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Editorial Tuesday 5 February 2013: The Big Beast Fallacy and a thousand chocolate teapots - on responsibility for Mid-Staffs

The Francis Public Inquiry into Mid-Staffs will publish tomorrow. Prime Minister David Cameron will respond in the Commons.

Will it make any difference?


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There are ample grounds for scepticism, if you look at previous clinical scandals. The Bristol Inquiry took place twelve years ago and Private Eye covered it twenty-one years ago, and as BRI anaesthetist Steve Bolsin’s fellow-whistleblower Dr Phil Hammond pointed out today on Twitter, “we still haven’t safely reorganised children’s heart surgery”.

And outcome measurement more generally remains a work in early progress.

There has been plenty of speculation on what Francis will suggest. It is unclear whether the Prime Minister will echo the promise made by Andrew Lansley (who granted the public inquiry) to implement all Francis’ recommendations.

Francis’ original report can be found here. The closing submission notes:
(1) Some senior managers had a forceful style of management which was viewed by some as bullying. The Inquiry heard evidence which suggests that in the case of at least one senior manager, these concerns were well founded.
(2) Staff feared repercussions if they complained. The Inquiry will wish to consider the manner in which the whistleblowing incidents it has heard about were handled and may consider the way in which they were handled did not encourage staff to raise their heads above the parapet.  The Inquiry may be particularly concerned to note that these incidents were drawn to the attention of the Inquiry by two of the whistleblowers themselves and by Cure the NHS, not by the hospital.
(3) Pressure to meet targets. It is clear that there was pressure from the board down to meet targets, especially the four-hour target in A&E.  It seems likely but surprising that the board had no appreciation of the effect this had on staff on the wards but with pressure from the very top, it may be that complaint about the effect was effectively discouraged.

(4) Low morale and an acceptance of poor standards, leading to a sense that there was no point in complaining because it would not make any difference”.

The same document notes, ”until the middle of 2006, the director of clinical standards, who also variously held the title of director of nursing and chief nurse, who was herself a senior nurse, had responsibility for strategic nursing matters but not managerial or line management responsibility for nurses.  She told us that she did not consider it part of her duties to spend a lot of time on the wards”.

Who was responsible?
There is no one individual responsible for the appalling care that was delivered by many of the staff on some of the wards in Mid-Staffs.

There are a lot of people who need to take responsibility. To date, I’m not aware of a single one that has.

These people had roles in assuring that the healthcare care they were being paid our tax money to provide or oversee was safe. They failed spectacularly to do that.

Back in 2009, I wrote that “the senior management and board of the trust are of course highly and principally culpable. If they knew and did not act, then they are criminal. If they did not know, they are incompetent and negligent”.

It’s still true.  Likewise that “the Healthcare Commission did not cause the problems. But its job was to notice them, and act. It took far too long to do so”.

“The Care Quality Commission’s chief executive Cynthia Bower was, of course, the chief executive of West Midlands Strategic Health Authority, which was notionally in charge of the patch in the later, post-2006 spell of the period until it achieved FT status in February 2008.

“Prior to Cynthia Bower’s tenure, the SHA chief executive was none other than NHS chief executive David Nicholson

“Another group who cannot totally escape some element of responsibility … clinicians who have professional bodies and royal colleges, membership of which requires them to sign up to some form of ‘primum non nocere’ – first, do no harm … any clinician who stood by while their trust implemented a Mid-Staffs-style ‘Clinical Decision Unit’ – translated, a room to dump people to avoid target breaches – needs to have a bit of reflection on what they might have done. And the medical director of the trust should do likewise”.

The very small number of front-line clinicians at the trust who spoke out about the poor quality of care is deeply depressing. This was not just the nursing profession, by the way.

A thousand chocolate teapots
When you look at the various levels of management within Mid-Staffs, the directors and non-executive directors, the commissioners (the PCTs), the regional tier of the NHS (the SHA), the national tier of the NHS (DH), the quality regulator, the economic regulator, the National Patient Safety Agency, the royal colleges and the NHS Information Centre, it’s impossible to avoid concluding that around a thousand people had some kind of stake in and responsibility for how Mid-Staffs was performing.

And when the boiling water of a significant volume of dreadful care was added, they turned out to be as much use as a thousand chocolate teapots.

Patient voices were being raised, in particular by Cure The NHS. They weren’t being heard.

Are targets responsible? Mmmm. The public inquiry gave us much clearer evidence of the rather open secret of NHS management: that there are only two real rules:
1. Never blow up the money (unless you have major favours in the bank with the system)
2. Never embarrass the minister – always keep noise within the system down.

FT status was a target then and remains one now, with as flexible an end-date as ever. The non-communication between Monitor and the Healthcare / Care Quality Commission on quality concerns was a chasm.

National waiting time standards were a target – and have proven in many places to have perverse incentives. This probably means that we need intelligent flexibilities, rather than no targets. That requires intelligent metrics and potential embarrassment for ministers.

The real Nicholson challenge
Mainstream media attention has also focused on the Comrade-In-Chief. Maybe this means we should take a second to put a Comrade into context.

NHS management culture is centralised, to put it mildly. As NHS Alliance director of policy Michael Sobanja observed of his experience, the NHS has become more centralised with every reform since 1980.

Nicholson told the NHS Confederation conference in 2009 that he was part of a generation of senior NHS managers who made their careers by ‘making their numbers’.

It’s easy to demonise the Comrade In Chief. But he is, as we all are, a product of the environment that surrounds and shapes us. ‘Culture eats strategy for breakfast’, remember?

Comrade Sir David is (as I previously observed) a centralist to his core. Yes, of course he started out as a hardline non-Euro Communist (and now revels in playing up to it, “commanding heights of the health economy” and all).

Much more relevant to understanding Nicholson is the fact that he has flourished and risen in an NHS system that has increasingly rewarded Stakhanovite compliance and managing upwards.

In his HSJ 100 introduction, the journal’s editor Alastair McLellan gave a fascinating insight into the thinking of Comrade Sir David Nicholson.

The Comrade In Chief’s world view, McLellan writes, “divides the world of healthcare leaders between ‘barons’ and ‘knights’. Barons command armies, knights quest between castles doing good needs. Robert Francis is a knight, as is Sir Bruce Keogh.

“But it is the barons who will rule healthcare in 2013”.

Hmm. Barons and knights reminds me of Professor Julian Le Grand’s 1990s essay about ‘Knights, Knaves Or Pawns? Human Agency And Social Policy’ for the Journal of Social Policy.

Barons and knights … it’s feudal stuff.

It’s also something that is out of time – very much like the pop parodies of The Barron Knights (see their ”>Pop Go the Workers, or perhaps more pertiently, A Taste of Aggro).

Will the Francis Public Inquiry report dispatch Comrade Sir David to The Golden Oldie Old Folks’ Home?

Well, he doesn’t think he should go, as he told HSJ.

Last week, Nicholson made his first apology for Mid-Staffs. That is epically late in the day.

The Big Beast Fallacy
Some of the pre-match reports on the Francis Public Inquiry have taken the ‘if not Nicholson, then whom?’ approach.

Let’s borrow veteran commentator Roy Lilley’s nickname for the Comrade In Chief and call this the ‘Big Beast Fallacy’. A centralising power structure such as the NHS likes and recognises big beasts. They are known, safe quantities: good at grip.

And that Big Beast version of the NHS brought us to the place where Mid-Staffs happened - and where the pain and suffering caused was ignored for years.

Big beasts are bad for succession planning, because they cast too large a shadow where nothing can grow.

The NHS needs to be moving to a place where big beasts are an anachronism – where sharing bad news about dangerously inadequate care upwards is not only culturally tolerated, but encouraged.

Do we have any evidence that Sir David Nicholson can achieve that?

The Francis Public Inquiry report matters hugely. It matters most of all to those whose loved ones were harmed or killed because of the dreadful care at Mid-Staffs – and elsewhere.

It matters because when we allow these things to happen, when people’s humanity is ignored or degraded and their vulnerability is met with contempt, irritation and ignorance, the end result is empty chairs and early graves, and a child crying for a parent who’s never coming home again.