Brendan Martin and Roger Kline - How the Stafford scandal could renew the NHS
Jeremy Hunt has accused Labour of a “deafening silence” about the horrors at Stafford Hospital, where at least 400 and perhaps as many as 1,200 patients died unnecessarily over four years of neglect and abuse. In fact, Andy Burnham has described the scandal as “a betrayal of everything the NHS stands for”, and he now plans to put its analysis and recommendations “at the heart of Labour's health and care policy review”. (Guardian, 10 February).
Hunt is also wrong to say Labour has failed to apologise for a disaster caused in part by its NHS reforms, since Alan Johnson did that when he was Health Secretary (House of Commons, 19 March, 2009).
However, neither Hunt’s typically opportunistic response to Francis, nor Labour’s contrition, mean we can move on. On the contrary, that would compound the original betrayal, whereas learning profound lessons from Stafford could transform public services for the better.
With nearly 2,000 pages and 290 recommendations, Francis offered plenty of scope for picking and choosing. In his Guardian article Burnham drew three lessons: that the “new managerialism and a focus on finance and targets” had gone too far; that the increasing challenge of an ageing population requires integration of health and social care services; and that reorganisation should not be imposed without consultation.
Undoubtedly those are important issues, but while they allude to Labour’s failed approach to public service reform they neither challenge its fundamental flaws nor provide the basis for the alliance of NHS staff and patients required to defeat the Tory agenda.
The core lessons of Francis involve culture rather than structure, and show that Labour’s approach to reforming the latter did a great deal of damage to the former. The inquiry revealed widespread toxicity in NHS relationships caused not only by top-down targets but also by the way managerial and professional hierarchies were used to enforce them.
The route to renewing the NHS culture finds concise expression in these 40 words of paragraph 1.118 of the Francis Report:
“The patient must be first in everything that is done: there must be no tolerance of substandard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations.”
That sentence not only captures the essential values required but also identifies the key relationships through which they must find expression, as deconstructing it can show:
- “The patient must be first in everything that is done”: don’t take that for granted -- Francis revealed how much it is honoured in the breach;
- “There must be no tolerance of substandard care”. Again, Francis showed how complacent we have become, and not only in Stafford.
- “Frontline staff must be empowered with responsibility and freedom to act in this way ...”. This highlights how to build a culture around the required values. Not only must frontline staff be held responsible for their duty of care; they must also be free from command-and-control pressure to betray that responsibility, and from bullying when they resist that pressure.
- “ ... under strong and stable leadership ...”: The report showed that rather than the macho management of top down diktats that drove the descent into neglect and abuse in Stafford, “strong and stable leadership” supports team work that enables and requires personal and mutual responsibility for maintaining high standards of patient care.
- “ ... in stable organisations”: speaks for itself, and means “please, no more reorganisation for now, even with consultation!”
The focus must instead be on building relationships that enable and require every healthcare organisation and worker to uphold their own and each other’s duty of care. This will enrich working lives too, and provide the strong and stable cultural foundation for any structural change that might be needed to further improve services and productivity.
Public service improvement needs to begin with the essential relationships that define its behaviour and form its culture – the relationships between staff and users, and among staff. Starting from the wrong end, Labour’s reform agenda damaged those relationships in catastrophic ways, whereas a progressive agenda would focus on improving them.
If Labour faces up to that, and if the unions embrace the new roles implied by the cultural revival required, no Tory health secretary will be able to break the social bonds from which the NHS derives not only its enduring strength but its very legitimacy.
Brendan Martin is managing director and Roger Kline an associate consultant with Public World, which has launched a Duty of Care project to support healthcare workers to assert their responsibility and right to put patients first.
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