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Feeding the beast

Feeding the beast

In the introduction to his report Robert Francis urges the NHS to make “a fully effective response and not merely expressions of regret, apology and promises of remedial action”.

A section is dedicated to hindsight: the word occurs 123 times in the transcript of the oral hearings and the phrase “benefit of hindsight” a further 378 times. Francis pointedly observes that hindsight had been an equally conspicuous feature of the Bristol inquiry. The rear-view mirror appears to be the visual aid of choice for witnesses at inquiries.

The Francis report tells us nothing we did not already know about the suffering of patients at Stafford Hospital, but it does deliver his conclusions about what to do to stop it happening again. The first report produced 18 recommendations; there are now 290.

This enormous prescription could easily become a bureaucrat’s charter. Francis blames many of the problems that led to Mid Staffs on the management’s emphasis on process over patients and in particular its obsessions with meeting targets and attaining foundation trust status. It is easy to see how implementing Francis could become the new obsession for the NHS inspiring more plans, forms, checks, reviews and reports than ever.

Changing the culture of the NHS is a constant theme of the report:  management culture – complacent, bullying and inward-looking – and staff culture, particularly in nursing.  No doubt some people are simply in the wrong jobs, but poor recruitment and training does not explain how the problem becomes commonplace, how nurses routinely have the compassion ground out of them, how managers become helpless to act.

Most people become unhappy in their work when they spend most of their time doing the wrong thing and when they no longer feel it is possible to do a good job. We can blame the “culture”, but cultures are notoriously hard to change. The other word for it is bureaucracy and you can fix that.

Bureaucracy is the primary NHS response to anxiety – the fear of getting it wrong makes us cautious, prone to planning, checking and reviewing, keen on controls, fond of sharing accountability and averse to risk and responsibility. As more things go wrong and management feels the need to press down harder to keep the lid on, bureaucracy itself becomes a cause of fear.

Other organisations have lighter management structures, more freedom for individuals to take decisions, more career mobility, less paperwork, better information management, fewer policies, less onerous procedures and – as a result – higher morale, higher productivity, happier customers.

The traditional NHS management view is that what works for hamburgers or hotels won’t work for healthcare; that without “grip” the system will spin out of control with disastrous consequences. So we try carefully controlled experiments involving devolution of power, introduce policies for the empowerment of staff or try to graft leadership skills onto disenfranchised and demoralised managers instead of devolving power, empowering staff and breeding leaders.

In nursing, there is no shortage of visions and strategies for compassion and care, which generally rely on nurses to become more compassionate and caring by making an extra effort, but little sign of willingness on the part of leaders to address the causes of poor nursing. Only some of these are about resources. Others are about simple things, which could improve working lives and save money, like cutting paperwork and pointless box-ticking tasks.

The Francis report recognises all of these problems as well as its own potential to feed the beast it sets out to slay. It challenges the NHS to stop confusing caution with safety and fearfulness with vigilance.

In the wake of Francis, the secretary of state’s preoccupations with a five-year strategy for a paperless NHS and measures to cut bureaucracy may be less sterile and peripheral than they seem.

The full report and associated documentation can be downloaded here

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