Contextual Factors in the NHS in England which are likely to have influenced the Occurrence of the Serious Untoward Events in Mid Staffordshire

Quality of care Regulation

Note: This analysis is not applicable to the NHS in Scotland, Wales and Northern Ireland where organisational principles and practice are different.

On the basis of more than forty yearsʼ experience as an NHS manager, researcher , teacher and consultant adviser, I believe that there is evidence to suggest that the following combination of contextual factors in the wider NHS (in England) and the United Kingdom Government are likely to have contributed to the specific problems which occurred in Mid-Staffordshire:

1. The failure to make population health gain, quality of treatment and appropriate, evidence-based (management and clinical) practice the over-riding policy objectives (see first recommendation of first Mid Staffs Inquiry):
• See ʻClinical Governance: Making it Happenʼ and extensive other literature on successful health and other organisations
• Failure to fully implement Bristol, Shipman and many other Inquiry recommendations
• Lack of positive promotion and encouragement of a ʻblame freeʼ culture of honesty and open disclosure of perceived problems
• ʻTop-Downʼ, rather than ʻBottom-Upʼ organisational design

2. The destructive and corrupting competitiveness of the internal / external market:
• The myth that competition drives up quality and reduces cost
• Secretiveness and self-protectionism induced by competitive/quasi-commercial context
• Perverse financial incentives to focus on inputs and outputs rather than quality and outcomes
• Incentives for hospitals to over-treat and stretch beyond their areas of competence
• The primacy of financial targets and financial viability of quasi-independent institutions (Monitor)
• Inappropriate focus on hospitals and specialist services rather than total health care system
• The lure, distraction and opportunity costs of Foundation status (which does not improve performance : York, 2011)
• Fragmentation of services (particularly separation of mental health from other specialist services and between GPs and Consultant specialists) and associated peer review
• Emphasis on local self sufficiency with demise of regional support and development networks
• Absence of reliable and relevant indicators of comparative performance (impact and outcomes).
• Failure of commissioning and lack of comprehensive health planning

3. The single-minded and ridiculously simplistic top-down target culture:
• Gross over-simplification of complex systems for political purposes
• Local tension inherent in the conflict between of ʻtop-downʼ targets and the local commissioning, competition and ʻchoiceʼ agenda (mixed messages; the Blair/Brown policy divide)
• Suppression of honest, evidence-based clinical concerns about evidence, quality and outcome
• Inappropriate focus on input, process and output targets rather than outcomes and quality
• Bullying intolerance of failure to meet irrelevant targets, regardless of the consequences

4. A bullying NHS management culture:
• Political aspirations driven by consumerism and short-term political objectives
• Insatiable political demands for promulgation of good news and for burial of bad
• Political interference with operational management of the NHS and associated failure to determine long-term strategy
• Politically disabled NHS Chief Executive unable to stand up for the NHS (no independent governing Board for NHS England)
• Manipulation and corruption of data to deliver good news
• Active suppression of whistle-blowers and those not ʻon messageʼ.
• Complicity of Regulators (the self-serving complicity of the ʻelite circleʼ)
• Substitution of patronage for long established open and competitive principles for NHS management appointments

5. The ambiguity of the role of ʻNHS Chief Executiveʼ (in England) which attempts (but fails) to combine the role of a CE of a major national enterprise
with a top civil service adviser:
• Inability to stand up to politicians and speak for the Service
• No supportive NHS Management Board
• Confused accountability of other DoH roles
• Top-heavy DoH Structure
• Self-protective national ʻguidanceʼ which is either ditched or unenforced when inconvenient (eg consultation regulations)
• ʻCentralisation of credit and devolution of blameʼ (Klein)

Bullying SHAs and regional officers:
• Identification with politically driven ʻcentreʼ: the ʻenforcersʼ
• Lack of identification with, and representation of, the operational perspective
• Limited operational experience of senior staff
• An opportunity for careerists
• Inability or disinclination to read warning signs: ʻwilful blindnessʼ ?
• No focus on quality

Bullying and suppression by too many Trust Chief Executives and other Managers:
• Concerns about job security
• Performance judged on inappropriate criteria
• Inadequate managers adopt bullying, autocratic or repressive management style
• Shortage of high calibre candidates

Over-elaborate, confusing, yet inadequate governance structures in NHS Trusts:
• Confused accountability of mixed executive/non/executive management boards
• Confusion about two tier management/governor board structure
• Confused accountability and conflicted role of different kinds of governor
• Lack of clear accountability to a defined local population
• Inadequate local community/patient voice
• Disintegrated governance

9. Inadequacy of too many non-executives and governors:
• Inadequate as community representatives
• Inadequate experience and understanding of complexity of NHS & public sector
• ʻCareerʼ non-executives: financial and career interests in acquiring and retaining positions
• Failure to champion quality and best outcomes
• Obliged to comply with ʻparty lineʼ: ʻethical fading”
• Governor role seen as stepping stone to (paid) non executive Director position or (for staff governors) to career progression

10. The Careless Abolition of Community Health Councils:
• Failure to put anything effective in their place to act as local effective independent representatives of and advocates for patients and defined local community
• Loss of local power to question ʻsubstantial variationsʼ

11. The failure of the Public Interest Disclosure Act 1998 and Codes of Management practice:
• PIDA too easy to evade
• Requirement to protect whistleblowers conflicts with dominant and pervasive bullying culture
• Failure to enforce codes of practice: no sanctions
• The Lansley ʻbroken promiseʼ

12. The failure of Professional Associations and Trade Unions to articulate concerns at an aggregate level and to support whistle-blowers:
• Tendency to try to achieve relatively easier settlement of individual cases as an employment issue
• Failure to detect or tackle evidence of systematic bullying in specific places
• Cowed and cowardly clinical professionals (eg BMA survey)

13. The active suppression of reported concerns by the Department of Health and regulators (and apparent collusion between these parties):
• Absolute and overriding priority to protect politicians at any cost
• Vested personal interest of careerists to serve political objectives
• The ʻelite closed circleʼ of ambitious managers
• Ineffectiveness of NHS Confederation and IHCM

14. The inadequacies of the NHS complaints system:
• Diffusion of accountability
• Failure of local resolution
• Inadequacies of regulators, NPSA and NHSLA
• Health Select Committee Report (June 2011)
• Lack of proactive management

15. The Inadequacies of Monitor:
• Lack of health management experience and idiosyncrasies of its Chair/CE and staff
• Overriding primacy of financial management and institutional viability

16. The inadequacies of the CQC and its predecessors:
• Bureaucratic, box-ticking processes and measurements which do not spot critical indicators of organisational pathology
• Failure to respond with speed and effectiveness to serious reported concerns
• Lack of flexibility
• Inappropriate application of routine regulatory procedures to investigative processes
• Failure to understand the complexity of organisational pathology, particularly in manipulative organisations
• Inexperienced staff easily deflected and manipulated

17. Continuous restructuring of the NHS driven by political ideology (including current government proposals):
• Disruption of organisational processes, experience and continuity
• Loss of organisational memory, experience and maturity
• Erosion of trust, stability and constructive relationships
• Diversion of managerial energies
• Sapping of morale

18. The failure of commissioning, the absence of an integrated, NHS structure based on partnership and collaboration and a planning process based on
population health needs:
• Compare integrated, population-based, local accountability structures based on cooperation and partnership (and absence of internal market) in Scotland and Wales
David Hands / 17.12.10 (Revised 19 July 2011)