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.

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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.

What does it take to shock us?

However deplorable the terrorist attacks were a decade ago, and however much the impact has reverberated around the world, it remains a mystery to me how we can be shocked beyond measure by one circumstance, whilst another source of pain to society remains almost unnoticed.

There were just under 3000 awful and premature deaths on September 11th 2001 – devastating terorist strikes, destroying the hopes and plans of 3000 families;  reverberating across New York communities, leaving orphans and widows in its wake.  There have been almost daily incidents around the globe since then, with too many of them causing death tolls above 100.

But in the decade since then, nearly 7000 US citizens (military personnel and contractors) have been killed on the war fronts of Afghanistan and Iraq.  It is difficult to count the deaths on the other side, but estimates vary between 25 and 50 thousand directly killed and maybe 20 times that number of “excess” deaths caused by a combination of sanctions and war conditions.  What an awful term: “excess deaths”!

But where are our thresholds of unacceptability?  The same decade has seen around 150 thousand homicides across American society – 15 Americans killed by local violence for every single one killed either in the twin towers or in the war zones since.  And what of the 360 thousand Americans killed in road traffic accidents – casualties of life.  Are these any less devastating to the friends and relatives?

But here is the real rub!  Nearly 1 million “excess” deaths across the USA because the American health system has so many holes in it!  If the life expectancy in the USA was equal to the average value across the OECD nations, more than 900 thousand lives would have been saved in the last decade.  Investment in UK health reform in the same period has successfully closed the gap from its poor performance, so that in 2009 – the latest full year data, the UK crossed over to better than average life expectancy.  But procrastination about American healthcare reform  has seen its gap continue to widen almost every year, so that the average American can expect to die 4.8 years sooner than his or her Japanese counterpart, and 2.1 years sooner than the average throughout OECD countries.

How does the shockwave of such appalling devastation of life and relationships pass by so unnoticed?