It’s all about leadership. Inspirational leadership.

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.

Too many buses?

With a spate of bad publicity about the apparently rapid vanishing sense of caring from the world of care it was bound to happen.  The kind of fight back reminiscent of the queue of buses clogging up the roads just after it has stopped raining!

With the anticipation of a white paper on social care in the Spring: first in the queue was the minister himself.  Paul Burstow speaks about the importance of care with a degree of sincerity and authenticity that is compelling.  He has established a series of working groups under the title Caring for our Future with the specific aim of consulting with key groups before the white paper is published in Spring.  Whether he has seen the value of the Future Forum process led by Steve Field for the Health bill is open to speculation, but if this consultation process can get in touch with the real issues, rather than rely too heavily on the rather less connected view from Richmond House than it has my vote.

Then, this morning, a press release crossed my desk from the Care Provider Alliance – a body setup to represent the vast majority of social care provision inEngland.  They have just published a vision document to stimulate debate about the nature of regulation and inspection.  In it they suggest an approach to the co-production of the regulation regime, encouraging CQC to tap into the knowledge and experience of the members, most of whom admit they are seeking re-establish credibility and shrug of the tainted image left by Southern Cross.

Lo and behold, this afternoon, I bumped into another press release, this time from Dignity and Care Partnership, an alliance launched in July between the NHS Confederation, the Local Government Association and Age UK.  This worthy group has just launched a Commission, to gather evidence from all interested parties to help improve dignity in the care provided to older people whether that be in hospitals or residential care.

Together this constitutes a chorus saying enough is enough.  I applaud it, but can we have some degree of joining up to avoid dissipation of effort to get this right.  

Now I leave it to you to decide whether the Centre has just allowed another bus to leave the depot, or is offering a suitable interchange station at which those on the buses may meet up for the next leg of their own particular journey.  In responding to Caring the Future, we have already billed one of the Centre’s seminars on 28th November as a forum to support its work and bring academic and practitioners together around the quality and workforce topics.  One of our planned speakers from that working group is also a leading player in CPA, and we will continue our quest to be truly interdisciplinary in our approach as we plan out that seminar.  Do help this important debate – contribute, follow and maybe even join us.  

Hashtag #Futurecare.

Report from our annual debate

The Centre’s annual debate sought answers to the question of how key policy areas might contribute to the drive to improve both quality and efficiency of care.  Excellent contributions to start the debate were provided by experts in standards, regulation and competition. 

An online survey conducted before the debate had indicated a near perfect bell-shaped distribution in the degree of optimism people shared in the future sustainability of health and care services.  This was offset marginally in favour of the pessimists.  One in 8 registered “not at all confident” with only one in 40 declaring that they were highly confident. 

That same survey indicated that Mike Kelly of Nice might have the easiest task in making his case that standards would indeed drive both quality and efficiency, albeit that the survey did indicate only a minor contribution in the short term, with improvement taking several years to pay real dividend. 

From this advantageous starting point, Mike kicked off the debate with an excellent exposition reminding us that the whole work of standards began over 40 years ago when Archie Cochrane recognised that the apparently arbitrary degree of variation throughout the system was simply not good enough. 

Mike went on to express that the value of establishing standards based on a shared and common interpretation of the best available evidence is shared across all stakeholder groups because it establishes a common language of exchange, which:

  • defines the basis on which professionals make their decisions about treatment;
  • sets a clear expectation for patients and carers to make their choices;
  • defines the benchmark performance against which different providers will be compared;
  • enables commissioners to define the criteria they will use to reward quality and performance.

Mike reminded the audience that in driving for continuous improvement, it is important to understand the health gradient linking social and health status.  It is all too easy to deepen health inequity by improving the quality of outcomes disproportionately for those who tend to have the least complex care needs.  The ideal aim in driving new and better standards is to target improvement on those with complex care needs to overcome the current inequity in outcomes.

In contrast, Nick Bishop of CQC entered the debate for regulation with a small opening handicap, having been assessed as the policy area most likely to be neutral in its effect, although it too was perceived to contribute more positively in the longer term.  Nick began by praising the importance of standards as the essential basis against which regulations were defined and compliance assessed. 

Nick reminded us of the sheer scale involved in anything to do with healthcare – 1 million GP visits and 2 million prescriptions issued per day, 50 000 visits to A&E and 2000 births just to provide a sample.  To drive home this point, Nick illustrated the sheer scale, by pointing out that a £1 million stack of £50 notes would be roughly the height of the tallest human, whereas the NHS budget would stretch to 220km high – more than 26 Everests. 

With so many events in a risky business, there will always be some which don’t turn out as planned, and the quality regulator’s role is to expose where this is happening more than is reasonable.  With over 30 000 organisations to regulate through annual inspection (that is over 120 organisations per day, small and large), the challenge for CQC boils down to the same issue with which Mike began – understanding the unwarranted variations in health.  Somehow, amidst the millions of events and thousands of organisations, CQC must spot an anomalous pattern within the plethora of intelligence to enable them to weed out those providers who are simply not performing within agreed and safe limits – and to do this with a substantially reduced budget compared with historical inspection.

Andrew Taylor was our final speaker in the debate.  Until recently, Andrew was the Chief Executive of the Co-operation and Competition Panel – the body charged with ensuring that none of the provider organisations within the NHS is able to wield its power to the detriment of the service user/ patient or carer. The stance of the Health and Social Care Bill towards competition has probably been the cause of the greatest volume of dispute and objection.  This was no exception in our debate, as again demonstrated in the pre-debate poll, where results showed a strongly polarised opinion.  A strong showing both for and against its contribution to improving quality, and a much smaller neutral vote.  Competition was also felt to offer the strongest contribution to rapid improvement in quality, though with much reducing value over the longer term.

Andrew distinguished between the effect of competition within the NHS, and between the NHS and other providers.  The influence of patient choice to incentivise better performance should not be minimised – currently mainly between providers, but soon to be opened up to choice of individual consultant.  The new area of competition signalled by the Bill is that of increasing market testing by commissioners, with the opening up of the market to any qualified provider (AQP).  Andrew pointed out that in the current wave, the maximum value of community services covered by AQP is unlikely to exceed £50-100m.  Borrowing a leaf from Nick’s scale of measurement less than 0.1% of the NHS budget and a mere BT tower high stack of £50 notes.  In the current round of competitive tendering, commissioners have been instructed to market test 3 services from a list of 12 – every one a service in which the NHS generally fails to offer a service of credible quality – wheel chair services being the archetypal example.

In the debate which followed, there was considerable agreement that these policies are not an either/or choice – each has its place, and each can contribute positively to improving quality and efficiency.  The survey results reinforced the expected views that structural change is seen as the least helpful of any policy approach and integration offers the greatest hope for improvement.  Overwhelmingly though, the plea from the audience was to find voice to the patient, service user or carer, and for a greater sense of local ownership with reduced imposition of centralist control.

A more detailed report, including the survey results will follow.

What of the Bill?

As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them? 

I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.

Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you.  But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return.  Going back is not an option.  Too much has already changed for that to happen.  Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid. 

It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane.  Such a debate would pivot around what it takes to secure a sustainable future for health services:

  • that are better at adopting innovation,
  • in which all elements of the system drive together towards best possible outcomes for available resources,
  • that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.

Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains.  The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance.  Such ambiguities include:

  • detail of how Clinical Commissioning Groups (CCG) will be held to account;
  • how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
  • how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards. 

Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done.  If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.

Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact.  Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working.  These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged.  “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat.  What we need is an open-minded focus on how to achieve successful transition to a new shape.  The health system is too big and complex, to be susceptible to management by central diktat.  We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives. 

We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system.  GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care.  There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision.  That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour. 

Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account.  Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together.  Success of these boards is pivotal to the future.  It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions.  We see no attempts being made to nurture the new relationships on which success can be assured.

The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date.  There are important matters to be understood, which will make a real and important difference.

David & Rob

The perils of squeezing out judgement

Our recent past is littered with large scale systemic failures, each of which has led to probing reviews, a myriad reports and the inevitable rewriting of regulation, each time marking a new dawning of governance and protection for innocent casualties.  Maxwell!  Enron!  Clapham!  Barings!  Baby P! Bristol!  Alder Hey!  MidStafford!

In some ways the review findings are predictable.  Technology has enabled practice to outstrip and outsmart the regulator.  The regulator caught napping!  Regulators essentially caught colluding with the deceit – Enron was the first of these to reach my consciousness. 

When you peel the layers away, every one of these is a failure of risk management process.  Inadequate consideration of, and planning for, the risk that things might not work out as we want them to.  Insufficient integrity in those controls which should have been starting to glow red as the likelihood of impending failure rose.  Insufficient emphasis on assurance – that triangulation process which seeks independent confidence that all is well. 

But then, risk management is too easily relegated to the “process nerds” who interfere with innovation and shun entrepreneurial flair, demand that proper time is allocated to consider complex issues in depth. 

An opportune moment perhaps to rewrite that perception?

In 2009, Sir David Walker’s report on the failure of banking recorded some of the most memorable words from a governance review:

“……improvement in corporate governance will require behavioural change in an array of closely related areas in which prescribed standards and processes play a necessary but insufficient part. Board conformity with laid down procedures such as those for enhanced risk oversight will not alone provide better corporate governance overall if the chairman is weak, if the composition and dynamic of the board is inadequate and if there is unsatisfactory or no engagement with major owners. The behavioural changes that may be needed are unlikely to be fostered by regulatory fiat, which in any event risks provoking unintended consequences. Behavioural improvement is more likely to be achieved through clearer identification of best practice and more effective but, in most areas, non-statutory routes to implementation so that boards and their major owners feel “ownership” of good corporate governance.”

Earlier this year, Professor Eileen Munro reported on the circumstances of the Baby P tragedy, concluding that the child protection system had been built up of layer after layer of so-called assurance, which ultimately diverted attention away from the very purpose for which the processes existed, recommending that energy in safeguarding needed to be brought back to its core aims:

“These forces have come together to create a defensive system that puts so much emphasis on procedures and recording that insufficient attention is given to developing and supporting the expertise to work effectively with children, young people and families”;  and:

“instead of ‘doing things right’ (i.e. following procedures) the system needed to be focused on doing the right thing (i.e. checking whether children and young people are being helped)”

Can the combination of Walker and Munro mark a sea change in thinking about risk management and governance?  Yes, process is an important part of the story, but it can never be seen as more than just a part. 

I have a few simple mantras which, if applied in a few more places could improve effectiveness.  One of these applies here.  Information rarely gives you answers – it simply helps you understand and formulate the important questions to ask! 

Put simply, it is the duty of management to use the best available information and evidence, combine it with experience and professional judgement, and subject it to peer review from as wide a cross section of perspectives as practical.  That for me is a statement of good governance and the duty of both individual managers and whole boards.

So, when we read the litany of misfortune and the apparent disarray within CQC, we have to be worried, even after stripping out the undoubted misreporting, exaggeration and sensationalising of the telling. 

Easy to make a transcription error that puts the wrong number down for the number of inspections carried out last year, but impossible to misjudge your core business by a factor of two!  Valuable for board members to be setting aspirational plans for how they want to see processes becoming more consistent and controls being tightened, but unacceptable to then misjudge the gap between today’s reality and that future goal.  Commendable to see an internal review conducted when staff properly raise concerns about process quality, and easy to understand why sharing such a review publicly would need careful handling, but impossible to see how an organisation whose very raison’d etre is to provide public assurance, could misjudge the importance of transparency and consider disciplinary action as a first resort.

And the biggest question of all!  What can be done to enable the CQC board to achieve Walker’s sense of “ownership of good governance”, to generate an effective balance between process and culture, when the government imposes increasing demands, expands the scope and reduces resources at the drop of a hat?  Where is the meaningful consideration of risks, the integrity of the controls and the confident, independent assurance and exercise of professional judgement.  Surely, at the very heart of this governance minefield, it is ironic indeed to see the Department of Health acting almost in the role of Shadow Directors of CQC, removing the very ownership the board should have in determining how to square this shrinking circle! 

This feels to me to be the very antithesis of the assurance process for which CQC exists.