Prevention is better than cure

Accountability Regulation

A five-point plan to prevent a repeat of the failings at Mid Staffordshire NHS Foundation Trust 

A response by Unite

The terrible events that engulfed Mid Staffordshire NHS Foundation Trust (Mid Staffs) should serve as a stark warning to politicians, care providers and commissioners of services, both within and without, the NHS.

The reports by the Health Care Commission (HCC) and Robert Francis QC have highlighted the tragic scale and depth of management failure, bad practice and mistreatment that occurred.

This briefing details the concerns of the Unite health sector, which represents more than 100,000 members in the health service, and recommends a plan of action to prevent such events happening again in the NHS and other health providers.

Mid Staffs is one of the worst NHS hospital care scandals in recent years. There were reports of hundreds of patients dying unnecessarily and many others suffering from the poor standards of care and what amounted to abuse that they received there.

Unite is proposing a five-point plan to ensure that such a terrible catalogue of errors never happens again within the NHS:

Patient safety officer

The role of a patient safety officer (PSO) would ensure that safety and good practice are maintained, and concerns are tackled in a timely fashion.

Unite envisages that this role would need:

  • the powers to investigate individual cases, make recommendations and review in conjunction with the Care Quality Commission (CQC). They would also have the power to make statutory orders to enforce changes.
  • to be externally accountable
  • to provide advice on patient safety and would be the link with the National Intelligence Unit (see below)
  • to ensure the organisation had annual action plans, put together with the trade unions, and aimed at improving culture, behaviour and morale
  • to provide advice and support to whistleblowers whether they are staff, visitors and patients

National Intelligence Unit (NIU)

The NIU would co-ordinate the intelligence gathered by those organisations involved in monitoring health care. These include: the regulatory bodies, such as Nursing & Midwifery Council, the Health and Care Professions Council and the General Medical Council, and other bodies such as trade unions. The NHS staff survey would also play a part in this.

This will enable the NIU to identify organisations causing concern and prevent another ‘Mid Staffs’. This would be accompanied by a dedicated whistleblowing helpline which would be run by the NIU and would relay cases for investigation to local PSOs.

Accountability and management

Those in management positions should receive recognised training and assessment to ensure they possess the appropriate skills for their positions.

Organisations must also demonstrate ongoing development of managers. There must have clear lines of responsibility and accountability. This should include much greater involvement of all staff in governance and more input from an employee representative on the board (as currently happens in Scotland).

This would link the board level with operational activity. All proposed changes must be evidence-based and risk assessed. It should be mandatory to consult staff and their trade unions on proposed changes, and then listen and respond to their concerns/suggestions.

Change of culture

Organisational values and behaviours that are required to create an enabling, and open culture – where staff are encouraged to develop and share good practice – need to be indentified. A culture of blame, bullying and low morale leads to poor productivity. It is essential that the highest organisational values form an integral part of recruitment process.

Change of government policy

Continuing the current policies which are fragmenting the NHS will increase the risk of further ‘Mid-Staffs’.

There needs to be an end to privatisation, cuts, unnecessary reorganisations, and attacks to staff terms and conditions. The NHS needs stability and resourcing. Ministers must stop stripping the NHS of money – cuts, skill mix and grade mix are all unsafe and will mean that the next ‘Mid Staffs’ will happen all-too-soon. Cuts have a cost and the government must accept some of the responsibility for this situation.

Francis Report

The report’s conclusions included:

  • core failures of management
  • insufficient staffing numbers and resourcing
  • financial concerns and mismanagement
  • lack of responsibility from the trust board, which was driving change through in an unsafe manner
  • a culture of fear and bullying
  • a concentration on statistics and targets to the detriment of patient care
  • failure to listen to staff and patients
  • failure to defend professional standards
  • failure of external organisations to intervene
  • poor transparency and accountability
  • lack of support for staff
  • a failure to integrate care, particularly for the elderly and vulnerable

What happened at Mid Staffs is not unique and many of the factors that led to it exist across other parts of the NHS. These factors are being aggravated by current government policy towards the NHS.

Government policy

The previous Labour government had begun to reverse its policies to return to an NHS preferred provider approach, following the publication of the previous Francis Report.

The coalition government’s new Health and Social Care Act (2012), however, has led to an avalanche of privatisation across the NHS.

Indeed, the NHS is now in the midst of the most radical reorganisation since its inception in 1948.

The changes are being undertaken at a rapid pace and without an evidence base.  The Act opens up all elements of the NHS to competitive tenders from the private sector. ‘Any Qualified Providers’, such as Virgin Care and Serco, are already winning contracts to deliver services and there is a growing trend of fragmentation and outsourcing of services.
The competitive contract environment will further reinforce the culture of silence in many organisations, as managers increasingly place the demands of shareholders, contract conditions and bidding processes ahead of patient care. Profit, not care, will be the paramount consideration.

Ministers have already begun to push NHS privatisation as the panacea to the issues raised by Mid Staffs. However, there is no evidence that the private sector is any better at delivering health services than the NHS.

The scandals in private sector organisations, such as Winterbourne View Hospital and Southern Cross Care Homes, indicate that they are not.

The reverse is much more likely, as accountability will become clouded by commercial confidentiality rules that form part of the contracting and sub-contracting process, that make it more difficult to identify who is responsible or liable for problems.

The disconnect between the strategic and operational sides of ‘Mid Staffs’ demonstrates the compounded risk of the purchaser-provider split and further fragmentation. This will result in commissioners having few powers to control failing providers.

Staff will also become more insecure about their jobs and, therefore, reluctant to expose abuses.

Reorganisation and foundation trust status

Mid Staffs’ focus on arbitrary government ‘targets’ and its push to achieve foundation trust status at all costs were highlighted as a major cause for its failure. 

Yet, the government has just pushed through the biggest ‘top down’ reorganisation of the NHS in its history. This has included major changes to the accountability structures, bureaucracy and management. It also requires greater efficiency savings to be made to the spending at trusts.

The Health and Social Care Act 2012 requires all NHS trusts to become foundation trusts by April 2014. Chaos in trusts will ensue due to these changes as they will replicate many of Mid Staffs’ failings.

Industrial and pay policy

The Francis Report highlighted problems with staff morale, support and bullying. Current NHS employment policy is likely to make these factors much worse.

Staff across the NHS already report that morale is at an all time low, following several years of reorganisations, redundancies, pay cuts and pay freezes.

In 2012, NHS staff side unions commissioned an independent survey of their membership. This was a repeat exercise of two previous biannual surveys. The survey showed major problems with morale, workloads, unpaid overtime, staff shortages, restructuring, cuts to pay and resources that were affecting the standard of service delivery.

Members overwhelmingly felt that NHS pay policy was unfair (90 per cent) and the vast majority of respondents reported that they were worse off than 12 months ago. The majority of respondents said that they were considering leaving their jobs. Many of these statistics had shown a sharp decline since the 2010 survey, suggesting a direct correlation to this government’s policies.

Worse still, NHS employers are continuing to drive ahead with a plan to introduce performance-related pay for staff increments challenging the equality premise and enabling culture of the Agenda for Change national agreement.

There is little doubt that performance related pay will drive a new culture of silence and bullying for all NHS employers, as it will create financial incentives for staff not to report failings and abuses, or criticising management on professional issues.

Management will be responsible for assessing performance and this will open the risk of whistleblowers being penalised for “poor performance” and speaking out.

Finance and resourcing

The Francis Report highlighted issues with finances, poor workforce planning and under-staffing in many wards.

This again is being made worse by current policy. Many of the trusts are financially struggling due to real terms cuts to the national health budget, the cost of reorganisation and the so-called Nicholson ‘challenge’, to make £20 billion of efficiency savings.

Further cuts are expected as trusts attempt to gain foundation trust status and make themselves competitive with other ‘Any Qualified Providers’ which have entered the commissioning market.

The result has been increasing numbers of redundancies, vacancy freezes and closures as trusts struggle to balance the books. The legacy of Private Finance Initiatives (PFI) contracts is also eroding trust finances.

Again the independent survey for staff side sheds light on the gravity of the resourcing problem: Key findings include:

  • research suggests that the majority of staff working in the NHS are regularly working in excess of their contracted hours
  • over 80 per cent of NHS staff have experienced an increase in their workload in the last 12 months

Worryingly, over 70 per cent of NHS staff said that increases to their workload have resulted in a negative effect on morale. This is heightened by staff shortages.

Poor management, professional standards and accountability

At the heart of the Mid Staffs crisis is the failure to support staff and build a culture that maintained high quality professional standards. Unite is a strong advocate of supporting NHS professionals to defend the standards.

Health care professionals, such as doctors, nurses and midwives. who are statutorily regulated have personal accountability for their practice and must always be able to justify their decisions and actions (The code: Standards of conduct, performance and ethics NMC 2008, Good Medical Practice GMC 2006).

They have a responsibility to report circumstances that prevent them working safely within their code or nationally agreed standards. This applies equally to those in clinical practice and management positions. All concerns must be investigated.

Unite officers continue to receive reports of staff being forced by managers to work in conditions or ways that go against standards of good practice.

Unite will ensure that staff feel supported and confident to raise their concerns.  Staff, wary of doing so through conventional channels, should be able to go in confidence to an independent ‘champion’ in place throughout all the provider and commissioning NHS organisations, as advocated by Unite.

For further information, please look on the health section on the Unite website.