dr Drew (@NHSWhistleblowr) and his BMA representative to the Trust Chairman.
    The Review amongst other things concluded;
    1. There appears to be a gap between what the Board understands of the Trust’s governance and performance and the reality. The Board did not have the capability to interrogate the system for detail as to what was happening to a core system in the hospital.
    2. The departmental change programme to reduce bed capacity was necessary but was not focussed on improvement.
    3. The Executive made inappropriate appointments to divisional and departmental leadership roles.The divisional leadership lacked the necessary paediatric domain knowledge to effectively manage the changes and relationships. The key critical clinical leaders in the structure did not have paediatric qualifications or experience.
    4. Divisional managers exhibited an aggressive management style. There was no evidence of active engagement between divisional management and front line staff.
    5. A view particularly evident from senior management suggests that the difficult issues can be quickly closed with the move to the new PFI building but it is people and teams that deliver healthcare not buildings.
    This was the situation that faced me when I requested the Review. I had been Head of Department, Clinical Director, until 2 years earlier.
    The Review’s report was effectively embargoed. Only the CEO, Trust Chair and I had a copy. I have it in writing from a NED that even the Board was not allowed to see the full report on grounds of “confidentiality.” Compare a similar Review (RCPCH conducted) of Paediatric Services at the next door Trust, Heart of England Foundation Trust. This was published on the web and is still available there. It pulled no punches. It stated that interpersonal relationships between consultants at one of the hospitals were sufficiently bad to be a potential risk to patient safety.
    At the time the Walsall report was delivered in 2010, the then CEO was looking for another CEO post hopefully at a bigger hospital. She applied to HEFT but was beaten by Mark Newbould the open culture Tweep CEO. She is now the incumbant CEO at Derby. The previous year she had been under threat of a vote of no confidence by the hospital consultants committee. I do not think she wanted this report known and so it was vigerously supressed. She committed to present the reports findings to the consultant committee but never did.
    You may not be surprised to hear that in December 2010 I was dismissed by Walsall Hospitals NHS Trust for Gross Misconduct and Insubordination.
    The RCPCH Review Chair described me as of extraordinary value as a clinician. The Trust even acknowleged in writing that I had been an effective manager for 7 years. In 18 years at the Trust I had not had a complaint against me. I was sacked because I refused to accept an instruction not to play any part in disseminating the report. I also refused to accept an istruction to stop imposing my religious beliefs on other staff. The BMA described this as a ludicrous smokescreen to the real issues. I recently presented evidence to the House of Commons Health Select Committee on the extensive slurs made concerning my mental health over the last 2 years I spent in Walsall, most of which I would have known nothing about with using the Data Protection Act.
    This is a great example of a closed culture of secrecy and fear. I now work with PatientsFirstUK to try and ensure that this kind of treatment of good staff who raise legitimate concerns about care is stopped.

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