How are hospital managers responding to the Francis report?: NHS hospital managers have the most urgent need to change their ways, but are they taking the Francis report seriously?
Of all the groups at fault at Mid Staffordshire hospital, the hospital managers and governors have been portrayed as the really bad guys. It is they who created the "toxic" climate of fear and bullying. It is they who suffered, in the words of inquiry chairman Robert Francis QC, from "a lack of openness to criticism; a lack of consideration for patients; defensivenes; looking inwards not outwards; secrecy; misplaced assumptions about the judgments and actions of others; an acceptance of poor standards; and a failure to put the patient first in everything that is done."
Not only all that, but the managers are accused of focusing on "finance and targets" as they ignored good practice elsewhere, cut down the nursing staff on the wards, so that patients were neither fed nor watered, and manipulated the mortality data to make them appear better. Compared with them, the nurses were mere victims of staff cuts, and GPs were just bystanders – who "passed by on the other side".
How do you respond to that? Some managers have replied that Mid Staffs was a one-off, and all other trusts were perfect. But of course anyone who reads between the lines of the Francis Report will realise that he is talking about widespread systemic management failure in the NHS. Last week, at an international forum for quality and safety in healthcare, Francis confirmed that he held this view, saying, there is "no way of knowing at the moment whether there is another Stafford out there … while there may not be another trust with such extensive failings, it is perfectly possible that small silos in individual trusts may be guilty of similarly poor care."
So, hospital managers and governors have a more urgent need than most other players in Mid Staffs – and elsewhere – to fundamentally change their ways. Is there any evidence that they are taking the Francis Report seriously, that they are confronting their demons, and taking the painful steps towards changing their culture? Or are they just mouthing the usual bureaucratic platitudes: "We are learning the lessons of Mid Staffs; "We will draw a line and go forward"; "The patient's wellbeing is paramount", and all that guff.
I have read the initial responses to Francis by two of the bodies that represent managers and governors, NHS Employers and the Institute of Healthcare Management, and I have been quite impressed by the way they are biting the bullet.
The NHS Employers want to "use the moment created by the publication of the report to reflect on our individual and collective actions and ensure that we do not lose sight of the fact that the main contributing factor to the failure was culture." This does not admit mea culpa, mea maxima culpa, but it does agree that the culture was at fault, and the culture must be changed. They warn that "focusing solely on the recommendations will take us into tick box mode, centrally developed policy and targets. We know, and the report affirms, that top down edict does not help to create ownership locally. We must ensure that we do not simply address the recommendations and miss the purpose and opportunity to affect cultural change." Indeed, local ownership is what matters.
The IHM wants a statutory obligation to be imposed on "healthcare providers, registered medical and nursing practitioners to observe the duty of candour".
It adds: "It should be a criminal offence for any registered doctor or nurse or allied health professional or director of a registered or authorised organisation … to dishonestly or recklessly to make an untruthful statement to a regulator." Tough stuff.
The NHS Employers are more reticent about getting the law involved. They point out that: "Legislation and the thought of criminal sanctions can drive a fear culture and result in the type of individual and organisational behaviour we are seeking to eliminate." I have a nasty fear this might make some managers believe they can carry on as they did before.
Both bodies are tough on governors. They should be provided with appropriate training, and "consideration should be given to establishing a minimum level of relevant experience".
The implication is that currently governors do not have the relevant experience. The NHS Employers want to "increase the amount of time board members listen to staff and patients".
Amen to that; I have never glimpsed a governor on a ward. Both bodies support Francis's recommendation for a leadership staff college, to train governors and senior managers. They certainly need the training.
The IHM points out that: "The responsibility of boards is to concentrate on fiduciary, strategic and generative modes of governance is paramount, but too often the members of the board can find themselves with; mundane agendas, ritualised meetings and sterile discussions where they have passive roles, dealing with pre-determined decisions". Such boards, says the IHM, are a waste of time.
The IHM admits that staff are still frightened to raise concerns about the treatment of patients, and wants the legislation on whistle-blowing to be updated. It does seem as if both the NHS Employers and the IHM do want to oversee culture change, and they have identified the bits of the Francis report that they have to address. Whether their wish for change will filter down to their members in individual hospitals is another matter.
In his speech reported in the Telegraph, Francis expressed fears that hospitals are not acting quickly enough to improve standards, as he criticised what he called the NHS tendency to "wait for someone else to tell it what to do". He claimed that "there is an "awful lot" NHS bosses could be doing to improve care in hospitals without waiting for official directives. Guardian Professional.
Of all the groups at fault at Mid Staffordshire hospital, the hospital managers and governors have been portrayed as the really bad guys. It is they who created the "toxic" climate of fear and bullying. It is they who suffered, in the words of inquiry chairman Robert Francis QC, from "a lack of openness to criticism; a lack of consideration for patients; defensivenes; looking inwards not outwards; secrecy; misplaced assumptions about the judgments and actions of others; an acceptance of poor standards; and a failure to put the patient first in everything that is done."
Not only all that, but the managers are accused of focusing on "finance and targets" as they ignored good practice elsewhere, cut down the nursing staff on the wards, so that patients were neither fed nor watered, and manipulated the mortality data to make them appear better. Compared with them, the nurses were mere victims of staff cuts, and GPs were just bystanders – who "passed by on the other side".
How do you respond to that? Some managers have replied that Mid Staffs was a one-off, and all other trusts were perfect. But of course anyone who reads between the lines of the Francis Report will realise that he is talking about widespread systemic management failure in the NHS. Last week, at an international forum for quality and safety in healthcare, Francis confirmed that he held this view, saying, there is "no way of knowing at the moment whether there is another Stafford out there … while there may not be another trust with such extensive failings, it is perfectly possible that small silos in individual trusts may be guilty of similarly poor care."
So, hospital managers and governors have a more urgent need than most other players in Mid Staffs – and elsewhere – to fundamentally change their ways. Is there any evidence that they are taking the Francis Report seriously, that they are confronting their demons, and taking the painful steps towards changing their culture? Or are they just mouthing the usual bureaucratic platitudes: "We are learning the lessons of Mid Staffs; "We will draw a line and go forward"; "The patient's wellbeing is paramount", and all that guff.
I have read the initial responses to Francis by two of the bodies that represent managers and governors, NHS Employers and the Institute of Healthcare Management, and I have been quite impressed by the way they are biting the bullet.
The NHS Employers want to "use the moment created by the publication of the report to reflect on our individual and collective actions and ensure that we do not lose sight of the fact that the main contributing factor to the failure was culture." This does not admit mea culpa, mea maxima culpa, but it does agree that the culture was at fault, and the culture must be changed. They warn that "focusing solely on the recommendations will take us into tick box mode, centrally developed policy and targets. We know, and the report affirms, that top down edict does not help to create ownership locally. We must ensure that we do not simply address the recommendations and miss the purpose and opportunity to affect cultural change." Indeed, local ownership is what matters.
The IHM wants a statutory obligation to be imposed on "healthcare providers, registered medical and nursing practitioners to observe the duty of candour".
It adds: "It should be a criminal offence for any registered doctor or nurse or allied health professional or director of a registered or authorised organisation … to dishonestly or recklessly to make an untruthful statement to a regulator." Tough stuff.
The NHS Employers are more reticent about getting the law involved. They point out that: "Legislation and the thought of criminal sanctions can drive a fear culture and result in the type of individual and organisational behaviour we are seeking to eliminate." I have a nasty fear this might make some managers believe they can carry on as they did before.
Both bodies are tough on governors. They should be provided with appropriate training, and "consideration should be given to establishing a minimum level of relevant experience".
The implication is that currently governors do not have the relevant experience. The NHS Employers want to "increase the amount of time board members listen to staff and patients".
Amen to that; I have never glimpsed a governor on a ward. Both bodies support Francis's recommendation for a leadership staff college, to train governors and senior managers. They certainly need the training.
The IHM points out that: "The responsibility of boards is to concentrate on fiduciary, strategic and generative modes of governance is paramount, but too often the members of the board can find themselves with; mundane agendas, ritualised meetings and sterile discussions where they have passive roles, dealing with pre-determined decisions". Such boards, says the IHM, are a waste of time.
The IHM admits that staff are still frightened to raise concerns about the treatment of patients, and wants the legislation on whistle-blowing to be updated. It does seem as if both the NHS Employers and the IHM do want to oversee culture change, and they have identified the bits of the Francis report that they have to address. Whether their wish for change will filter down to their members in individual hospitals is another matter.
In his speech reported in the Telegraph, Francis expressed fears that hospitals are not acting quickly enough to improve standards, as he criticised what he called the NHS tendency to "wait for someone else to tell it what to do". He claimed that "there is an "awful lot" NHS bosses could be doing to improve care in hospitals without waiting for official directives. Guardian Professional.
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