The horror of the circumstances leading to the Francis enquiry demand urgent action. We understand the temptation to impose punitive controls on a system that demonstrably failed to understand its core purpose. But the danger of such populist intervention is that it will exacerbate the very cultural flaws that created the hole into which Mid Staffordshire Hospitals Trust fell. At its heart, there is only one sure-fire way forwards.
The solution must lie in reinforcing the statutory duty Board directors already have. Their duty is first to do no harm, but then to inspire everyone in their organisation to do great things using the resources available to them to maximum effect. This is hard and difficult stuff. We need people of courage to step forward and lead the way. For too long, we have prevented leaders from making the right decisions at the right time, conditioning them to look over their shoulder to the heavy handed interference of the army of regulators, government departments and politicians.
There are three imperatives for anything that flows from the Francis report. These are messages for all leaders and managers in the NHS, and potentially even wider for all organisations, whether they are public, private or not-for-profit sector:
- the failings which occurred in Mid Staffordshire hospitals were horrific, unacceptable, inexcusable and must never be allowed to happen again;
- the friends and relatives of those caught up in these failings were confronted with a system which was completely deaf to their pleading and complaints: a level of arrogance, complacency and closing of ranks which must never be allowed to be repeated;
- the review has exposed a level of systemic failure of both leadership and governance in which accountability, priority-setting and decision-making are always someone else’s responsibility.
Francis produces 290 recommendations targeted liberally throughout the system. The report condemns the system for allowing the target culture to supplant the core purpose of the NHS. Francis rightly demands a new culture which is dominated by patient outcomes, and does not tolerate harm to anyone caused by failure to implement known practice. It is astonishing that these recommendations then are designed to reinforce that purpose with an unprecedented level of micromanagement and imposition of a regime in which the centrality of that purpose is threatened by total emphasis on compliance. Evidence points time and again to the fact that cultures built around compliance lose the spirit and passion that constantly strives for improvement. CHE is proud to be a major partner of EIGA – the European Institute of Governance Awards – a body whose purpose is to encourage and celebrate organisations that have an approach to governance designed to demand more from continuous learning and improvement. This is liberating, empowering stuff that encourages leaders to inspire and motivate their staff. It treats clarity of purpose, insatiable curiosity and fearsome courage as bedfellows in leadership.
This report is entirely about leadership. It is about Boards that have developed a subservient culture of seeking both direction and permission from multiple regulators and government departments: outsourcing their very duties to others. It is about a system-wide style of management that focuses on centralised control of power rather than leadership capable of inspiring a whole workforce to align behind the great values of service on which the NHS was built. It is about performance management that focuses irrepressibly on enforcement of process targets, rather than encouraging a relentless drive for improvement and learning at every level and by everyone.
In any and every organisation, it is the single-minded duty of the board of directors to act with integrity and commitment to ensure that they deploy the scarce resources of their organisation to achieve the very best outcomes for the groups of people whom they serve – customers, patients and relatives, staff, suppliers, community, shareholders. Boards must ensure that they have an unequivocally clear purpose and that they drive towards this purpose working with a clearly exhibited set of values – the ethos they personally live and breath, and which they expect their staff to live and breath at all times. Boards must put in place the mechanisms of accountability by which the directors personally and collectively know categorically that their teams are doing the best they can. And they need to encourage the curiosity in leadership that is hungry for new learning, new insight and new experience, which will help them to shape a better future.
None of this can be imposed from outside by fiat or mandate, or strengthened under the watchful gaze of regulation by compliance but nor can it be delivered behind closed doors. An external view from regulators and those who have direct experience of the services will stimulate the openness, without which hubris and complacency lurk.
Francis demands a populist response of the iron fist and a tightening of control, and even a little bit of vengeance. But this is just a rewiring of the stuff that got us to this point. The emasculation of real accountability by those whose job it is to guarantee the quality, safety and effectiveness of services that created the breeding ground within which compassion was replaced by soulless complacency. We need to rebuild trust in the management and leadership provided by the Boards who understand that their duty is first to do no harm, but then to inspire everyone in their organisation to do great things using the resources available to them to maximum effect. This is hard and difficult stuff. We need people of courage to step forward and lead the way.
See how this has been reported in the Huffington Post, and the National Health Executive.
Watch my interview on the subject as part of the Cass Talks series of video recordings by Cass Experts on topical new stories.
David Welbourn 