Mid Staffordshire – change culture, don’t just scapegoat or restructure

A report on why Mid Staffordshire hospital failings went unchecked for so long makes important points. Robert Francis QC, who led the inquiry, avoided the temptation to blame all that went wrong on a few people who could then be punished, or call for yet another round of reorganisation. Instead he revealed disturbing flaws in the culture of the NHS and other agencies linked with health and social care.

This followed an earlier inquiry which revealed the appalling standard of care experienced by many patients at Mid Staffordshire NHS Foundation Trust, leading to unnecessary suffering and death. This was due mainly not to a few rogue staff lacking in compassion and professionalism but rather failings in the system, though individuals who failed to challenge this had some responsibility.

While NHS care is usually adequate and sometimes very good, there are various systems set up to detect when quality is poor, so that weaknesses can be corrected. So why did the Trust in charge of the hospital, those at higher levels of the health service and various professional bodies and watchdogs fail to take prompt action at Mid Staffs, and how can this be prevented from happening elsewhere?

In a media statement in February 2013, Francis explained that “There was an institutional culture in which the business of the system was put ahead of the priority that should have been given to the protection of patients and the maintenance of public trust in the service. It was a culture which too often did not consider properly the impact on patients of actions being taken, and the implications for patients of concerns that were raised. It was a culture which trumpeted successes and said little about failings.”

He also recommended various improvements, including a focus on key standards, a duty to be open about healthcare mistakes and better training for healthcare assistants and managers.

For those involved in organising, providing or regulating health or social care, or (like me) supporting involvement, the findings may make disturbing reading, prompting us to think about our own part in allowing a system to develop in which what matters most to patients sometimes gets lower priority than organisational or personal self-interest.

Mid Staffs managers were under pressure to focus on achieving foundation status, in line with the latest policies of the previous government, and to cut costs, so the focus shifted away from attentiveness to patients, carers and frontline staff, some of whom tried in vain to flag up concerns about the impact of understaffing and other problems affecting quality and safety. This government too has embarked on major reorganisation, and finances are more tightly squeezed, with potentially deadly results.

The wider background (not examined in depth in what is already a very long report) was a shift in the NHS over the past three decades or so from doctors’ dominance to being ‘business-like’. While there was sometimes poor care in the old system, particularly for disabled and older patients, and a lot of paternalism, there was usually a stronger sense of personal connection and responsibility for standards. But decision-makers were increasingly expected to focus on finance and figures, rather than actual experience. The ‘purchaser-provider split’, with different organisations responsible for funding and delivering care, aimed in part at opening up opportunities for privatisation, increased the distance between those with most power and patients.

In addition managers and health professionals wanting to advance their careers (or at least keep their jobs) have been expected to put into practice ministers’ latest policies rather than calling for these to be carefully examined. New structures have been set up, then dismantled almost immediately, wasting resources and distracting staff from what should matter most. Voluntary organisations have also become more ‘professional’, which has brought some improvements but means they sometimes put funding for themselves above defending the rights of the vulnerable.

Discrimination of various kinds, including on grounds of class (top decision-makers can usually afford private care themselves), age and disability, has also been a backdrop to human rights abuses. Head of the NHS Commissioning Board Sir David Nicholson recently stated that hospitals “are very bad places for old, frail people. We need to find alternatives." While most people would agree that patients should receive community-based support where most appropriate, it is extraordinary to suggest that the age-group most likely to suffer from conditions like heart disease and cancer should be prevented from accessing high-tech facilities and consultant-led care when they need it.

The report of the Mid Staffordshire NHS Foundation Trust Public Inquiry raises important concerns for those who believe that justice and compassion should be at the heart of health and social care and other public services. Politicians, staff and the wider public have a responsibility to learn from what went wrong and act to prevent this from happening to others.

The report is available on http://www.midstaffspublicinquiry.com/report [1]

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(c) Savitri Hensman is a regular commentator on religion, politics, theology and church affairs. An Ekklesia associate, she works in the equality and care sector.

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