Mid-Staffs: the inquiry has missed the mark

7 Feb 13

The terrible failures at Stafford Hospital were not about resources. They were about deep-rooted cultural problems that top-down recommendations will do little to change.

The report on the Mid-Staffs NHS Foundation Trust makes appalling reading for any of us, let alone those who were intimately involved. Worryingly, there is some evidence to suggest that this is not an isolated case.

There are news reports that five other hospital trusts are to be investigated over their mortality rates following the publication of the Mid-Staffs report.  It is said that an immediate probe is to be launched into Colchester Hospital University NHS Foundation Trust, Tameside Hospital NHS Foundation Trust, Blackpool Teaching Hospitals NHS Foundation Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust and East Lancashire Hospitals NHS Trust.

Furthermore, a firm of solicitors is reported to be representing relatives and patients with regard to legal action at ten NHS Trusts. If this is the case then I suggest we cannot just dismiss Mid-Staffs as an aberration but we must look for more systemic causes and solutions.

In spite of the length of the inquiry - and the effort put into to it by the inquiry team in coming up with its 290 recommendations - I am not convinced that it really hits the nail on the head, or offers workable solutions.  At first glance, it seems to me that the inquiry report is correct when it talks about the need for fundamental change and shifts in attitudes and culture in the NHS.

However, it is not clear there is any evidence that the cultural changes needed will be achieved by: legislation, criminal charges, regulation, inspection, greater ministerial supervision and other controlling methods. Changing cultures is much more subtle than that.

First, let us deal with the resource issues head on. I find it difficult to believe that patients being forced to drink water from flower vases and lying in soiled sheets for many hours is a consequence of financial pressures.  In much of the past decade the NHS has had record growth in resources.  Furthermore, between 1997 and 2006 the Royal College of Nursing’s own figures show that the numbers of qualified nurses in the NHS grew by 25% in England and by around the same in the rest of the UK.

 Can we really believe that this sort of behaviour can be put down to ‘lack of resources’ or ‘pressure of work’? I know from personal experience that there are many many dedicated and hard-working professional nurses.  But am I the only person to have noted in some hospitals  four or five nurses sitting at the central station in a ward chatting or texting?  It looks more likely to me that a lot of the problems of Mid-Staffs can be put down to a lack of proper professional leadership in the nursing profession, not shortage of resources.

Second, there is an issue about the role of effective financial management and control in an NHS Trust. The inquiry report comments that it was the board which took the decision to pursue a cost-cutting drive to achieve foundation trust status, and it was the board which refused to listen to the complaints of patients and - at times - staff. Now whether the board went too far in a drive to cut costs I do not know but what I do know is that there is a balance that must be struck between the delivery of services and effective financial planning and control.

The reality is that NHS Trusts have finite resources and have to deliver services within that resource constraint. This problem will not go away no matter how many inquiry reports are produced. The danger now is that NHS Trusts will go too far in the other direction and take decisions resulting in huge financial overspends. This is particularly a concern at present in a period of financial austerity where NHS Trusts are having to identify large scale savings. Research I have recently completed on financial governance in NHS Trusts suggests that there are significant weaknesses in NHS financial governance which will be exacerbated by the pressure of austerity.

Third, I would also focus on the relationships between managers and health care professionals in the NHS. In my 35 years’ experience of the NHS it seems to me that this relationship is at best, somewhat distant and at worst antagonistic and lacking in trust. Health care professionals often see NHS managers (or administrators as they prefer to call them) as ‘the enemy’ involved in collaborating with government to deny them the resources they need to treat patients as they think fit.

On the other hand, NHS managers often see health care professionals as unwilling to accept the realities of finite resources, defensive about their own professional status and practices and unprepared to engage, fully, in the decision-making process as to how resources should best be used. (Anyone who doubts this situation exists should have a look at TV programmes such as Casualty or Holby City to see how NHS managers are portrayed.)

This week I heard a debate on the radio about the NHS which involved a number of health care professionals and a politician (no, there was no NHS manager invited). As usual, the cry came up for a greater involvement by healthcare professionals in decision-making in the NHS. Similar arguments were heard at the time the Health and Social Care Act 2012 was going through Parliament and indeed subsequent changes were made to take this on board.

I actually think most NHS managers would welcome such increased involvement and engagement by health care professionals provided those health care professionals accepted the realities of finite resources and were also prepared to be fully accountable for those decisions that they were involved in and would not stand on the sidelines carping.

Let me give an example to illustrate this point – the issue of budgetary management in the NHS. In my experience, health care professionals often argue for them to hold budgets and have more influence on the way resources are used.

However, when we explore this further what this often means is that while they want to get their hands on the money, they do not usually want to deal with the administrative workload associated with managing budgets; deal with, for example, problems such as high levels of staff sickness or maternity cover which impact on budgets; deal with the pressures of declining budgets caused by financial austerity; or be accountable for the services they provide based on the resources available.

If any of the above take place the usual response is to pass the problem to managers or administrators to deal with.

 I think it is essential  that cultural change takes place in the NHS if we are to avoid repeats of the Mid-Staffs scandal. However, I am not convinced that the inquiry’s recommendations are the way forward. Much has been much written about how organisational cultures can be changed and the first thing to say is that it is difficult.  Maybe iwe should heed the words of John Kotter, perhaps the leading global expert on cultural change in organisations. He makes a number of key points.

First he asks, what is the nature of the problem?  Virtually no one clearly defines what they mean by ‘culture,’ and when they do they usually get it wrong. 

Then he asks, how does culture change?  It changes through a powerful person at the top, or a large enough group in the organization, deciding the old ways are not working, figuring out a change of vision, acting differently, and enlisting others to do the same.

If the new actions produce better results, then this is communicated and celebrated. And if they are not killed off by the old culture fighting its rearguard action, new norms will form and new shared values will grow.

And finally he asks, what does not work in changing a culture? The answer is, some group deciding what the new culture should be; drafting a list of new values which are passed to the PR or HR departments, with an order to tell people what the new culture is. They cascade the message down the hierarchy, and little or nothing changes.

In Kotter's words: that’s the whole story. Which path to cultural change will the NHS take?


  • Malcolm Prowle
    Malcolm Prowle

    Malcolm Prowle is professor of business performance at Nottingham Business School and a visiting research professor at the Open University Business School. Malcolm is an expert on the economics, finance and management of public services. He has advised ministers, senior civil servants and public service managers on a wide range of public policy and implementation issues.


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